I think you are *wildly* overestimating Trump’s competence.
Deservedly or not, Trump really does represent the GOP's "excluded" base and he's pretty clearly "not an elite". In theory, if he reluctantly signs onto "amnesty" as a needed compromise to fix problems, then maybe he brings his base with him.
...result in a cabinet member not getting a security clearance and having to resign...
Trump is a lot more willing to fire people than most and views it as a cost of doing business. And yes, he was unprepared to win... just like everyone else.
IMHO him hiring people late is a *good* thing. Back in July he would have needed to stock his cabinet with the alt-Right because most serious people would have been totally unwilling to work with him. As it is, he was brought in to roll back the gov and do reforms. He's taking risks, some of his people choices are *not* going to work out and he's going to need to fire them.
The real problem is that he’s refusing to *talk to anyone who does*.
Pence is in charge of the Transition team and is responsible for the nuts and bolts decisions on making it work. Pence doesn't suffer from Trump's personality issues nor his inexperience. So these criticisms are really being leveled against Pence.
Which means we're dealing with two issues. First, NO ONE expected Trump to win so there's a *lot* of missing time. 2nd, the Press hasn't yet recovered from their shock of their gal losing, and they're magnifying every expected issue into something earth shaking.
...except under Clinton they did it via scandal...
Normal politicians manage to hold office without winning the lottery (via cattle futures), continually mixing their personal and public interests, or having sex with interns. Typical politicians who do these sorts of things are thrown out of office or arrested. That the Clinton way to deal with their personal failings is to deny, lie, and claim it's politically motivated just prolongs and expands the scandal.
they were forced to demonize the entire process of the government passing laws.
As the gov has gotten bigger, more complex, and more intrusive, the rate of GNP growth has gone down. Lack of growth leads to social problems including discontent. Return growth to 4% and a lot of these problems go away. Growth is a rough way to measure how well the government is serving the people, and at the moment, it hasn't been very well.
What Republicans were calling death panels, way back then, is that Medicare was going to pay for end-of-life counseling.
IMHO it's fair to think UHC advocates will sneak in death panels at some point and there will be multiple layers of obfuscation to prevent notice. Socialized medicine can't work without death panels, which is why I've repeatedly suggested the left learn how to sell them if they want to move forward with UHC.
If memory serves there was supposed to be a team of unelected "experts" (carefully shielded from political interference) who were going to make decisions on what the gov would pay for and what it wouldn't. This Bill was exceptionally (deliberately?) complex and confusing, to the point where no one knew what was in it. If the people who wrote the bill had no clue what was in it, then it's unreasonable to expect the average person.
A government run death panel hits a lot of people as a lot more scary than some insurance company. Movies about insurance companies killing people for profit or convenience are rare, movies about the gov doing so are common (Nazis count).
Some amount of the people already here are going to get to stay here, because it is *way* too expensive and time consuming to do otherwise.
This is a policy evaluation I agree with, others do not. You can call it racism or fear if it makes you feel better, but the problem isn't a lack of understanding of the issues.
If the people that people get political news from say that amnesty is needed, people believe it is needed. If those people say it’s the worse possible thing ever, people will believe that.
Bring back 4% growth and all this social angst becomes manageable.
But the right has been taught, for two decades now, to ignore the media, to listen to their own private media…and even to ignore what their own party is saying if their private media says to.
The media is vast-majority-Dem and decades ago they dropped impartiality and fact checking in favor of becoming Social Justice Warriors pushing "narratives". Witness the claim that Jeff Sessions is a clan supporter and "You can keep your plan" being listed at "true" by politifact while the ACA was voted in. I'm seriously pro-science, which means seriously pro-vaccination. I didn't blink an eye at Trump putting an anti-vac guy at the head of vaccinations because my faith in the media was *that* low.
As for "their own party", wave after wave of GOP have been elected to roll back the gov, but once in office they've fallen in love with spending other people's money and expanded the gov. If expanding the gov had increased the rate of growth, then we could argue that it was worthwhile. Instead what we've got is a reduction in the rate of growth.
And this is just one of the many things the Republican have done upon mostly the same lines, all the stuff they had presented to *make it look as if a large section of voters have no say in the political process*, whereas the actual fact is the Republican party is deliberately operating in such a way to make it look like that.
Interesting take on things. The implication is that Trump could be a *really* good thing because of his ability to pull these people in.
Immigration reform was another thing, where ‘amnesty’ was serving the same purpose as ‘death panels’ and the Republicans got cold feet because of various people feeding their base nonsense.
Hardly "nonsense", more like "unpleasant reality". A panel of experts who decides who gets medical care and who has it priced out of reach so they don't, can reasonably and accurately be called a "death panel".
Most people don't want to die at any cost. I got a LOT of pushback *here* for suggesting we put a solid dollar number on this sort of thing.
Deciding to forgive large groups of people of crimes they've committed is normally called "amnesty". If we're going to be serious about the law our basic options are "amnesty" or ripping apart families for the crime of existing.
If you talk to someone who opposes amnesty (I have), you'll find out they favor the later.
It's reasonable to say that they're wrong, or being emotional, or that what they actually want isn't reasonable or can't be implemented. However the problem in both cases isn't that they don't understand the issues or the solution, the problem is that they do and they don't agree with you.
So politically maybe Trump is the best guy to handle both of these issues in a "Nixon goes to China" way.
The population is getting older as the baby boomers age.
Further it's easier to find your "tribe" now days. Be it role playing games, a minority religion, or whatever you're into, you're one internet search away from finding your fellows.
But we’re actually arguing because he says *it was so unpopular it was illegitimate as a law*, however that was supposed to work. Like it requires majority approval of the population for some reason, despite that not being how laws work.
The ACA was more intrusive than the typical law, affected more people, was sold on bigger lies, and so forth. The only similar thing I can think of is GWB's attempt to reform Social Security. I'm not sure "illegitimate" is the right word, but the ACA was clearly not business-as-usual.
someone had called *Trump* illegitimate
One of Google's definitions of 'illegitimate' is "not in accordance with accepted standards or rules". That describes both Trump and HRC. Trump clearly likes breaking standards and, if she'd won, HRC would have been investigated to see if she'd stepped over her "not provably criminal" line *before* she even took office.
Having said that, by common speak, winning elections (by definition) gains legitimacy in a Democracy. IMHO we're running into linguistic issues here, the word "illegitimate" has several different flavors and by some definitions the ACA/Trump/HRC are that and by others they aren't.
Let's reverse the question, if GWB had forced SS reforms down the throat of the American people, would it have been "illegitimate"? Can Trump pass laws that are illegitimate? If the answer is 'no' (because any law he passes is legit no matter how bad or how unpopular), then that's a truism and also the answer for the ACA. If the answer is 'yes', then where are the lines?
…health care reform has been a huge issue since the 90s, and the Republicans had *six years under Bush* to try to fix it...
Bush was a big government guy and would have also reached for an anti-market big gov solution. Market solutions don't have financial backers because the big players don't like competition which is going to reduce their profits. Growth in HC costs is *popular* with the groups who benefit from them, and those groups give a lot of money to politicians.
I see no evidence Bush had a clue of how/why markets worked or why they're a good thing. Ditto Obama.
This country has suffered a lot in recent decades because neither party has been interested in letting markets work. They're both more interested in using/creating gov power to further their own interests. The idea of markets in control is in opposition to the idea of the gov in control and politicians like power.
UHC is EASY since all you have to do is open the doors to everyone who currently doesn’t have insurance/access/money to pay cash. So he’s imagining a situation in which UHC is overlayed on the exact same system we have right now, and if we did that, then he’s absolutely right that costs would go thru the roof
This.
Dark’s insistence that advocates of singlepayer (say) present evidence that instituting an NHS-like system will actually lower costs. That data, as far as I can tell, isn’t out there.
Also this. We don't have any examples of massive savings... because UHC has always been just bolted onto the existing machinery? That's probably the political reality.
others (me included) are focusing the systemic changes in pricing and absence of bureaucracy (not to mention multi-layered profit motive) that such a system would entail.
If it were this easy and actually going to save money, then it should be possible at a state level. The various state level experiments have had costs go through the roof until the budget breaks.
Next, I'm not sure how "absence of bureaucracy" gets into play here. Are we going to outlaw the hospital having a bureaucracy? We're not going to use prices to signal anything, and presumably they'll remain invisible (like what Kazzy found)... So why is this supposed to make anything cheaper? Is having someone else pay those insane bills going to reduce them? Are we going to micromanage the bills with a bureaucracy?
It feels like you're suggesting GM could save money by getting rid of it's entire bureaucracy and sales force by simply giving way it's cars for "free" and billing the government (or that we're going to double down on everything that makes the system expensive). My expectation is the increase in demand makes other changes moot.
Triage medicine has been suggested... but presumably that means deliberately not treating the old and dying because they're old and dying. That could work (except politically), but I *think* this is what you want the system will *prevent*.
Savings probably needs to happen by reducing demand some way. "Price" is one way, Queues or Triage/Death Panels is another.
You seem to think that I’m saying that making it universal results in savings. It’s the other way around. Adopting a better system saves enough money to make it universal.
Somehow I doubt there's *any* history of this kind of thing being put into place without large tax increases, that's a problem right there considering how many countries have done this.
The focus here seriously seems to be on universal with the "save money" aspect being either an afterthought or the calm assurance of ideology. So are you confident enough to do it in two stages? One to save money and two to make it universal?
So your complaint is not that it doesn’t work economically, but that it won’t work politically.
Oh, I don't think it works economically with where we're at, and I also don't think it can work politically either (and you can add culturally to that list). The Dems had a super majority and Obamacare was as far to the left as they could bring themselves to go.
But your objection holds for any reform that will reduce costs. Any cost reduction anywhere will cost somebody some profit.
Markets have done this before, many times. Coal is currently coming under the ax, the Steel workers were brutalized.
That's in addition to problem that I don't think *anyone* have any clue, at a detail level, what needs to happen. Do we have too many specialist doctors? Not enough?
This feels like one of those cases where my idea needs to meet political feasibility tests but yours doesn’t, even though it’s just as politically infeasible (if not more).
We already have vouchers around, is it really politically infeasible to force providers to publish prices?
Wrapped up in your economic arguments is the assumption that we’re currently getting as much as we possibly can for our money and that it is not possible to get the services for less–that there’s no excess billing or wasted administrative overhead.
Hardly. But the people you claim will step in and make $25 dollar aspirin cost only $15 are the same people who have given us a single source for an epi-pen (in the name of helping us) and allowed that $25 dollar aspirin to begin with.
Given that we're already dealing with regulators who have been captured by hospitals (etc), and given that providers understand how to do this, why should I expect the same group of regulators will do better in the future than an impersonal market?
we’ve got a price problem and that the preferred solution of the elites is to create ways to manage the price problem but the elites tend to manage the price problem in ways that subtly increase demand without increasing supply and, thus, make the problem worse.
Think about the world the elites live in. Money isn't an issue for them or *anyone* they talk to. Healthcare isn't an issue because they're always at the head of the line.
So we see solution after solution which expands access (at the expense of price signals) and/or shields people from price.
without a useful measuring stick of how to measure what, we’re just stuck either saying “the stuff I care about is more important than the stuff you care about!”
And the useful measuring stick is normally "price", and the way to react or evaluate that is through a market.
I think you’re mixing and matching percentages in a way that compounds error.
Certainly a possibility.
which still puts it at just over 1% of GDP.
Fair enough.
Basically, you’re suggesting we have dramatically (like 1.5x to 2x) better health services than those other industrialized countries and we aren’t using metrics that capture that fact. I could definitely see us having better results depending on the metric, but without at least some sensible metric...
I've seen hints of this, very different survival rates of certain cancers, lack of queuing for important surgeries and the like. The problem is this *very* quickly gets into cherry picking.
Ideally we'd adjust for culture (murder, being fat), which intuitively should be large, but I have no stats for that. Another strong possibility is we're deep into "diminishing returns".
You still seem to be speculating that we’d do those dumb things in a way that other countries don’t seem to be.
Oh, they do dumb things too, and because they're not using markets either, they're certainly subject to insane prices and so forth. However IMHO we're further down that path than they are.
As a share of the nation's Gross Domestic Product, health spending accounted for 17.8 percent.https://www.google.com/webhp?sourceid=chrome-instant&ion=1&espv=2&ie=UTF-8#q=what%20percentage%20of%20the%20gdp%20is%20health%20care
The estimated annual health care costs of obesity-related illness are a staggering $190.2 billion or nearly 21% of annual medical spending in the United States.
I'm curious as to whether those links will work for you (how personal does google make it?). If you don't get what I do I'll supply what it seems to be pulling from. Then to get 3.7% I multiplied one by the other.
So they’re defining health care costs in a strange way that makes the calculation work out badly.
That's certainly possible. When I look at it, yes, $190B seems really low.
Even allowing for the idea that on top of those variables, those people consume 25% less healthcare than we do, they’re still beating the tar out of us. So how?
Two problems. First consumption of healthcare has little effect on the stats that we use to evaluate healthcare when we're at this level of things.
We tend to rank HC systems by things like child mortality, life expectancy, and so forth. But those sorts of things are drastically affected by things like murder, obesity, SIDS and so forth which are almost entirely cultural in the first world. For example, for all the talk about how poverty creates SIDS or makes it worse, the way to prevent infants from dying is to lay them on their backs, not their fronts.
The 2nd problem is our spending suffers, dramatically, from things already mentioned on this board, tests/visits that are not connected to cost and are impossible to compare and so forth. Bluntly these things seem like what we should expect from "command/control" and are the sorts of things which markets clean up.
...I still don’t see why we can’t afford a European system.
Because these systems don't reduce costs, they reduce the growth of costs (and even that would be difficult here). They're also an expensive expansion of the existing system because they bring sick people who were previously untreated into the system.
Our system is already really expensive. Expanding that expensive system onto more, often sick, people isn't going to reduce the total cost of the system.
I mean it’s not like European bodies behave differently than ours...
If only that were true. If we weren't the fattest first world nation we'd have a lot fewer sick people. Give us European bodies and many of our problems go away.
...or that hospitals operate differently.
Also untrue. For example many European hospitals use the "ward" model where one doctor or nurse can deal with dozens of patients at once. Ours are mostly built with private rooms to prevent the transmission of disease (and I suspect, require more doctors and nurses).
We're not going to burn down our hospitals and build European style ones, so we're stuck needing vastly more people to run them.
Politics are diffrrent, yeah, but that’s the variable were trying to change.
Politics is a stand in for culture, and culture is one of the hardest things to change.
Dark Matter: What you want to do is implement UHC to cover people who aren’t covered, and that’s it.
Troublesome Frog: No, that’s just a thing you’re ascribing to me because it’s easy to dismiss.
Then when I ask for how you're going to control costs, you need to say something other than "UHC" (which increases demand and hands out free stuff).
UHC is politically the easy part because handing out free stuff is popular. The really hard part is paying for it and structuring things so it doesn't bankrupt the system.
DM: Other countries implemented it when costs were cheap and their gov spending was a much smaller percentage of the GDP than it is now.
TR: This claim makes absolutely no sense to me. Why would lower costs when they implemented it have anything to do with whether it’s affordable now? If the system didn’t work, lower costs at the start would not save it decades later.
This is pretty important. It's *much* easier to stop someone from getting something than it is to take it away, that's *especially* true for things like jobs, salary, and life giving care.
Say we look at other countries and decide *half* of all tests are medically worthless, so we the gov decide to make it a lot harder for doctors to schedule tests with the explicit goal of cutting the number in half. Those tests are people's jobs, how they get their incomes, etc, and there's going to be a lot of political protests and claims that what we have now is absolutely needed. Ditto if we try to prevent anyone over the age of 90 from being treated for certain types of cancer when we know that these treatments work. Ditto if we try to cut doctor's salaries in half (or even attempt to double the number of doctors).
On the other hand preventing the creation or import of a band new (seriously expensive) drug or technique is much easier because the people who are going to die without it don't know that there's an (expensive) alternative.
When other countries introduced UMC, it increased the cost of the system, but because the gov was paying for it the gov put huge pressure on various parts of the system to lower it's growth. At the time, per person costs were very cheap because all these fancy cures hadn't been invented yet and we weren't spending vast percentages of the GDP on medical care.
Because these systems were on budgets, they needed to find ways to cut costs. However our absurd costs are already baked into the system. Lowering our GDP expenditures on medicine implies people die and lose their jobs. That's going to be politically unpopular.
Implementing UMC without changing anything is just applying our absurd costs to sick people we used to let die. I don't see how we do that without breaking the budget, and thus far you've been unwilling or unable to say where the cost savings come from, and much more importantly, how those cost savings can work politically.
The low hanging fruit (economically) is not paying for expensive treatments for the old and sick. Half your lifetime medical costs are in the last year(ish) of your life. However you seem to be wanting UMC for the purpose of *not* doing things like that.
Interestingly, none of the other, much more theoretical proposals, offer no suggestions for reducing costs either.
Oh good grief. Make HC providers post prices and give everyone vouchers so they have a reason to compare. There's more but the root of fixing a dysfunctional market is to fix the dysfunctional market.
So the question is this, Dark: if you think healthcare cost per capita GDP is absolutely outrageous and going to get worse, in particular given how shitty our overall healthcare is,
Yes.
then you’ve got a faith-based decision to make too. Or an ideological one, I suppose. I mean, you can stick to your guns about “free market” solutions and watch health care spending rise to 22, 25, 30% or our GDP, or you can bite the bullet and concede that the free market can’t solve this problem.
As far as I can tell we're not *trying* anything close to the free market, and that's one huge reason why it's expensive.
One epi-pen, 3rd party pays, no prices posted so no comparisons possible, supply deliberately restricted, and I'm sure there's more.
"Faith based" is thinking one more layer of government (on top of every layer we already have) is going to make everything work even though we're nakedly increasing demand, handing out "free" things, and can't describe why prices will go down other than "other countries have do things we're not willing to".
I can and have described ways to make UHC work with reducing prices, but the control of prices is separate from the handing out of "free" goodies aspect that you like.
Of course all of the market-based reforms that might have a shot in hell of reducing per-unit costs have a similar cultural problem.
Actually no. We already have health savings vouchers, there's no cultural reason why hospitals (etc) can't be forced to publish their prices.
The nice thing about (some) market based reforms is it mostly wouldn't be obvious who is going to be forced out of business in 10 years, nor who is over priced for what they actually do.
So your complaint against European systems is what, then?
That they don't reduce costs, and we can't afford what they're doing.
They ration care, which you appear to approve of, except they don’t ration by price?
Which gets back to original question of why price rationing is better than triage rationing.
I don't trust "triage rationing" to actually reduce the costs of the system (as opposed to reduce the growth of costs). To the best of my knowledge there's no examples of it working this way.
We can't afford what we're doing now so the issue is whether we go for more government or more markets for reducing costs. Markets actually *are* compatible with "helping the poor" (food stamps), but we have to lose this false idea that we're always going to help everyone.
But doing what other countries with objectively lower costs than us do seems like it would lower costs. Why would that not be the case?
Because you're not going to:
1) Get doctors to accept half their salary
2) Kick trial lawyers out of the system
3) Fire whatever percentage of test lab people don't fit the model
4) Implement serious gun control
5) Have serious death panels
6) Make Americans less fat/murderous/etc, etc, etc.
The concept of bringing in their system in total is simply nonsense. What you want to do is implement UHC to cover people who aren't covered, and that's it. You've suggested nothing for reducing costs other than pointing to other countries which have some or all of that list (and other things besides), but you're not going to try doing those things here so that doesn't really help.
Comparing France in 1945 to France in 1950 is an increase.
So you're admitting that UHC has *never* actually reduced costs? If so, and assuming you're not trying anything on my list above, what makes you think we'd reduce costs here?
Can you explain exactly what you’re trying to get from the total costs metric?
Whether or not we can pay for it. Other countries implemented it when costs were cheap and their gov spending was a much smaller percentage of the GDP than it is now.
The justification is this: pick your model, do what they do, cost goes down. It’s not like there isn’t a solid evidence base to work from Dark.
Great, so if "doing what they do" means we have to be...
1) Less murderous
2) Less fat
3) Not have pockets of people who are poorly educated
4) Have a different racial make up.
5) Have a unified culture which frowns on abusing the government's generosity
So when you say that European nations ” let people die”, is that a metaphorical statement, or a literal one like the US example?
I'm saying that there are seriously expensive treatments, which could save lives, that they don't fund.
And because they (sanely) refuse to pay for these, people die. Of course the death rate remains 100% everywhere so paying for them would do nothing but break the budget.
An interesting example is Abdelbaset al-Megrahi (bomber of Pan Am Flight 103). He was released from a British Prison on "compassionate" grounds, he was dying from cancer and had less than three months to live. Then he went back to Libya, and lived for years apparently with a different level of cancer treatments than he would have gotten in England.
Great. So if you're claiming that total costs are actually going to go *down*, then please provide justification for that, ideally examples from other countries experiences. Personally I keep remembering how our politicians keep flinching away from how much UHC will cost.
You're increasing demand, probably by a lot, how exactly are you going to increase supply or otherwise lower costs?
And btw I can think of actual real-world answers for this.
1) Really strict and broad use of death panels would do it (half your lifetime use of HC is in the last year or two of life)
2) Really strict rationing would also do it (although we'd instantly have queues and probably a two tier system).
But if your answer is something like "the government will do it" then you're basically claiming magic based on an ignorance of economics.
If you don’t want people dying in the streets, and you don’t want society paying for their care, then you’re at an impasse.
Again, countries which have UHC *do* *not* have blank checks for every single one of their citizens. They let people die. By the standards of your rhetoric, they let people die in the streets because of lack of care. They're just less honest about it than what I'm suggesting.
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On “Liberals are Smug”
Deservedly or not, Trump really does represent the GOP's "excluded" base and he's pretty clearly "not an elite". In theory, if he reluctantly signs onto "amnesty" as a needed compromise to fix problems, then maybe he brings his base with him.
Trump is a lot more willing to fire people than most and views it as a cost of doing business. And yes, he was unprepared to win... just like everyone else.
IMHO him hiring people late is a *good* thing. Back in July he would have needed to stock his cabinet with the alt-Right because most serious people would have been totally unwilling to work with him. As it is, he was brought in to roll back the gov and do reforms. He's taking risks, some of his people choices are *not* going to work out and he's going to need to fire them.
Pence is in charge of the Transition team and is responsible for the nuts and bolts decisions on making it work. Pence doesn't suffer from Trump's personality issues nor his inexperience. So these criticisms are really being leveled against Pence.
Which means we're dealing with two issues. First, NO ONE expected Trump to win so there's a *lot* of missing time. 2nd, the Press hasn't yet recovered from their shock of their gal losing, and they're magnifying every expected issue into something earth shaking.
Normal politicians manage to hold office without winning the lottery (via cattle futures), continually mixing their personal and public interests, or having sex with interns. Typical politicians who do these sorts of things are thrown out of office or arrested. That the Clinton way to deal with their personal failings is to deny, lie, and claim it's politically motivated just prolongs and expands the scandal.
As the gov has gotten bigger, more complex, and more intrusive, the rate of GNP growth has gone down. Lack of growth leads to social problems including discontent. Return growth to 4% and a lot of these problems go away. Growth is a rough way to measure how well the government is serving the people, and at the moment, it hasn't been very well.
IMHO it's fair to think UHC advocates will sneak in death panels at some point and there will be multiple layers of obfuscation to prevent notice. Socialized medicine can't work without death panels, which is why I've repeatedly suggested the left learn how to sell them if they want to move forward with UHC.
If memory serves there was supposed to be a team of unelected "experts" (carefully shielded from political interference) who were going to make decisions on what the gov would pay for and what it wouldn't. This Bill was exceptionally (deliberately?) complex and confusing, to the point where no one knew what was in it. If the people who wrote the bill had no clue what was in it, then it's unreasonable to expect the average person.
A government run death panel hits a lot of people as a lot more scary than some insurance company. Movies about insurance companies killing people for profit or convenience are rare, movies about the gov doing so are common (Nazis count).
This is a policy evaluation I agree with, others do not. You can call it racism or fear if it makes you feel better, but the problem isn't a lack of understanding of the issues.
Bring back 4% growth and all this social angst becomes manageable.
The media is vast-majority-Dem and decades ago they dropped impartiality and fact checking in favor of becoming Social Justice Warriors pushing "narratives". Witness the claim that Jeff Sessions is a clan supporter and "You can keep your plan" being listed at "true" by politifact while the ACA was voted in. I'm seriously pro-science, which means seriously pro-vaccination. I didn't blink an eye at Trump putting an anti-vac guy at the head of vaccinations because my faith in the media was *that* low.
As for "their own party", wave after wave of GOP have been elected to roll back the gov, but once in office they've fallen in love with spending other people's money and expanded the gov. If expanding the gov had increased the rate of growth, then we could argue that it was worthwhile. Instead what we've got is a reduction in the rate of growth.
"
Interesting take on things. The implication is that Trump could be a *really* good thing because of his ability to pull these people in.
Hardly "nonsense", more like "unpleasant reality". A panel of experts who decides who gets medical care and who has it priced out of reach so they don't, can reasonably and accurately be called a "death panel".
Most people don't want to die at any cost. I got a LOT of pushback *here* for suggesting we put a solid dollar number on this sort of thing.
Deciding to forgive large groups of people of crimes they've committed is normally called "amnesty". If we're going to be serious about the law our basic options are "amnesty" or ripping apart families for the crime of existing.
If you talk to someone who opposes amnesty (I have), you'll find out they favor the later.
It's reasonable to say that they're wrong, or being emotional, or that what they actually want isn't reasonable or can't be implemented. However the problem in both cases isn't that they don't understand the issues or the solution, the problem is that they do and they don't agree with you.
So politically maybe Trump is the best guy to handle both of these issues in a "Nixon goes to China" way.
On “Sam Dresser: The increasingly mobile US is a myth that needs to move on”
The population is getting older as the baby boomers age.
Further it's easier to find your "tribe" now days. Be it role playing games, a minority religion, or whatever you're into, you're one internet search away from finding your fellows.
On “Liberals are Smug”
The ACA was more intrusive than the typical law, affected more people, was sold on bigger lies, and so forth. The only similar thing I can think of is GWB's attempt to reform Social Security. I'm not sure "illegitimate" is the right word, but the ACA was clearly not business-as-usual.
One of Google's definitions of 'illegitimate' is "not in accordance with accepted standards or rules". That describes both Trump and HRC. Trump clearly likes breaking standards and, if she'd won, HRC would have been investigated to see if she'd stepped over her "not provably criminal" line *before* she even took office.
Having said that, by common speak, winning elections (by definition) gains legitimacy in a Democracy. IMHO we're running into linguistic issues here, the word "illegitimate" has several different flavors and by some definitions the ACA/Trump/HRC are that and by others they aren't.
Let's reverse the question, if GWB had forced SS reforms down the throat of the American people, would it have been "illegitimate"? Can Trump pass laws that are illegitimate? If the answer is 'no' (because any law he passes is legit no matter how bad or how unpopular), then that's a truism and also the answer for the ACA. If the answer is 'yes', then where are the lines?
Bush was a big government guy and would have also reached for an anti-market big gov solution. Market solutions don't have financial backers because the big players don't like competition which is going to reduce their profits. Growth in HC costs is *popular* with the groups who benefit from them, and those groups give a lot of money to politicians.
I see no evidence Bush had a clue of how/why markets worked or why they're a good thing. Ditto Obama.
This country has suffered a lot in recent decades because neither party has been interested in letting markets work. They're both more interested in using/creating gov power to further their own interests. The idea of markets in control is in opposition to the idea of the gov in control and politicians like power.
So we need someone to clean house.
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I'm not sure what "enough" means in this context. Didn't do anything to reduce costs? Didn't expand access enough?
I think a *lot* of people think moving to a Western Europe style system would result in EU style prices.
Picture the Dems doing that with a tax increase of multiple percentage points of the GDP.
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This.
Also this. We don't have any examples of massive savings... because UHC has always been just bolted onto the existing machinery? That's probably the political reality.
If it were this easy and actually going to save money, then it should be possible at a state level. The various state level experiments have had costs go through the roof until the budget breaks.
Next, I'm not sure how "absence of bureaucracy" gets into play here. Are we going to outlaw the hospital having a bureaucracy? We're not going to use prices to signal anything, and presumably they'll remain invisible (like what Kazzy found)... So why is this supposed to make anything cheaper? Is having someone else pay those insane bills going to reduce them? Are we going to micromanage the bills with a bureaucracy?
It feels like you're suggesting GM could save money by getting rid of it's entire bureaucracy and sales force by simply giving way it's cars for "free" and billing the government (or that we're going to double down on everything that makes the system expensive). My expectation is the increase in demand makes other changes moot.
Triage medicine has been suggested... but presumably that means deliberately not treating the old and dying because they're old and dying. That could work (except politically), but I *think* this is what you want the system will *prevent*.
Savings probably needs to happen by reducing demand some way. "Price" is one way, Queues or Triage/Death Panels is another.
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Somehow I doubt there's *any* history of this kind of thing being put into place without large tax increases, that's a problem right there considering how many countries have done this.
The focus here seriously seems to be on universal with the "save money" aspect being either an afterthought or the calm assurance of ideology. So are you confident enough to do it in two stages? One to save money and two to make it universal?
Oh, I don't think it works economically with where we're at, and I also don't think it can work politically either (and you can add culturally to that list). The Dems had a super majority and Obamacare was as far to the left as they could bring themselves to go.
Markets have done this before, many times. Coal is currently coming under the ax, the Steel workers were brutalized.
That's in addition to problem that I don't think *anyone* have any clue, at a detail level, what needs to happen. Do we have too many specialist doctors? Not enough?
We already have vouchers around, is it really politically infeasible to force providers to publish prices?
Hardly. But the people you claim will step in and make $25 dollar aspirin cost only $15 are the same people who have given us a single source for an epi-pen (in the name of helping us) and allowed that $25 dollar aspirin to begin with.
Given that we're already dealing with regulators who have been captured by hospitals (etc), and given that providers understand how to do this, why should I expect the same group of regulators will do better in the future than an impersonal market?
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Think about the world the elites live in. Money isn't an issue for them or *anyone* they talk to. Healthcare isn't an issue because they're always at the head of the line.
So we see solution after solution which expands access (at the expense of price signals) and/or shields people from price.
And the useful measuring stick is normally "price", and the way to react or evaluate that is through a market.
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Certainly a possibility.
Fair enough.
I've seen hints of this, very different survival rates of certain cancers, lack of queuing for important surgeries and the like. The problem is this *very* quickly gets into cherry picking.
Ideally we'd adjust for culture (murder, being fat), which intuitively should be large, but I have no stats for that. Another strong possibility is we're deep into "diminishing returns".
Oh, they do dumb things too, and because they're not using markets either, they're certainly subject to insane prices and so forth. However IMHO we're further down that path than they are.
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As a share of the nation's Gross Domestic Product, health spending accounted for 17.8 percent.https://www.google.com/webhp?sourceid=chrome-instant&ion=1&espv=2&ie=UTF-8#q=what%20percentage%20of%20the%20gdp%20is%20health%20care
The estimated annual health care costs of obesity-related illness are a staggering $190.2 billion or nearly 21% of annual medical spending in the United States.
https://www.google.com/webhp?sourceid=chrome-instant&ion=1&espv=2&ie=UTF-8#q=how%20much%20does%20obesity%20cost%20the%20us
I'm curious as to whether those links will work for you (how personal does google make it?). If you don't get what I do I'll supply what it seems to be pulling from. Then to get 3.7% I multiplied one by the other.
That's certainly possible. When I look at it, yes, $190B seems really low.
Two problems. First consumption of healthcare has little effect on the stats that we use to evaluate healthcare when we're at this level of things.
We tend to rank HC systems by things like child mortality, life expectancy, and so forth. But those sorts of things are drastically affected by things like murder, obesity, SIDS and so forth which are almost entirely cultural in the first world. For example, for all the talk about how poverty creates SIDS or makes it worse, the way to prevent infants from dying is to lay them on their backs, not their fronts.
The 2nd problem is our spending suffers, dramatically, from things already mentioned on this board, tests/visits that are not connected to cost and are impossible to compare and so forth. Bluntly these things seem like what we should expect from "command/control" and are the sorts of things which markets clean up.
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Both from google:
Obesity is responsible for 21% (ish) of our health costs
Health spending accounted for 17.8 percent of the GDP.
So Obesity Health costs are 3.7% of our GDP.
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Because these systems don't reduce costs, they reduce the growth of costs (and even that would be difficult here). They're also an expensive expansion of the existing system because they bring sick people who were previously untreated into the system.
Our system is already really expensive. Expanding that expensive system onto more, often sick, people isn't going to reduce the total cost of the system.
If only that were true. If we weren't the fattest first world nation we'd have a lot fewer sick people. Give us European bodies and many of our problems go away.
Also untrue. For example many European hospitals use the "ward" model where one doctor or nurse can deal with dozens of patients at once. Ours are mostly built with private rooms to prevent the transmission of disease (and I suspect, require more doctors and nurses).
We're not going to burn down our hospitals and build European style ones, so we're stuck needing vastly more people to run them.
Politics is a stand in for culture, and culture is one of the hardest things to change.
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Then when I ask for how you're going to control costs, you need to say something other than "UHC" (which increases demand and hands out free stuff).
UHC is politically the easy part because handing out free stuff is popular. The really hard part is paying for it and structuring things so it doesn't bankrupt the system.
This is pretty important. It's *much* easier to stop someone from getting something than it is to take it away, that's *especially* true for things like jobs, salary, and life giving care.
Say we look at other countries and decide *half* of all tests are medically worthless, so we the gov decide to make it a lot harder for doctors to schedule tests with the explicit goal of cutting the number in half. Those tests are people's jobs, how they get their incomes, etc, and there's going to be a lot of political protests and claims that what we have now is absolutely needed. Ditto if we try to prevent anyone over the age of 90 from being treated for certain types of cancer when we know that these treatments work. Ditto if we try to cut doctor's salaries in half (or even attempt to double the number of doctors).
On the other hand preventing the creation or import of a band new (seriously expensive) drug or technique is much easier because the people who are going to die without it don't know that there's an (expensive) alternative.
When other countries introduced UMC, it increased the cost of the system, but because the gov was paying for it the gov put huge pressure on various parts of the system to lower it's growth. At the time, per person costs were very cheap because all these fancy cures hadn't been invented yet and we weren't spending vast percentages of the GDP on medical care.
Because these systems were on budgets, they needed to find ways to cut costs. However our absurd costs are already baked into the system. Lowering our GDP expenditures on medicine implies people die and lose their jobs. That's going to be politically unpopular.
Implementing UMC without changing anything is just applying our absurd costs to sick people we used to let die. I don't see how we do that without breaking the budget, and thus far you've been unwilling or unable to say where the cost savings come from, and much more importantly, how those cost savings can work politically.
The low hanging fruit (economically) is not paying for expensive treatments for the old and sick. Half your lifetime medical costs are in the last year(ish) of your life. However you seem to be wanting UMC for the purpose of *not* doing things like that.
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Oh good grief. Make HC providers post prices and give everyone vouchers so they have a reason to compare. There's more but the root of fixing a dysfunctional market is to fix the dysfunctional market.
Yes.
As far as I can tell we're not *trying* anything close to the free market, and that's one huge reason why it's expensive.
One epi-pen, 3rd party pays, no prices posted so no comparisons possible, supply deliberately restricted, and I'm sure there's more.
"Faith based" is thinking one more layer of government (on top of every layer we already have) is going to make everything work even though we're nakedly increasing demand, handing out "free" things, and can't describe why prices will go down other than "other countries have do things we're not willing to".
I can and have described ways to make UHC work with reducing prices, but the control of prices is separate from the handing out of "free" goodies aspect that you like.
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Actually no. We already have health savings vouchers, there's no cultural reason why hospitals (etc) can't be forced to publish their prices.
The nice thing about (some) market based reforms is it mostly wouldn't be obvious who is going to be forced out of business in 10 years, nor who is over priced for what they actually do.
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That they don't reduce costs, and we can't afford what they're doing.
I don't trust "triage rationing" to actually reduce the costs of the system (as opposed to reduce the growth of costs). To the best of my knowledge there's no examples of it working this way.
We can't afford what we're doing now so the issue is whether we go for more government or more markets for reducing costs. Markets actually *are* compatible with "helping the poor" (food stamps), but we have to lose this false idea that we're always going to help everyone.
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Because you're not going to:
1) Get doctors to accept half their salary
2) Kick trial lawyers out of the system
3) Fire whatever percentage of test lab people don't fit the model
4) Implement serious gun control
5) Have serious death panels
6) Make Americans less fat/murderous/etc, etc, etc.
The concept of bringing in their system in total is simply nonsense. What you want to do is implement UHC to cover people who aren't covered, and that's it. You've suggested nothing for reducing costs other than pointing to other countries which have some or all of that list (and other things besides), but you're not going to try doing those things here so that doesn't really help.
So you're admitting that UHC has *never* actually reduced costs? If so, and assuming you're not trying anything on my list above, what makes you think we'd reduce costs here?
Whether or not we can pay for it. Other countries implemented it when costs were cheap and their gov spending was a much smaller percentage of the GDP than it is now.
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Great, so if "doing what they do" means we have to be...
1) Less murderous
2) Less fat
3) Not have pockets of people who are poorly educated
4) Have a different racial make up.
5) Have a unified culture which frowns on abusing the government's generosity
How exactly do you think we're going do that?
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So you're claiming we'll actually get lower total costs.
Who cares about now? We have dozens of examples, what did total costs look like 5 years after they went with UHC?
If I recall correctly, I looked at a graph of this years ago and the answer was "up, not down".
We're pulling sick people into the system who don't get care now. We're pulling poor people into the system who don't get care now.
This STRONGLY suggests UHC will be a lot more expensive than what we have now.
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I'm saying that there are seriously expensive treatments, which could save lives, that they don't fund.
And because they (sanely) refuse to pay for these, people die. Of course the death rate remains 100% everywhere so paying for them would do nothing but break the budget.
An interesting example is Abdelbaset al-Megrahi (bomber of Pan Am Flight 103). He was released from a British Prison on "compassionate" grounds, he was dying from cancer and had less than three months to live. Then he went back to Libya, and lived for years apparently with a different level of cancer treatments than he would have gotten in England.
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Jaybird,
Just wanted to say "Very, very well done summation". I haven't seen it put together like this before.
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Great. So if you're claiming that total costs are actually going to go *down*, then please provide justification for that, ideally examples from other countries experiences. Personally I keep remembering how our politicians keep flinching away from how much UHC will cost.
You're increasing demand, probably by a lot, how exactly are you going to increase supply or otherwise lower costs?
And btw I can think of actual real-world answers for this.
1) Really strict and broad use of death panels would do it (half your lifetime use of HC is in the last year or two of life)
2) Really strict rationing would also do it (although we'd instantly have queues and probably a two tier system).
But if your answer is something like "the government will do it" then you're basically claiming magic based on an ignorance of economics.
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Total Costs.
Various people seem to be claiming that going to UHC means we'd actually be spending *less*.
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And still is now. And will be in the future. I know people society could save (i.e. prolong the life of) if we were spend without limits.
The problem is, in a world with limited resources, would society as a whole would be poorer for it?
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Again, countries which have UHC *do* *not* have blank checks for every single one of their citizens. They let people die. By the standards of your rhetoric, they let people die in the streets because of lack of care. They're just less honest about it than what I'm suggesting.
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