At The New Republic‘s The Treatment blog – in a post under the winsome and lighthearted title “Have You No Decency?” – Professor Harold Pollack of Chicago University has responded to the widely discussed and widely criticized statement of Sarah Palin’s that we recently highlighted as a “Contention of the Day” (also HotAir Quote of the Day, over 950 comments at last count).
Where Pollack directly addresses Palin’s actual words, his response is more interesting for what it concedes than for what it disputes :
Governor Palin writes: “And who will suffer the most when they ration care? The sick, the elderly, and the disabled.” It’s telling that she omitted one category: Poor people, whose care is now cruelly rationed in ways the Obama administration and congressional Democrats are trying to address in health care reform. Palin brings genuine moral passion to the issue of cognitive disability. I wish she would bring that same passion to the plight of uninsured patients forced to seek substandard, delayed care, or the millions of Americans facing the dual challenge of serious illness and large medical bills. If you live in any big city, go down to your local public hospital emergency room. You will probably find people in visible discomfort or illness languishing for hours. A society that cares about human rights and dignity would not tolerate this.
It would be an interesting argument – how best to relieve the plight of the poor, improve conditions at emergency rooms, deal with whatever trade-offs, etc. – but that’s not the argument the country has been having.
Instead, we’ve been arguing about a supposedly unsustainable insurance-based system and the costs imposed on businesses and workers. The “uninsured” come up a lot in Democrat talking points, but mainly as free riders whose costs are borne by the “rest of us.” How Medicaid, Medicare, and other services that help the poor might be affected (indeed, encumbered) by the Democrats’ plan is an issue that has been brought up more often by conservatives. Professor Pollack and other honest liberals are also “passionate” about this subject, but President Obama and his allies talk at least as much or more about rising costs and the impact on the insured, on businesses, and on the federal budget.
The problem is that the two ideas – help the poor, save money – contradict each other, in a way that runs parallel to the “fatal flaw” in the Obama sales pitch isolated by Ramesh Ponnuru, the contradiction between (my words) shouting in alarm, “This system is an urgent interstellar catastrophe from top to bottom!” and soothingly promising, “Don’t worry, what you’re happy with won’t change, and it won’t cost anyone but the evil rich anything!”
“How can both be true and when has it ever been?” wonder uncertain citizens the heartless racist Nazi terrorist McCarthyites of America. Similarly, between Pollack and Obama, we see that on the one hand, the poor one, the empathetic colorblind nice and virtuous reformers are aiming to expand and improve coverage rather substantially. On the other hand, the middle class and independents hand, they’re aiming to “bend the cost curve down.”
Massively (to the tune of $1 T over the first decade at least) increase demand, yet reduce overall costs? Again, we heartless etc. people scratch our heartless heads. How does that happen? Is there something you’re leaving out? Could it possibly have something to do with the hundreds of billions of dollars you say are to be diverted from Medicare – even as we commence a national discussion about the disproportionately high costs of end of life care and the desirability of keeping seniors up to date on “options other than raging, raging against the dying of the light”? Those of us with Medicare users in our families, or who figure we might become Medicare users some day if we’re lucky enough to make it that far, experience disturbing sensations in those empty places in our chest cavities (where the better people like Harold Pollack and Barack Obama have an organ that allows them to experience feelings… I guess).
Okay, I fibbed up there: No one but me is using the words “options other than raging, raging against the dying of the light.” That’s not, as far as I know, anywhere in bills currently being debated. Neither, according to Pollack, is a certain idea encapsulated (and, perhaps misleadingly, set in quotation marks) by Palin in two words – “death panel” – that generated a bit of a “firestorm.” Poor Professor Pollack:
I can’t find the words “death panel” in any administration position paper, the stimulus package, or the House and Senate draft health reform bills. Don’t take my word for it. Read the bills.
Here I can say, “Keep looking, Professor!” It’s right there next to the mandatory “Dying of the Light” PowerPoint presentations, under the “Cost Ballooning in Out Years Til It Pops Catastrophically” provision, in between the “Destroy Innovation Forever” and “Make Mom & Dad Wait in Line behind Illegal Aliens – Haw-Haw-Haw!” subsections. It’s easy to miss if (as I know you like to do!) you skip ahead to Title 2368/b-89l and -90g, the “Lawyer and Academic Analysts Full Employment” and “Giveaways to ACORN” sub-paragraphs.
Don’t take my word for it. Read the bills.
Much of the rest of Pollack’s post consists of a defense of Dr. Ezekiel Emanuel, a respected oncologist who has taken on the position of health-policy adviser at the Office of Management and Budget and is a member of Federal Council on Comparative Effectiveness Research. Seeking to justify the allusion to Joseph Welch in the post’s title, Pollack accuses Palin – by way of her reference to Emanuel’s “Orwellian thinking” as explicated by Representative Michele Bachmann, who was in turn referring to the work of Betsy McCaughey – of using McCarthyite tactics toward the poor defenseless doctor, who (just) happens to be White House Chief of Staff Rahm Emanuel’s brother.
Pollack concedes that Dr. Emanuel has in the past engaged in “ incautiously blunt commentary,” but asserts that a key McCaughey op-ed “mushes together and distorts” his views. He declines to address the op-ed in any detail, but seems to imply that the New York Post should have demanded changes or never published it. “I wish the Post would exercise greater quality control over what appears in its pages,” he says. After striking this blow for democratic debate and freedom of expression, Pollack offers some doubtless entirely well-justified praise of Dr. Emanuel – “nothing Orwellian about him” we’re assured – then closes on a rather nonsensical admonition:
Emanuel’s work offers a model of sustained achievement that both Governor Palin and Representative Bachmann would be wise to emulate. He deserves better than to be trashed in this way. So do the rest of us.
I’m not sure how Palin and Bachmann are supposed to go about emulating the Emanuel “model,” and I have severe doubts as to whether, at this stage in their lives and careers, it would be wise for them to make the attempt, even assuming they can figure out what it would consist of and avoid practicing oncological medicine without a license. As for whether Emanuel deserves to be “trashed” – well, no one does, but merely having friends willing to vouch for your good character, deeds, and intentions doesn’t oblige others to accept your arguments and self-justifications, or even to presume that you’ve thought your own positions and proposals through with sufficient regard for their implications.
In a follow-up post to the “death panel” statement, Palin has provided a reading list for those interested in the bases of her views. Whether or not the proponents of Obamacare consider them “decent,” she has the same right that they do to explore, argue, and state them – and even including her belief that Dr. Emanuel’s approach, indeed the entirety of the Obamacare campaign, amounts to Orwellian doublespeak, a promise of expanded and improved care that never gets around to admitting at whose expense it would have to come, and how.
Apparently, the forthright expression of this perspective strikes the advocates of Obamacare as the fishy, heartless, ignorant, and indecent equivalent of Nazism, McCarthyism, racism, and terrorism. If so, I hope when Congress returns to business in September, it’s with new proposals on mental health care, which obviously is not what it could be in our nation today. As for self-inflicted political injuries by unhinged Obamaists: I say, let them suffer, and suffer, and suffer. It’s the American way.
cross-posted/adapted at the HotAir Green Room
Comments 53
Colin hear hear!
There is this thing called Medicaid, see? Big as life and spitting out dollars, see? If, under a very expansive construal of the word, you are in fact “poor,” you are permitted to apply for it, see? Yes, poor you! Your whole family too, no kidding. They give you a laminated card, see? (NB: I know this from personal experience.) It’s got your name on it, see? You can go to a doctor, not just to an emergency room, see? Now try to follow me here: After treatment, grip the card firmly between at least two fingers and, you know, show him the card! End of story. End of bill. What friggin’ more do you want?
Get it? If you can find your ass with one hand, you can also find this card without Congress overhauling the entire health-care system of the United States.
August 9th, 2009 at 3:33 pm
Thanks, Joe – you express the thought nicely – and I need to correct mine for diction!
August 9th, 2009 at 3:35 pm
In truth, the death “panel” may be a schlub on a phone bank who puts you off til you call two or three times and say, on the third day, “The pains in my chest are really bad, honest!” to which the phone person might reply, “How do you know? You’re not a doctor.” Then you get in to see the doc, for 11 minutes, who prescribes a pain pill (because The One says that’s better than surgery) and you go home and die.
http://www.dailyrecord.co.uk/news/2009/08/03/exclusive-fury-after-hospital-sends-heart-attack-mum-home-to-die-86908-21567473/
Or, the government guardian of you health might be a 16 year-old: http://www.dailymail.co.uk/news/article-1205113/NHS-pays-16-year-olds-run-swine-flu-hotline.html
August 9th, 2009 at 4:17 pm
Babs, the culminating question is simultaneously deep and searching. Is it the “pains”? Is it the “chest”? Is it the “bad”? Give a “schlub” paid three-pounds-six an hour a break here. Inquiring schlubs need to clarify such vagaries before intervening, not after. Come on!
August 9th, 2009 at 4:35 pm
CK -
I’m not sure what all the fuss is about. A quotation of the offending language would go a long way toward focusing the discussion. Even a link would be nice. All I can find on the subject is this, which looks like another benefit, but what do I know?
August 9th, 2009 at 6:56 pm
@Lawrence Kramer – whose offending language, LK?
I’m unclear as to what’s unclear to you.
August 9th, 2009 at 6:58 pm
The offending language in the proposed bills. (I guess it’s lawyer jargon to refer a legislative provision that causes people agita as “offending language,” but that’s what we do.)
August 9th, 2009 at 7:50 pm
LK – I think you’re having a lawyerly “can’t find a tree with this forest in the way” moment. Kind of like the professor. The offending language in “the bill” is… the bill, which is actually a meta-bill made up of drafts and possibilities…
August 9th, 2009 at 7:57 pm
Is there something in the water in Chicago? That’s what comes to mind reading this bit of drivel.
August 9th, 2009 at 8:51 pm
@aelfheld – No kidding. Kinda bizarre, actually: the assumption that the state is responsible for the lives and health care choices of your baby, your toddler, your minor child. That the parents of children don’t figure into the chain of responsibility. In fact, and I’m sorry for repeating myself, but Barack Obama has already weighed in on this question. The state has no interest in what you want to do with your “temporarily alive” baby. You can let it die in a soiled linen room. By the same token, if the state is paying the bills, it gets to call the tune. So now your temporarily alive baby becomes a cost to the state.
The connection here is that the Left wants to move into our lives in a way that gives them the ultimate power over life and death. Because they are in a better position than we are to handle the ugly truths: that premature babies should be left to die, especially if they are “defective.”
August 9th, 2009 at 9:11 pm
I think Shalen is drinking Chicago water and doing pretty damn well.
August 9th, 2009 at 9:20 pm
CK -
I thought the topic was death panels. I was wondering what specific provision of which bill provoked that particular concern.
August 9th, 2009 at 10:13 pm
LK – the point is that the death panel is arguably implicit in a government takeover with the power to ration care, a built-in massive funding and resource shortfall creating a powerful impetus to ration care, and major advocates and implementers, including Dr Emanuel, already introducing the justifications for declaring this, that, or the other sub-group of patients to be lebensunwertes Leben.
The proposed Medicare advisory panel has already been isolated as a death panel in vitro, as it were. Read the McCaughey article for her take, or skim through the Palin reading list.
August 9th, 2009 at 10:38 pm
LK, or read the post (itself a linkfest) previously linked via “firestorm”: http://hotair.com/greenroom/archives/2009/08/09/an-inconvenient-truth-about-the-death-panel/
Like I said, it’s a virtual forest full of death panel trees.
August 9th, 2009 at 10:42 pm
OK, I get it. The “death panel” is our scare tactic to counteract their snake oil. Carry on.
August 9th, 2009 at 11:43 pm
@Lawrence Kramer – non-responsive.
August 9th, 2009 at 11:56 pm
@fuster – Thanks fuster, but like W. C. Fields, I haven’t let a drop of water cross my lips since the Gold Rush days.
August 9th, 2009 at 11:58 pm
Good piece, CKM. Wish I had time to respond better. The point is excellent that nothing in the bill is about providing better care to the poor. What it’s about is controlling the amount of care the solvent people, who can pay for their own care, are able to get.
August 10th, 2009 at 12:24 am
It does strike me now that there are probably already several college bands calling themselves “Death Panel.” That shouldn’t stop us from using it as the name of the ZC House Band.
Thanks, JED. Again, happy trails!
August 10th, 2009 at 1:13 am
Because Spinal Tap is taken?
August 10th, 2009 at 1:25 am
No, because The Grateful Dead is taken.
August 10th, 2009 at 8:56 am
Some kind of voucher plan would surely be preferable to Ø’s ideas, even if the gov’t makes the vouchers usable only at institutions that implement fee schedules or other centrally-imposed restrictions. I know, I typed a bad word. Voucher. Hee. Voucher.
Btw, how much of that ER rationing is attributable to illegal immigration?
And it’s indeed the case that cost-cutting and socialization of costs (ie to protect the poor) are opposite priorities. If no insurance existed, doctors and hospitals could only charge what individuals could afford to pay.
August 10th, 2009 at 10:14 am
Is the view of people here that there is no aspect of our healthcare system that requires significant tweaking? Is our international competitiveness not adversely affected by our employer-based healthcare regime? Is too much of the GDP (2.5 trillion?) not going to healthcare? Are we, as a society, providing as much necessary care as we could without killing the golden goose or surrendering too much autonomy?
I see healthcare as an infrastructure issue. Our power grid, our roads and bridges, and our healthcare delivery system are all natioal quality of life issues. And they all compete for resources. Should we build a bridge or pay more fraudulent Medicaid bills and malpractice lawyers’ fees? Are there too many people lingering in a persistent vegetative state because they didn’t have advance directives? Shouldn’t the young and healthy be made to contribute now to reserve their place in line when they are old and sick? Is nothing to be done?
And, if something is to be done, what?
August 10th, 2009 at 10:28 am
@Lawrence Kramer – I can’t speak for all of the others here, but I’ve said before that I found the proposal McCain ran with, similar to others that are still knocking around, reasonable if you presume that the government WILL be heavily involved in health care for the foreseeable future, or at least the rest of our miserable lives. It was essentially, to use Seth’s word, a voucher or voucher-like plan combined with market reforms, and easy to grasp at least as compared to the Democrats competing Rube Goldberg proposals. Unfortunately, BO demagogued the heck out of McCain’s proposal, meaning that it’s not politically available, especially key features (subjecting some employer-based plans to taxation) that the Democrats might otherwise have wanted to adopt for funding purposes.
August 10th, 2009 at 11:12 am
Larry, do you consider the House’s 1000plus page bill “tweaking”?
If the percentage of our GDP which Americans voluntarily give for their health care is a matter of huge concern for our competitiveness, how about the tax regime of about 1/3 GDP?
August 10th, 2009 at 11:17 am
Here are some tweaks to ways of paying for health care that I favor. They have all been proposed by Congressional Republicans.
Repeal the tax deductibility to businesses for health insurance, and give it to individuals. This immediately makes insurance “portable” from job to job.
Make it legal for insurance companies to sell insurance across state lines. (Under the commerce clause, this should be the case anyway). This makes a nation-wide market in health insurance.
Repeal regulations requiring insurance companies to offer coverage for every possible medical sitaution and provider (including such non-medical providers as herbalists, etc.). This enables insurance companies to offer a range of insurance from catastophic illness to total coverage, just as they do for car insurance. AS a result, people who pay out of pocket for physician office visits and routine exams will negotiate for prices, and providers will have incentives to bundle visits and exams more economically, lowering the prices for all.
Continue Medicare. (See Joe NS’s explanation above.) This gives people below a certain level of wealth free medical care of all kinds. It is the safety net if someone without insurance gets a catastrophic illness; they use up their wealth, and then become eligible for Medicare.
Lower taxes by eliminating give-aways to selected industries and unions, so that people can afford more of whatever they want to spend their money on. Price supports for mohair are not needed!
August 10th, 2009 at 12:31 pm
Margo -
I’m not defending the Dems’ bill. I’m saying that the right’s criticism’s should be more constructive than “Here come the death panels.” It’s OK for Sarah Palin to say such things, but not for people who actually think about the subject.
So let’s look at your tweaks.
I don’t understand how shifting the tax deduction makes insurance portable. How would individual insurance be priced? Would pre-existing conditions be excluded? Could companies reject sick people? A rather robust regulatory regime must accompany individual-only access. Otherwise, the socialization already achieved by employer-based plans – which is substantial – would be lost, and people wouldn’t like that when they ran up against it.
Individual purchasing is also very inefficient in terms of marketing costs and consumer skill. The advantage of the employer model is that a professional shopper (a benefits manager) with a stake in not wasting money negotiates a deal with a big piece of business to offer. Where does John Q. public get his negotiating clout? Competition – if it actually develops – will drive price to cost, but with individual marketing, what will cost be like? And if you are dissatisfied, where do you go? And do your pre-existing conditions go with you? I just don’t see how the process plays out satisfactorily. Can you explain how the redundancy and skulduggery of individual marketing can be avoided? (I know – it’s all details, but it’s the details that make insurance viable or not.)
Selling insurance across state lines is an odd issue. Certainly, the big players sell in more than one state, so I’m not really clear on the actual obstacles. I know the states regulate insurance, so I suppose jumping through a particular state’s hurdles may not be worth the trouble for a company intending to compete with an established and entrenched vendor. So national standards and a national license does seem like a good idea. At the end of the day, though, how much of the annual healthcare bill goes to monopoly or oligopoly profits, especially after all taxes thereon have been paid? It’s only that excess profit that competition can suppress.
Repealing (tweaking, actually) the requrements for a health care policy is the same thing a saying that people don’t have to buy insurance at all. So the dominoes need to be reversed. First, you have to decide whether coverage will be mandatory. Where are you on that question? I think it is essential that anyone of a certain age (25?) who can afford insurance buy it as the price of having it be available at a reasonable cost later on. So I can’t get rid of too much in the way of coverages. On the other hand, I have no problem with the mandatory coverage being catastrophic. I like HSA’s, and I think that’s the way to promote price sensitivity. I still like the idea of the employer doing the shopping, though.
I agree with continuing Medicaid (which is what I think you meant to say.) But it does need to be policed better. Lots and lots of fraud there.
The percentage of GDP going to healthcare is not what worries me from a competitiveness standpoint, although maybe it should. What troubles me is that employers have to charge their customers to recoup the cost of what is essentially a convenience they provide by shopping in bulk. I like that convenience, and I think employers should still be the focus of healthcare acquisition. I just think the government should offload the cost from the consumer to the taxpayer, who is for the most part the same guy, who will find that what money he has left doesn’t have to pay so much for American goods.
Another tweak I like is virtual reimportation from Canada. We need to put an export duty on drugs equal to the excess of the selling price in the US over the selling price in the destination (with quantity tests to make sure that stuff is staying where it is shipped). Right now, US consumers are subsidizing Canadian consumers. The Canadians limit what the drugs will cost, and the drug companies go along because the marginal cost of a pill is negiligible, and the money can be made at home. That should stop.
So what about death panels? Where are we on DNRs and living wills that forbid heroic measures and persistent vegetative states. Are they ok for the well-informed or for no one? If the former, wouldn’t we save money and grief by making information easier to get? Divorced from Obamacare, what do we think about health insurers paying for end-of-life counseling sessions with your own docs?
August 10th, 2009 at 1:50 pm
Margo, I think you meant to write “continue Medicaid” in your last comment. No?
I indicated that I once was a card-carrying Medicaid beneficiary. The circumstances are instructive, and I’ll share them with you.
In 1965, I was a sophomore in college in NYC when my wife became pregnant. My total income for that years was approximately $2000, earned busing tables at Nathan’s Finest, not the one in Coney Island but on Central Park Avenue in Yonkers (I think it’s still there). I also had a $1500 student loan, which was, I believe, the maximum possible back then. My tuition was paid for by scholarship, and the physics department at my university gave me a part-time work-study job in the machine shop maintaining the atomic lab’s mass spectrometers, for which I netted maybe another $30 a week. All in, I had access to about $4000, give or take, from year to year, not so much, true, but my rent on a one-bedroom, fifth-floor walk-up was only $87.50 a month (I’ll never forget that peculiar figure so long as I live), and that included heat!
Our daughter was born in the spring of 1966, and, believe it or not, we paid for the whole business ourselves. Anyway, nine months later, my wife was pregnant again. Naturally we expected we’d have to come up with the money on our own a second time. But, unbeknownst to me, at some time between the first birth and the second pregnancy, the Federal government had set up Medicaid.
One day I went to a dentist for a cleaning. The bill was, I don’t know, $15 or so, strictly fee for service. The dentist suggested, as dentists will, that I get a series of x rays. I thought about it and declined, because I didn’t want to spend the money. Well right away, don’t you know, the good doc piped up, like the serpent in Eden, that I wouldn’t have to! There was this new program called Medicaid, he wanted me to know. I did not have to be on welfare to receive coverage. Full-time students were eligible! Pregnancies were covered, doctor and hospital!! And, sonuvagun, he had the paperwork right there in his office!!! So I signed up.
In an amazingly brief time, less than two weeks, as I recall, I had my Medicaid card and my x rays and a few other items the dentist insisted on and an appointment to see him again in six months. Talk about a smooth operator.
It was all smooth sailing, just as he predicted. Our obstetrican, the same doctor who delivered my daughter, was happy to accept Medicaid. The hospital, too, naturally. My son was born in the Fall of 1967, safe and sound, just like before. Everything just like before. . . . Well, maybe not every little thing. For instance, between doctor and hospital, I bought my daughter for less than $800. My son, it seemed, when I got a look at the bills, cost the Federal government and the State of New York $1200. The doctor and the hospital had each charged $200 more for a baby born 18 months after the first one. Do boys cost more? I doubt it. Somehow, I believe, all that tax-payer derived moolah lying around had influenced everybody’s pricing decisions, that’s the most charitable way I can put it.
We left the Medicaid program a few years later, but I was also left with a number of deep suspicions, among them that the government should be kept out of such things as much as possible, as well as a tiny bit of shame that someone else had paid for my son when I could have done it myself. I got over it, believe me, which is why this whole safety-net talk is so insidious and corrupting.
August 10th, 2009 at 1:56 pm
Larry, employment is not the only mechanism for spreading insurance across a group of people, and it’s not necessarily the best. Many people buy life insurance through charitable, religious, professional and fraternal organizations and unions. Health insurance would be no different. Many of these kinds of organizations, by the way, are able to group people in much larger numbers than employers.
Buying insurance for pre-existing conditions is a problem for the buyer. Insurance for risks that have already happened (that is, are no longer risks) is not usually available. That is the incentive people have to buy insurance beforehand, and it is why people who are responsible for their own health insurance and who have financial assets to protect will buy insurance before they have medical problems. In short, this mechanism makes it unnecessary for the government to require and police people about buying insurance.
States currently provide medical coverage for children with congenital problems and adults with chronic problems. That should continue.
About drug costs: Canada is not the only population that buys American drugs at discount prices. Many low-income Americans also do so. This resembles any other discount situation in which a company gives a discount to capture a market not otherwise available. The Canadian drug market is about 10% of the American, so drug companies can afford the discount. The rule you suggest would simply cause the drug companies to stop selling in Canada and stop discounts to poor Americans.
Eliminating profits on drugs would have the same effect that eliminating profits on any enterprise has. It immediately makes innovation too expensive. And why does Canada buy drugs from America anyway? Because American drug companies create drugs that Canadian companies cannot make.
August 10th, 2009 at 2:16 pm
Margo – Life insurance is not health insurance. A life insurance actuary has a far better handle on expected indemnity costs than does the health insurance actuary. As a result, large employer group health insurance is experience-rated. Within certain limits, the employer pays for whatever care is needed. The insurer basically handles the paperwork and absorbs the risk of catastrophic underestimation. The Elks cannot do that, no matter how many of them there are.
Also, an employer group is less likely to feature significant anti-selection. People cannot volunteer to be employed. They have to be hired. That has an impact on underwriting and adverse selection not found in other groups. You may be right that it can be done, but unless you can account for the significant actuarial differences between life and health insurance, you cannot simply assume that what works for life works for health.
The issue on pre-existing conditions relates to the socialization already implicit in our health insurance system. The employer provides the plan, and the employer’s customers pay the freight. So we’re all paying anyway. One way we can lower our cost as consumers is to limit anti-selection in the programs we indirectly finance. The way to limit anti-selection is to not let young people wait until they think they’re vulnerable. The Right complains that the 47 million uninsured number is bogus because a big chunk of them are simply choosing not to buy. If that’s the case, the incentive of not being denied coverage later is obviously not working.
I don’t agree with your logic on Canadian drugs. The rule I suggest would raise the price of drugs to Canada. Do you really think Canada would just walk away from our drugs if there were a tariff on them that made them no more expensive than they are here? I singled out Canada because they are the poster child for the problem. I don’t know what happens in other places, but I’m proposing a rule that would apply to all developed countries.
Nothing in my suggestion implies that discounts could not be offered to poor people or even to poor countries. But why should we subsidize the industrialized West just because remainder pricing works for them and the drug companies?
August 10th, 2009 at 2:52 pm
Larry, “we” are not subsidizing Canada; drug companies are offering discounts in order to capture markets they could not otherwise get. Do you think that the drug companies are doing this from some kind of charitable impulse? They are maximizing profits. Your plan would cut profits to the drug companies. If your goal is for American drug companies to make the max from Canada, you should be in favor of the arrangement.
About spreading costs, my point was not that health insurance and life insurance are the same, but that the same mechanisms for creating groups of the insured would apply. Nothing you’ve said about their differences changes that. The fact you mention, that you have to be employed to be in the employee group, is one of the big drawbacks of health insurance now. People have to change their insurance when they change jobs, and they have to spend a lot of money on insurance if they are between jobs for long, starting up businesses, or just goofing off.
Not covering pre-existing illnesses is exactly the way to eliminate “anti-selection.” Or as I prefer to put it, the way to give people an incentive to buy health insurance while they are young and healthy.
Yes, we are all currently “carrying the freight” for the health care of those who use more of it. But with the changes I am talking about, users of health care would have the knowledge of prices and the incentives to push back on prices, something lacking in our current system, as Joe’s narrative points out. Applying this pressure loally, in specific situations can have an effect on health care costs and health insurance costs, just as it does on car repair and car insurance costs.
August 10th, 2009 at 3:07 pm
Lawrence: I’m learning a lot from your back and forth with Margo, CK, et al, but let’s not forget the premise of this legislation: that by covering 50 million more people and introducing the government as a “competitor” to keep insurance companies “honest,” we, as a nation, are going to save money.
This is crap, full stop. Anyone can see that. Even people (like me, for instance) who are on the very steep learning curve about this legislation and all of its complexities, can see that it is a bad bill, taking the long way around many problems to come up with solutions that maximize government intrusion and to take away choice. It sets up private industry as “exploiters” who only want to rip us all off and the government as the altruistic guardian angel.
I think the polling data is showing that the majority of people don’t think this is the top priority for our national well-being and that this legislation is being rushed and that it does too much to fundamentally change 1/6th of our economy. You may be able to argue with some credibility point-for-point, but you can’t argue the validity of these common sense objections. The government has proven over and over again to be a poor manager of practically everything: why would we want them to be the principle guardians of our health care?
August 10th, 2009 at 3:17 pm
Margo -
The only reason our drug companies can afford to charge Canadians so little is that they can charge us so much. That’s how we subsidize the Canadians in an economic sense. And there is no other sense that matters. Why should Canada’s single-payer system be able to negotiate so effectively? Why don’t we get ourselves a single payers sytem, by gum?
The mechanism for setting up a store to sell tweezers and a store to sell DIY LASIK machines would be precisely the same. You rent a store, hang up a shingle, buy some inventory, and voila. But the products would be different: one would sell and the other wouldn’t. Health insurance cannot be delivered as economically through a voluntary association as through an employer group. The antiselection and contingency charges would be prohibitive. But the mechanism would work fine.
Of course, not covering pre-existing prevents anti-selection. But denying coverage for pre-existing conditions is just more Draconian than we as a society want to be. The Zeitgeist has moved past tough love. The Right needs to get over that.
The amount of time, education, and savvy it takes to make an informed health-insurance decision in the stew-in-you-own-juice world you seem to favor is simply not available outside of Lake Woebegone. The average person is, dare I say it, of average intelligence. The healthcare system has to be designed for him, not for the smartest kid in the class.
August 10th, 2009 at 3:44 pm
I heard Jay Rockefeller on the radio a while ago talking about why it’s important for the government to provide an alternative to the private insurance companies “which exist only to make money.” What does that mean? How is it any more or less true of insurance companies than of any other company? Why wouldn’t the same argument apply to the federal government’s competing-in-or-taking-over any other industry? The terms of the entire discussion are really strange.
August 10th, 2009 at 3:45 pm
I don’t know what’s wrong with a return to a fee-for-service health-care-system. As I understand it employer-provided health insurance originated under conditions of wartime wage controls, an unusual situation.
Health care is an entirely foreseeable expense, as far as I can tell. You make sure you set aside enough money to have regular checkups. You also purchase low-cost insurance against a catastrophic failure of your health, the premiums of which increase as you age. Let’s face it, the days when the elderly were the poorest of the poor are long gone. They are now the wealthiest quintile in the country, with homes paid for, no children, social security frequently on top of one or more pensions, and whatever they have saved. They should be paying a lot more for health care than they are, and that definitely includes the cost of prescriptions.
Let’s face it, right now I am paying through the nose for basically catastrophic insurance coverage. I’m 63 and my wife is 59. My employer deducts $330 a month from my wages for medical and dental. That’s $4000 a year. Premiums have been steadily rising, so let’s say that over the past 10 years that I’ve been with my current employer I’ve paid on average $3000 a year. That’s $30,000. My and my wife’s total medical and dental expenses for the same period have been about $5000, and that’s including a four-day stay in the hospital, for which my 20% came to $1200. Supposing I had not had employer insurance, I would have had to pay another $4800. I do not consider that catastrophic, and my total expenses would have been under $10,000 for the decade. I spent $20,000 more for insurance than I would have spent on actual health expenses if I had just used fee for service. And that’s not including what was my employer’s share of the premiums. What would a catastrophic-care insurance package have cost me? I don’t know, but I’m sure it wouldn’t have been anywhere near $20,000. I’m sure my employer would love to cover it fully and get out from under his end currently.
August 10th, 2009 at 3:50 pm
Barbara – I couldn’t agree more. I’m for a few small tweaks. I just don’t like pretending that a slogan is an argument. (I should say that I’ve pretty much abandoned the idea of a pre-existing condition reinsurance company in favor of mandatory participation at a young age in at least a catastrophic plan.)
August 10th, 2009 at 3:52 pm
Larry, where is the tough love if we are paying for Medicaid for people? There is a safety net. We are simply refusing to pay for people to keep their own assets while they collect ours.
But for someone who doesn’t want to get tough, you are fast off the mark with the idea of requiring people to do things, rather than relying on incentives.
About the drug companies, what they are doing is like what the airlines do when they charge less for some seats on the plane. The people who pay more are guaranteed a seat, the others get the leftovers and are the first to be cut off if there’s a shortage. The result of this strategy is that prices for everyone are less than they would be if the airlines couldn’t sell all the seats.
August 10th, 2009 at 10:14 pm
The tough love to which I referred is the denial of coverage for pre-existing conditions for people who weren’t smart enough to buy insurance when they were healthy. It has nothing to do with Medicaid.
I say people should be required to buy insurance. You say people should not be required to buy insurance, but if they don’t respond to your incentives and they get cancer, they should be required to die. So, yeah, I’d rather require certain people to do certain things than rely on certain incentives already shown not to work. (When you feel the urge to overgeneralize a specific proposal, a little bell should go off in your brain to warn you that you are probably painting with way too broad a brush.)
On the drugs, your airplane analogy doesn’t work. The “full-fare” patent drug buyer gets nothing he wouldn’t happily swap for the chance to pay what Canadians pay. It’s not a market; it’s a monopsony. Canada has a single payer, an ill-favored thing that the drug companies fight tooth and nail to prevent Medicare from becoming.
The drug companies sell to monopsonists because they make more money doing that than if they don’t, and so, yes, those sales lower the cost of drugs here. But they don’t lower them to the level they would be if Canada did not have price controls. And that’s the test of a cross-border subsidy.
The whole matter of international drug pricing is made much murkier by the fact that we actually pay less than our peers for generic drugs, so the overall bills may not be as out of whack as the patent only bills. But they say that quantity has a quality all its own, and I think that paying half as much for patent drugs and twice as much for generics would make more prohibitive drugs affordable than affordable drugs prohibitive.
Substance, not form, is what matters in these economic issues. A distorted market has consequences, even as the actors do their best within it. The Jews fleeing Germany “maximized their profit” by selling whatever they could for whatever they could. But that alone hardly demonstrates a satisfactory economic situation. Likewise, the claim that the drug companies are “giving a discount” and “maximizing their profit” under the monopsonistic circumstances doesn’t refute the claim that something is very wrong and that American shoppers are getting hurt.
August 11th, 2009 at 12:10 am
Larry, the tough love for people with preexisting conditions has everything to do with Medicaid. Medicaid exists to provide medical care for people who do not have resources to provide it for themselves. People who don’t buy insurance, and then get ill, and then use up their resources, qualify for Medicaid. No one is required to die–that’s why we have Medicaid.
It’s not really OK for people to decide not to insure their assets, and then expect to use everyone else’s assets to pay for their medical care.
Equally, it’s not really smart to require people to buy insurance to protect their assets if for instance they don’t think they have assets worth protecting or they think they have plenty of cushion. Why is the government intrusion into everyone’s life worth that?
August 11th, 2009 at 3:53 am
Larry, against about Canada: It is a market for the drug companies in that it is a customer. Its being a monopsony has nothing to do with their calculations. Of course the “full fare” drug buyer would like to pay less, but remember that that person is not buying one tenth of the market in one fell swoop.
However, the full fare is decreased by the fact that the drug companies can wring a little profit from Canada, even though it’s not as much as it would be if Canada paid full dollar. If the drug companies did not believe that they were wringing a litttle profit from the situation, believe me, they wouldn’t do it. And since they are profiting, however little, the overall cost for full fare is being decreased, however little.
August 11th, 2009 at 3:58 am
Margo -
On Canada, I am saying that we are subsidizing Canada, and you are answering pretty much that we have to subsidize Canada, because if we don’t, they’ll stop buying from us and we’ll have to pay even more at home. But that response does not deny that we are subsidizing Canada: it merely says that we have no choice.
You also seem to care whether the drug companies are acting rationally. Of course they’re acting rationally: they are selling in Canada for what they can get there and selling here for what they can get here. Their best play under current US law is to have us subsidize the Canadians.
You are assuming that under my proposal, our drug companies will not be able to sell to Canada, so we’re better off with the way things are. If you’re right that we have no choice but to sell to Canada at the price its single payer is offering now, then you are right that we should continue as things are, i.e., we should continue the subsidy.
But if I am right that if by government action we make it unprofitable for our companies to sell to Canada at the current price, Canada will agree to pay more, then that’s what we should do, because that would reduce or end the subsidy.
So the whole thing turns on whether my proposal would raise the price the Canadians pay or shut down the export business, whether it would be ending the subsidy or tolerating it. I don’t have any problem disagreeing on that score. But the idea that there is no subsidy because we have to put up with the subsidy does not compute.
On Medicaid, you may be right that all we currently require of the jerk who fails to buy insurance when healthy is that he impoverish himself and his family. That’s not too tough, I suppose. Lots of people are poor, right?
August 11th, 2009 at 8:08 am
Larry, we require him to pay for himself as far as he can–either by insurance or not. That’s because we consider him a human being with the capacity to direct his own course in life.
For the same reason, we are modest about confecting legislation for what everyone else in our society should do. We hesitate to send around government agents to check on his expenditures and make sure he is spending what someone else considers the right amount on his health insurance. Or on his electricity either.
August 11th, 2009 at 8:39 am
Margo and Lawrence, in every area of life, insulating a buyer from the true costs of his consumption is never a good thing. That is especially true when it comes to health care, which is why I am so in favor of fee-for-service medicine. Under such a regime, you at some point become aware that “This is what it will cost. Do you want it?” whatever “it” may be. With health care purchases, most of the time, “it” is quite flexible. “It” may include a lot of stuff that is unnecessary, purchased mainly from fear and ignorance. When it comes to preserving their health, people cannot be depended on to behave completely rationally. One of the reasons that single-payer systems always resort to rationing is because the very access to “free” health care drives up demand astronomically.
At my job, I have no choice but to sign up for health insurance. It’s a condition of employment, unless, that is, I can demonstrate that I have equivalent coverage some other way; and m employer gets to decide what “equivalent” means. Nine years ago my wife was in an automobile accident. To recuperate she used the services of a chiropractor, whose services are covered under my plan. So, every other month she sees her chiropractor. For nine years now the statements having been coming like tracer bullets: $135, of which she pays $30. Does she really still need those 15-minute adjustments, as they’re called? I myself doubt it. I don’t tell her that, at least not anymore. It’s a sore subject between us. She says they make her feel better, end of discussion. But it’s also a matter of $800 a year that someone is paying. I’m fairly sure that if she had to pay the whole amount, as she would under fee for service, that she would have stopped seeing him a long time ago, or would see him twice, not six times, a year.
Another for instance, four years ago I had to change a flat tire. In removing the lug nuts, I wrenched my shoulder quite severely. After a day or so the pain subsided, and I thought, well, that’s okay then. But slowly the pain in my arm returned and worsened and became more or less continual. I am a great believer in simply tolerating pain. It has marvelous psychological benefits as long as it’s not incapacitating, so I never went to see a doctor but simply protected the shoulder as much as possible. Human beings evolved with muscle strain being fairly routine, I’d bet, but if you see a physician, the first thing he’s going to do is give you a prescription for pain killers and steroids, which, in my opinion, interfere with the body’s natural healing. The pain in my shoulder, often quite severe, came and went for the next two and one half years and then simply went away.
I have indulged your patience recounting those anecdotes because that’s the sort of thing that medical care actually is: countless idiosyncratic situations demanding countless decisions from millions of people and their doctors, a lot of it quite wasteful and unnecessary, which is what fee for service ideally mitigates. There are no comprehensive systems that can be devised by men to deal with “it,” and that includes paying for “it.” Attempts to do so betray a totalitarian mentality.
In one of your comments, Lawrence, concerning pre-existing conditions, you said that providing coverage for those suffering them was now “part of the Zeitgeist” and that “the Right” must simply “get over it.” I could scarcely believe my eyes reading that. The Zeitgeist! What an obiter dictum and what question-begging baloney, as if a doctrine of Hegelian Idealism may be blithely impersonated as expressing an opinion on a detail of insurance. That we must “get over it” is just another one of those “‘Shut up,’ he explained” arguments that seem so popular these days.
Still, as long as you’ve raised the topic, then I shall reply that the coming Zeitgeist, one even now aborning, is that same totalitarian mentality referenced above. Requiring tens of millions of people to buy insurance is not tweaking the system by any stretch of the word, is in fact a flagrant instance of I-know-best-what’s-best totalitarian tut-tutting. When it comes to it, allowing such people the freedom to go uninsured and still, when the day comes, admitting them to Medicare unmolested and unstigmatized is far more representative of the fabled Zeitgeist of this country than is coercing them into health-insurance collectives. One could call it der Zeitgeist der Freiheit, the spirit of freedom, and not be far wrong. The finger-pointing bean counters can go knit, as far as I’m concerned. I might be wrong, but I suspect most Americans agree with me.
In similar question-begging mode, you asserted that health care was part of our national “infrastructure,” like bridges and highways. Some word or other is being abused here. The number of bridges and highways privately owned and operated in this country is vanishingly small. The remainder are truly public undertakings, which can legitimately be called national, public infrastructure. As for health care, seniors and the indigent notwithstanding, the vast majority of its delivery and financing is privately managed You are not permitted to redefine it as a public responsibility, like the sewer system, if only because, whether it is or isn’t, should or shouldn’t be, is the very issue that is being joined in this debate. By your logic, what is to prevent redefining the apparel business as part of our national, quality-of-life public infrastructure? Food, shelter, and clothing are the traditional trio of human necessities (note, medicine is not on that list). Are all now to be encumbered by the rubric “national public infrastructure”? Of course, in an utterly trivial sense they are, moreover one that would makee the scope of public responsibility unnecessarily enormous. Health care and its financing is not fundamentally different.
August 11th, 2009 at 8:39 am
Margo -
What’s you view on coercively integrating lunch counters?
Joe -
Too much heat, not enough light. Maybe next time.
August 11th, 2009 at 9:28 am
Larry, don’t know if you recall, but there were Jim Crow LAWS in the South. The problem began when lunch counters were coercively segregated.
Thanks, Joe. Just to support what you said: One colleague of mine at work protested the insurance requirement. He was a young man, divorced, with two children, and although he was living in a single-occupancy only room, he was sending his children to Catholic schools. Who is to say that was not the wiser investment?
August 11th, 2009 at 10:03 am
Margo-
Nice evasion. Congress could have simply abrogated segregation laws, but it didn’t. The Civil Rights Act forbids segregated public facilities. Are you for that or against it?
August 11th, 2009 at 10:08 am
Congress didn’t act, but then again, it seems Congress did act.
“Jim Crow” laws and the Civil Rights acts were both matters of government coercion, as are all laws. The Commerce Clause and the 15th Amendment were also in the mix. So it was like fighting fire with fire, which seems sensible enough.
Your own example illustrates that not every law, i.e., not every legal coercion, is equally situated with respect to enforceability, not to mention desirability. Are you implying anything more than that Congress may pass any law that is not un-Constitutional? That is not a groundbreaking insight.
If you are, instead, attempting to draw a more exact parallel to one of your recommendations for health-care reform, namely, the coercing of certain members of the uninsured population into purchasing insurance, then the analogy would seem to fail. What coercion are such people exerting on other people? I mean, what legally cognizable coercion – because what you are proposing is a not a sentiment but a law – not some metaphorical influence. Or perhaps I am missing the thrust of your argument.
August 11th, 2009 at 10:41 am
@Margo – We hesitate to send around government agents to check on his expenditures and make sure he is spending what someone else considers the right amount on his health insurance. Or on his electricity either.
I’m assuming you mean *we* as in conservatives and no *we* as a nation. The electricity bills are being monitored as we speak.
@Larry, re: lunch counters. I’m not sure it was politically feasible to abrogate segregation laws, or that so doing would have made a dime’s worth of difference as opposed to forbidding the segregation of public facilities. Abrogating them is ex post facto and doesn’t apply to future legislation. In any event, this seems to not be a terribly good parallel.
August 11th, 2009 at 10:45 am
Larry, you nailed me! I’m a secret racist! It’s a very good secret, since I live in a mostly-black neighborhood in Chicago, and am on very friendly terms with my by no means upper-class black neighbors.
Nonetheless, I do think that businesses that serve the public are open to kinds of regulations that individuals are not. That includes lunch counters.
So I can only turn the tables, and ask if you are in favor of outlawing skydiving, or snorkeling, or horseback riding, or —
Also, do you think the government should regulate how much profit any company or individual makes on a sale of any kind to any one?
August 11th, 2009 at 10:57 am
Even better question for you, Larry: How about, in the current world of HIV, outlawing homosexual relations between consenting adults? This could yield hunge savings to “society” in general and Medicaid.
See you all, I’m off for beautiful Missouri.
August 11th, 2009 at 11:02 am
Barbara -
I know that merely abrogating Jim Crow wouldn’t have made a dime’s worth of difference. (But section 202 of the CRA does in fact abrogate them, retroactively and prospectively.) That’s why Margo’s appeal to those laws as a relevant fact is so unpersuasive. The problem was not Jim Crow; the problem was the attitude of the White community.
Actually, my reference to the Civil Rights Act was another appeal to my old friend the Prisoner’s Dilemma. Let’s suppose a few visionary lunchcounter operators realize that integrated lunch counters would have more customers than non-integrated ones if, but only if, the Whites have no place else to go. All Congress had to do was require that anyone who wanted to eat out had to eat in an integrated establishment, because that’s all there would be. Before Title II of the Civil Rights Act, a lunchcounter operator could not afford to integrate. But with that law, he could integrate and profit from it, too.
Compare the lunchcounter operator to the insurance company that excludes pre-existing conditions. Contrary to popular opinion, insurance companies are not terribly interested in limiting loss per se. Insurance companies are banks. They take money in as premiums, and they pay it out as claims, making their money by investing the float. The greater the risk, the higher the premium, and the higher the premium, the more the profit.
But insurance companies compete on price, so whereas Insurer A wants its risks to be as high as possible so that its premiums will be, too, it doesn’t want its risks to be higher than anyone else’s. So, if a health insurer wants to get business from healthy people, it must exclude pre-existing conditions, just as a lunchcounter operator who wanted to have White customers had to exclude Black ones. Until the law changed.
“Bring me a risk and let me price it” is the insurance man’s mantra. So, if Congress forces insurance companies to cover pre-existing conditions, the insurance companies will jump for joy, so long as they all have to cover them. But as an old Harry and Louise ad pointed out, such community rating is very expensive because, outside the employment setting where coverage is mandatory, the antiselection problem is severe. As a result, health insurance is unaffordable for many more people than it would be if young, healthy people were required to participate.
And that brings me to the real red herring: the idea that mandatory coverage “forces” people to be insured. It does not. Mandatory coverage is simply a tax on young healthy people who don’t want insurance. Their only obligation is to pay the money. If they don’t want to have anything else to do with the insurance company, that’s up to them.
And better yet, rather than a tax, these early “unnecessary premiums” are really just loans. Health insurance is priced to pre-fund the higher risk of illness at a later age. So, some part of the money a young person pays in premiums becomes part of an intergenerational loan to be repaid later in the form of coverage that’s worth more than it costs. It’s all about money. No one is being forced to do anything. Just as the White diner is free not to eat out ever again if he doen’t want to.
I think Margo’s questions about what I would outlaw are very telling. None of the things she lists (other than the HIV thing) poses a systemic threat to the national well-being . There is no “skydiving system” that involves a significant public subsidy. I have no problem with allowing people to take risks. (But: If at first you don’t succeed, skydiving’s not for you.) My problem is with allowing so many people to take a risk that, when it matures in large numbers, absorbs zillions of dollars. Not buying health insurance is such a risk, as community rating plans with no pre-existingcondition clause prove. Skydiving and the other risky behaviors Margo lists are not systemic importance.
So what about AIDS? As a practical matter, we can’t get into people’s bedrooms, so a prohibition on (unprotected?) homesexual sex would not be practical. But maybe we should allow health insurers, Medicare, and Medicaid to exclude coverage for anyone who turns up HIV-positive and cannot show that he had a bad transfusion. No coercion, just incentives. How’s that Margo? Just a small tweak to your position on pre-existing conditions, as I understand it?
August 11th, 2009 at 12:25 pm
Look, Lawrence: I find the “examples” tit-for-tat tedious. You can look around the world and see to what extent governments intrude in the lifestyle choices of their citizens and their responses. So far, with this healthcare bill, I see the elements of Cuban-style intrusion and control. They don’t care what you’re doing in your bedroom, but if you get AIDS, you are quarantined. A “doctor” visits your dwelling once a month to find out if you’ve missed your last period and who’s sleeping with who. If you are an unmarried minor and you need “menstrual regulation” you go for your abortion, no matter how far along you are, and your baby is induced and left to die, in a way that BO endorses for this country.
This healthcare bill has provisions for all kinds of intrusion as well as funding for abortion as the ultimate in preventative healthcare. And, by the way, smoking is a lifestyle choice uniquely treated in this bill as one that can be penalized at the insurance level (already is at the sales tax level of course, but, to paraphrase Dr. Emanuel, you can’t let a good addiction go to waste.)
August 11th, 2009 at 1:48 pm
Never mind, then.
August 11th, 2009 at 2:27 pm
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