Putting Health Care Policy in Comparative and Philosophical Perspective

The problem with all the replacement talk is that there is no evidence that the GOP pathways will work.

health-costs-money-stethoscopeRoss Douthat notes the following in his NYT column:

the right’s best health care minds believe that markets and competition can deliver lower costs and better care, and they believe it even though there is no clear example of a modern health care system built along the lines that they desire.

The dominant systems in the developed world, whether government-run or single-payer or Obamacare-esque, are generally statist to degrees that conservatives deplore.

[…]

there is no existing system on a national scale that looks like the health care system that Paul Ryan or Tom Price would design, no wisdom of developed-economy experience that proves that such a system would actually keep overall costs low and prevent too many people from being shut out of insurance markets.

(Emphases mine)

This is absolutely the case and, to add some insult to injury, the US spends more per capita on health care than does any other country but still lacks true universal coverage.

Indeed, the utter lack of a model that works the way Republicans claim coupled with a panoply of models that Republicans claim are disastrous, but in reality actually do work (and work well), changed my mind on market-based health care policy proposals many, many years ago.

Now, I will accept that markets, true markets, could reduce health care costs.  Indeed, a true market would deny health care to a person who could not afford it the same way a true market denies an automobile or new iPhone from someone who does not have the ability to pay.

The harsh reality is that the actual goal of health care policy is to provide acceptable levels of health to the general population and all of us view our individual health care access as a means of getting treatment when we are sick or injured (and while one may claim that that should not be the goal, I am certain that one wants precisely that for themselves and their families). And, more significantly, when we face the choice between long-term disability or death versus trying to figure out how to pay for treatment, we will always opt for treatment first and figuring out how to pay later.  This is even more true when we are faced with making choices regarding the well-being of our partners, children, or parents.  Since the cost of health care is not driven by treating the common cold, but rather in treating serious injuries, significant illness, and/or in mitigating the effects of aging, I cannot see, ultimately, a health care system that actually is driven by market forces in a way that actually also provides the services we want the system to provide.  And, moreover, since the market is actually for insurance and not services, we have a bizarre system in place where charges are leveled for individual services, but in a way that do not mean what prices usually mean.  I may get an invoice for a doctor’s visit, which I would have to pay if I did not have insurance, but my insurance company pays a different amount. There is a total disconnect between costs, payments, and the consumer.  Even if we state, correctly, that the real consumer is my employer who provides my insurance, there is still an ultimate disconnect between the person who makes the choice to pursue treatment (me, when my son breaks his leg riding his bike) and those who pay for the treatment (my employer/insurance company).

Simplistic statements about market forces in no way reflects the reality of health care.

I would state that the main problem with Obamacare is that it attempts to maintain the private insurance business alongside a model that provides near-universal coverage. In simple terms (and I am not expert on the internal workings of the ACA) it takes the pre-Obamacare system (which already was dealing with rising costs and an inability to provide universal coverage) and grafted on elements to try and provide broader (and deeper) coverage.  I have no problem accepting that the system as it currently exists is flawed, and may not even be sustainable.  The notion, however, that it can be repealed and easily replaced in a way that improves the overall quality and coverage for the US strikes me as delusional.  If the Trump administration and the Republican Party was serious, they would be taking a slow, deliberate (and, dare I say, conservative) approach to changing the system. * But, alas…

Douthat makes a key philosophical point:

So embracing even the smartest conservative Obamacare alternative requires a not-precisely-Burkean leap of faith.

That is to say: a truly conservative mindset should caution against taking policy plunges into the unknown based solely on hypothetical models.  Indeed, the collective evidence summed from the experience of the past should be weighed heavily when making major decisions.  Ideology should not trump experiential knowledge accumulated over time.  However, contemporary American “conservatives” do not take that approach these days, veering widely between the radical and the reactionary.

Douthat’s column, however, while it raises these issues doesn’t really (in my opinion) take his own assertions to their logical conclusion, and instead becomes a lukewarm endorsement of what strikes me as, at best, a half-measure in terms of a possible ACA replacement.  One may read the column for that discussion if one likes.

*I apologize for any computer/phone damage that may have resulted from spit-takes induced by that sentence.

FILED UNDER: Health, US Politics
Steven L. Taylor
About Steven L. Taylor
Steven L. Taylor is a Professor of Political Science and a College of Arts and Sciences Dean. His main areas of expertise include parties, elections, and the institutional design of democracies. His most recent book is the co-authored A Different Democracy: American Government in a 31-Country Perspective. He earned his Ph.D. from the University of Texas and his BA from the University of California, Irvine. He has been blogging since 2003 (originally at the now defunct Poliblog). Follow Steven on Twitter

Comments

  1. DrDaveT says:

    Now, I will accept that markets, true markets, could reduce health care costs.

    I’m not sure you should even concede that much.

    Let’s turn this around. Would anyone, even Paul Ryan, argue that we should let the free market provide municipal water treatment? Police? Primary education? All of these are things where everyone recognizes that we are all better off in the long run if everyone has roughly equal access to these things, even if we have to subsidize it heavily with tax revenues to make that happen. We call these things “infrastructure”.

    Public health is infrastructure. We have a Public Health Service precisely because we collectively realized this, many decades ago. It took lots of rich people dying of tuberculosis and other infectious diseases for us to get there, but we figured it out eventually. Sort of. Almost. We never quite took the last step, the way we did with free public education and universal police/fire/EMT service.

    The burden of proof should be on anyone arguing against universal subsidized healthcare, to explain why it is less of an infrastructure issue than water or police or education. Particularly that latter one, which sure looks like a luxury if you are sufficiently nearsighted.

  2. Ben Wolf says:

    A functional market would require that health itself (and by definition people) be commoditized; otherwise the market they’ve hypothesized would not be self-adjusting in response to supply/demand. But these are not things that are given to becoming commodities because people don’t like being made equivalent to copper or wheat. Therefore making such a market appear functional would require massive state intervention to force individuals to accept their new role as tradeable goods, the exact opposite of the goal claimed by free-marketeers.

    Even were it possible to commoditize health without such intervention we would still not have a free market. The insurance and drug industries wield far too much power over their respective markets to see the prices they charge disciplined. Insurance is well-entrenched to continue blocking access to health-care providers unless rents are paid. Pharmaceutical companies, thanks to patent protections, monopolize publicly-funded research and can dictate the prices they set. The AMA restricts entry for new doctors to maintain high-incomes (two to five times doctors’ incomes in other developed countries.)

    Free-market “solutions” are more ideological than economic in construction.

  3. Argon says:

    I’ve also come to the conclusion that the ‘unfettered market’, ‘private-supplier’, HSA-driven plans are pure ideology. The difference between theory and fact is that in theory, theory and fact are the same but in fact, that’s often not true.

    Facts,
    1) Healthy people use less healthcare than sick people.
    2) You can’t make coverage affordable for all without having everyone in the same pool at the same time. If you split pools into ‘healthy’ and ‘unhealthy’, you essentially price the unhealthy out of any pool. The unhealthy and the marginally poor will never be able to save enough money in their HSAs to cover their real needs.
    3) You can’t get everyone in the pool if you make it optional. Those who think they’re going to be healthy in the near term are more likely to avoid paying if possible. This raises the cost per person of those remaining in the pool. It’s actually the too low non-compliance penalty of the ACA which its having a huge impact on viability. Unlike in the US, the Swiss set substantial penalties (including paycheck extraction), that are comparable to the actual cost of insurance.
    4) The GOP plan to “incentivize” young and healthy individuals into plans with ‘fantastic service and lower costs’ (i.e. catastrophic coverage only), is a pipe dream. At best, it still splits pools into multiple groups, resulting in unaffordable coverage for much of the population. At worst, the young and healthy are still going to gamble with health coverage as no hospital is every going to be allowed to let non-insured die without service.

    Not that facts matter when it come to religious belief in the power of free markets.

  4. Moosebreath says:

    “Would anyone, even Paul Ryan, argue that we should let the free market provide … Primary education?”

    Unfortunately, yes. See Betsy DeVos, the nominee for Secretary of Education.

    Not that I disagree with your point, but …

  5. Bob@Youngstown says:

    I may get an invoice for a doctor’s visit, ….but my insurance company pays a different amount.

    More exactly ‘ my insurance ALLOWS a different amount, of which my insurance company pays some fraction and I pay the remainder’.
    The point is that there is seemly no connection between the original invoice amount and the allowable.

    There is a total disconnect between costs, payments, and the consumer.

    Further complicating the “costs” discussion is conflation between the actual “cost” of a service and the amount being billed and/or the amount actually being paid. By example, back in 2009 (during the ACA discussions) a hospital administrator in Texas, when pressed for the actual cost of a specific MRI (including the overhead, equipment rental, labor, etc.), allowed that the total cost to the hospital of conducting the test was in the range of 190-200 dollars, but that his hospital charges 1400, and the insurance companies generally “ALLOW” full payment to be 375 to 400. Asked why the difference between 200 and 400, the reply was “to make up the short fall for all those who have no coverage at all.

  6. Bob@Youngstown says:

    @Argon:

    It’s actually the too low non-compliance penalty of the ACA which its having a huge impact on viability.

    AMEN

  7. Pch101 says:

    Free markets ensure that there will be suppliers who are willing to supply a good at a profit.

    Free markets do not ensure that everyone will be able to afford that good.

    Thanks to free markets, there are companies that will willingly build Ferraris and Lamborghinis and Aston Martins for you to drive. But the free market will not put one in every driveway.

    If you need healthcare that is the price of a Ferrari and you can’t afford it, then someone else has to either subsidize it for you or else you will suffer the consequences. Of course, you can fulfill your transportation needs with something that is considerably cheaper than a Ferrari, but you can’t simply reduce your healthcare costs by buying a $5 bottle of ointment when a pacemaker is required.

    That’s the healthcare problem in a nutshell. No Republican is going to be able to use a free market to provide $100 heart transplants or cancer surgery for $59.99.

    If the demand for healthcare functioned as a free market, then we could cure cancer by making it so expensive to treat that nobody would bother to get it because they couldn’t afford it. But of course, that isn’t how it works, but mindless free marketeers aren’t smart enough to figure out something that basic.

  8. michael reynolds says:

    Let’s be clear that if we’re talking significant savings, those savings will have to come from letting old people die. It’s not pediatric exams or mammograms that run up the bills, it’s grandma refusing to die at an economically propitious moment.

    So, simple solution: everyone dies at age, um, let’s see, I’m 62, so let’s say age 80. At age 80 you go to a nice place, like the one in Soylent Green, and you are put to sleep while enjoying Beethoven’s Sixth, just like Edward G. Robinson. If you decide to pull a Logan’s Run, we set a bounty and the armed citizenry hunts you down.

    Overnight Social Security, Medicare, the entire social safety net, would be secure. Plus NRA members would get to shoot people which would make them very happy.

  9. al-Alameda says:

    Douthat makes a key philosophical point:

    So embracing even the smartest conservative Obamacare alternative requires a not-precisely-Burkean leap of faith.

    That is to say: a truly conservative mindset should caution against taking policy plunges into the unknown based solely on hypothetical models. Indeed, the collective evidence summed from the experience of the past should be weighed heavily when making major decisions. Ideology should not trump experiential knowledge accumulated over time. However, contemporary American “conservatives” do not take that approach these days, veering widely between the radical and the reactionary.

    Philosophically, I understand the problem we have now.
    Many years ago America said to itself: We will socialize healthcare for senior citizens only, until then get a good job with a good employer who will hopefully provide adequate health insurance coverage for you, tour spouse and your family. The inference has always been the market will take care of you until you’re 65.

    Other countries, such as Switzerland, have figured out how to provide excellent quality healthcare for nearly 40% less cost on a per-capita basis. Our problems are rooted in ideology and impracticality.

  10. george says:

    @DrDaveT:

    Police?

    I’ve always found it interesting that many conservatives say its not their responsibility to take care of other people’s health, and that independent, self-sufficient people should be able to take care of their own. Fair enough.

    And then they turn around and demand that its society’s responsibility to protect them from other people who might want to do them harm. Shouldn’t independent, self-sufficient people be able to fight off robbers, thieves, fraud artists and the like themselves too? Same for fire fighters – if your house catches fire, you should be able to put it out yourself, especially if you’re a real man (trade mark pending).

    And policing, and fire fighting, are potentially very profitable businesses – lots of room for young, healthy entrepreneurs with good pain tolerance and nothing to lose.

    I like the Canadian philosophy better. Policing and fire have obvious public benefits for everyone. So does fighting disease and health care in general. So both are paid out of the public purse. Arbitrarily saying policing and fire fighting are different is odd.

  11. Ben Wolf says:

    @Pch101:

    Free markets ensure that there will be suppliers who are willing to supply a good at a profit.

    A “free” market would effectively eliminate profits.

  12. Argon says:

    @michael reynolds: “So, simple solution: everyone dies at age, um, let’s see, I’m 62, so let’s say age 80.”

    In the book, “Logan’s Run”, the cut-off date was 21. In the movie, it was 30.

    I guess your palm-flower turned black decades ago.

  13. Pch101 says:

    @Ben Wolf:

    No, a competitive market will eliminate economic profit over the long run. Not all profit is economic profit, and there is a short run in addition to the long run.

  14. Facebones says:

    The problem with a free market health care system is that comparison shopping is impractical if not impossible.

    If a child has a broken leg or a 103 degree fever and needs to get to a hospital, I can’t imagine a parent taking time to do a cost comparison of ambulances and ERs. No, it’s a call to 911 and a trip to the nearest ER.

  15. Scott says:

    @michael reynolds:

    So, simple solution: everyone dies at age, um, let’s see, I’m 62, so let’s say age 80. At age 80 you go to a nice place, like the one in Soylent Green, and you are put to sleep while enjoying Beethoven’s Sixth, just like Edward G. Robinson. If you decide to pull a Logan’s Run, we set a bounty and the armed citizenry hunts you down.

    In Main in the High Castle, the humans that outlived their usefulness, or were otherwise defective, were called “useless Eaters”. In one episode, ash was falling from the skies. It was explained that the incinerators were operated on Tuesdays. I don’t know if the writers were making allusions to Randian “takers”.

  16. Scott says:

    @Facebones: My dream protest would be to be standing in an ER dripping blood and publicly demanding a pricing schedule and proof that my insurance covered everything.

  17. george says:

    @michael reynolds:

    When public health started in Saskatchewan (the first Canadian province that had it), it covered medical bills up to a certain point. Being based on the life experiences of farmers (back when that meant 320 acres of land, a small tractor, and a huge amount of physical labor with the inevitable accidents that come with it), there was a recognition that people eventually died, and the goal was to keep people healthy until the point where death was imminent. Somewhere along the line that changed to trying to keep people alive at all costs, and as you say, that drove up the price of Canadian health care dramatically (though I note Canadian health care is still considerably cheaper on a per capita basis than American health care (about half the cost according to wikipedia), and does as well on serious health issues, though not as well on elective surgery, which has a long waiting list).

    Its wasn’t a question of people turning 80 and showing up to be processed into soylent green, but at saying that if you were 80, had a history of heart disease, were 100 pounds overweight, smoked and showed no interest in exercising, that the government didn’t have the resources to put a million dollars into an operation that, even if successful, would only add another year or two onto your life. If you had good health at 80 then a big operation, which could give many years of life, was still a go.

    I kind of think that makes sense. So do many older people I know up here; the feeling among many is that with kids you pull out the stops, with old people you help make life better, but you don’t spend 85% of the health care budget on people’s last year.

    People have become afraid of dying. That’s going to be expensive for any health care system. And is pointless; everyone is going to die. The goal is to make people’s lives better while they’re alive, not trying to give people immortality.

  18. Gustopher says:

    @Pch101:

    If you need healthcare that is the price of a Ferrari and you can’t afford it, then someone else has to either subsidize it for you or else you will suffer the consequences. Of course, you can fulfill your transportation needs with something that is considerably cheaper than a Ferrari, but you can’t simply reduce your healthcare costs by buying a $5 bottle of ointment when a pacemaker is required.

    No, no, you will definitely reduce your healthcare costs that way.

  19. Ben Wolf says:

    @michael reynolds: Japan has an older population that consumes much more health care per capita than we, and spends half as much. They tightly control their costs and doctors don’t get rich.

  20. Pch101 says:

    @Facebones:

    If a heart surgeon had a menu hanging outside of his office with a $50,000 price for basic surgery, that isn’t going to do you a whole lot of good.

    The basic issue with healthcare everywhere is with exceptionally high labor costs. Countries outside of the US manage this by buying in bulk, while providers in the US have divided-and-conquered the market so that they have more pricing power than their foreign counterparts.

    Price transparency doesn’t play much role in this. We need a two-pronged approach that includes (a) using the government to create a massive buyer pool that gives us buying power of the sort that Costco has when it buys wholesale and (b) an increase in the supply of healthcare, which would include boosting the number of interns who can become the doctors of the future and by creating new pools of providers who are cheaper than doctors and can do a lot of the work such as nurse practitioners and pharmacists.

    We could push the cost of at least some healthcare down while increasing access by making pharmacies the first line of defense. The local drugstore can’t cure cancer, but it should be able to deal with basic maladies and prescribe many drugs on its own without a doctor ever being involved in the process. Instead of waiting days for an appointment at a costly doctor’s office, a pharmacist with supplemental training could serve you almost immediately while you pick up your shampoo and toilet paper

  21. reid says:

    “If the Trump administration and the Republican Party was serious…” That really sums up what is so wrong with our government these days. The answer is that they aren’t serious, of course, and problems won’t be solved by people who aren’t really trying. It’s all about spin, lying, outrage, attacking, and ideology (right or wrong) at the instinctive spinal cord level, not about solutions. Even when the Democrats have tried to implement solutions, like ACA, the glee with which the Republicans tear it all down is savage.

  22. Guarneri says:

    “The problem with all the replacement talk is that there is no evidence that the GOP pathways will work.”

    That’s a fair point. However, we have plenty of evidence that ObamaCare doesn’t work. It’s a sure thing.

  23. gVOR08 says:

    @Pch101:

    Thanks to free markets, there are companies that will willingly build Ferraris and Lamborghinis and Aston Martins for you to drive. But the free market will not put one in every driveway.

    Exactly. GOPs weasel word about everyone having “access”. That’s access as in I have access access to a Ferrari.

  24. David M says:

    @Guarneri:

    However, we have plenty of evidence that ObamaCare doesn’t work

    Some 20 odd million people would disagree, so you’ll need to actually show your work.

  25. MarkedMan says:

    Healthcare is complex and for many of the reasons stated above, it doesn’t move in socially useful directions by simple market forces. Private insurance works well for things like cars and houses, because incidents are usually relatively low cost (comparative to health care) and acute – meaning payouts occur, but then stop. Individual health care insurance doesn’t work all that well because once a person gets sick there’s a significant chance that the insurance company will lose money on that person going forward forever, so there’s a very high incentive to drop them or find some other reason not to cover them. The only way to overcome that is some mechanism that makes it impossible for the companies to get the healthy patients without getting the sick ones too, at the same price, which would distribute the cost of illness across everyone with insurance. (You know, kind of like… insurance.) That’s what the mandate does, similar to the auto insurance mandate that most (all?) states have.

  26. reid says:

    @Guarneri: There’s a difference between “doesn’t work” and “isn’t perfect”. Also, the system “didn’t work” before ACA, either.

  27. Pch101 says:

    @Gustopher:

    Admittedly, a quick death will substantially lower healthcare costs.

    Logan’sRunCare would be the cheapest solution of all. Of course, we could name that after a Republican.

  28. gVOR08 says:

    Not my line of territory, but I believe there is ample, compelling, econ research that says modern health care absolutely cannot work on a free market basis.

    Republicans are pretty much hoist on their own petard here. It is true that Obamacare is based on a Republican plan, the same plan Romney based his successful Massachusetts plan on.* It is also true that Obamacare is working pretty well, contra Guarneri. It could be significantly improved, but what can’t? And it is true that if you remove Obama’s name, the public love all the parts of Obamacare, except the penalty, which is necessary to get the rest of it.

    But Republicans decided to oppose everything Obama did, so they made a huge issue out of Obamacare for no reason except politics. They made out like Obamacare was the worst thing in the world. And being conservatives, to some extent they believed their own BS. So now they have to make good on their promise to repeal, and it’s dawning on them there will be a political price if they don’t have a decent replace. And they’re too dumb to repeal it, relabel it The New Improved Affordable Care Act, and reinstate it. A problem purely of their own making.
    _____
    * Romney got through the ’12 primaries and general running against Obamacare without his fellow Rs seeming to recognize that Romney had done the same thing. Republicans is weird.

  29. J-Dub says:

    @george: It’s always been my understanding that areas with volunteer firefighters are under no obligation to put out a fire at your house and that if you haven’t made any contributions they may just watch it burn to the ground.

  30. J-Dub says:

    @gVOR08:

    modern health care absolutely cannot work on a free market basis.

    Not if you aren’t willing to let people die if they aren’t willing to pony up for the cost of their treatment, either in cash or by insurance. Let’s go to that system and see how quickly we get to universal coverage.

  31. J-Dub says:

    @DrDaveT:

    Would anyone, even Paul Ryan, argue that we should let the free market provide municipal water treatment? Police? Primary education?

    I wouldn’t be so quick to assume that Republicans wouldn’t dare privatize any of those services. There was a time when prisons would be on that list and now many are private, and an unmitigated disaster.

  32. Mikey says:

    @reid:

    There’s a difference between “doesn’t work” and “isn’t perfect”.

    There’s also the ever-shifting Republican definition of “work.”

    And the fact some of the problems with the ACA are caused specifically and directly by Republican sabotage (see: refusal to expand Medicaid, removal of the risk corridors provision).

  33. Liberal Capitalist says:

    @Pch101:

    Logan’sRunCare would be the cheapest solution of all. Of course, we could name that after a Republican.

    Trump Panels

    Plenty of opportunity for Alternative Facts there: “The absolute best care! Terrific! Everyone will be covered!”

    http://www.rootsweb.ancestry.com/~txhopkin/CemPhotos/BrashearCem/T/UnknownNewBurial.jpg

  34. Joe says:

    @Ben Wolf:

    People as commodities means people have finite value. Health care responds to the market as soon as I say “Your surgery is too expensive. I would rather die” and mean it dispassionately. Similarly, “your charge to set my son’s leg is too high. He will just have to hop.” That is not how we – at least we Americans – see ourselves. There’s no market force because we individuals have no leverage in the face of pain and death.

  35. gVOR08 says:

    Off topic, but via Balloon Juice, WAPO reports that the top four officials at State, the whole top level of management, resigned yesterday. These are long service career diplomats, not political appointees.

    This whole experiment in burning things down is not going to turn out well.

  36. David M says:

    @gVOR08:

    resigned/pushed out/fired

  37. Mikey says:

    @gVOR08: @David M: Both CNN and NBC have confirmed they were “asked to resign.”

  38. MarkedMan says:

    @Guarneri:

    However, we have plenty of evidence that ObamaCare doesn’t work. It’s a sure thing.

    I’m not arguing with Guarneri, because there is no point to that. But for the rest, there is a germ of wisdom I what he says. What about if we evaluate Ocare against what it said would happen six years ago? And it turns out that every metric has been met or exceeded. There are fewer uninsured than were predicted. Medical inflation is lower. More employers kept their employees on their plan.

    That last bit is interesting. Remember the doomsaying Republicans who said employers would drop everyone and flood the exchanges? That didn’t happen. But that doesn’t deter them. Since what they predicted didn’t come to pass, they now call that a failure. Yes, Republicans now complain that the original plan predicted millions more on the exchanges, but since that didn’t happen, it’s a failure. You can’t make this stuff up…

  39. Pch101 says:

    @gVOR08:

    There’s a lot wrong with Obamacare. But its worst features are conservative in nature.

    The effort to maintain as much of the employer-based system as possible was a serious mistake. It is this over-reliance on employer-based patient pools that is exactly the problem. They get relatively good deals (at least “good” when measured by absurdly expensive US standards) that are effectively subsidized by everyone else. We would have more pricing leverage if we had one large national pool instead of numerous smaller ones.

    ACA also did not do anything to expand the supply of care. But I don’t see the Republicans offering to address that, either.

  40. Daryl's other brother Darryl says:

    @Guarneri:

    we have plenty of evidence that ObamaCare doesn’t work

    You do not have evidence…you have ideology.
    If you have some credible evidence…let’s see it.

  41. Daryl's other brother Darryl says:

    there is no existing system on a national scale that looks like the health care system that Paul Ryan or Tom Price would design, no wisdom of developed-economy experience that proves that such a system would actually keep overall costs low and prevent too many people from being shut out of insurance markets.

    This is a pointless argument. There is also no existing system, or wisdom from experience, that says trickle-down economics works…yet we have allowed trickle-down economics to decimate our economy for over 30 years.
    It does not matter if something works or doesn’t work…if Republicans can sell it to their rubes, like Guarneri and bill, and Daryl and Paul L.,…and it benefits wealthy white guys…then we will be saddled with it. Consequences be damned.
    Mark my word…we will get one of these non-functioning systems…and the non-functioning part will be blamed on the Democrats. Then, of course, the 4th Estate will parrot that straight from Republican mouths.

  42. george says:

    @J-Dub:

    It’d be interesting to see if they’d go for a private army. There certainly are many historical precedents for that, and it’d fit in very well with their philosophy.

    And it’d be a hugely profitable enterprise, especially with private nukes. “Nice city you have there, shame if anything happened to it.”

  43. george says:

    @J-Dub:

    I was thinking of the Roman general who’d show up at a fire with his fire fighters and negotiate payment before helping put the fire out. I don’t know its true or an urban myth, but if true it probably made for interesting negotiation – timing would have been important. Bargain too long and there’s nothing worth saving, which means no house for owner and no money for fire fighters.

  44. Bob@Youngstown says:

    @J-Dub: It is also my understanding (and actual experience) that volunteer fire departments receive public funding. It may be in the way of equipment, it maybe in the cost of insuring the volunteers, or tax free real estate. I have yet to hear of a volunteer fire dept that is completely devoid of municipal or state support.
    Accompanying that municipal/state support is the expectation that volunteers will take all reasonable steps to protect life and property. When a VFD picks and chooses when and where to fight a fire based on contributions, you can bet the municipality will be looking to dissolve that fire company.

    All that said, I don’t see the application to a ACA replacement plan.

  45. Han says:

    @michael reynolds:

    If you decide to pull a Logan’s Run, we set a bounty and the armed citizenry hunts you down.

    Why on earth would you pay a bounty? You should be charging for the privilege to hunt the Most Dangerous Game. Good God man, there’s profit to be made here!

  46. Daryl's other brother Darryl says:

    @gVOR08:
    @David M:
    @Mikey:
    Presidential appointees always “resign” at the beginning of a new Presidency.
    Then it’s a question of if the resignation is accepted or not.
    Whether the 4 chose to go, or Trump simply accepted their resignations is a moot point.
    The scary thing for the country is that we have a President and a SOS with no foreign policy experience running the State Department minus 4 career administrators.
    Like the rest of the Trump administration….I fear this doesn’t end well.
    Imagine for a moment, a terrorist looking to test the new President. Mr. Trump is making it look pretty inviting. He is fomenting tensions in the Middle East by talking about torture and immigration bans, and stealing their oil. Now he has left our foreign policy arm weakened. He seems to be saying; “Bring it on!!!.” I look forward to the tweet in which he blames the coming calamity on someone, anyone, everyone else.

  47. David M says:

    Regarding Trump and health care policy, he talked to the GOP today and said he considered doing nothing for two years on the ACA so it could implode and hurt the Democrats.

    What a sad little man. He obviously doesn’t know the “Obamacare is imploding” was a lie meant to fool the rubes, and secondly, he’s OK with it imploding and millions of people losing health care if he can then use it to hurt the other political party.

  48. SKI says:

    @Guarneri:

    However, we have plenty of evidence that ObamaCare doesn’t work. It’s a sure thing.

    As someone who works inside the actual system, let me educate you.
    After the first year’s fiasco with respect to buildout of the websites, the issues with our HealthCare system aren’t the fault of the ACA as opposed to the underlying structure, which the ACA made de minimus changes to.

    What the ACA did was (a) set minimal standards for what counts as insurance, (b) created a easier way to allow individuals to compare and purchase insurance, (c) spread the actuarial risk out wider by moving to community rating and must-issue + mandate (which allowed previously uninsurable individuals insurance coverage), (d) provide subsidies to lower and middle income individuals and families to assist in complying with the mandate and (e) institute numerous pilot programs to try to reduce the overall cost of care.

    What it did NOT do: change how health care is delivered (still mostly a FFS model that is heavily weighted towards acute interventions) or change how we pay for care (other than the pilot programs which have actually had a material impact in some areas).

    Has it worked: Mostly. The overall rate of increase in healthcare costs has slowed – despite the boomers ageing into the more expensive years). More people have meaningful coverage. Less medical bankruptcies. Less uncompensated care for hospitals and providers (meaning less need to pass those costs onto commercial rates and public financing).

    Still needs fixing:
    – insanely complicated and variable billing rules that create huge overhead costs for providers – costs that get passed on in rates. Note this also happens on the payor side. Medicare administrative/overhead costs are about 4%. Commercial insurers are around 12%.
    – eliminating the gap in coverage/subsidies caused by GOP states refusing to expand medicaid
    – creating a public option to create competition in those areas where there isn’ta robust individual market

    etc.
    etc.

    Needless to say, there is a lot to fix but all of those things pre-date the ACA.

  49. KM says:

    @george:

    People have become afraid of dying. That’s going to be expensive for any health care system. And is pointless; everyone is going to die. The goal is to make people’s lives better while they’re alive, not trying to give people immortality.

    Correct – heroic measures taken for poor prognosis is a leading cause of medical bankruptcy. Nobody wants Grandma to die but also don’t want to pay the half million for the transplant surgery that buys you weeks at best.

    A client of mine with a terminal cancer diagnosis decided to extend his short time from one month to supposedly 6 by basically having all his intestines and colon removed at an absolutely insane cost. He was under the (mistaken) impression he was going to scarf down a steak and go climb Everest afterwards because he got a “second chance”. We sadly had to inform him he was on the BRAT diet till he died and he was never leaving that bed. He was furious with the reality of it all and kept pushing for more and more aggressive treatment past all good sense. He died two months later and left his family with a million dollar bill they had no way to pay. All for one extra month that was full of pain, stress, denial and misery for all involved.

    Its cold but at some point, society had to be able to say “We’re sorry but we can’t justify spending these resources on you anymore.” We let people drive themselves to ruin and take their families with them. Obamacare was an attempt to stop the financial devastation but it doesn’t really address the cultural aspects of “Live at all costs”. Someone could have saved my client’s family a ton of grief and hard lives by refusing to do the surgery. He could have had a comfortable month surrounded by loved ones but instead chose a painful surgery, recovery and fostered resentment among his family with the knowledge he was ruining their futures to buy himself another day. The system is full of people like him – driving up your costs, taking away resources and generally refusing to accept the inevitable. America totally needs to have a discussion about end of life issues and why its not just “giving up”.

  50. SC_Birdflyte says:

    @Pch101: The temptation to name this solution “Ryan’s Hope” instead of “Logan’s Run” is just too much to resist.

  51. gVOR08 says:

    @KM: Obamacare provided for people having a discussion with their doctor about end of life. The GOPs decided to demagogue this as “death panels”. Republicans are truly evil.

  52. gVOR08 says:

    @SC_Birdflyte: wins. Perfect.

  53. Moosebreath says:

    @george:

    “I was thinking of the Roman general who’d show up at a fire with his fire fighters and negotiate payment before helping put the fire out. I don’t know its true or an urban myth, but if true it probably made for interesting negotiation – timing would have been important. Bargain too long and there’s nothing worth saving, which means no house for owner and no money for fire fighters.”

    You are likely thinking about Crassus. Wikipedia’s entry on him includes. “He notoriously purchased burnt and collapsed buildings. Plutarch wrote that observing how frequent such occurrences were, he bought slaves ‘who were architects and builders.’ When he had over 500 slaves he bought houses which had burnt and the adjacent ‘ones because their owners would let go at a trifling price.’ He bought ‘the largest part of Rome’ in this way.[10] He bought them on the cheap and rebuilt them with slave labour.”

    There was a scene in one of Steven Saylor’s novels where such a negotiation took place, with Crassus negotiating with the neighbor,of the person whose building was on fire to buy the neighbor’s building rather than have the fire spread to it. Crassus lowered his price every minute or so.

  54. Blue Galangal says:

    @Pch101: I humbly offer “RyanCare.”

  55. reid says:

    @Blue Galangal: Maybe “Don’tCare”?

  56. Pch101 says:

    @SC_Birdflyte:

    Congratulations, you have won the interwebs.

  57. grumpy realist says:

    @george: Crassus, IIRC. Notorious for his definition of a “fire sale”

  58. george says:

    @Moosebreath:

    @grumpy realist:

    Thanks, its a story I heard as a kid, and I’ve never known if it was true or not. Have to look him up.

  59. Tlaloc says:

    Now, I will accept that markets, true markets, could reduce health care costs.

    No, they wouldn’t. for a market to operate a customer has to have a variety of options and has to be able to intelligently choose the option that is best for them. Neither of these hold true when it comes to healthcare. Most areas do not have a variety of hospital facilities available. And even in a large city a person is unlikely to have more than 2 or three options and choosing any but the closest may mean death in an emergency.

    Similarly the VAST majority of people do not have enough medical knowledge to be able to intelligently compare costs and benefits of various care options. Unless you are an orthopedic surgeon or work directly with them you very unlikely to be able to rate such surgeons and decide how much more you’d pay to see smith instead of doe.

    Healthcare simply does not work as a commodity to be sold on a market.

  60. DrDaveT says:

    @michael reynolds:

    At age 80 you go to a nice place, like the one in Soylent Green, and you are put to sleep while enjoying Beethoven’s Sixth, just like Edward G. Robinson.

    Formative experiences, part 7 — that movie opened my ears to Beethoven and a love affair that hasn’t ended these many decades later. (The soundtrack to A Clockwork Orange also helped; I was too young to actually see the movie until years later.)

  61. Blue Galangal says:

    @reid: RyanDon’tCare? I mean, I know the grammar’s bad and all, but, hey, they’re confirming DeVos, so they probably won’t even notice.

  62. Hal_10000 says:

    The problem with healthcare reform in this country is that people can’t make up their minds what they want. You can not provide universal coverage of everything for less money. It just doesn’t work that way. Every socialized system out there has to restrict what is covered (e.g., Britain’s NICE agency). And the second Medicare (or similar system) would refuse to cover anything, people would have a fit.

    (As an aside, these socialized systems have seen their healthcare costs rise in similar proportion to ours. The real growth in our expenses was in the 70’s and 80’s).

    As for no country having a functional private system, the top-rated European system in the Netherlands is entirely private. Same with Switzerland.
    Australia has a combined system where you can get a very basic level of guaranteed care but buy into more extensive plans. And multiple systems keep costs down by having patients pay for healthcare out of their own pockets before being reimbursed. So yes, there are markets in healthcare. There are markets in everything.

  63. al-Ameda says:

    @Hal_10000:

    As for no country having a functional private system, the top-rated European system in the Netherlands is entirely private. Same with Switzerland.

    The Swiss legislated a comprehensive national plan that is incorporated into health insurance plan that every citizen may purchase from any insurance company, and profit to insurance companies is limited by law. Also, if a citizen desires to purchase additional or catastrophic coverage they may do so in the private market. The Swiss government does not operate a national health care system, the system is not integrated and socialized from top to bottom.

    It is very rational and sensible, and so it is the kind of system that is unlikely to ever be adopted by America.

  64. Pch101 says:

    @Hal_10000:

    If you can figure out how Costco is able to sell a bottle of hooch for a lower price AND generate more profit than the corner liquor store, then you should be able to figure out why American health care produces less bang for the buck as it fails to serve so many people.

    We could save money and deliver services more efficiently by buying in bulk as does Costco, yet we go out of our way to behave like the higher cost, more inefficient liquor store. I’m not sure what’s worse: the fact that we do go out of our way to operate a system that is so patently stupid, or that so many conservatives are eager to peddle a high-cost, low-efficiency model just because.

  65. Ben Wolf says:

    @Hal_10000:

    So yes, there are markets in healthcare. There are markets in everything.

    1) No, there are not markets in everything. That’s a silly and dogmatic statement and markets are not written into the fabric of the cosmos as physical law.

    2) the Swiss and Netherlands systems are not private; they are public-private hybrid systems and both are struggling to control costs.

    3) Of course markets play a role in some systems. We, however, are discussing the incoherent and contradictory conception of “free” markets. Neither system you reference has anything resembling a free market in health care.

    4) In real dollars health care costs grew at an accelerated pace from 1961 to 2003, after which the trend significantly moderated.

    https://www.google.com/url?q=https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/Downloads/HistoricalNHEPaper.pdf&sa=U&ved=0ahUKEwiT2_ury-LRAhXFQyYKHYlGAcgQFggVMAQ&usg=AFQjCNHop3Rt9GVNJBh1mn2-A2iNXAkETQ4)

  66. JohnMcC says:

    @KM: As a companion view of the ugly ways that death and finances interact let me also give the sad but often-seen situation that occurs in ICUs everywhere. This is the sad creature with sores and contractures that turns up in the ER after being ‘cared for at home’ by descendants who had calculated the size of the estate in comparison to the social security check. Transferred to the ICU because she is tired of life their means of income suddenly looks like it’s over. Their demands to keep gramma around at all costs result in sometimes lengthy rounds of surgeries and procedures that have no effective effect on the outcome.

    Probably there is not an increase in the supply of the world’s cruelty, greed and such but modern civilization has given them great ability to do general harm instead of keeping it confined in family’s lives.