The Problems with Rivlin-Ryan

By James Kwak

Uwe Reinhardt has a post about the Rivlin-Ryan Medicare Plan, which would convert Medicare into a voucher program for people currently under 55 and also fix the growth rate of the value of the vouchers at GDP growth plus one percentage point. The issue Reinhardt focuses on, and which I also blogged about a while back, is that health care costs have been climbing considerably faster than that, so over time the value of the vouchers will fall relative to real health care costs.

But another problem is that, at least according to the CBO’s summary, the Rivlin-Ryan plan doesn’t say anything about how elderly people will buy insurance. Today, the cost of Medicare is reduced by the program’s bargaining power with providers. which means the total amount spent by Medicare is less than the total amount that would be spent by all Medicare beneficiaries if they had to buy insurance on the individual market. A voucher system would push them into the individual market, which means that the amount they would have to spend would go up dramatically.

Now, it’s possible that the Rivlin-Ryan plan takes the Obama health care reform and its reforms to the individual market (including a prohibition on medical underwriting and the creation of exchanges for buying insurance) as a starting point. But that would be interesting, since Paul Ryan voted to repeal the Obama health care reform.

The Rivlin-Ryan proposal leaves the payroll tax unchanged, so it doesn’t change the amount people are forced to spend on health insurance up front. If you don’t like the idea of forced saving, Rivlin-Ryan doesn’t do anything for you.

It does two main things. First, it reduces the dollar value of the benefits people get, which is unequivocally bad for beneficiaries. That is, for every dollar by which it reduces the deficit, it takes one dollar out of someone’s pocket. In this sense, it’s exactly the same as a tax increase – in this case, a tax increase levied on the elderly.

Second, it gives people more choice over how they spend their benefits. It’s theoretically possible that this could compensate for the fact that those benefits are now lower. It’s theoretically possible for two reasons. One is that people can now buy the plan that they want, instead of the one-size-fits-all Medicare plan. But that’s not much of an advantage here, since if you’re sick you’ll want to buy at least what Medicare provides already, and if you’re healthy you can’t buy a really cheap plan and cash in the unused part of your voucher. The other reason is that, theoretically, the operation of the free market could lead to general efficiencies in the system. In practice, however, we’re talking about the market for health insurance, which is already terribly inefficient and, as Reinhardt shows anecdotally, has been completely unable to keep the cost of healthcare in check. So while government provision of services introduces inefficiencies, you have to compare those inefficiencies to the ones in the private sector — you can’t hypothesize a private sector that always produces optimal results.

72 responses to “The Problems with Rivlin-Ryan

  1. Herbert Wetherby

    you can’t hypothesize a private sector that always produces optimal results.

    In actuallity, you can, you just can’t get anyone to believe it.

  2. I posted this on the original blog as well:

    Let’s run some numbers.

    Median Personal (Not Household Income): $30k
    Current Medicare Tax: 1.45%
    Assume real (after-inflation) returns of 2%
    Assume 45 year working period
    Calculate future value.
    You end up with a little over $31k.
    Does anyone think that will enough to pay for all of someone’s post-retirementmedical expense? Or to buy private insurance “vouchers”?

    Now assume a $100k income instead of the median income.
    You end up with $104k.
    A little better, enough to provide care for a retired person for a few years.

    Now assume a $250k income.
    You end up with $261k.
    Now we’re starting to get into the range of what’s needed, assuming NO CATASTROPHIC illness.

    If you assume several million in income (remember, the Medicare tax has no income cap unlike the OASDI component of FICA), you end up with several million at the end of 45 years, which is well in excess of what is needed.

    What the Ryan-Rivlin plan does is the following:

    - Ensures that the lower 50% of the income distribution will have no medical care in retirement
    - Ensures that the next 44.9% of the distribution has varying degrees of medical care in retirement, though probably not adequate levels, and likely less than they have now
    - Ensures that the top 0.1% of the distribution has adequate levels of medical care in retirement, but pays significantly less than they do today.

    Does this sound like a good plan?

  3. kudos to RueTheDay – another Ryan transfer upward to the wealthy.

  4. Alice is a Washington insider, among the better at actually understanding how policy works, but still a denizen of politically-motivated policy discussions. Still, she is showing a certain recklessness with her reputation. Why would someone of her stature willingly link her name with Ryan? It’s as if she decided to marry her own evil twin brother.

  5. I haven’t looked at the recent numbers, but my memory suggests that insurers really aren’t making big profit margins. (now I don’t know how efficient they are at conversion…) But what’s interesting is that no one really looked at the profits on the provider, drug and medical equipment supplier side. GE is in medical devices for a reason…. Not to begrudge their profits, but….

    Some how we still treat medical providers as if they provide a craft, not a service. There are some business models out there that actually work (Cleveland Clinic got a lot of mentions.) But at most hospitals, the duplication and the cost structures are really just stupid.

    Until this side of the medical costs are tackled, we’re not going to get anywhere.

    Eventually, we’ll also have the courage (or need) to start actually having a discussion about rationing. Sorry, but if you are 90 and get cancer, you get hospice. If you are 15 and get cancer, you get the full monte.

  6. Part of the evaluation of any new Medicare plan, in this fiscal and political environment, necessarily involves its approach to cost containment. In a defined benefit program, the large negotiating power of the provider and the ability to simply “define” the payment for each benefit serves to contain costs.

    In a defined contribution system, The provider simply assigns the task of cost containment to the beneficiary in the first instance. Squeezing the beneficiary through slow growth in benefits has the secondary impact of reducing demand for medical attention, which should slow cost growth for a while. Longer term, though, it could simply mean the supply of medical (elderly) care may contract to size itself to reduced demand. That makes assignment of cost containment to individual beneficiaries a somewhat fragile approach to holding down costs. We could simply see elderly care spiral downward, as the medical care sector responds to reduced effective demand through reduced supply instead of by keeping prices down.

  7. We need lower prices. That is the only hope. Japan has $98 MRI scans. Here they cost $1400. Lower prices are the answer. Forget about the monetarists who demand higher prices. Monetarists are bankrupting our country.

  8. The productive people of America (i.e. those who do 100% of the work) create far more than enough wealth that we could all be guaranteed decent health care, which is a human right and one of the basic reasons to have a society in the first place.

    (I’ve asked many times what “America” even is if all its people don’t at least have access to decent affordable health care. No one’s even tried to answer, because everyone knows America is no longer a society, but a Hobbesian free-fire zone.)

    That these infinitely vile parasites keep thinking up new ways to steal what we produce and cut what little bit they were deigning to restore to us, like such a modest program as Medicare (and at the same time seeking to impose a mandate to buy a worthless “insurance” Stamp which won’t pay for care), is a crime beyond comprehension.

    How long are we going to put up with this swine?

  9. “The issue Reinhardt focuses on, … is that health care costs have been climbing considerably faster than that, so over time the value of the vouchers will fall relative to real health care costs.”

    This is only an issue if you actually care about the people receiving the vouchers. I’ve seen no evidence that Paul Ryan would object to seniors dying homeless in the street if it would keep his taxes down.

  10. CBS from the West

    Where do I even begin?

    “and also fix the growth rate of the value of the vouchers at GDP growth plus one percentage point. The issue Reinhardt focuses on, and which I also blogged about a while back, is that health care costs have been climbing considerably faster than that, so over time the value of the vouchers will fall relative to real health care costs.”

    But that, of course, is exactly the point. And apart from the Rivlin-Ryan proposal (which, to be clear, I detest) this *has* to happen under any new health care regime. The rate of growth in real health care costs is simply unsustainable. If we don’t find a way to bring health care spending down below that trajectory, we are simply out and out sunk financially.

    Now, the good news is that there is enormous waste in current health care spending patterns. Everyone who has looked at it seriously acknowledges that a third or more of what we spend on health care does nothing to improve health. (Personally, I would put the figure closer to a half.) So there is plenty of room to bring costs way, way down without actually harming anybody.

    The problem is how to make that happen. If we just impose some spending limit (which is, in effect, what Rivlin-Ryan does), it is unlikely that we will end up with reduction in waste in the system. Instead, we will see the different sectors of insurance/hospitals/doctors (and various specialties therein)/drug companies/equipment manufacturers scrambling to capture as large a slice as they can of the shrinking pie. The division that results will reflect mostly political power/marketing savvy (as does the current division of health care resources) and will lead to an equally wasteful, but downsized, system that harm lots of people.

    We need to stop pretending that anything good can come of a market-based health care system. Health care does not lend itself to the incentives of a market system. Consumers are completely incapable of judging the value of health services offered to them. They are too frightened by the prospect of their own mortality to make rational decisions and they lack the education/training and information resources to make these decisions even if they can put raw fear out of the picture. While one might envision some approach to making better information available to patients, it is hard to see why good information wouldn’t just get drowned out by disinformation promulgated by the health care system itself seeking to profit from ignorance and confusion.

    We need a completely different way of delivering health care that strips out the predatory incentives in place today. Designing such a system will be very difficult at best, and it is hard to imagine our dysfunctional political institutions getting it anywhere near right.

    Nevertheless, in a more ideal situation, one can envision a system in which disinterested but knowledgable people identify the more valuable, the less valuable, and the useless aspects of health care and and set payments accordingly.

    Doing this would entail major adjustments to health care in other ways. Achievement of real cost control will make it impossible for publicly held corporations to reap ever-growing profits from health care (unless they can actually add ever-growing value to health services–which seems unlikely) and will exit the scene. Other institutions will need to be created that will take over their functions as developers and marketers of medicines and equipment. Insurers, who add no value to the health care system and whose practices make the costs of services even more opaque, will need to be extirpated from the system and replaced by a transparent and lean organization that oversees the financing.

    Physician incomes, especially in the surgical specialties, will plummet. While the established senior practitioners can well afford this, it seems unlikely that adequate numbers of younger physicians will seek to replace them when they are getting out of residency training up to their eyeballs in debt. So some better way of financing medical education and training will need to be found.

    Of course, none of the proposals being bandied about today are even in the ballpark of what is required. And I don’t plan to hold my breath waiting for one that is.

  11. Herbert Wetherby

    The better question is, how long CAN you put up with it. Before you strike out on your own and provide the decent affordable health care yourself/ves. And I can answer but you won’t comprehend.

  12. We are now able to provide universal public healthcare. We have a pervasive administrative and medical services infrastructure. A private system may have once made sense. It no longer does.

    We are not fiscally constrained as a nation sovereign in our own currency. Healthcare can be offered as a public service. And as Mr. Wetherby above mentioned, private management does not ensure a good product. If we make it a priority we can fund research, pharmacology, medical education, and healthcare service delivery. Ideology is the only thing that stops us. We can be better than that.

  13. Well written essay, CBS. Agree with most of your points and conclusions. First a disclaimer: I am an MD retired from the surgical side of the aisle.The surgical specialties would indeed take a haircut but are you aware of the kind of incomes most of us are forced to live on? Take Orthopedics.High 6 and 7 figure incomes are the rule out here in the west. The old rich ones will quit if they can afford to. A cut of 50-75% will still be a huge income to survive on. The med students will do the math when it comes time to choose a specialty. If it costs too much to train, the residency programs and Med Schools will just have to take in their belts. You pay to go to med school. You get paid in residency. There is fluff and overcharging throughout the whole system which will not be helped by obamacare using a corporate insurance based model unless the administrators decide to play hardball with all the providers like medicare does. All of the dominant players in the health system will be fighting to keep their privileged status, just like the banks. They(we?) have seen that it has worked for the banks in spades. Why not us?

  14. I forgot to include my major point. The entire obamacare effort and product was a colossal waste of everyone’s time. The obvious solution was staring everyone in the face, Move everyone to Medicare. It is a going concern with all the pieces in place.The premiums are currently $1.45 % of your income with no upper limit, unlike SS funding. Adjust the percentage as necessary for all quartiles of income to balance the budget. It would be a helluva lot less than what obamacare is going to cost which was a gift to the insurance companies and big pharma. Don’t exclude capital gains income and executive bonuses. That way you’ll capture the heavy hitters like the hedge fund boys and the LLoyd Blankfeins. AS a doc I wasn’t thrilled at medicare reimbursement rates compared to the major insurers but with medicare and medicaid at least we got paid something. When folks lost their insurance, in many cases we got nada. WE docs were very annoyed having to be on call sometimes working most of the night taking care of the uninsured and the illegals and getting, NADA. Most of us would stay to play with medicare.

  15. Herbert Wetherby

    I agree, and even more than that, I could have some race horses you might be interested in.

  16. the reason Medicare exists is because the elderly couldn’t buy insurance as insurers can’t afford to provide benefits for them. and nothing has changed in that regard, even with a mandate to buy insurance. because as we get older you are guaranteed to reap what ever problems you have sowed. I.E> if you ever had any habits that impact your body, they will come home to roost. then there are the problems based in your DNA passed on to you by your family. neither of which you can address later in life. and this excludes any sort of accidents etc that may happen in past, today or the future. the body just wears out as we get older. nothing can be done to address that. so the elderly will always have more health care needs than younger people. so the plan to replace medicare with private insurance is dooming the elderly. and will certainly shorten our lives

  17. doubt we have a chance to get/provider our selves affordable care. that appears to not be the plan. the new health care plan is trying to adopt the private health care plan to the whole country. if that fails, the only real option is to put us all in Medicare since the private plans have failed.

  18. Herbert Wetherby

    And I mean really folks, the M2 supply is growing for a reason, and the correlations are also set to repete the history books. I know its tax time again, but do we really want to revisit the good old days of yester year? I’m looking forward to it.

  19. Bayard Waterbury

    We can discuss or not discuss rationing, but, it is a fact, regardless. I am due to start Medicare in April. For the last ten years, I’ve had no medical insurance (or care) at all. I am fortunate not to have any serious illness during that 10 year period, considering my age. So, I have been essentially rationed. It will take me a long time to catch up on my fair share of what is provided. But, I’ve been offset by hundreds of thousands of others, who, during that time have endlessly accessed the system. There was, is, and always will be, rationing. The real question, given that the supply of doctors is insufficient, who will be rationed, how and why? I am a proponent of abrogating the “reform” as unworkable in the long run. I am a proponent of single payer, Medicare for all (essentially Canadian style socialized medicine), because it is far more workable. Or, in the alternative, the Netherlands plan where everyone must be sold insurance at a government determined cost, providers must provide care at government determined fees, and the private market profits are determined by its efficiency of operations. But, by my belief, in every system, there will be rationing.

  20. Bayard Waterbury

    James, the Rivlin-Ryan nexis is the same nexis that collects the massive campaign contributions to continue to flim-flam us into oblivion. It’s the same group who advocates pushing money out of the FED to allow the banks to bid up commodity prices and cause countries like Egypt to tip over. It’s the same group who buys out the regulators so that we get oil spill and credit default swaps. It’s the same group who turns a blind eye while the Pentagon schemes ways to pay criminal contractors hundreds of billions in scam money. It’s the same group who always try to engineer the world’s political environmen to “protect American interests.” It’s the same group of treasonous, wealthy, greedy, amoral globalists who give all of mankind a bad name. It’s the same group described so subtly and so stridently by Thomas Stearns Eliot in his famous poem “The Hollow Men” who will bring on humanity’s extinction.

  21. Bayard Waterbury

    Thank you, Doc!! These are truly rational ideas, not political polemic. And you should know, after all. But then, as Obamacare was being contrived (not conceived, you understand), much of the medical community was opposed to it. Many of those kicked out of the hearings were in the provider community. Anyone not watching this just didn’t understand what kind of fraud was being perpetrated on us, the citizens whom Congress is supposed to serve.

  22. Bayard Waterbury

    Nice piece, CBS, and something especially interesting appears at the end. First, I assume that anyone who wants to become a doctor is motivated. The ten to twelve years of education and training without real earning are quite a “price” to pay to become anything for your career. The big question is, are these people motivated by love of medicine and healing, or by money? I suggest that there is probably a little of each, with the greater weight going to the love of being a care provider and healing people. But, after the rigors of so many years of nearly monk-like existence, something happens when they leave training and have such a huge debt load. Thus, one of the major things which could be done to change that would be for the government to sponsor the training, in exchange for them providing at least the equivalent number of years of service at nominal income and being relieved of all debt in exchange. That means that they would be paid a normal salary (we’ll say the equivalent of today’s $100K) for the next ten to fifteen years, and then they could be freed to earn what they wanted or could get. Think about it. After all, in Cuba, which has great outcomes, doctors are both trained by and paid by the state. All care is provided at a minor nominal cost. Cuba’s health outcomes are far better than ours, including life expectancy.

  23. It is essentially the only relevant area of conflict on prolific federal spending and deficits. SSI can easily be balanced with minor tweaking of benefits and COLAs. Medicare is dead man walking right now. Every industrialized country but ours has pulled it off at a much lower percentage of their GDP than we spend now. First off, I opposed to making poor young people pay for old wealthier people that are hiding their wealth(for instance to get free nursing home service). The whole thing will have to be needs based on some scale. I believe there will be a marriage of SSI and medicare on a needs basis where people with incomes in addition to SSI will pay more medicare premiums than the poor. Yes doctors don’t want the low paying Medicare patients. Doctors in DOD would like to make more too but they are paid a salary independent of the number of procedures, patients, and surgeries they perform. The federal government simply needs to copy their DOD model. People who want more choice can buy their own private insurance. We all know the end result of a voucher system: Poverty, bankruptcy, endless parade of denied claims, litigation, finger pointing and yes death panels run by the insurance companies. Obamacare will never work as advertised. In a free market the doctors, hopitals, medical device makers, would compete on a price and performance basis like a wireless provider. There is no free market in health care and never will be. There is a cartel and they meet every year in Hawaii to take”classes” and set prices.

  24. I’m glad the dark side of the for-profit health insurance business got exposure in the American debate on healthcare reform. It left many Canadians feeling how lucky we are to have universal healthcare. A vocal minority (right-wing politicians, lobbyists and owners of private clinics) in Canada, keeps chipping away at our system, claiming all sorts of wonderful improvements and benefits, if Canada allowed more private healthcare into our system.

    The way I see it, the dysfunction in American healthcare, tells Canadians we need to be very-very careful about allowing privatization into universal healthcare.

    I read somewhere that the Canada Health Act is 16 pages long and that includes both English and French versions. In contrast, the healthcare reform bill signed by President Obama is 2500 pages long. The legislation may have missed the forest for the trees.

  25. Race horses! (lol) I’m missing something here.

  26. In an ideal wold, under a plan like this, people should really get three kinds of vouchers: one kind for basic health-and-life-preserving care (not cosmetics, luxuries, damage caused by substance abuse, hunting accidents etc) maybe with a cap for medicines that only lead to prolonged suffering. A second kind should be for use as a downpayment on extraordinary care (rare, highly expensive medicine, hip replacements for 150 yr olds, sports injuries, substance abuse-induced conditions, etc). A this should be for use when money has run out, to be spent at a yet to be established network of Dignitas clinics…

    But indeed, the problem is the extraodinary average cost of healthcare in the US. There may be some areas of unique excellence and the US may have been the cradle of pharmaceutical innovation (which it is no longer), but consumers of healthcare should be educated on how to consume these offerings. In national health care countries, rules (and indeed those systems’ bargaining power, as they often seem to be run by people who understand that the public as a whole has a budget constraint and that much of the stuff they buy can be made much more cheaply if you shop around). My problem with a NHS-style system in the US is that it will tend to look like Medicare, run by risk-averse people on the side of over-provision.

    So maybe, a voucher system (but then all this hypocricy about life issues should be abandoned -especially in a country where there are over 300 mm firearms in private hands (four times as much as in all of the world’s armed- and police forces)) would maybe more economical than the current program, given available institutional and bureacratic capacity.

    Maybe the Pentagon could work on a voucher system too. Soldiers buying their own kit at Home Depot, for instance.

    Great issue for this blog though. Much better than whingeing about the unfairness of financial regulation and the lack of altruism in bankers.

  27. The Swiss and Dutch models (regarded as the most effective “socialized” systems in the world provide excellent care with the gvt acting only as a regulator of insurers, healthcare providers and products. It works even though in both countries there are supply frictions possibly exploited by vendors (maximum number of new med student positions, barriers to entry for foreigners, etc. And of course there is some risk sharing by consumers.

    But the key is that the gvt monitors prices with an aim to keep subsidies (by itself and employers) as low as possible and treats the supply side responsibly (the supply side tends to disagree). In both cases there is no need for very sick or old people to suffer needlessly while being medicated expensively at communal expense. Instead there is excellent access to palliative care and voluntary termination. And these systems will even allow “pro life” extremists to express themselves as they wish. There is no “terminations tribunal” and doctors can be prosecuted for acting against patients intentions, in case of unauthorized terminations, but not for refusing to terminate.

  28. Apologies, the first para should end with “a third voucher” and then continue with “should be for use…”

  29. Ray, I hope that was sarcasm, because it reads like lunacy of the highest order.

  30. You need to reverse those jumper cables, guy.

  31. I’m chuckling at your comment, but for a goof, humor me. What is it I “won’t comprehend” about what we need to do for ourselves?

  32. Hip replacement surgery wait time: 26 weeks.

    Some system.

  33. Herbert Wetherby

    Education required to reduce the need for hip surgury: 26 years, Some hole.

  34. Herbert Wetherby

    I won’t trouble your mind over it, I can tell in your voice you will not comprehend, and much more.

  35. Herbert Wetherby

    Yes you probably are,___, no sweat off my back.

  36. Fred in Cinci

    @Bayard: You rightly point out two efficient alternatives to the U.S. model of healthcare.

    And not only is there rationing in every healthcare system, I believe there should be more of it, not less. A fact too often overlooked is, according to a study by Dr. Jonathan Bergman of the UCLA, we spend about a third of our overall health care resources in the last year of life. Unfortunately, the U.S. healthcare system takes full advantage of our desire to deny our mortality.

  37. Well considering that obama thinks Ryan is a smart guy, it wouldn’t surprise me if something like incorporating the two plans is the way we are going.
    In fact it would be an excellent deal. Obama keeps his reforms and in exchange ryan and the insurance industry get to finish destroying the power medicare has over the market. Whereby insurance companies get their money back from any lost profits obamacare cost them. And obama gets to claim another great victory ffor his health plan

  38. We are 73 and 66 years old, married couple with comfortable, but not lavish, private sector pension, Medicare, and a private employer provided post-retirement health insurance plan.

    First, a correction to Mr. Reinhardt’s column – no copay is apparently required now for preventive care under Medicare, per recent experience.

    One arrangement that is becoming more common is the so-called “concierge plan.” Some doctors have discovered that they can make a good living and provide better care by seeing fewer patients. They do this by charging an annual fee for basic care, in the Washington DC area, this appears to be $1500 per person, though there are lower and higher fees mentioned.

    We’d like to have a plan, Medicare or not, where we pay that basic fee out of pocket and get some sort of catastrophic coverage beyond that. That would be quite a bit less then we are currently paying for our backup insurance that basically provides us with nothing (in good health, we never reach the deductible).

    Having consumers pay for basic medical tests could also be useful. It’s our experience, that necessary or not, you are sent for every imaginable screening test because that’s the incentive built into the fee for service arrangement. It would mean that individual consumers would have to make some judgment, along with their doctor, about tests they are willing to pay for. But that’s really how it used to be done before medical insurance existed.

    I haven’t seen anywhere any discussion of any plan that talks about arrangements such as the above. Perhaps they would be untenable, but I’d at least like to see someone take a look at it.

    I used to support a single-payer plan, but I’m convinced now that that is not possible in the US – most people are against it, so we have to find a cost-effective alternative.

  39. For the average NORMAL person, it’s almost impossible to stay engaged in the “debate” because of the amount of hard core, irrational malice involved in the motivations of those who “debate” the loudest.

    Briefly, there is a new type of med student, the one who seeks the power to play “god” through pain and suffering. No wonder why some discreet European cultures decided, most a thousand years ago – a thousand years after the fall of the Roman Empire, to practice careful breeding.

    Pushing through all the horror of what lies in the empty space where a soul should be

    is something that cannot be “debated”.

    The DATA, reams and reams of it, that are generated by “health insurance” business models

    is of absolutely no scientific value. It does nothing to advance real science, and much worse, it obfuscates what the real needs and condition of the human species IS at this point in time when there are 7 BILLION stressing the supply of basics and the environmental pollution still taking out more productive resources – water, farm land, solid ground for housing…

    So I totally agree with CBS from the West, we really do not have the data we need.

    I’m not holding my breath waiting for real data to come up for the light of day – FRAUD rules:

    1. complicated business arrangements that seem to serve little practical purpose
    2. changes in auditors, or frequent management disagreement with auditors
    3. financial figures that routinely match targets, particularly if the targets are overly aggressive
    4. unusual balance sheet changes
    5. unusual accounting policies
    6. reversing or changing contingent liability and other reserves to smooth out earnings
    7. frequent changes of estimates for no good reason
    8. frequent “management overrides”
    9. entries that hide a change in earnings or a failure to meet expectations
    10. entries that change a loss into income, or vice versa
    11. changes that affect compensation or compliance with regulatory requirements

  40. Herbert Wetherby

    I’m not holding my breath waiting for real data to come up for the light of day –

    And that is a good thing too, for once that day arrives, most of you shall be SCARED to death (and not by a clown). And no one really wants confront that day, now do we?

    And yes, fraud is wide spread, from the cops on to the board members. Everyone is paid too much for the services they provide. And not nearly crafty enough to avoid the fox hole of war.

  41. Health insurance premiums should be scaled on the basis of percent body fat and instructions for end of life care.

    Fatsos should pay a lot more, and so should sissies who want interminable care after their already disfunctional brains are operating at even lower levels.

  42. ” I used to support a single-payer plan, but I’m convinced now that that is not possible in the US – most people are against it, so we have to find a cost-effective alternative. ”

    Most people don’t even know what it is and think the government should keep its hands off Medicare.

  43. Herbert Wetherby

    I’m certain the Govt would like to keep it hands clean of Medicare, but medicare can’t seem to keep its eyes on the prize. Possibly from the disfunctional brains being operated at many levels, includeding yours.

  44. I doubt that “starve the beast” will work in healthcare any more than in the size of government.

    And let’s hope that Mr. Ryan, if he gets this thing approved, is also right about climate change.

    Cause we are going to need an awful lot of ice floes for senior citizens.

  45. supposedly eskimos used to put their dying elderly and incurable on ice floes. I am surprised that Ryan hasn’t introduced that except that global warming may have put a crimp in the idea.

  46. You say it takes 26 weeks.

    But in the United States if you don’t have the money you don’t get the hip replacement. That means some wait longer than 26 weeks. Some wait forever.

    In Canada you get the procedure. It is paid for by taxation, so the cost of a hip replacement, comes out of the pool of personal and corporate income taxes, you and your family, have paid and will pay, into.

    Legislators in Vermont have decided to adopt universal healthcare for their state. I find this a moment of light in the American debate on healthcare reform. Perhaps, the Vermont legislators will be better than what we have in Canada. This might be achievable depending on the constraints.

  47. Good point, RayW, we do have the infrastructure in place.

    Which makes it all the more obvious how Nihilistic is the “ideology” that “stops us”.

    What moral obligation does one have towards the Nihilist?

  48. What the hell are you talking about HW?.. Yep, there is coruption in Medicare, but it still runs at a 3-5% clip vs. ‘insurance’ bandits 20+..
    Just say it, you’ve got a dog in the ‘insurance’ race-and you’re worried about having to sell 3-4 of your houses..

  49. @RueTheDay,

    an impressive rebuttal

  50. Herbert Wetherby

    Calm yourself whipper snapper! Your youth is straining your system. Us people can hardly keep a car on the street, more less maintain your houses, and pay the taxes too. Did you have to sell or just decide too now?

  51. You stated ‘the operation of the free market COULD lead to general efficiencies in the system’ (my caps). Because we know the operation of the ‘free market’ in, let’s say, mortgages, did not seem to lead to efficiencies.

  52. I believe that’s because we all have extensive real world evidence to the contrary.

  53. It’s not just a belief. It’s a fact. Our resources are limited, and that imposes rationing at some point. When the shrill cry goes up from the pundits about “rationing”, it’s not the fact that there’s rationing that bothers them. It’s the fact that THEY might be rationed for the sake of someone else they don’t like that bothers them.

  54. Exactly. A doctor with the right idea. Thanks!

    I keep telling doctors “We’re ALL subsidizing those that DON’T pay you and the hospital right now. Every time you jack up your rates to compensate, the insurance companies jack up their premiums to compensate, and we patients drop our insurance. Wouldn’t you rather always get paid?”

  55. [citation needed]

    Cite only a metric they aim to beat, don’t cite if they’re successful meeting or beating it. Don’t bother to cite the variations that occur by region, possibly leaving a out a large portion of the time that might be shorter in most places. Don’t try to find out if it’s just statistical outliers that push the average time up. Don’t bother to actually make your argument valid with proof. Just state a single number in a short sound bite as though it were fact, and consider your contribution to the discussion done.

    All arguments against socialized medicine have gone this way, and they’re all garbage.

  56. “We need to stop pretending that anything good can come of a market-based health care system.”

    CBS, that’s it, right there. Anyone who has ever been sick in this country, or who is related to anyone who has been sick in the U.S., and who has a brain left at all, knows this is true. I’ve had health insurance salespeople admit as much to me. But you know, they need to make a buck, and it’s a job.

    Ever known anyone with cancer? Well, this country has metastatic cancer at the center of our healthcare system, but we are too deluded to solve even this relatively simple problem.

  57. The per capita cost of healthcare in Cuba is $200 per year. Of course, if we had a decent system here, it would be much higher than that, because even with the devastated condition of our economy, our cost of living is much higher. Still, according to many very reputable experts we could provide excellent care to every American for half of our current per capita cost
    with Medicare For All.

    BW, I’ll go your government-funded medical training
    proposal one better. We are in desperate need of primary care physicians precisely because the specialties pay SO much more. So just let the government cover the full cost of medical education for primary care docs who agree to stay in primary care for, say, 10 or 15 years. Of course, this would not provide care for everyone, but at least it would rather quickly start to fill the pipeline with the kind of physicians we really need.

  58. DW, you say “the reason Medicare exists is because the elderly couldn’t buy insurance as insurers can’t afford to provide benefits for them.” And you are so right in this point and the rest of your comment.

    Wake up, people! We can’t afford a for-profit healthcare system. It is a cancer, and it is killing US. (That means doctors, patients, insurance execs, drug sales reps, nurses, bankers, politicians, teachers, cops, freelance writers, waitresses, factory workers, actors, plumbers, ETC.) Do you get it now?

    Every single person in this country has been or will be dependent on our corrupt and inadequate healthcare system at some point. It is a disgrace and a disaster. WAKE UP!

  59. @RA: from your comment, since you are clearly no sissie, I assume you have your means of escape readily at hand. Considering that your brain is not operating a level that allows you to correctly spell “dysfunctional,” perhaps you will relieve the world of your presence forthwith.

  60. None. They voluntarily (and with gleeful aggression and violence) cut all bonds with the citizenry and with humanity itself.

  61. Free for all, ’till the music stopped. Another chair is taken away and the music begins again.

  62. I saw a television news clip of a senior Republican legislator, waving a copy of the 2500 page Patient Protection and Affordable Care Act, declaring that government-mandated health insurance is going to take away your freedom (or something to that effect.) I had a moment of total astonishment. I cannot think of any Canadian politician ever suggesting that our singlepayer healthcare system is evil.

  63. Herbert Wetherby

    And they don’t have any yellow submarines in Canada either. If that’s considered Evil.

  64. @ tippygolden press

    My neighbor from Ontario, Canada is going back to his native country next week. The man is in his late 70′s and quite healthy. Both his eyes will need cataract surgery that will be done separately…then he will get an enlarged prostrate (no signs of cancer – fingers crossed) operation shortly after, at absolutely no personal out-of-pocket expense/cost!
    The total time he will be in Ontario, Canada if all goes well…approximately one month!

    America can certainly learn from our Canadian brethren.
    Thanks tippygolden press :-)

  65. It’s the “gleeful” part that takes everyone by surprise –

    normal people are frozen by the “cognitive dissonance”….but the day will come…

    We need to seize back the precision of the English language – the “gleeful” part makes them a true psychotic and their politics/economics is Nihilism…

  66. 26 weeks? That’s nothing. My mother had to wait ten years to get hip replacement surgery here in the U.S. She was self-employed and never had the insurance. So instead she walked around with a cane and was fairly immobile — till her Medicare kicked in and she was finally able to get the procedure.

    We’re got waiting lines all over the place in America. It’s ironic that self-proclaimed ‘realitychecks’ choose to ignore them — but then again, it’s a free country.

  67. @Herbert Wetherby

    If you are super rich you might find the Canadian healthcare system too plebian. It’s not a problem for super rich Canadians. They can just board their private jet and fly to France or the Mayo Clinic.

  68. Herbert Wetherby

    Well thats is great for them, but I have not even been shut down (ill) for some 33 years, and I don’t plan to be either. Mechanicly is another story, and avoiding trouble there entails risk, but since out of the woods, I aint even concerned bout that.

    Now, as for others who are not as fortunate with their behavior, and their needs. Well I’ve seen councilors go bankrupt just talkin about it.

  69. Doesn’t Ryan essentially want to go from a Medicare system to a Medicare Advantage system? If the history of Medicare Advantage is any indication, the Ryan plan would be a colossal failure

  70. I make a joke about morons not knowing that Medicare is a govt. program, and another one comes along self identifies himself.

    You’re obviously in over your head, even in simple arguments.

  71. Seeing as how you can’t make an intelligent argument, and instead need to nit pick spelling, maybe it’s you who should be departing.