What’s Wrong with Our Health Care Debate

Uwe Reinhardt has a post on Economix that zeroes in on Senator Kay Bailey Hutchinson’s criticism of the new mammogram guidelines. Here’s the quote from Hutchinson:

“So this task force says all of a sudden we’re going to change the guidelines that we have had for all these years. And now the public option may not pay for those, and that means the insurance companies are going to follow. The key is that these are covered by insurance so women will not have to decide if they’re going to spend $250 to get a mammogram because they and their doctors believe it is right to do so.”

Basically, the critics of the mammogram guidelines* are bemoaning the fact that certain women may not be able to get mammograms paid for by insurance — without mentioning the fact that many women don’t have insurance to begin with.

Or, to paraphrase Reinhardt: If certain medical procedures are so important to people’s health — shouldn’t everyone get them regardless of income or insurability?

* On which, let me make clear, I have no opinion, nor any qualified basis on which to have an opinion.

By James Kwak

73 thoughts on “What’s Wrong with Our Health Care Debate

  1. Ugly. The one thing that this would quagmire is not, is a “debate.” You watched the Saturday Night Live rerun last night of Barack Obama morphing into The Rock (Incredible Hulk) Obama after listening to the republican senator explain that the only way they would vote for Health Reform was if the democrats would suddenly change their position to being against it. Really, Obama just morphs into James Stewart and throws a gala to showcase his wife’s newest Oscar De’ la Renta creation. And of course, along comes TMZ and turns the national conversation into a reality show, Health care, huh, what?

    This cake has fallen. The accident victim is DOA. There is only one option left. Throw the cake in the dumpster, move the former patient to the morgue. Take up unemployment and Afganistan, Obama. TRY do do something smart and productive or else you are looking at a Huckabee/Palin Administration in a few years. Democrats always regress into a 3 ring circus. At least Republicans are serious, stupid and primitive, but dead serious.

  2. Were this issue not being so politicized, there might be a chance to sit back and analyze the science behind the recommendation being made. Peer reviewed analysis would quickly determine whether this decision was one based on financial or scientific analysis. Unfortunately, too many people work to turn such recommendations into a political debate instead of allowing those with the scientific knowledge to provide comment.

  3. If memory serves, Reinhardt and Bill Frist have collaborated in the past — which raises a question: where is Frist in this debate? I know he’s not in the Senate anymore, but you figure you’d still hear from him.

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  4. You know, underlying all the loud-mouthed rhetoric being thrown about is the fact that health care reform is progressing through Congress. It’s been debated in various committees and on the floor of both the House and the Senate. A bill on reform has passed out of the House and sent on to the Senate. This is how our system is supposed to work.

    The so-called problem with the debate is that we have 24 hour news coverage now, along with multi-channel opinion outlets, which put the debate before a wider audience than ever before. Nowadays, the public sees and hears much of what is going on in Congress and we get the chance to spout our own opinions of it.

    Study your history and you will find that such harsh, rancorous debate has always gone on in this nation, especially where government policy is concerned. The debate used to be covered in newspapers and magazines that reached a limited audience. The whole of the American public can now see it virtually as it happens and can partake in the debate like never before, thanks to 24 hour news channels, talk radio and the internet.

    This, for good or bad, is progress. Every future issue will be covered and debated in this same manner.

  5. Peer reviewed analysis would quickly determine whether this decision was one based on financial or scientific analysis.

    Yes, but then the people in congress claiming this is all a big money making scheme would have to go on the record saying they believe in the validity peer reviewed scientific results. Given many Republicans’ positions on other scientific issues that have come before them, publicly trusting the scientific process may become something of a political liability.

  6. I doubt if Kay Bailey Hutchinson has done any research into the amount of low-income woman who die of breast cancer versus affluent women. My guess is the low-income women don’t donate as much to Senator Hutchinson as insurance companies do.

    Miss Hutchinson can play her little gender card any time she wants, but those of us who don’t fall for Glen Beck style community theatre aren’t going to buy it.

  7. It’s not “what’s wrong with the debate”, which is just focusing on a symptom.

    It’s, what’s wrong with this country, that it is (or was) so rich and is yet so mean, so cruel, so petty, so ugly, that it doesn’t recognize basic health care as a human right the way all civilized, human countries do?

    The question is, why is this place so barbaric? Why are there so many fundamentally rotten hominids here?

  8. It’s interesting to observe which topics/issues Republicans suddenly decide scientific research should have a bearing on.

    Of course if this was a prostate cancer guideline Senator Hutchinson would be scratching her rear eating barbeque with Dick Armey and some Texas teabaggers somewhere with nothing to say.

  9. “At least Republicans are serious, stupid and primitive, but dead serious.”

    Well, being dead serious alone does not cut it! Neither does being stupid and primitive. We need some brains in the administration and Obama has them. Huckabee/Palin would be a step back towards the stone age and I will fight with my vote to oppose that ever happening.

  10. Palin specializes in deceiving people. Fortunately for America Palin only manages to deceive fundamentalists and those who just barely managed to get their high school degree. Here she is twisting facts at a rally in Wisconsin. Make sure to listen carefully and read the ending. http://www.youtube.com/watch?v=q-SIoi8SiiY

  11. Can anyone who has listened to Senators Nelson, Lincoln, Landrieu and Liberman find any sense behind their oppostion to the public option? Why do they oppose the public option? I confess that I have not been able to understand their opposition. Can anyone out there help me out here? Thanks

  12. Stop for a bit and look at the entire medical system from two points of view. What is the already fixed and irretrievable investment in the medical system? The other question is what was the aggregate level of human usage on which the investment is based?

    Huge portions of that total investment is financed by the credit system. Professional educations, medical facilities, medical equipment, research facilities, pharmaceutical and other fixed investment. It is quite obvious that even a nominal reduction in revenue generation of the medical system , as a whole, will imperil the financing of the system. Think of the US medical system as hugely overextended if the contemplated usage of the system expressed as revenues declines even moderately. The debts of the entire medical system are fixed. That leaves only reallocation of exiting total revenues to accommodate servicing different elements that utilize the medical system. Consequently, services available will be required to be rationed. That , or the system is bankrupted to force debt reduction so that revenues may be allocated to cover more people.

    The system can pay the interest and principle on the debt and serve less people if the US winds up living at a lower standard of living.

    It is obvious that much of the capital to service aged baby boomer’s has been anticipated and already invested. The pie, total available revenue inputs, is more and more going to be limited.

    I suspect this is the observation that few expert types want to see gain ground. Robbing Peter to pay Paul is already a fact of life in much of the medical system.

    The system is not rich enough to cover the very aged as we do now yet we already have the physical and professional capacity in place. Just look at the waiting rooms and hospital patients. Very heavily geezers like me. Yet without servicing these aged users of the system revenues collapse and bankruptcy ensues. The non insured still use the system and are tending to bring the existing system to it’s financial knees . The non insured are not insured because they cannot afford the cost. They get services by showing up in the emergency room or being covered by Medicaid.

    What a mess. Will the credit system here too be forced into haircut?

  13. Joe Lieberman is a U.S. Senator of Connecticut. I took this passage verbatim from the link at the end of this post:

    “Connecticut has the highest U.S. concentration of insurance jobs, with the industry accounting for about 64,000 jobs as of June 2009, according to the state’s labor department. That’s down 23 percent from the 83,000 jobs in 1990, although the state projects a slow growth of 4 percent through 2014. The state is home to 72 insurance headquarters, with three times the U.S. average of insurance jobs as a percent of total state employment. The state’s unemployment rate currently stands at 8.6 percent.”


  14. There remain a little over 3 years before the Inauguration of the next President. To start getting anxious over who that might be seems a huge sign of nervousness with the current President. Obama has had his way on a lot of significant issues already in his Presidency, and I anticipate he’ll get a lot more of what he wants over the next 24 months. 2012 is a long way off, but even this early it seems to be shaping up that Obama will be re-nominated and have a clear record to run on. Why worry about Palin or Huckabee – or any other Republican – now?

  15. My newly found opposition to the public option has to do purely with the pricing market we have created for healthcare. Insurers and hospitals negotiate prices, the largest insurers get the lowest prices, the smaller insurers in a market get higher prices. This creates fewer choices–being 5th or 6th in a local/regional market isn’t profitable so those companies leave.

    All the public option will do is create a largest market share entity is every market that will be able to negotiate the lowest prices. This option will surely best the others, and sooner or later it will be the only option.

    Instead we need to get at the heart of the problem, the price negotiation structure needs to change, to add more competition between medical providers.


  16. I think the root of opposition to the public option is that availability
    of high quality medical care might suffer, for people who have excellent
    coverage under today’s system. This might be of special concern to those
    with relatively rare chronic health problems in rural areas, who might
    find their access to regular treatments becoming more difficult, even
    though they would be free. Universal coverage is intended both to serve
    everyone and to reduce aggregate costs, so the fear would be over losing
    one’s existing benefits due to the tyranny of the beancounters. Unlike
    the author I believe this question is an important factor in the debate
    over healthcare reform.

    Does anyone have a comparison of the rate of consumption of offshore
    medical services (e.g. India, Thailand, Mexico, etc) between residents
    of countries with different healthcare systems?

  17. The task force concluded that one cancer death is prevented for every 1904 women age 40 – 49 who are screened for 10 years; vs. one prevented cancer death for every 1339 screened between ages 50-59 and one cancer death prevented for every 377 women screened between age 60-69. That is the ‘science’ of screening.
    Whether one life is worth saving per how many are screen isn’t a scientific question but a political question. Maybe we should try to save 1 life in 1339 or conversely maybe we shouldn’t try to save even 1 life in 377.

  18. I thought Senator Grassley of Iowa had solved the health care problem months ago. Obviously Grassley is a visionary thinker who can think “outside the box”. We can all get the same health care Grassley and other Senators have had for years. Just follow his advice in this town hall meeting.

  19. You think “peer reviewed science” would make this a debate? Guess you’ve never heard of the climate change “debate” then…

    Private emails with natural human snarkiness is considered as greater evidence than decades of public, peer review science…

    The U.S. is screwed. It has lost the capacity to act as a nation, unless it involves dropping bombs on brown people.

  20. What is wrong with the Health Insurance debate?

    What is wrong with the Health Insurance debate is the wrong issues are being debated. There is no mention anywhere about the employer tax deduction for employee insurance. The employer tax deduction for employee insurance is the single largest tax deduction eclipsing even the tax deduction for home mortgage interest. The reason we have high cost health insurance is that the individual person is not in control of their health insurance dollars. If each person purchased their own health insurance there would be competition among the health insurance companies. At this time there is no competition. Reducing this employer subsidy by 20% each year would eliminate this subsidy in five years and give both employers and employees adequate time to re-negotiate salaries. Employers would be expected to increase salaries by the same amount they are currently paying for each employee’s health insurance.

  21. This really and clearly demonstrates the completely out of kilter “debate” on health insurance, and health care in general. Let’s be clear, America rations health care more than any country worldwide. So, we can disregard all rationing arguments out of hand, especially considering how we generally match up against the world in outcomes. We are, in some ways, as discriminatory as a third world nation.

    We, of course have the resources, in every way, to be the best, but the incentives all support the outcomes that we have. It is a sad statement of the amount of control those with the big bucks (health care oligarchs, from insurers to care conglomerates) have in the system, and in the so called debate. All one has to do is read the comparison in Wikipedia between the Canadian system and ours to understand the problem, but also to look at the Western European programs. We could do this thing, if Congress hadn’t been bought off so effectively.

    Once again, when it comes to controlling the negative effects of the money and power conspiracy, until there is massive election finance reform, nothing meaningful will happen, and many thousands of Americans will continue to die needlessly.

  22. If you look at the “summary of recommendations,” they not only do not recommend mammograms, they also do not see any benefit for women to routinely perform breast self-exams.

    Given these recommendations, not sure how a pre-menopausal women would discover she has breast cancer until it’s too late to treat it. So then why bother with chemo/radiation/surgery at that point?

    That’s another way to cut down on costs. Just acknowledge you’re dead if you discover a cancerous lump.

    Here’s the URL for the committee’s recommendations:


  23. “At least Republicans are serious, stupid and primitive, but dead serious.”

    Dead serious, yes, about running up the deficit, starting wars they don’t want to fund, preventing any serious debate about health insurance reform, bailing out banks in ways that make it impossible to provide funding for job creation later….

  24. If these proposed changes went into effect, how would a woman under 50 learn she had cancer in time to treat it at all?

  25. We also have to consider how many cancers are *caused* by mammography. Yes, friends, X-rays cause cancer, just like other radiation.

  26. In Denmark we see the issue as follows: a sick woman can not work -> no income -> does not pay income tax -> do not contribute to the stability of the state finances. Therefore we are routinely (every three years from the day we turn 25) called in to have a mammogram and a pelvic exam (to check for endometrial cancer) – both types of cancer are highly treatable when caught early. These checks are free and voluntary, and are in recognition of the fact that dead and sick women/mothers are a much bigger problem, economic and social, than the states expenses on this model.

    I’m aware that You have a totally different healthcare system in the States, but I still feel that a healthy woman contributes much more to the world and the state, than a dead one.

  27. Because then we’d have to actually discuss the issues and the course chosen by the current administration and not just threaten the public with how awful the other guy will be.

    As this sort of distracting Hitler sign waving tactic is exactly what partisan Democrats have been objecting to since last summer, you’d think they’d refrain.

  28. The House Republicans, with a few liberal House Dems, were the political block to vote against the TARP. I’m afraid that this fantasy distintion people seem to want to retain between the two major political parties no longer holds.

  29. “What a mess. Will the credit system here too be forced into haircut?”

    Not before first attempting to do what they did in the housing bubble: handing the bill to people who can’t afford it.

    The median income workers that the government will force to purchase insurance (to protect assets they don’t have) in more or less the current “healthcare” financing market, are the same people who could not support the bloated housing market.

    I don’t understand why we allow ourselves to be talked into permitting the kleptocracy to keep making the same costly mistakes at our expense.

  30. For my white knight, Ted K:


    “U.S. Cancer Screening Trial Shows No Early Mortality Benefit from Annual Prostate Cancer Screening.”

    “The U.S. Preventive Services Task Force, whose recommendations are considered the gold standard for clinical preventive services, recently concluded that there is insufficient evidence to assess the balance of benefits and harms of prostate cancer screening in men younger than age 75 and recommended against prostate cancer screening in men age 75 and older.”

    This is the same U.S.PReventive Services Task Force who made the mammo recommendation.

  31. This is a subject that for some reason I don’t find myself being as sensitive about the topic as most people. Under the current system those who have the money and want to do the tests can do it. Under the next system more low income people could have the test done. Those things will be adjusted in time if it’s found it’s worthy.

    What people like Senator Hutchinson are afraid of is that we’re going to have a better system and cheaper system over time, just like the Canadians have NOW, and Hutchinson and her Republican colleagues will end up looking like jackasses for protecting the insurance industry. She should be afraid, that scenario is highly plausible.

  32. “The absolute benefit is smaller[in women age 40-49] because the incidence of breast cancer is lower among women in their 40s than it is among older women.” No duh?

    Breast cancers appearing in women in this age group tend to be more agressive than cancers appearing in older women which may account for the smaller absolute benefit. Younger women tend to die of the disease more often than older women.

    As someone who experienced a 1 in 20,000 medical event, 1 in 1904 looks like a sure bet.

  33. It’s worth noting, that SELF-EXAMINATION FOR BREAST CANCER IS FREE, and no task force or committee can stop a woman from doing that.

  34. In 1990, Congress passed the Breast and Cervical Cancer Mortality Prevention Act to guide Centers for Disease Control in creating the National Breast and Cervical Cancer Early Detection Program. Currently, the program funds all 50 states, the District of Columbia, 5 U.S. territories, and 12 American Indian/Alaska Native tribal areas. “The program helps low-income, uninsured, and underinsured women gain access to breast and cervical cancer screening and diagnostic services”, including mammograms and PAP smears.
    THe program is evidence of our government’s agreement that “certain medical procedures are so important to people’s health everyone get them regardless of income or insurability.

    If I recall correctly, this bill had broad bi-partisan sponsorship and support and was signed by G.H.W Bush.

  35. Personally, I think about 50% of the issue is that 95% of the US doesn’t understand probability and statistics.

    The other 50% of the issues that most people think that people who disagree with them are idiots, rather then just having a different opinion. (Only some people really are idiots – but that is probably in the low single digits – there’s no cure for stupid)

    The problem is the 1st 50% of the problem prevents just about everybody from seeing the true problem, and the last 50% of the problem just doubles down.

    Anyway… back to my tea (no pun intended).

  36. @anne

    I will resist the temptation to do a lengthy analysis of the Task Force’s recommendations–that doesn’t belong on this blog. I do encourage you, however, to go beyond the summary and read the full text. I think you will see that you, as many other people, have misunderstood them.

    The Task Force does not say that women should not examine their own breasts. What they have said is that strong scientific evidence has shown that *counseling and training* women to do so leads to a huge increase in breast biopsies but does not even make a small dent in breast cancer mortality. In fact, this has been a settled issue in the scientific community for a very long time. In this regard, the Task Force is playing catch-up ball.

    The matter of women between ages 40 and 49 is more subtle. If you examine the data carefully enough, you can demonstrate a very tiny reduction in breast cancer mortality when you do mammograms in this age range. Unfortunately, to get that benefit, you have to put a lot of women through a lot of testing, including biopsies of ultimately benign lesions, inflicting on many of them the enormous distress of believing (temporarily) they have breast cancer when they don’t, and inflict on some poorly-quantified number of women the substantial harms of treatment for something that appears in all respects to be breast cancer but, in fact, would never have harmed them if left alone.

    So the Task Force, in my view appropriately, felt that doing this *as a matter of routine* is inappropriate. The full recommendation says that women 40-49 should discuss with their doctors this trade-off of harms and benefits and come to a decision that comports with their own risk preferences.

    So, to respond to your questions about what is a woman to do to detect pre-menopausal breast cancer: the answer is that we just don’t have good options for this. Mammography and teaching breast self-examination, when examined carefully, are seen to be wishful thinking. The latter doesn’t save lives at all, and the former may do more harm than good. _Pre-menopausal_ breast cancer is a bad disease: mammography is not very effective at detecting it early, and even when detected early the outcome is often poor. (Post-menopausal breast cancer is an entirely different story.)

    Promoting breast self-examination and routine mammography among women under age 50 are great for the balance sheets of doctors, hospitals, and insurance companies, but not for women.

  37. Everyone definitely deserves healthcare but just like everything else shouldn’t people have to pay something for it.

  38. As far as I can tell, the difference between D and R is how much religion you want with your fascism.

  39. I might add that its because republicans don’t especially value peer- reviewed science in general.

  40. CBS from the west –

    Thank you for your thoughtful reply.

    I did not phrase my own post correctly, but I agree that that committee says that mammograms and BSEs for women under 50 as a matter of routine is inappropriate.

    As a “high-risk” woman, whose mother died at 41 from breast cancer, I read this and wonder if all young women who discover a cancerous lump in their breast are simply SOL. I still find it hard to grasp that these tests, held up for years as a means to catch cancer early enough to hope for survival, are now “inappropriate” as a matter of routine.

    I’ve long realized that “pre-menopausal breast cancer is a bad disease.” I just didn’t realize that it was a hopeless disease as well, with no reliable way to catch cancer early enough to hope for a cure.

  41. The problem with the current Health Care debate is that the proposed legislation is not intended to improve health care.

    This is not “Universal Health Care”. This is government mandated insurance. I’m tired of people discussing the merits of the UK or Canada system as if the proposed bill is like those systems. It is most certainly not. It simply makes everyone buy a policy.

    I think the Gov option is simply a new way of taxing people without calling it a tax. The government doesn’t have to operate as a real insurer – and thus can set premiums/payouts as it sees fit. In this way I see it more as a money/power grab than a true public service.

  42. Hopeless is, I think, too strong a word–some women with pre-menopausal breast cancer do well. And newer treatments appear to be somewhat more effective than those that were available before.

    But I think it is quite fair, however, to say that mammography has been greatly oversold. Originally this was due to sincere belief in the then untested theory that early detection would save many lives. Later, as evidence to the contrary accumulated, the overselling persisted because segments of the health care industry made a lot of money from the mammograms themselves and the subsequent procedures they generated.

    The lesson that I hope will be drawn in the health care industry and at the National Cancer Institute is that we need to stop letting our partial successes with post-menopausal breast cancer obscure the remaining, intractable difficulties presented by pre-menopausal disease. We need to put some serious research into altogether different approaches to early detection (probably not based on imaging) or truly novel treatments of pre-menopausal breast cancer, and not just blindly apply to younger women what works for the very different disease that is seen after menopause.

  43. “Hopeless is, I think, too strong a word–some women with pre-menopausal breast cancer do well. And newer treatments appear to be somewhat more effective than those that were available before.”

    Again, if mammograms and BSEs are not done routinely, which could result from these new recommendations, how will young women discover a tumor in time to treat it? That’s what leaves me feeling rather hopeless about this topic.

  44. You are correct in that it is mandated insurance.

    I do not believe that it is a tax, since a majority of people will instead pay for private insurance (which isn’t insurance per se), much (if not most) of which is for profit. It is redistribution of wealth once again, from the middle class to insurance oligarchs.

    Something must be done to change the incentive of profiteering health “insurers” from benefiting from denying coverage to providing it. This is best done by oulawing profit – only non- profits can compete. But this might not be possible here in the US of A, so cap profits (as a % of premiums) instead. By capping profits, it should give payers incentive to provide the best coverage because the only way they can make more money is to enroll more people and *bingo* the free market works for the consumer.

    Then the problem with medical costs can be addressed.

    I still think that single payer is the best option, especially if funded (at least in part) by sales tax.

  45. “All the public option will do is create a largest market share entity is every market that will be able to negotiate the lowest prices.”

    But the version of the public option that is in the bill the Senate is debating is very restricted in accesibility. And the CBO says it will end up only covering 3-4 million people. Not only is that not a largest market share entity, it isn’t even large enough to exert a meaningful impact on prices at all. It may find itself like the small private insurers that flee the market, except that it will be captive!

    It amazes me that we are having a “debate” over a health care “reform” bill that reforms nothing and just forces people to buy into a thoroughly dysfunctional, and exorbitantly expensive system.

  46. Yessir. This also brings up another bubble, the debt fueled higher-education bubble.

    Personally, I am OK with paying lots of money to well- educated doctors. They should be well compensated (even GP’s and Pediatricians, which apparently are not, relatively speaking).

    The problem is that our health care $$ goes to drugs and payers disproportionate to the benefit of receiving care.
    if that makes any sense…

  47. A vigorous debate is needed. Instead, we get “debate” based on choices that are already decided for us by an essentially bought-and-paid-for congress.

    I use the same tactic with my children: do you want songs or books before bed. Presented as an either-or rather than an open debate to frame the problem and solve it. I am so sick (excuse the expression) of being treated like a child by my “representative government”!

  48. You are entitled to your opinion, but that doesn’t make it factual.

    Limiting profits is superficial – it does not address the problem. Profits drive businesses, even governments. “Profits” are not the problem.

    How many people total would end up in the government option? 10%? 50%? If it were only 5%, then why even have it? No one in Washington is going to risk the political clout for a plan that will only cover 5%. I submit that over time the government option would become more and more the plan of choice – hence, its an additional tax.

    For example, lets say 30% (a conservative number) of of the population go to the gov option – that is 100 million people giving the government an extra $300 a month on average…30 billion dollars a month in new cash flow to the government. If 70-80% go …

    That is why it is a tax, it is not about improving health care but $ and control.

  49. Agreed.

    Also, Health Care != Health Insurance.

    Listen carefully to the debate – the talking points are over high-level concepts that are easy to garner support.

    The beauty of framing the discussion that way is that people can take the concept and believe that it will be implemented in the way that they, personally, desire.

    Concepts like “Universal Coverage”. Numerous times we have heard politicians say “I want everyone to be covered” or “This bill provides a way to cover everyone” …. OK — but they don’t say this is achieved by legislating mandatory coverage, and failure results in an income tax penalty. That reality is lost on most people who believe that the government option will be ‘free’ … it will be a slap to the face when they realize instead of ‘free’ insurance they have to go buy it from someone for $100-400 a month.

  50. I see that realization as a tipping point. I think that the average American will get mad enough to actually do something (beyond yell at their TV) when they realize that their mandated health insurance is paying for the bigwigs at Aetna’s next yacht.

  51. Keith, I see your point. It would be a tax to the 30%, however for the remaining people it would not be since the money would go to private coffers – technically not a tax. I also think that the number of employers that would shed health insurance benefits would be astonishing, if given the opportunity.

    I think the politicians will pass a public option, one that is so small that it can be ignored and restricted so that it would remain forever irrelevant. That way they can claim that they did it (and voted against it – both R’s and D’s would benefit equally).

    Politically, even though I personally support single payer, I think that it (single payer) will never happen here (people are so afraid of socialism that they ignore blatant fascism). But mandating that (e.g.) 95% of all premiums collected go to pay for actual care might change the incentive structure to benefit the consumer, allowing for better care and actual competition based on coverage and price. This would be IMO more of a free market system than currently exists, so it should get some support from the middle-right. This shouldn’t be the end game, as other problems with the system need to be worked out, but just changing the incentive structure would be a radical improvement.

    Unless I’m mistaken, this is how life insurance works – something close to 99% of the premiums get paid out and the issuers profit by investing premiums in the meantime.

    But if I were king, I would decree single payer and levy a sales tax to fund it. Its the only way that makes any sense to me. But I’m not king, so I’m tilting at windmills for any possible solution that will offer improvement over the status quo in the hope that something -anything!- positive might happen.

  52. I live in Canada where we have universal health care funded by taxation. A mentor once told me it is our civic duty to pay taxes. It’s an interesting state of mind.

  53. Ok. So we disagree on the outcome of the public option. Your position is that if a public option is passed, it will irrelevant. Mine is that it becomes the largest used option in the country.

    On what metrics do you base your opinion of a single payer system? Why is a single payer the right solution? If so, would that be the right solution for car insurance? Home owners insurance? Why stop at health insurance?

    What % of the population smokes? What % drinks? There are taxes on the consumption of those goods that not all people pay, and they are very much a tax.

    I tend to think that with anything the lack of competition breeds inefficiency, and a single payer system would ultimately become bloated and not sustainable…like many of our other gov run programs.

    Personally, I think the power has to be given back to the consumer. I think heath insurance should ONLY cover catastrophic illness or chronic conditions and that HSA type methods should be used for general care. Only by giving the consumer back the purchasing power will we see competitive price reductions.

    On a side note, part of the problem, and something I find very strange, is that people will go pay $1000 for a new TV and $200 a month for cable+internet+cellphone but then turn around and balk at paying $100 a month for medicine to keep them alive. Or $150 for a visit to the Dr when sick … they want it covered, for ‘free’ …

  54. What is wrong with the Health Insurance debate?

    What is wrong with the Health Insurance debate is the wrong issues are being debated. There is no mention anywhere about the employer tax deduction for employee insurance. The employer tax deduction for employee insurance is the single largest tax deduction eclipsing even the tax deduction for home mortgage interest. The reason we have high cost health insurance is that the individual person is not in control of their health insurance dollars. If each person purchased their own health insurance there would be competition among the health insurance companies. At this time there is no competition. Reducing this employer subsidy by 20% each year would eliminate this subsidy in five years and give both employers and employees adequate time to re-negotiate salaries. Employers would be expected to increase salaries by the same amount they are currently paying for each employee’s health insurance.

    We don’t need single-payer. We don’t need a government option. What we need is competition. The main reason health insurance costs so much is that there is no competition. Eliminating the employer tax deduction for employee health insurance is the right way to move forward.

  55. The only thing hopeless here is the debate. You being a high risk woman should still get tested regularly, according to the panel, since you have a history of cancer in the family. The rhetoric here is getting in the way that Submitting all women, regardless of history, to screenings isn’t worth the complications that arise from doing so.

  56. But in the US, we want the services without having to pay taxes. Cognitive dissonance should be a clinical disease.

  57. The best value for health insurance is having premiums exceeding payouts (I’m disregarding overhead etc. to make a point, so bear with me). Single payer paid for by sales tax means Everyone pays in and everyone is covered. Tax vices more to cover increased health care use. This would eliminate medicare, VA, etc., and cover illegals and foreign visitors since they pay in by purchasing stuff. Profit is the difference between premiums collected and claims paid. The current system’s goal is (by and large) to maximize profit, and this is easy when you collect premiums and never pay claims – it’s ALL profit! So if the ultimate goal is to maximize coverage i.e. PAY for medical care, you have to maximize premiums collected since claims will be paid. The ultimate maximum in premiums is to have everyone pay in to cover the costs paid out. Single payer means everyone pays into the same pool to pay for care. Sales tax is the best approximation I can find to a user fee that has everyone paying in. Single payer also maximizes bargaining power to lower costs without infringing on the doctor’s ability to charge more for high quality care and for an individual to shop for that quality care should they decide to pay the difference.

    The current “system” divides Everyone into groups and limits the pool of premiums. People often opt out, meaning that they don’t pay in to the system (which would reduce overall premiums) and can go bankrupt when they get pneumonia (raising premiums since they get care anyway, and can’t pay – cost gets passed to those who can). Competition in this case is twisted, since costs are reduced by denying coverage for care (which also increases the insurer’s profit).

    Health insurance differs from car insurance because the government OWNS THE ROADS (huge difference). They do not own people (anymore, although those in the military might argue otherwise). Homeowners insurance is mandatory (by law) for rentals, but is only required by the mortgage lender and not law for residences (I own both a residence and rental property) or so it is in my neck of the woods. So these are not direct equivalents with health insurance even without going into what each covers where they are also incomparable.

    I think your comment about inefficiency applies to the current system in spades, so I see a single payer as (at worst) a wash in that regard. I’ve dealt with the VA too, so I know how inefficient socialized medicine can get (but I’m not an advocate of socialized medicine, just single payer). In most circumstances you would be correct, but this is an exception to that rule. Duplication of effort is inefficient, and single payer would eliminate that inefficiency “tax”, if you excuse my expression.

    I agree that health insurance should only cover low probability catastrophes. The current system lumps insurance with warranty work, which doesn’t make any sense. But ones health is predictable by both behavior and family history, in addition to the fact that we are all mortal, which means that nearly all health issues are probable (death is certain) and can be excluded from coverage. For the current system to work there needs to be: 100% open enrollment; adoption of the most strict State regulations as the National standard; transparent pricing to allow shopping; re-importation of drugs to control prices; elimination of the “preexisting condition” and “maximum benefit” cap; and outcome based payment rather than fee for service. The current “system” is unsustainable in addition to being a drag on the economy.

    That’s as much detail as I can go into given time constraints.
    Thanks for the civil debate, BTW

  58. To Agoraphobic,

    My mother was the first woman in the family to discover a lump in her breast – i.e. not high risk.

    I know three under-50 women who are today dealing with breast cancer, all of them are the first in their families to be diagnosed. Two found out via mammograms; one found out via BSE. The one who found out via BSE then discovered after surgery her cancer had spread to the lymph nodes.

    Mammograms can catch it earlier – but not if you just do mammograms on high-risk women. That’s why I find these recommendations so disturbing.

  59. I cannot let this comment pass without response. The problem with Climategate is not snarky scientists. You must take your blinders off and really look at the science. In fact some of the temperature reconstructions used to show “unprecedented warming” was done with cherry picked evidence. What do I mean? I mean that tree rings were used as a proxy of temperature, and only trees that fit the predetermined conclusion were used. The other trees in the forest were inexplicably left out of the dataset. This is one tiny example of the perversions of science that have been going on. “Hide the decline.” Do you know what that email was talking about? Probably you don’t. *sigh* You complain about the idiocy of the people, yet you yourself gloss over the facts of this scientific fraud. You can’t handle the truth.

  60. We can’t even begin to have a sensible debate on health care until our representatives read and understand the concepts in The Atlantic’s recent landmark article, How American Health Care Killed My Father. It’s written by a Democrat, who comes up with some remarkably free-market oriented solutions, yet incorporating important factors that neither Republicans or Democrats seem to have considered.

    Our system is fundamentally out-of-whack on many levels that affect patient care and mortality, even for those with Cadillac insurance coverage. (The author’s father was needlessly felled by hospital-acquired infections, the final bill was $600,000, and it could have been prevented.) The health care debate in Washington is focused on how to provide this out-of-whack care to everyone, and how will it be paid for. Stupid.

    We need to go back to square one and eliminate a lot of what doesn’t make sense in our health care system. Who does or doesn’t have insurance is a sideshow issue in comparison to issues of unnecessary treatment, iatrogenic illness, and preventable errors.

    Then we need to think about how incentives can bring down prices — this involves giving patients more choices, not a great health care dictatorship thousands of miles away in Washington deciding what will be covered, and how much we will be allowed (or forced) to pay. No thank you.

  61. @redleg

    Lots of good thoughts. We differ on our principles.

    We are discussing how a system:
    1) Allocates Care (coverage)
    2) Controls Costs (payments)
    3) Improves Performance (care)

    One way to try to reduce costs is to ‘bargain’. In a single payer system the assumption is that the bargaining power is maximized. I disagree and do not believe that is the most efficient nor stable way to control costs. Cost/service improvements are best driven by individual consumer choice. Look at lasix or cosmetic surgery over the past 10 years. Costs have plummeted because they are not covered by health insurance.

    A sales tax is an interesting idea. A national sales tax focused on vices would disproportionately impact the poor. But that might be your goal? The bigger issue I have is that I don’t trust the government to allocate or disperse those funds efficiently. Example: Medicare, social security, etc. The only thing we do ‘world class’ is our military, which, I support fully. Most everything else is a disaster waiting to happen.

    I disagree that universal coverage should be a main principle. My list of principles for a health care system:
    1) provided the best care in the world
    2) at the lowest cost
    3) be customer led

    Profits drive businesses and innovation. Without competition service and innovation stagnate. It may sound heartless, but I’d rather provide the best care in the world to 85% of the population than average care to 100%.

    I would:
    1) Strip all employer based incentives for health coverage
    2) Relax government regulations on cross state line insurance sales
    3) Set incentives for catastrophic coverage policies
    4) Set incentives for personal consumer choices
    5) Tax incentives for charitable giving / care
    6) Limit monetary malpractice damages
    7) Set clear truth-in-coverage standards (like truth-in-lending)

  62. I agree with your 7 points except #6. I think that limiting the scope of what constitutes malpractice is more appropriate than capping damages. Frivolous lawsuits are the problem, since capping the damage award for someone who has lost the “good” limb (for example) defeats the purpose of malpractice at all. I would add 8) eliminate “maximum lifetime benefits” and “pre-existing conditions” and 9) allow the re-importation of drugs from Countries with equivalent safety standards.

    Health insurance as it exists today in the US is rent seeking – no different than predatory rent-seeking mega banks. Despite my agreement with much of your argument, I believe that single payer is the only way to reform the system. This is because the political power of big insurance and pharmaceuticals leaves the current system with no hope of redemption without breaking their political power, just like the mega banks. Therefore, I advocate single payer over system reform.

    I believe that the US has the best high-end medical care in the world: Mayo, Johns Hopkins, etc. I don’t believe for a minute that medical care is a problem in the US. Paying for it that is the problem, and that for-profit “insurance” is the primary cause of the problem and needs to be completely re-done. What value does health insurance add to actual medical care? Have you ever arrived at a hospital by ambulance and been confronted by the business department while on the gurney? (I have) There are other contributors to cost, but they are best addressed after the insurance beast has been tamed.

    I agree that profits reward innovation, but I would prefer that the profit go to the doctors and not the middlemen.

    Regarding the sales tax, I’m aware that it would disproportionately affect the poor. But if you are going to cover everyone, everyone has an obligation to pay for it. It is also a way to cover illegals, solving the problem of having them pay for care (and reducing conservative opposition). This will hurt the poor, but it should keep costs down since unbillable care will effectively cease to exist.

  63. Goldhill’s article is essential reading for anyone looking at health care reform. I don’t agree with all his solutions (I did a blog entry on that), but he definitely points out many of the problems in a unique way. To solve the problem we need fewer politicians positioning for election and more common sense thinking. In James’ original post he said he had no qualifications, but what he did have was the clear logic to show that Hutchinson’s position made no sense. More logic, less grandstanding, I say.

  64. The average profit margin of the large health insurance companies is somewhere in the range of 4%. Even if insurance companies became “non profits,” they would still have to operate with some level of “profit margin” for lack of better terms, or end up operating in the red. Non-profits do not operate for free. Those who lose money and cannot pay bills face the same risks as for-profits (I would say except for the higher likelihood of government bailout/funding but that seems to no longer apply).

    NO legitimate insurance companies collect premiums and turn down “ALL” claims as someone else here claimed. I assume it was merely hyperbole, but what exactly do broad exagerations do for honest debate?

    If there were a full “public option” where the government was the insurer, who would be carrying out these functions for the government? It most likely would be the current insurance companies hired as subcontractors! With some political contribution padding, and, say, an agreement to keep their own profits let’s hypothetically at a mere fixed 5% above cost for managing the program for the government, they could increase their average profit margins by 25%!! What a deal!

  65. I am the guilty party, and I was showing the end member of the continuum. I stand by my hypothetical, simplified example – there was a disclaimer in there about what I was disregarding to make a point.

  66. Single payer would reduce medical costs by lowering overhead by simplifying billing.

    Profit is income – expenses. Overhead is an expense.

    Your point about the politics of subcontracting is valid, which feeds back into my point somewhere up above about how mega-health insurance should be broken up for the exact same reasons that the TBTF banks should. They do nothing to benefit the people, their health/medical care, or society as a whole.

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