What’s Next

The PPACA extends the current system to more people to increase coverage, but doesn’t fundamentally reform health care at the delivery level. As such, it will not succeed in bending the cost curve to make the growth rate of health care spending sustainable. The interesting question now is what path it takes when it inevitably collapses. I see one of two options: 
 
1. “Individual Market Based” – Some combination of Ron Wyden’s and Paul Ryan’s reforms are enacted eliminating the employer based tax preferences and replacing them with individual tax credits, thus eliminating the already tenuous “firewall” between the exchanges and the employer based system.  
 
Medicare and Medicaid (and potentially TriCare) are voucherized and integrated into the existing subsidy system in the exchanges so that all health insurance is purchased by individuals in the exchange system with varying levels of subsidies and tax credits based on age and income. About as close to “Free Market” as you are likely to get. 
 
2. “Single Payer (sort of)”. Medicaid for all is enacted replacing the exchange system entirely with a universal minimal standard insurance package provided by the government. Coverage and reimbursement is dictated by a more robust version of the Medicare Payment Advisory board that strictly limits name brand drugs and other expensive treatments in favor of generics and applies similar cost/benefit analysis to approved procedures (and reimbursement rates). The ability to see specialists without a referral or otherwise go “out of network” is curtailed, as are end of life procedures.  
 
In parallel with the public system, private insurance and medical care remain to provide enhanced care for those who can afford it.  
 
Eventually, the public system comes to resemble public schools vs private schools as taxpayers who opt for the private system are not receptive to tax increases to maintain and improve a public system that they themselves do not participate in, thus regulating the public system to a second tier level of care, much like Medicaid is today.

53 Responses

  1. My holy grail is portability. I do not like the idea of having to change providers if I change jobs.

    Like

  2. Portability! Yes. And pre-existing conditions. Especially if you have had coverage. It sucks to have to switch providers, and then get a pre-existing condition written out (I had a rider on my insurance policy that permanently wrote out my wife’s hip at one point . . . fortunately, my current insurance only had a year limit on pre-existing conditions, and then only if you had seen someone about that condition within the last year . . let’s hear it for working for a county school system with 5000 employees!).

    Like

  3. JNC, there are more options. Real cost cutting can now become the business of the system, if there is universal or near universal care. At the delivery level we here have discussed all the reforms that are necessary. The current patchwork system allowed for cost shifting that will become more apparent and less palatable under this system.
    Opportunities for increasing clinic care, moving non-exigent cases out of the ERs, information exchange to reduce medical mistakes, forgiving student loans to GPs and
    nurses, training more nurse practitioners and GPs and dentists and pharmacists and optometrists, fee for results replacing fee for service; you name it. The incentive is greater under a near universal care setup, even a private one – see Switzerland and Germany. There are lessons from other countries and NoVA has linked to the great “Frontline” series on this before.

    I also take issue with your characterization of the public schools as second rate. I have read the horror stories of both inner city and small rural schools, but in the suburban environment public schools are generally pretty good. I have mentioned here before that I was NMS in 1960 and my eldest daughter was NMS in 1991, but she had about 40 hours of college coming out of public high school and I had none.
    All three girls had more and better HS than I did. And my son, initially a dropout, went back to CC and became highly skilled in computer networking and successfully employed, at good money, with a GED plus 45 or so CC hours. I don’t see public ed as sinking from my experience.

    Like

  4. jnc

    I agree with Mark here. I think there are many more options than the two you’ve highlighted even though you left the door open for a few different scenarios under each. One of the reasons I’m happy the ACA was upheld by the courts, although it’s still very tenuous IMO, is that it’s at least a launching pad for more reforms and cost controls and gets us a little closer to universal coverage. Like Mark I believe that some scenario where everyone, or close to it, is covered is the most advantageous way to move forward. The ACA doesn’t get us there so I’m still hoping for something more or different, I’m just not smart enough to figure out what it should be. If the entire bill had been undone I doubt there would be a damn thing to replace it for another decade at least. I also sympathize with the constitutional concerns but the status quo wasn’t working for too many Americans at great risk of negative health scenarios and financial armageddon.

    I read that the dissenting decision would have stricken the entire bill and even some speculation, which I have reservations about, that Roberts may have changed his vote at some point believing that the four had gone too far. It’s interesting to contemplate and wonder what he was thinking but whatever his thoughts, I’m personally grateful as are thousands of other Americans. Are we being selfish, maybe, but it is, in some cases, a matter of life and death.

    Something I’ve been thinking about in relation to ATiM and my purpose here is that I am not a professional anything, other than a small business owner and volunteer hospice worker. I don’t always understand global finances, the Constitution and legal matters, scientific advances, or even politics as well as many of you but I do interact daily with, and am, a middle class woman whose life has taken many different turns and a member of a family that has survived many challenges. I think my perspective is valuable in that I can at least remind all of you who are probably more accomplished, and yes even wealthier, what some of this policy stuff we discuss means to others like myself. In reality, that’s probably the reason I’m still commenting here………………………….You. Guys. Need. Me.

    Like

  5. I hope you don’t think your contributions here are not welcome — or more accurately — sought out.

    Like

  6. You. Guys. Need. Me.

    Yes we do. In every Aaron Sorkin show there is a naive pretty blonde the hypercompetent male lead gets to lecture to and impress with the breadth of his vast knowledge. You are our Dolphin Girl.

    Seriously, I always appreciate your perspective and life experience. Don’t sell yourself short.

    Like

  7. No, I’m not saying that nova, just reminding everyone that some of this stuff affects real live human beings and I think it’s easy for some of us, myself included, to forget that on occasion. Lack of insurance coverage means lack of health care for a lot of people so this stuff is more important to some than even the Constitution. It probably shouldn’t be, but it just is.

    Like

  8. I think my perspective is valuable in that I can at least remind all of you who are probably more accomplished, and yes even wealthier, what some of this policy stuff we discuss means to others like myself.

    I work for a county school system, and I’m always in personal debt (our assets outstrip my person debt, but that’s all committed to college education and, if anything is left over, to retirement, which will otherwise be what little I’ve accumulated in pension (about $5k so far–that will serve me well!) and SS. But, I’m definitively middle-middle class . . . I discuss things in the abstract a lot, but when the property taxes go up here, I groan, as (a) those same property taxes pay my salary, and (b) I don’t have that money right now. We could skip the vacation . . . but the oldest is going to high school, youngest is only going to be seven once . . . argh! Consumer-debt fueled spending it is!

    Hell, you only live once, and I’m not getting any younger, and life is short.

    But I digress. I went to a lower-middle tier art school, graduated with a bachelors in photo/computer, and work for a county school system. The money we have for our kids college tuition was all inherited. Without that, we’d have next to nothing. Point being, you aren’t the only one firmly in the middle here. 😉

    Like

    • It is not a mere coincidence that LMS and Kev, more than anyone else, brought this group together.

      We absolutely require both of you. Both of you think deeply and broadly about the body politic. Lawyering and banking and mastery of physics or molecular biology or genetics are not prerequisites for good citizenship. Specialties just add seasoning. This is even true for libertarian lobbyists.

      You two ARE BOTH NEEDED here.

      I will be in-and-out for the week while I move my office.

      Like

  9. Kevin

    Point being, you aren’t the only one firmly in the middle here. 😉

    I know I’m not Kevin, but you and Okie (also firmly middle class) aren’t here all that often. Maybe if we all participated more frequently the perspective here wouldn’t be so slanted and maybe I’m just full of BS anyway. I really don’t know. I’m not even sure why I brought it up. Something Scott said yesterday made me think about it all night, not that he’s at fault for anything. He seemed surprised that I could still not understand why conservatives oppose universal care and I truly thought the general principle appealed to at least some conservatives. It doesn’t matter, really.

    Like

    • lms:

      He seemed surprised that I could still not understand why conservatives oppose universal care and I truly thought the general principle appealed to at least some conservatives.

      What does this have to do with who is or is not middle class?

      Like

  10. I truly thought the general principle appealed to at least some conservatives

    It appeals to me. And I suspect the lower you can get the costs (which is going to happen mostly via technological advancement, not bureaucratic brilliance), the fewer conservative objections you are going to see. When it looks (as it usually does) like a blank check being written with the money of the Average American Taxpayer™, they are going to have some objection.

    I am all for universal coverage—but not if the outcomes are worse than the status quo. And how it reflects on certain politicians or whether or not certain people feel good about saying that “now we have universal coverage” doesn’t really figure into it for me. If we rob Peter to pay Paul, then it’s not worth it. If we arbitrarily crush one sector of the economy, or chase doctors out of business, or incentivize (unintentionally) fraud in the medical community, then “universal coverage” may not be worth the unintended consequences, or at least may not seem so, at first.

    A small “c” conservative approach to achieving the goal of universal coverage would be to slowly expand the coverage of existing programs (a subsidized Medicare buy-in for individuals and for small-businesses, for example). The ACA still strikes me the wrong way to go about it. I don’t think the court’s decision was a good one, and (like the Bush v. Gore decision) could set bad legal precedent. We shall see, I suppose.

    I’m not prone to hyperbole and drama (They’ve set fire to the Constitution!), but I am prone to cliches. They’re Ain’t No Free Lunch. And sometimes the “free” lunch costs a lot more than you’d think, before the lunch gets started. That tends to be my concern with such things—that the cost of universal coverage (especially to those who are ostensibly meant to benefit) is going to be onerous, through mechanisms hard to see at the outset.

    Like

  11. Lawyering and banking and mastery of physics or molecular biology or genetics are not prerequisites for good citizenship.

    Thank goodness for that, or I’d be stuck!

    Like

  12. Scott

    It’s my impression that a lot of people in the middle class and working poor are the ones who will benefit most from universal care. I don’t have time to look the numbers up right now so perhaps I’m wrong? Like I said, I’ve pretty much given up on the idea that conservatives, at least the political class of conservatives, have that as a goal precisely because of the reason/reasons you mentioned. I suppose I’m disappointed on some level but I understand it now. I guess my head is in the clouds most of the time.

    Like

    • lms:

      It’s my impression that a lot of people in the middle class and working poor are the ones who will benefit most from universal care.

      That is a very complicated issue, but undoubtedly some of them will benefit.

      Like I said, I’ve pretty much given up on the idea that conservatives, at least the political class of conservatives, have that as a goal precisely because of the reason/reasons you mentioned.

      Have what as a goal? Helping poor people or instituting universal care?

      I still don’t understand what any of this has to do with my or your membership in the middle class.

      Like

  13. He seemed surprised that I could still not understand why conservatives oppose universal care and I truly thought the general principle appealed to at least some conservatives.

    Ezra Klein reported on this recently:

    Indeed, influential conservatives have been turning on the idea of universal coverage entirely. In June 2007, National Review published an editorial arguing that Republicans should reject “the goal of universal coverage. Deregulating health insurance would make it more affordable, and thus increase the number of Americans with coverage. But to achieve universal coverage would require either having the government provide it to everyone or forcing everyone to buy it.” Michael Cannon, director of health-care policy at the libertarian Cato Institute, formed the “Anti-Universal Coverage Club,” whose members “reject the idea that government should ensure that all individuals have health insurance.” This attitude is now the norm within the Republican Party, even if it is rarely acknowledged so starkly.

    The goal of small and limited government trumps any desire to assist those less fortunate. As someone who has had employment gaps and found COBRA coverage ridiculously unaffordable, I sympathize with those whose jobs pay too little to include health care coverage, which I consider a basic right.

    Like

    • yello:

      The goal of small and limited government trumps any desire to assist those less fortunate.

      Not at all true. It simply trumps any desire to assist those less fortunate by increasing and/or de-limiting the power of government. I welcome your desire to help those less fortunate, and if you do assist them, I applaud it, and there is nothing about my small/limited government ideology that would prevent you from doing so.

      …which I consider a basic right.

      The notion that health-care coverage could be a “basic right” in the moral, non-legal sense is incoherent.

      Like

  14. yello

    I read some quotes last night, unfortunately I can’t remember where exactly, that indicated that the reason so many Republicans, particularly politicians, reject the notion of universal health care is because passing it would give Democrats a political advantage for decades as people begin to appreciate the benefits. It reminded me a little of the “Norquist Pledge”.

    Like

  15. Scott

    Have what as a goal? Helping poor people or instituting universal care?

    Instituting universal care. People of all walks of life and political persuasion, if they are so inclined help the poor, individually or institutionally. Again, I’m not accusing conservatives of being heartless monsters.

    I still don’t understand what any of this has to do with my or your membership in the middle class.

    I’m not sure really. I just identify with the health care needs of people who don’t have insurance, even though we do for now, and I think most of us/them believe we/they are living on the edge of some health care catastrophe. That’s why I said our/their personal situation sometimes trumps ideology/constitutional authority. It may be wrong on our/their part but it’s just the way it is. I doubt that made any sense at all. 😉

    Like

    • lms:

      Instituting universal care.

      It is probably wise not to expect conservatives in general to have universal care as a goal. Just as it is wise not to expect liberals to have limiting the government’s involvement in health care as a goal.

      Like

  16. “our/their personal situation sometimes trumps ideology/constitutional authority. It may be wrong on our/their part but it’s just the way it is”

    I understand that — but it strikes right where my heart would be if I had one 🙂

    Like

  17. It only trumps ideology if the ideology is that providing goods or services to an individual on a means tested basis is always and invariably wrong. We already provide lots of things from the government directly to individuals such as food and shelter. Under existing Medicare we also already provide medical services. ACA just expands this to the working poor who cannot afford/access health insurance through the market system. The individual mandate is intended to solve the dual problem of free-riders and individuals with pre-existing conditions.

    Like

    • yello:

      It only trumps ideology if the ideology is that providing goods or services to an individual on a means tested basis is always and invariably wrong.

      Correct. And conservative ideology does not hold such a thing. But of course the thing that prompted this thread, universal care/coverage, is pretty much by definition not means tested. It is, well, universal.

      Like

  18. The notion that health-care coverage could be a “basic right” in the moral, non-legal sense is incoherent.

    That it should be in a legal sense is equally questionable, and implies a slippery slope that tends to be unavoidable. Food and water is more important than healthcare. Shelter and clothing nearly as important. Etc. At what point does everything become a right? And how do medical procedures, many of which were not even possible 20 years ago, and were inconceivable a hundred years ago, become a right to which others are entitled at the expense of the general populace?

    yello: It only trumps ideology if the ideology is that providing goods or services to an individual on a means tested basis is always and invariably wrong

    … at the expense of others, and invariably at the expense of other application of those limited resources. For many, it may well be a starkly black and white issue that giving anybody anything is just wrong, but the reality is that basic healthcare is one potential application of limited resources, and perhaps not the one that gives us the biggest bang for the buck.

    Like

  19. It is probably wise not to expect conservatives in general to have universal care as a goal. Just as it is wise not to expect liberals to have limiting the government’s involvement in health care as a goal.

    Exactly true. And not desiring universal care as a goal is not any more a deficit in the conservative’s soul than not wanting to limit government involvement in healthcare, or limit the fostering of the entitlement culture, is a deficit in the liberal soul.

    Like

  20. “t only trumps ideology if the ideology is that providing goods or services to an individual on a means tested basis is always and invariably wrong”

    I’d flip that. ACA means tests to determine your price (ranging from Medicaid to 9.5% of income for those up to 400% FPL), not for access. Medicare is much more wrong in that we tax everyone, including the working poor, to provide health care for the richest segment of our society, seniors. this is why i’m so popular at parties.

    true safety net would take of those who can’t afford/access regardless of age.

    Like

    • Medicare is much more wrong in that we tax everyone, including the working poor, to provide health care for the richest segment of our society, seniors.

      Absolutely correct. The regressivity of the Medicare tax is shameful. At the time of its introduction, it was assumed the elderly were largely impoverished. Nowadays that is not the case. I don’t see a free market solution though as the mortality rate of senior citizens approaches 100%.

      Like

  21. nova:

    Any inkling on how many states might accept the Medicaid expansion and how the disparities in coverage might affect the whole program? I know, I ask really open-ended questions.

    Like

  22. “lmsinca, on June 29, 2012 at 6:35 am said:

    Something I’ve been thinking about in relation to ATiM and my purpose here is that I am not a professional anything, other than a small business owner and volunteer hospice worker. I don’t always understand global finances, the Constitution and legal matters, scientific advances, or even politics as well as many of you but I do interact daily with, and am, a middle class woman whose life has taken many different turns and a member of a family that has survived many challenges. I think my perspective is valuable in that I can at least remind all of you who are probably more accomplished, and yes even wealthier, what some of this policy stuff we discuss means to others like myself. In reality, that’s probably the reason I’m still commenting here………………………….You. Guys. Need. Me.”

    I for one enjoy and value your contributions. Also, when one posts anonymously (or semi-anonymously) on the Internet external credentials are irrelevant, as they can’t be validated anyway. What matters is the strength of your arguments. Here, everyone’s equal.

    Like

  23. Hey you guys, I wasn’t threatening to leave or feeling sorry for myself…….lol. I was just letting y’all know I’m sticking around so you don’t get too full of yourselves, and just because you need me. Although maybe I do need to get out more.

    Like

  24. “markinaustin, on June 28, 2012 at 4:06 pm said:

    JNC, there are more options. Real cost cutting can now become the business of the system, if there is universal or near universal care. At the delivery level we here have discussed all the reforms that are necessary. The current patchwork system allowed for cost shifting that will become more apparent and less palatable under this system.
    Opportunities for increasing clinic care, moving non-exigent cases out of the ERs, information exchange to reduce medical mistakes, forgiving student loans to GPs and
    nurses, training more nurse practitioners and GPs and dentists and pharmacists and optometrists, fee for results replacing fee for service; you name it. The incentive is greater under a near universal care setup, even a private one – see Switzerland and Germany. There are lessons from other countries and NoVA has linked to the great “Frontline” series on this before. ”

    I have no expectation that there will be real reform in the current system. The lobbying effort will successfully execute regulatory capture. See the annual Medicare doc fix as an example.

    There may well be more options half way between the current state and the two examples I lay out, but I do expect the system to evolve from an employer based one that the ACA tries to “firewall” from the new exchanges into one of the two paths I identify: a (regulated) individual insurance system in the exchanges or a centralized single payer system with a private opt out for those who can afford to.

    “I also take issue with your characterization of the public schools as second rate. I have read the horror stories of both inner city and small rural schools, but in the suburban environment public schools are generally pretty good. I have mentioned here before that I was NMS in 1960 and my eldest daughter was NMS in 1991, but she had about 40 hours of college coming out of public high school and I had none.”

    I went to good public schools as well, but those pockets are facilitated by the strict delineation of the tax base by district. I.e. all the wealthy people self segregate by neighborhood and thus have a tax base high enough to fund their own schools. As evidence, I point to the difficulty in changing the school funding system to anything other than local real estate taxes, and the resistance of the entrenched system to reform. I specifically had in mind the state of the Washington DC school system, where the various well off people in that city tolerate it because they have the option of not participating in it.

    My main point though is that where you have a significant bifurcation of private and public schools, you will get substantial resistance to tax increases to pay for a public system that the people who are being taxed do not utilize. I believe the same dynamic would carry over to a “single payer” system as well.

    With regards to the goal of universal coverage, for me cost control is a higher priority than extending coverage. President Obama attempted to finesse the issue by claiming we can do both at the same time, but I don’t believe him. It costs more to cover more people.

    The ACA is the Status Quo Extension and Sanctification Act. It does not fix the current system, it merely extends it to cover more people. Unless real reform happens along one of the two scenarios laid out (individual market based or single payer), health care costs will continue to rise.

    Like

  25. honestly, that’s what i’m working on right now. quick reaction: 26 states challenged, 13 filed amicus briefs supporting the Feds. 2 were on both sides.

    there’s 16 million people were supposed to be captured by the Medicaid expansion. how that’s divided up among the states I don’t know. but if a state balks, it’s basically leaving the expansion population (non-disabled adults younger than 65 with household incomes at or below 133% FPL) uninsured. from what i can tell — and the trade press and advoctes are backing me up — the law does not provide help outside of medicaid. so people above 133 will get the exchange subsides and those below will, presumably, remain uninsured. 133% for a family of 4 is about 30K a year.

    This population has the churn problem — on and off the exchanges as incomes vary. so potentially, they could go insured on the exchange, drop below 133%, and lose (!) their coverage. or they could be below 100%, have a kid qualify for medicaid, turn 6 years old and lose Medicaid, while the neighbor kid at 140% is on the exchange.

    as for what states — assuming were dealing with the 26 — pure specualtion. they will be under immense pressure not to decline the funds.

    Like

  26. Medicare is much more wrong in that we tax everyone, including the working poor, to provide health care for the richest segment of our society, seniors

    What’s with the senior envy going around? Not you necessarily nova but I see it a lot at the Plumline and elsewhere. I’m not getting medicare yet but we need it and I’m neither impoverished nor wealthy. Most of our friends are just hanging on until we all turn 65 as health care and insurance rates have skyrocketed in the last decade or so. I know for a fact that a small group insurance policy at age 60 to 65 costs $800/month here in CA (per person), I can’t imagine what it would cost at 65 or 70 or 75, if I live that long. We paid into it our entire adult life just like everyone younger than us is doing now and it’s not the people’s fault that what we’ve paid in hasn’t kept up with the costs. I’m not very popular at parties either or facebook for that matter……….

    Like

    • And so it begins:

      A top surrogate for President Obama insisted Friday that the individual mandate in the Affordable Care Act was not a tax — despite the fact that the Supreme Court narrowly preserved the law on those grounds.

      “Don’t believe the hype that the other side is selling,” Massachusetts Gov. Deval Patrick told reporters on a conference call.

      In some ways you have to admire the sheer brazenness of it, referring to “the hype the other side is selling”. The contempt for the intelligence of his audience is simply awe-inspiring.

      Like

  27. yes — it’s been rechristened a penalty for freeloaders. I can’t recall D politicians using the word “freeloader” before.

    Like

  28. “lmsinca, on June 29, 2012 at 10:14 am said:

    What’s with the senior envy going around?”

    The seniors have effectively organized themselves such that their programs are immune to any of the budget changes needed to bring the fiscal house in order. All domestic discretionary programs will get hit and taxes raised before any changes are done to unlimited fee for service medical care for seniors that results in each beneficiary receiving three times what they paid into it.

    I have no expectation of receiving the promised Medicare and Social Security benefits when I retire. The system will have long since blown up by then. Neither party will address the problems before we have an actual crisis. The Democrats just added one more entitlement on top of the unsustainable ones we already have and the Republicans just want to cut taxes and “protect Medicare”. David Frum had a nice description recently:

    “Rather than workable solutions, my party is offering low taxes for the currently rich and high spending for the currently old, to be followed by who-knows-what and who-the-hell-cares. This isn’t conservatism; it’s a going-out-of-business sale for the baby-boom generation.”

    http://nymag.com/news/politics/conservatives-david-frum-2011-11/index4.html

    However, I’m not mad at seniors per se because I don’t blame the player. I blame the game.

    Like

  29. “ScottC, on June 29, 2012 at 10:47 am said:

    And so it begins:

    A top surrogate for President Obama insisted Friday that the individual mandate in the Affordable Care Act was not a tax — despite the fact that the Supreme Court narrowly preserved the law on those grounds.

    “Don’t believe the hype that the other side is selling,” Massachusetts Gov. Deval Patrick told reporters on a conference call.

    In some ways you have to admire the sheer brazenness of it, referring to “the hype the other side is selling”. The contempt for the intelligence of his audience is simply awe-inspiring.”

    He should have said “John Roberts is certainly entitled to his opinion, but eight other justices on the court felt differently.”

    Like

  30. jnc

    However, I’m not mad at seniors per se because I don’t blame the player. I blame the game.

    If each side wouldn’t hype the proposals from the other I believe we’d find that most seniors would and could willingly subject themselves to whatever changes seem reasonable without killing them or putting them on the street. Instead we get a lot of hyperbolic things like “death panels”, “killing medicare as we know it” and plans that actually add to the deficit instead of cutting it. I work with a lot of more elderly people than I am, of much more modest means, who are quite confused by it all.

    One of the reasons I like to hang out here is because we generally try to cut through the hyperbole and lies rather than just repeat them, even though we don’t agree on everything.

    Like

    • If each side wouldn’t hype the proposals from the other I believe we’d find that most seniors would and could willingly subject themselves to whatever changes seem reasonable without killing them or putting them on the street.

      How is that supposed to expand or preserve the power of DC politicians?

      Washington is full of Politicrats calling themselves Democrats or Republicans as part of their performance, but they are Politicrats at heart, all about the expansion of their own power and status, and getting re-elected and/or reappointed (or newly appointed) to positions that give them power and status. At least, that’s how it appears to be at a far distance. 🙂

      Like

  31. Here is Tyler Cowen’s Not Modest At All Proposal:

    We need to accept the principle that sometimes poor people will die just because they are poor. Some of you don’t like the sound of that, but we already let the wealthy enjoy all sorts of other goods — most importantly status — which lengthen their lives and which the poor enjoy to a much lesser degree.

    In other words, just set them on ice floes.

    Like

  32. “yellojkt, on June 29, 2012 at 11:36 am said: Edit Comment

    Here is Tyler Cowen’s Not Modest At All Proposal:

    We need to accept the principle that sometimes poor people will die just because they are poor. Some of you don’t like the sound of that, but we already let the wealthy enjoy all sorts of other goods — most importantly status — which lengthen their lives and which the poor enjoy to a much lesser degree.

    In other words, just set them on ice floes.”

    No, in other words they aren’t going to get the same level of care for cancer that Steve Jobs did. You chose to omit the preceding sentences in your quote:

    “2. A rejection of health care egalitarianism, namely a recognition that the wealthy will purchase more and better health care than the poor. Trying to equalize health care consumption hurts the poor, since most feasible policies to do this take away cash from the poor, either directly or through the operation of tax incidence. We need to accept the principle that sometimes poor people will die just because they are poor. Some of you don’t like the sound of that, but we already let the wealthy enjoy all sorts of other goods — most importantly status — which lengthen their lives and which the poor enjoy to a much lesser degree. We shouldn’t screw up our health care institutions by being determined to fight inegalitarian principles for one very select set of factors which determine health care outcomes.”

    Like

  33. they aren’t going to get the same level of care for cancer that Steve Jobs did.

    Steve Jobs got the care he got because he was able to venue shop for the hospital with the shortest donor list. He was a carptetbagger patient.

    Like

  34. “yellojkt, on June 29, 2012 at 12:17 pm said: Edit Comment

    they aren’t going to get the same level of care for cancer that Steve Jobs did.

    Steve Jobs got the care he got because he was able to venue shop for the hospital with the shortest donor list. He was a carptetbagger patient.”

    Correct. Because he had money. He also had access to better doctors than the poor would.

    In many ways this is an irrelevant argument anyway as no one is proposing that everyone receive equal care. The question is what’s the minimal acceptable level for those who can’t afford better?

    Like

    • jnc:

      In many ways this is an irrelevant argument anyway as no one is proposing that everyone receive equal care. The question is what’s the minimal acceptable level for those who can’t afford better?

      Yes, but of course the higher that minimal acceptable level is placed, the more the proposal becomes one of equal care. Someone has to pay for those who can’t afford it, and that necessarily means reducing the level of care affordable to those who must pay for those who can’t afford to pay. So moving the bottom up necessarily moves the top down.

      Like

  35. The question is what’s the minimal acceptable level for those who can’t afford better?

    That really is the bottom line. Right now the answer is life-saving emergency room care and nothing more.

    Like

  36. “Right now the answer is life-saving emergency room care and nothing more.”

    officially, yes. unofficially it’s more complicated.

    http://www.advisory.com/Daily-Briefing/2011/12/19/charity-care

    Like

  37. unofficially it’s more complicated.

    So if you put on your best wide-eyed orphan look and humbly ask “More, please.” they might cut a few hundred grand off your transplant bill?

    And forcing charity hospitals to give away medical care would be an unparalleled invasion of religious liberty. Just ask any Catholic bishop. They are very good at spotting those sorts of things.

    Like

  38. my understanding is its more like college. the price depends on what you can pay. and Catholic hospitals would give you that hundred thousand dollar transplant. just not $20 worth of BC.

    edit: an example http://www.chsli.org/charity-care-policy.html

    Like

  39. Steve Jobs got the care he got because he was able to venue shop for the hospital with the shortest donor list.

    Ironically, Jobs wouldn’t have had to have all that expensive care if he had just gotten the standard surgery at the time of diagnosis. He found out the hard way that wishing the cancer away with dietary supplements doesn’t usually work.

    Like

  40. “yellojkt, on June 29, 2012 at 12:51 pm said:

    So if you put on your best wide-eyed orphan look and humbly ask “More, please.” they might cut a few hundred grand off your transplant bill?”

    Transplants for those on the dole? Whether they even get them will depend on where you fall on a cost/benefit calculation. There will be rationing. Taxpayers will demand it. President Obama noted this directly when discussing the hip replacement surgery that his grandmother had after being diagnosed with cancer. That won’t continue.

    http://www.bloomberg.com/apps/news?pid=newsarchive&sid=aGrKbfWkzTqc

    Original citations in the NYT:

    http://www.nytimes.com/2009/05/01/us/politics/30web-baker.html

    http://www.nytimes.com/2009/05/03/magazine/03Obama-t.html?_r=1&ref=magazine

    Like

  41. “The permanent class stays in power because it positions itself between two deep troughs: the money spent by the government and the money spent by big companies to secure decisions from government that help them make more money. ”

    http://www.nytimes.com/2011/09/10/us/10iht-currents10.html?_r=2

    Like

  42. Kevin

    At least, that’s how it appears to be at a far distance.

    I agree of course. It’s so frustrating because there are so many great ideas out there but never any political will or courage to pursue them. And no I don’t mean Paul Ryan kind of courage, lol. I like a lot of Mark’s ideas as he already knows and I think jnc has some good ideas for a libertarian, but none of their ideas, or yours or mine, will ever be realized because very few politicians seem willing to tell the truth. That’s why people hate Congress I think, they know they can’t be trusted. I don’t think Presidents fare much better.

    Like

  43. jnc:

    There will be rationing.

    Yes, there will, and Oregon, that bastion of liberal thought, has had it in place for about 20 years now.

    Wiki, but a good summary

    Like

Be kind, show respect, and all will be right with the world.

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out /  Change )

Google photo

You are commenting using your Google account. Log Out /  Change )

Twitter picture

You are commenting using your Twitter account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

Connecting to %s

%d bloggers like this: