The New Republic

It is DEAD or maybe it is part of the WALKING DEAD like zommbies. Can your expand your circle of contacts beyond Ron Pollack, Andy Stern, and the House Staff. Maybe talk to some of the common citizens of this country and judge their attitudes about health care (or read one of thousand polls which dcouments the overwhelming negative opinion of the health care reform bills). One of the best things about health care expiring is that those who like the rest the New Republic will no longer have to read your advocacy (as opposed to analsis) about health care. My suggestion is just to join a Democratic House Staff as one of their P.R. flacks. You have alread had alot of practice.

- lawphd

January 21, 2010 at 5:37pm

Stranger things have happened. Like a Republican elected to the Kennedy Senate seat. It would take real political courage for the Democrats to adopt reform. Real courage, for the most vulnerable members are most likely to suffer the worst consequences. When Republicans are in the majority and adopt major reforms, they typically front-load the benefits and back-load the costs. Health care reform? Front-loaded costs and back-loaded benefits. If you were a member, would you vote for this legislation after what happened in Massachusetts?

- raylward

January 21, 2010 at 5:39pm

If a vulnerable Democrat who's already voted for reform believes that by letting it die now, he has in any way reduced his vulnerability, then he's so stupid that he deserves to lose his seat. As to the abortion differences, (A) The Senate bill actually does prevent federal funding of abortions, unless by "federal funding" one means something other than what the words actually mean in English, and (B) That's an easy one to amend immediately afterwards. Make the next bill you send to the Senate a standalone bill that applies the Stupak language to the already-passed healthcare law. Republicans will vote for it unanimously, and so it will quickly pass both houses. Problem solved.

- rhubarbs

January 21, 2010 at 5:55pm

There are a lot of common citizens of this country on these boards, and generally we support the health care reforms. The notion that there's a simple, clear dividing line between a few "flacks" in Washington and the rest of the "citizens" who are all opposed is nonsense. If we'd had a decent candidate in MA we wouldn't be having this conversation

- ironyroad

January 21, 2010 at 6:06pm

no irony, what some mean by common citizens are those that are quite content to let people die so long as they don't have to spend even one penny. Neverminding the fact that most Americans are clueless as to what is in the bill, or that America's competitive edge is daily eroded by spending twice or even three times as much on health care as other countries (Taiwan spends 6.2%, the US 17%, guess which is market based and which is state run, and might I suggest looking at where that Iphone you have was assembled). If the American people are too stupid to know this, then it takes leadership to fix it and to suffer the consequences. If Obama can't persuade the Democrats to get off their asses then he should spend most of his time at the SOTU putting the onus on Republicans. Tell them that he wants the Republicans to put forward a comprehensive plan that increases coverage, eliminates denial of care, and is revenue neutral and that he would vote for it however it is done. Tell the motherfuckers that they have to do more than say no. And then everyday ask where is the Republican plan, shove the process down their throats. But Obama has no balls.

- blackton

January 21, 2010 at 6:40pm

Allow me to play Frank Luntz for a moment (I know, I know; I feel like I have to wash my hands after typing that). Can this bucking bronco be tamed by refining the language of the thing? Could Pelosi start by emphasising that the Senate bill is in reality the foundation of the new edifice, not the edifice itself? It's all to easy to imagine the scenario in which the House Democrats are cajoled and arm-twisted into voting for the Senate bill, only to have Obama and the leadership rejoice that health reform had been finally achieved, with apparently nothing left needing to be done. I'm sure the House Democrats themelves can imagine it, and they fear it. But by using terms like "foundation" and "first floor" (or their more artfully coined equivalents), it would be much easier to reinforce that the process would continue, and that further work (via reconciliation, almost certainly) would go on. And have Reid, Pelosi, Obama and whoever else sign it in blood -- or whatever it takes behind the scenes -- that this will happen. Master the language of the thing, and hearts and minds (have a chance to) follow.

- Mormon Socialist

January 21, 2010 at 6:41pm

It can't be sold the way it is, and the conservative Democrats who are responsible for making it so unpalatable are more scared than ever -- so there's no real likelihood that it can and will be improved (in any way that addresses the real concerns of health care consumers, rather than the political concerns of frightened, out-of-touch legislators and operatives). This is policy shaped to address internal party political considerations rather than designed to most effectively address the broader interests of consumers and voters, especially those suffering the most ill consequences from the incoherent way health care is financed in this country. "We can fix it later. It's the best we can do. No one's come closer. Sit down and shut up." aren't really great talking points or sales premises. But, nonetheless, these are actual arguments advanced by supporters of the Senate's abomination, here at TNR and elsewhere. These same supporters were and are blind to the serious political shortcomings of the one thing they most consistently tout as a positive; subsidies. But subsidies based on income are, and are perceived as, welfare -- a concept as unpalatable and unpopular with the working poor and lower middle class insurance consumers who will receive the benefit as it is with the not-that-much more affluent middle class insurance consumers who will be asked to pay for those benefits through an excise tax that will increase health insurance cost for, or decrease the benefits available to, or both, themselves and their loved ones. And that's the best part of the bill. Even it's supporters, I think, understand the political weakness of the insurance mandate, especially when combined with weak and unproven efforts at cost containment, handcuffs on the government's (and therefore the taxpayer's) ability to negotiate drug prices, the administration's reversal on drug importation, and other aspects of "reform" that favor the interests of insurers and providers over those of consumers. As a marketing professional, I've tried to think of how to quickly and effectively explain what the Democrats managed to fashion after all this time. Something other than; "Welfare for some. Higher taxes and/or fewer benefits for others." "An experiment that MAY "bend the curve" on cost -- with you and your health as the guinea pig." "We don't tax the rich. Just the middle class." "Health care isn't a right -- it's welfare." I don't think any of the above arguments are likely to have much appeal for the small business owners, self-employed, contract workers, low wage workers and middle class voters for whom this issue is so important. But they seem to have great appeal to beltway wonks.

- esmense

January 21, 2010 at 7:00pm

esmense: "I Was Ill and You Cared for Me." Matthew 25: 30 I never realized it was an admonition, and should be read as you are wrong to care for those in need as it is a form of welfare. Amazing that after 13 years of Catholic education I got something so simple wrong. Of course Health care is a right, not only is it a right, it is a responsibility, ordained by God himself. If it is not, then we are nothing but animals. So you stick with your Ayn Rand atheism what is in it for me. I guess Jesus needs to hire a new marketing exec. What a silly savior he was.

- blackton

January 21, 2010 at 7:22pm

Dead but not buried. The Dems seem intent on dragging the corpse around until November oblivious to the impact the putrescence will have on their re-election prospects.

- dtohmatsu

January 21, 2010 at 8:16pm

Yes, dt, because "burying" health care reform and running away is going to be so much better for their re-election prospects! As has been repeated over and over again, do any of the wavering Dems think that people will give them a pass when they've already voted for a bill? To paraphrase whichever sage it was: if the Dems pass a bill, then there is at least room for debate over whether or not it represents a failure. If they don't pass a bill, then there is simply no debate at all.

- Mormon Socialist

January 21, 2010 at 10:03pm

MS - The Dems only hope is to accomplish something worthwhile between now and November. Unless your name is Cohn, Klein or Obama, you know that HCR is not going to happen this year so you better bury it quick and focus on something else. As I predicted on these boards a long time ago, the Dems screwed the pooch because they were more interested in socializing health care than they were in reforming it.

- dtohmatsu

January 21, 2010 at 10:12pm

By the way, thank you Jonathan Cohn for continuing your level-headed reportage amidst this almost devastating debacle.

- jhildner1

January 21, 2010 at 10:18pm

Excellent point MS. One problem, though, is that the Democrats who I think are responsible for killing health care *today* are not the conservatives -- who, after all, should like the Senate Bill -- but the liberals, who having nothing to fear from passage, except their constituents' irritation that it didn't go far enough. How big will that irritation be when they pass nothing? I don't understand these guys.

- jhildner1

January 21, 2010 at 10:22pm

Sorry, dt, but "socializing" health care? Under what definition do these proposals amount to socialism or anything resembling socialized health care? These are utterly conservative, free-market based proposals. I live in a country which has single-payer, universal health care (Australia). Ours is neither the best nor the worst of such systems, but it shares many common features with the British, European and Canadian models. And yet it is really not, I would argue, "socialized medicine", that political bugbear; which really means a system where doctors and health care providers are all owned by the state. At most, it is a hybrid system, where most hospitals are staffed by government-paid doctors and nurses, but doctors in private practice (GPs and specialists) are not employed by the government. But compared to this, the reforms are positively capitalist in nature.

- Mormon Socialist

January 22, 2010 at 12:02am

mormon, Republicans are only interested in empty headed talking points that have zero relation with reality. And of course we all see the Republicans proposals, like the ones Bush presented to America when he was at the height of his popularity, oh wait...the Republicans never did, they were far more interested in tax cuts and financing foreign wars with Chinese money.

- blackton

January 22, 2010 at 10:07am

Everyone gets gold plated insurance. No price controls. Health care cost inflation accelerates. Government then has to set prices and determine what treatments are made available. When the government takes over the resource allocation function in this manner, it's called socialism. The inevitability of this chain of events is patently obvious. If you don't believe this is what the Antoinette wing of the Democrat party wants then you are on non-medicinal drugs. Also as for the Republican proposals, I don't suppose you have ever heard of HSAs or the prescription drug benefit.

- dtohmatsu

January 22, 2010 at 12:02pm

dtohmatsu, HSA's ha ha ha hahaha. Of wait, you are serious, then HA HAHAHAHAHAHA. How the hell can Health savings account help poor people living paycheck to paycheck. HSA's are nice tax dodges for the rich, just another way to invest your money tax free. Only people under the age of 65 are eligible and even then, you must already carry a health insurance plan that has a high deductible. This means that even though you are already covered for some costs, you still must pay a premium for any services rendered because of the high deductible you’re already paying. This also means that those who are over the age of 65 are not eligible. This is perhaps one of the biggest drawbacks of these types of plans. This restriction means that those who are elderly will not be able to open one, even though they might be the ones that need them the most. So you are a poor person, with a high deductible, as it is since you are poor you are not paying income taxes so there is no real tax benefit, and you manage to squeeze out a few bucks into it, you get sick, spend it all but stay under the limit, repeat process. HOORAYY. I am not totally opposed to it, small business owners who are healthy, it can save them some money, but we aren't talking about a game changer here, a few percentage points at most. And the prescription drug benefit was financed by deficit spending with zero cost controls added (what, negotiate with drug companies, how horrific). And with the baby boom generation coming, well it is good I speak Chinese and have a house there since your kids are going to be paying the Chinese back for generations. You do know that the Baby boomers start to retire in force next year? Is this really the best you got? Really? Pathetic.

- blackton

January 22, 2010 at 12:30pm

Blackton So much to refute so little space. 1. You said Republicans never presented any proposals. Are you still saying they did not or are you now saying that in fact they did but that you disagree with what they presented. 2. What do the elderly or the poor have to do with the debate. They're already covered by Medicare and Medicaid. These are not problems we're are trying to fix. 3. The two big problems with health care are: a) as a society we're spending too much on it and b) some small but not insignificant number of people are getting financially hurt by the cost of health care. As you well know the purpose of HSA's is to encourage people to have high deductible plans not to give them tax breaks. High deductible plans are cheaper so more people can afford them and they hold cost downs because consumer are paying out of their own pocket and have an incentive to negotiate for lower prices. If all employer provided plans were high deductible, it would be a game changer.

- dtohmatsu

January 22, 2010 at 12:58pm

Not even freshman econ, dtohmatsu. We don't live in a Syrian bazaar. In our society, people are generally price-takers for most of what they buy. The discipline that the market exerts on prices is through lack of demand -- people buying less when the price goes up -- not through negotiated prices. So, if they are not covered by some explicit or implicit form of insurance, they don't negotiate with the medical establishment and get a better rate, they just don't get served, or they go bust paying. The whole problem with medical care is that, as a society, we do not want people to fail to get health care they need because of price. One means of smoothing this out is insurance. That only makes matters worse when it is private insurance. The present system leaves insurance companies free to extract super profits by denying care and coverage. And the oligopolistic nature of the insurance industry actually fuels higher prices for care because they can be passed on to the declining pool of people able, directly or indirectly, to pay for coverage. We therefore have the worst of all possible worlds, high prices for care with no effective restraint on demand. Overuse combined with overpaying. It is perfectly obvious that the market has absolutely no solution to these problems and can never have a solution. Every other industrial nation has long-since figured that out. Only we, beset by free-market radicals such as yourself, have not.

- roidubouloi

January 22, 2010 at 2:41pm

And the free marketeers suddenly jump behind the bushes when the question of regional cartels or market-skewing dominance comes up. How do you deal with regions where there is only one insurance provider, and zero competition? It's not enough to say, well open up all health insurance markets to nationwide business, because that only translates the problem higher to the point (in the not too distant future) when we suddenly wonder why there are only two providers in the entire nation, and they cooperate with each other while pretending to be in competition. Which was why, in the first place, we need a public option.

- ironyroad

January 22, 2010 at 4:35pm

Let's follow dtohmatsu's logic here : "As you well know the purpose of HSA's is to encourage people to have high deductible plans" Why would that be? What's in it for the individual? Shouldn't people be acting rationally and just selecting the plan that suits them best; i.e. the one that gives them the best return? Surely people act in this rational fashion, and surely employers invest huge amounts of effort in offering a wide range of plans to suit each individual's need? Perhaps that's what things look like from Japan and when you just nip back to the states for the odd procedure that you don't pay for (something dtoth quite proudly proclaimed a few months back) but it doesn't jive with my experience or anyone that I know. High deductible plans are (hopefully) the last gasp of our dysfunctional for-profit system; they came into being due to pressure from employers to find any way to lower premium costs. Of course, conservatives celebrate the transfer of the risk onto employees, but that's to be expected. To even think of HSA's as "reform" is incredibly simplistic; of course they are a tax dodge. As blackton enumerated, they are utterly useless for anyone who does not have cover, and only those who take a qualifying plan. However, given that it looks like I'll be pumping mine up with money that might otherwise have been donated to some Democrat effort I can't complain, as I'll probably be needing it at this rate.

- Nari224

January 22, 2010 at 4:56pm

Roi You could easily address your concerns with a bill that required insurance companies to offer a high deductible policy to anyone who wanted it at a rate that could only vary based on how old they are and where they live and which restricted insurance companies to selling other policies only to those individuals who were also enrolled in the high deductible plan. It would not take a 2000 page bill to do this. Also, your perception of the problem is way off. The problem is access to insurance not access to health care. There is not a significant problem with people not getting health care because of price. Nari You would not need the incentive of HSAs if you were not competing with traditional plans that have the benefit of full tax deductiblity. You only need HSAs to fix the mess that has been created by previous government attempts to meddle with the market mechanism for health care. The nature of the disagreement here boils down to a very simple fact. You, Nari, Irony and Roi all believe that the market is dysfunctional and that government can do a better job of resource allocation, i.e. socialism. Some of us believe the market can do a better job than the government and therefore oppose the current HCR plan. Well it's pretty obvious that the majority of the electorate are in the latter camp, which is why the current HCR undertaking is dead.

- dtohmatsu

January 22, 2010 at 7:23pm

It's true, that many believe that the market can do better than the government. But it's a belief for which we pay a great price. We pay 17% of our GDP for health care, leave many uninsured, have growing numbers of us underinsured, and have relatively poor outcomes. Over 20 other countries cover everyone, spend on average 8-9% of GDP on health care and have better outcomes. Even though we try to rely on for-profit insurance we still have to prop things up with tax deductions, Medicare, Medicaid, VA, Federal Employees Health Plans, medical spending from auto insurance, workmans comp, etc. The profit motive drives insurance companies not to pay for health care - there are lots of ways to do that - but do that they must to be competitive. It's a bad model and we pay for it dearly. Many of us believe a single, not-for-profit health care financing system, run by the government (a la Medicare) and paid for by taxes would do a much better job. If only we had the spare 25 million to bulldoze our legislators.

- bsemple

January 23, 2010 at 1:48am

Dtoh says, "Also, your perception of the problem is way off. The problem is access to insurance not access to health care. There is not a significant problem with people not getting health care because of price." What planet are you living on? How do you think that the tens of millions of Americans who cannot afford health insurance pay for health care? This is nuts. Worse, your notion that the marketplace should regulate the price and consumption of care absolutely depends on the population NOT getting care that it needs. If the demand is perfectly inelastic then there is no restraint on price. Your "model," if one can even call it that, requires that people forego care they need. The simple point is that price is an inappropriate mechanism for allocating medical care, and in fact we do not allocate care by price through the mechanism of health insurance. But the insurance industry is rife with fraud -- collecting premiums and denying care and coverage, cherry-picking, short-paying through a variety of devices -- and is grossly conflicted when it comes to managing treatment. Every dime saved in denying coverage for a service on the grounds that it is "unnecessary" goes straight into the insurer's pocket. What is more preposterous than that? When you consider the tax subsidies that already go into the medical system, via employer-paid insurance and charitable donations, the fact that we pay twice as much as every other industrial society for care that is no better and often worse -- and unquestionably denies care to many people -- it is perfectly obvious that Americans are being screwed to the wall by the current system of financing for medical care. It is destructive of our international competitiveness and costs lives and suffering. It is this wretched system that the Republicans -- in dual thrall to the monied interests that they serve instead of the voters and their absurd free-market extremism -- refuse to fix. * * * The system does not actually requires "single-payer" to fix. That is, indeed, a bit of a distraction. The core issue is that the decision about what to pay for and how much to pay has to be removed from private insurers. The decision what to pay for should be made on the basis of broadly accepted scientific protocols. It simply cannot be the case that "best practice" under the same indications calls for a C-section in Minneapolis and not in Miami. Recognizing the possibility of small differences that cannot be adequately captured in any general protocal, it is perfectly possible to devise a system that gives physicians and hospitals a budget for "exceptions" in which they are allowed to provide services that the protocol does not on its face allow. And it is relatively easy to monitor statistically whether particular caregivers are abusing that system. Management by exception. Prices for care need to be set in a standard cost system that covers the costs of inputs, with recognition of the costs that are responsive to regional cost of living and those that are national in nature. Inevitably, this requires a decision about the "standard income" of medical practitioners. There is no way around it. If we cannot allow supply and demand to determine the income of practitioners -- because that entails rationing care based on price -- then there must be another means of doing so. That is an ineluctable fact. Either the market sets prices for medical care and we ration based on price or, if we do not want care allocated by price, we have to have another means of setting price. This is the hardcore economic reality that the extremist free-marketers just don't get: there are exactly two alternatives, the one is a proven failure and the other a demonstrated success in many other advanced industrial societies. In the aggregate, the system must be designed to cover the necessary costs for the aggregate services that the population requires, based on age and statistical incidence of medical problems, something that will be relatively stable when the population is 300 million. Providers who cannot make it based on standard costs will go bust, just as all service providers who cannot make it based on market prices go bust. Providers who are more efficient and can do well based on standard costs will expand. Annual surveys of costs and profits should suffice to adjust reimbursement rates. With reimbursement rates and service protocols determined by the government (hey you free-market boobs, the alternative is to have them determined by insurers who pocket everything they screw you for), multiple payers can compete on the efficiency of their administration. Nothing wrong with that. They just have to be out of the business of setting rates and service protocols.

- roidubouloi

January 23, 2010 at 1:36pm

hey roi, I shall not hold my breath waiting for any rebuttal from dtoh, except that Americans don't like Socialism, so nyah. And, the Republicans solution to health care already exists in practice, yet has not solved anything remotely necessary to dealing with our problems. These "solutions" are already available HSA's or high deductible plans (by the way, they are already being sold, when I go on vacation to the US I buy a temporary policy, I am well enough off and well enough that I can deal with any emergency, but statistically speaking a few weeks a year ain't much of a risk) The Republicans solution to health care already exists in practice, yet has not solved anything remotely necessary to dealing with our problems. Dtoh have obviously never heard of the internet (wait, he did manage to find us, but he can't find the 25,800,000 hits for cheap health insurance you find on google?)

- blackton

January 23, 2010 at 1:58pm

Bsemple - Check your facts. We've been over this many times on this board. 1) The U.S. does not spend 17%. 2) The average for other countries is not 8 to 9%. Even if your facts were correct, the opposite conclusion (other countries are under-spending) is equally possible from a logical point of view. 3) And.. other countries do not have better outcomes. They have worse outcomes. 4) The profit motive drives insurance companies to pay for health care.... that's the business they're in, and that's how the economy works. 5) And yes, I know you believe the government can do a better job....that's the fundamental disagreement. You advocate a socialist approach. Others think the free market can do a better job. Roi, 1) Getting health care and paying for it are entirely different things. 2) All health care is not "needed." 2) Your argument is that insurance doesn't work and presumably all other contractual agreement don't work because the parties have a financial incentive to breach the agreement. ...I guess that's why you are advocating a socialist approach. 4) We are not paying twice as much. Care is better. Show me where people are being denied treatment. 5) The ties to the monied interests are not the monopoly of the Republicans (e.g. a big reason the Senate bill can't clear the House is because the unions won't allow it. e.g. Dodd's ties to the insurance industry.) 6) The rest of your argument is that the the government allocate health care and set the price. I respectively disagree. Also the alternative is not to have it allocated by insurers, but rather to rely on the mechanism of the market through increased use of high-deductible plans. I guarantee you the insurers would much rather have the Democratic plan than to have widespread adoption of high deductible insurance. Blackton - HSA is not the solution just something to encourage adoption of high deductible plans, which have..... had an impact, but a) it takes time and b) you need wider adoption of high-deductible plans before the impact is large. Also cost is not the only problem. There are two other specific problems. One, insurance needs to be available to everyone. Two, a lot of people can't afford insurance and/or care and need to be subsidized beyond what is being provided by Medicaid. (Not sure what internet hits have to do with anything other than to bolster the argument that consumers have an incentive to save money and the market is a good mechanism for controlling costs.)

- dtohmatsu

January 23, 2010 at 6:16pm

I find it odd, dtoh, that anyone would suggest that with 43 million people uninsured (or uncovered) we are doing better than equivalent advanced nations that cover everyone in the nation. Is water no longer wet, or something? I guess if you're in the health care business, then reaping greater profits from treating less people is a kind of success. Seems a little inhuman, however. But no massaging of statistics will get us away from one basic truth -- we are less healthy as a nation than equivalent countries. In terms of longevity, natal care, diet, and a bunch of other factors that almost bite you on the nose, so obvious they are. You may disagree, but I think that the skewed and unsustainable health care system we have contributes to a less healthy society. I don't know this, of course, but I strongly suspect that the Mass. system will begin to pay off not only for individual citizens of the state but also for the general health of the population.

- ironyroad

January 23, 2010 at 6:41pm

Irony, You make a good point, but I think you need to distinguish between three very separate things: Health, Health Care, and Health Care Insurance. The U.S. does a crappy job on Health and Health Care Insurance, but we do a very good job on Health Care.... probably the best in the world.....at least in terms of outcomes (I think you can argue and I would probably agree that we spend too much on health care.)

- dtohmatsu

January 23, 2010 at 8:09pm

Until you stop abusing numbers, dtoh, you can't be taken seriously. http://www.reuters.com/article/idUSTRE5510RC20090602 White House report says healthcare is currently about 18% of the US economy. All the other cites I see are to the same effect. If you have any reliable source to the contrary, let's see it. Contra to what you say, insurance companies are in the business of not paying for health care, not in the business of paying for health care to the extent they can avoid it. Your huffing and puffing about "socialism" and how the government cannot do one thing or another fails to address to critical issue: there exists no market mechanism for controlling costs without allocating care based on ability to pay. That is how markets restrain costs, by limiting consumption based on ability to pay.

- roidubouloi

January 24, 2010 at 1:24am

I'm not an avid supporter of state-run health care. But I am a supporter of universal coverage because only universal participation and contribution will trigger the economies of scale that the U.S. has going for it. Everyone has to pay in, in some way. In many respects, key ideas from "medicare for all," through cost controls via best-practice observation and application, to a genuinely competitive insurance exchange could all have a role to play in a reformed system. Indeed, other than administering the basic framework and regulating the operation of insurance contracts and payments, there is no reason why the feds should be involved deeper -- provided that the structure is in place to maintain basic standards. I agree that there should also be restrictions on medical liability in order to prevent health care turning into a bigger party for lawyers, but they should certainly not ban legal recourse in serious cases of negligence. Botton line" what has been missing from the story is a Republican Party with a serious interest -- I emphasize, a serious interest -- in doing this thing for the American people, and I'm bemused at the Dems' inability to make that truth stick.

- ironyroad

January 24, 2010 at 4:07am

Roi - OECD Health Care 2009 16%, but I'm not at all the WH is exaggerating. As for your other argument. A system where consumers are insured for catastrophic health care but pay most bills out of their own pocket will reduce costs. This is common sense. If you have to pay the first $5k out of your own pocket, you are going to shop for the cheapest provider, make sure treatments are necessary and maybe take a semi-private room instead of a private hospital room. For those who can't pay, the government could pay the premium for catastrophic insurance and reimburse insurance companies up to a reduced deductible which varies depending on income. This would avoid the problem of second class treatment for Medicaid patients and have the benefit of insurance companies proactively enrolling many of the needy and working poor who currently don't have insurance or are not enrolled in Medicaid.

- dtohmatsu

January 24, 2010 at 6:03am

Irony, I pretty much agree with what you're saying. I would advocate a) requiring all insurance companies to offer a standard high deductible policy whose rate could vary depending only on age, residency and weight, b) require that they post rates on an industry maintained website, c) allow anyone to enroll who is under 25 or has been insured in the previous year (to whack free riders who don't enroll until they are sick), d) prohibit insurance companies from selling any additional insurance to anyone who is not first enrolled in a basic catastrophic plan, and e) get the government to pay the premium on catastrophic plans for the poor and subsidize a lower deductible. As noted elsewhere, I strongly believe the government can not do a good job at resource allocation (i.e. determining what treatments should be given to whom and at what price). As noted, I believe the promulgation of high deductible will help to control costs. As for malpractice, I agree but I think you should have expert panels who provide compensation to patients who have been harmed by malpractice.

- dtohmatsu

January 24, 2010 at 6:16am

Why re-invent the wheel? The Wyden-Bennett Healthy Americans Act addresses most of the serious problems in detail, and it has ten Republican co-sponsors in the Senate. I suspect political empire-building has overtaken common sense. Bag the Pelosi/Reid monstrosity, and get new Congressional leadership. One way or the other, the latter is inevitable--either Democrats do it themselves, or the Republicans will.

- Robert Powell

January 24, 2010 at 2:22pm

Mr. Powell, you don't have the foggiest notion of the differences between the Wyden-Bennett proposal and what you refer to as the "Pelosi/Reid monstrosity," except that you intensely dislike both Pelosi and Reid so you assume that the bill that emerged under their leadership has to be a monstrosity. If you do think you know the key differences, by all means go ahead and explain them to us. dtoh, the rate in the US for percent of the economy devoted to healthcare is 17-18%, up from 16% in 2007. In France, the highest among OECD countries, it is 11%. http://seekingalpha.com/article/146992-comparing-u-s-healthcare-spending-with-other-oecd-countries http://www.dallasnews.com/sharedcontent/dws/dn/latestnews/stories/051709dnbusfrance.40cc221.html You are still making up numbers to suit your arguments. You also misunderstand price formation. You seem to think that "shopping around" lowers prices. It doesn't. It eliminates inequalities in prices but does not alter supply or demand in the aggregate and hence does not in the end affect the overall price level -- it is important in the flow of information that equilibrates supply and demand but does not alter the equilibrium. For the market to hold prices below their maximum level, demand has to be downward sloping, which implies that some people are not buying at the market-clearing price. Price rations the good allocating it to those with the greatest willingness and ability to pay. But if we want people who need care to to get it, then there is no downward sloping demand curve, demand is completely inelastic at a level that is techically determined (by your medical condition, not your appetite for consumption), and the market cannot restrain price. Medical care is then a tax, whether acknowledged or not. That's why our care is so expensive, because the medical profession is able to levy a tax. The standard mumbo-jumbo about the government allocating resources does not apply when the predicate to consumption is your physical condition, not your utility of consumption. You also seem to have very optimistic notions about people's practical ability to shop for medical care. What are you supposed to do when your doctor orders a lab test, get on the phone and start shopping around for lab test prices? Do you shop doctors for whoever orders the cheapest therapy? Is that how we want medical care to be consumed? In fact, government can do a perfectly good job of determining what treatment should be given to whom and at what price, as a minimum standard that must be paid for, as demonstrated by other industrial countries and by the VA in this country. In contrast, I as an individual have zero capability of establishing the proper medical protocols for my care; insurance companies are conflicted in wanting to minimize the cost; providers are conflicted in wanting to maximize the cost. But medical care is not a matter of taste -- like which cabinets you want in your kitchen. So, government is actually in the best position to allocate resources. This is not an ordinary consumer good where the individual's taste governs efficiency. Would you like to have consumers setting standards for jet aircraft? For aircraft carriers? For automoblie safety or drug safety? When the appropriate standards are technical and not a matter of taste, we need a common resource with the integrity and means to set standards -- that's called the government. You have some slightly familiarity with economic jargon, dtoh, but you don't really understand the concepts to which the jargon applies. Either your ideas about the efficacy of markets are immature or you are one of those free-market ideologues who takes no interest in how markets actually function and fail to function but just likes to repeat the jargon.

- roidubouloi

January 24, 2010 at 10:23pm

In my reading of the two proposals, Wyden is much more oriented to state, rather than federal, control. This is the most likely explanation for why it has so much Republican support. That, and the fact that most reasonable Republican Senators, and there are some, have been quite clear for some time that they have been systematically excluded from meaningful input where the Reid/Pelosi plan is concerned. Wyden has been working with them on this issue for years. You are correct in stating that I intensely dislike both Pelosi and Reid, and am assuming that by now this feeling is, or should be, shared by the President...

- Robert Powell

January 25, 2010 at 1:38am

dhurtado made hash of your reading over on "The Abyss." He is very polite in stating that he is still "missing" what you see as the critical differences between the current senate bill and W-B.

- roidubouloi

January 26, 2010 at 5:58am

dhurtado made hash of your reading over on "The Abyss." He is very polite in stating that he is still "missing" what you see as the critical differences between the current senate bill and W-B.

- roidubouloi

January 26, 2010 at 5:58am