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Open Thread | 260 comments (260 topical)
I'll admit that it is only (5.00 / 1) (#81)
by 1jpb on Wed Apr 02, 2008 at 03:26:58 PM EST
political convenience that inspires me to quote him because I don't think he's much of an expert on anything, but Michael Moore is on to something when he says that there is no best choice between the BO and HRC health plans.  He rightly notes that both plans leave the private companies soaking up income directly (gov payments) and indirectly (gov takes high cost, low profit patients) from the government's participation in health care.

Until we talk about a big reform that actually adjusts the power of the private companies I believe that BO has a better plan because he doesn't have an unfunded, regressive, mandate fee as high as 10% for middle class families who live pay check to pay but aren't poor enough for the subsidies (btw, the BO and HRC subsidy plans are indistinguishable if you  read them side by side.)

We know mandates don't work, look at MA.  Nearly half of the uninsured are still uninsured, and the system is out of money.  Many of the newly insured were simply put on existing federal programs, regardless of mandates.  Some people can't afford the least costly insurance so they pay the fee without getting insurance.  

Look at CA; the mandate plan only got 1 out of 11 votes in the committee, but big insurance companies were in favor of that mandate plan.  Why was that?  For that matter, why did the insurance companies favor the SCHIP expansion that Bush vetoed?  I'm in favor of that expansion, but at least my eyes are open: I know that the legislation is setup to provide income to private companies at the same time it helps kids.

Car insurance mandates don't work either.  The level of uninsured drivers is as high as 20% for states with mandated car insurance.

Listen to HRC carefully: she hedges by saying mandates are a "goal."  She has talked about them as a strategic starting point, so they can easily be tossed aside when it becomes politically expedient.  

People who can afford health insurance don't need a mandate "gun to the head" to make them buy it.  Most people who can afford health care have good jobs, so they get the insurance as a benefit.  People who can afford insurance but don't get it from their jobs already have a gun to the head.  If they have money and they have a health care emergency, they will spend a ton of money, or they'll go bankrupt.  The problem is not that we need a mandate "gun to the head," the problem is that costs are too high.  Costs must be dealt with before implementing a regressive mandate penalty.

Our health care system is way too expensive, and mandates will make this worse.  Our health care costs are paid by two sources: 1) the government and 2) the private sector.  The level of our government spending alone (excluding the part paid by the private sector) is not much less than the level of total health care spending in some developed countries.  Our problem is the entrenched insurance companies who live off the government money.  Our problem is that politicians invent programs like mandates that sound good to the public at the same time they greatly increase income to the insurance companies.

Until we get to a plan that confronts the powerful insurance companies, we need to avoid a regressive unfunded mandate that hurts middle income (but not poor enough for subsidies) families.  BO has the best plan.

[ Parent ]

Michael Moore's comment (3.00 / 2) (#145)
by badger on Wed Apr 02, 2008 at 04:02:59 PM EST
is about the same as Obama's vote against capping credit card interest at 30% because he thought that was too high. If you want perfection, then yeah, neither Hillary's nor Obama's plan is perfect. You can say that and still admit Obama's imperfect plan is much worse than Hillary's imperfect plan.

As to the rest, there's so much wrong it's hard to know where to begin, but one place is with the fundamental misunderstanding of who pays for health care costs. It isn't just the public and private sectors - if it were, the problem would be smaller.

The problem fundamentally is that health care is increasingly paid for by private individuals and the number of people who can fund, say, a coronary bypass out of income and/or savings is vanishingly small.

Just like on the MI/FL votes where people are concerned about the candidates, and don't care a whit about the voters, your post cares about punishing big insurance companies, and shows little interest in actually providing health care to indviduals and families who desperately need it - as long as the insurers suffer, it's all good.

And please don't tell me again that we agree 100%.


[ Parent ]

Michael, God Bless Him (5.00 / 1) (#182)
by SantaMonicaJoe on Wed Apr 02, 2008 at 04:25:23 PM EST
was a bit naive on his health care story. One, the problem is worse, and two, the problem is not what he thinks it is.

Yes, there is a great success story in Medicare, but Medicare claims have been administered by private companies, not the government, from the outset. There's a lot of crossover he didn't talk about.

There is the whole concept of fee-for-service. Doctors only get paid if a service is provided, so the incentive is provide services. Doctors aren't evil, but there are documented instances of unnecessary levels of service being provided (the US used to have the highest number of cesarians in the world, for example, but prenatal care was at an all time low).

There is a problem with cost-shifting, but here's the thing: some of that is reduce payments for medical services the public insists on, but aren't either medical or necessary. Not to over play the hand, but these do exist. Some of it is to protect profits, but necessarily for the insurance company. It protects drug companies, and the employers who pay the premium. And hospital corporations who are increasingly pressured to show a bottom line.

And then there's the whole back end thing. Going to an ER because you don't have a doctor, either because you don't have insurance, or you just don't have a doctor.

The insurance industry isn't a saintly institution by any means, but neither are they the complete demon in all this. The medical care inflation index has a lot more factors contributing than most people understand.

The thing is though, the industry is used to making reforms when those are passed on a state level (the only current effective regulator) and enforced. They have to be told, and they have to receive consequences.

But expanding the pool of insured persons will reduce the costs. It eliminates actuarial risk, a phenom in insurance when the people most at risk are the main ones who buy coverage because they know they need it, while the ones who will need it down the road don't buy until it's clear that they do.

The issue isn't simple.


[ Parent ]

Great response (none / 0) (#238)
by 1jpb on Wed Apr 02, 2008 at 05:13:12 PM EST
I know you know this; but for clarification, Medicare  can be fee for service (original w or w/o sup) or HMO/PPO/PFFS.

And, you are correct lots of health care providers rely on the fee for service Medicare payments to compensate for the deals they cut with the private insurance companies.  In my opinion this is an example of what I call private insurers indirectly increasing their income because of the government programs.

I loved your comments about adjusting payments for particular services, as is practiced most notably in Japan.  If you're proposing an overhaul to match Japan, you've got my attention, but you need the underpinnings too, and fine tuning is needed.  Sort of related to managing what procedures are done; Duke has shown that sometimes (depending the treatment facility) care for some medical situations can cost half as much because of less expensive, fewer, and different procedures, but the patients have better results.

To be sure large pools are good, but if something costs $11,500 (fam av 06) and you have no extra money, no amount of mandates will turn nothing into $11,500.  As I noted, BO and HRC have the same subsidy strategies, and they will leave out some so called middle class people.  Yes, BO mandates kids, fortunately the increased SCHIP, his new subsidies, and putting people into federal programs for which they have always been eligible takes care of most kids.  

Again, your comments about price controls as done in Japan was brilliant.  Your acknowledgment that talking price controls, in any way, is problematic in the US is 110% brilliant.  When ever Krugman et. al. talk about other countries they neglect two not unrelated facts. 1) our private insurers live off the government programs in fundamentally different ways than do private companies in other countries, and 2) the other systems presented as models have strong price controls in one way or another, which is a (perhaps the) critical difference.

[ Parent ]

So, a plan that give the insurance cos (none / 0) (#99)
by SantaMonicaJoe on Wed Apr 02, 2008 at 03:35:03 PM EST
more profit is a good thing?

'Cuz that's what Obama's plan is.

15 years in the insurance industry here. If you want to make them comply, you have to do it in steps, and make them used to it.

And PS: People don't buy insurance not because it's expensive. They don't buy insurance because they think it's not necessary. Sit by a medical underwriter for a day or so.....

[ Parent ]

Many people don't think they need it (none / 0) (#179)
by Manuel on Wed Apr 02, 2008 at 04:21:56 PM EST
I used to be one myself.  We used to complain while vacationing about how unfair it was that we couldn't just pocket the money our company paid for health insurance since we were healthy.

If mandates are so bad why is it OK to mandate that employers provide health insurance?

[ Parent ]

Yep. Anectodotal (none / 0) (#213)
by SantaMonicaJoe on Wed Apr 02, 2008 at 04:44:10 PM EST
but the lawyers we covered used to scream about suing when they found out the hospital bill wasn't going to be covered.

And I remember a baby with a heart valve problem. The medical underwriter was really upset about that one... I think we got an underwriter and a lawyer to make a special exception for that one. Based it on the potential bad PR....

[ Parent ]

Open Thread | 260 comments (260 topical)

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