I love Village wisdom like this, from David Ignatius:
To get started on these big reforms, Obama should propose changing incentives in the areas the government already controls — Medicare, Medicaid, care for veterans and military families. Once these giants begin to move, the private market will inevitably follow.
It’s about moving health care towards a Cleveland/Mayo clinic model (which I favor).
But it’s always — always — about entitlement programs with the Village. Entitlement programs are always the problem. The private sector always functions perfectly, given a chance.
For the life of me, I can’t see why the behavior of the private sector will change if we change public medical policies, unless the private sector is forced to compete with the public. Probably, Ignatius opposes a public option as “too divisive”. At best, he thinks it isn’t worth mentioning.
El Cid
So, Medicare can be made to encourage hospitals to reform along patient-centric, salaried doctor models? Really?
aimai
I just had this argument with a dude who was shouting at me that “if insurance companies could just sell policies across state lines” everything would be fine. You have to go all the way back to basics with these guys and even then you wont’ win. No, there is no magical number of for profit insurance companies cherry picking desperate individuals and offering them fradulent, partial, uninsurance policies that will solve the problem of paying for needed health care. As long as we treat health insurance like other kinds of insurance–in which the consumer is paying heavily and gambling that he won’t ever need the payoff and the insurance company is underpricing and gambling that they can deny payout–we can’t have a rational discussion of what to do about health care.
I try to say:
every person needs health care throughout their lives
good health care is expensive
it makes for good jobs–doctors, nurses, lab techs.
I want to find a way to club together as a society to guarantee everyone a minimal level of constant care and an adequate level of emergency care and a humane level of hospice/end of life care. I think we can best do it by bringing everyone on board and taxing everyone while they are earning so we can all be cared for as children and as unemployed or seniors.
But when you start to just talk to people about insurance they are so badly informed that they simply have forgotten that the point of health insurance is to purchase health care. The point of health care is not to pay money to insurance companies.
aimai
Leelee for Obama
@El Cid: I’d see this as a possibility if, and only if, Community Health Centers were the core of the Public Medical Model. I am only recently becoming aware of these places as anything more than the Clinics I used for awhile when my kids were small. That they have morphed into the good programs they are, and could one day be even better, is a major surprise for me. The CHCs could indeed do the Cleveland Clinic Model, fairly easily, and if they became the default Medical Home for almost all recipients of Medicare and Medicaid, then they could really impose market pressures on the rest of the system. What’s needed is more of them, with better funding, and most young Docs getting some help with loan forgiveness for a few years service. Primary Care would look much better in a decade.
MikeJ
If that were true, it would seem that there should be one state out of fifty (plus Puerto Rico, DC, Guam, et al) where health care is cheap and great and instead of ambulances everyone rides a pony. Can your friend tell us where that is?
aimai
I know, mikej, I wasn’t quick enough to give your response! I think the assumption is that either these would be tiny start up insurance companies (which, in the real world, wouldn’t have enough premiums backlogged to pay for your care) but which would leap into the fray to capture your dollars. I think that libertarian/macho/economics dudes are some of the stupidest people on earth and, worse, that their stupidity is of a particularly intractable kind. Like Megan’s commenters they have ahold of some magic terms “spread the risk!” “ammeurtize the cost!” “profit motive” “laffer curve” etc…etc… (while they dont seem familiar with externalities and free riders) and once they have incanted their words the listening part of the discussion is over.
TJ
Health care should probably be like a utility. And run the same way. But we won’t do this, of course.
El Cid
@Leelee for Obama: No, that’s not what I’m saying. It might be a great idea, but it won’t come out of Medicare — it would have to come out of some other reform, i.e., this current health care reform being proposed.
General Winfield Stuck
Most people in this country are pleased as punch with their health care insurance and don’t what that commie black dude messin’ with it. And if it wasn’t for them bellyachin’ few who have actually used their great healthcare and tell us them horror stories fed them by George Soros and the Dixie Chicks, this Murkin’ painting would be suitable for hanging (pun could be intentional, you RedoCrats!)
rmp
Let me ask a couple of question that I know I should know the answer to but I don’t.
1) The number commonly thrown around for the cost of health care reform (to the government) is about 100 billion/year. I understand the government is going to subsidize insurance premiums to those who need it but what are the other major reasons that reform is going to cost the federal government millions?
2) If there is a public option, and the government provides subsidies for people who need it, what will still be the need for medicaid?
Feeling ignorant …
rmp
typo above, meant billions not millions
rmp
oh, and one more thing while I’m ranting. WTF do people think when they say that if everyone had insurance that the lines at the Dr’s office would be too long? Do they really mean that we are lucky that there are so many uninsured because?
cleek
ask them: wouldn’t The Market step in and create more doctors to satisfy the demand ?
Sloth
It probably can, actually. Medicare is large enough and influential enough that it could probably legislate a move to electronic billing and institute other efficiency measures that the private companies could then either adopt or copy.
You would argue that the private companies could do this themselves, and they could, but they won’t (and haven’t) because it’s easier for them to simply fuck people over by not offering coverage, denying claims, and rescission than it is for them to do the hard work and drive down costs.
The invisible hand of the market is truly a wonder to behold when the incentives don’t line up with the societal good.
arguingwithsignposts
@aimai:
Well, given that Megan is herself known for apparently making shit up and then brushing past it when she’s taken to task, that’s not surprising about her fanboy commenters (does anyone notice their overwhelming maleness?)
JK
When David Ignatius appears on tv he should be wearing clown make-up to give viewers a heads-up that he is breathtakingly clueless.
JK
@arguingwithsignposts:
Megan McArdle is paralyzed from the neck up.
El Cid
@Sloth: No, no, no, no, no, the point isn’t to fetishize private medical care or anything — just that I didn’t see how the actual, existing Medicare programs could without legislative change bring about a transition to a more sensible hospital system such as the salary-based model.
Wouldn’t such goals require new legislation and new programs?
How the hell did you get from my comments that I was some sort of free market fetishist? My question was not with what should be but with what is.
El Cid
Every time I make the mistake of turning on GE’s “Marketplace” on NPR and I hear that worthless pinhead McAddled blurting off the reams of idiot lies, it reminds me why I hardly listen to NPR any more.
Sloth
Oh, hey, I did sort of imply that and I didn’t mean to. Sorry. That’s a sort of a general “you”.
I wasn’t sufficiently snarky, BTW, because what I really trying to say was that yeah, medicare can force the private industry to fix itself to some degree, because private industry’s easy path (so far…) has been to basically kill people rather than solving the actual problems it faces. So maybe medicare can solve the problems for it.
Which really *should* put a laserlike focus on “why the fuck does private this private industry actually exist, then?”
Irony Abounds
But the Mayo Clinic model IS the way to go. No matter what is done cost cutting is essential, and that model has shown the way to get higher quality at lower cost. I don’t care how it is done, but somehow provide incentives for all involved to follow that model and it will be much easier to provide health care for all.
MikeJ
Marketplace is produced by American Public Media, not NPR.
El Cid
@MikeJ: Pardon me — I mean, why I listen so infrequently to my NPR-affiliated public radio station which chooses to air a limited slate of programs produced by NPR, APR, etc., and it’s really a shame that Joan Kroc willed so much money to NPR specifically based on their news division performance before the invasion of Iraq, because they simply didn’t deserve, what with more genuinely useful news organizations than NPR.
Slaney Black
But it’s always—always—about entitlement programs with the Village. Entitlement programs are always the problem…For the life of me, I can’t see why
Rich people own bonds. That is why they hate entitlements.
Once you get used to the fact that all of our politics is driven by income investors, and there are only two parties – serving bondholders and holders of dividend stocks, respectively – everything starts to make sense.
Ivan Ivanovich Renko
The Clinic is one of the really great things about living in Cleveland.
Maus
“The private sector always functions perfectly, given a chance.”
Oh RonPaulogists, always waiting for the Truly Free Market that can never occur.
Leelee for Obama
@Maus: I’ve heard Somalia is the perfect laboratory. How’s that working out? Anyone, anyone, Beuller?
Political Pragmatist
Doug, I agree. It makes me nuts when people say this stuff. Medicare has LOWER costs per capita than private health insurers and as we all know Medicare has actual sick people versus none in the private insurers because they rescind their insurance when they get sick.
I believe the national average for Medicare is $6500 vs $7500 for private insurance.
For those who say Socialized Medicine is worse and government can’t run a health care system, the VA is I believe $3500 and their avg patient has way more problems.
Sloth
Spin that around just a tiny bit. If we moved 100 million people from private insurance to medicare, at their current rates, and gave the same the coverage as medicare (which, based on satisfaction polls, would be a big upgrade for them), we’d be adding $1000 a year in profit to medicare – since we can assume that medicare covering $6500 is an upper bound on cost, those over 65 being by far the most expensive to cover.
That amounts to about $10 Billion more allocated to medicare a year, before any cost savings are realized. Before you do anything else.
It’s actually probably at least twice to three times that much, since the new people are going to be less expensive to cover than $6500.
Talk about budget neutral.
KDP
This year the premium that I must pay, through my job, to cover myself and my partner went up 60%. My employer can no longer afford to fully cover my premium, and I’ve always paid for my partner (his employer doesn’t offer insurance). Last year, his premium cost me $586/month (the year before it had been 546, the year before that was 512, and prior was 456/month). This year, my share of my insurance was going to be 85/month, plus 402.50 for the partner. A total monthly premium of 910.00. I opted to downgrade the policy to one that is still adequate but has higher copays and a higher annual out of pocket. That took me down to 828./month; this is going to hurt. I’m already looking at what I can reduce or cut back on to offset the reduction in income.
I count myself fortunate that, this year, I can absorb the $250 pay cut, plus the additional out of pocket costs. But what about next year? And the year after that?
And what about all of the people who don’t have a high enough salary to absorb a $250 premium increase?
We need universal health care with regulated rates, now!
rmp
So tell me again where does the 100 billion per year cost come from? I can’t believe it’s all from premium subsidies to those in need.
Political Pragmatist
@rmp: “So tell me again where does the 100 billion per year cost come from? I can’t believe it’s all from premium subsidies to those in need.”
There are plenty of sources including increasing taxes on the rich–the one proposal would have raised a millionaire’s taxes $1500/yr–taxing the “luxury health insurance policies,” and through cutting Medicare Advantage, which adds huge costs for no “advantage.” (This is a private health insurance addition created by Republicans to shovel more money to insurers.)
Think of this, rmp. We spend 50% more and do not cover everyone. If we simply did it as well as every other industrialized country it would PAY FOR ITSELF!
rmp
Maybe I’m not making myself clear. I’m hearing that the health reform will cost our government 100 billion a year. Why will it cost anything more than the subsidies we give to people to help buy insurance and the administration costs to have a public option?
jl
Read the crazy old conservatie John Adams on aristocracy, he predicted it.
jl
Geez, do I need that edit function back.
Read the crazy old conservative John Adams on aristocracy, He predicted it.
A. Hidell
Actually, Medicare has been working on reimbursement models that support the “Cleveland Clinic” model. They are running a pilot where instead of paying on a fee for service they are paying globally for an “acute care episode.” I’m terrible with links and such, but it can be found here:
http://www.cms.hhs.gov/DemoProjectsEvalRpts/MD/itemdetail.asp?filterType=none&filterByDid=-99&sortBYDID=3&sortOrder=descending&itemID=CMS1204388&intNumPerPage=10
And Medicare is the big dog here. What Medicare does, the private insurers do a variation of within about 5-10 years. Simply because the claim volume at a large insurer can be 50% or more Medicare Crossover.
bellatrys
@El Cid:
Holy shit, she’s on Marketplace now? That used to be a *good* program.
…yeah, I haven’t been able to listen to it for a long time now. But they used to do shit like report on Blackwater abuses, even. And offer debunking of popular myths about economics.
How the mighty are fallen &c &c
ET
It is quite obvious that politicians and the political class who feel the private sector always works better have obivously never worked in the private sector. If they had the would realize that private companies can be just as innefficient, sluggish, etc. as government.