I wasn’t around to watch Obama’s speech yesterday. I did go to CNN later and try to listen to it. I haven’t watched cable TV in months and I don’t know if I was tired and thus vulnerable to confusion or sensory overload, but I had to turn it off. It was 30-second bursts of the speech interspersed with 30-second bursts of oddly high-pitched whining from Ryan, with Wolf Blitzer in the foreground shouting seemingly random questions. I saw Anthony Weiner hopping around trying his best to cut through the din but I have no idea what he said.
I read the transcript, and I’d like to try to answer this question:
Indeed, to those in my own party, I say that if we truly believe in a progressive vision of our society, we have the obligation to prove that we can afford our commitments. If we believe that government can make a difference in people’s lives, we have the obligation to prove that it works – by making government smarter, leaner and more effective.
Indeed. I say, too.
Medicare, the public single-payer program, costs too much. We’re paying too much for health care. We’re not getting a good value. The onus is on liberals (because we support universal single payer) to explain what we plan to do about that. If we want to protect Medicare or (wonder of wonders) expand public single-payer, we’re going to have to address this problem. It isn’t going away.
The conservative solution is to simply stop paying for health care past a certain random point. While not paying for health care beyond some arbitrary point is one way to cut costs on health care, we don’t support the conservative solution because it doesn’t address health care costs. It simply shifts them. In some cases it shifts them right out into the parking lot, but that’s still shifting. It’s dodging.
Medicare is a beautiful opening, because it’s a public single payer program. The advantage to that is we don’t have to go off track into the payment mechanisms, like we do when talking (fighting) about the PPACA and the for-profit insurance system. The Medicare payment mechanism is single payer and liberals support universal single payer. We can focus exclusively on health care costs (not insurance costs) when discussing how to save money on Medicare. I know that Medicare Advantage is a privatized portion of Medicare, but Medicare Advantage failed spectacularly as a cost control measure so it doesn’t matter for our discussion. Tried that. It failed.
This is one example of the Medicare cost controls contained within the PPACA:
The next cost control worth mentioning is an effort by Congress to solve the problem of, well, Congress. Medicare’s cost problem is, in many ways, a political problem: Saving money means cutting someone’s profits or someone’s benefits, and politicians are afraid to do either.
Enter the Independent Medicare Advisory Board. Modeled off of the highly respected (but totally toothless) Medicare Payment and Advisory Commission, IMAC is a 15-person board of independent experts chosen by the president, confirmed by the Senate and empowered to cut through congressional gridlock.
IMAC will write reforms that bring Medicare into like with certain spending targets. Congress can’t modify these proposals, it can’t filibuster these proposals, and if it wants to reject them, it needs to find another way to save the same amount of money. Making the process of passing tough reforms easier is the single most important thing you can do to make sure tough reforms actually happen.
Before we start yelling about rationing, let’s leave that to conservatives, and look at the law (pdf).
Here’s the substantive limit:
Prohibited from including any recommendation that would: (1) ration health care; (2) raise revenues or increase Medicare beneficiary premiums or cost sharing; or (3) otherwise restrict benefits or modify eligibility criteria.
In addition, for implementation years through 2019, mandatory proposals cannot include recommendations that would reduce payment rates for providers and suppliers of services scheduled to receive reductions under the ACA below the level of the automatic annual productivity adjustment called for under the Act.1
As a result, payments for inpatient and outpatient hospital services, inpatient rehabilitation and psychiatric facilities, long-term care hospitals, and hospices are exempt from IPAB-proposed reductions in payment rates until 2020; clinical laboratories are exempt until 2016.
These exclusions leave Medicare Advantage, the Part D prescription drug program, skilled nursing facility, home health, dialysis, ambulance and ambulatory surgical center services, and durable medical equipment (DME) as the focus of attention.
It’s gradual, and it starts with the programs that are most vulnerable to for-profit lobbyist…shall we say… input.
And here’s what Congress can do to trump the board:
The Board’s legislative proposal must be introduced by the majority leaders of the House and Senate on the day it is submitted to Congress, and is referred to the appropriate committees. The committees must report those recommendations, with any changes, in just two and one-half months, no later than April 1 of the proposal year, or the proposals are formally discharged from the committees. The committees, and the full House and Senate, cannot consider any amendment that would change or repeal the Board’s recommendations unless those changes meet the same fiscal criteria under which the Board operates.
Congress has to act (“with any changes”) or the recommendations go into effect.
Discuss this law or any other ideas on how control costs in public single-payer health care.
different church-lady
You appear to be attempting to discuss complex information in a thorough, rational way, like and adult.
On the internet.
I have no idea how to process this.
AAA Bonds
Well, if you read that transcript, you find a solid affirmation of cuts in Medicare, Medicaid, and Social Security, along the lines of the catfood commission, and along the lines of Obama’s stated position since he was running for President.
The rhetorical genius is that he merely failed to contradict any of his actual policy positions.
If you’re in favor of deep cuts in social spending during a time of high unemployment, I can see why you would like President Obama’s speech.
Certainly, the choice before us is a right-wing Democratic attack on these benefits, or a further-to-the-right Republican demolition of them.
dr. bloor
I got partially through your excerpts, but quit when I hit the part about not touching anyone’s benefits, not modifying eligibility, and not messing with payments. Presumably there was something about sparkle ponies for all after that.
Cap charges, ration care. Everything else is nibbling around the edges.
Kay
@AAA Bonds:
I’ll take that as an “I don’t know”.
TooManyPaulWs
This is a thoughtful, researched, coherent essay on the issue of Medicare as a budget issue and how it can be resolved.
I applaud the effort.
But I also know outside of this place, no one’s gonna pay attention to it because ZOMG Arizona wants to see everyone’s birf certificates and Donald Trump is gonna run and etc. :(
Kay
@dr. bloor:
These go first. The rest that you mentioned are phased in.
Villago Delenda Est
All health care, NOW, is rationed, based on ability to pay.
So this is a bullshit non-starter.
The first step is to accept the reality that health care is rationed, no matter how you provide it. It’s rationed by ability to pay, or if your insurer feels like taking a profit hit today, or whether you’re in the line at the hospital before the put up the “full” sign. It is rationed. Period. To deny this is to become unrealistic from the very beginning.
Let’s be honest about this “rationing” shit. For once.
OK, I might as well be hoping for those ponies that shit gold into the treasury that Ryan’s budget plan depends on.
Chyron HR
@AAA Bonds:
You forgot the part where Obama told us all very clearly that he loves Ryan’s plan and he’s going to work hard to make sure it becomes law, and he told us that by saying the exact opposite.
kay
@Villago Delenda Est:
Nope. Medicare isn’t. I think we have to answer the question.
Villago Delenda Est
@kay:
Kay, if you don’t have Medicare, then you don’t have the ability to pay.
It’s that simple.
Health care MUST be rationed by some means. “Supply and Demand” is a form of rationing.
If Medicare gives you health care without regard to cost (and you’re implying it does) then you’ve opened up the door
to fraud, waste and abuse that must be addressed.
I have no problem with doing this. It’s just that right now, we are doing next to nothing to address the systemic problem created by a for profit health care system. Inevitably, it will lead to people being denied the care they need because providing that care is not in the profit interest of some party.
Also, we need to get serious about end of life care. Keeping people alive for the sake of keeping them alive, without regard to the quality of that extended life, is folly.
This requires the sort of thought that most of the electorate seems to be incapable of engaging in.
Which again is where the profit mongers come into the picture.
Susan S
I have worked with retired clients and their money for over forty years. Not one of these ordinary people..teachers, doctors, truck drivers..could possibly have afforded private medical insurance at age 75, not to speak of age 85. Ryan’s proposal would decrease drastically life expectancy in retirement. That’s a given. 2nd issue..my 92 year old client went in for heart surgery ..complications arose..they spent 14 hours in surgery trying to save him..he died. He was 92!..Very difficult issue, but costs cannot be controlled without addressing same. Finally, the Medicare tax should be lowered to 1%..and applied to unearned income as well as earned..simple, fair, clean.
different church-lady
@Chyron HR: Say… this isn’t your first rodeo, is it?
Elizabelle
I foresee Senatorial gridlock confirming 15 people to the board. Obama cannot even get his choice to head Medicaid/Medicare through.
But you’re on to something, Kay, in that liberals and sane people need to address cost issues with Medicare in proposing single payer for all.
I would also suggest putting up some credible business (and other) leaders, of both parties, to espouse taking insurance coverage and costs off the backs of American business and coming up with a model more like European countries have.
If it’s good for business, and will help us be more competitive and healthier …
I think there’s a case to be made for it. And that we’ve got receptive ears in this country.
Just Some Fuckhead
I thought it was bullshit, Kay. We’ve already proved the worthiness of the social safety net. It’s ridiculous for Obama and Republicans to borrow a couple trillion dollars and give it to rich people, then say prove government can afford to help the poor and sick.
You, and he, are just underscoring Republican framing.
Southern Beale
This Thom Hartmann clip can’t be watched enough in my book …
atlliberal
One thing that has been talked about as saving money without “cutting benefits” is to change the way we pay for health care. Paying for outcomes rather than for each service is one way to do that. If the doctor knows he’s going to get paid based on the patient’s health, he has less incentive to order extra expensive tests, (even if he owns the MRI machine) and every incentive to get that patient healthy as quickly as possible.
PTirebiter
@AAA Bonds:
I’m guessing this is where you gleaned the solid affirmation you referred to, or was this the rhetorical genius? Maybe it’s just another one of Obama’s signature twofers. Damn, he’s scary good.
kay
@Just Some Fuckhead:
That’s interesting, because you were the first person here who said the problem wasn’t health insurance costs, the problem was health care costs.
I am sick to death of the word “framing”. You were RIGHT, Fuckhead, but now it’s all about “framing” or some shit.
I asked a simple question. I included an attempt to answer the question.
I guess your response is: “we will spend an unlimited amount of money of health care, because even raising this question means we’re Republicans”.
kay
@atlliberal:
That’s actually in the PPACA, a pilot attempt. It’s called “bundling”.
Just Some Fuckhead
@kay:
If you can spend trillions and trillions of borrowed money on permawar and subsidizing the wealthy and then say we gotta prove the poor and old deserve our help, yeah, you are a Republican.
kay
@Just Some Fuckhead:
You don’t have to prove the worthiness of anything. You ahve to explain how single-payer health care (like Medicare) controls costs.
I don’t even understand your attitude from a liberal of Lefty perspective. We have a FOR PROFIT health care system. You’re saying we’re obligated to pour money into it, without end and with no meaningful limits,, to prove some point about social safety nets?
That’s going to work out great for the for-profit health care system, but how much are we supposed to pay them?
Just Some Fuckhead
@kay:
That wasn’t my idea. That was Obama’s idea. Again, he and Republicans are the ones launching the assault on the safety net. Don’t then turn around and tell us we need to justify it. Here’s a thought: stop assaulting it asshole.
kay
@Just Some Fuckhead:
I’m not talking about shifting from one outlay to another.
Take the Medicare system, alone. Can we limit how much of available funds we pour into that? Can we ask for some kind of value for dollars spent? Because if you’re a proponent of single payer, Medicare IS single payer, so what the plan?
All of these questions are OFF LIMITS in the interest of framing?
Aren’t you the one who’s always worried about hall monitors?
kay
@Just Some Fuckhead:
Insurance, not health care, as you know.
Obama didn’t invent the for-profit health care system, and Medicare doesn’t involve a for-profit insurance system.
If you can’t answer the question, just say that.
Here, I’ll do it for you. Given that Medicare is a public single payer program, making all of my objections to the for-profit insurance system irrelevant, I can’t address the question of how to save wasted money on health care.
dr. bloor
@atlliberal:
This is also a great incentive to undertreat (or just run away from) patients, particularly those whose problems are likely to be most intractible and/or self-exacerbated.
slag
I dunno, kay. I feel like we’re hopping into the wayback machine for this one. Wasn’t a lot of this issue discussed during the ACA debate already? And to answer it on a meaningful level, don’t you kind of need to be a real-deal healthcare expert?
Not being a real-deal healthcare expert myself, I tend to defer to Atul Gawande (2 links) who, though probably making his living being the Tom Friedman of healthcare, at least explains the cost-control possibilities in a way that interests/informs me. And as has been mentioned, many of his recommendations come down to changing what we’re actually paying for–not rationing. However, it seems to me that quite a lot of restructuring needs to happen within the system before any real savings would be realized. But maybe I’m a pessimist.
kay
@dr. bloor:
Thanks, as usual with you on this topic, for engaging on the actual question.
Cris (without an H)
Piffle to CNN. The speech was available on whitehouse.gov before the day was over.
kay
@slag:
Well, sure, but if we’re promoting universal single payer, we already have limited single payer, and so I would think that we’d need an argument on how that controls costs.
I know the conservative position is easier. That’s a given. It’s also moronic.
NonyNony
@kay:
here, let me try:
JSF – given that the for-profit healthcare system of doctors, hospitals and other health-care providers is sucking money out of Medicare because Medicare gives them a blank check with no cost controls, what ideas do you have to fix this very real problem?
Kay ain’t talking about the insurance industry – she’s talking about the for-profit healthcare system. Corporate-owned hospitals and whatnot. Even with a single payer insurance system you’d still have the problem of cost control if the single payer system were “Medicare for everyone” because in the for-profit healthcare system there’s no incentive to control costs when there’s no pushback from the payer.
Is that better? Can you understand the question kay is trying to ask now?
kay
@NonyNony:
Fuckhead and I once had this discussion warring over the PPACA (I support, he opposes) and he was the first person here to cut to the chase that the problem was health care costs. Come to think of it, you were probably there, too.
I don’t know what happened to that person
Now he talks about “framing”, like some kind of hardened operative looking for secret Republicans.
sfrefugee
To: Question
Memo: Answer
No.
You are asking rational questions about how to provide medical care to the entire community at a price that produces both quality care and rational profits. Unfortunately, Conservatives believe that each individual is on his/her own – good luck. This is also known as the “hope you don’t get sick plan.”
The problem is you can’t argue with the magical Health Care Fairy who wishes fairness and economic rationality and “bing” they exist.
So – we have to stick with do nothing. The system is broken, but trashing it is not a solution. The best outcome is nothing, and wait for the situation to become clearer.
patrick II
@kay:
Yes it does. It exists in an environment created by a for-profit insurance system. Although Medicare is single-payer from the point of view of Medicare, Blue-cross is also single payer from the point of view of Blue-cross, Aetna is single payer from Aetna’s point of view. The entire system, however, has to manage the varied requirements, allowances, and fee schedules for all of these entities, of which Medicare is just one. Medicare does not cure that complexity.
In the 1990’s Taiwan went from a private, for-profit insurance environment to single payer. Thirty percent of Taiwan’s people had been uninsured. Now everyone in that country is fully insured with a governmnet run single payer system. And it costs no more than their old system did. Thirty percent increrase in coverage — no additional costs.
When medicare exists in a more cost-effective environment, it too will be more cost effective.
atlliberal
@dr. bloor: No it isn’t because if the patient doesn’t do well then the Doctor gets paid less. He has an incentive to treat appropriately.
I’m not suggesting this is the only answer.(Or that I have the answer) I am suggesting that in order to find the answer we have to think differently. We can go back and forth all day with “cut services” or “bankrupt the government” arguments and never solve the problem. It doesn’t have to be either of those two things.
Mark S.
@kay:
Here’s one way:
Developed countries spend on average 8% of GDP on health care. Shit, we spend about that much just on Medicare and Medicaid.
kay
@Mark S.:
But that doesn’t address the problems in Medicare, because your own cite says that administrative costs in Medicare are low.
That’s my point. Medicare includes the cost savings realized on 1. public single payer (no profit on insurance), and 2. the administrative costs in the for-profit health care system.
We spend too much on health care. You can’t get there with insurance savings and administrative, because those are realized in Medicare.
That gets you to the real problem, which is the cost of health care.
kay
@patrick II:
That’s an answer, so thank you.
JCT
@dr. bloor: Exactly.
And the elderly fit right in here.
We saw an interesting effect in NY when the surgeons had their “track records” posted. In the “old days” (OK, yes, back when I was in training) the Chief/Chair of Surgery would often take the most challenging cases, including so-called trainwrecks with poor post-operative prognoses. Once those rankings went up, those high-risk patients fell in the laps of the junior guys to keep the senior surgeons record all buffed up.
In the end, to get medical costs down we will have to change the nature of payment, medicine is very procedure-oriented in terms of billing/costs. That has to be drastically changed. We will also have to confront the sky-high (and largely futile) end-of-life costs. Not easy to do, but we just don’t have a choice.
Elizabelle
@Kay:
Popping in and out and have not read thread’s good comments.
But applauding Kay, again, for raising this issue, and think that it’s a tack that moderates/liberals would be advised to use on a lot of topics.
(1) Discussing how to improve the system is coming from a position of strength. It might be seen as weakness (sadly), but is not.
(2) Medicare and a lot of social programs are popular. Otherwise, the conservative think tanks would not have to work so hard to undermine them.
You will have receptive ears on actual plans to make a popular program work more efficiently and effectively and ensure its sustainability.
(3) Ryan and the GOP are offering Americans a path to serfdom and debt peonage, wrapped in the guise of independence and prosperity.
It’s not that hard, honestly, to come up with a better plan. And yes, it will take more tax revenue and shared sacrifice.
I think a lot of Americans would be willing to sacrifice, if they knew they and their kids would benefit in the long run.
Ryan and the GOP are trashing the future to get votes from a disappearing demographic in the present.
(4) Moderate politicians/liberals need to learn how to communicate more simply, and more repetitively.
It’s how the simple false messages of the right are implanted.
I would think a lot of people are appalled at how quickly “hope and change” turned into obstruct everything and where’s the birth certificate.
Work that.
Yutsano
@JCT:
We tried a common sense solution to this and it got twisted into death panels. But we all should have advanced directives regardless of age that determine the exact amount of medical intervention we want to have at the end of our lives. I have one and I’m 38. But it’s also pretty specific and written when I was aware and conscious enough to know what I was doing. That’s the real key with that.
patrick II
@kay:
Medicare administration costs are cheaper than a private insurer. However, it exists in a system where costs are generally higher, in part because costs are set by doctors and hospitals having to deal with the complex system they exist in. A hospital’s administration fees are enormous. Medicare gets cheaper rates than normal, and is internally less expensive, but it would be even less expensive it it did not have to pay some share of the cost of a generally inefficient system.
Joel
@Villago Delenda Est: Health care rationing goes well beyond ability to pay:
1) Geography; you’re a lot better off in Raleigh or Boston than you are in Roanoke or Springfield. You’re much worse off if you live somewhere far from the city…
2) Personality; hate to say it, but if you push for care, you’re treated better. Doctors share this observation all the time…
dr. bloor
@atlliberal: @atlliberal:
Not to put too fine or crass a point on it, it’s not particularly difficult to keep one’s record intact while getting “problem patients” off your caseload. As JCT mentioned, the most difficult patients are at risk to end up with those least prepared to treat them. I’ve seen some capitated patients get turned into human pinballs. Or hot potatoes, pick your tactless metaphor.
Chrisd
Controlling nursing home spending is a good start (I live in Ohio, the mecca for for-profit nursing homes), but that and all those other IMAB-approved targets barely address end-of-life costs, and that’s at least a quarter of Medicare dollars.
I’m with Dr. Bloor–cap charges and ration care. The rest is a lot of bad-faith discussion. Also, it would have been great if health care reform required sacrifice across the board (and by this I mean a FAR bigger hit to the insurance and pharmaceutical industries), but it didn’t, and that makes the inevitable rationing and provider cuts an even more bitter pill to swallow.
JCT
@Yutsano: It actually goes deeper than that. Those of us who are physicians are often complicit in that we are uncomfortable with saying “enough is enough”. It’s a fault of our training and the fact that we have also drunk the “we can save everyone” Kool-Aid despite the fact that we KNOW we should not save everyone. And these are scary decisions for families.
These sorts of brutal conversations are not facilitated by the focus on volume in primary practice because people have lost their connection with their physicians that help them have these important discussions. This is a real problem.
And I, of course, have an advance directive as well. But trust me, like almost all of them, there is a “reversibility” clause — in other words if your MD feels that your condition is acute and potentially reversible, extraordinary measures will be taken (think about an elderly person with pneumonia — do they get intubated or not?). This happened to my father-in-law and I had to have a full-fledged argument for days before I could get them to pull his tube and let him die like he would have wanted. And frankly, I was able to get this to happen because I was a physician and had an affiliation at the hospital. Otherwise, who knows how long he would have been unconscious on that vent — generating a huge hospital bill.
I have little hope for changes in the current political climate as real GROWN-UP conversations have to occur and all I can see are a bunch of freaking toddlers.
atlliberal
@dr. bloor: Fair enough. Though there could be an incentive put in there to treat those patients who aren’t going to have a good outcome, without giving them every test and procedure under the sun before they go.(I still remember the 96 yr old man I had who just wanted to die before his kids moved him to TX. He ended up in the ICU for weeks before he died, but at least he didn’t have to go to TX too. )
But there are still other ways to reduce costs other than either cut benefits or bankrupt the government.
catclub
@Villago Delenda Est: Nope again. Rationing is: “you have money and are willing to pay but you still can’t have any.”
This is: we won;t pay for it, but if you got the money, go right ahead.
The limits are recognition that the world is finite.
(But stupidity is infinite!)
Plus what kay said.
Chris
@kay: Medicare is, in fact, rationed health care. You cannot submit a Medicare form for your Magical Magnet Health Improvement treatment. It’s not on their list of approved procedures. (It’s also a useless procedure, so this a Good Thing.) It’s just not specifically rationed by price, unlike most of the rest of the health-care system.
HyperIon
@kay replying to someone stating we already have rationing that’s called “cannot pay”:
Several points:
1. Thanks, Kay, once again, for posting seriously about a serious subject. You are a treasure!
2. I have to give an example from my parents that addresses the “on medicare but can’t afford the co-pay” because there are co-pays for medicare. My father has macular degeneration and is receiving extremely expensive ranibizumab (Lucentis®) injections in each eye every six weeks. I saw the notice that medicare sends every month and the item amount was about $1600. If my father were not a military retiree on TriCareForLife, he would be responsible for the 20% co-pay ($320) every six weeks, which he cannot afford. But TCFL handles it. So only TCFL folks are getting this therapy (or patients of much greater means than my parents).
3. There are two drugs for his condition. The one cited above and bevacizumab (Avastin®). All the discussions I hear about wet macular degeneration treatment (from friends and relatives) mention Avastin, which costs about $50/treatment. Which is more effective? Which is more cost effective? We do not know currently. This gets into the pathology of BigPharma and FDA, which I don’t want to discuss now, just mention. In a more perfect world this info would be available and perhaps it could be shown that the cheap treatment is as effective. That’s an easy change to make to save money. But what if the expensive one is more effective?
4. I also examined one of my mom’s monthly statements from medicare and see that she racks up about $900/month in prescription charges (but pays $9 per prescription MAX). She is on Praxada now (the coumadin replacement). When she decided to change from cheap coumadin to the expensive replacement, cost was never an issue. But only because of the TCFL benefit.
I want my parents to get quality care and quality meds BUT I don’t see how we the taxpayers can afford to provide EVERYONE with this level of coverage. My parents are getting a medicare benefit that is not universally available: freedom from large co-pays and high drug costs.
So are non-TCFL seniors having their macular degeneration treatments rationed? I guess it depends on the definition of rationing.
Anyway I have no answers, just questions (and an opinion about how long TCFL will exist for military retirees).
kay
@Chrisd:
Right. But if Medicare (and Medicaid: nursing home costs) were effective at cutting health care costs (beyond the realized savings in insurance and administrative), that’d be a wonderful argument for expanding them.
The advantage you have in Medicare is some measure of control, by either Congress or an administrative agency.
That has to work, or we can’t point to it as something that has to be expanded.
That’s essentially Obama’s point: we have a single payer system for one group, and we’re defending that existing system and pushing for expansion.
Now SHOW that it can work at containing health care costs.
slag
I don’t know why my comment got eated, but nonetheless, @kay:
I’m not sure we can make that argument since we already have Medicare and we still have really high healthcare costs. Unless we try to argue that healthcare would be even more expensive for everyone if we didn’t have Medicare (Has anyone made that argument using realistic economic models? I’d be interested in seeing it), but even if, it’s still hard to persuade with alternative universe arguments.
In short, based on my limited understanding of the problem, I’m with patrick II. This is a systems-level problem and requires a systems-level solution.
Chris
@HyperIon: The Lucentis-vs-Avastin thing is a great example. It’s effectively the same drug, it’s just derived (from the same parent molecule) with a different process to make it “smell just different enough”, as it were, to get approved separately.
PPACA includes (as I understand it) a set of effectiveness studies for Medicare, which—if it can be applied correctly—should help push providers towards the cheaper-but-as-effective solution (i.e., increase the “ration” level for that one, while decreasing the “ration” level for the expensive drug).
HyperIon
@kay wrote:
Remember, he’s just some fuckhead.
Bruce S
“Medicare, the public single-payer program, costs too much. We’re paying too much for health care. We’re not getting a good value. The onus is on liberals (because we support universal single payer) to explain what we plan to do about that. If we want to protect Medicare or (wonder of wonders) expand public single-payer, we’re going to have to address this problem. It isn’t going away.”
This is actually posing the problem backwards – Medicare delivers full coverage at less cost than private insurance can do the same. The problem isn’t that Medicare costs “too much” but that our health care system costs too much. The burden of proof isn’t on Medicare, but on the system of delivery and – among other things – the slice that insurance companies take in “administrative” costs and profit. Compare our overall medical care costs to any “single payer” system across Europe and one can see that the problem isn’t in government-regulated universal insurance, but in a health care system that isn’t subject to the kind of cost controls that a universal insurance system can actually deliver. Medicare’s problem is that it isn’t the primary insurance system – or at least part of a universalized system that can enforce the kind of effective cost controls that, say, France delivers while also producing better overall outcomes. Don’t cede the argument and put the onus on Medicare before one even starts the discussion.
kay
@slag:
It would be. First, people put off care until they’re “covered”, and so Medicare covers that, and second, I have no idea what Ryan thinks will happen when we dump the heaviest and most expensive health care users onto the private insurance market.
That’s why the whole “generational” argument made by conservatives is such a crock of shit. Older people are cordoned off now. They’re not in, and health insurance is expensive. What happens when they enter?
The PPACA is a system. It was drafted within reality, to work within the existing system, and carefully constructed to not cause a massive disruption of 1/6 of the economy. It needs the public systems (Medicare and Medicaid) if it’s to work at all.
That’s what all those “you can keep your doctor!” assurances were about.
kay
@HyperIon:
Luckily, I’m shallow and unserious, so I’ll survive the internet dispute:)
HyperIon
@JCT:
i agree. and everybody in the conversation has to be a GROWN-UP.
however, the current batch of douchebag republicans cannot refrain from shouting “death panels” whenever they feel like it. so good luck with the conversation.
patrick II
@kay:
That works both ways. Medicare would be cheaper if the entire country was single-payer.
Bruce S
Look at the first graph here for starters – it’s all the argument one needs in favor of expanding single payer. Every liberal should carry this in their head – and it’s not some fantasy based on a paper hatched in the bowels of the CATO Institute, which is all the “free market” advocates of individuals competing for better deals in fully privatized markets have – it’s the real, actually-existing world of all industrialized countries that are also relatively wealthy, have aging populations, etc. and have at least as good or – more often – better care and outcomes.
http://titanicsailsatdawn.blogspot.com/2011/04/what-does-affordable-care-act-do-to.html
eemom
You are the best, Kay.
In fact you’re too good for this blog, love it to death though I do. You are the only FPer here who consistently thinks shit through and doesn’t talk out their ass.
Triassic Sands
Kay, I don’t think that represents the conservative solution at all. I’ve never heard a conservative call for less health care for him/herself or his or her family. The conservative plan is to simply not pay for health care at all for millions of people. Typically, rationing involves not paying for some procedures or drugs for some conditions because they have poor cost-benefit relationships. For example, there is a new melanoma drug that extends life, on average, for about 3-1/2 months and costs $30,000 per dose or $120,000 for a four-dose course. A new prostate drug extends life for a few months and costs $93,000 — and Medicare is going to pay for it. Is paying for one of those drugs the best use of our health-care dollars? I’m not arguing that denying these two drugs would solve any systemic problems, but if we can’t deal with questions like that, then we’re never going to solve the major issues. We can’t say “yes” to everything, all the time, so how do we decide what to say “no” to and when?
Should we deny a first bone marrow transplant (that has a reasonable chance of success) to a Medicaid patient, while saying “yes” to a second or third bone marrow transplant (that has almost no chance of success) to someone with private insurance or Medicare? If we get a single-payer system, then all people should be on an equal basis and there won’t be the difference between Medicaid and private or even Medicare. So, the decision to deny or approve will be the same for everyone. Right now we aren’t a mature enough people to make those decisions in an adult, responsible way. But someday we’re going to have to grow up.
joe from Lowell
Great post, Kay. Too bad you had to put up with the idiots.
One of the things I despised about the Republicans during the Bush/Delay era was that they had no interest whatsoever in governing. The entire purpose of government and of politics was to wage ideological and interest group war. What material should we use to repave the street? We shouldn’t buy it from liberals, and we should only pave streets full of people who voted for us! And is street paving even something we should be collecting taxes for, anyway? That kind of thing.
Same thing on this thread. How to control health care costs is one of the most important issues facing the country in the coming years. We’re not going to be able to afford decent care for a large segment of the country unless we do something about it. But we get these dumbasses who don’t have anything to say about the problem (which is fine), and denounce anyone who even asks the question because it’s not part of an ideological program.
“We’ve already proved the worthiness of the social safety net.” Yeah…no, that’s not the question.
Mark S.
@kay:
Huh? I thought you were asking why single payer costs less. If you’re asking why Medicare costs so much even with administrative savings, well, there are several reasons, the main one being it covers old people who need the lion’s share of health care.
There are some ways to save money on Medicare, such as ditching Medicare Advantage and bargaining with pharma companies.
HyperIon
@Bruce S wrote:
Exactly. I wish I could post the gif I captured from Kevin Drum some time ago that shows the cost of hip replacements in different countries.
So I will quote him: US average = $34K. “That’s 2X what it costs in Germany, 3X what it costs in France, and 6X what it costs in Switzerland. WTF?”
Now I’m wondering if I got it from Drum; he’s not really a WTF kind of guy. But you get the point.
This is certainly due in part to how much we pay specialists here. But that can’t explain it all.
HyperIon
uh-oh. i wrote a bad word (“specia1ist”) in my last comment.
waiting….
slag
@kay:
Hard to argue with this point. Although the airy-fairy conservative rebuttal lives in the “pathology” that HyperIon mentions (although I would extend it to the whole healthcare system). How did that pathology get there in the first place? The conservative argument, which I agree is moronic, is that the iron fist of the ironically impotent government created that pathology via Medicare and Medicaid. Make them go away, and poof, problem solved. No surprise there, but from a straight up rhetorical perspective, that argument seems to play fairly well in peoria. I’ve recently started to wonder if we shouldn’t change the dollar to say “In Magic Asterisk We Trust”.
Given that problem, how realistic is the idea that liberals can create an equally compelling message that explains what we want to do about it (or in the case of PPACA have already started doing about it) that doesn’t also involve magical invisible hands? Don’t moral appeals, as Fuckhead suggests, make a more compelling case for us here? Or are we, as a notoriously scientifically illiterate country, still capable of ferreting out and eliminating that damn Asterisk?
I like the way you said this.
Just Some Fuckhead
Kay, not ignoring you. Up to my ears in plumbing AND my freakin internet is coming and going so when I do take five minutes to reply, I get the page not found error.
There’s no need to prove anything. We’ve got the rest of the developed world to look for in terms of cheaper care and better outcomes. We already know what the issues are and we already know the best alternatives.
There is nothing to prove.
This was just the usual, look-at-me-I’m-so-above-all-the-partisan-bs nonsense that we’ve come to know and love from Obama. I was mildy critical of one side, now let me ding the other side. The real crime here is that he’s complicit in undermining the social compact.
Just Some Fuckhead
@eemom:
Well you should love that I suggested her.
HyperIon
@eemom wrote:
I don’t think that’s true. It’s the FPers cranking out lots of posts everyday who fall into that category. Folks who post at a more moderate rate are generally more thoughtful. Nothing too surprising about that.
eemom
@Just Some Fuckhead:
even a broken clock, etc.
HyperIon
@ust Some Fuckhead:
Is this true?
Do you mean that YOU suggested to JC that serious and substantive commenter Kay should be promoted to the front page?
If so, please consider changing your handle to JustSomeFuckheadWhoOnceHadAGoodIdea.
Bruce S
“Exactly. I wish I could post the gif I captured from Kevin Drum some time ago that shows the cost of hip replacements in different countries.”
Check out the chart I linked at Comment #60 – it’s got a comparison of US vs the other major industrialized countries re health care costs per capita. It’s obvious – overwhelmingly – that we have a more profit-driven, less regulated, more “private insurance overhead/profits” system driving up costs (also cost/profit shifts of pharmaceutical companies to the US market, where they can get away with it) which drives up our costs astronomically – nearly double what others pay – with no more effective outcomes. This is a real-world, empirical “truth” that no amount of theorizing by whiz kids at CATO or Heritage can make a dent in, unless of course one’s motive is to impose unhinged ideology imbibed from reading Hayek or Ayn Rand.
As I said, the issue isn’t the cost of Medicare – which as an insurance system is also demonstrably, by the numbers in terms of overhead, very, very cost-effective compared to the private markets – but a system that has huge pockets of excessive fees driven by profits and – yes – “competition” (such as regional over-investment in expensive technology and the push to recover those costs.)
patrick II
@Bruce S:
Fully agree.
slag
@Bruce S: The funny thing is that those charts were everywhere during the debate over the Affordable Care Act. Everywhere in the leftosphere. Couldn’t get away from them. They were probably even here at some point. And how’d that argument go over? It’s by the grace of Nancy Pelosi that that bill got passed. And it won’t become popular until it starts actually doing its job. Assuming it does its job.
HyperIon
@Bruce S wrote :
I am already familiar with it. Everyone should watch T. R. Reid’s frontline Sick Around the World. It goes into some detail of how other systems work. It is very informative.
Someone up thread mentioned (maybe one of your comments) that we just need to look at how other countries do it. I think that is the answer to Kay’s question. Nobody spends as much as we do with as poor outcomes wrt mortality and quality of life. Study all those countries in your graph and take the best ideas for the US.
Don
Just read all 70 comments, and not one mentioned health promotion and preventive care. A properly run health care system would be spending an immense amount of effort on promoting health and preventive care to reduce actual disease. Then the disease-care system has less to do. That could include such proven tactics as:
* Banning all tobacco and alcohol advertising—all of it, including promotional t-shirts and event sponsorship.
* After-school contraception clinics.
* Universal free access to drug and alcohol addiction treatment. (Properly thought of as disease treatment, but this has a big prevention component.) (Yes, I realize it doesn’t work on many addicts.)
Another cost savings is built into the single-payer system: under single payer, you pay less to collect the bill. Today every hospital has a roomful of employees who do nothing but produce insurance claims (under hundreds of different sets of rules) to maximize the hospital’s income. This eats a huge amount of money. Last time I looked the figure was 17 cents of every dollar paid to the hospital. Compare that to Canada, where there’s one payer to interact with, and they pay less than 10 cents to collect the bill.
One person mentioned nursing home expenses. We could eliminate a lot of cost (and a lot of disease) if people had better access to in-home care as an alternative to nursing home care. The current system reflects years of successful lobbying by the nursing home industry.
Obviously any single-payer system should be able to negotiate lower drug prices. And the government should be raising the bar for drug patents. Better yet, the for-profit drug industry ought to be in competition with a government-owned drug company.
There’s more, but that sure would be a start.
slag
@HyperIon:
The counter argument there is that those costs go to innovation. Here’s Ezra (2 links) on that.
OK. Enough with the deja vu. If we ever get universal healthcare will it cover Post-ACA Debate Stress Disorder (PDSD)? Because that may be the selling point we are looking for.
patrick II
@Don:
As I understood it, Kay’s original question was about ways to cut Medicare costs to demonstrate liberals seriousness about cutting the deficit. And, while I generally agree with you that preventive care is a good thing, I wonder how getting 65 year old medicare patients to attend after school contraception clinics would help cut medicare costs?
Mnemosyne
I think several people here have come up with the answer to kay’s question: Medicare/Medicaid is an efficient and low-cost way to pay for healthcare, but the problem is that the whole system, from top to bottom, is for-profit. Getting rid of the for-profit insurance companies will only take us so far because the government will still be paying for-profit hospitals, for-profit drug manufacturers, for-profit nursing homes, etc.
The really big problem with our healthcare system is that it’s set up so that everyone involved makes a profit. That’s going to be a very, very hard thing to get out of our healthcare system because companies like Tenet are going to fight tooth and nail to keep as much profit as they can.
kbcarter
I wish I knew the answer(s) – as one who sees the claims, though, I have to say: what the HELL are the real costs anyways?
e.g., I recently had a situation where one of our members incurred a hospital bill of $850K (his Medicare was maxxed), so we – as his supplemental carrier – stepped in as the primary payer. We hired a vendor to negotiate a discount with the hospital prior to payment.
We ended up paying a little over $300K. So I’m wondering if the hospital can write off $500K, how much are those costs inflated to begin with? Seems to me that if we are ever to get healthcare costs under control, we need to at least start with providers charging the real costs for crying out loud.
Our current system is insane, but Medicare – as it is NOW – is indeed a life saver for millions of Americans, and must be preserved as close to it’s current form as possible.
And the posts here are very thought provoking and informative. Thank you!
Glidwrith
One thing I haven’t seen anyone mention yet – I read a report saying that the suppliers to hospitals had themselves a cozy monopoly ring going, thus vastly blowing up costs. I read far too many blogs and comments, so I don’t remember where this was…sorry.
Nick
Check out Phillip Longman’s book Best Care Anywhere. I just finished it.
Apparently, the VA is much better at healthcare than most people realize. This could be a major beachead in the fight for healthcare. The VA often offers care that’s better, faster, and cheaper.
elm
@Bruce S: Exactly.
Medicare is one of the few parts of the U.S. healthcare system that does work.
Medicare spends a lot of money because of the rest of the broken system. For-profit pharmaceutical companies charge what they want, private health clinics provide services of little to no value, millions of people have access to health care only through the Emergency Room, and private insurers add directly to Medicare’s cost via Medicare Advantage.
Medicare is like the dressing on a serious wound. It looks strained, but it’s not the root of the problem. Our inefficient private healthcare system is the wound, it’s the root of the problem, and it’s what needs to be fixed.
Perhaps it’s reasonable to use Medicare as a tool to fix the rest of the health care system, but that doesn’t make Medicare the problem: that makes the rest of the health care system the problem and Medicare the solution.
If you frame the discussion in terms of “fixing Medicare”, then you’ve already given up a lot of ground to the Ryan & Republicans (who want to ditch the bandage and keep the wound).
Also, what @Mnemosyne said.
BruceS
“The funny thing is that those charts were everywhere during the debate over the Affordable Care Act. Everywhere in the leftosphere. Couldn’t get away from them. They were probably even here at some point. And how’d that argument go over?”
All over the leftosphere isn’t very many places in terms of the public debate that actually took place regarding health care. I’m not one who thinks that single payer had a chance, but it should have been part of the debate – and mainstream Dems should have been making the case regarding real-world approaches to delivering high-quality, effective medical care by countries with a variety of single-payer to “regulated, universal insurance” systems. Most of the stuff that comes from the “left” on this tends to be moralistic, but the argument should have come, starting with the White House, that there are far more economic ways to deliver effective care. The White House analyzed the political terrain, which is crucial, but I also happen to believe that they fell into the political trap of accepting the existing debate as a given, rather than trying to build some ground to the left of what they thought they could actually get. I had an Organizing for America apparatchik tell me that they didn’t know exactly what to organize around because they didn’t know what the bill would be! That is pathetic and characteristic of the alleged “grass-roots organizing” that the terrific campaign movement of ’07-’08 collapsed into, as sycophancy replaced Obama’s call to “Make me do it!” when he was running. I’m a big supporter of the President, but I realize that what he needs is folks out in front, blocking and tackling – not “standing with him.” If the 49ers had merely “stood with Joe Montana” he would have gone down as one of the most ineffective quarterbacks in NFL history. I’m actually sick over this neutering of the grassroots after the election – and realize that it’s on us, without relying on campaign strategists to build a movement. I’ll not make that mistake again.
Catperson
Healthcare does cost too much, for a variety of reasons. But Medicare’s solvency could be fixed by a buy-in option for younger people. Two reasons for that–1) Genuine competition for private insurance 2) Older people use more healthcare resources. Allowing younger people to buy in creates a broader insurance pool.
Insurance companies cherrypick, but Medicare has helped them by removing the “bad” cherries. (Please excuse the metaphor. I fully believe in Medicare and in providing medical care for everyone.)
Slightly tangential: Financially single-payer makes the most sense. But the possibility of right-wing reality-denying women-hating morons in Congress having power over my medical decisions makes me squeamish, especially if the idea of fungibility of federal funds catches on.
Catperson
@Mnemosyne: Totally agree. I also think there’s a cultural issue as well. We have a “more is more” mindset about healthcare and a fixation on pills as solutions to problems that leads to a lot of futile if not counterproductive care.
Don
@patrick II: To be sure, prevention programs aimed at teenagers are mostly of no benefit to Medicare for a long time. But if we’re tasked with demonstrating our seriousness, we have to think in terms of long run costs and benefits—against which standard the Republicans are laughably unserious. So yes, it makes sense to talk about promoting child and adolescent health as a means of cutting Medicare costs.
If you’re in a hurry to win the next election, can’t help you. There isn’t a large, ready-made constituency that gets it about single payer. We have to build the constituency, and that will take time and education—and politicians willing to speak the truth about single payer even if they’re going to get beat as a result.
patrick II
@Don:
I was just kidding about grandma’s at contraception clinics. As for single payer, if you read the previous comments you know I am already there. And I actually have some new hope. I was disappointed that it was not included in the ppaca act, but recently I find that something that is perhaps almost is good is included. And that is the right of each state to submit there own plan if it meets ppaca care and expense requirements. Two states, vermont and oregon, are rumored to be interested in installing single-pay systems. For me, that would be ideal, since if it is shown to be effective (as I believe it will be) more states will be willing to give it a try and it will grow organically as positive results are experienced.
Maybe I’m just a cockeyed optimist.
JITC
@kay:
The problem with Medicare is that it IS a limited system. It’s limited to a high risk group – an older (and therefore less healthy) population.
Open up Medicare to the entire population of the U.S. (or a single large state or a region) and you spread the risk across healthy and not-so-healthy alike and costs are controlled significantly.
Further, when more people are in a single payer system and more profit is removed from the insurance part of the equation, more dollars go to health care. So this larger single risk pool is less, risky, has more dollars to control and is therefore a larger price negotiator.
JITC
@patrick II:
Yep. And that’s why we need a single, non-profit insurer.
Not true, actually. Blue-Cross has thousands of chunked up plans (and therefore risk pools) within itself. Same with every insurer. Which is precisely why they offer better health plans for a company than it does for individuals.
They stupidly, and incomprehensively, dump similarly risky people in the same plan-types and therefore the same risk pool rather than spreading the risk around all risk types.
In fact, if Anthem/Blue-Cross saw all their customers as one big risk pool then all its customers would pay a heck of a lot less.
Instead, Anthem ekes out extra profit by charging different pricing to different people (e.g. more if you want pregnancy coverage, more if you’ve had an ingrown toenail as a teenager). Each plan type is a tiny risk pool.
And all those separate, different plans cause a bureaucratic nightmare for health providers (doctors, clinics, hospitals). Each plan, even each Anthem plan, has its own pricing, allowances, billing codes, co-pays.
So much money is saved by everyone having one, single insurance plan with one set of coverage allowances, billing codes, etc. Doctors could hire one office assistant to handle billing rather than outsourcing to a large, expensive medical billing company, which is what many do now.
patrick II
@JITC:
You are right, I stand corrected.
I don’t think it is stupid. If they had all people regardless of risk in one plan, another company would offer a lower cost plan to people with lower risk and pick off Blue Cross’s best customers. The market simply fails here.
shano
You know what would save Medicare?
Letting younger, healthier people pay into the program.
Thats right, Medicare for all.
JITC
@patrick II:
Yes, good point. And especially the conclusion that the market fails.
kay
@Just Some Fuckhead:
Sorry I couldn’t respond. I had to work.
I don’t think your answer is good enough, Fuckhead, because I think you and I both know that if we’re going to national single payer, things will change for the 94% of white college educated people who have health insurance.
The medical delivery system has to change. That’s what’s going to happen in Vermont.
I want you to tell me that you’re ready to accept that.
Something interesting happened on this thread, if you go back and read it. They physicians and others who are actually working in our current system called for changes to delivery of health care, some of which will be wildly unpopular. I think that’s because they’re dealing in reality.
As I’ve written here before, I’m up for that. I accept the risk, both personally and politically. I don’t think you have considered that.
kay
@:
You’re still talking about insurance. You’re still talking about administrative costs. That will get us part of the way there, but it doesn’t touch the cost of health care. The actual item.
I think liberals have to grapple with that. They’re doing that in Vermont. They’re betting heavy on community health centers, trying to wring value out of service.
Will people in Vermont accept that? I don’t know. I know the people who are currently uninsured will accept it, but I’m talking about the vast majority of people who have insurance.
It’s easy to talk about a big disruption of the current health care delivery system, and how wonderful it will be. Have you considered any of the ramifications of that?
Most people (voters) are insured. Most people (voters) like their current health care set-up (it’s all they know).
At some point, you have to move off insurance and administrative costs and get to the scary part, which is health care.
kay
@shano:
That’s the revenue side. What about the outlay side?
In other words, it is perfectly okay and even desirable to spend hundreds of millions of dollars on a bloated for-profit health care system, as long as we put younger people into the pool to cover the cost?
How does that solve the problem of the fact that we have the highest health care costs in the world?
You’re shifting costs. That’s all your doing.
Just Some Fuckhead
@kay: I agree the medical delivery system is going to have to change. But we still don’t have anything to prove.
Don
Well, the premise of the discussion is that we do have something to prove. I’m willing to play on that field, and suggested some ways to cut actual health care costs, beyond just administration (which is also real money).