How Conservatives Can Begin Thinking About a Public Health Option

~by Tim Kowal

Someone mentioned recently that conservatives ought not cast so many stones in the health care debate when none of them are coming up with any viable alternatives. I figured I’d use that as my cue to finally jump in and explain some of the principled ways that a conservative ought to think about health care.

Insurance: “You keep using that word. I do not think it means what you think it means.”

The first problem that keeps us from intelligently discussing health care is the vocabulary. Health “insurance” is not really insurance. Insurance is how we pay for something in case some contingency in a pre-defined class of contingencies occurs. Health “insurance,” instead, means something more like pre-paid health service, or a fixed-rate health plan. The point is, regular doctor visits, properly speaking, are not part of health insurance any more than oil changes are part of auto insurance. Of course, we know what insurance is supposed to mean. Most of us have car insurance. Many of us have home insurance, or renter’s insurance. We might even have insurance on the flat screen we bought at Best Buy. So why do we insist on speaking as if our annual checkups should be included in our health insurance? To be productive with talk about public alternatives to health insurance, we need to remember what insurance means.

The Dateline Effect

The next thing to think about is what exactly we are trying to accomplish with public health care. Noting the difference between “insurance” and something more like a fixed-rate health plan, it should be pretty clear that what we are not particularly interested in making sure everyone is able to get cheap doctor visits whenever they get a sniffle. My co-pay is just $10. Had I more time and less aversion to doctor visits, I would never opt not to see the doctor. I am not interested in the least in paying more taxes so that everyone can have such whimsical access to chat with the doc. The “least among us” are not known by whether they have ready access to a Wellbutrin prescription.

Instead, what we are after is eliminating the “Dateline effect”—gut-wrenching in-depth news-show stories about families just like yours and mine having financial ruin heaped on top of emotional ruin resulting from little Billy’s bout with terminal cancer, made all the worse by the plucky lad’s resolve to push on beyond all doctors’ predictions and cost estimates before finally reaching the end. That’s what the clamor for the public option is all about. People will still break their limbs and split their heads open and accidentally shoot their thumbs off, requiring the occasional trip to the emergency room. And if they don’t have insurance, they’ll grumble about how to pay for the services they received. But it’s not going to break anybody—and, more importantly, it’s not going to make Dateline. The stories of indigents struggling to pay off a few grand in emergency room bills are not the ones that are galvanizing the move toward public health coverage. If you can’t imagine a story about it on your favorite TV news journal, it shouldn’t be covered by the public option.

The Agony of Having No One to Blame

The other benchmark driving the push for a public option is fault, or rather the lack of it. When we hear about tragic health stories, the first thing anyone does is try to place blame. It’s the natural human response. If we can identify the cause—i.e., smoked too much, drank too much, carried on so fat, visited that dubious third world country, was negligent, etc.—the whole thing becomes much less terrifyingly arbitrary. Humans are stupid and silly and repugnant, to be sure, but at least they’re predictably so. And a surprising amount of satisfaction and all-around peace with the universe can be derived through comeuppance. At any rate, once we find the loathsome culprit, we can direct our fist-shaking accordingly. And then we can forget about the whole thing and get back to Dancing with the Stars.

But things like cancer leave us feeling so unresolved, at odds with the universe. Without someone to blame, we have no way to turn the grief into indignation. After a while, that dull sense of guilt that starts to really eat at us. It’s an entirely irrational guilt, of course. But guilt, like the rest of our emotions, does not shrink at name-calling. So after shaking our fists at the sky yields no results, we turn to the next most powerful and arbitrary force known to us: government.

So long as we insist on waging this war on guilt by devising a public health care option, let’s at least limit the scope of that war to those things that are actually causing the guilt—to those ailments that are not properly attributable to the fault of some individual. The test could be quite simple:

“When you discovered your ailment, what was your response?
A. ‘D’oh!’
B. ‘That bastard!’
C. ‘Goddammit.’”

The public option only covers C; both A and B indicate there’s already someone to blame—yourself or someone else—and thus the rest of us are quite capable of activating our grief-to-indignation conversion mechanisms without footing your bill.

That is the key to the whole thing, after all. This is a war on guilt, and whatever the cheapest way of beating our guilt is the way we ought to go. The best way, incidentally, is to just tell our collective guilt to go suck an egg. But since it seems we’re unwilling to do that, we should examine any public health option in terms of how well it assuages the guilt. I submit that only those ailments that are, by all accounts, arbitrary and owing to the fault of no one, should be covered by a public option.

Of course, I echo the sentiments of E.D. Kain in this post, and thus reserve the right to flip-flop upon further consideration.

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73 thoughts on “How Conservatives Can Begin Thinking About a Public Health Option

  1. I’m reminded of a Mitch Hedberg bit about alcoholism being one of the only diseases you can yelled at for.
    “God dammit, Otto, you are an alcoholic!”
    “God dammit, Otto, you have lupus!”
    One of those two doesn’t sound right.

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  2. So what you’re saying is that a person’s mistake or weakness should result in them not being able to access the health care that they need?

    If a college kid gets drunk and crashes into a light pole, they should be punished by the criminal justice system. But that person has paid into the national health care system. They’ve paid their taxes and should thus have the right to access the system they paid for. Doesn’t matter what they did.

    A person’s punishment in a civilized society should not involve the withholding of necessary medical care.

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    • I think “crashing your car” generally falls into the catastrophic category and the insurance category. Being a couch-potato and getting fat and then having the resultant health care problems probably does not…

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      • Who decides whose fault the ailment is?

        Does the government medical system get to do background checks and investigations and in-home visits to figure out if your heart disease is a result of one too many burritos or one too many years?

        That doesn’t sound very conservative to me.

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        • The idea would be probably to compile a list of certain ailments. With few exceptions, any form of cancer would be covered. Probably heart disease and other genetic diseases. I’m not well versed in medicine, so I’m at a loss for other suggestions to the list.

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          • Right, and how likely is it that the public would get to decide what goes on that list, rather than the vested interests controlling which diseases get put on the list? Regulatory capture will run wild.

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            • Willy – that’s (one of) the core problems with the public option to begin with. You can bet on all sorts of lists and preferred treatments etc. etc. and when it all comes down those will be heavily lobbied for and subject to massive regulatory capture. The whole thing is bound to be captured.

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              • Yes. But: 1) I’m not sure that will make for worse outcomes than we have now, since the big insurance companies have already captured the health system, and therefore could accept this if more people get covered in the end; and 2) Tim’s proposal doesn’t actually deal with any of this. It just says, look the government is going to decide on some set of things that we will and won’t cover using apparently some magical discernment formula that he made up that he seems to think people will accept despite the fact that it makes health care a whole lot less easy and reassuring.

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                • For one thing, yes, I am making this up as I go, thank you very much.
                  For another thing, why on earth would we insert the condition that a public option ought to be “easy and reassuring”? If you’re one of the sods who’s on the public system, you ought to be plenty worried whether you’re covered. Why remove the incentive to get off the public dole?

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                  • It needs to be easy and reassuring because you need to sell this plan to the public. You can’t honestly imagine we can just tell people, sit back and shut up, we don’t care if you like this plan, trust us it’s good for you… can you? People want the government to deal with what they now see as a big problem with health care. Those expectations need to be met or managed. Something that looks like (indeed, is) it’s going to make it a lot harder and cost them a lot more to get care when they are sick isn’t going to sell.

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  3. Furthermore, this idea would penalize victims of an accident or a criminal act.

    Say you get shot in the leg by a mugger. Under this idea, I gather, you’d have to sue the mugger for damages in order to pay off your medical bills? You’d have to front the fee for a lawyer and deal with all the legal hassles, not to mention there’s probably not going to be anything to collect anyway.

    Doesn’t make sense.

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    • How does this work at this point in time? Honestly, I don’t know. I’m assuming your normal insurance would cover it. If you didn’t have insurance, I’m assuming the hospital you went to would get footed with the bill – and maybe lump it back off on you unless you could get state coverage. I’m assuming that being shot might be an outlier here – I certainly think it would be covered under catastrophic…

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      • Yes, normally an insurance plan would cover it.

        But this piece argues that someone who’s covered by the public option insurance plan would not be covered – because there’s someone else to blame, so the mugger should be responsible for paying.

        “I submit that only those ailments that are, by all accounts, arbitrary and owing to the fault of no one, should be covered by a public option.”

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    • You’ve got the general idea–civil suit to recover damages. But there’s no reason we could not create a process by which some preliminary discovery could be had to determine whether anything could be recovered from the bad guy and, if not, plaintiff would be entitled to draw from the public option.

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      • So the burden is on the person who’s injured to prove all this? He has to go through some huge bureaucracy and the legal system to keep from being stuck with the bill? Who pays for the lawyers?

        It all sounds profoundly unconservative to me. You’re talking about creating a whole new bureaucracy empowered to decide whose fault a particular illness or injury is.

        No-fault would be infinitely simpler.

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  4. If you are going to define insurance, at least apply the definition properly. Why not claim that retrospective workmen’s comp isn’t insurance why we’re at it. And since when did a broken become the equivalent of an oil change or cancer become the equivalent of a new set of tires?

    I don’t even know where to begin with the rest of your piece.

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  5. Alright – I do have problems with the proposal. First of all, if we hope to achieve any reasonable success in health care terms we need to have strong preventative measures in place and easily accessible. Otherwise you have people basically avoiding doctors and avoiding care, and then something big just boils up waiting to happen. Then, whatever that is, gets foisted off on the public system or the hospital or whatever.

    If we do involve government I think the best way to do it would be to provide some sort of means-tested catastrophic insurance – and more and more I think we need to mandate this. If you can afford it you can buy it, if not, you get a voucher for it. Then you also get vouchers for people – maybe scaling in amount depending on income – to purchase either health care directly, or to buy into a plan or a co-op. Then, hell, have the government write grants to local communities to build community health centers that fit their needs and offer cheap preventative care. Staff them with nurses and nurse practitioners.

    I could go on about breaking up cartels etc. but I won’t.

    A good idea for progressives would have been to just fight to expand Medicare and maybe work toward some catastrophic coverage plan. It doesn’t look like that’s going to happen.

    I do think a lot of what Tim is saying in this post about collective guilt, etc. is right on the money. Of course, we should be collectively guilty for some of this, but that should not be how we come to policy decisions. I also think that he makes a strong point that getting into the mindset that we should purchase our basic health care is very important. I hope that even under a public option we will require some form of payment either out of paychecks or up front, though there are better ways to do it than that – ways that make people conscious of their decisions and responsible for them to some degree.

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    • I was thinking the same thing about prevention. But then I thought, if the guiding principle is assuaging our collective guilt, then only limited prevention measures are needed. This can be accomplished with a biennial checkups, probably at a checkup farm. Think high school physicals. Hell, maybe even a mail-in survey.

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  6. Last October, I suffered a sports injury – I slipped and fell on the ice while playing broomball (an intramural version of hockey sans skates) and dislocated my right shoulder. A trip to the ER was required – the doctor reset it, took a couple X-rays to ensure there was no bone damage and I walked out an hour later.

    My response to the ailment was definitely “D’oh!” Nobody forced me to go out on the ice, I didn’t get pushed, I just misjudged my speed and went flying.

    So, if my insurance was public option, should I have been covered?

    Point is, everyone engages in behavior that may result in their being injured or sickened. Skydiving is a risk. Swimming is a risk. Driving a car down the Interstate is a risk. Walking across the street is a risk. Having a beer is a risk. Eating a chicken wing is a risk.

    Are we prepared to empower a government bureaucracy to determine how much risk we can take on before we get dumped from the public plan?

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    • If you want to have risky hobbies, that’s something that I think you should be allowed to do, so long as I don’t have to pay for them. Body check one for me!

      My problem comes when the benefits are all localized and the costs are all socialized (my biggest problem with corporation/government collusion) and I (among others) am put on the hook for the risky lifestyle choices of others and I’m paying the same for health care even though I eat right, I drink in moderation, I quit smoking, and walk a mile every day.

      Answers involving the government asking intrusive questions like “do you smoke?” or “do you have unprotected sex?” are intolerable to me as it’s not their right to know that… but that also means that they will have only one-size-fits-all insurance coverage which means that there will be an intolerable number of “free riders” on the system.

      And none of this seems to address the problem that there isn’t as much health care out there to ensure that everybody who needs some can have some.

      Jeez Louise. The Mustang Ranch in Nevada got taken over by the government and the government couldn’t handle selling booze and (redacted) and the brothel closed down. I don’t see how putting them in charge of insurance will turn into anything less of a fiasco.

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    • Well, I imagine if you had the funds to skydive you could probably afford to buy some insurance.

      It might help also if we had a cheaper medical apparatus, that made things like getting a bone set cost a whole lot less than having to go the emergency room and pay a doctor and staff and ambulance, etc.

      The public option, if it pays for everything than can possibly go wrong, will explode in costs without smart changes to the system, which would require that we seriously change how we think about medicine.

      And I think the only way we can justify a lot of expenses in the public option is if people of every income bracket are paying into the system. It can’t be free.

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  7. Travis: you’re asking the question of the wrong guy. If the decision is mine, I say, no public option at all. Break a bone, get diagnosed with cancer, none of it’s my problem. My post is about if we insist on having a public option, let’s at least identify why we’re moved to do so. And the answer seems pretty clear: guilt. Guilt-assuasion, then, becomes the guiding principle. If I’m your buddy, sure, I’d like to see you get covered for your ice-skating accident. If I’m just another John Q. Taxpayer to you, then I feel no compunction to apportion my tax bill towards your extra-curricular injuries.

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  8. guilt != empathy

    The implication that universal health care is some sort of content-free sop to make us feel better about ourselves is. . well, I understand why the author considers himself a conservative. It seems to be a modern conservative pastime to try to dredge up why exactly liberals pretend so much to care about other people, since it’s clearly impossible to actually care.

    On the specifics: I think there’s some merit in disambiguating true catastrophic health insurance from cost pooling routine health care, but you’re ignoring the reason that they’re bundled up. Because they’re both provided by the same agents (doctors) at the same facilities (hospitals and clinics) and the line between them isn’t even particularly clean. Advanced cancer is one, yes. And getting a wart removed is another. But what’s pneumonia? My son has a congenital heart defect. He tends to have to go to the hospital for routine illnesses (like the flu) due to his being at greater risk. Do those extra X-rays and so on constitute normal health care because of the proximate cause or are they insurable due to the distal cause? For the cost and stress you’d get trying to create this disambiguation, you’re much better off just calling flu shots and stitches insurable.

    On the Dateline effect: Certainly coverage of catastrophic events is the highest priority, but you ignore the fact that an accumulation of minor events can become catastrophic. Is diabetes catastrophic? It gets expensive over time. Also, suggesting that we want to avoid hearing about stories on Dateline is more of that perverse conceit. Obviously if you want to avoid hearing gut-wrench stories on Dateline, you can sell your TV. Problem solved! Actually, we want to avoid the underlying events.

    Blame: Again, more weird psychoanalysis. The reason most people want a comprehensive health system is because we don’t want people to have to pile financial ruin on top of bodily ruin, because we empathize with such plight, plus ‘there but for the grace of God’, etc. I’m not sure how guilt enters into it.

    If you really believe that the goal of the whole enterprise is to assuage guilt, then the cheapest option is simply to stop caring about other people, and then hey, no guilt for free! Enjoy.

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    • I agree with this poster – guilt and empathy are two different things. Both might be in play, but it is insulting to human nature to pretend that no one cares for a stranger except out of guilt, that no empathy exists in us at all.

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      • Political discourse requires that we think of ourselves as two different selves: a human, and a citizen. We carry very different sets of duties and obligations in those respective capacities. Please note that my general apathy towards other citizens is expressed wearing my “citizen” hat. Similarly, just because I would give everything I own for a loved one, I reserve my right to object to every penny taken from me in taxes to give to other nameless faceless citizens.

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        • True, but just because you object to every penny taken, doesn’t mean I do, and it doesn’t mean I do so out of guilt, or out of guilt alone. I dispute the behavioral psychology assumptions about human nature that underly your post.

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    • Pneumonia and other conditions might not be anyone’s fault, but they’re probably not going to be frequent enough to bankrupt anyone. Thus, it’s not going to cause society at large any real guilt or grief or sadness (the terms for the psychological motivation at play here can be used loosely).

      I’m not sure why it would be hard to legislate care regimes for congenital heart defects any more than it would be for cancer. Both of those would pass either standard I’ve set forth (gravity of the condition, and absence of fault).

      Again, I suggested in my original post that the best way to solve our problem is to dump the utopia project and learn to live with the reality that life is full of real bummers. So long as we are not going to do that, these are some ways we can think about achieving our implicit objectives.

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      • Hm. My better self would say to let this one go, but I just had an ice cream drumstick (side note: possibly eligible for ‘guilt’ for diabetes under future health care regime) and my better self is knocked out from a glucose spike.

        Pneumonia and other conditions might not be anyone’s fault

        Maybe they are. What if my kid got pneumonia because a mother knowingly sent her sick kid to school because she needs the school to babysit because she can’t take a day off work? In your care regime would I have to pay for it out of pocket and then sue her in a civil case to get my money back?

        they’re probably not going to be frequent enough to bankrupt anyone

        But now you’ve moved from a fault standard to a financial viability standard. How do they interact? What if it’s cheap but nobody’s fault? Or someone’s clear fault but debilitatingly expensive? Assuming you would endorse coverage for the expensive, you have to recognize that a financial standard will just compress everyone around whatever poverty line you want to make the standard. I can pay for all of my chemo out of pocket until I’m out of money, and then hey! you can pay for it until I have some money, and then I get to use it again to. .

        guilt or grief or sadness (the terms for the psychological motivation at play here can be used loosely

        No, not really. There’s a pretty profound difference between motivation by ‘guilt’, ‘sadness’, ’empathy’, ‘justice’, etc, and I would hope any hat-in-the-ring attempt to offer a conservative foundation of health care policy would address it.

        I’m not sure why it would be hard to legislate care regimes

        You want Congress to legislate the care regime for my son? That’s nuts. Also, the opposite of ‘getting the government out of care decisions’ which I kind of thought was the foundation of the conservative argument against public health care.

        utopia project

        I’m not sure why you consider a health care policy that is working fairly well in any number of other well-functioning nations to be a ‘utopia project’. I mean, I’m not uncritical of whatever crap the Democrats want to pass and I have no illusions about anything profoundly good making it out of conference, but it’s hard to take a critique seriously that pretends France doesn’t exist.

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        • I proposed two standards that have to be satisfied, one based on the financial impact, the other on fault. If a condition fails either, it doesn’t trigger the requisite public emotion to require them to dig into their pockets to pay for it. That’s the idea.

          A fair amount of thought and debate (and risk of capture, as others have pointed out) would have to go into building that list of conditions that would be covered. I haven’t done that legwork yet myself, admittedly. But the idea would be that they would be fairly black and white. At the fringes, there would be judicial remedy, probably through an administrative court.

          I don’t understand your objection to my loose use of guilt/grief/sadness. I’m just talking about whatever the peculiar emotion we have collectively that’s galvanize this move to a public option that apparently we have to ram through right away.

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  9. Shorter Tim- Conservatives can begin to talk about health care by being up front about using strawmen arguments, not understanding the concept of preventative health care and being selfish.

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  10. Ezra Klein posted something a commenter wrote yesterday. I wasn’t sure it was completely apt, but then I read this post. Epicycles indeed, Tim. Could you make the system any more complicated and subjective and open to interpretation and litigation than you’re doing here, all in some wrongheaded attempt to name a Great Authority of Payment to step in to replace all the other people that are already between people and their health care providers?

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  11. Shoot, here’s the Ezra Klein piece I was referring to.

    Before Copernicus, people generally believed the sun revolved around the earth, but as we got more data it became increasing hard to reconcile this basic idea with the observed facts. People thought up the Ptolemaic system in which the heavenly bodies didn’t just revolve around the earth, but they revolved in small circles called epicycles as they went around the earth. That eventually turned out not to be sufficient, so they hypothesized epicycles within the epicycles. The last few iterations of the Ptolemaic system were incredibly complicated messes that were almost beautiful.

    That’s what we are doing today with health care reform. We want a “uniquely American solution.” So we have weak plans, strong plans, coops, exchanges, individual coverage, community ratings, etc., etc., etc. I still haven’t seen we are going to handle the problem of people with pre-existing conditions. If we cover them, people will take out minimal insurance until they get sick and then switch. We need some more epicycles.

    If Copernicus were alive today, I am sure he would say, “If you simply give everyone Medicare, you wouldn’t need all this complication, and I’ll bet it would be cheaper, too.”

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    • Yeah, I still don’t quite understand why this wasn’t the preferred method. It would be cheaper and easier to pass and wouldn’t run nearly as many risks as other approaches. I’m confused.

      But you’re right – Tim, your ideas make sense in a lot of ways, but in the end you’re opting for way too much government control and it’s way too vulnerable to bad-decision-making and capture.

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      • Even if that were true (I truly haven’t thought enough on it), the idea is to make the scope of the public plan much smaller than what we’re currently talking about. So even if all the shenanigans that go along with a smarmy government program turn it into a circus, it’s a side show rather than a big tent circus.

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        • Tim, here in essence is why your post misses the mark, and more generally why conservatives are seeing the health care discussion move on without them. You just said, “the idea is to make the scope of the public plan much smaller than what we’re currently talking about.” What the public wants is more people covered, and less general risk to themselves that they may get sick and not be able to afford getting care.

          It sounds like you, and conservatives in general, want to say, “Poppycock. This isn’t a proper concern of government.” I’m not 100% sure that’s what you believe, but that’s the attitude that comes across in your post and your comments. If that’s the case, you’ve lost, and relinquished control of the solution to liberals.

          I think the more fruitful avenue to go down, the one you in fact start off your post heading towards but then veer off of sharply, is to recognize that the public’s goal is to broaden the scope of health care to affordably cover 100% of people, and then to ask, what’s the most conservative, limited means for accomplishing this? How do we meet the public’s demand while doing the best job at mitigating the potential for corruption, waste, regulatory capture, over-reliance on centralized “experts” likely to be too far from the situation to make good judgements… that would be a serious policy discussion. Instead, you dismiss the concerns of the people or look past them as if they are silly, and classify as “poor sods” — essentially, losers — the people who may actually need to rely on such a plan while characterizing anyone else’s desire to address the issue as a collective guilt-induced delusion.

          You don’t really believe providing health coverage to people is necessary or desirable, so it’s only because you’ve had your arm twisted by the likelihood that this is going to happen no matter what you think. So you offer a half-hearted attempt at abstract principles that betray a sense of condescension and superiority towards the affected people. You’re no doubt smart enough to realize that you aren’t going to have any credibility with the public when you start from a place of looking down on them or dismissing their concerns as misguided. Unless you start from the desire to serve the public and genuinely act in their interest — to address what they want but really create what they need — you just aren’t going to be helpful. And in the end people choose to listen to other people they think are helpful.

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          • There is actually very little here that I disagree with. To begin, the point I most take to heart regards the perceived condescension and superiority in my post and/or comments. This I do regret. Of course, I hope it is understood that a bit of color is added for purpose of making the reading a bit more enjoyable, rather than to beat anyone over the head or to intimidate.

            I recognize that the health care debate is going to get away from conservatives. Conservatives ought to do what they can to rein it in, of course, but by and large I realize that we’re going to be saddled with a very unconservative, unprincipled, and I daresay, un-American health system. You and others have mentioned that this is what the people want, suggesting that this alone makes it legitimate. If this were a pure democracy, perhaps it would. But it is not. Our founding documents reflect higher principles than simple prevailing sentiment. The prevailing sentiment on this issue is perhaps enough to ignore those principles. But the train will come back around to the station sooner or later.

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  12. THIS IS IT!

    The healthcare reform bill released by the House Of Representatives is an excellent bill as I understand it. It is carefully written, and thoughtfully constructed, informed, prudent and wise. This bill will save trillions of dollars, and millions of your lives.

    This is the type of bill that all Americans can feel good about. And this is the type of bill that has the potential to dramatically improve the quality of healthcare for all Americans. Rich, middle class and poor a like. Democrats, Republicans, Independents, and all other party affiliations. This bill has the potential to dramatically improve the quality of life of every American.

    The house healthcare bill should be viewed as the minimum GOLD STANDARD by which all other proposed healthcare legislation should be judged. All supporters of true high quality healthcare reform should now place all your support behind this healthcare reform bill released by the United States House Of Representatives, as the minimum Gold standard for healthcare reform in America.

    You should all now support this bill with all your might, and all of your unrelenting tenacity. This healthcare bill is a VERY, VERY GOOD! bill for all of the American people. Fight tooth, and nail for every bit of this bill if you have too. Be aggressive, creative, and relentless for this bill.

    AND FIGHT!! like your life and the lives of your loved ones depends on it. BECAUSE IT DOES!

    SPREAD THE WORD

    (http://www.youtube.com/watch?v=RSM8t_cLZgk&feature=player_embedded)

    God Bless You

    Jack Smith — Working Class

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  13. In a way, I suspect that something along the lines of this proposal is one of three possibilities for how universal publicly-funded health care will turn out in the US. If, as is generally anticipated, you set up a system that automatically covers any illnesses, no matter the responsibility of an identifiable individual, you wind up with a situation where each individual’s personal habits are the business of everyone else. Someone who spends their life eating tons and tons of cholesterol is doing so at the expense of the rest of society but is not being asked to pay any more into the system than anyone else.

    The lack of penalties creates an incentive to engage in various unhealthy activities – you pay no more into the system to engage in those activities yet you receive the same benefits as if you did. This will, over time, mean that society will need to find a way of curing the free rider problem. One way to do that would be something akin to the proposal in this post. Another way would be to make it illegal to engage in various unhealthy activities. A third way would be to tax said activities heavily, with proceeds going into the public health plan.

    My guess is that what would result would be a mixture of these three approaches, albeit with a particular emphasis on the taxation approach, which will seem like the least intrusive of the three. So you’ll see ever-higher taxes on tobacco (although I suspect you’ll eventually just wind up with tobacco added to the roster of the War on Drugs), taxes on various products that are high in cholesterol, taxes on tanning booths, a carbon tax (which I’m not necessarily opposed to on AGW grounds, but that’s neither here nor there). In some cases, these taxes will be so high as to create black markets.

    We will likely also see slightly more consumer “safety” legislation like the CPSIA, which amounts to a complete ban on products that don’t conform to the regulations. I also don’t think it’s outlandish to expect that there may be some prohibitions or tighter restrictions on supposedly dangerous activities.

    Finally, we will also see rules cropping up similar, if significantly less extensive, to those in this post. I can see an expansion of worker’s compensation laws to help the public avoid paying for “you bastard!” scenarios. Although I have a hard time seeing government denying coverage in most “godammit!” scenarios, which would be mostly counteracted by taxes, regulations, and bans on unhealthy activities, I can definitely see some tight restrictions on the government’s willingness to cover various procedures under the questionable rationale that those procedures are “elective.”

    I don’t think that these are outlandish concerns – a lot of the proposals with regard to taxation are already on the table, for instance, and it’s hard to see how things like CPSIA wouldn’t become somewhat more prevalent if everything that could remotely affect someone’s health were the taxpayer’s business. The public option would create a pretty strong rationale for pushing these proposals through.

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  14. “The lack of penalties creates an incentive to engage in various unhealthy activities”

    There are already penalties for unhealthy activities: death, chronic disease, etc.

    There is already a massive free rider problem of a sort in the type of system we have now. People who don’t have insurance either have to wait until they get sick enough to get on some public plan or use ER’s. In both cases earlier care or preventative medicine would have lessened the cost of care and the negative impact on peoples lives. We end up subsidizing poor care and those costs get passed on to everybody else through inflated insurance premiums and hospital costs.

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  15. One (final?) point: my post was obviously not intended to set forth a full framework of how a public option could or should work. It was instead to explicate some of the guiding principles. Whenever the government gets involved in something, especially at the scale we’re prepared to do with health care, we need to identify the purposes to be achieved. That’s easy to do in the marketplace: it’s profit we’re after. Much more difficult to pin down just what it is we’re doing when it’s the government at the helm. It’s almost never “efficiency,” or “profit,” or other aims traditionally in the sphere of the market. Instead, and as I posited in my post, the aim of crafting a public option in health care is to address whatever the negative psychic impacts our existing health care regime is creating.

    Given that premise, it was not my intent to create an “efficient” system, or an “elegant” system. Indeed, there’s no reason any system needs to be “good” in any sense other than the single necessary condition that any government program must adhere it: it must be principled. Adopting the German system, or the French system, or expanding Medicare might all be more fiscally prudent, elegant, easily deployable systems. But those questions are not relevant unless and until it can be first established that those systems are principled.

    I now sense that I am putting myself in the position of demonstrating why my ideas would lend to a principled health care system, but I have spent too much time on this today already. I simply wanted to offer, both here and in my original post, that questions of efficiency and whether we can pass it through Congress are not the right ones for those of us who care about principled government, and that instead we look to the limited purposes that our limited federal government should be tasked with.

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  16. Preventitive care might be smart for the individual, but it doesn’t save money — studies have proven preventitive medicine increases the cost of healthcare. You can look it up — I am sickly, right now, and I went to get medical tx today — she told me “no Googling”. I got in to see her in 10 minutes, a physician’s assistant, and it cost $130.00 — they are doing something right. I should be back to googling in no time.

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  17. “Some preventive measures save money, while others do not, although they may still be worthwhile because they confer substantial health benefits relative to their cost. In contrast, some preventive measures are expensive given the health benefits they confer. In general, whether a particular preventive measure represents good value or poor value depends on factors such as the population targeted, with measures targeting higher-risk populations typically being the most efficient. In the case of screening, efficiency also depends on frequency (more frequent screening confers greater benefits but is less efficient). Third, as is the case for preventive measures, treatments can be relatively efficient or inefficient” from http://content.nejm.org/cgi/content/full/358/7/661

    A meta analysis of cost effectiveness studies in the New England Journal of Medicine 2008.

    Like everything else in the world it is not a simple great or bad answer, but requires some thought and , dare I say, wonkish analysis to determine what truly works. Still as you say preventive health care makes sense for individuals. That sounds like part of a good health plan to me.

    One aspect of good preventive health care that is hard to measure is the value of decrease of lost work days, weeks, years.

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  18. This makes sense, except for the fact that everything has a cause, and a cost (there is no true C). Covering all cancer might turn out to slow research in preventative gene therapy (as much as Gattaca makes this sound like some kind of disutopian nightmare, I wouldn’t mind a world lacking genetic diseases). Do we want to delay this reality for our kids by another 20, 50, or 100 years?

    We never get to discuss the opportunity cost lost in government control. Hindsight is not remotely close to 20/20 in judging government failures without a true control group. As far as I can tell the US is one of a few nations with a mildly private system.

    If you really want Universal Care, go to Europe. Oh that’s right, Social Democratic states fail under open immigration. Would we be helping more people by opening borders or giving a few million people (that typically don’t need it) health insurance?

    Liberals need to answer this question when making claims of a lack of empathy among libertarians.

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  19. The fact is, gregniak, that although some preventive measures save money and some don’t, the research shows on the whole, preventive medicine increases healthcare costs — this is not a judgement on whether it should be pursued or not, but it helps to stick with reality.

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  20. I worked in healthcare for 15 years and part of my job at the end was to analyze some of these matters, because part of the marketing angle for our treatment was aimed at the efficacy of preventive tx, but it couldn’t be established to save money, only identify some problems sooner.

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  21. Well, I think a major problem with the health care system is that you can’t get catastrophic coverage, at least at a price you can afford, if you have a non-catastrophic chronic condition. Take a person with Type 1 diabetes – which is a chronic condition with a genetic cause. It’s not their fault they’ve got it and most people earning a middle class income can afford the insulin needed to manage it. However, these people cannot get catastrophic coverage at a reasonable rate, and therefore are not protected against large financial risks, whether or not these risks are associated with the disease.

    Another problem is that there are a lot of fairly routine medical procedures that cost a lot of money these days. If your insurance doesn’t cover and MRI, they’ll bill you upwards of $2,000. Maybe not enough to drive you into bankruptcy but there goes your summer vacation. And why does a scan that takes roughly 30 minutes cost $2,000? Granted, they’re expensive machines (about $3 million a pop) but even if the think only does 4 scans a day at $2,000 per pop you’ll have recouped the cost in 1.5 years at that price. Which is a long way of going about saying that my suspicion is that what health care providers and insurance companies charge has virtually no relationship to the actual cost of providing a service. They charge so much because we have to pay it or risk an inaccurate diagnosis, with more pain or possible death as the consequence – not because MRIs actually cost that much in terms of resources consumed.

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    • You first point is absolutely correct.

      I think you are oversimplifying in the second example. A lot more than the initial cost of a machine must be considered when determining the cost of a procedure. It is sort of like saying the only cost a restaurant has to consider is the cost of food. Hospitals or clinics that do MRI’s, any procedure, have to pay salaries to custodians and up the line. Maintenance, energy costs, insurance, etc. Theses are continuing costs.

      I’m not saying these procedures are always fairly priced because I don’t know if they are.

      It does seem however that there is a general recognition that our current system is unsustainable. I read in the NYT today that Massachusetts is considering abandoning their fee for service program and moving to a single payer system, or as the Times puts it, hospitals “…would be compensated with a flat monthly or annual fee known as a global payment.”

      Sounds good to me.

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      • “…would be compensated with a flat monthly or annual fee known as a global payment.”

        In my brain, I am seeing hospitals closed from the 27th through the last of the month… or, maybe, for the last half of the last month of the fiscal year.

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        • Single-payer works.

          My brother and his wife live in Australia. A few years back she was diagnosed with breast cancer. Her treatments were top notch, quick, and without any out of pocket expense.

          Whenever we talk about the American system of health care they are gob-smaked by the shear stupidity of the “American Plan.”

          And from what I hear Australia is no hellhole, unlike Canada, Great Britain and the Continent.

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  22. If individuals and their healthcare provider were negotiating, and the provider had to convince everyone who has an MRI that the cost is $2000.00, they wouldn’t be $2000.00 a pop.

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  24. I think Bob makes an important point. There are alot of different universal care options out there. Whenever those systems get demagogued, people bring up Canada and Great Britain, which are two of the worst performing universal care systems going (in Great Britain’s case the main problem is they spend less per capita than just about any other universal care system – you get what you pay for).

    France, Australia, and the Scandinavian countries all have systems that spend roughly half what we in the US pay per capita on health care but provide service that is equivalent to or better than what we get. We should be borrowing from the best systems out there rather than believing that that we’ll wind up with the worst version of universal care. Since when did it become inevitable that the US would wind up with the “also ran” crowd when it comes to health care?

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  25. Tim Kowal in sum: we must live in an unpopular Nightmare World that is less efficient then what the public wants, in service to some “principle” to be named later, which we will construct while group-hallucinating some secondary, sociopathic persona.

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