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Mugged By Reality: A Conservative for Universal Health Care

Twenty years ago, I learned of the importance of health insurance and the role of the government in health insurance the hard way.

In November 1996, I caught the flu. At the time, I was 27 and working at a major coffee chain making $6/hour. Health care was available, but when you make only $6/hour and have to pay for various things like food and rent, health care becomes out of reach.

So, I spent a few days in bed until I felt good enough to go back to work. I felt okay for a few days after that, but then the illness came back with a vengeance. I couldn’t keep anything down. I started having trouble breathing. I should have gone to the clinic I frequented which offered care to the low income on a sliding fee scale. But I went to the county hospital in downtown Minneapolis. A young doctor examined me and said it was penumonia. He gave me a five day supply of antibiotics (the usual course is ten days for something as routine as sinus infection). I didn’t get better. I got worse. I had a high fever and I was getting a case of thrush on my tongue turning it white. In the meantime my parents drove from Michigan to take care of me. I was able to see the nurse practitioner at the clinic and she took a blood test and an xray. She came back into the examination room and told me that I needed to be admitted into the hospital. My white blood cell count was 70,000, which meant my body was fighting off a massive infection. I wondered aloud how in the hell was I going to pay for this. The nurse practitioner told me not to worry. Before I go any further, if any of you have to go through this make sure to contact The Medical Negligence Experts so you can get the justice you deserve.

I was in the hospital for two long weeks. My lungs had filled up with fluid so the doctors made some incisions to drain the lungs. If that didn’t work, the next route would have been a risky surgery. But that wasn’t needed. After a ton of antibiotics, I got better.

But how was this paid for? I didn’t have to face a big medical bill (or at least not so much) because the wise nurse practioner was able to get me on to General Assistance health care, which is Minnesota’s version of Medicaid, the national program that offers health care for the poor.

It’s funny; around that time, I was moving from a liberal to a conservative, but I still believed government had a role in providing health care, because it took care of me at a point in my life when I needed it.

Conservatives believe in a limited government. It’s not because we hate the government, but because big government can easily crowd out other spheres of society. Conservatives believe government has a role in our lives, but we don’t think it should be running the show. We believe in the role of civil society and the church as institutions that can also offer help to the least of these in our society.

So, I understand that conservatives get a little nervous when talk of health care insurance comes up. Liberals fail to understand that conservatives don’t see government as a wholly good. Government’s main power is usually to compel you to do something. Knowing that power, there is always a fear of the power of government among conservatives. When you are thinking of having the feds have expanded power over 1/6 of the economy it will make a conservative feel uncomfortable. More government can seem like less freedom. This is why conservatives railed against the Affordable Care Act, especially because it mandated that people have health insurance. It’s why the American Health Care Act passed the House of Representatives: it seems to give more freedom and choice to Americans. Listen to conservatives talk, and you will hear that people should be free to not have health care, that government should not impose themselves on an issue like our health.

Conservative writer and thinker John Podhoretz sums up some of modern conservative thinking on health insurance. Here is what he says about the American Health Care Act when it went through the House the first time and the Congressional Budget Office said the new plan would cover 24 million less people:

The consensus headline: “24 Million Will Lose Coverage.”

As a simple matter of fact, that isn’t right. The verb “lose” suggests these 24 million will unwillingly be booted out of the system. No: The CBO says that most of those people will not be covered because they will not buy an insurance policy when it’s no longer the law of the land that they must do so.

In other words, they’ll be exercising their freedom of choice as adults to opt out of the system — and should they try to get back in only when they get sick, they will have to pay a 30 percent penalty for their effort to game the system.

Maybe there are people who decide to opt out of health care insurance and then only purchase it when they are ill. But looking at my own experience and the experience of others, it’s more likely that health care will become unaffordable and that people will forego insurance. I know of very few if any people who just opt out of insurance for the heck of it and purchase it when they become ill (which means buying more expensive insurance since you’re sick).

The AHCA which passed the House assumes universal access, that people have the opportunity to buy insurance. But this plan doesn’t even give many opportunities to get access to insurance. I had the chance to buy insurance, but on my salary I couldn’t do that. Having access is not the same as having some peace of mind. Which is why conservatives should be supporting universal health care.

In the same way that we have Social Security that gives Americans peace of mind that even if they didn’t get a pension or a 401K, they will have at least a basic stipend in their old age, we need to have a health care system where people know that there is at least some basic coverage; a safety net when things get bad. The United States needs universal health care. Now, note I said universal health care, not single-payer.That is one form of coverage, but there are other ways of getting there. We could push for a system like the Swiss Healthcare System or the Singaporean model. We don’t need to have something like Canada’s single payer we just need some system that, as conservative Pascal Emmanuel Gobry says, protects people from the “expenditures of catastrophic health problems.”

Freedom is a cherished conservative value, but there is another value among conservatives that has been ignored: solidarity. That concept, which stems from Catholic social teaching, means that all of us are connected. Pope John Paul II describes solidarity as follows:

“Solidarity is not a feeling of vague compassion or shallow distress at the misfortunes of so many people, both near and far. On the contrary, it is a firm and persevering determination to commit oneself to the common good; that is to say to the good of all and of each individual, because we are all really responsible for all.”

We should have universal health care because we believe in the dignity of each person. We want universal health care because we believe in the words of Abraham Lincoln who said:

The legitimate object of government is to do for a community of people whatever they need to have done, but can not do at all, or can not so well do, for themselves — in their separate, and individual capacities.

All of us at one point or another will hit a point where we can’t do health care on our own. It could be the cost of treating cancer. Or it’s the cost of a new drug to control your diabetes. Or, it could be a premature birth leaving a baby in intensive care for months. The thing is, you don’t know when something could happen that could wipe out your savings in an instant. I didn’t think that at 27 I could get a life-threatening illness, but I did.

It’s past time for conservatives to ensure that no American has to worry about health care coverage because in the end we are our brother’s (and sister’s) keeper.

Crossposted at Dennis’ Medium blog.


Staff Writer

Dennis Sanders is the Associate Pastor at First Christian Church (Disciples of Christ) in Minneapolis, MN.  You can follow Dennis through his blogs, The Clockwork Pastor and Big Tent Revue and on Twitter.  Feel free to contact him at dennis.sanders(at)gmail(dot)com.

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424 thoughts on “Mugged By Reality: A Conservative for Universal Health Care

  1. I’ve always been okay with social safety nets, even as a conservative, and I am increasingly feeling that way about health care. Will people abuse it? Certainly. But the net good far outweighs the bad. Yes, universal healthcare is hard to navigate and problematic in other countries. So let’s fix it and make the American version the envy of the world.

    Great post Dennis.

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    • I’m sorry it this has already been posted but I didn’t want to read through almost 500 comments.

      In Dennis’s first few paragraphs he talks about getting sick when insurance was too expensive for him at his low wage job. Not having insurance he went to a hospital emergency room where he received inadequate treatment. If he had health insurance he would probably have gone to his primary physician soon after getting sick and received better care. (I suspect the hospital physician was overloaded as happens in emergency rooms.)

      Since Dennis did not receive the care he needed he ended in the hospital for an extended – and expensive – care.

      This is what we should be calling “Reagancare”. Ronald Reagan signed the legislation that requires hospital emergency rooms to treat anyone who comes in their door. The emergency room is the default doctor for those without health insurance. And it’s a very expensive way to deal with non-serious health issues.

      Those expensive emergency room flu, twisted ankle, injuries are paid by the rest of us through higher hospital bills when we get sick and higher health insurance premiums.

      We need to understand that prior to the ACA we were paying the health costs for the millions of Americans who did not have insurance. And we were paying for them to receive basic service at luxury prices.

      One of the great values of the ACA is that it meant that everyone could get affordable health insurance and get their problems dealt with before they became more serious and more expensive to treat. And they could get an annual checkup and routine tests so that problems could be spotted sooner – fixed cheaper.

      Want to replace the ACA? Hate that Obamacare? OK, take a stab at it. But don’t shoot us all in the foot by putting us back into the condition where the millions who will no longer have health insurance return to the emergency room where it will cost hundreds of dollars to deal with something that could have been dealt with for tens of dollars.

      Let’s be wise. Please.

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      • But don’t shoot us all in the foot by putting us back into the condition where the millions who will no longer have health insurance return to the emergency room where it will cost hundreds of dollars to deal with something that could have been dealt with for tens of dollars.

        We have had attempt after attempt to make policy based on this idea.

        It makes intuitive sense, however apparently it’s cheaper to not treat large groups of people (even if that on rare occasion results in an EM room stay) than to treat them. Our bodies either heal on their own or we die. The “it’s cheaper to treat them” concept appears to not be true.

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          • Yes, Palin’s Death Panels should be a big money saver.

            Half your *lifetime* use of medicine happens in the last year or two of life. Write someone a blank check during that time and it’s a problem.

            Death panels are necessary to make the system work. If you can’t stare those facts in the face and live with them, then math breaks the system.

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              • Like we don’t have “death panels” currently. It’s just called something else, like DOB, or review boards or policy limitations, etc.

                Do I sound like I’m arguing against panels? I’m bringing up the issue because the supporters of this sort of thing have to get real comfortable with supporting them.

                …and the politics of it may make this impossible. The issue is less the facts and more the political optics.

                1) Politicians who vote for (or to maintain) this are going to face ads *literally* showing them throwing little old grandmas off of cliffs, and the crying relatives talking about how their child could have been saved with more money.

                2) There’s a shockingly high number of people who think *everything* medical should be funded for *everyone* because the public “has the money”. These types of programs are often politically sold with that sort of promise, and the politicians who do are may be serious rather than cynical.

                It’s the whole “tier 1” vs “tier 2” thing but on steroids. Our political system is not well equipped for this. If we can’t convince the public it’s a good idea then those political ads showing throwing grandma off a cliff sink the entire program.

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              • Interesting… although I’m not sure this detracts from the whole “death panels” issue. We keep unhealthy people alive year after year.

                This might make death panels more politically palatable because they’re mostly not out there waiting for everyone. Or it may make the whole idea of rationing both more needed and less palatable because the people affected could be kept alive.

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      • The ACA, was IN THEORY, a decent idea. I’d have a whole lot less of an objection to it if:

        1) people could keep their doctors/plans they already had if they wanted to.
        2) the plans didn’t have one size fits all components….like my single unmarried female friend really needs dependant care coverage.
        3) that stupid idea to tax people for not having healthcare.

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        • So you like it except for the parts that are necessary for the whole to function? guaranteed issue and community rating are going to effect the insurance market and make some people’s plans go away, change their price, or fiddle with their coverage networks. If you don’t include an individual mandate, then you get the actuarial death spiral. How do you have anything like the ACA without 1) and 3)?

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  2. I really think that if you asked some random person what their idea of “ideal health insurance” was, they’d describe Medicare.

    But if you say “Medicare for all” then you hear “ermagerd, SOCIALIZED MEDICINE” from some, and “psshhht, get real, nobody will ever go for that” from others.

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        • Uncertainty is a killer.

          If what you have is enough — just barely enough, maybe back-breakingly expensive, would you take the leap to what someone says will be better? Something never really tried in the US?

          Most people won’t make the leap unless they’re so desperate they can’t imagine anything could be worse. The bird in hand, no matter how sickly…

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          • And I thought that the entire tourism industry would be a big advocate for mandatory paid vacations like they have in Europe because people would head to the beaches, theme parks, cities, mountains, and forests to spend their time and money but they aren’t. There are hundreds of thousands of businesses and individuals that would benefit from mandatory paid vacations but the entire tourist industry doesn’t seem to have any interest in lobbying for it.

            Most American employers as individuals with beliefs seem mainly opposed to any welfare state or government intervention in the economy with some notable exceptions. This is true even if the welfare state or economic intervention could help them by unloading certain responsibilities like providing health insurance or giving them opportunities to make money as in the tourist industry and mandatory paid vacations. Low taxes and a general strict anti-statism when it comes to government intervention in the economy seems more important to the employer class as a whole and they act on that belief.

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            • I think you’re painting with way too broad a brush here. Most people aren’t policy experts, they respond as best they can to incentives within the system. I’ve been on the business side of the healthcare industry long enough to know that views about the government’s role vary pretty widely. There are bad and cynical actors but you don’t find a lot of ultra libertarian ideologues. They’d never make it in an industry so intertwined with the government.

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        • I think people would happily give up their employer based insurance.
          …if they thought the replacement would be as good.

          It probably *can’t* be as good.

          Employer based insurance is for people who are (or were) healthy (and *functional*) enough to be employed. It’s also often only located in zipcodes where various problems are minimized.

          UC implies either the current employer based types either accept less service or pay a lot more.

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          • It probably *can’t* be as good.

            It has a better ability to negotiate prices, is much more likely to be accepted by a given provider (if it’s actually UC), and likely to be better-subsidized.

            A lot of existing employer-based plans are pretty crap.

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            • It has a better ability to negotiate prices, is much more likely to be accepted by a given provider (if it’s actually UC), and likely to be better-subsidized.

              There are factors which suggest it’d be better, there are others which suggest it’d be worse and/or more expensive. On the balance, I suspect between regulatory (& political) capture, increased demand, and decreased (because of price controls) supply, I’d be worse off.

              I’d love to be proven wrong, but we’ve seen states try things like this and it’s blown up the budget. My assumption is the math simply doesn’t work (without serious restrictions which are never mentioned) or we’d have done it already.

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              • As I understand it, the problem for states is that they can’t run Y1 deficits and a change this fundamental will require significant startup costs. The other problem I remember when Vermont failed was having to deal with citizens of other states (meaning the change would ADD administrative complexity because healthcare providers would still need to accommodate everyone else’s private insurance).

                Also, of course, the very real political problem is that you’ll have to significantly increase taxes to pay for the program, which is a tough sell even if you’re raising taxes a lot less than the insurance costs people would no longer have to pay.

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                • …a change this fundamental will require significant startup costs…

                  If memory serves, the problem has been costs explode until the budget breaks. That doesn’t jibe well with “start up costs”. It does jibe with the below.

                  Also, of course, the very real political problem is that you’ll have to significantly increase taxes to pay for the program, which is a tough sell even if you’re raising taxes a lot less than the insurance costs people would no longer have to pay.

                  A lot less?

                  The amount of taxes you need to raise is NOT equal to what we’re currently paying in insurance. You’re adding a large number of currently untreated (or under treated) sick people into the system. If we were going to wave a wand and insure those people, it’d be hugely expensive. You’re also giving better insurance to people who currently are uninsured.

                  That’s over and above the political problem of “no death panels” or whatever which is one of the functions that insurance companies play. Trying to give everyone a GM Autoworker plant’s insurance is way more expensive than the money you save by getting rid of insurance overhead.

                  The budget breaks because of the underlying assumption that the new system will be cheaper (a lot less), and there’s a lack of politically painful “death panels” method of restricting access.

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                    • You underestimate the waste in private insurance. Medicare’s admin overhead is a few percent. private insurers are 15-20%.

                      Even assuming that’s true, the big costs of the system are driven by a small percentage of sick people. If you’re going to be increasing that by a lot, then 15% more doesn’t come close to balancing out.

                      That’s over and above the problem that firing two administration types working for an insurance company won’t create one doctor.

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        • What, including affordability? My brother had stage II Hodgkin’s. (Has, technically. A surgery to go). I believe the projected premium increase for having had a case of cancer was 150k a year?

          Peanuts for someone working in the lucrative field of helping special needs students.

          I’m sure he’ll take that out of his spare change jar.

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        • Employer-based health insurance is a tricky issue. It started during WWII when there were restrictions on raising wages but worker’s were getting restless and it stuck. Now we are stuck with this system and 150-160 million Americans (so nearly half the nation) get insurance because they or a loved on is employed. No politician is going to suggest just pulling the rug from this system and ending it immediately without something in place.

          The truth is that no one knows how to sell ending the system except everyone knows it is kind of nuts. I’ve seen liberals try to talk about how single-payer would encourage entruprenurship because people would not worry about losing healthcare but most people just want good jobs with benefits and pay so that is not a great argument.*

          I could see the self-titled Freedom Caucus being for ending the employmer tax break for health insurance but not having anything in place because they are chaos agents.

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          • I could see the self-titled Freedom Caucus being for ending the employmer tax break for health insurance but not having anything in place because they are chaos agents.

            Every American loves the idea of a giant hike in their taxes. Seems like an electoral winner.

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          • I know the history, and I know the likelihood of it changing, neither of which should stop me from calling a spade a spade. (I just double-checked, and the expression doesn’t have a racist origin.)

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        • I welcome the opportunity to move from a system where an expert who represents a lot of purchasing power negotiates health insurance for me to one where I have no power whatsoever.

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          • I welcome the opportunity to move from a system where an expert who represents a lot of purchasing power negotiates health insurance for me.

            I have news for you. That expert isn’t negotiating on your behalf.

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              • How about this:

                I’d rather the “expert with a lot of purchasing power” be a government employee with no profit motive (and near-infinite purchasing power) who will thereby seek the best over all deals (for example, if a more costly short-term method prevents long-term issues, it could be on-balance cheaper) instead of trying to maximize his next bonus.

                I’d also rather the guy processing my claim not have a direct financial incentive to reject it.

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                • Hey, me too.

                  I’m just saying your insurance company has a lot of money invested in keeping the costs down, because they’re on the hook for them too. They’ll get a better deal than you will.

                  Unless you think it’s normal for the doc to slash 50% or more off his cash price for you. (Seeing the “negotiated prices” stuff just drives home how nuts this is. Billed Price: 2500. Negotiated price: 212 dollars. WTF?)

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                  • That’s certainly true. Which is why the individual market pre-ACA (and post-AHCA if enacted) is such a disaster. But its less true for insurance companies than for the government (to go along with insurers having less leverage).

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                • Having no profit motive doesn’t mean you stop caring about costs.

                  ” if a more costly short-term method prevents long-term issues, it could be on-balance cheaper”

                  If the more costly short-term method doesn’t fit under the organization’s mandated budget cap for this year then it doesn’t make a damn bit of difference what the long-term issues might be.

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                  • Of course it doesn’t mean you stop caring about costs. It means you are more likely to be objective.

                    Does medicare have a mandated budget cap that works in the manner you describe?

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              • He’s jacking up the price the insurance company pays?

                Not sure where you’re going here. I assumed Mike was talking about his companies HR/Benefits specialist.

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                • Ah, I was thinking his insurance company. Then again, my company is big enough to self-insure, and thus uses Aetna/Cigna/Whatever as administrators. So I happen to know my HR works hard to cut what they actually pay doctors.

                  On a related note: HDHP/HSA’s would be great if I was a single, 25-year old guy with a good attitude towards savings and investment. As a 40-year old with a family, they are the absolute worst form of insurance coverage I’ve ever used.

                  Co-pays and those 80/20 plans have always pushed against going to the doctor for trivial things, but HDHP’s….

                  It’d be one thing if I’d had a few years to build my HSAs up, but they forced us to switch the year I hit 13k out of pocket. Single sickest year, by far, my family has ever had.

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  3. I read a very interesting comment somewhere the other day and wish I could attribute it to its author but I can’t find it and so I’ll just paraphrase it.

    It said something to the effect of:

    Both sides are going to have to compromise to make this work.
    Republicans/Conservatives are going to have to reconcile themselves to there being Socialized Medicine
    Democrats/Progressives are going to have to reconcile themselves to there being two tiers of medical care

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      • I’m suspicious that that deal will quickly turn into discussions about how we, as a country, have a responsibility to provide the same care to undocumented dreamers that would also be available to ex-Presidents and anyone who says “no, there are treatments that should be available to ex-Presidents that would not also be available to undocumented dreamers” are really arguing, at the end of the day, that undocumented dreamers should die.

        And that suspicion makes me suspicious that that deal described above would *NOT* be taken.

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        • Your evidence, presumably, being that the ACA did none of those imagined (I assume you think) horribles?

          is dead right on this one, which is why your BSDI attempt fails.

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          • Your evidence, presumably, being that the ACA did none of those imagined (I assume you think) horribles

            My evidence, what little of it I have, consists of nothing more than discussions about health care reform that I have had with people online and with people in real life. Here’s an example of a conversation I had back in 2011:

            In discussing health care, I discussed one of my fixes which was a two-tiered approach. Everybody is covered for X and Y. If you want Z? That costs money. We will always have someone argue that we, as a society, are rich enough that we ought to be able to cover Z for the poor. The person I was arguing with asked “well, why *CAN’T* we provide coverage for Z?”

            So we’re going to have a situation, no matter what, where someone will ask what kind of society we live in where Donald Trump can afford Z but poor children from the wrong side of the tracks cannot. “Do you want the poor children to just lie down and die?” seems to be a question that can be asked unless, of course, Trump can’t get the treatment either.

            Do I have proof that that will happen?

            No. Not really. Though I suppose I could find other examples of conversations of Health Care coverage/reform that we’ve had on the site… would comments count as evidence?

            As for this part, responding to the statement that “both sides will have to compromise” with “BOTH SIDES DO IT!” seems to not get the argument.

            Whatever we end up with will leave a lot of people (on both sides, even) unhappy.

            This is not intended to demonstrate that both sides are morally equivalent? I guess?

            It was intended more as coming out and explicitly saying that, yeah, we’re going to end up with Socialized Medicine someday and, yeah, women and minorities will be hardest hit.

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            • Oooh, I remembered another exchange I had.

              I discussed the two-tier system here (in a comment that I’m still kinda proud of) and it led to this exchange with Francis:

              “And if you can’t afford to pay out the nose, well, then we’ve got this 1987 health care available right here”

              a/k/a

              “go die”

              Why be subtle about it?

              So when you ask “Your evidence, presumably, being that the ACA did none of those imagined (I assume you think) horribles?”

              I can only say “my evidence is conversations I’ve had when I’ve discussed two-tier systems”.

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              • “The best available healthcare that 1987 can offer should be made available and affordable to all.”

                To be clear, the proposal contemplates that:

                hospitals will split in two, one with current equipment and one with 30-year old equipment;
                doctors will keep two sets of medical expertise in their heads, current and 30-years old;
                pharmacies, nurses,and the entire rest of the medical industry will split into two – one current and one 30 years old.

                Since the 30-year old health care is to be available and affordable for all, at least insurance companies are excluded from this exciting idea. Of course, the federal government will be just thrilled with the idea of running (or at least funding) an entire health care system on a running 30-year lag.

                Think of all those exciting new jobs that will be created! Think of all the monitors you’ll need to hire to ensure that doctors are using only 30-year old teaching and that hospitals are using only 30 year old equipment.

                Or, think of the avoidable deaths, pain and suffering. Think about how to find doctors and nurses willing to give up everything they’ve learned about medical ethics and treat only to a 30-year old set of medical knowledge.

                This country is going to make a multi-billion dollar investment in devising a system of delivering medical care to a 30 year old standard? No, that’s just magical thinking. Anyone who purports to be serious about such a proposal is sending a clear message to people too poor to afford existing insurance: You are not deserving of taxpayer support. If you cannot find charity care, then go die.

                I just jumped straight to the conclusion last time. I thought that the readers of this blog would be smart enough to fill in the intervening analysis on their own.

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                • Hey, if you don’t like the idea, that’s great.

                  Part of what I argued at the beginning was that some people would argue that they don’t like this idea.

                  Somebody else asked me if I have any evidence for this.

                  Could you please check in with Nevermoor? Thanks.

                  Now to the meat:

                  To be clear, the proposal contemplates that:

                  hospitals will split in two, one with current equipment and one with 30-year old equipment;
                  doctors will keep two sets of medical expertise in their heads, current and 30-years old;
                  pharmacies, nurses,and the entire rest of the medical industry will split into two – one current and one 30 years old.

                  It’s more that I suspect that we will have doctors who keep up on new techniques and doctors who will be allowed to no longer keep up on new techniques. Hospitals that feel the need to buy the latest and greatest new technology… and hospitals that have the same equipment they had right until the moment they stopped feeling the need to buy the latest and greatest new technology.

                  If you’re not crazy about the 30-year lag, change the number to 20, or 10. I’m fine with working with that.

                  One thing we do, right now, is extend patent protection to new and improved drugs (and we allow generics to be created after patent protection ends). My idea was that we’d have a continually evolving baseline that moves along every day.

                  I’m not married to the number of years. Hell, I’m not even particularly married to the mechanism. I’m just noting that we kinda have something set up like that right now for pharmaceuticals and wondering if we could get stuff like “doctors” and “hospitals” to work the same way.

                  Let the doctors eventually say “I don’t want to learn new techniques” and just coast on what they’ve spent years doing.

                  If you want something that was developed recently? Get yourself one of the new doctors or one of the doctors who keeps up on such things.

                  Let’s face it, the vast majority of problems that the vast majority of Americans suffer from are things that do not require bleeding or cutting edge tech.

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                  • There’s a difference between objections to two tiers as a concept and objections to a shitty bottom tier.

                    I take from ‘s reply that he wouldn’t object to the bottom tier being Medicare. Where does that fall in your BSDI can’t-we-all-be-reasonable proposal?

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                      • How much of cheap health care today is somewhere around the same as cheap health care in 1987? (I imagine that the advice is somewhat better today… “You need to lose weight! Stop eating so much food with high fat content and start eating more pasta!” has not held up well.)

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                        • Would you accept “it’s complicated” as an answer? Either way, I don’t understand what you’re getting at with this point. The ACA includes some form of tiered coverage, in which some procedures are paid for by the government while other types of care are not but can be purchased with private money by the wealthier. The pre-ACA programs create similar de facto tiers, with Medicare, Medicaid, the VA, and private coverage all offering varying levels of stinginess. The systems in other countries that Liberals want to emulate all have some level of tiered coverage, even the most radical single payer systems like Canada. The trouble isn’t the left, it’s that the right rejects the concept of universal coverage outright.

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                          • Would you accept “it’s complicated” as an answer?

                            Sure. This is a topic where it’s impossible to talk about this thing without also talking about that other thing and, oh yeah, we also need to take these five things into account.

                            The difference between acute and chronic care, for example, is *HUGE*.

                            I think that something like Medicare-For-All will do a great job with stuff like, for example, the problem given by Dennis in his original posting. Something like that would have helped him immensely in that situation.

                            “But what about people with chronic problems?”
                            “Well… it’s complicated.”

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                        • Jay,
                          Absolutely zilch in immunotherapy. We learned tons of shit from AIDS.
                          Heart Disease went through a downswing in quality when they started putting stents in everyone.
                          Strokes ain’t got anything to speak of that’s evidence based, so we’ll call that a wash.
                          Physical Therapy? You don’t want the difference between 87 and Now, you want the difference between “We show you once” and “we guide you through the screaming pain, every time”

                          … just off the top of my head.

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                          • Change it to 20 years then.
                            Change it to 10.
                            Change it to 7. I don’t care.

                            I just think that, if you don’t, the engine changes.

                            And we do *NOT* want the engine to change.

                            (If we’re lucky, China will pick up where others leave off.)

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                                • We’re talking a billion+ people. Somehow…I don’t think “sending them to the US” is anything but a rare oddity. I don’t think we get millions of medical tourists a year…pretty sure people would have noticed.

                                  Even the “Canadians come to American to get MRIs” are statistically non-existent.

                                  (2015: 52,000 Canadians sought non-emergency care in the US. Assume they’re all medical tourists, which is laughable. Average number of doctor’s visits per capita in Canada: 7.6, per 2013 numbers. Canadian population in 2015: 35 million. Thus, medical tourism: 0.02% of all Canadians in 2015. Clearly, they are outsourcing modern care to the US)

                                  Honestly, it seems you’ve thought up what you think is a nifty idea and have decided to stick to it. In fact, I don’t even think you think it’s a good idea. You’re just arguing for the hell of it, which is waste of everyone’s time no matter how entertaining you find it.

                                  In the meantime, the rest of the first world (and also the US) has solved this problem. And your idea is…not even ballpark, for obvious reasons.

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                                    • O RLY?

                                      Extra health insurance
                                      Government health insurance plans give you access to basic medical services. You may also need private insurance to pay for things that government plans do not fully cover.

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                                      • Not Invented Here syndrome, in spades.

                                        Mental roadblocks not just to the notion that it’s been solved elsewhere, but sometimes to the very notion that the problem has even been considered before — much less solved.

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                            • It’s not the number, it’s the nonsense concept.

                              Trivial example: everyone should get this year’s flu shot.

                              Less trivial example: Imagine we came up with a 10x better resolution CT scan that costs 1.1x current technology. What possible reason would there be to delay it X years? Likewise, if we came up with a 1.1x better one that costs 100x current technology, why would we roll it out just because X years passed?

                              The idea makes no sense on any vector, and appears designed to solve a problem that exists only in your mind (and not, as correctly points out, in any system along the lines of what liberals want).

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                              • Why does he even want that system?

                                If it’s for “cost control” or “cost savings” it’s the stupidest possibly approach. Why not…actually take all the possible treatments for a condition, and actually determine the costs?

                                Treatment length, efficacy, lifetime results — it’s not like this data doesn’t exist. In fact, Medicaid and Medicare spend a great deal of time doing that sort of work.

                                Why on earth would you say “Let’s use stuff from 10 years ago, across the board” instead of “Let’s look at the most cost-effective treatment for this condition” like every insurance company already does.

                                Does your prescription plan cover 10 year old drugs at 90%, 5 year old ones at 60%, and new ones at 0%? No. Why would they? They’re not run by idiots.

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                                • Why does he even want that system?

                                  Less subject to regulatory capture when there’s a year attached to it.

                                  It’s an attempt to attach some of the driver behind drug research to medical research.

                                  Why on earth would you say “Let’s use stuff from 10 years ago, across the board” instead of “Let’s look at the most cost-effective treatment for this condition” like every insurance company already does.

                                  Because I am trying to create an ever-rising floor where everyone on Tier 1 can eventually receive the medical care that was bleeding edge 10 years ago.

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                                  • I don’t even know what to say to that.

                                    I will say, given we live in a country where every private insurer in the United States has solved that problem, where the governmental programs (Medicare, Medicaid, VA) have solved that problem, and in a world where every other first world country on earth has solved that problem…..

                                    Your deep investment in perhaps the most ridiculous possible solution to an already solved problem is….commendable.

                                    I’ll take the one that works in the real world already, thanks though. It’s not as simple, I admit — you can’t pass it down in a single paragraph from an ivory tower for the world to marvel at– but it works pretty well for what, a billion people at least? Not perfect, of course. Nothing is, in real life.

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                            • And we do *NOT* want the engine to change.

                              Are you sure we don’t we want to change that? If you do NOT want to change the engine driving innovation, then you cannot change the incentives driving that engine, which means you cannot change the formula by which expected profit is determined, which means you cannot change the model (the status quo) upon which that expected profit is determined.

                              Seems to me that viewing the preservation of that engine as a necessary condition on healthcare policy is an argument for either the status quo or alternatively increasing expected profit (and hence total HC cost, all else equal) by making that engine even more robust.

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                              • When it comes to the incentives driving the engine, I have a little more faith in avarice over long periods of time than in good will over long periods of time.

                                When it comes to increasing expected profit, it seems like it’s a lot easier to do that through regulatory capture and making it so that only your epipen can be sold in this country rather than in allowing all eight major brands to sell epipens here.

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                                • That doesn’t address the issue, tho. If you don’t want to change the engine driving innovation you have to maintain the same financial incentives which drive that engine, which in turn means NOT changing (in particular reducing) the expected price points, which (in turn again) means keeping the current price points and more importantly the methodology by which those price points are determined as they are. Status quo.

                                  Limiting the power of patent protection would lower price for existing drugs but would also disincentivize innovation slowing down the engine you don’t want to change.

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                                  • If you don’t want to change the engine driving innovation you have to maintain the same financial incentives which drive that engine, which in turn means NOT changing (in particular reducing) the expected price points, which (in turn again) means keeping the current price points and more importantly the methodology by which those price points are determined as they are. Status quo.

                                    Very true. Given that we’re making a major shake-up to coverage, I’m trying to figure out a way to keep GE in the business of coming up with another handful of percentage points of innovative improvements to their technologies every few years.

                                    This protection is the best way that I can think of that.

                                    Limiting the power of patent protection would lower price for existing drugs but would also disincentivize innovation slowing down the engine you don’t want to change.

                                    My thought process is something like this: If we limited the power of patent protection *RIGHT NOW*, we could allow generics to be made of all of the drugs that are so very expensive. Then everybody could be covered.

                                    And then, in 10 years, everybody could still be pleased to be buying the same generics as they were buying 10 years prior without having to worry if there were a drug that would do it 8% better without one of the seven side effects.

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                                • I’ll ask a question to get at the issue a little more clearly:

                                  Why do you think the innovation engine MUST be maintained as is given the constraints imposed on comprehensive (two tier, universal) healthcare provision? Ie., why is maintaining current financial incentives for innovation excluded from the cost cutting measures such a system necessarily imposes?

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                                      • I must not have understood it… let me reread it…

                                        Oh. Let me try again. I know that going for universal coverage is going to be a bear for profit margins for the companies that make drugs and equipment.

                                        We’re changing a lot of things and it seems to me that there’s a chance that we’re going to be killing at least one goose laying golden eggs for us. That said, we could really use the meat in the short term (and, maybe, we’ve reached a point in R&D where all of the low hanging fruit is plucked and we won’t mind that we’re using ten year old tech ten years from now).

                                        But if we want to keep some of those geese growing strong (if not growing larger), we have to provide an incentive to not fly away.

                                        The setting a year thing struck me as the best incentive given that we’d be giving quite a shock to the system.

                                        The whole “it’s a canard that the US does more than its fair share of the heavy lifting” argument has been given me a handful of times and I don’t know… but it strikes me as one hell of a risk.

                                        But something that doesn’t get invented isn’t even close to measurable.

                                        Hell, if we play our cards right, we might finally get more than one brand of epipen salable in the US.

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                                        • Epipen is a bit of a red-herring in this argument since changing IP laws so they apply to delivery systems means changing IP laws for non-medical devices too.

                                          But for my part, I’m not at all wedded to preserving the profit margins that currently fuel the innovation engine (I don’t see how to do it consistently with constraining total expenditures, myself) so I’m curious about the reasoning of someone who views maintaining it as necessary. I’m not sure you’ve answered the question yet, to be honest, unless you misspoke above and are actually OK with not maintaining the current engine just so long as incentives still motivate at least some innovation.

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                                          • Insofar as the epipen allowed to be sold in this country legally recently jacked up its prices, I don’t see it necessarily as an IP issue but an FDA issue. I think that moving to a more-European health care system requires also moving to a more-European attitude towards risk. Allow 8 kinds of epipens!

                                            I may have misspoke because it seems obvious to me that changing to a Medicare-For-All system is going to be changing, significantly, remuneration for innovation. The engine, already, is going to be changing. Maybe Tier 2 insurance will keep things well-oiled… but whatever we end up with won’t be the status quo for the people who invent the next-gen imaging systems that will then be sold to hospitals that will be treating people handing them Medicare-For-All cards.

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                    • There’s a difference between objections to two tiers as a concept and objections to a shitty bottom tier.

                      Certainly. For now.

                      My main assumption is that health care will quickly become a positional good.

                      Where does that fall in your BSDI can’t-we-all-be-reasonable proposal?

                      It pretty much assumes that the second that people start measuring health care as a positional good the bottom tier will, by definition, become the shitty bottom tier.

                      If you have an argument that only one side will be able to create a two tier system that will have the majority of the people who enjoy Gold Level Support (as opposed to Platinum Level Support) will see the baseline tier of health care as sufficient, I’d enjoy reading it.

                      Bonus points if it’s set up in such a way that people who support there being things covered by Platinum (but not Gold) will not thereby evidence themselves as hating the poor. (Is it by just saying that the only stuff covered by Platinum but not Gold be stuff like breast implants, rhinoplasty, and private birthing rooms with Wifi?)

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                      • Isn’t this just an observation that we will continue to have political debate in this country? Of course if we have a universal program we’ll continue to bicker and argue about how generous it should be, who should pay for it, how it should be run, etc. No matter what the status quo is, it’s not going to keep us from arguing about it. I’d much rather have those arguments than the ones we’re having now about whether or not people should be sentenced to preventable death or financial ruin because of a bad pull of the genetic slot machine.

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                        • I’m not arguing that I think that you’re arguing that this plan will finally install Utopia.

                          God, that always pissed me off whenever I argued something like “we need to end the war on drugs” and people argued against me as if I were arguing that ending the war on drugs would install Utopia. Jesus.

                          I’d much rather have those arguments than the ones we’re having now about whether or not people should be sentenced to preventable death or financial ruin because of a bad pull of the genetic slot machine.

                          Fair enough.

                          I think you’ll be surprised by the ones that pop up, though. “The government is withholding treatment that will allow my loved one to live!” is going to be one.

                          “I thought we finally have Medicare-For-All! Why do people still have gofundme pages for treatments that I would have assumed would have been covered by Medicare-For-All?!?”

                          Wanting to trade our current problems for different problems is a perfectly reasonable position (and doubly so if the different problems are not as bad).

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                          • I think you’ll be surprised by the ones that pop up, though. “The government is withholding treatment that will allow my loved one to live!” is going to be one.

                            We’re already hearing this argument. I don’t know why hearing it again, after universal HC is up and running, constitutes any kind of interesting or noteworthy worry or is an issue worth noting except trivially.

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                            • I think we’ll feel differently when it’s the government denying the treatment rather than the capitalists.

                              I don’t know why hearing it again, after universal HC is up and running, constitutes any kind of interesting or noteworthy worry or is an issue worth noting except trivially.

                              My original statement was that it’s something that the left will have to reconcile itself to.

                              As trivially noteworthy things to point out, you’d be amazed at the amount of tumult followed.

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                      • Again, I don’t hear a lot of old people complaining about Medicare, even though RIGHT NOW rich people can afford higher tier services.

                        You’re inventing–and insisting upon–a problem that is not serious and insolvable (in other words, we can NEVER prevent rich people from buying better stuff if they want to). I don’t understand why.

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                        • The problem is not that rich people can afford higher tier services.

                          It’s that poor people cannot afford the services that could possibly save their lives (these same services that rich people *CAN* afford) and people who insist on two tiers of service are saying that poor people should just hurry up and decrease the surplus population.

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                          • What does it even mean not to “insist on two tiers of service”? Can you tell me what that system even looks like? Or are you just concern trolling?

                            I suspect if there is a life-saving service not in tier 1, I’d actually be wondering whether there was a reason not to include it.

                            Also, since no one with your theoretical concerns seems willing or able to answer this question, I’ll try again: what life-saving services are not being provided by Medicare?

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                            • Or are you just concern trolling?

                              Snort.
                              Were you here when I was accused of wanting people to die?
                              This is something that *IS* going to happen.

                              I’ll try again: what life-saving services are not being provided by Medicare?

                              I know I’ve heard of horror stories about the stuff that Medicare doesn’t do or doesn’t cover (and I know that I’ve heard this stuff on NPR) and a quick google got me this.

                              It’s a handful of hard-luck stories from people who, surely, aren’t representative of anything.

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                              • What does it even mean not to “insist on two tiers of service”? Can you tell me what that system even looks like? Or are you just concern trolling?

                                Response: ignore the first part and snort. The Jaybird experience! (I’ll wait to hear what you actually think, if anything, before discussing that part further)

                                As for the other thing, these are case-by-case questions. Why doesn’t Medicare cover stem cell transplants? Because they’re too expensive? Because they don’t work? Because there’s a different better treatment? I certainly don’t know. But I’d want to before forming an opinion on whether Medicare should cover them. And I’d certainly want to before concluding this was a problem with low-grade services. And, most importantly for your two tiered argument, EVEN IF that procedure is considered officially worse than another one (or officially ineffective), people should still be able to pay their own money for it if they want. Which is–GASP!–a liberal endorsing a two-tiered system.

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                                • Okay, fine.

                                  What does it even mean not to “insist on two tiers of service”? Can you tell me what that system even looks like?

                                  To acknowledge that we have one and that it’s not going to change no matter how much political will is spent on it.

                                  To go back to the original comment that spurred all this crap, “to reconcile oneself to it”.

                                  As for the other thing, these are case-by-case questions.

                                  I’m glad we agree they exist.

                                  If we can agree that doing this on a national level is more likely to result in case-by-case questions, we’re golden.

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                                • Haw. Remember how you got all mad that we wouldn’t give concrete examples of specific things that Medicare didn’t cover and people thought it should? And here Jaybird does just that, and we get:

                                  “Why doesn’t Medicare cover (thing)? Because they’re too expensive? Because they don’t work? Because there’s a different better treatment? I certainly don’t know. But I’d want to before forming an opinion on whether Medicare should cover (thing).”

                                  So. All abstract together, it seems.

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                          • I find this comment utterly bizarre.

                            First of all, the entire discussion about two tiers of service has no basis in reality. Employment-based health care varies widely in networks, co-pays, deductibles, and covered medications. Then we can layer on Medicare, Medicaid, the VA, Tri-Care, what Senators and Congresspersons get, the ACA bands, the actual policies issued in the 50 states in each ACA band, and true out-of-pocket payors. Two tiers? How about thousands?

                            Second, the number of people truly rich enough to pay out of pocket is microscopic. What rich people do is get super-premium coverage from their employer. The ACA did a neat thing in taxing those policies as income (which it is, of course).

                            The churn for low-income Americans between coverage under the ACA and under Medicaid is unfortunate. But that’s where the votes were. Between needing every vote in the Senate and a very unusual Supreme Court decision, Medicaid ended up in an odd place with states being empowered to opt out of covering their own citizens.

                            Non-expansion states are, today, telling their worst-off: Go Die, Already. What the Republicans are proposing doing is to take so much funding out of the plan that the remaining states who want to do the right thing are forced to tell some of their worst-off: Sorry, You’ve Been Triaged.

                            As you feel free to tell Kazzy how well he’s doing in writing comments, let me feel free to share my comments about yours: you consistently commit the fallacy of the excluded middle. According to you, health care policy discussions must be phrased in terms of balancing the coverage of ex-Presidents with that given to illegal immigrants.

                            If you get people to debate you on those terms, more power to you. But it’s still a fallacious argument. 11 million illegal immigrants plus 4 ex-presidents is still only 3% of the population. The rest of us are talking about the other 97%.

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                            • If you get people to debate you on those terms, more power to you. But it’s still a fallacious argument.

                              Depends on the fallacy.

                              For example, it certainly gets rid of the “NOBODY IS SAYING THAT! THAT’S A STRAWMAN!” argument.

                              If we’re saying that what we need is a system that is very good at taking care of the needs of most people and understands that that means that some people who could theoretically be treated will be denied care that, had they sufficient means, they could theoretically purchase is something that’s going to happen… then great.

                              I’d be down.

                              I’m just saying that we will be surprised by where the edge cases show up and what we will have expected to have been covered.

                              According to you, health care policy discussions must be phrased in terms of balancing the coverage of ex-Presidents with that given to illegal immigrants.

                              One of the fun tricks to use back before the PPACA was passed was to ask about whether Undocumented Dreamers should get “free” health care in a single-payer system.

                              You wouldn’t believe what I was accused of.

                              Or, hell, maybe you would.

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                                • “Edge cases” is a term that was used above.

                                  In the case above, everybody agreed that stuff like “the flu” should be covered. Everybody agreed that stuff like “boob jobs” should not be covered. The “edge case” was that of insulin pumps being given out rather than blood drop tests and needles.

                                  As such, the edge case wasn’t the edge where some poor child is born with some super-rare disease, but the edge between “obviously, this ought to be covered” and “obviously, this shouldn’t be covered”.

                                  With that in mind, allow me to repeat what I said in the comment that you’re responding to:

                                  I’m just saying that we will be surprised by where the edge cases show up and what we will have expected to have been covered.

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                                  • And again, there will always be edge cases and choices about what to cover. There are in any and every health care plan in the world, in the US before the ACA, with the ACA, after the ACA and when all our care is provided by Star Fleet Medical.

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                      • My main assumption is that health care will quickly become a positional good.

                        good god, why would you ever make that assumption?

                        When I get sick, I just want to get better, preferably as soon as possible. I don’t much care what someone else’s care is, I just want mine (a) to work and (b) not to cost too much.

                        There’s this weird idea floating around in certain conservative and libertarian think tanks that health care really be a “market” if we just get the federal government out of the way.

                        The fact that health care shows very few characteristics of being a market and mostly shows market failure does not disturb this thinking.

                        A positional good? Health care is by definition a zero sum game? That’s absurd. Basic dentistry for all does not deprive Hollywood stars from getting super-fancy teeth. The people who get access to the care for the first time are both living better and not depriving anyone else from paying for premium services. Not enough dentists? We can always make more.

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                        • good god, why would you ever make that assumption?

                          Because, when I was growing up, I referred to my grandparents’ medicare as “medicaid” and they sat me down and gave me a talking to explaining that they were on medicare, something that they *EARNED*.

                          There’s some status points in there. I can’t claim to understand it.

                          A positional good? Health care is by definition a zero sum game?

                          Also there’s the issue of whether “Medicare-For-All” will provide the same level of service as “Medicare-For-Some” and there’s reason to fear that, maybe, it won’t. The people who don’t get Medicare right now might well be better off… but the people who do have reason to be worried.

                          I mean, if the supply of health care is, by definition, limited.

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                          • The field of economics is not defined by the misunderstandings of the elderly, or their grandchildren. I would happily step on the toes of your grandparents if that would get the votes for a more rational system.

                            I get the impression, both from this conversation and the one we had over marijuana deregulation, that you don’t actually put any effort into understanding the underlying issues. You come up with wild ideas — use 30 year old tech! fire everyone who won’t sign a new Rule — and then appear to be offended when commenters here tell you (a) other people have spent years of their lives looking into these issues and they are actually hard problems not likely to be solved by random ideas coming from people who haven’t put in the effort and (b) your ideas bear no real relation to how the world works.

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                            • “and then appear to be offended when commenters here tell you (a) other people have spent years of their lives looking into these issues and they are actually hard problems not likely to be solved by random ideas coming from people who haven’t put in the effort”

                              I’m pretty sure that Jaybird would accept your proposed solution.

                              What he wants is for you to think about why it’s your proposed solution, because the reasons why you proposed it will help us guess at what you’ll do when it doesn’t actually solve the problem.

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                  • I went back to your linked comment and I think I understand our disconnect.

                    We, here, are talking about insurance, not about government-provided health care (i.e. the doctors are not going to be government employees). So if the government provides medicare-for-all, the issues are going to be about what procedures get covered. Cosmetic plastic surgery? No. Chemo for cancer? Yes. But there are edge cases. highlighted a fair one: what consumables do you give diabetics for free? That’s a cost/benefit consideration (pumps are more expensive, which means you may need to raise taxes more, but if they also reduce complications they may largely pay for themselves, so you may not need to raise taxes a ton), and one I’m sure Medicare has grappled with. What it doesn’t have anything to do with is your iron triangle point in the linked comment.

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                    • We, here, are talking about insurance, not about government-provided health care

                      Which very much goes back to my original comment insofar as it’s creating incentives for more people to go to the doctor without creating incentives to become a doctor.

                      If all we’re talking about is the government cutting checks, we’re going to find that the same thing happens to health care as happened to, say, college tuition.

                      But there are edge cases.

                      If you create more demand without creating (or incenting) more supply, you will move where the edge cases are.

                      What it doesn’t have anything to do with is your iron triangle point in the linked comment.

                      If you’re arguing that you can get it done fast and get it done cheap, I think that you’ll find that it has everything to do with my iron triangle point.

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                      • Right now the government provides health insurance services that are good and cheap. I don’t know what “fast” means in the context of health insurance, but if it means “doctors know how to use it and can rely on payment when promised” then it’s fast too.

                        If you disagree with that, please tell me why.

                        Do you actually think there’s a lack of people who want to become doctors and nurses? If so, why is it so damn hard to get into even the worst medical schools?

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                        • If it’s hard to get into a school, then you are discouraging a large population of interested students from even trying to become a medical professional.

                          And this isn’t a case of, “well those folks would be marginal at best”.

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                          • Right, which is why I find concerns about supply of medical professionals to be dramatically overblown. We could easily create more doctors than we currently do, if that was really a problem. There are plenty of bright young folks who are desperate for the opportunity.

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                        • nevermoor,
                          Jesus, it ain’t fast. We have programs to get the most out of Medicare, because it ain’t fast, simple or logical.

                          Economics is a bitch. Medicine is more of one. I can tell you outcomes for a variety of acute issues that vary based on how many minutes you are away from an ER (We’re about 5ish minutes away). If you’re 30 minutes drive, well, you may be a goner. If you’re a full hour out, your odds of survival have plummetted.

                          Doesn’t matter about having enough doctors. Gotta have the money to support them.

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                      • I don’t think it’s supply and demand, even.

                        I think it’s more about the way that every argument that We Need Healthcare Reform Now is either A) ill-analysed statistics or B) a raft of edge cases.

                        And there will always be edge cases. Always someone who would have lived with Tier 2 treatment, but died because they only got Tier 1 treatment.

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                  • I don’t know enough about health care financing to know whether that’s true or not. Over at Balloon Juice, Richard Mayhew / David Anderson blogs a lot about health care financing. Based on my reading, the industry is plagued both by single individuals whose care costs millions per month and by an entire system of providers who get paid more than they would under any European system.

                    By the way, the word to describe the practice of medicine / law / engineering by people who don’t want to learn new things is “malpractice.” No state regulatory agency is going to tolerate such conduct. Separate but equal has a bad history in this country, so I honestly don’t see the wisdom of recreating it on the federal level.

                    England, France, Germany and Switzerland, among others, manage to deliver very high care virtually universally at a total cost that is a fraction of the US system. Before we start building an entire new system around laziness and dysfunction, I suggest we learn from the experience of other countries.

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                    • Based on my reading, the industry is plagued both by single individuals whose care costs millions per month and by an entire system of providers who get paid more than they would under any European system.

                      I have no doubt of this.

                      I heard of a nightmare case where a guy experiencing some mental health issue checked himself into a clinic for a short while, and they demanded that he stay longer than he wished to. Like, they got a doctor to have him committed “for his own good”. They wouldn’t let him go until he threatened to call and cancel his own insurance.

                      By the way, the word to describe the practice of medicine / law / engineering by people who don’t want to learn new things is “malpractice.”

                      So a doctor who isn’t using current year bleeding edge techniques is engaging in malpractice?

                      Even if using the bleeding edge techniques from 2007?

                      Man, no wonder poor people can’t afford health care.

                      England, France, Germany and Switzerland, among others, manage to deliver very high care virtually universally at a total cost that is a fraction of the US system. Before we start building an entire new system around laziness and dysfunction, I suggest we learn from the experience of other countries.

                      Stay tuned. You’re not going to believe what happens to England, France, and Germany over the next five or so years. It’s not going to be “man, we should be more like *THEM*!” kinda stuff.

                      Though you never know. We had people saying “But they have such great health care!” about Cuba for the last 50 years…

                      As for Switzerland, well. Switzerland is Switzerland. I doubt it will scale.

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                          • So a doctor who isn’t using current year bleeding edge techniques is engaging in malpractice?

                            Even if using the bleeding edge techniques from 2007?

                            Man, no wonder poor people can’t afford health care.

                            Are you not?

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                            • There’s an excluded middle in there.

                              It seems to me that there’s a lot of medical care that can be dispensed by a trained professional that will be helpful using techniques and knowledge from years and years ago.

                              You get the flu? Here’s some treatment, get lots of fluids, get a flu shot next year.

                              You break your arm falling off your bike? Here’s a cast.

                              We don’t require Dr. House in every hospital in the country. Just having doctors who are good enough to deal with 80% of their patients and know enough to kick the other 20% on to the big guns downtown would cover SO MANY PROBLEMS for SO MANY PEOPLE.

                              And me acknowledging that is not the same thing as me objecting to professionals engaging in continuing education.

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                              • What if we learn something about how to treat the flu?

                                Continuing education is a cornerstone of any profession. And, of course, the medical profession ALREADY HAS GPs who can fix simple things and refer complicated things. So I utterly fail to understand where you’re going with this, other than to further defend your incoherent idea that we should forget 30 years of medical developments to really shaft poor people, because reasons.

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                                • I’m not married to the 30 years. Change it to 20. Change it to 10. Change it to 7, I don’t care.

                                  If what we’re talking about is something as simple as telling patients “we’ve discovered that an intensely spicy meal with ghost peppers is an effective cure for constipation”, sure. I’m not talking about doctors not telling patients things and not giving patients advice.

                                  I’m talking about keeping up with new treatments and making new therapies available the moment they arrive.

                                  If they’re cheap? Sure! Why not have it be covered. Aspirin crushed up and mixed into applesauce for everybody!

                                  If they’re expensive?

                                  We’re back to talking about brand new therapies being made available to anybody and everybody within weeks of them making it past the FDA… and expecting every medical professional to offer it, lest they engage in “malpractice”.

                                  Especially since the vast majority of medical treatments given in this country, including the one mentioned in the post that inspired these comments, are fairly tried-and-true therapies that don’t need to be bleeding edge to be effective.

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                                  • Jay,
                                    If we suddenly got a new drug tha tfixed depression better and with less side effects, then hell yes, they should switch. These are the sorts of things that ought to go out as broadband bulletins from the CDC or something. (okay, not the cdc for that specific thing).

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                    • Switzerland

                      What specific aspects of the Swiss health care system do you think the US should emulate? My understanding is that under the ACA, they’re already quite similar. The Swiss health care system works via a mandate to purchase private health insurance and subsidies for low-income individuals. The major difference that I can see is that deductibles are more highly regulated in Switzerland, with the maximum deductible allowable by law limited to about $1500, but if anything, that should increase costs.

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                      • What specific aspects of the Swiss health care system do you think the US should emulate?

                        The most relevant differences that seem to be that everybody gets their insurance through the Swiss equivalent of the exchanges, and that the government sets reimbursement rates.

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                      • I could be wrong, but I thought Swiss insurers who provide base coverage are tightly regulated and non-profit. For-profit insurers can only provide coverage for services above the base level.

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                    • Francis,
                      Are you okay with leaving everyone in West Virginia to die of heart attacks and strokes?
                      Because Europe has a lot better connectivity for rural locations than America does.

                      It’s okay if you want that, truly it is.

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              • Jaybird, there are countries with universal healthcare that manage to do quite a bit of medical innovation in research. Switzerland and Israel are good examples. Costa Rica is poorer than the United States by several hundreds of magnitude but has universal healthcare, does some stellar research in pancreatic cancer, and is a hotbed for medical tourism.

                Your entire line about 1987 healthcare is a fantasy that bears no resemblance to actual reality. There is not a bit of evidence to support the hard line free market position that all medical research and advancement would cease if we had universal healthcare paid for by taxes.

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                • I always enjoy “We should be more like Switzerland or Israel” discussions, but I’m not sure that there aren’t a lot of things tied together in the culture.

                  There is not a bit of evidence to support the hard line free market position that all medical research and advancement would cease if we had universal healthcare paid for by taxes.

                  The argument is not “IT WOULD CEASE!”

                  It’s “it would stop acting like someone is pouring nigh-endless money into it and start acting like it needs more funding to do more stuff.”

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                  • Is your argument that there’s something in American culture that makes us unsuitable for UHC that is distinct from the culture of France, the UK, Canada, Germany, Japan, Australia, Spain, Italy, New Zealand, etc etc etc? If so, what do you think it is? If not, where am I getting you wrong?

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                    • Is your argument that there’s something in American culture that makes us unsuitable for UHC that is distinct from the culture of France, the UK, Canada, Germany, Japan, Australia, Spain, Italy, New Zealand, etc etc etc?

                      Yes, I think so.

                      If so, what do you think it is?

                      Hrm. That’s a toughie. If I had to guess, I’d say that a lot of it is some weird “bootstrap” attitude, some weird Protestant attitude about people getting what they deserve, and, at this point, an entrenched élite who have received their health care as part of their remuneration packages for as long as they remember (and remember their parents doing the same).

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                      • The United Kingdom, Anglo-Canada, Australia, and New Zealand had the same bootstrap attitude. Adding Germany and Switzerland, they also had some the same Protestant beliefs about people getting what they deserved. Australia, Canada, and New Zealand even had their own forms of white racism. They still managed to create UHC in their country.

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                • There is not a bit of evidence to support the hard line free market position that all medical research and advancement would cease if we had universal healthcare paid for by taxes.

                  In principle, this is correct. How health care consumption is funded, as such, has very little to do with the incentive to develop new health care technologies. In fact, insofar as universal health insurance increases demand for new treatments (by increasing the number of customers who can pay full price), it can act as a spur to innovation.

                  However most (all?) European countries do reduce the incentive to innovate via price controls. Pharmaceutical revenues in the US exceed revenues in the the EU and Japan combined, despite the greater population and GDP of EU + Japan. A major concern of mine is that the US moving towards a single-payer health care system will facilitate the imposition of price controls, leading to lower profits and less incentive to develop new drugs.

                  Yes, I’m well aware that many pharmaceutical companies are based in Europe and Japan, and I have no idea why so many seemingly intelligent people believe that this is in any way relevant. A pharmaceutical company’s market is not limited to the country in which its headquarters are located, so demand, or lack thereof, from the American market has just as much effect on a Swiss pharmaceutical company’s incentive to research new drugs as it does on an American company’s. Conversely, American companies’ incentives are affected by European price controls just as much as European companies’ are.

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                  • On the other hand, I’ve never been particularly moved by the argument that US healthcare consumers should be all that enthusiastic about paying extra to let the EU, et c., free-ride on the innovation we fund by paying through the nose for drugs.

                    Even if the shift towards price controls in the US slows drug development and innovation [2], the costs of slowed innovation will be spread out across the entire world of healthcare consumers, while the savings will be reaped almost entirely by American consumers.

                    [2] Not unlikely.

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                    • To that end, how much do EU, etc countries with price controls spend on pharma research grants? If the EU offers a tiny amount of money to labs for drug discovery, and passively relies on the US to fund breakthroughs, then US price controls would be a problem if other countries don’t step up.

                      On the flip side, having more public funding for drug research could be good since it could (ideally) set research targets for low profit drugs.

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                      • I think we’d see a rough couple of years in the pharmaceutical industry if the US adopted pretty-much-everywhere-else-style controls, and then things would shake out with other countries having somewhat higher rates while the US has significantly lower ones.

                        Of course, if we did have reimbursements fixed that way, it might provide a push towards making our regulatory agencies more concerned with allowing for competition (as regulators in other countries tend to be). A more libertarian-minded poster than myself might argue that we should do that first.

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              • Having private expenditures cover some things that universalized care doesn’t is pretty ubiquitous in healthcare systems that aren’t the US [1] . It’s usually not focused on essential care, nor does it seem like it would have to be.

                Having one of the tiers of care being “current state of the art” and the other being “stuff from 30 years ago” is a ludicrously bad idea.

                [1] And supplemental, private insurance plans to go along with Medicare are very much a thing here.

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                • Having one of the tiers of care being “current state of the art” and the other being “stuff from 30 years ago” is a ludicrously bad idea.

                  I was trying to figure out a way to capture the magic of patent protection offered to pharmaceuticals to medical care in general (and figure out a way to still run with doctors who find themselves less and less willing after every passing year to retrain every six months with the latest and greatest).

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                  • Sure, but this is a problem that other systems, and for that matter a chunk of ours, have solved. FSVO of “solved”–it works pretty weirdly in the UK, frex, but it’s a thing there. It even comes as a (fancy) employment benefit.

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                      • Well, when you get right down to it, most people are just asking to have the problems their parents or grandparents have with health insurance, not the problems the British have.

                        I wouldn’t want an American NHS (unless literally the only other choice was the nonsense we have now), and any half-bright Congressional staffer or AEI intern could straight wreck a proposal for one over the course of a lazy summer afternoon.

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                  • Why do you think patent protections would be jeopardized by the US moving to a two-tier universal healthcare system? I don’t see the connection between the two things.

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                    • I’m not arguing that it would be.

                      I saw the set of incentives created by patent protection (both in developing new drugs and in the cost benefits to generics) and was trying to figure out a way to apply that to more stuff than just drugs.

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                      • Although given the FDA’s cussed insistence on fucking things up, I expect they’d invent a category for “orphan techniques” and allow some dork to put a patent on sticking a Q-tip up your nose

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                        • That’s a legal impossiblity. One, the FDA has no authority over patent law, two, by long standing common law tradition, medical techniques are inherently unpatentable, they are an exercise of professional skill, not an invention.

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                          • It’s a legal impossibility now. Jaybird is wondering is that’s something that’s true because truth, or something that’s true because tradition.

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        • How do we know that we’ve raised the basement floor as high as it can possibly go, though?

          After all, if a second story exists then we could, quite obviously, raise the basement floor further.

          Oh, the basement floor is high enough already? What about my grandmother, who died in the basement even though there were things on the second story that could have saved her? What if that happens to ME–do you think that *I* should go die in the basement? Do you HATE ME PERSONALLY SO BAD THAT YOU WANT ME TO DIE IN THE BASEMENT?!

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    • I think the former is really the tougher battle in the political world as it currently exists. Even Bernie voted for the ACA.

      The Republican party, or at least it’s leadership in Congress does not seen to understand how most people experience healthcare in this country, or deliberately avoids discussing it by referring to some mythical group of people who are choosing to opt out (something I don’t think is really possible as long as ERs are treating uninsured people).

      Of course it also isn’t clear to me that most voters are sophisticated enough to understand the nuances of our system. I suspect most vote out of fear of losing what they have or paying more for less.

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      • “Most voters”.

        If I counted up the voters who had employer-subsidized health care and added the ones who were on Medicare, I wonder how close I’d get to “most voters”. (If I added the ones on Tricare, how much closer would that get me? Across the 50-yard line?)

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        • I suspect that would get you there by the numbers. Excepting the ‘keep your government hands off my Medicare’ crowd I’d guess most people know who in particular they’re beholden to. But is there an appreciation for how employer, HIX, Medicaid, and Medicare interact, and the big holes in the webbing that anyone could fall through?

          I’m not so sure.

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        • Employer-subsidized including worker’s comp, plus Medicare, plus Medicaid, plus the parents of kids on CHP+, plus Tricare and the VA, plus the folks who get care at state- and locally-funded clinics,… At that point, I’d be surprised if you didn’t have 90% of voters.

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      • I think my brother Saul has it right, Most Republican politicians are sincerely against the welfare state and do not believe that providing universal access to healthcare is something that they government should do. They also believe that people should be subject to the free market rather than protected from the vagaries of life through the welfare state. They are intelligent enough to know that will be a politically loser argument if said directly on the campaign trail. Even during the 19th century, many Americans were angry when Grover Cleveland argued that its not the government’s job to take care of the people in times of distress or need. Its even going to be more unpopular when we have a welfare state in place and certain expectations.

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      • Of course it also isn’t clear to me that most voters are sophisticated enough to understand the nuances of our system. I suspect most vote out of fear of losing what they have or paying more for less.

        Yep.

        It’s why you’ll have a hard time finding people complaining about the ACA and addressing things other than health insurance.

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    • Who isn’t reconciled to two tiers of medical care? The ACA already had at least four (and fully allowed people to go over and above the top tier). And, of course, the ACA is the compromise position as it preserves market-based insurance (having been developed by conservative think tanks).

      But yeah, BSDI.

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      • “Who isn’t reconciled to two tiers of medical care? ”

        Are you happy with the thought of rich people having insulin pumps while everyone else has to make do with needles?

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          • The majority of lefties/Libs would agree with you, given that the only way to achieve a fully comprehensive two tiered system would require socializing the increased healthcare costs. But DD does have a point here. A small one. Shouting very loudly from the cheap seats will be some cohort of woke intersectionalists waily waily waily-ing about how a two tiered system codifies subjugation and victimizes oppressed marginalized populations who only just yesterday didn’t have access to insulin at all.

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          • I agree with this 100%.

            It’s just that, two years later, we’ll find ourselves wondering why (new treatment) costs money.

            Are you arguing that only rich people should be allowed to not die of provably preventable causes?

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              • I’m not objecting to improvements in the status quo.

                I’m making the (I thought obvious and trivial) observation that whatever we end up with will suck and people (ON BOTH SIDES!) will hate different things about it that they won’t be able to change, not even in theory.

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            • Generally the rest of the developed world gets by with euphemisms and the majority of the populace doesn’t know nor give a rip.

              I think you’d be on more solid ground if you dialed it back to the McMegan line that “the US is the last moneypot for medical development and if it socializes medicine then we won’t have any more near as many future medical advances.”

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          • Except that two tier systems are generally the reason the lower tier doesn’t provide good care – because everyone with power to change the lower tier, experiences and is affected by only the upper one.

            So, two tier systems aren’t the issue as long as they don’t behave as two tier systems unfailingly do.

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            • There’s ALWAYS a two tier system, though. Someone with lots of money is always going to be able to spend it to obtain better services than the government provides by default.

              I’m not sure why I should be worried about that, when I can instead worry about shoring up the bottom tier. It’s why liberals don’t hate the existence of private schools, or think it is unfair that prison inmates can buy stuff while incarcerated.

              We aren’t actually the communists (certain) conservatives imagine.

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              • “I’m not sure why I should be worried about that, when I can instead worry about shoring up the bottom tier. ”

                Welp. Insulin pump therapy leads to demonstrably better outcomes than needles alone, so it’s entirely possible to say that not paying for insulin pumps means that people will go blind.

                My point being that when Jaybird says “we need to get used to a two-tier system”, the way I interpret that is “we need to get used to the idea that the government healthcare plan will explicitly not have The Best Possible Outcome as a goal”.

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                • That would be an argument for including insulin pumps in tier 1 (I honestly don’t know if bronze ACA plans pay for insulin pumps, but I sort of assume they do). That’s not an argument for having some rule forbidding people from buying more expensive pumps if they can afford to (for example, someday there’ll be pumps with more advanced intelligence than current models, but if they cost 10x as much for 1.1x the effectiveness, do they need to be free for everyone? It’s a question to consider).

                  My point is that we need to look at alternatives and status quo.

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                      • This comes down to the “on an absolute level” vs the “on a positional level” distinction.

                        On an absolute level, Tier 1 will be awesome.

                        On a positional level, Tier 1 will not be Tier 2.

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                        • So let’s do that. I’ll even stipulate that someone will want Tier 1 to be better, basically all the time. Someone else will want Tier 1 to be cheaper, basically all the time.

                          But no one serious will propose laws to prevent people with money from going above the system.

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                        • And this is important why, Jaybird. You are acting like any people being unhappy with an amendment to or replacement of a law is enough of a reason not to make an amendment/replacement.

                          Your argument sounds a lot like “Well, if people will still be shrieking about multiple tiers when we move from a one multiple tier system to another multiple tier system” then of course we shouldn’t move, I mean people will still be shrieking. But that can;t be your argument. So what is it?

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                          • You are acting like any people being unhappy with an amendment to or replacement of a law is enough of a reason not to make an amendment/replacement.

                            I am not arguing that we should not make an amendment/replacement.

                            I am, in fact, arguing that Socialized Medicine is inevitable.

                            Also, I am arguing that it will have two tiers… and the two tiers won’t be “life saving stuff vs. boob jobs” tiers either.

                            “So are you saying we should keep things the same as they are now?”

                            “Should? I don’t understand the question. I am arguing that socialized medicine is inevitable. Also that it will have two tiers.”

                            “Liberals/Progressives will *JUMP* at the chance for that!”

                            “Sure they will.”

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                      • “So tier 1 is, by definition, terrible?”

                        Tier 1 covers Treatment X.

                        Someone invents Treatment Y, which is better than Treatment X in every possible measure except cost.

                        Should we expect that Tier 1 will now cover Treatment Y despite the increased cost?

                        I’m keeping my hands over the gauges here, because the point of this is not to twiddle the cost knobs around so that we can make vague statements about long-term outcomes.

                        “there are things which are better but not covered by Tier 1” is not the same thing as “Tier 1 is shitty”. Socialized medicine depends on understanding and accepting that.

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                        • I agree. It’s a case-by-case decision that cannot be reduced to a principle from the limited information in your hypothetical. Which means people are sure to disagree on specific cases. Yet, somehow, Medicare seems to manage these questions reasonably well, given how much people like Medicare.

                          I suspect, given our priors, I’ll want a more generous and expensive tier 1 than you. But that just means that political debate is a never-ending adventure, not that we somehow can’t provide insurance in a two-tiered system (because, again, OBVIOUSLY we would have a two-tiered system).

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                          • “It’s a case-by-case decision that cannot be reduced to a principle–”

                            (slap) No, keep your hands away from the knobs. You’ve got all the information you’re getting.

                            “I suspect, given our priors, I’ll want a more generous and expensive tier 1 than you.”

                            That’s fine–but you’ll also need to reconcile yourself to the fact that when someone says “we can’t afford that in Tier 1”, it can be for reasons that aren’t “I hate poor people and want them to die”, “dummies should work harder if they want better”, and so on.

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                        • Should we expect that Tier 1 will now cover Treatment Y despite the increased cost?

                          Is treatment Y way better and a bit more expensive, or is it a bit better and way more expensive?

                          I mean, we could (and maybe should) formalize that by agreeing on a way of measuring the incremental improvement in outcomes. It’s not quite enough to acknowledge that there’s a difference between “not the best” and “shitty”: there needs to be some agreed-upon method of distinguishing between the two.

                          (And then we’re going to totally throw that method away when dealing with adorable children who have really rare diseases. Fortunately really rare diseases are really rare by definition.)

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                          • Insurance companies have this particular conversation *all the time*. They use it for multiple tiers of drug pricing, for instance.

                            It’s funny the amount of time we’re arguing over problems that, well, have working solutions.

                            Universal healthcare has a few dozen, over the Western world. Multiple-tier access and pricing has…a lot more! Not just all those countries with universal care, but even the insurance plans you pick from here in the US cover those things.

                            (Bronze, Silver, Gold….different variations of deductible, network size, prescription coverage).

                            It’s amazing the time we spend arguing about whether solutions exist to problems that are, bluntly, already solved.

                            We’re not breaking new ground. We’re just trying to figure out which canned solution is best, and what minor (given the scope) modifications would work best. Yet we treat it like a jump into the utter unknown.

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                            • “It’s amazing the time we spend arguing about whether solutions exist to problems that are, bluntly, already solved. ”

                              Oh, so you definitely totally accept a two-tier system of healthcare?

                              What about (thing)? “Oh, that should be covered.”
                              What about (thing)? “Oh, that should be covered.”
                              What about (thing)? “Oh, that should be covered.”
                              What about (thing)? “Oh, that should be covered.”
                              What about (thing)? “Oh, that should be covered.”
                              What about (thing)? “Oh, that should be covered.”
                              (and so on).

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                              • What does Medicare cover that you don’t think it should? What doesn’t it cover that you do think it should?

                                This isn’t abstractable, no matter how much you seem to wish it were.

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                                • “What does Medicare cover that you don’t think it should? ”

                                  I’m not the one who’s asking for it to cover more things.

                                  What is your response to people who ask “why doesn’t Medicare cover (thing) without which I shall suffer and possibly die?”

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                              • Oh, so you definitely totally accept a two-tier system of healthcare?

                                I’m not understanding how our current system differs from a two-tier system. The arguments seem to be that people won’t accept an increase in the number of tiers when in reality, a two-tier system would be a whole lot less tiers than we currently have.

                                It’s not like we’re talking about replacing a system where rich and poor alike get exactly the same thing care and trying to tease out what the consequences of this strange new system would be.

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                                • “The arguments seem to be that people won’t accept an increase in the number of tiers…”

                                  It’s not that they won’t accept an increase in the number of tiers; it’s that they’ll be angry to learn that after hearing how we needed healthcare reform so that (thing) wouldn’t force people into bankruptcy, (thing) is part of the Tier 2 coverage.

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                                  • So hypothetical promises that we can’t specify here won’t be kept? We can’t say what treatment X is, but we can be certain that treatment X will be promised to the masses and then denied?

                                    This is not making any sense to me. We have a system with a bunch of tiers and a bunch of treatments that people can’t afford the lower tiers don’t get. Is the worry that if we rejigger the system so the lower tiers get substantially more but not everything, they’ll reject the system? Is this a “perfect being the enemy of the good” type of thing?

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                                    • “So hypothetical promises that we can’t specify here won’t be kept? ”

                                      The people asking us to reform healthcare are asking for exactly those promises!

                                      “We have a system with a bunch of tiers and a bunch of treatments that people can’t afford the lower tiers don’t get.”

                                      …and then you say…

                                      “Is the worry that if we rejigger the system so the lower tiers get substantially more but not everything, they’ll reject the system?”

                                      If the whole reason you’re rejiggering the system is because the lower tiers can’t afford things, then it looks pretty derpy to end up with a system where the lower tiers still can’t afford things. It looks less like reform and more like rearranged deck chairs. Maybe there’s slightly more deck chairs because of a more efficient arrangement, but there are still people who can’t sit down, and your stated reason for tearing things apart was to help the people who couldn’t sit down.

                                      Which gets me back to what Jaybird was talking about in the first place. The harder job, in healthcare reform, is not dealing with the people who Hates Socialized Medicines Forever. It’s dealing with the people who see healthcare reform happen but still can’t pay their doctor bills. Or, maybe, it’s figuring out how we can be Good Kind Empathetic Rational Well-Meaning Inclusive Persons who nonetheless will look a single mother in the eye and tell her to buy her own chemo meds.

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                                      • If the whole reason you’re rejiggering the system is because the lower tiers can’t afford things, then it looks pretty derpy to end up with a system where the lower tiers still can’t afford things.

                                        C’mon. I know you’re smarter than this and don’t actually think in conservative bumper stickers.

                                        Let’s assume that the AHCA passes and there are 24 million people who can’t afford 1,000,000 things. And we pass a system where those people get onto tier one and therefore can’t afford 100 things. That’s not “derpy,” it’s progress. Health care isn’t an abstraction.

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                                        • “And we pass a system where those people get onto tier one and therefore can’t afford 100 things.”

                                          And if one of those 100 things is the thing they need to live?

                                          “That’s not “derpy,” it’s progress.”

                                          I can progress from seventy feet underwater to seven, but if I can’t swim I’ve still got problems.

                                          And again. You’re arguing as though I’m saying “it should be perfect or it should not happen”. I’m saying that the thing you propose does not address people’s stated reasons for wanting it, and that has a strong likelihood of turning into “okay well you did the thing but it didn’t fix the problem, now you HAVE to do this other thing, and this OTHER thing, and this other thing…”

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                                          • If one of the 100 things is something “they” (as in everyone) needs than it better be in Tier 1.

                                            If not, then you’ve reduced the problem from millions of people to fewer than millions of people, which is a pretty good policy.

                                            Again, in discussing the problems with Medicare–which actually does this stuff–so far I’ve seen one link to one treatment that may-or-may-not be necessary for one woman, but that Medicare apparently only approves sometimes (including maybe for her, or maybe not). From that you weave a conclusion that Medicare-for-all would be “derpy” (but do so insistent on staying at an abstract remove).

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                                            • “If one of the 100 things is something “they” (as in everyone) needs than it better be in Tier 1.”

                                              What if it’s not “everyone”? What if it’s just one person? Why should that person die just so that there can be 100 not-covered things instead of 99?

                                              Or is it that when you say that you’re on board with two tiers, you mean that Tier 1 is “everything but boob jobs” and Tier 2 is “boob jobs”?

                                              “If not, then you’ve reduced the problem from millions of people to fewer than millions of people, which is a pretty good policy.”

                                              if your policy goal is “reduce the number of overall uninsured”.

                                              The people asking for healthcare to be reformed aren’t, generally, saying “reduce” in any other context than “to zero”.

                                              “From that you weave a conclusion that Medicare-for-all would be “derpy” (but do so insistent on staying at an abstract remove).”

                                              I guess you missed all the posts where I said that I supported single-payer and medicare-for-all? I get that you argue with fake people inside your head, but there are words here on this page that are directly opposite from what you said here.

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                                              • If you waive away the fact that numbers are different, and everything everyone has said in response to this answer, then this is a strong point.

                                                I supported the ACA, which definitely didn’t reduce anything to zero. Because it made things better than they were. I oppose the AHCA because it makes things worse. I would support Medicare-for-all (subject to solving the transition shock) because I believe it would make things better than now. None of those solutions eliminates all pain and suffering and sadness in the world. Which is true of literally everything anyone has ever done.

                                                But you keep right on misinterpreting that and making the same comment over and over again. .

                                                Also, words: “If the whole reason you’re rejiggering the system is because the lower tiers can’t afford things, then it looks pretty derpy to end up with a system where the lower tiers still can’t afford things.” I take from this more recent comment that you’re either retracting that point or it was a rambling unrelated to anything we are actually discussing.

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                                                • “None of those solutions eliminates all pain and suffering and sadness in the world. Which is true of literally everything anyone has ever done. But you keep right on misinterpreting that and making the same comment over and over again.”

                                                  That’s because you still focus on “I want to reduce the pain and suffering and sadness”, and yet you also say that you’re OK with some of it not being reduced. So…what’s wrong with the system we have now, then? It is, after all, one of the best.

                                                  And I can hear you fumping about “well what’s YOUR solution then, you say you favor Medicare For All but what ARE the reasons other than improving outcomes”, and my answer is that there are benefits from a national healthcare program that don’t have anything to do with improving outcomes. It’s about improving the freedom of movement between opportunities; if I can’t be sure that I’ll get healthcare coverage for a particular condition then I’m not gonna move to a better place (or to leave a bad one.) I don’t, actually, think that a MfA system will give us better outcomes than we’ve got right now.

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                                                  • The system we had pre-ACA (and would go back to post-AHCA) would be one of the worst in the world, not one of the best. The ACA system, though much better, is also FAR more expensive than other countries while not providing excellent outcomes (your link, for example, concludes that care is dramatically more expensive and outcomes might be a teeny bit better. That’s a problem).

                                                    So the reason to move to MfA is that it would almost certainly reduce cost substantially (you’d win at least 10% on admin overhead right off the bat, while likely also reducing fees paid for services dramatically), increase access dramatically (the “fA” part), and provide exactly the sort of benefits you describe while also freeing Americans from things like medical-bankruptcy (though the ACA already did a lot of that work). These are all good things, even if none of them are perfect. And it’s ok not to pretend that the result will be perfect, especially in the early stages, to support the change.

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                                          • I’m saying that the thing you propose does not address people’s stated reasons for wanting it, and that has a strong likelihood of turning into “okay well you did the thing but it didn’t fix the problem, now you HAVE to do this other thing, and this OTHER thing, and this other thing…”

                                            And maybe we can, and maybe we can’t. Some of the complaints will seem pretty fair, and some of them won’t, and I doubt there will be universal consensus on which is which.

                                            Some people will die even if you spend that billion dollars. Other people will die because some routine-ass procedure that doesn’t cost much at all gets screwed up. And so on.

                                            But fewer complains is better. More met needs is better.

                                            Fewer heart-rending unbelievably-bad-luck sob stories is better.

                                            Meeting moral obligations to more people seems obviously better to me [1], all else being equal, even if, for various reasons, we can’t meet our obligations to everyone.

                                            [1] I mean, once you accept that there are moral obligations to be met.

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                                            • “Fewer heart-rending unbelievably-bad-luck sob stories is better.”

                                              Yes, it definitely is.

                                              But if you’re motivated to change things because you heard heart-rending unbelievably-bad-luck sob stories, and your proposed change knowingly and intentionally will not handle all those stories, well. What are you even doing this for, then?

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                                            • I’m not sure why so many people seem to be having a hard time understanding ‘s point here, almost as if everyone is trying to talk about anything but what he’s addressing.

                                              There is a, if not large, then certainly vocal (with access to popular national platforms) contingent of HC reformers that are lobbying, agitating even, for a vision of HC reform that is without a doubt unsustainable, and if the rest of the groups lobbying for SP or UC don’t clearly address that those folks aren’t being realistic, those agitators could tank reform efforts by being a “perfect is the enemy of the good” set.

                                              Every movement has such people, and they have to be told to go fume quietly in the corner while the adults get work done.

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                                              • The irony – or perhaps confusion – here is that DD said he supports single-payer even while he’s criticizing a two-tier advocate for failing to address political/policy obstacles which pertain to his preferred system as well. Seems like ankle biting to me.

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                                                • “DD said he supports single-payer even while he’s criticizing a two-tier advocate for failing to address political/policy obstacles which pertain to his preferred system as well.”

                                                  I’ve already solved those obstacles, at least in my own mind, by the expedient of declaring them not relevant to the goals which I think a single-payer system ought to strive for.

                                                  My concern is conversations that go like this:

                                                  Jaybird: “you’ll have to get used to a two-tier system”
                                                  People: “well of course that’s what we’ll have”
                                                  Me: “what about (thing)”
                                                  People: “well of course that’ll be in Tier 1”
                                                  Me: “what about (thing)”
                                                  People: “well of course that’ll be in Tier 1”
                                                  Me: “what about (thing)”
                                                  People: “well of course that’ll be in Tier 1”

                                                  And what I conclude is that these people do not, actually, want a two-tier system. As I keep saying, they’re imagining that Tier 1 is “everything but boob jobs” and Tier 2 is “boob jobs”. And I feel like they don’t have a backup plan for when the two-tier system rolls out and we immediately hear stories about how so-and-so contracted boneitis and that’s not covered under Tier 1 and they’re gonna have a medical bankruptcy and we need reform.

                                                  And they say “well yeah but it’ll help some people“, and hey, that’s great, but the stated goals of the healthcare reform movement are not “maybe we’ll help some of you”. The motivation is not “make things better on average for typical people who don’t have weird problems”.

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                                                  • For my part, I don’t think that line of reasoning is persuasive except as an argument for single payer where (presumably) those types of concerns don’t obtain. So two things: within your single payer system there will almost certainly be a private insurance option for folks who desire it and can afford it unless those type of market opportunities are prohibited by law. I don’t see that happening. Do you? (Would you desire such a prohibition?) So even on your preferred model there will be two tiers.

                                                    The other thing is that in single payer there will be edge cases in which provision of services will be denied unless spending is unlimited. But that’s the type of unsustainability Oscar was referring to. So even on your own model hard political decisions need to be made regarding what services will be denied to specific individuals. So it seems to me the types of problems you’re challenging Nevermoor to account for apply just as much to universal single payer.

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                                                    • “even on your preferred model there will be two tiers.”

                                                      A setup where Tier 1 is “everything that has any medical benefit whatsoever” and Tier 2 is “boob jobs” is not meaningfully divided into two tiers.

                                                      “So even on your own model hard political decisions need to be made regarding what services will be denied to specific individuals.”

                                                      I’m willing to make those decisions.

                                                      I don’t think that’s true of someone who tells me that there’s a Fierce Moral Urgency to provide medical care. I think that people who talk about Fierce Moral Urgency are remarkably good at coming up with reasons why in this case we need to stretch the rules just a little bit, this one time.

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                                                      • A setup where Tier 1 is “everything that has any medical benefit whatsoever” and Tier 2 is “boob jobs” is not meaningfully divided into two tiers.

                                                        I’m not sure why you’re so insistent on the boob job thing. Imagine it more like Canada, where there’s a foundational single payer system constrained by cost and therefore a form of rationing of healthcare provision determined by whatever constraints they’ve imposed, and a private insurance system which (perhaps) has no spending caps and therefore covers every conceivable medical situation.

                                                        Boob jobs have nothing to do with it.

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                                                        • “I’m not sure why you’re so insistent on the boob job thing. Imagine it more like Canada, where there’s a foundational single payer system constrained by cost and therefore a form of rationing of healthcare provision determined by whatever constraints they’ve imposed…”

                                                          I’m not the one who’s upset about rationing by cost.

                                                          But I’m not the one who you’ll have to convince that the New Improved (But Still Rationed) System represents real reform that was worth fighting for.

                                                          “Boob jobs have nothing to do with it.”

                                                          The reason I keep bringing up boob jobs is that whenever people talk about how they’re totally OK with there being two tiers of healthcare coverage, it turns out that their idea of “Tier 2 uncovered private-spending care” is, well, boob jobs, and Viagra, and things where the knobs of the Example Machine were spun to reductio ad absurdum levels.

                                                          Like, I’m pretty sure they don’t imagine that Lipitor would be put in Tier 2 because “just eat less fat, fatty, and you’ll be fine once you aren’t so fat”. Or that insulin pumps would be put in Tier 2 because “needle injections combined with proper diet and exercise regimens result in acceptable long-term outcomes”. Or that proton therapy for tumor reduction would be in Tier 2 because “it’s still considered experimental whereas chemotherapy is a well-understood protocol”.

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                                                          • Tier 1 is “everything I need”.
                                                            Tier 2 is “things I don’t need”.

                                                            Fertility treatments are a great example, better imho than boob jobs.

                                                            I’m perfectly willing to back UC if we have something which can be reasonably (mis)called a “death panel”.

                                                            One way to do it is to give every treatment a rating (say, a ratio created by dividing benefit by money), and then putting as much money in the pot as we want to, and then seeing what we can afford. Fund everything above a certain line and don’t fund anything below it.

                                                            But wherever that line is, people will die, and their relatives will scream to the media that it’s not fair.

                                                            My feeling is that you’re right. UC proponents envision that *everything* will be covered. I remember Nancy Pelosi explaining it that way to some of her backers.

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                                                      • I think that people who talk about Fierce Moral Urgency are remarkably good at coming up with reasons why in this case we need to stretch the rules just a little bit, this one time.

                                                        They are. They just aren’t remotely unique in that.

                                                        Every one who wants the reform along the lines we’re talking about, even if the reform program goes as well as is feasible, is going to be bitterly disappointed with some aspect of it.

                                                        Some of them are going to be people with type I boneitis who don’t have a promising treatment covered because it’s too expensive.

                                                        Some of them are wondering why we’re spending billions of dollars a year on dodgy treatments for type II boneitis when spending the money on better insulin pumps would help a lot more people in a much more significant way.

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                                              • Every movement has such people, and they have to be told to go fume quietly in the corner while the adults get work done.

                                                Those people will be out there, but when they come, I’m going to go out on a limb and say that they aren’t going to be coming from where DD thinks they are.

                                                It’ll be about whether it’s OK to have any sort of direct payments from patients at all or whether it’s OK to have anyone but the “rich” support the plan.

                                                That, I predict, is where the fracture points on the left will be: “How dare you suggest that a poor person should have to make a $5 copay?” or, “What do you mean a 10% premium from someone making median income?”

                                                I.e., it’ll be another front in the fight over economic inequality, wages and (effectively) taxes. Not so much “if one life be saved” stuff.

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                                          • I can progress from seventy feet underwater to seven, but if I can’t swim I’ve still got problems.

                                            I’m trying to figure out how what you’re arguing here can’t be reduced to, “There has been no economic progress since the Dark Ages because there are still things that some people don’t get to have. All of our efforts were wasted.”

                                            Or maybe, “I don’t get why you’re so happy about the polio vaccine. There are still dozens of cases per year, so the system still sucks if you’re one of those people.”

                                            Or is there some reason why it’s just healthcare provisioning where comparing two sets of outcomes is a logical impossibility?

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                                            • “I’m trying to figure out how what you’re arguing here can’t be reduced to, “There has been no economic progress since the Dark Ages because there are still things that some people don’t get to have. All of our efforts were wasted.””

                                              I’m not arguing that.

                                              The people who say “of course insulin pumps should be in Tier 1″ are arguing it.

                                              The people who say “yes” to every “should (thing) be covered” are arguing it.

                                              The people who say “the purpose of healthcare reform is to make sure that everyone gets the healthcare they need” are arguing it.

                                              Because if you’re saying that the current system is immoral and needs to change because not everyone gets all the doctoring they need, then you cannot go in saying “we’re going to set up a system that we know will not give everyone all the doctoring they need”, because that isn’t in concordance with the moral imperative you’re taking as justification.

                                              “Or is there some reason why it’s just healthcare provisioning where comparing two sets of outcomes is a logical impossibility?”

                                              If you go out to buy bread but come back from the store with a hammer, then you haven’t achieved your goals, and saying “well I went all the way to the store and bought something” doesn’t make it so.

                                              ******

                                              And so I guess after all this yak we see the answer to Jaybird’s question, and the answer is “no”. Democrats and Progressives will not, it seems, be able to reconcile themselves to a two-tier system of medical care. They’ll destroy Medicare-For-All by insisting that it cover everything, and while it burns to the ground they’ll yell at each other about how they let Perfect Be The Enemy Of Good-Enough.

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                                              • “Because if you’re saying that the current system is immoral and needs to change because not everyone gets all the doctoring they need, then you cannot go in saying “we’re going to set up a system that we know will not give everyone all the doctoring they need”, because that isn’t in concordance with the moral imperative you’re taking as justification.”

                                                This is about as ridiculous as anything ever written here.

                                                I believe we have a moral obligation to set up a system to identify and imprison murderers. According to DD though, unless my plan is 100% effective, I cannot propose it. Awesome, you just ruled out every solution to every problem ever proposed.

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                                                • Man, good thing no one ever proposed such a system, and quite specifically sold the idea of an inherently imperfect system that would fail towards not catching 100% of murderer

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                                                  • Are you talking about the ACA? If so, that’s not fair. It was never billed as a 100% solution to healthcare problems. It was designed with a few primary goals in mind: preserve Medicare; mandate guarantee issue and community rating; set a medical loss ratio floor; bend the cost curve; expand Medicaid and the private market; etc.

                                                    It was a highly imperfect bill along a whole slew of vectors. I don’t think anyone would dispute that.

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                                                  • Oscar,

                                                    I’m having trouble parsing this. If your claim is that the ACA was sold as the 100% solution to countries health care ills I would strenuously disagree. I heard “don’t make the perfect the enemy of the good” so often it nearly induces a gag reflex at this point.

                                                    Im sure there were those who claimed it would solve all health care problems, but they were a pretty insubstantial minority, right?

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                                                • “I believe we have a moral obligation to set up a system to identify and imprison murderers. According to DD though, unless my plan is 100% effective, I cannot propose it.”

                                                  Hey cool analogy bro, but for it to be really representative the cops would have to say things like “we know that your wife was murdered, but unfortunately we think it would be too expensive to chase the criminals and so we aren’t going to investigate at all. You’re welcome to hire a private detective though.”

                                                  (Kim: Yes, I know. Shut up.)

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                                                  • “but for it to be really representative the cops would have to say things like “we know that your wife was murdered, but unfortunately we think it would be too expensive to chase the criminals and so we aren’t going to investigate at all. You’re welcome to hire a private detective though.”

                                                    You understand that is what police forces do, every day in every jurisdiction, right. Albeit a bit more diplomatically.

                                                    Even your back up position – “beware of passing this law, because people who don’t think its 100% effective will keep agitating to make it better,” while completely true, is just banal.

                                                    Maybe analogies aren’t your thing.

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                                              • Oddly enough, there are about a half-dozen models for the delivery of health care, including Canada, England, Switzerland, France, Germany and Singapore, that a vast majority of Democrats / Liberals / Progressives / Leftists would prefer to the existing system.

                                                But since employer-based health care is so deeply embedded in our society and tax code, Obama and the Congress realized that they didn’t have the votes or support for such a radical change.

                                                Without a single Republican vote, they substantially raised taxes, pumped hundreds of billions into Medicare, and imposed stiff regulations on employer-based health insurance policies.

                                                Yet it’s the Democrats who will burn the system to the ground?

                                                The ACA could use some tweaks to work better; the AHCA will actually burn the system to the ground if the CBO is to be trusted. It is way past the time to continue absolving the Ryan-led House of its utter failure to govern.

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                                              • Democrats and Progressives will not, it seems, be able to reconcile themselves to a two-tier system of medical care. They’ll destroy Medicare-For-All by insisting that it cover everything,

                                                DD, I’m not sure we’re using the term “two-tier system” the same way. The way I understand the term, a two-tier system is a public single payer system (like Medicaid and Medicare) and a private health insurance system. Structurally, we already have a two tier system, and progressives/liberals/lefties/lots of righties merely want an expansion of one tier already existing in the current HC system.

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                                                • I’ve never meant it any other way. The question is, do the people talking about how they’ll die without the ACA understand that the thing killing them might not be in the “public health coverage” tier?

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                                                  • I still have no idea what you’re actually arguing. Nevermoor, TFrog, switters, others, me, we’ve all responded to your comments yet you persist in thinking there’s an issue which hasn’t been addressed. I don’t know what it is, to be honest. Politics is an issue in any major policy change. Everyone agrees with that. Hard choices need to be made regarding provision of covered services. Conceded. Everybody admits these things.

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                                              • Because if you’re saying that the current system is immoral and needs to change because not everyone gets all the doctoring they need, then you cannot go in saying “we’re going to set up a system that we know will not give everyone all the doctoring they need”, because that isn’t in concordance with the moral imperative you’re taking as justification.

                                                So it really is the case that any law that’s passed in furtherance of an objective is not in concordance with that objective if it doesn’t satisfy it 100%?

                                                If it’s wrong that we allow children to be uneducated, proposing public schools would not be in concordance with that imperative because they eventually graduate and we could potentially teach them more.

                                                If it’s wrong that people get murdered, putting together a police force with any budget less than 100% of our economic output is not in concordance with the murder imperative because we could still potentially spend more money stopping murder.

                                                If it’s wrong that there’s no way to transport goods from place to place, building roads is not in concordance with that imperative because some goods will still not be movable and we could always demand teleporter research.

                                                If the argument is that there’s a slippery slope that will eventually cause those crazy leftists to spend 100% of our output on healthcare, I’m not clear on why it already hasn’t happened with schools or policing.

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                                                • “So it really is the case that any law that’s passed in furtherance of an objective is not in concordance with that objective if it doesn’t satisfy it 100%?”

                                                  If “people don’t have care” represents a failure state, then a proposal that doesn’t drive coverage to 100% is a proposal that’s failed before it even gets off the ground.

                                                  One way to solve this is to explicitly not make improved coverage a goal. But I keep asking “how are you going to sell that to people who want 100% coverage”, and you keep replying by turning up the knobs of the example machine until they snap off and saying “see? THAT is how!”

                                                  You all keep writing as though I’m the one you need to angrily denounce until I agree with you. But–and I can’t believe that I need to keep writing this down, I can’t believe that people keep ignoring it–I’m not the one saying that lack of coverage is a problem. I’m not the one retelling sad stories about people dying from Totally Preventable Things. I’m not the one talking about medical bankruptcies. I’m not the one describing people setting up crowdfunding accounts to pay for surgery.

                                                  I am not the one making a case for reform based in moral imperatives.

                                                  I understand that you’re yelling at me because I’m here.

                                                  “If it’s wrong that we allow children to be uneducated, proposing public schools would not be in concordance with that imperative because they eventually graduate and we could potentially teach them more.”

                                                  Wow. This is what you come at me with? No wonder you dopes can’t figure out what I’m saying!

                                                  “If the argument is that there’s a slippery slope that will eventually cause those crazy leftists to spend 100% of our output on healthcare, I’m not clear on why it already hasn’t happened with schools or policing.”

                                                  I’m going to give you the benefit of the doubt and assume that you are just not paying attention to the ongoing arguments about how we’re spending more on college and policing than ever before, getting less result than we ever got before, and how the solution is to spend more money on these things.

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                                                  • There’s always something interesting going on when someone makes a statement X and the responses come:

                                                    How come you’re opposed to the proposition in statement X?
                                                    Statement X isn’t going to happen!
                                                    We’re already doing statement X now!
                                                    Nobody is opposed to statement X!
                                                    Statement X is really a merely trivial observation…

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                                                    • What’s statement X in this debate?

                                                      As far as I can tell, it’s this: DD thinks a two tier system creates edge cases in which private tier healthcare may not be available in the public tier.

                                                      That’s descriptively accurate, and as far as I can tell true by definition. DD thinks it constitutes a fatal problem for a two tier system. Other people disagree.

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                                                      • Well, the statement for X that first came to my mind was something like “Democrats/Progressives are going to have to reconcile themselves to there being two tiers of medical care”.

                                                        While, I can’t really prove that such a statement would set off a shitstorm, I can look for evidence, if you’d like.

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                                                            • Jaybird, it’s a two tier system before that rich person, with private insurance receives a treatment the public tier doesn’t provide. It’s a two tier system precisely because it provides both public healthcare and private insurance.

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                                                                • Well, in that case …. every liberal/progressive I know and every liberal/progressive in this discussion would love Medicare for all in a two tier system. Are you and DD on board? Let’s get this done!

                                                                  {{For some reason I feel like the liberals/progressives aren’t the problem, here… }}

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                                                                  • “every liberal/progressive I know and every liberal/progressive in this discussion would love Medicare for all in a two tier system. Are you and DD on board? Let’s get this done!”

                                                                    Sounds good to me. I’ll let you field the questions about “why doesn’t the government cover (thing)”, though, because all along you’ve been saying you have the best answer for that.

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                                                                    • I don’t mind when the bleedin’ heart libs start saying “why won’t you cover this?”. I MIND when the conservatives fall for some stupid drug company’s propaganda, and start saying the same fucking thing. I expect better from them.

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                                                        • You’re getting a spectrum of answers because there is a spectrum of “Democrats/Progressives” who have different (if perhaps not extremely different) perspectives on this just commenting on this very thread.

                                                          I don’t know if this is tantamount to saying that X is trivial, but I will cop to saying X is happening now.

                                                          I am also going to stick with my contention that differing availability of essential care between private and public markets isn’t likely to be a serious threat to the pro-reform coalition (though there will be others).

                                                          But maybe I’m wrong. I think we’ll know in the next 5-10 years.

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                                                          • I am also going to stick with my contention that differing availability of essential care between private and public markets isn’t likely to be a serious threat to the pro-reform coalition

                                                            Best of luck to them!

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                                                              • Not exactly a paraphrase of my position, I’d like to point out.

                                                                It’s more that I think that there will be a two tier system where my part of town will have a lot more doctors willing to accept the first tier (and that there will be no shortage of second tier doctors).

                                                                And, at the end of the day, the system we have is defined by culture rather than by law, and so changing the law is most likely to result in a system a lot like the one we have now. Only codified into law.

                                                                Maybe we’ll pass some laws saying that doctors *MUST* accept some percentage of Tier 1 patients. Surely that will fix it.

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                                                                • Another problem that doesn’t seem to exist in other countries.

                                                                  If everyone has Tier 1 insurance, only a few doctors will have sufficient tier 2 customers/expensive enough services to not accept it.

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                                                      • What’s weird is he doesn’t note that this is the pre-ACA system.

                                                        Insurance had stuff it paid for, stuff it didn’t. Didn’t have cash and it wasn’t covered? Sucks to be you.

                                                        And whether or not you could get insurance was yet another tier.

                                                        “Oh no, under two tiers some things might not be covered”. Yep. But pre-ACA we had like…60 tiers, one of which was “No money, no coverage, no healthcare at all” and some were “Some money, we rescind your coverage instantly if you get sick” and some was “We cover some stuff, not others” to varying degrees.

                                                        So the amazing massive problem of “How do we, as a society, handle the notion that our health insurance might not cover everything” can be summed up “Like we did before, only there’s a lot less examples?”

                                                        I mean we all lived through the ACA and pre-ACA, right? We’re not talking some hypothetical martian society?

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                                                        • What’s weird is he doesn’t note that this is the pre-ACA system.

                                                          I didn’t think I had to.

                                                          I just am not seeing the moral urgency of switching to a system more or less identical to the one we have now. Is it because Sweden is doing it?

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                                                            • One of the biggest things I’ve noticed in any sufficiently progressive discussion is that we have a moral imperative to have pretty much exactly what we have right now, only with more people getting exactly what we have right now, for cheaper. (See, for example, college degrees.)

                                                              And we’re not going to end up with that.

                                                              Some people will be better off. Hurray!
                                                              Others will be worse off. Well, you have to understand…

                                                              The amount of health care, more or less, will remain the same because this isn’t going to create more doctors, nurses, nursing assistants, hospitals, so on and/or so forth.

                                                              We’ve got a problem *NOW* with doctors moving from an “accepts Medicare” paradigm to a “doesn’t accept Medicare” paradigm. Medicare-for-All ain’t gonna address that.

                                                              It’s going to accelerate that and make it worse.

                                                              But I accept that it’s inevitable. Hell, I think we should probably hurry it up and institute it.

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                                                              • We’ve got a problem *NOW* with doctors moving from an “accepts Medicare” paradigm to a “doesn’t accept Medicare” paradigm. Medicare-for-All ain’t gonna address that.

                                                                [Citation needed]. As a simple illustration, many more retailers refuse to accept Discover cards (which few people hold) than Master cards (which many people hold).

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                                                                  • After Medicare-for-All, the costs for refusing to take Medicare will be much higher, and the ability to offset those costs by accepting private insurance will be much lower, if not strictly non-existent.

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                                                                    • After Medicare-for-All, the costs for refusing to take Medicare will be much higher, and the ability to offset those costs by accepting private insurance will be much lower, if not strictly non-existent.

                                                                      Only if you take all comers.

                                                                      If we go down this path I expect a boom in Concierge Medicine.

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                                                                      • That’s the biggest risk. I think it underestimates the extent to which providers would be thrilled if they could know how much they’re going to get paid, when they’re going to get paid, and, frankly, that they’re going to get paid at all.

                                                                        (The biggest weakness of the ACA, I think, is that it tied outcomes to reimbursement in a way that makes one of the worst problems in our health care system even, like, more bad.)

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                                                                        • (The biggest weakness of the ACA, I think, is that it tied outcomes to reimbursement in a way that makes one of the worst problems in our health care system even, like, more bad.)

                                                                          IMHO the biggest weakness is it doubles down on the parts of the system which make it expensive. It was insurance reform, we need medical reform.

                                                                          Infection rates for hospitals and doctors are hidden. Costs are hidden. Success rates. Etc, etc.

                                                                          Force the publishing of all of them and we’d at least have potential solutions that involve markets, at the moment we don’t and can’t.

                                                                          Without markets we have rationing and/or money cannons.

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                                                              • The flaw in your argument is that you seem to believe that, in order to get better outcomes for people who aren’t covered now, they need as much care as people who are currently covered and can get treated.

                                                                But the thing is people who are covered often get way more treatment than they need, in the sense that they get treatment that has little or no benefit. If you think, “Currently health care is basically a free market where people aren’t going to spend a lot of money on care that has little or no benefit,” this will strike you as, at best, counter-intuitive, and perhaps you will hit on the idea that health care is basically a positional good.

                                                                But healthcare isn’t basically a free market in the US, so that reasoning doesn’t obtain. It’s a bunch of (shitty) heavily regulated cartels, government paid systems, and socialized systems that have been tossed into a burlap sack, beaten vigorously with a hammer, and slathered with “I Can’t Believe It’s Not a Free Market” capitalism-substitute spread.

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                                                                • But the thing is people who are covered often get way more treatment than they need, in the sense that they get treatment that has little or no benefit.

                                                                  We’re going to run with that pretty hard in the coming years.

                                                                  But healthcare isn’t basically a free market in the US, so that reasoning doesn’t obtain.

                                                                  Fair enough. I’m remain pretty sure that doubling down will get the same results as the other fifty billion times we’ve doubled down.

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                                                      • “DD thinks a two tier system creates edge cases in which private tier healthcare may not be available in the public tier.

                                                        That’s descriptively accurate, and as far as I can tell true by definition. DD thinks it constitutes a fatal problem for a two tier system.”

                                                        I don’t think it’s a fatal problem. I don’t, actually, think it’s a problem at all. As you point out, we’re already living in a world where (some) people can’t afford (some) healthcare.

                                                        Or, I should say, I don’t think it’s a fatal problem for me.

                                                        But when someone says “we need to reform healthcare because some people can’t afford healthcare“, then for that person it is a fatal problem that (some) healthcare is unaffordable.

                                                        The only way out of that problem is to put every conceivable medical treatment in the “paid for by the government” category. And if someone says “okay fine, we’ll just do that”, then their answer to Jaybird’s question is “no, I refuse to reconcile myself to a two-tier healthcare system”.

                                                        Or you say “well, okay, we’ll define some level of Baseline Health, and ensure that the government tier fits that level”. And then you can go figure out how to not-racist-ly tell poor black diabetics that needles and diet and exercise provide sufficient blood-sugar control, while rich white diabetics buy insulin pumps.

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                                                  • If “people don’t have care” represents a failure state, then a proposal that doesn’t drive coverage to 100% is a proposal that’s failed before it even gets off the ground.

                                                    “People don’t have care” doesn’t represent a failure state, though. “People have less care” is simply not as good as “people have more care.” This isn’t hard to understand. Having airlines is better that not, even though some flights are late. Having polio vaccines is better than not, even though people get polio.

                                                    I’m going to give you the benefit of the doubt and assume that you are just not paying attention to the ongoing arguments about how we’re spending more on college and policing than ever before, getting less result than we ever got before, and how the solution is to spend more money on these things.

                                                    It’s almost as though when deciding how much to spend on a particular public service, there’s a variety of preferences and beliefs, and we ultimately end up with a solution that does some of it but not all of it. Like in absolutely everything government does.

                                                    But since there’s clearly a disagreement and some people aren’t being educated to the absolute maximum and not every murder gets solved, that’s a failure. Clearly no different from having no cops or education at all. If only we had skipped the whole thing, we’d be better off.

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                                                    • ““People don’t have care” doesn’t represent a failure state, though. ”

                                                      Welcome to the Republican Party, sir.

                                                      It’s not worth discussing the rest of your post because you insist that I’m saying that we shouldn’t have medicare-for-all because it’s “not perfect”. I’m not saying that. I’ve ever ever once said that. I think it will be better than what we have now, hugely so, and I can’t understand why there’s so much resistance–from the progressive Democrats, in fact!–to the idea.

                                                      What I am saying is that after it happens, you’ll still hear stories about people dying from things we could’ve treated, you’ll still see GoFundMe drives to pay for surgery, you’ll still see poor people making do with crutches and wheelchairs while the rich buy new legs. Medicare-for-all will not solve the problem of people being unable to pay for medical care. If you’re selling it based on the idea that it will, you’re telling a lie. If you think that people won’t expect it to, you’re a fool.

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                                                      • I can’t understand why there’s so much resistance–from the progressive Democrats, in fact!–to the idea [of medicare-for-all]

                                                        Medicare-for-all may mean “worse than what we currently have for the seniors”.

                                                        You’re not adding more doctors to the system, you’re probably not adding more money, you’re just adding more people.

                                                        Scarce resources will need to be shared with the new people, i.e. uninsured or under-insured sick people that you’re bringing into the system. It is reasonable to wonder if the new people will crowd out the current ones, or at a minimum if unintended side effects will negatively affect the current winners.

                                                        For example Medicare-for-all may mean Medicare can no longer underpay for things, or that doctors will focus on treating “healthy” medicare patients rather than sick ones.

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                                  • DD,
                                    All I wanted out of the ACA is a decent catastrophe system, and no more delisting women for failing to disclose a C-section 20 years ago as a “preexisting condition.”

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                          • “Is treatment Y way better and a bit more expensive, or is it a bit better and way more expensive?”

                            (smack) No, you may not play with the knobs.

                            The intent of this line of questioning is thus:

                            Given the number of arguments for the ACA that espouse the moral necessity of providing healthcare, does this not imply that a plan which does not provide The Best Possible Healthcare Available should be considered immoral? And if so, is it possible to accept a two-tier system of healthcare?

                            People here are saying “well OF COURSE we will accept a two-tier system of healthcare” but based on the Moral Necessity Of Treating Edge Cases style of argument used in discussions over the ACA, I get the feeling that people’s idea is that Tier 1 is “everything” and Tier 2 is “Viagra and boob jobs”.

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                            • I love how the conservative with the incomplete abstract hypothetical is criticizing the liberals with the existing set of coverages for being abstract about what Tier 1 should look like.

                              For time #8927: just about exactly like Medicare, except to the extent Medicare doesn’t cover problems exclusive to the sub-65 set right now.

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                            • (smack) No, you may not play with the knobs.

                              Why not? Playing with the knobs is the best way to defend putting something in Tier 2 instead of Tier 1.

                              Given the number of arguments for the ACA that espouse the moral necessity of providing healthcare, does this not imply that a plan which does not provide The Best Possible Healthcare Available should be considered immoral?

                              I don’t see why it would, any more than, “We should ensure people don’t starve,” entails giving everyone the best possible food.

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                              • “Playing with the knobs is the best way to defend putting something in Tier 2 instead of Tier 1.”

                                The point is not to play with knobs. The point is to explain to someone who lives with Tier 2 treatment but dies with Tier 1 treatment why they don’t get to live.

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                                • The point is not to play with knobs. The point is to explain to someone who lives with Tier 2 treatment but dies with Tier 1 treatment why they don’t get to live.

                                  “It’ll cost a billion dollars, and you’ll still end up dying next Thursday instead of tomorrow.”

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                                  • ““It’ll cost a billion dollars, and you’ll still end up dying next Thursday instead of tomorrow.””

                                    That’s a week I wouldn’t have otherwise, and a billion dollars is only three bucks from everyone in America. Are you really saying that you won’t give three dollars so I can have a chance to say goodbye to my family?

                                    (You see how this goes, right?)

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                                    • Sure, someone might say that, but I bet they’re a lot more likely to say that when it’s, “Well, it’ll cost $9 000 to let you live until 2032 instead of dying tomorrow,” and a lot less likely to say it when, “We can spend 17% of the US GDP to keep you alive for another hour and a half.”

                                      I wouldn’t spend a billion dollars of other people’s money (let alone my own, if I had it!) to extend my life a week. Hell, I don’t even forego extra cheese when I order pizza.

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                                      • “Sure, someone might say that…”

                                        If we need healthcare reform because there’s a Fiercely Urgent Moral Need for it, then they’ll say it and we’ll be obligated by morality to listen and act on it.

                                        If we need healthcare reform because American healthcare is inefficient and wasteful then OK, that’s good too, but I don’t think that’s what this person has in mind. I’m pretty sure she isn’t thinking about bending the cost curve. I’ve got the sense that her goal is not to decrease the year-on-year rate of increase.

                                        I don’t, actually, disagree that healthcare reform is necessary. I don’t even think that single-payer is bad (if nothing else it gives us a way to negotiate costs without being part of an employer-provided plan, which will actually address the cost of care).

                                        But I’m not the one out there in the street cornering Senators with stories about cancer. I’m not the one on Twitter posting about my treatment for mental illness being described as a preexisting condition. I’m not the late-night TV talk show host telling us about his son.

                                        I’m not the one being told “fuck you, I got my health”.

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                            • DD,
                              Yeah, that is most people’s conception of Tier 1. Everything medically recommended (NO Mammogram every year unless medically warranted. NO test me for everything batteries for no reason other than I worry too much).

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                              • If nothing else, having a Tier 1 gives doctors a great basis for motions to dismiss malpractice lawsuits. “I did everything that was medically necessary for me to do. If you think extra tests would have spotted something or additional intervention would have prevented a bad outcome then take it up with the US Government, not me.”

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                                • DD,
                                  Please note: Actual practice will probably be “come back next time for a better diagnosis. Here’s Generic Answer 1.”

                                  … ya know, like it is now.

                                  Yeah, it’s probably going to be “I told you you could buy more tests, and I gave a 5% likelihood that they’d catch something of Y degree of severity.” People don’t get numbers, but the doctors can at least claim to have done something well.

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                                  • Yep; I have a feeling that single-payer healthcare is not actually going to look all that different from what we have now, it’ll just be that your insurance card says “Medicare” instead of “Aetna”, and if you’re paying for something yourself it’ll be very clear what that is and how much it costs.

                                    Which, y’know, won’t be a bad thing, but neither will it be the disease-free Eden that some folks imagine Cuba to be.

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                                • Well, if you’re right, the whole Tier 1/Tier 2 system is even better than I’d previously thought, and I hypothetically pity the hypothetical folks who get that fancy private insurance or pay out of pocket for Tier 2.

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              • Come to Canada, sit in a pub at happy hour and say that nobody is worried a two-tier health system will result in the deterioration of the lower tier. You will have no shortage of conversation partners all night.

                That said, as says below, an upper tier that consists of things like private rooms, elective cosmetic surgery, is not so worrisome.

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            • Two systems can be like they use in Germany where everybody has solid UHC provided by highly regulated insurance companies but people can buy more HC if they wish. I don’t have a problem with that. The goal of UHC should be to get everybody to have access to good health care of their choosing. But there will always be elective procedures or experimental procedures or even some things which aren’t covered but people should be able to buy if they wish.

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    • I think we already have.

      Most Democrats understand the sheet power it took to get the ACA in place and most of us are not fully pleased with the result

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        • No weirder than other BSDI examples.

          David Brooks just spent 8 years writing articles of exactly the same form as Jaybird’s comment, often with the benefit of pleading with President Obama to support a policy he already explicitly supported just so the issue could be framed as both sides being intransigent.

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      • I’m sure that we’ll see “Socialized Medicine is on the table? SOLD!”

        I have no doubt of that.

        I just deeply suspect that we will see people argue that any possible treatment that would save the life of an ex-president is a treatment that should be available for undocumented dreamer… and, if it is not, such would be a betrayal of the promise of Socialized Medicine.

        I don’t doubt for a second that Democrats/Progressives would *LEAP* at the chance at Medicare For All. It’s that they’d rankle at the thought that there would be life-saving treatments not covered by Medicare and yet available to the Rockefeller types… thus demonstrating that they would not, in fact, be willing to reconcile themselves to there being two tiers of medical care.

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        • Exactly. That’;s why all the noise from the left about healthcare focuses on all the tummy tuck and botox treatments the rich are getting that they should be prohibited from getting, and not on the lifesaving care people are priced out of receiving. So yeah Jaybird, I agree, lets ignore the latter problem to make sure the former never becomes one.

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          • You may notice that in the examples given above (and not by me!), the assumptions are that the 2nd Tier will involve private rooms and/or cosmetic surgery.

            The edge case example was the difference between fancy-schmancy insulin pump regulators and blood tests/needles.

            That ain’t where the edge cases are going to be.

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            • OK – Let me restate your position, as I think i better understand it now. Let’s disregard the discussion about whether the orphan without insurance should have life saving care delivered until we either work out all the edge cases Jaybird identifies or guarantee him that people will be quiet about those that remain. You still understand why someone might think thats a bit ridiculous, right?

              Or are you just pointing out that in a country of over 300 million, someone will always be there to complain about whatever is enacted. Cause you could have made that point much more directly. And much more efficiently.

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              • I’m not asking for a guarantee.

                I’m saying “X is going to happen.”

                And, for the record, there’ll be more complaining than the trivial amount of people who are the type that would find some way to complain if you brought in bagels for the team to share.

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                • I’ve followed the argument Jay and if we were talking policy in a vacuum perhaps you’d be right but the weakness of your position is that pretty much the entire industrialized world except the US has had socialized medicine for ages and the outcome you’re fretting about hasn’t come about.

                  It’s not even mysterious why it hasn’t come about. People get rare/hard/expensive to treat condition and the national system says “Sorry, can’t swing it” and the desperate patients say “But look there’s this gold plated/experimental/rich option we could try!” and the national system says “Sorry can’t pay it for you”. There’s some hubbub and in the most sympathetic cases the media run some heart aching stories and people get exercised about it and call their politicians. Then the politicians puff and huff then go off into an office with the National System administrators and say “We need this gold plated option for everyone!” Then the administrators say “Yes sir, here’s what it’ll cost.” The politician turns pale, gets swirly eyes, comes out, says some political stuff about compromises and tax rates and the masses move on. The marginal patents are sad (and it is sad), but they were going to be sad anyhow, and then they have non-cutting edge care as biology proceeds along its tragic course and their families are not mired in penury to pay for it.
                  Then the pollsters ask “what do you think of your national health services” and the masses grumble and says “oh it has all kinds of problems” and then rate it around 65% or so and the tiny fringe of people talking about getting rid of socialized medicine get looked at like the guy peeing on the lamp post in downtown and talking to his teeth.

                  So I struggle to see why it would be different in the US if there was some sort of universal socialized medicine.

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