The Health Care Finale

However nothing seriously was offered

You do realize that a bill cannot so much as come up for debate unless the majority party wants it to, right? So what do you mean by “seriously”?

the very group who ought be for financial limits, the conservative Republicans

Conservative Republicans believe in financial limits – self imposed ones. The most effective way to control health care costs is to eliminate the third party payer problem. Government rationing is not required. That is what individuals are for – to decide whether something is worth the cost.

This may not be socialism writ large, but it certainly is the near-socialization of health care. Mandatory Medicare for all, more or less. It will fail, in the long run, for exactly the same reasons Medicare is failing now, the third party payer problem chief among them. The GDP of the country is simply not big enough to pay for all the health care people want. If you write people a blank check, it is hardly surprising that so many of them try to cash it.

Dan (#1), that’s one of the most frustrating things. Republicans really could have oriented a lot of structure. Yes, they weren’t likely to get concessions from Democrats on major issues such as torte reform. (this post probably sums up the skeptical view) But I tend to agree with David Frum that Obama’s plan is, in several key ways, fairly Republican. I also think that Republican actions the past year or so have undermined their ability to actually achieve things by empowering some unfortunate forces. (David Frum’s post on health care has been justly quoted a lot this week)

While I think Frum over-estimates the power of the Limbaughs and Becks of the world I tend to largely agree with him. The problem Republicans face is that the tea party movement is nearly as skeptical of Republicans as they are Democrats. Further while the center has become somewhat disenchanted with Democrats they aren’t terribly happy with Republicans either. I suspect there will be blowback against Democrats. And, much like Republicans were ignorant about the implications in 2006, I suspect Democrats will continue to ignore the outcry. (The parallels between Republicans in 2004, 2006 with Democrats in 2008 and looking like 2010 are remarkable)

Mark (#2), as Dan mentioned look at the 1994 debate when Republicans had some fairly fleshed out medical plans. And there were some think tanks offering even better plans this go around. One of the biggest problems with the current plan is how it continues to tie medical care to your job. Had the Republicans come out with a specific plan in opposition to the Democrats, had a big press conference and acted a little more wonkishly I think they’d have been in a much better position. Instead we got some vague, hardly fleshed out plans (some which were horrible) and then a whole lot of fear mongering and obstructionism.

Of course I have to admit that as early as a week ago this obstructionism looked like a winning plan (while Democrats were ready to tar and feather Emmanuel who now looks like a hero) So one has to be careful about Monday morning quarterbacking the situation. Still I think that at least really acknowledging the problem at hand would have been a nice move by Republicans.

All that said, I do think the current plan will fail for some of the reasons you mention. It really doesn’t get at the key problems. However it now sets the structure for how those problems will be addressed. In unfortunate ways, in my opinion. (Once again, for the record, I was opposed to the current plan)

John (#3), speaking from experience this year, merely having excellent medical insurance isn’t all that proponents make out. Most do a 80/20 split with deductables. That means that while I had about $50,000 in medical expenses this year for my family I still ended up covering more than $6000 out of pocket. Most lower income people aren’t going to be able to afford that out of their disposable income. And that’s with excellent health care. So I think proponents are deluding themselves about what this bill is (it is very limited) and what its effects will be.

I’m not sure we’ll be worse off with the bill. While I opposed it, I opposed it because of how it structures future debate rather than being against health care itself. I really worry about how future changes will be addressed. Look at medicare. Republicans should have been the biggest proponents for medicare rationing whereas instead they were the biggest opponents of any limits on medicare.

Clark: One of the problems is that Republican leaders hold press conferences and nobody comes, and _especially_ when they are the minority party.

The alternative House bill offered by the Republicans includes malpractice reform, allowing people to purchase health insurance across state lines, expanding health savings accounts, expand and increase the coverage of high risk pools, allowing small businesses to join together and purchase insurance as a group, and so on. Most favor transferring the tax deduction for health care from employers to individuals as well, possibly in the form of an individual tax credit. Many Republicans also favor eliminating restrictions on pre-existing conditions, although there are serious cost issues with that.

In addition Rep. Paul Ryan has a Medicare reform plan not yet endorsed by the leadership as a whole to solve the Medicare cost crisis by changing from a fee-for-service program to a health care voucher system.

I should add Mark that I’m very much in favor of many of those reforms. But fundamentally I don’t think they’ll solve the health care or medicare problems. At some point you have to ration. And rationing demands cutting off health care at a certain level (or requiring more out of pocket payment for many end of life treatments). That’s what Republicans have not only not embraced but have attacked. Why should medicare, for instance, have none of these limits? Why not make it a base health care, impose limits, and then let people buy secondary insurance if they want extended end of life care? Instead we got the fear mongering on death panels.

To be fair Ryan is proposing limiting medicare via his voucher system. (As I said I’m not familiar with the details) And of course liberals attacked this. However while I’m sympathetic to Ryan’s proposal, unless you deal with the issues of free riders, mandates and pre-existing coverage it’s not at all clear putting retirees onto the market will help in the least. That’s the group that’s the most expensive. Why would insurance companies pick them up at all?

For rationing to be rationing it’ll always be due to things outside of your control. You can introduce some choice. But it’ll always be there. One could limit medicare in a method akin to what most countries do but allow people to pick up secondary insurance. It’s too bad the Republicans flinched. I expect the Democrats will to, although it was nice there was at least the attempt to put more limits on medicare.

The problem with Ryan’s plan is that the pools retirees are in are such that there’s no economic way it would work. Yes you can create high risk pools but then you’ve effectively just recreated a limited medicare.

The problem is that medicare already did that. Now you and I probably agree. Health care should be totally private and not a government organization. Privatize medicare. But a high risk pool is still just medicare by an other name and if the government does it then it’ll be government regulated. I mean private insurance has all sorts of regulations. It’s impossible for a government one not to either.

The only way to really ensure private health care (i.e. closer to a German model) is to have a set of minor regulations (i.e. don’t micromanage) and then make sure the pools for each are large. There’s no way to do that without mandates and penalties.

Regarding the subsidies, I agree some of the subsidies are far too generous. Worse yet are the penalties being too small, incentivizing many to simply pay the penalties.