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Will health-care insurance save your life?

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Megan McArdle's column questioning the link between insurance coverage and mortality (researcher speak for "dying") is interesting, but ultimately misleading. At its base, it takes a methodological difficulty (it's hard to measure mortality) and blows it into something approximating a conclusion (insurance coverage has no effect on mortality). It gives an accurate impression of one of the problems bedeviling efforts to answer this question, but an inaccurate impression of the conclusions the best researchers draw from the best research.

There are two basic problems with establishing a causal connection between insurance and mortality. The first is that you can't run the truly random experiment you'd want to run. In that experiment, you'd pick a random sample of the population, divide it into two groups, and take one group's insurance away. But if you can't do that, then you're stuck with all sorts of differences between people who have insurance and people who don't have insurance. You can control for the obvious ones -- smoking, weight, income, etc. -- but there's a lot that you'll miss. This is the problem that drives McArdle's essay.

What you'd want to do in this case is find what researchers call "natural experiments." This is when the world does the work for you. One natural experiment, for instance, is that there are a lot of uninsured Americans who are 64 years old, but at 65, everyone gets Medicare. McArdle spends a lot of time on these studies, saying that the absence of an observable effect on death rates is "probably the single most solid piece of evidence" in favor of her position.

Then her position is pretty weak. Michael McWilliams is an assistant professor of health-care policy and of medicine at Harvard Medical School and an associate physician in the Division of General Medicine at Brigham and Women’s Hospital. The type of guy, in fact, who runs Medicare discontinuity studies. But he's quick to explain the problem with gleaning mortality data from them. "It's great study design," he tells me. "But you're looking for abrupt changes in health outcomes. For mortality for the general population, you don’t expect an immediate benefit."

To put that slightly more simply, people don't die very often. What discontinuity studies identify are abrupt effects, and you don't expect abrupt death at age 65. One Medicare discontinuity study, however, checked in with a group at risk for abrupt death: the critically ill. The study, conducted by David Card, found "a nearly 1 percentage point drop in 7-day mortality for patients at age 65, implying that Medicare eligibility reduces the death rate of this severely ill patient group by 20 percent."

But if the critically ill are the subpopulation that makes the most sense for a discontinuity study, they're still a small subset of the whole. "Medicare study designs lend to very robust studies about disease control," continues McWilliams. "They're very good for measuring effects on blood pressure or self-reported health status. They don’t work as well for mortality. It's misleading to say that just because those studies don’t show those mortality benefits, that means they weren’t there. The study wasn’t suited to measuring that outcome."

But as McWilliams says, if these studies aren't very good at measuring the effect insurance has on whether you die, they're very good at measuring the effect insurance has on things that kill you.

"Mortality is particularly hard to discern statistically," says Katherine Baicker, a Harvard health economist and a former member of George W. Bush's Council of Economic Advisers, "because, fortunately, mortality is a less common health outcome than lots of intermediate steps. But you can look at things like heart disease, which is more prevalent."

There are a lot of those studies. They appear in the Urban Institute's analysis, though McArdle doesn't mention them. McWilliams, in fact, recently conducted a large review of this literature, including the newer class of natural experiment studies testing the impact of insurance on conditions like heart disease, cancer and HIV. "Based on the evidence to date," his study concluded, "the health consequences of uninsurance are real, vary in a clinically consistent manners, [and] strengthen the argument for universal coverage in the United States."

What we're left with is three classes of evidence. The first are the major observational studies attempting to model something difficult to model, which is the causal effect of insurance on mortality. They do their best to control for the confounding factors and find an effect anywhere from 18,000 and 45,000 unnecessary deaths a year. The second are the natural experiment studies. The only one that measures people who are actually facing death in the near-term -- and these studies are only really useful in the near-term -- finds a 20 percent reduction in death rates. Then there are the many, many studies assessing the effect of insurance on conditions that kill you, like high blood pressure and cancer. And they show a large protective effect from insurance.

"Policy can't wait for perfect evidence," Baicker says. "The evidence we have is strong enough that insurance is important for people's health that one oughtn’t use the excuse of the absence of perfect information for not doing something about it."

Photo credit: Linda Davidson/The Washington Post

By Ezra Klein  |  February 12, 2010; 6:16 PM ET
Categories:  Health Reform  | Tags: health insurance, healthcare, medicare  
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Comments

What?? McArdle wrote a misleading piece of garbage??? Get out!!

Posted by: AZProgressive | February 12, 2010 6:54 PM | Report abuse

According to a PolitiFact article (http://www.politifact.com/truth-o-meter/article/2009/aug/20/second-opinion-deaths-totals-uninsured/), the study which results in the 18000 figure does not account for factors such as smoking habits, weight, etc. FWIW.

Posted by: JanglerNPL | February 12, 2010 7:08 PM | Report abuse


Jangler,

I'd read that and it's pretty weak. Adjusting for smoking and BMI is precisely the wrong thing to do if you want the data to be meaningful.

I have iffy feelings about a healthcare nanny state but, regardless, people with insurance get tobacco cessation counseling, chantix scrips, etc. People with higher BMI also get some sort of appropriate medical intervention in a primary care setting (as opposed to the uninsured who might only be getting care in the ER). Removing factors that are most likely (to some extent) RESULTING FROM being uninsured is bad science. It is not always appropriate to adjust for everything.

Posted by: ThomasEN | February 12, 2010 7:26 PM | Report abuse

Interesting points, Thomas. I had not thought about that. I guess I still _hope_ that the 18000 figure is off the mark, because it seems very unlikely that HCR will pass. Either way, it's not like there aren't plenty of other arguments for HCR.

Posted by: JanglerNPL | February 12, 2010 7:33 PM | Report abuse

I think McArdle should do us all a favor and cancel her health insurance, since she feels it does not lead to death. She can do this experiment upon herself, since she so desires to continue to impose this condition on tens of millions of Americans.

For those of us in the real world, who don't want to die, here are some reasons why ... whaddaya know ... it's good to have insurance.

A committee headed by Dr. John Z. Ayanian of the National Academies’ Institute of Medicine reviewed nearly 100 such studies released since 2002. And in March he summed up the findings for Congress this way:

Ayanian’s testimony to Congress, March 2009: Uninsured Americans frequently delay or forgo doctors’ visits, prescription medications, and other effective treatments, even when they have serious disease or life-threatening conditions. … Because uninsured adults seek health care less often than insured adults, they are often unaware of health problems such as high blood pressure, high cholesterol, or early-stage cancer. Uninsured adults are also much less likely to receive vaccinations, cancer screening services such as mammography and colonoscopy, and other effective preventive services.

link
http://www.factcheck.org/2009/09/dying-from-lack-of-insurance/

Posted by: mminka | February 12, 2010 7:35 PM | Report abuse

Ezra famously tried to pin 45,000 deaths a year on Joe Leiberman because he would not vote for the health reform legislation without modifications. Ted Kenedy also blocked universal health care legislation that was proposed by Nixon in the early 1970's, so by Ezra's twisted logic senator Kenedy is responsible for more than a million deaths, and that is not even including Mary Jo Kopechek.

Posted by: cummije5 | February 12, 2010 7:49 PM | Report abuse

Let me know I'd my reasoning is wrong here: one issue with the point about those who just become eligible for Medicare is that, in a way, the older you are, the older you'll live. I can't access actuarial tables right now (I'm on my phone), but aren't you expected to live much longer if you reach 64? Please tell me if I'm missing something.

Posted by: gocowboys | February 12, 2010 8:13 PM | Report abuse

18,000 - 45,000 unnecessary deaths a year and Obama, most Democrats, no Republicans see the importance of universal health care coverage. Were the House of Representatives to pass the deeply flawed Senate bill, as advocated by Mr. Klein and Obama, still tens of thousands would needlessly die over the next decade.
This is morally unacceptable, especially as Obama is willing to waste trillions on unnecessary military spending during the same period.

The Republicans are hopeless. Obama and Democrats were supposed to represent hope, but this has been proved to be mere campaign propaganda.

Posted by: Aprogressiveindependent | February 12, 2010 9:21 PM | Report abuse

1) The 18,000 number, which is Urban's estimate, does include studies controlling for smoking and obesity, as you'll see on page 4 of their report.

2) I used the 18,000 number for Lieberman, not the 45,000 number. Figured I'd stick to the low end.

Posted by: Ezra Klein | February 12, 2010 9:52 PM | Report abuse

Is it okay to deliberately confuse causation and correlation for political purposes? It's a lot easier to score political points when you act as though you're working against something that causes something bad. It's not as affective when you're working against something that is merely correlated with something bad. The public is stupid anyway, right? So what's wrong with manipulating them for their own good?

Posted by: fallsmeadjc | February 12, 2010 10:04 PM | Report abuse

These numbers are fabricated entirely for political purposes. This is all politics. It's about increasing the power of those who hold political office and reducing the power of those who do not. The more the Government becomes involved in healthcare the worse healthcare will get for everyone. There's a correlation (causation for the public) between Government involvement and the general deplorable state of whatever it is they're trying to fix (affordable housing anyone?).

Posted by: fallsmeadjc | February 12, 2010 10:20 PM | Report abuse

WT F?


So .. it does not? Or does?

JESUS! Only 1,500 words, and NO FRIGGIN' point?!?

Kid -- you screwed up. Don't do it again.

Posted by: russpoter | February 12, 2010 10:32 PM | Report abuse

"The only one that measures people who are actually facing death in the near-term -- and these studies are only really useful in the near-term -- finds a 20 percent reduction in death rates."

A 20% reduction in death rates for an unspecified period of time for people actually facing imminenent death....hmmm. And this statistic is being included in this discussion for what purpose, exactly?

Posted by: bgmma50 | February 12, 2010 10:36 PM | Report abuse

I dunno. If we're talking about preventing 18,000 deaths per year, let's just lower the speed limits back down to 55 mph and fulfill our Copenhagen obligations at the same time. Where I come from, that's known as a twofer.

Posted by: bgmma50 | February 12, 2010 10:57 PM | Report abuse

Every time I hear Ezra use the 45,000 number I always get a chuckle. Blame it on Joe to kill thousands of Americans. hardy har har

Hyperbole anyone? I could feel the venom in Ezra's blood that day, you can't blame him though, Liebermann was going viral that day amongst all the libs, it was truly a sight to see.

lol

Posted by: Magox | February 13, 2010 1:20 AM | Report abuse

You're posting in the comments of a post where Ezra explains how the 18k-45k numbers came about, the reasoning behind them, and the studies that support them. You're going to have to be a little bit more specific about how it's hyperbole. If the methodology is wrong, fine, but you can't just say, "Ah, thousands of people dying because they don't lack health insurance? Hyperbole I say!"

Well, this is the internet, I suppose you can, but that doesn't mean you should.

Posted by: MosBen | February 13, 2010 1:40 AM | Report abuse

Well, Obama can fix that critically-ill disparity by giving the old folks a pain pill instead of "unnecessary" treatment.

And deaths of uninsured can only be appreciated when compared to the alternatives. Technically, "uninsured" means someone who doesn't get a ration of care -- our rationing model is based on your ability to purchase insurance.

"Universal healthcare" countries have switched rationing models, but still they all ration -- usually with waiting lists.

Honest debate over rationing models requires comparing our uninsured deaths to other countries' deaths while waiting on a list. The work I've seen in this area suggests that our rationing model is competitive.

Posted by: cpurick | February 13, 2010 2:12 AM | Report abuse

cpurick, forgive me but an anonymous assertion from an uncredentialed internet commentator is hardly persuasive. Perhaps you could share where to find "the work you've seen in this area".

Posted by: lostinthemiddle | February 13, 2010 9:13 AM | Report abuse

cpurick:
What studies? And please define "competitive" as you are using it here. I understand your point to be that in countries with universal health care, a similar proportion of their population die waiting for care as die in the US due to uninsurance. Is that right? Please clarify.

Posted by: TomServo | February 13, 2010 9:26 AM | Report abuse

The 45000 figure is exceptionally misleading. It is a projection of excess deaths based on lack of insurance based on a difference of 4 people from the expected in the figures.

Let's add a couple of more things into the mix. The 45000 study assumes that people who did not have insurance earlier still did not have insurance and the people who did have insurance still had insurance. Rather big jump there. The actual data of the people who had insurance or did not have insurance at the time of death is not known, rather, it is guessed at based on 7 year old figures.

There is more. The figures do not weigh in the factor of traumatic deaths, that is deaths in which the presence or absence of insurance would make any difference whatsoever.

This does not address the question of experimenter bias (Neutral author of experiment specifically stated that a universal health care program run by the federal government was needed). It also does not address the difference between causation and correlation. Even if you could prove a strong correlation between insurance/lack of insurance and death, you don't have causation. Causation requires a but for proof, that is, if the person had insurance, any excess death person would have lived. Can one really say that if an uninsured person was suffering from a heart attack, he dies, but if he has insurance, he lives? You don't conduct studies to prove or disprove such a theory. The last such device available anywhere in the literature was he dipping of Achilles in the River Styx.

Posted by: Paladin7b | February 13, 2010 9:59 AM | Report abuse

It's interesting that the GOP approach to health care is that if you're not dead, you're doing just fine.

Teeth falling out? OK
Low birth weight? OK
Cancer past the treatment stage? OK
No doctor within 200 miles? OK
Cholesterol through the roof? OK
Eyes can't read street signs? OK
Depression untreated? OK

...and so on and so on.

The study in question is practically worthless. Why is it even being discussed?

Posted by: st50taw | February 13, 2010 11:16 AM | Report abuse

lostinthemiddle:
"cpurick, forgive me but an anonymous assertion from an uncredentialed internet commentator is hardly persuasive."

I completely agree, lostinthemiddle. Don't take my word for it by any means. What figures have you seen in *your* search for the truth?

I can't tell you where I saw it, but the last estimate I saw said either 6000 or 8000 people per year die on waiting lists in the NHS. Among others, this included people whose cancers progressed to terminal stages, and those whose advancing conditions left them too weak for therapies that might have worked at an earlier stage of illness.

That's in the vicinity of 1 in 10000 Britons -- which would be about the same rate as 30000 deaths in the US.

But I'm not trying to establish what the numbers actually are -- my point is that our uninsured mortality is *only* useful if you're comparing it to other systems' waiting list mortality.

And another thing -- everything of value is rationed -- *everything*. More or less, care in our system is rationed according to the exclusion principle. Universal healthcare advocates *pretend* that no rationing occurs in other systems, and they all swear that there would be no rationing in American universal healthcare. But that is simply *not* true, and so to have an honest open debate we must talk about what the proposed rationing model is.

When's the last time you heard Ezra explain how the bills currently before Congress will actually ration care???

Posted by: cpurick | February 13, 2010 11:18 AM | Report abuse

This is the kind of back and forth that blogs were invented for. Excellent stuff -- and thank you very much, Ezra.

I felt something was amiss when I read McArdle's entry. It just didn't seem right that whether or not you have insurance really doesn't make a difference in your health. (Would she voluntarily give up insurance?) This helps clarify my concerns on her analysis. And I look forward to her response.

An excellent debate.

Posted by: robbins2 | February 13, 2010 11:27 AM | Report abuse

Megan McArdle has been on a mission to prove that there really isn't a problem in our healthcare and health insurance systems: medical expenses aren't really causing that many bankruptcies, despite substantial, peer-reviewed evidence to the contrary; medical outcomes relative to other countries really aren't that bad, despite substantial, peer-reviewed evidence to the contrary; increased mortality is not well-correlated to a lack of insurance, despite common-sense and substantial, peer-reviewed evidence to the contrary, etc. (Yes, Megan, there really is a problem outside of the subset of the population that didn't have their Ivy-League educations subsidized by rich parents and who don't have swank jobs as journalists for prestigious magazines. It really is conceivable that such a problem exists).

Her M.O. vis-a-vis healthcare and insurance discussions is to grasps desperately at any weakness - regardless of how insignificant - in the data or methodology of whatever is the major, peer-reviewed study du jour showing that, yeah, there really is a problem. Or, she will latch on to any contrarian interpretation of the problem, even occasionally using her own woefully inept skills of analysis to come up with her own contrarian theories. This makes her a SERIOUS thinker, able to go toe-to-toe with established health economists with Ph.Ds and very long CV's. She's thoughtful and earnest, I'll give her that. But, she is almost always wrong.

Posted by: atlasfugged | February 13, 2010 11:36 AM | Report abuse

"I can't tell you where I saw it, but the last estimate I saw said either 6000 or 8000 people per year die on waiting lists in the NHS."

This statistic remains nothing more than an "an anonymous assertion from an uncredentialed internet commentator."

But that aside, there is no argument to be made that NHS waiting lists as a form of "rationing" relates in any way to the HCR bills passed by both houses of the US Congress in 2009. The NHS is a truly socialized single payer system. The HCR bills do nothing to dismantle our current web of private providers and insurers.

The bills instead provide subsidies to allow more enrollees in the private plans, and to eliminate current means of excluding care based on pre-existing conditions, lifetime caps, etc. The bills also create mechanisms to lower costs by making the insurance market more competitive, and by creating new efficiencies.

So a better analog than Great Britain would be the Swiss health care system, which provides universal coverage but relies on a fully private system with no public option. An article in the Journal of the American Medical Association refers to the Swiss model as "regulated competition without managed care," which would also be a good way to descibe the relatively modest insurance reforms that are on the table at the February 25 "summit."

If you want to point to unnecessary deaths or "rationed" care in a comparable system, you'll need to find statistics from a health care system like Switzerland, which uses a model that actually resembles what the Democrats are attempting to achieve here in the US. Any comparison of American HCR proposals with the NHS in Britain is simply a meaningless distraction.

Posted by: Patrick_M | February 13, 2010 12:46 PM | Report abuse

Way to go, Ezra. Michael McWilliams is exactly the guy who knows most about Medicare transition studies. The absence of any mention of his work in McArdle's article really makes one question whether she really did her homework on this topic.

Posted by: allhealthpol | February 13, 2010 12:58 PM | Report abuse

Most doctors who deal with chronic conditions know only too well the true picture of American 'healthcare'. Here's the president of the American Cancer Society in 2008:

'Evidence presented in this issue of CA2 documents the substantial cancer morbidity and mortality caused by inadequate access to health care in the United States. This evidence includes lower rates of screening, later stage at diagnosis, and poorer survival for several cancers, including breast and colorectal cancer, among the uninsured compared with the privately insured. The numbers in this report do not surprise me at all because I practice in a medically underserved community and continually observe how barriers to health care take a toll on my patients—medically, financially, and emotionally. Some of the current realities of health care in the United States remind me of my years of practice in my native Peru, where lack of access to quality health care was a concern throughout much of the country.'

More here: http://www.cancer.org/docroot/subsite/accesstocare/content/Articles_and_Information.asp

It certainly was valid to point out shortcomings in other countries, but the UK has revamped its cancer care targets. for example, and the old criticisms do not hold - but of course you do have to go see the primary care doctor (free and same day in the UK if urgent).

Posted by: healthobserver | February 13, 2010 5:37 PM | Report abuse

It's no worse than all the other statistics thrown around like the lower US infant mortality rates (measured differently), the number of people who die from lack of health care insurance and the number of "medical" bankruptcies, to name a few.

There's no shortage of questionable data being used to substantiate a public option.

Why stop at this one?

Posted by: AndreainNY | February 13, 2010 5:47 PM | Report abuse

"The bills instead provide subsidies to allow more enrollees in the private plans, and to eliminate current means of excluding care based on pre-existing conditions, lifetime caps, etc. The bills also create mechanisms to lower costs by making the insurance market more competitive, and by creating new efficiencies."

It is impossible to get more healthcare without paying for more healthcare. Many of your "inefficiencies" are actually valid medical procedures that insurance companies are currently paying for. If they weren't valid, insurance companies wouldn't pay for them.

You may pick the system of your choice. All that matters is that *every* system has a rationing model, and ours is well understood. If you wish to change the rationing -- such that people with greater needs and fewer dollars cannot be limited in the care they receive -- then you still have to explain how care will be rationed.

The moment you stipulate that everyone must be provided all the care they want, and that nobody can be denied, you set in motion the inevitable collision between infinite demand and finite supply. It really doesn't matter which country you'd like to use as your model.

When we can no longer deny care to anyone on the basis that they're not paying enough to cover their own costs, we unleash infinite demand. So unless your plan includes infinite supply, I'd appreciate your honest explanation of where the rationing will occur. We all know where that rationing occurs now -- where will it be under your model?

Posted by: cpurick | February 13, 2010 6:49 PM | Report abuse

"It is impossible to get more healthcare without paying for more healthcare...We all know where that rationing occurs now -- where will it be under your model?"

Your rationing model displays a socialist mindset, comrade. You envision a closed system in which a thing can only cost what it costs, and the thing can only be produced in the quantity in which it is currently produced, and so if there are more customers, the system must spend more for increased production, or else ration the existing production among an expanded number of customers.

However, here in a more dynamic free enterprise system, we find that competition lowers costs, and there are always ways to introduce new efficiencies, which do not require lowering output of the product (such as taking the technology of medical record keeping and sharing out of the stone age, removing redundancies in the way different insurers qualify the same providers, etc.).

Most importantly, when competition is enhanced, insurers will be forced to find their own internal ways to maximize efficiency, other than simply hiking their premiums at the obscenely accelerated rate that consumers have faced in recent years. This increased competition is the value of the exchanges, and it would have been the value of having a public option in the mix alongside the private insurers.

Of course there is new revenue going into the system too. But that investment is expected to result in a lower rate of inflation in future medical costs, which leads to lower costs for the taxpayers AND expansion of care ~over time~ than not investing in reform.

I'm sure you have no confidence in the CBO, but that's what their modeling confirms. There may not be a "free lunch" in life, but that does not mean that better competition and reforming wasteful systems can't lead to serving more customers at a lower costs.

Posted by: Patrick_M | February 13, 2010 8:23 PM | Report abuse

cpurick: "When we can no longer deny care to anyone on the basis that they're not paying enough to cover their own costs, we unleash infinite demand."

Absolute nonsense. Learn some economics:

http://www.american.com/archive/2009/september/forecasting-the-cost-of-u-s-healthcare

Posted by: Lee_A_Arnold | February 13, 2010 11:22 PM | Report abuse

As Megan has already pointed out, this post attacks a claim she never made. It fails to address the one she did.
http://meganmcardle.theatlantic.com/archives/2010/02/firming_up_the_argument.php

Posted by: MikeR4 | February 13, 2010 11:44 PM | Report abuse

Patrick_M, Lee_A_Arnold

Everything of value is rationed. Everything -- there are no exceptions. None.

I make no apologies for our current rationing model, but at least we all understand it.

It is "absolute nonsense" to believe that everyone can have all the care they want. It doesn't happen anywhere on the face of the earth -- or with anything -- and it won't happen here with healthcare.

So, I would like one of you rocket scientist liberals to explain how care will be rationed under the bills before Congress. And if you say there will be no rationing you're simply lying. Or maybe stupid, in which case, Lee, perhaps you should learn some economics.

Posted by: cpurick | February 14, 2010 12:57 AM | Report abuse

"I'm sure you have no confidence in the CBO, but that's what their modeling confirms."

CBO modeling is worthless because Congress defines the universe in which their proposals are tested. So bills are scored assuming revenues that will never materialize, and assuming the impact of policies that will never be enacted.

Posted by: cpurick | February 14, 2010 1:08 AM | Report abuse

MikeR4, the trouble is McArdle's is trying to have it both ways. Her point in the post you cite is that she is not claiming "that insuring the uninsured wouldn't save anyone's lives." Her only point is that there are studies, including "the largest observational study done to date" that show that we "often cannot exclude the possibility that there is no effect." Well, in my opinion, that should be obvious if you consider the following, but that doesn't mean much.

Recall that, like Klein, she also cites Card's paper and gives several other examples of how being insured versus uninsured has a significant effect on mortality if you are in any of the subpopulations with a chronic and/or critical health need, i.e., ER, heart attack, cancer, etc. patients. She is just puzzled that when you add in the population of non-chronic and/or non-critical populations, this effect is not significant or can no longer be found.

But why should she be? The population you just added in are those with routine healthcare needs that typically do not lead to death, or put another way has some baseline mortality rate present in the general population. Because there are many more of them than the original chronic/critical group (which has a higher mortality rate if they do not have health insurance), no statistical analyses will show you the significant effect you saw before. In fact it is reasonable to assume that, for the large population, the overall mortality rate (not number) will go down because of a larger proportion of non-chronic/non-critical people.

Now, if we could identify them, it would appear McArdle would not object to providing health insurance to the uninsured with chronic and/or critical
needs...we all agree having insurance matters to mortality if you fall within this group. The problem is we have no way of doing this, so you either cover all the uninsured or you don't...and leave those with chronic and/or critical conditions to perish.

That is the primary issue, even if as McArdle wants to argue, the aggregate data does not show a significant effect on mortality in the general population between the insured and uninsured. Is the current health insurance scheme we have the best way to tackle this problem? That is another point entirely.

Posted by: ZnanaB | February 14, 2010 1:44 AM | Report abuse

"Everything of value is rationed. Everything -- there are no exceptions. None."

Things "of value" quite regularly become more affordable, and better, and more widely accessible, all at the same time.

Compare the quality and affordability of a personal computer in 1990 and a PC today, as just one of many obvious examples. If everything is rationed, what accounts for the fact that far more people in 2010 own computers purchased for such lower prices and with such higher quality than was true 20 years ago? Were computers taken away from some to make them available to others? No, comrade cpurick, that is not what happened.

I know it is heresy to your closed system communist-style rationing mindset, but it is quite possible (and if fact rather common) for "anything of value" (goods and services) to become less expensive and more widely distributed within a functional, competitve, dynamic market economy.

I have owned my own business for over 30 years, and I still look for and succeed in finding ways to improve quality and lower costs and pricing every week. My customers and my competitors don't see any "rationing" guiding the market, just the pressure of honest competition to deliver the best product at the best price.

"So, I would like one of you rocket scientist liberals to explain how care will be rationed under the bills before Congress. And if you say there will be no rationing you're simply lying. Or maybe stupid, in which case, Lee, perhaps you should learn some economics."

See above regarding the "rationing" mantra, and pssst ... cpurick, the insults don't add weight to any of your arguments, in fact they make you look positively rattled. Lastly, here's hoping all of us might now return to the topic of the thread, which is the published data concerning mortality rates for uninsured Americans.

Posted by: Patrick_M | February 14, 2010 2:26 AM | Report abuse

"CBO modeling is worthless because Congress defines the universe in which their proposals are tested. So bills are scored assuming revenues that will never materialize, and assuming the impact of policies that will never be enacted."

I see. So you are saying that after the legislation passes, new taxes in the legislation to finance HCR will never be levied, and that new expenditures in the legislation will not occur because of the cpurick-y rule.

Nothing contained in any legislation will transpire, but bad things NOT set forth in the legislation will inevitably occur. Thus CBO expert & non-partisan statistical scoring is worthless and cpurick's idelogical scoring is so very awesome.

Got it...thanks.

Posted by: Patrick_M | February 14, 2010 4:40 AM | Report abuse

Nothing McArdle rights should be taken seriously as her assumptions and arguments are typically unfounded in evidence. She is a bloviator, pure and simple.

Posted by: OHIOCITIZEN | February 14, 2010 6:54 AM | Report abuse

Nothing McArdle writes should be taken seriously. She is a pure bloviator, whose assumptions and conclusions typically are lacking in evidence. She is a distorter of facts.

Posted by: OHIOCITIZEN | February 14, 2010 6:56 AM | Report abuse

ZnanaB, I think that Megan McArdle probably agrees with everything you said, with one exception. Both she and the studies she cited expected the effect to be big enough to measure; apparently it wasn't. Her question was simple: Can we quantify how many people health care reform would save? Is the number small, or large? Ezra, for instance, recently claimed that Joe Lieberman was apparently willing to let hundreds of thousands die for lack of insurance. Is that true, or is it tens of thousands, or thousands? We need to know that, if only to know if Ezra is guilty of slander. And, while every human life is precious, we have to understand how to best use our resources.

Posted by: MikeR4 | February 14, 2010 9:44 AM | Report abuse

"Things "of value" quite regularly become more affordable, and better, and more widely accessible, all at the same time."

Absolutely. Even now we feed everybody. But we don't all eat the same, do we? Are you trying to admit that you'd like to make across the board cuts in care in order to provide a share for people who currently get none?

Or are you saying that even though we can't even feed everybody to your satisfaction, you actually believe we can give everybody top-notch healthcare?

"Compare the quality and affordability of a personal computer in 1990 and a PC today, as just one of many obvious examples. If everything is rationed, what accounts for the fact that far more people in 2010 own computers purchased for such lower prices and with such higher quality than was true 20 years ago?"

Well, for starters it turns out that some people still don't have computers. And people who pay for their computers seem to have better computers than those who do not, much like those who don't pay for insurance can only get emergent care. If we demanded that those who can afford computers fund the computing of those who cannot -- or of those whose computers are "inadequate," then it's easy to see how everybody who pays will have to take a cut in their own computing power (or in some other area of their lives) to achieve it. Is that your plan to ration healthcare?

What liberals propose to do is to provide additional care by eliminating "unnecessary" care. To put it in Obama's terms, we can give kidney transplants to more homeless people by giving more pills to Grandmothers whose doctors would like to give them a pacemaker.

That's "rationing by death panel," where some expert body overrules your doctor based on the efficiency (success rate) of a procedure. If a procedure only saves one in ten patients, you declare it "inefficient." But what you're really saying is that the procedure's too expensive as a way to save one in ten patients. Eliminating "inefficiency" means we no longer "waste" the procedure on nine patients -- but the other side of the same coin is that we don't save one out of ten lives with it anymore, do we? These "inefficient" and "unnecessary" procedures -- overuse -- save lives, however costly they may be. If you don't want to pay those costs, then you're saying those lives aren't worth it. You are rationing that care so you can provide to someone else. Admit it.

What you cannot honestly say is that you're going to cover a whole bunch of people without making cuts for others. What I'm asking you to do is to explain where those cuts are, instead of pretending that they're not cuts.

Posted by: cpurick | February 14, 2010 10:10 AM | Report abuse

cpurick: "Everything of value is rationed. Everything -- there are no exceptions. None." That is a long way from the idiotic statement that the "demand is infinite." Does everybody in the developed countries have all the water they want to drink? Hayek in The Road to Serfdom pointed-out that the demand for healthcare is FIINITE -- you don't want endless amounts of it, you want to be well -- and this demand can be met, at least theoretically. (Let's except cosmetic applications, which shouldn't be covered publicly.) Supply is NOT static, it can grow. And we should make arrangements to meet the demand by increasing supply in a way that reduces cost, as a matter of healthy society and economics. The healthcare bills as I understand them are only a first step and pretty much ration healthcare the "way" it is done now, while revealing the legitimate hidden (but finite) demand. There are lots of other issues that are involved, such as streamlining care and increasing the supply of doctors and nurses, and of course we have to keep jumping over rank stupidity by blog commenters.

Posted by: Lee_A_Arnold | February 14, 2010 11:01 AM | Report abuse

The following word pairs are not interchangeable.

Mortality / Health
Health / Health Care
Health Care / Health Care Insurance
Access to Care / Utilization of Care
Link / Causal Relationship
Ration / Allocated

It would be helpful if the author and posters were more precise in their use of words.

Posted by: ktoh | February 14, 2010 11:49 AM | Report abuse

Actually, "ration" and "allocate" are almost perfectly interchangeable.

Posted by: Lee_A_Arnold | February 14, 2010 1:26 PM | Report abuse

"To put it in Obama's terms, we can give kidney transplants to more homeless people by giving more pills to Grandmothers whose doctors would like to give them a pacemaker."

Your latest post really jumps the shark, cpurick. To put in Joe Biden's terms, you are "either misinformed, or misinforming."

There is no rationing, there are no death panels. There is instead an investment made to get more people covered. There is not an unlimited demand and a fixed supply of health care that requires we deny a benefit to grandmothers in order to provide care to the homeless. Increasing "efficiency" does not require turning people away, in fact with health care enhanced efficiency is a natural result of enrolling more people.

Here is an example. "Grandpa" is 60 years old and he can't obtain affordable health insurance. He should have started having periodic colonoscopies when he reached the age of 50, but he can't afford the procedure and has never had one. When he finally reaches the age when he can receive Medicare benefits, he will have a late stage colon cancer, that would have been completely preventable if he had had access to affordable preventive care earlier in life. Grandpa's cancer will lead to huge bills that Medicare will be paying, and those costs would have been unnecessary had we invested in a modest subsidy to allow Gramps to have access to affordable private insurance earlier in his life.

(to be continued...)

Posted by: Patrick_M | February 14, 2010 4:07 PM | Report abuse

(continuing...)

This week I purchased a new piece of equipment for my business that cost nearly $20,000. Very expensive initially, but it will lower my production costs and allow me to produce more units at a lower price per unit. So it will expand the distribution of my product, allow me to produce at a lower price, and the investment will thereby more than pay for itself over time, by increasing the efficiency of the systems inside my business. We can and should make investments in our health care system that will similarly lower costs and expand the pool of customers that are served, and such an investment will likewise pay for itself over time.

Measuring the efficiency of a specific medical treatment or device already takes place with your private insurance company today. It is not a question of whether a treatment can only help one in ten people, it is a question of whether that treatment is the best available way to treat the one person who receives it, or whether there are more effective alternatives. If a pacemaker is the most effective treatment for your heart problem, but you prefer to treat the problem with acupuncture, your insurance company may not want to pay for the acupuncture, even though it is cheaper than the pacemaker which they will pay for. That does not mean they are behaving, in that instance, like a death panel, in fact quite the opposite.

I know that you will stubbornly cling to the meme that there can only be as much as much health care provided in the USA as is being provided today, and so in order to provide care to anyone who does not have it today, we must be deny care to someone else. Thus in your mind HCR must depend on rationing and government-run death panels, because you are incapable of imagining that any enterprise can grow and lower production costs at the same time. Fortunately, the real world (and our health care system) simply does not work that way, cpurick.

Posted by: Patrick_M | February 14, 2010 4:08 PM | Report abuse

PatrickM,

i've looked over briefly what you've stated and i'll note one inaccuracy.

You said:

"This week I purchased a new piece of equipment for my business that cost nearly $20,000. Very expensive initially, but it will lower my production costs and allow me to produce more units at a lower price per unit. So it will expand the distribution of my product, allow me to produce at a lower price, and the investment will thereby more than pay for itself over time, by increasing the efficiency of the systems inside my business."

This does NOT work in healthcare. MRI's are the greatest example of this. MRI cost varies so immensely because there is no pricing available to consumers and consumers are way too immune to the cost differentials. We've heard many times on here how an MRI in one place costs "X" and across the street its half of "X". It is not a better MRI. People are just hidden from the price and even if the price wasn't hidden they're hidden from the COST because their copay treats them the same wherever they go. Hence the benefit of an HSA.


Also another example as to why healthcare does not act as you say. Have you ever noticed that ER docotrs and anesthesiologists do not participate in almost ANY insurance networks? Do you know why? Its because they don't have to accept less from an insurer. When you lose a limb, break an arm, are in a car accident you can't shop for the best ER or one that has doctors in your network. Same goes for anesthesiologists. Once the American public clues into this (hopefully before its too late cost wise) then we'll all be a little more understanding of who is ruining the healthcare system.

Posted by: visionbrkr | February 14, 2010 4:29 PM | Report abuse

visionbrkr,

"This does NOT work in healthcare. MRI's are the greatest example of this."

First, my argument was only that if more people have access to routine preventative care, fewer people will need more expensive extraordinary care later on, so there is a delayed cost reduction reward in making the investment to expand coverage. As the oil change commercials used to say, "pay me now or pay me later" (when the engine fails for lack of maintenance).

I readily acknowledge that there other factors that also contibute to the current inflation in the cost of health care.

As for the MRI example:

"People are just hidden from the price and even if the price wasn't hidden they're hidden from the COST because their copay treats them the same wherever they go."

Kind of. Insurance policies cap what they will pay for any procedure, and you must go "out-of-pocket" for the difference when you go to a provider that charges more than the insurer's cap. I have never had an MRI, but if I ever do, I will comparison shop for a provider that can deliver the service without gouging me on the out-of-pocket contribution, and I have done that for other procedures in the past. My dentist charges me a little more for some procedures than my dental plan allows, but I choose to keep seeing that dentist and pay him the slight difference, because I am really happy with the care that I receive. Yes, the co-pay is the same wherever you go, but the out-of-pocket is anywhere from zero to "the sky's the limit," but as a consumer I do have some ability to make some phone calls and compare and choose, the cost is not always completely hidden. But I would certainly agree with you that anything that will make the costs of different providers more tranparent and thereby more competitive would be a welcome change and would help to further lower overall costs.

I also agree that the larger percentage of emergency room doctors and anesthesiologists staying "out of network" (just because they can) is a problem in the current system that deserves a solution.

Posted by: Patrick_M | February 14, 2010 5:16 PM | Report abuse

"There is no rationing, there are no death panels."

Ever heard of "Comparative Effectiveness Review"? If they deem a procedure "ineffective," it won't be covered. Not even if your doctor thinks you should get it. Remember, it was Obama, not me, who suggested the old lady take the pill.'

""Grandpa" is 60 years old and he can't obtain affordable health insurance. He should have started having periodic colonoscopies when he reached the age of 50, but he can't afford the procedure and has never had one. When he finally reaches the age when he can receive Medicare benefits, he will have a late stage colon cancer, that would have been completely preventable if he had had access to affordable preventive care earlier in life. Grandpa's cancer will lead to huge bills that Medicare will be paying, and those costs would have been unnecessary had we invested in a modest subsidy to allow Gramps to have access to affordable private insurance earlier in his life."

Bull's hit. While much of what you say about Grandpa is true, there are many, many grandpas, and only a *few* of them will get colon cancer. You say that it's cheaper to give any particular grandpa a colonosopy than to treat his cancer, and technically that's true. But it's not cheaper to give all grandpas colonoscopies -- that's a lot of procedures to detect only a few cancers.

Think about it: people don't get screening tests because screening's cheaper. It's not done to save money. People get screened because it's worth the *extra* money to find cancers when you have the best chance of stopping them.

"Measuring the efficiency of a specific medical treatment or device already takes place with your private insurance company today."

True. And if an insurance company is willing to pay for a procedure, then you know it's not "overuse." And yet all this "overuse" you libs hope to "eliminate" is actually approved by insurance companies. Have you ever considered that?

Posted by: cpurick | February 14, 2010 5:43 PM | Report abuse

Lee_A_Arnold
"Supply is NOT static, it can grow."

And it grows with an opportunity cost in everything that doesn't grow instead. In order to grow the supply of care to cover people who don't pay for theirs, somebody who does pay for it must pay more than they would have to.

So either everyone else takes less care in order to provide for the free riders and the chronically ill, or they pay more for their care in order to underwrite the free riders and the chronically ill.

Are you going on record as saying that everyone should expect less care, or higher bills? Or both? Which "allocation" model are you suggesting?

Posted by: cpurick | February 14, 2010 5:55 PM | Report abuse

"Ever heard of "Comparative Effectiveness Review"? If they deem a procedure "ineffective," it won't be covered."

Yes, I have heard of CER. No different conceptually than your current insurance, as I already addressed with the acupuncture vs. pacemaker hypothetical. Your insurance company today will not honor any claim that you and some quack doctor may wish to present, they have guidelines based on demonstrated effectiveness. That's not a death panel.

"But it's not cheaper to give all grandpas colonoscopies -- that's a lot of procedures to detect only a few cancers."

If what you were saying was true, then insurance companies would not pay for colonoscopies now. They do. Because it saves them money to prevent cancer for many patients than to pay for the enormous costs of treatment among the smaller number of patients who would otherwise develop late stage cancer.

"Think about it: people don't get screening tests because screening's cheaper."

I know. People get preventative care to prevent illness. Insurance companies (and single payer systems like the VA and Medicare) pay for prevention because it is cheaper to prevent illness than to treat it. Everybody wins when illness doesn't happen.

"And if an insurance company is willing to pay for a procedure, then you know it's not "overuse." And yet all this "overuse" you libs hope to "eliminate" is actually approved by insurance companies. Have you ever considered that?"

HCR leads to the very same insurance companies enrolling more patients. They will continue to make the same "effectiveness" decisions in the structuring of their policies that they have made in the past. You won't get your claim paid today if your insurance company has data showing that the treatment is useless and another treatment is more effective, and the same will be the case if HCR were to pass.

As I said before, I know that you will stubbornly cling to you core belief that health care is a zero sum game. I can see that within the dark confines of your head it is impossible to imagine that your private insurer might tomorrow enroll a new customer (with a public subsidy, or with a winning lottery ticket) unless the company also pulls the plug on somebody's Grandma. To use your term, that's some utter

"Bull's hit."

Stay classy, and auf Wiedersehen.

Posted by: Patrick_M | February 14, 2010 6:27 PM | Report abuse

cpurick: "And it grows with an opportunity cost in everything that doesn't grow instead."

Incorrect. "Opportunity cost" is short-term, a choice you make between two products. Long-term, "opportunity cost" doesn't apply: supply grows to meet demand, and efficiency in one sector frees-up resources for use in another sector. The economy grows in all dimensions (though currently we have an energy-waste problem, CO2.) It is definitely NOT zero-sum, or else we'd be still living in caves.

We should think of healthcare as a growth industry that employs people and has many side benefits for unrelated sectors such as construction and retailing.

cpurick: "Are you going on record as saying that everyone should expect less care, or higher bills? Or both? Which "allocation" model are you suggesting?"

We have 40% HIGHER bills than any other developed country, where they cover EVERYONE. If "rationing" is so drastic there, why aren't there riots in the streets? Far from it -- they are happy. You've been misled.

As for me, the way to go is a TWO-TIER system, like almost everybody else has. A baseline non-profit plan that covers everyone regardless of ability to pay, funded by a mandate or out of taxes, PLUS private coverage on top if you want the latest tech and drugs for your rhinestone-encrusted lifestyle.

Posted by: Lee_A_Arnold | February 14, 2010 8:01 PM | Report abuse

Patrick,

I agree with you totally on the idea of prevention first.

On your other point I'll disagree though. While some insurance plans have caps like you speak of, the large majority do not. My one suggestion. don't buy insurance from a fax you receive that promises healthcare for $99 a month. Its not comprehensive.

Posted by: visionbrkr | February 14, 2010 10:01 PM | Report abuse

visionbrkr,

Most health insurance now is based on the model of a provider network. The doctors and other care providers that join an insurer's network have agreed in advance to accept the insurer's maximum rate of reimbursement for the services they provide. Often they will bill an uninsured patient a higher rate, but they agree to the insurer's pricing model in order to get the big book of business from the insurer's pool of enrollees.

So imagine that Blue Cross reimburses $100 for a specific service. Doctor A charges $200 for that service whereas Doctor B charges $100 for the same service. If both doctors are in the Blue Cross network, Doctor A will be writing off $100 from his or her standard fee when he or she bills Blue Cross, and Blue Cross pays the same amount to both doctors.

If you go "out of network," there is no such contract between the insurer and the physician, and so the rate of reimbursement offered by your insurer is much less, and your out of pocket cost is variable (plus you may have to process the insurance claim yourself for a direct patient reimbursement).

An insurance plan that pays "full price" to both Doctors A & B would be extremely rare these days, because logic dictates that without being able to predict the costs that will be billed, it is virtually impossible for an insurer to calculate a fair premium that ensures the continuing solvency of the insurance plan.

A more detailed explanation can be found here:

http://health.howstuffworks.com/provider-network.htm

And yes, you get what you pay for with health insurance. If a plan costs $99 a month, you'll get close to nothing.

Posted by: Patrick_M | February 15, 2010 12:07 AM | Report abuse

"I have heard of CER. No different conceptually than your current insurance, ...Your insurance company today will not honor any claim that you and some quack doctor may wish to present, they have guidelines based on demonstrated effectiveness."

Ah, but there *is* a difference. If a procedure *could* help you, and your doctor requests it, then an insurance company cannot refuse the procedure on the grounds that "it only helps 20% of patients." If you're in that 20% (and nobody can tell until the procedure's been tried), and the procedure is refused, then that refusal seals your fate. Of course, that part works the same either way.

What's different with private insurance is that the insurance company has to answer for 100% of the cases it refuses -- which means the system gets as good as it can at determining who the procedure will help, and then it gives the procedure to everyone it can't exclude in order to avoid lawsuits.

In contrast (since you said it's conceptually no different), CER is the foundation of a plan that simply refuses care because the treatment is "statistically unlikely to help." So the plan changes from "give the procedure by default" to "refuse the procedure by default."

A lawsuit asks the government to decide who's right. But in setting policy, government has already taken a side.

Now I have no problem admitting that this is a major source of spending on care that doesn't work, but then I think the minority of lives that are saved/improved may be worth that cost.

But more importantly, I'm not going to let you libs gloss over the fact that the "unnecessary care" you want to deny is currently saving lives, and that some of those lives will be lost if you have your way. I *favor* rationing. And that's a debate we need to have. But I'm not going to let you lying libs just tell everybody that the procedures you want to cut are "unnecessary" or "inefficient." Those inefficiencies are the high costs of saving lives. So while we have that debate, it's important that the public understand what's really in the balance.

"If what you were saying was true, then insurance companies would not pay for colonoscopies now."

Yes, they certainly would. They pay, not because colonoscopies are cheaper than cancer, but because they're cheaper than *lawsuits*.

Now, personally, people should pay for their own routine colonoscopies. "Insurance" is not to protect you from the perfectly foreseeable cost of getting old; it's to protect you from the unforeseeable costs. You should *look* for illness at your own expense, and "insurance" is something that only kicks in if you turn out to be sick.

Posted by: cpurick | February 15, 2010 8:17 AM | Report abuse

Lee_A_Arnold
"Incorrect. "Opportunity cost" is short-term, a choice you make between two products."

Opportunity cost lasts for as long as something would have been better if the other choice had been taken. If people are less free forever, then that's a long time. If someone dies tomorrow as a result of the choice, then the cost lasts for as long as they might have lived. If someone dies a hundred years from now, then the balance of their natural life is also an opportunity cost of the decision made today.

Liberalism relies on the fact that opportunity costs can only be imagined. But that doesn't mean they aren't real.

"If "rationing" is so drastic there, why aren't there riots in the streets? Far from it -- they are happy."

With the right propaganda campaign, people will happily live in slavery. Consider the nonsense suggestion that Cuba and the US are neck and neck in terms of healthcare quality. Do you honestly believe anyone in the world thinks getting care in Cuba is the next best thing to getting it in the US? But you're okay torturing the numbers like that to keep everyone "happy"?

I'm not in it for the happiness -- I'm in it for the freedom (and everyone's freedom to pursue their own happiness). I appreciate your position, though, comrade.

Posted by: cpurick | February 15, 2010 8:36 AM | Report abuse

Switzerland is happily living in slavery? Australia? Canada? People who have poor health in the U.S. because they couldn't afford insurance are freer? Pretty twisted stuff, dude!

Posted by: Lee_A_Arnold | February 15, 2010 9:23 AM | Report abuse

visionbrkr,

Most health insurance now is based on the model of a provider network. The doctors and other care providers that join an insurer's network have agreed in advance to accept the insurer's maximum rate of reimbursement for the services they provide. Often they will bill an uninsured patient a higher rate, but they agree to the insurer's pricing model in order to get the big book of business from the insurer's pool of enrollees


Patrick M,

I believe it works in the converse. Providers of services know that they need to receive "X" to make their finances work. They agree to accept less than "X" from an insurer for that additional guaranteed business you speak of. Its not that they're charging the uninsured more, its that they're paying retail.

What most people don't know about out of network is that its based upon usual and customary (what every provider in a given area charges) so with doctors billing well over the norm it inflates that figure and costs the system much much more which in turn increase costs in the form of premium for all of us.

Posted by: visionbrkr | February 15, 2010 10:12 AM | Report abuse

"People who have poor health in the U.S. because they couldn't afford insurance are freer?"

People who forgo insurance because they want to purchase other "necessities" are exercising their freedom. That's liberty.

What happens as a result is called "justice."

Are there some people who could use some help -- people who truly can't afford insurance? Yes. Is the entire system in shambles? No -- it's just too expensive.

I have all kinds of ideas for fixing the cost problems, but none of those start with a new entitlement.

Posted by: cpurick | February 15, 2010 10:54 AM | Report abuse

visionbrkr,

My point about the provider network model was simply in response to your statement that "While some insurance plans have caps like you speak of, the large majority do not." I was pointing out that insurers do in fact cap (standardize) the amount that they will reimburse providers for any covered procedure.

Posted by: Patrick_M | February 15, 2010 11:35 AM | Report abuse

"People who forgo insurance because they want to purchase other "necessities" are exercising their freedom."

A neccessity is (by definition) something you need, not something you want. If there is not enough money left for health insurance after you pay for necessities like food and shelter, you are not "exercising your freedom," you are not making a choice among things that you want, you are simply priced out of the market.

"Now, personally, people should pay for their own routine colonoscopies. "Insurance" is not to protect you from the perfectly foreseeable cost of getting old; it's to protect you from the unforeseeable costs. You should *look* for illness at your own expense, and "insurance" is something that only kicks in if you turn out to be sick."

Insurance companies should no longer have the "freedom" to fund the prevention of illness and save lives and money at the same time. A colonoscopy costs thousands of dollars and is typically repeated every three to five years after the age of 50, so anyone in the working class who can't bear that expense out of their own pocket should be left to spin the roulette wheel, and some of them will develop colon cancer. The other members of the insurance pool will then pay to treat the preventable cancers. This is a sensible policy? Expenses arising from preventive care and from procedures that lead to early diagnosis during a curable stage of an illness (the smartest and least expensive way to maintain good health) should be excluded from insurance coverage. Ok....

"I have all kinds of ideas for fixing the cost problems, but none of those start with a new entitlement."

We can see that.

Posted by: Patrick_M | February 15, 2010 12:00 PM | Report abuse

cpurick: "Are there some people who could use some help -- people who truly can't afford insurance? Yes. Is the entire system in shambles? No -- it's just too expensive.

"I have all kinds of ideas for fixing the cost problems, but none of those start with a new entitlement."

Then write up your comprehensive list, next. The world awaits your wisdom.

Posted by: Lee_A_Arnold | February 15, 2010 2:51 PM | Report abuse

@Lee_A_Arnold: That list will comprise only two substantive ideas, ideas that are so innovative, so revolutionary that few in the world have ever dared to conceive of them: TORT REFORM and INTERSTATE COMPETITION. I'm waiting to see what contortions of logic and what Econ 101 concepts (opportunity costs!) he'll abuse in order to show that those are the panacea to all of the healthcare system's inefficiencies.

@Patrick_M: I've admired your patience in dealing with a certain commenter on this thread and your skillful dissection of his arguments. You seem to have a fairly deep knowledge on the topic of healthcare and healthcare insurance. I was wondering whether or not you study these issues academically. If not, what literature have you read to educate yourself about these issues?

Posted by: atlasfugged | February 15, 2010 4:03 PM | Report abuse

"A neccessity is (by definition) something you need, not something you want."

Ah, but "necessities," in *quotes*, indicate something that is *called* a necessity, but is not necessarily so.

Set your way-back machine to, oh, 1970, and consider all the things a liberal then would have demanded that every family have. Would you have insisted that everyone have health insurance, or perhaps the ability to afford a college tuition?

Because I'm thinking you would have found those things more important than having, say, a house with three or four color TVs, cable service and internet, multiple video players, camera-equipped cell phones, iPods, microwave ovens, personal computers, central air conditioning. Multiple Cars with on-board computers, air bags, power windows and air conditioning.

In fact, I'm thinking a family today pays for so many "necessities" that didn't used to be necessary at all, that it could easily afford *real* necessities like healthcare if it had its priorities straight.

And then this:
"A colonoscopy costs thousands of dollars and is typically repeated every three to five years after the age of 50, so anyone in the working class who can't bear that expense out of their own pocket should be left to spin the roulette wheel, and some of them will develop colon cancer."

First, the more expensive you admit colonoscopies are, the more you prove my point that scoping everyone regularly is much, much cheaper than just paying to treat the few who get cancer.

And second, by the time someone reaches 50, he's had five decades to sock away money for both his healthcare needs and his retirement. Instead, he's bought countless color TVs, a lifetime of cable service and internet, multiple video players, camera-equipped cell phones... well, you get it.

Posted by: cpurick | February 15, 2010 4:46 PM | Report abuse

On the point of colonoscopies, scoping everyone is more *expensive* than simply treating cancers. That's what I get for editing in a tiny window.

Posted by: cpurick | February 15, 2010 4:48 PM | Report abuse

Lee_A_Arnold:
More cost-sharing. The end of the relationship between employment and health insurance. The legalization of catastrophic-only health insurance, starting with Medicare and Medicaid, and including a risk pool for people with pre-existing conditions. Tax deductibility for only the catastrophic component of any healthcare plan. Means-testing for Medicare. Liability caps for Medicare and Medicaid providers. Expanded health savings accounts. Ending rescission.

Posted by: cpurick | February 15, 2010 5:07 PM | Report abuse

@atlasfugged,

"@Patrick_M: I've admired your patience in dealing with a certain commenter on this thread and your skillful dissection of his arguments. You seem to have a fairly deep knowledge on the topic of healthcare and healthcare insurance. I was wondering whether or not you study these issues academically. If not, what literature have you read to educate yourself about these issues?"


Thank you. No, I don't study the issues academically. I own a business, comparison shop for health care policies for my employees, and I also try and understand the issues surrounding health care for the sake of myself and my family.

Posted by: Patrick_M | February 15, 2010 5:18 PM | Report abuse

"Because I'm thinking you would have found those things more important than having, say, a house with three or four color TVs, cable service and internet, multiple video players, camera-equipped cell phones, iPods, microwave ovens, personal computers, central air conditioning. Multiple Cars with on-board computers, air bags, power windows and air conditioning.

In fact, I'm thinking a family today pays for so many "necessities" that didn't used to be necessary at all, that it could easily afford *real* necessities like healthcare if it had its priorities straight....

And second, by the time someone reaches 50, he's had five decades to sock away money for both his healthcare needs and his retirement. Instead, he's bought countless color TVs, a lifetime of cable service and internet, multiple video players, camera-equipped cell phones... well, you get it."

You are describing an upper middle class life style, I was not. Please consider the fact that the median income for a family now is at $52,000. Then consider the following (from Karen Tumulty):

---

"AP reports that insurance companies in at least four states are raising their premiums for individual insurance policies (those that people have to buy themselves, because they don't get coverage from an employer) by 15% or more. To give you a sense of what we are talking about if these rates go into effect, a family of four in Maine (which is a relatively poor state) can expect to pay $1,876 a month--about $22,500 a year--for health insurance, starting in July."

---

Your argument that working class families that do not have employer subsidized insurance could pay for their own insurance policies (or their own health care) today if only they owned fewer iPod's simply reveals your own disconnection from reality, and the apparent contempt you have for average Americans.

(to be continued...)

Posted by: Patrick_M | February 15, 2010 5:49 PM | Report abuse

(continuing...)

"First, the more expensive you admit colonoscopies are, the more you prove my point that scoping everyone regularly is much, much cheaper [sic] than just paying to treat the few who get cancer."

No, both are expensive procedures. But paying for the extraodinary treatment that takes place in late stage cancer is exponentially more expensive than "scoping" a middle-aged patient 2 or 3 times each decade. Insurance companies find that funding a periodic opportunity to remove polyps before they can become cancerous is far less expensive than providing cancer treatment for the significant percentage of persons who would develop colon cancer if left undetected until a late stage. It is the same reason insurer's also pay for annual check-ups & why many insurers even waive the co-pay for any such preventative care. It is in the financial self-interest of the insurance pool to promote prevention and early detection for all.

You can continue to argue that prevention and early detection of disease is more expensive than letting people develop serious diseases (and to die of them), and you can continue to argue that insurance should pay only for treating advanced illness rather than prevention and early detection, but you may only do so if you also invent your own facts.

Posted by: Patrick_M | February 15, 2010 5:51 PM | Report abuse

cpurick, Your list shifts costs or else hides costs, but none of it controls costs.

Posted by: Lee_A_Arnold | February 15, 2010 9:00 PM | Report abuse

So, if health insurance doesn't help people stay healthy and live longer, then why on earth are so many people that try to say it doesn't matter paying for health insurance?

Can't have it both ways. Either it helps, and it's worth it to pay and that's why they are paying, or it's not worth it and they are paying so the insurance companies can make a profit, and that's the only reason. They LIKE to give their money away to millionaires, and the people who can't afford it are actually smarter because they are using their money for survival.

Riiiiight.

Posted by: splashy8 | February 15, 2010 9:25 PM | Report abuse

"cpurick, Your list shifts costs or else hides costs, but none of it controls costs."

Bingo. It is the LTEC ("let them eat cake") health care plan.

Certified 100% laissez-faire toward reduction in the annual inflation of the cost of medical care services. Less coverage & higher costs for all individuals and businesses (by ending all tax deductions, designed especially to end employer participation completely).

Only catastrophic benefits under LTEC (and oddly he or she thinks catastrophic private policies, which already exist, need to be "legalized"). Catastrophic only
~even for retirees on Medicare~ and only then if they meet the means test, although they have all involunatrily paid into the Medicare system throughout their entire working life, in the expectation they were buying into a plan that guarantees reasonably comprehensive basic medical care benefits at retirement.

And (of course) under LTEC no insurance system (public or private) will continue to support wellness by reimbursing for preventive medicine and early detection. Those with the means to pay can prevent their diseases. It is cheaper for society (he or she thinks) to allow the rest to get sick and treat them afterwards, in the event the illness happens to be catastrophic.

Promoting wellness, after all, should not be the goal of the American health care systema. LTEC!

Posted by: Patrick_M | February 15, 2010 10:10 PM | Report abuse

Another odd thing is that a libertarian would advocate means testing. You need a very large and intrusive bureaucracy for that. A really bad idea.

Posted by: Lee_A_Arnold | February 15, 2010 10:38 PM | Report abuse

"Your argument that working class families that do not have employer subsidized insurance could pay for their own insurance policies (or their own health care) today if only they owned fewer iPod's simply reveals your own disconnection from reality, and the apparent contempt you have for average Americans."

Hmm. Some thoughts on "disconnection":

"What does it mean to be “poor” in America? For the average reader, the word poverty implies significant physical hardship — for example, the lack of a warm, adequate home, nutritious food, or reasonable clothing for one’s children. By that measure, very few of the 30 million plus individuals defined as “living in poverty” by the government are actually poor. Real hardship does occur, but it is limited in scope and severity.

"The average person identified as “poor” by the government has a living standard far higher than the public imagines. According to the government’s own surveys, the typical “poor” American has cable or satellite TV, two color TVs, and a DVD player or VCR. He has air conditioning, a car, a microwave, a refrig­erator, a stove, and a clothes washer and dryer. He is able to obtain medical care when needed. His home is in good repair and is not overcrowded. By his own report, his family is not hungry, and he had sufficient funds in the past year to meet his family’s essential needs. While this individual’s life is not affluent, it is far from the images of dire poverty conveyed by liberal activists and politicians."

http://article.nationalreview.com/405914/understanding-poverty-in-america/robert-rector

The problem is that you will give many colonoscopies for each cancer you detect, and costs will be higher to find them all than to only deal with the ones that present. Colonoscopies aren't designed to save money -- they're designed to save lives.

And let's try to remember that you're only attempting to use that argument to question why insurance companies pay for colonoscopies when it would therefore be cheaper to let people die. I've already explained that, and government doesn't have the same incentives.

Am I now supposed to put up a "[sic]" when I quote your misspellings, like "neccessity"? Just checking, because I was going to let your illiteracy slide.

Posted by: cpurick | February 16, 2010 12:20 AM | Report abuse

"cpurick, Your list shifts costs or else hides costs, but none of it controls costs."

I find that when you make people personally conscious of the cost of each procedure they tend to be more discriminating about which ones they pay for. I'd like to encourage a little more debate between patients and their doctors, a la "Do I really need this procedure, Doc?"

This is a similar strategy to "eliminating unnecessary procedures/overuse," except that it doesn't pretend the same procedures aren't medically valid. I find that aspect of your solution intellectually dishonest, though liberalism
admittedly embraces intellectual dishonesty.

The list would clearly cut net demand as consumers and doctors are pressured to omit costly procedures that have become all too routine. And cutting demand may or may not lower costs directly, but it *certainly* lowers prices and creates incentives to lower costs.

Relax -- I'm only trying to get people to skip the very same procedures that you're telling them are "unnecessary."

Posted by: cpurick | February 16, 2010 12:33 AM | Report abuse

"While this individual’s life is not affluent, it is far from the images of dire poverty conveyed by liberal activists and politicians."

Wow, good to know that the poor are doing so well. It is telling that your insight into the life experiences of struggling families comes from reading a magazine article in (of all places) The National Review.

"The list would clearly cut net demand as consumers and doctors are pressured to omit costly procedures that have become all too routine."

Yes, you reduce spending on health care when you reduce access to health care, or as you call it, cut demand.

"I find that when you make people personally conscious of the cost of each procedure they tend to be more discriminating about which ones they pay for. I'd like to encourage a little more debate between patients and their doctors, a la "Do I really need this procedure, Doc?"

Do you find that? I have heard this one before from critics of health care. the first problem with this theory is that insured care still involves co-pays, and (often quite substantial) co-insurance payments, even when the subsciber is "in network." So the patient tends to always have some financial "skin in the game," because the system is already designed that way.

Moreover, you health care critics seem to think that there are vast armies of people who enjoy trotting into medical offices and experiencing the incovenience, discomfort, embarrassment, and excruciating tedium that goes along with medical procedures, in order to experience the joy of wasting time and the thrill of obtaining completely useless services. Perhaps you suffer from that sort of masochism or hypochondia, cpurick, but if so you are in a distinct minority.

Everyone in my circle of acquaintances would rank medical tests and procedures as being very low on the scale of entertainment value, and would prefer to anywhere except in a doctor's office. There are built-in disincentives, in addition to the cost factor.

(to be continued...)

Posted by: Patrick_M | February 16, 2010 2:45 AM | Report abuse

(...continuing...)

"Relax -- I'm only trying to get people to skip the very same procedures that you're telling them are "unnecessary."

No, you are only trying to escape being part of a pool of contributors that together will pay for sensible basic medical care (to include cost-effective and life-saving prevention and early detection) for yourself and others in the pool.

I don't think anyone advocates providing treatments that have no effect in treating illness, but since you are so afraid of the CER concept, perhaps I am wrong and there is one such person out there.

"Am I now supposed to put up a "[sic]" when I quote your misspellings, like "neccessity"? Just checking, because I was going to let your illiteracy slide."

My typo does not indicate illiteracy on my part. Your use of a word that has an meaning which is opposite than your intention does not indicate illiteracy on your part. The use of [sic] does not signal illiteracy. Instead, it signals to the reader that a quotation is given verbatim, which can help alleviate confusion for the reader when someone has inadvertently used a word with a meaning opposite to the intent.

"I find that aspect of your solution intellectually dishonest, though liberalism
admittedly embraces intellectual dishonesty."

I suppose that you feel that your constant use of statements such as this lend weight to your arguments in some way.

Posted by: Patrick_M | February 16, 2010 2:52 AM | Report abuse

"Wow, good to know that the poor are doing so well. It is telling that your insight into the life experiences of struggling families comes from reading a magazine article in (of all places) The National Review."

LOL, I figured you'd go right for the source -- even though the author pulled his figures directly from government data. Perhaps you should withhold judgement until reading his credentials:
http://en.wikipedia.org/wiki/Robert_Rector

"Yes, you reduce spending on health care when you reduce access to health care, or as you call it, cut demand."

And that is *exactly* the same principle behind Democrats' current healthcare plan: Make certain costly procedures inaccessible by declaring them "inefficient." If you could just swallow your pride and admit that, then maybe you'd understand what you really are.

To clarify, I certainly believe there's a culture of perfection in US healthcare today. If the technology exists to perfect a diagnosis, or to rule out alternative diagnoses and conditions, then the expectation is that the technology will be used, leaving no stone unturned. And whether you admit it or not, armies of trial lawyers stand at the ready to sue in the case of any outcome that might have been better with additional medicine.

What we need are realistic expectations, and less-equal outcomes. Medicine is expensive, and those who cannot afford it should be purchasing less -- taking more chances, and cutting more corners at their own risk. And again, I'm only talking about cutting the same procedures that you libs keep calling "unnecessary." And I'm only talking about cutting them for those who can't afford comprehensive care, which is better than your convincing everyone to simply live more poorly.

"No, you are only trying to escape being part of a pool of contributors that together will pay for sensible basic medical care (to include cost-effective and life-saving prevention and early detection) for yourself and others in the pool."

In fact, I am perfectly happy to pay into my risk pool. But I don't want to pay for the chronically ill until they have done everything they can to pay for themselves. It's insurance -- not welfare.

"My typo does not indicate illiteracy on my part."
You misspelled it at least twice, dude.

"I suppose that you feel that your constant use of statements such as this lend weight to your arguments in some way."

Nope. I just like people to understand exactly what they're saying after the facade of political correctness has been removed. And you're advocating bondage.

Posted by: cpurick | February 16, 2010 7:25 AM | Report abuse

cpurick: "I find that when you make people personally conscious of the cost of each procedure they tend to be more discriminating about which ones they pay for."

That's in the reform bills, in about three or four different ways. But it wasn't in your list. The items in your list do nothing to reduce costs.

Posted by: Lee_A_Arnold | February 16, 2010 9:38 AM | Report abuse

"LOL, I figured you'd go right for the source -- even though the author pulled his figures directly from government data. Perhaps you should withhold judgement until reading his credentials..."

The point that failed to penetrate your solipsistic bubble is that others have some direct experience with people in different socio-economic positions, and that gives us a deeper means of appreciating the consequences of economic hardship. We don't all reach our conclusions about the lifestyles of the less fortunate by reading government data in conservative magazine articles. You really ought to try getting out into different sections of your community a little more, "dude."

"Medicine is expensive, and those who cannot afford it should be purchasing less -- taking more chances, and cutting more corners at their own risk."

This is a really fine summary of the guiding philosophy behind the list of "reforms" that you offered earlier. Thank you for that.

It would be refreshing to hear McConnell and Boehner use similar language to describe the Republican party's "ideas" to reform America's health care system. But I supppose these conservative leaders must be too "intellectually dishonest" and that they are constrained by "the facade of political correctness" to speak with the same level of clarity.

Posted by: Patrick_M | February 16, 2010 12:00 PM | Report abuse

"The items in your list do nothing to reduce costs."

We had this discussion. The items reduce demand, and that reduces price. Cost is something the industry fixes on its own to restore demand.

Any attempt at actually reforming healthcare or controlling costs is window dressing. The bill is about universal healthcare, and every other consideration is secondary.

Any "savings" are accounting gimmicks, and if the real cost was twice as high the accounting tricks would just be twice as tricky. You guys honestly, truly do not care what universal healthcare costs -- you're prepared to pay any price, tell any lie, to have it. Obama said it all when he told us Grandma should just take the pill.

Posted by: cpurick | February 16, 2010 3:26 PM | Report abuse

cpurick: "The items reduce demand..."

Saying it is so, doesn't make it so. The items on your list shift demand, or turn it into hidden demand.

There is in fact no reason to reduce the demand for healthcare. That is anti-economic growth.

The reform bills take a handful of steps toward real cost controls. They aren't much, but it's more than you've taken here.

Posted by: Lee_A_Arnold | February 16, 2010 4:02 PM | Report abuse

"There is in fact no reason to reduce the demand for healthcare."

And just what do you suppose telling Grandma to "take the pill" is...?

Posted by: cpurick | February 16, 2010 4:53 PM | Report abuse

How does telling someone to take their pills reduce the demand for healthcare?

Posted by: Lee_A_Arnold | February 16, 2010 5:45 PM | Report abuse

It isn't about telling someone to "take their pills." It's about Obama saying that maybe a 105-year-old Grandma, whose doctor thinks she needs a pacemaker, should "just take the pain-pill instead."
http://www.youtube.com/watch?v=U-dQfb8WQvo

Dems' entire (non) healthcare plan was summed up in that one quote.

And except for the intellectual dishonesty of calling obviously life-saving treatment "unnecessary," it reduces demand exactly the same way my idea does.

Posted by: cpurick | February 16, 2010 5:58 PM | Report abuse

More partisan misdirection.

It's pretty obvious from that video that Obama was describing a hypothetical UNLIKE the woman's mother, who has good quality of life: where there is no quality of life, and saying that doctors should be enabled to let families decide -- which they do already legally in Oregon. Everybody knows that families do it pretty much EVERYWHERE else, although it puts the doctor in violation of the law.

He didn't answer the woman's question however, and left himself open to careless interpretation and intentional propagandizing.

Posted by: Lee_A_Arnold | February 16, 2010 8:00 PM | Report abuse

"It's pretty obvious from that video that Obama was describing a hypothetical UNLIKE the woman's mother, who has good quality of life"

Actually, that's edited video. In the complete context Obama says, "I don't think that we can make judgements based upon people's spirit. That'd be a pretty subjective decision to be making."

So, yes, Obama does address the factors that were used to give this woman -- NOT some hypothetical -- her pacemaker, and he says that we shouldn't be using such criteria.

She'd be told to take the pill.

I'm amazed at the swimming pool full of Kool-Aid that's being drunk here, with all these libs who really don't understand the true rationing principle behind Obamacare.

A procedure that saves only 1 in 10 lives is not "waste." It's just an expensive way to save one life. Declaring the procedure "wasteful" and removing it from the formulary may save money without impacting 9 out of 10 patients, but it will also cost 1 life for every 10 patients who no longer receive the treatment.

I realize you liberals don't think that life is worth paying to save -- I'm not even sure it is, myself. But I'm not going to be so dishonest as to pretend that the procedure doesn't save lives, or that eliminating it won't result in deaths.

I think that, more than anything else, is where we differ. I know *exactly* what's going on -- do you?

Posted by: cpurick | February 16, 2010 10:09 PM | Report abuse

Cpurick, He's speaking legislatively. You can't write some law that defends a person upon their "spirit." There's no way to adjudicate that language in a courtroom because it's too subjective. The whole focus of his remarks is to LEAVE IT UP TO THE INDIVIDUAL AND THE FAMILY, and to STOP putting the doctor in legal jeopardy because he followed their decision.

Posted by: Lee_A_Arnold | February 17, 2010 2:02 AM | Report abuse

"The whole focus of his remarks is to LEAVE IT UP TO THE INDIVIDUAL AND THE FAMILY, and to STOP putting the doctor in legal jeopardy because he followed their decision."

B.S. There's simply nothing there (or implied) about "legal jeopardy" of doctors.

No, the focus of the remarks, more than anything else, is that expensive end of life care is "wasteful," but that we can educate doctors to stop prescribing it.

Government doesn't want to say "no," but it knows the care is too expensive. So it wants the doctors to say no on its behalf.

I'm proposing that we simply leave the price tag on the care, and after the doctor explains the odds the elderly (and their families) can say "no thanks" all on their own.

Posted by: cpurick | February 17, 2010 8:20 AM | Report abuse

Cpurick: Good luck convincing anybody who isn't already one of the "death panel" nut-jobs that the objective is to kill people. It makes no sense at all: you sure won't convince any doctors but Kervorkian!

Posted by: Lee_A_Arnold | February 17, 2010 9:37 AM | Report abuse

Lee, do you know what a "strawman" is? Because I don't believe the *objective* is *to*kill*people*.

The objective is to redistribute costly, inefficient end-of-life care to people without any basic care. And the "politically correct" way of thinking about it is to call that care "unnecessary" and "inefficient."

That care may be unnecessary and inefficient to you, but it's a lifeline for the people who receive it, even if it only saves a few lives. Calling it inefficient is just another way of saying those lives aren't worth saving at that price.

And I'm sort of okay with telling Grandma to take the pill because we can't afford to give her the operation. But I'll be damned if I'd tell her to die just so some other person with cancer won't have to declare bankruptcy.

I've made no such proposal -- but that's exactly what Democrats have proposed.

Posted by: cpurick | February 17, 2010 6:24 PM | Report abuse

Show me any place in the bills where it says the patient and family plus the doctor doesn't have total control over the situation.

Posted by: Lee_A_Arnold | February 17, 2010 7:56 PM | Report abuse

Anyplace where funding, reimbursement, evaluation, deductibility or cost-sharing are predicated on "efficiency." Anyplace where outcome statistics can be used to justify the withholding of particular courses of treatment, especially with regard to heroic end-of-life care for terminal or elderly patients.

Just because it's not *called* a death panel doesn't mean it isn't in there.

Posted by: cpurick | February 18, 2010 7:10 AM | Report abuse

Show me any place in the bills where it says that stuff.

Posted by: Lee_A_Arnold | February 18, 2010 9:51 AM | Report abuse

Page 1001. It took about a minute to find this example, but I'm sure there are more.
http://graphics8.nytimes.com/packages/images/nytint/docs/senate-health-care-bill/original.pdf

"It is the purpose of this section to...reduce the per capita rate of growth in Medicare spending-

...by requiring the Chief Actuary of the Centers for Medicare & Medicaid Services to determine...the projected per capita growth rate...

...by requiring the Board to develop and submit...a proposal containing recommendations to reduce the Medicare per capita growth rate...

...the Board shall give priority to recommendations that extend Medicare solvency; include recommendations that—

...improve the health care delivery system and health outcomes, including by promoting integrated care, care coordination, prevention and wellness, and quality and efficiency improvement; and protect and improve Medicare beneficiaries’ access to necessary and evidence-based items and services..."

This is all a big loophole through which "ineffective" or "unnecessary" procedures can be excluded if they're determined to be too costly. Not because they don't work, but because it's too costly to give these treatments to everyone if they only return a limited extension or improvement to patients' lives.

I note that this is also the part the Senate attempts to bind future Congresses from repealing.

Posted by: cpurick | February 18, 2010 11:43 AM | Report abuse

p. 1004 -- "The proposal shall not include any recommendation to ration health care, raise revenues of Medicare beneficiary premiums..., increase Medicare beneficiary cost-sharing..., or otherwise restrict benefits or modify eligibility criteria."

And it appears to be focused on administrative and profit considerations, it all happens in broad daylight, and it gets submitted to Congress for approval.

Posted by: Lee_A_Arnold | February 18, 2010 4:28 PM | Report abuse

Rationing only applies to healthcare. A procedure's no longer counted as healthcare once it's been invalidated for being "inefficient" or "unnecessary."

I realize it's possible that you actually believe what you claim to believe. But that doesn't make it true.

Here's a liberal being honest about the strategy.
http://www.youtube.com/watch?v=IT7Y0TOBuG4

Maybe the Dems don't think you're sufficiently "honored," "educated" or able to "separate myth from reality" for them to let you in on the secret.

And I don't really give a crap how you rationalize it, but perhaps you might want to ponder why this particular section of the legislation is being hardened against repeal.

You're being played for a fool, and not by me.

Posted by: cpurick | February 18, 2010 6:22 PM | Report abuse

"Being hardened against repeal?" This is Jim DeMInt's scare tactic at the end of December, about p. 1020.

Read through the ENTIRE section. The IMAB submits proposals, only proposals, and only about Medicare, to the President and Congress. The proposal goes to three committees: the Senate Finance, House Ways and Means, and the House Energy and Commerce committees. They can ALL make amendments to it (p.1018) and then they send it as bills ("report it") to the floors (p. 1018).

Once it is on the floors of the House and the Senate, they can vote it up or down.

Before that final vote, once it is on the floors there can be more changes, but there CAN'T be any change to the bills (p. 1020) that DOESN'T keep within the "savings target" of the Actuary (c)(2)(A)(i) (p. 1003) or that tries to INCREASE total Medicare spending set under the Medicare Act (c)(2)(C) (p.1007) -- UNLESS they get a 3/5 vote (p. 1020).

So basically they can do whatever they want, they just can't redo the Medicare growth rate through this act, they have to do it through the process in the ORIGINAL Medicare Act -- like they always do.

Jim DeMint started this scaremongering that there are "death panels" that can't be overturned on p. 1020, at the end of December. It's all lies. You're the one being played!

Sorry, I don't believe things spouted by kooks in videos.

Posted by: Lee_A_Arnold | February 18, 2010 10:18 PM | Report abuse

The wording is intended to allow the exclusion of care that isn't "necessary" or "evidence based."

In case you weren't watching the debates, "obstructionist" Republicans submitted multiple amendments to fix language like this so that it couldn't be used to ration Medicare. Democrats denied them all, instead offering non-binding "sense of the Senate" resolutions.

That "kook" in the video is Robert Reich.
http://www.youtube.com/watch?v=IT7Y0TOBuG4

The first kooky thing he calls for is an individual mandate on young healthy people, and the second one is to let old people die.

What's most interesting to me about liberalism is the thought manipulation. Elites know exactly what they're doing, and it's all okay to them because they have a "superior" moral code. (You call it "progress," I call it "rot.") The rest of you guys are just pawns, letting the elites tell you new ways -- politically correct ways -- to look at ugly truths so you won't lose any sleep.

You can't admit that you'd cut care to the elderly because it's too expensive -- after all, that would shatter the illusion that your utopian healthcare model can do everything.

So instead you manipulate the language, and now in the name of "efficiency" or "necessity" you can deny the same procedure.

And the interesting part is that this was not an accident. Some liberals actually thought this strategy up, and basically all the rest of you are letting those elites tell you how to think so you won't just vomit at the thought of your own policies.

I just can't find anything like that -- such blatant thought control -- on our side. It's simply fascinating.

Posted by: cpurick | February 19, 2010 7:12 AM | Report abuse

You can't find any blatant thought control? --- you swallowed Jim DeMInt's nonsense completely, which is entirely based on some "liberals are for death panels" crap.

At the end of the video, Reich says (as if he were a Presidential candidate,) "Also, I'm going to use the bargaining leverage of the federal government -- in terms of Medicare, Medicaid, we already have bargaining leverage, -- to force drug companies and insurance companies and medical suppliers to reduce their costs, but that means less innovation, and that means less new products, and less new drugs on the market, which means you are probably not going to live much longer than your parents."

It sounds to me like Reich is being sarcastic.

Posted by: Lee_A_Arnold | February 19, 2010 9:30 AM | Report abuse

I must tell you, I didn't expect you to go into full denial mode when you heard it from Reich's own mouth. That's a masterful evasion:

"It sounds to me like Reich is being sarcastic."

If he was being sarcastic, shouldn't the audience be laughing instead of cheering??? Who really doesn't get it -- them, or you?

You've got kool-aid on your chin.

Posted by: cpurick | February 19, 2010 9:44 AM | Report abuse

You know, I would urge you to investigate whether that speech *was* sarcasm.

Because if it's not, then that would mean you've got an entire reality to rethink, wouldn't it?

And God knows you need it.

Posted by: cpurick | February 19, 2010 10:11 AM | Report abuse

You believe that people are going to ACCEPT having, as Reich said,

"less innovation, and that means less new products, and less new drugs on the market, which means you are probably not going to live much longer than your parents?"

How will they be tricked into this, exactly?

You wrote up above, "those who cannot afford it should be purchasing less -- taking more chances, and cutting more corners at their own risk."

People should die because they don't have the money?


Posted by: Lee_A_Arnold | February 19, 2010 2:10 PM | Report abuse

"You believe that people are going to ACCEPT having, as Reich said,
"less innovation, and that means less new products, and less new drugs on the market, which means you are probably not going to live much longer than your parents?""

Not if you put it that way. Like Reich said, the public can't handle the truth, so it gets wrapped in PC language.

So, instead, you tell them you're just fixing an "inefficiency," and then you put lots of myrmidons on blogs to deny what you're really doing. Some of them might not even realize what they're doing, calling the truth "sarcastic" when they hear it.

"People should die because they don't have the money?"

People should live their lives as if healthcare is expensive. And as if other people are free. Is it really that hard for you to understand?

Posted by: cpurick | February 19, 2010 2:23 PM | Report abuse

So people should die if they don't have the money, because therefore they weren't living as if healthcare is expensive?

And we should do away with Medicare, because it makes poor little Cpurick less "free?"

Posted by: Lee_A_Arnold | February 19, 2010 4:13 PM | Report abuse

Are you aware of the argumentation term, "deflection"? Because I'm sensing that we've somehow changed the subject from life and death to freedom and bondage.

And I'm okay being for life and freedom if you want to admit you're for death and bondage. Most liberals are, but as you've proven here it's the actual admission that they have the greatest difficulty with.

Posted by: cpurick | February 19, 2010 5:15 PM | Report abuse

I'm just trying to follow your substantive arguments. They lead to contradictions. You say you are for life and freedom, but the things you say lead to denying people healthcare.

Posted by: Lee_A_Arnold | February 19, 2010 7:37 PM | Report abuse

"You say you are for life and freedom, but the things you say lead to denying people healthcare."

Requiring people to actually pay for what they consume is not "denying" them anything. In particular, when people have lived a lifetime, that is a lifetime they've had to prepare for the end of their lives. What care they can afford at the end is, more often than not, mere justice.

On the other hand, simply telling people they're being cared for -- while denying actual care because it's "inefficient" -- is out-and-out fraud.

Even worse, much worse, if your plan expects some patients to die so that others can avoid common bankruptcy. If you can't afford your expenses, you're *supposed* to go bankrupt -- that's what bankruptcy's for.

I note that veterinarians provide all sorts of care at prices most people would be willing to pay out of pocket. I'm not saying it's the care any of us would want, but if you *need* care, you should have the option of buying whatever care you can afford. And people who can't afford care at the standard established by the FDA should still be free to buy it at a lower standard. Current law does not permit that.

I guarantee you the US veterinary standard of care would be preferable to the "universal healthcare" standards of dozens of poorer countries which liberals hold up as models, starting with Cuba.

American doctors should be free to operate at those standards of care, too. Not to help the doctors save a buck, but to help sick people who can't afford more expensive treatment.

I keep hearing about how the uninsured are all dying for lack of care, but I see no effort being made to legalize care they could afford. It's sickening, really.

Posted by: cpurick | February 19, 2010 10:56 PM | Report abuse

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