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Access to medical care is not 'candy' or an 'indulgence'

For Robert Samuelson, the fact that the Affordable Care Act is fully paid for and in fact reduces the deficit isn't good enough. "If the administration has $1 trillion or so of spending cuts and tax increases over a decade, all these monies should first cover existing deficits -- not finance new spending," he writes. "Obama's behavior resembles a highly indebted family's taking an expensive round-the-world trip because it claims to have found ways to pay for it. It's self-indulgent and reckless."

"Self-indulgent." Wow. Jon Chait puts his back into it:

What an interesting phrase. Let's consider both words, starting with the end. It contains the assumption that some basic health insurance is an "indulgence," rather than a necessity. I defy anybody to make a careful study of the actual conditions of people who lack health insurance -- such as can be found in Jonathan Cohn's book "Sick" -- and come to this conclusion.

Next, there's the word "self." Self-indulgent is when you spend money to indulge yourself. The Bush tax cuts, which massively enriched George W. Bush and Dick Cheney, could be described as self-indulgent. Samuelson supported those, incidentally. President Obama and the Democrats who enacted health care reform all have insurance. Even if you consider providing basic medical care to people who lack it an "indulgence," they are not indulging themselves. They are "indulging" others.

And before you think this is all about Samuelson, consider that Charles Krauthammer calls coverage "candy." There's an absence of empathy here that borders on a clinical disorder. But even to play on their ground, let's be clear: There were no votes for cost controls in the absence of coverage expansions. Democrats accepted the excise tax, the increase in the Medicare payroll tax, the Medicare cuts and commission, and all the other pieces as part of a deal including near-universal coverage. No coverage? No deal. The deficit will be smaller because of health-care reform. The realistic alternative was not more deficit reduction, as Samuelson implies, but no deficit reduction.

The nature of these criticisms, however, should partially be blamed on the Democrats: They made peace with an elite -- and, I should note, insured -- consensus that cost control was the responsible driver of health-care reform. We are a rich, decent society, or so we say. Extending health-care coverage to those who can't afford it would be worth it even in the absence of cost controls. Health-care insurance is not candy, and it is not an indulgence.

By Ezra Klein  |  March 29, 2010; 1:30 PM ET
Categories:  Health Reform  
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Next: What happens when Congress can't do its job?

Comments

Shorter Samuelson: Wealth is inherently virtuous and the poors, being un-virtuous, should just frack off and die already, the filthy beggars.

Shorter Krauthammer: But first we should waterboard them. They might know something about the missing WMDs.

Posted by: matthewarnold | March 29, 2010 1:58 PM | Report abuse

"And before you think this is all about Samuelson, consider that Charles Krauthammer calls coverage "candy." There's an absence of empathy here that borders on a clinical disorder."

nicely played sir. Time for a multiple choice test. Which best describes said peoplez:

1) Narcissistic Personality Disorder: Behavior or a fantasy of grandiosity, a lack of empathy, a need to be admired by others, an inability to see the viewpoints of others, and hypersensitive to the opinions of others.

2) Histrionic Personality Disorder: Exaggerated and often inappropriate displays of emotional reactions, approaching theatricality, in everyday behavior. Sudden and rapidly shifting emotion expressions.

3) Paranoid Personality Disorder: Marked distrust of others, including the belief, without reason, that others are exploiting, harming, or trying to deceive him or her; lack of trust; belief of others' betrayal; belief in hidden meanings; unforgiving and grudge holding.

or

4) Antisocial Personality Disorder: Lack of regard for the moral or legal standards in the local culture, marked inability to get along with others or abide by societal rules. Sometimes called psychopaths or sociopaths.

Posted by: RoundedFork | March 29, 2010 2:00 PM | Report abuse

The sooner we stop treating opinions like this as just a difference in political philosophy and more like something meriting an entry in the DSM-IV, the better off we'll be.

Posted by: Jenn2 | March 29, 2010 2:00 PM | Report abuse

to troll my own post - I vote for FOUR

Posted by: RoundedFork | March 29, 2010 2:02 PM | Report abuse

The problem isn't whether health care is a necessity. Reasonable people can argue whether a) it is in fact a necessity and b) whether the federal government should be the guarantor of it. That said, what isn't a necessity or, as many people have claimed with health care, a right? I personally think food is a higher priority than having a doctor. When can we expect that necessity to be provided by Washington? And at what expense?

What Samuelson is, I think rightly, driving at is that we can't just keep deluding ourselves with this notion that all these things Washington pays for with taxpayer dollars are our entitled rights. At some point the rubber needs to hit the road and we need to decide what is more important: maintaining a financially strong country that provides the basics (security, freedom, and maybe needs for the truly poor) or a European-styled state which seeks entitlements funded on the backs of the fleetingly "rich" Read: middle class taxpayer. Over the past 70 years we have marched defiantly against the former in favor of the latter leading us to the disastrous financial state we have before us. Like Greece, the UK and other European benevolence before us, we'll soon face collapse and the sort of stagnation that will not easily be reversed.

So before we start this nonsense about "rights" and what is a necessity, consider where this debate inevitably leads us: making everything a "right" with the ultimate collapse of our empire. Period.

Posted by: ChrisDC3 | March 29, 2010 2:04 PM | Report abuse

There was an interesting exchange between Robert Samuelson and Paul Krugman on Fareed Zakaria's show yesterday. Samuelson talked about vouchers (I believe for Medicare, a la Paul Ryan) and Krugman explained that you wind up back where we are now, because the insurance market would have to be regulated so the elderly and sick would be able to obtain coverage with the vouchers.

Note also Samuelson's past writings indicating skepticism about the relationship of health insurance to health.

Posted by: jduptonma | March 29, 2010 2:04 PM | Report abuse

@ChrisDC3
"I personally think food is a higher priority than having a doctor. When can we expect that necessity to be provided by Washington?"

Ever heard of Food Stamps?

Posted by: wiredog | March 29, 2010 2:05 PM | Report abuse

Notice what they gain, though, by describing health care insurance as candy. The next step is to say: "Sure, I've got candy. I like candy. But I can afford it. You can't afford candy, so you have to do without. Surely you don't expect me, or the government, to subsidize your candy."

Posted by: LynnDee227 | March 29, 2010 2:10 PM | Report abuse

Nearly every single conservative take on policy can really be summed up by "I got mine, eff you." And now that I've moved to a conservative area in a conservative state, I've found that this extend beyond the editorial pages of political coverage but to nearly every aspect of life. Even things as simple as merging lanes become NIGHTMARES because everyone puts the self above the common good. I swear that most would prefer that a 10 car pileup happen in their rear view mirror rather than let another car merge into their lane ahead of them. The wife and I are shocked on nearly a daily basis by how much disregard and an absolute lack of empathy we see for others in all aspects of life on a daily basis.

And the GOP (and its increasing Randianism) actually tells them such behavior should be viewed as a virtue!

Posted by: nylund | March 29, 2010 2:10 PM | Report abuse

@wiredog

Yes I have. I was talking more about universal food than just food for the poor a la food stamps.

If we're talking about health care being a right that should be provided universally, why not food?

Posted by: ChrisDC3 | March 29, 2010 2:11 PM | Report abuse

@wiredog: "Ever heard of Food Stamps?"

Sure, and we don't give food stamps to people making 400% of the poverty limit. The means-testing on food stamps is exceedingly more restrictive than the subsidization of health care.

Posted by: ab13 | March 29, 2010 2:13 PM | Report abuse

"If we're talking about health care being a right that should be provided universally, why not food?"

Because feeding yourself doesn't cost more than a mortgage or rental payment.

But thanks for being the 46,937th silly glibertarian to demonstrate the intellectual power of individualism by coming up with that one. Sorry, you don't get a prize this time. Try again after 3,032 other silly glibertarians have said the same thing.

Posted by: pseudonymousinnc | March 29, 2010 2:16 PM | Report abuse

"Nearly every single conservative take on policy can really be summed up by "I got mine, eff you." "

GOP - Party of ME

Dems - Party of WE

Posted by: RoundedFork | March 29, 2010 2:16 PM | Report abuse

"The means-testing on food stamps is exceedingly more restrictive than the subsidization of health care."

That's because insurance salesmen get paid more than chicken pluckers, ab13. You should feel proud.

Posted by: pseudonymousinnc | March 29, 2010 2:18 PM | Report abuse

@pseudonymousinnc

Oh I'm sorry, government should only provide everything except the really expensive stuff, i.e. food?

Catastrophic insurance, HSAs, and a gym membership are far cheaper per month than feeding yourself. But we're not talking about the basic provisions of health care in this bill, now are we? We're talking about chiropractic visits, hair transplants and other exotics "necessities" mandated by Washington.

Which brings me back to my original point: If health care is a right, why not food? Why not housing? Why not flat-screen tvs?

Posted by: ChrisDC3 | March 29, 2010 2:20 PM | Report abuse

@pseudonymousinnc: "glibertarian"

Coulter's Law: referring to a group of people as Dumbocrats, Rethuglicans, glibertarians, etc automatically renders your argument invalid

Posted by: ab13 | March 29, 2010 2:22 PM | Report abuse

@pseudo "That's because insurance salesmen get paid more than chicken pluckers, ab13. You should feel proud."

Why would I be proud? I don't sell insurance, I just figure out how much it should cost, and why it costs as much as it does. And this experience gives me the knowledge to know that the imaginary free health care pony that so many here seem to think exists is in fact a fantasy.

But why bother with reasonable discussions about that, just stick to coming up with clever names to call people who disagree with you. That's far more constructive.

Posted by: ab13 | March 29, 2010 2:27 PM | Report abuse

Overall Comment:

Another point I'd like to make about this nonsense blog posting: When can we get past the fantasy that people who oppose government funded health care are opposed to helping the poor get health care? Once liberals can free themselves of this narrative that libertarians, conservatives, etc. aren't some mean-spirited bunch that like to see people die of maladies perhaps we can have a more nuanced discussion on the pros and cons of free (taxpayer funded) health care.

Posted by: ChrisDC3 | March 29, 2010 2:32 PM | Report abuse

ChrisDC3,

The U.S. is a pretty far-cry from a Western European style social democracy. Our tax-rates are substantially lower -- especially at the very top of the income scale.

As far as costs being foisted on the "near-rich" -- the people who are getting a tax increase under this proposal are pretty much by definition the wealthy.

e.g. couples over 65 with $250K or more of investment income will find capital gains taxed at a rate that's higher than the prior 15 percent rate.

Some "near-rich" people may have taxes on their benefits taxed in later years, but on balance this is a bill which provides a significant benefit to middle class workers and families.

In terms of the historical narrative too -- over the past 70 years we have enacted Social Security and Medicare. We've substantially expanded the social safety net without compromising our global competitiveness.

We've departed from Western Europe to a larger extent over the past 30 years where we've slashed taxes at the top of the income; slashed worker protections and undermined organized labor -- and the wages associated with manufacturing -- by effectively redistributing middle class incomes to the very top.

We've changed bankruptcy laws and taxes on capital gains effectively transferring more wealth from the middle class and working class families to the top of the income scale.

Providing a basic level of health care isn't going to bankrupt our economy.

If anything it should reduce a major financial burden on middle class and working families, so that they have the resources to direct a higher percentage of disposable income to other GDP-enhancing activities.

The key goal should be to find ways to enhance middle class incomes and reduce burdens on small businesses -- both of these objectives will increase GDP in such a way that the rising tide lifts more boats than some of the alternatives. Health care reforms should provide a substantial benefit to both middle class workers and small businesses.

Over the past 30 years, we've done a pretty good job of enacting policies that benefit those at the very top. But the trickle-down approach has proven to be a demonstrable failure for the majority of Americans. It has created a top-heavy economy, which produces suboptimal growth.

Posted by: JPRS | March 29, 2010 2:36 PM | Report abuse

Except, ab13 that healthcare isn't something that someone might one day need. It's something they will definitely need. When someone puts off going to the doctor because they simply can't afford it only to end up going when they can no longer stand the pain, where do they go? To emergency rooms. Hospitals don't have a magic pony that brings in magic money to cover this poor soul. You and me and society as a whole have to pay for that. If that person had access - ACCESS - to healthcare they would never need to be in a position where you and me and society as a whole have to cover them. And they wouldn't be in a position where they lose their lives over something as arbitrary as the haves and the have nots. That is an important part of why insurance is so expensive.

Posted by: ESJ79 | March 29, 2010 2:37 PM | Report abuse

@Chrisdc3:European-styled state

Are these the same European-styled states that provide universal coverage for their citizens at anywhere from 40-70% less than we spend to leave 40 million+ uninsured?

The same European-styled states that out score us in student achievements in math, reading, reasoning skills, etc.

The same European-styled states that have 6 weeks of vacation and 35 hour work weeks and still manage to outcompete us in manufacturing cars and other high end items?

Just askin...

Posted by: srw3 | March 29, 2010 2:53 PM | Report abuse

ESJ79, that is a very small part of why insurance is expensive. Far outweighing poor people using emergency rooms is the high unit costs (doctor salaries, intensity of services, technologically intense treatments, etc) and rapidly accelerating utilization of health care in the US. Fee for service medicine gives perverse incentives to providers, and subsidization of most health care leads to overuse and little or no cost sensitivity. Keeping the poor out of emergency rooms is not going to solve our problems. The only way those two problems are going to be solved is by exposing people to the cost so that they understand the trade-offs involved.

Posted by: ab13 | March 29, 2010 2:54 PM | Report abuse

@srw3

If you'd like to trade our economic growth and unemployment for Europes, be my guest.

Posted by: ChrisDC3 | March 29, 2010 3:01 PM | Report abuse

A corollary to the self-indulgent candy of paying for health insurance for everyone is that, if it is free, everybody will overutilize the health care system (i.e., we should be afraid that all the hypochondriacs will crash the system), and costs will go way up.

This ignores the facts that:

1. It's not free. We all pay a lot of taxes already that pay for a lot of peoples' health care -- Medicare, Medicaid, federal employees, all those public employees in state, county, and local govt., teachers, police... If you work, but are uninsured, you're still paying for somebody else's health care.

2. The really sick are already showing up in our E-rooms and costing the system much more than they should if they had gotten timely care, which insurance would have guaranteed them.

3. All the other western industrial countries with universal health care have somehow miraculously avoided the disaster of overutilization, and manage to do it paying half to two-thirds per capita to cover everyone, than what we do to leave 45 million out. I actually believe when health care is guaranteed, and people feel secure, they may need/use it much less, or when it's more appropriate.

Posted by: jshafham | March 29, 2010 3:04 PM | Report abuse

@ChrisDC3: "Another point I'd like to make about this nonsense blog posting: When can we get past the fantasy that people who oppose government funded health care are opposed to helping the poor get health care? Once liberals can free themselves of this narrative"

This is never going to happen. And there are some people who oppose government funded health care who also oppose helping the poor get health care. Very darwinian folks, but there are some. So there will always be some wing nut for liberals to point to as somehow being the radical, frothing-at-the-mouth standard bearer of the opposition.

In this particular case, Ezra actually links to the article in which Krauthammer supposed calls coverage "candy", while blissfully leaving the impression that he was trying to suggest health coverage was a frivolous indulgence. When, in fact, he's drawing a comparison, saying that Democrats are offering the good stuff about HCR--universal (or more universal) coverage before getting to the bad stuff about HCR--the rationing he says is implied by universal coverage.

I can imagine an argument against the idea that HCR will lead to rationing, but to read that entire article and take from it that Krauthammer was trying to call health coverage candy--in the sense that it is a frivolous indulgence . . . well, that's just a very odd take away.

But it's not the first time and won't be the last that a person has completely, and perhaps willfully, missed the opposition's point and focused on one bit that they then go through contortions to misinterpret.

Thus, expecting liberals to free themselves of the narrative that conservatives want poor people to suffer and are completely out for themselves and live their lives saying "I've got mine, so screw you!" is an expectation that is doomed to be disappointed.

Liberals will, generally, see conservatives as selfish, racist, xenophobic, jingoistic, self-centered, religious zealots who are also (naturally) intellectually and educationally challenged, while conservatives will see liberals as disingenuous, elitist, tax-and-spend hypocrites whose major goals in life are to burn American flags and kill unborn babies. Or advance the cause of socialism. One of those.

Softening our perceptions of our ideological opponents might result in dialog and perhaps a shifting of our positions, and we can't have that.

Posted by: Kevin_Willis | March 29, 2010 3:08 PM | Report abuse

Ezra,
If anyone is bordering on the insane, its you. Your comments about Charles lacking sympathy are flatly misleading and untrue. They speak to how the left loves to on one hand claim to love free speech and then demonize those who partake in that activity. Charles article is clearly about how Obama is using this as the first step to rationing, which is a situation most of America is afraid of. You claim that fox and other right wing groups often use misleading comments to steer their readers down the wrong path, but you are every bit as culpable for your misleading hate speech. You have become what you supposedly despise, or the real truth is that you just hate people who disagree with you.

Posted by: Natstural | March 29, 2010 3:09 PM | Report abuse

Ab 13

Salaried docs would be an improvement (see Cleveland clinic)

Ezra

Why so you separate govt spending from personal when its convenient like this.

The question I want answered is when we go further into debt for this how much more are we spending when factoring in what will be our higher interest rates

Posted by: visionbrkr | March 29, 2010 3:12 PM | Report abuse

Excellent comment Kevin_Willis

It's too bad though, because sometimes Ezra seems to want to engage in a more nuanced discussion without assuming bad faith or sociopathic motivations in the people he disagrees with, but all too often he falls into posts like this.

Posted by: ab13 | March 29, 2010 3:12 PM | Report abuse

Overall Comment:

Another point I'd like to make about this nonsense blog posting: When can we get past the fantasy that people who oppose government funded health care are opposed to helping the poor get health care? Once liberals can free themselves of this narrative that libertarians, conservatives, etc. aren't some mean-spirited bunch that like to see people die of maladies perhaps we can have a more nuanced discussion on the pros and cons of free (taxpayer funded) health care.

Posted by: ChrisDC3

///////////////////////////////////

A pure libertarian position would actually say that NO government resources should be directed towards any social service program (rich, poor, young or old). You clearly aren't a purist.

It's worth pointing out too that there is no pure libertarian answer to dealing with high risk, high cost groups. Their response is effectively "let them die".

e.g. Medicare exists precisely because there was a failure of the market to provide universal coverage at an affordable cost to the elderly -- it simply wasn't and will never be profitable enough to do so.

The current reforms address another market failure -- the inability of individuals purchasing insurance outside of the large group market to get high quality, affordable health insurance (e.g. the incentives in the individual market encourage cherry-picking by insurers, they reduce the financial leverage of purchasers, so the net result is a high cost, lower quality product than individuals and small businesses could otherwise afford if they had the ability to pool their risk more broadly).

Another point: For those who will benefit the current slate of reforms they are not getting "free" health care.

Some will get tax-payer subsidies, but many will end up covering a part or all of their coverage out of pocket. It's also worth pointing out that many -- if not all -- of these people are financing some else's health care through payroll taxes. e.g. by definition they are too rich to qualify for Medicaid -- which means that they must be deriving some taxable income. And they aren't old enough to qualify for Medicare.

Posted by: JPRS | March 29, 2010 3:14 PM | Report abuse

@ab13: "Coulter's Law: referring to a group of people as Dumbocrats, Rethuglicans, glibertarians, etc automatically renders your argument invalid"

It also makes them increasing difficult to understand. Glibertarians? That reads a lot like Gilbert. People who follow some dude named Gilbert?

The more clever people get with their name calling (they think), the more difficult it is to be sure which group their trying to insult specifically.

Posted by: Kevin_Willis | March 29, 2010 3:16 PM | Report abuse

@ab13: "sometimes Ezra seems to want to engage in a more nuanced discussion without assuming bad faith or sociopathic motivations in the people he disagrees with, but all too often he falls into posts like this."

I'm not entirely convinced he actually read Krauthammer's piece. A thoughtful reading of it should have made what he was saying clear: that universal coverage is a good thing, but that's going to have to come with a tradeoff: rationing.

But, people get busy, and we use our familiarity with (or, at least, what we believe about) people we disagree with to make assumptions about what they meant when we don't have time to fully absorb what they are saying. I cut Ezra some slack.

Posted by: Kevin_Willis | March 29, 2010 3:22 PM | Report abuse

Samuelson: we can't afford it.

Klein: oooh, you evil man.

Posted by: ostap666 | March 29, 2010 3:25 PM | Report abuse

"3. All the other western industrial countries with universal health care have somehow miraculously avoided the disaster of overutilization, and manage to do it paying half to two-thirds per capita to cover everyone, than what we do to leave 45 million out. I actually believe when health care is guaranteed, and people feel secure, they may need/use it much less, or when it's more appropriate."


---------------------------

Google "Canadian leader surgery"

and

"UK health care NICE"

Posted by: Holla26 | March 29, 2010 3:25 PM | Report abuse

@JPRS

A pure libertarian position would actually say that NO government resources should be directed towards any social service program (rich, poor, young or old). You clearly aren't a purist.

No, I'm not a purist but I believe that through government intervention in the health care sector throughout the years, we've completely rearranged all the things that typically drive costs down - competition, price transparency, barriers to portability - through large government intervention.

So, saving a full reversal of those policies, which I'd advocate, I think there are things we can do that would truly help the poor without some large $2.5 trillion adventure that we passed last week.

Posted by: ChrisDC3 | March 29, 2010 3:27 PM | Report abuse

ChrisDC3, you can place yourself among the people who will rationalize just about any position to avoid any sense of responsibility as a neighbor. There are many people in this country - long-standing citizens, I add - who work one or two jobs to make enough to put food on the table and keep a roof over their family's heads. You demean them without a care by suggesting that they should exercise and eat better and start a savings account (HSA). You deserve a sound slap, but in the interest of a conversation let me comment that your remarks lack any sense of human empathy. Not all are fortunate to be able apply your remedies. Further, taking those steps do not ensure against random injuries, communicable disease, or the hundreds of other kinds of medical possibilities that could arise.

If one thinks only that all people have the same circumstances or that we "deserve" our circumstances because of actions or personal "failings" of our pasts then perhaps a viewpoint such as yours can be understood. Maybe because I'm from a different generation, maybe because the idea of citizenship we learned in school wasn't one of what we were going to get but what we could give and share I feel that I see things quite differently from your position. I have had health coverage on active duty. I have had coverage through employers' group policies. I have worked for a small business that couldn't join a group and offered no coverage; the pay was so low there was nothing to use for premiums for individual coverage. I have had extended periods of unemployment in which I had no coverage.

It's discouraging to think that there are other Americans who believe that people whose means are stretched to the limit are somehow unworthy of care for their health. That somehow, they can avoid illness or injury until they can pay for any service required. I think that's just a wrong way of thinking. And I think that most Americans agree with me.

Posted by: Jazzman7 | March 29, 2010 3:32 PM | Report abuse

@ Holla26 : I don't have to google anything to know that there is not a single advanced democracy whose population would trade their health care system for the US system, not 1. Canadians, who get an up close and personal look at the US system are uniformly more satisfied with their system over ours.

Why is that? Something to do with all of those people getting universal coverage for 2/3 to 3/4 what we pay to leave out 45+ million people?

wait times for elective surgery are longer in many other countries, but the wait is forever here if you don't have insurance or can't afford the surgery even with insurance because of copays, loss of income from work, high deductibles, etc. Which would you prefer, waiting for 2 months for your elective surgery or not getting it at all?

Posted by: srw3 | March 29, 2010 3:36 PM | Report abuse

@ ChrisDC3 : I would trade Germany's balance of trade for ours. I would trade Norway or Sweeden's unemployment rate and social safety net for ours.

Is it your contention that the US can't adopt some of the health care policies of other countries without adopting every single part of their economy? Really?

Posted by: srw3 | March 29, 2010 3:40 PM | Report abuse

@Jazzman7

Spare me. From what I gather from your diatribe, you don't think we should be good neighbors, you think that the federal government should be the lead neighbor.

The arrogance to suggest that we're somehow a more compassionate country when we tax the most prosperous among us at 50% levels to fund free health care for millions.

I'm all for compassion and humanity, but that's just an arrogant view of it. Yours is a world where "the other guy" pays for your conceptions of a "just" world. But not your money, no, you're just the middle class who thinks up Shangri-La and has the boogieman with a Mercedes and an investment banking job pay for it.

Impress me with something more than that. Because, perhaps I'm old school too, that isn't American, that's lazy, class-warfare thinking.

Posted by: ChrisDC3 | March 29, 2010 3:43 PM | Report abuse

@srw3

"Canadians are less satisfied with hospital care than Americans. Canadians are less satisfied with their recent hospital care experiences than Americans (62% of Canadians vs. 74% of Americans were satisfied). "

"A majority of Canadians support expanding private care, as long as there is no impact on the public system and a reduction in wait times. More than half (56%) of respondents indicate they support increasing private care services if there is no impact on the current publicly funded health care system, while half (50%) of Canadians support increasing private care services if it resulted in an overall reduction in wait times for public care. "

http://www.deloitte.com/view/en_CA/ca/pressroom/ca-pressreleases-en/press-release/cdac709bf1325210VgnVCM100000ba42f00aRCRD.htm

Posted by: Holla26 | March 29, 2010 3:48 PM | Report abuse

People complaining about the post need to get a grip. The basic principle of universality is still up for debate in the US, and Samuelson and Krauthammer are on the side opposed to it. Developed countries that allow private participation in the healthcare system -- I exclude the US from this, of course -- do so on the basis of that principle.

> Google "Canadian leader surgery"

Oh, please. Danny Williams based his decision on proximity to his Florida condo:

http://www.theglobeandmail.com/life/health/williamss-heart-surgery-choice-was-based-on-ignorance/article1480937/

Now go and play in the MRI, if your insurance covers it.

Posted by: pseudonymousinnc | March 29, 2010 3:54 PM | Report abuse

@KW:Conservatives as selfish, racist, xenophobic, jingoistic, self-centered, religious zealots who are also (naturally) intellectually and educationally challenged,

Kevin, I don't see conservatives this way, but I do see the modern republican party pushing most of these themes in their actions and statements. Religious zealotry, check. Modern republicans are all for making the US a Christian nation and using the Christianist taliban as their storm troopers for God. On education, every time The Palinator denegrates the president by saying that we don't need a constitutional lawyer (ie and educated person) for president, she feeds the anti-intellectualism that is a broad plank in the republican party. As for racist and xenophobic, there are countless examples of demagoguing immigrants (documented or not) as the cause of all evil in the country. The republicans continue to use the "southern strategy" to keep their supporters in line and focused on the cadillac driving welfare queens, etc...
Jingoism eminates from the republican leadership, the latest example being the bomb Iran caucus in congress. So, I find your description of modern republicans (not conservatives) very accurate. I can't say the same about your liberal description. Most of what you list are rightwingnut caricatures of liberal positions. After all, it was the "liberal" president that at least attempted to pay for his health care initiative whereas the "conservative" Bush just ate the candy (passing medicare d) without the vegetables (actually paying for the benefit he was so publicly endorsing).

Posted by: srw3 | March 29, 2010 3:55 PM | Report abuse

"Coulter's Law: referring to a group of people as Dumbocrats, Rethuglicans, glibertarians, etc automatically renders your argument invalid."

ab13's law: insurance salesmen can't be trusted.

Glibertarians aren't libertarians; glibertarians are people who offer up glib cod-libertarian ideas. See: McArdle, M.

Posted by: pseudonymousinnc | March 29, 2010 3:57 PM | Report abuse

Ezra-

Have you or anyone else at WaPo ever checked Samuelson's track record? I would bet that he bought the whole line of Bush tax cuts and trumpeted the massive job growth and economic expansion that they would bring. In short, why is he still employed at reputable publications? If he was, say, a doctor, and many of his patients had died at his hand, he would have been sued....oh, wait a minute. He doesn't believe in doctors being held accountable in that manner. It's all making sense to me now.

Posted by: StevenEMedlock | March 29, 2010 4:12 PM | Report abuse

"The deficit will be smaller because of health-care reform."

Heath reform assumes a 21 percent cut in Medicare payments to physicians as part of the SGR. Do you really think this is going to occur? Are you going to write a post when Congress passes the "doc fix" and note that those budget assumptions used to pass health care reform we're basically a lie?

Posted by: NoVAHockey | March 29, 2010 4:14 PM | Report abuse

@ Holla26: Canadians are less satisfied with their recent hospital care experiences than Americans (62% of Canadians vs. 74% of Americans were satisfied). "

A classic example of an interesting but totally off point citing of statistics.

Who is the sample taken from? People who have recently been in the hospital, that is, people who have comprehensive insurance and/or can afford to pay copays and deductibles. It might also include some medicare (govt run) and medicaid (govt run) patients, who are no doubt satisfied with their single payer coverage, provided by the govt. I doubt if people who are not able to afford hospital care would rank the US higher than Canadians, where there are 0, none, nada, people who can't go to the hospital because of economic status.

Posted by: srw3 | March 29, 2010 4:15 PM | Report abuse

@ NoVAHockey: Hey, why don't you get the republicans to fight hard to cancel the doc fix if you think it is such a bad idea?

The medicare reimbursement rate "fix" for doctors has been kicked down the road by both democrats and republicans repeatedly since the "fix" to rising health care rates went in in the 90s. It is a problem that preceded HCR and will go on after HCR. At least the Dems are attempting to put in a permanent fix instead of a short term one that makes deficits in the 10 year time window look better (I'm looking at you republican controlled congress during the Bush years). Why is it bad to address this issue directly?

Posted by: srw3 | March 29, 2010 4:20 PM | Report abuse

In regard to helping the sick, the poor, the disadvantaged:

When it is VOLUNTARY, the helpers are happy about it, the helped receive benefits, and those helped are motivated by kindness to help others in turn.

When it is COMPULSORY (e.g., done through taxation), the helpers are resentful, the helped receive some benefit (minus administration expense), but are motivated to not help, but to vote for those who will continue or increase benefits to which they feel entitled.

When you assume that people will not help voluntarily, and that you must vote to compel them to help - you have stepped into elitism (because you feel that your notion of compassion should be forced on others) and into socialism (because you have little respect for the earned property of others).

Posted by: MKS1 | March 29, 2010 4:21 PM | Report abuse

srw3, most of the countries typically pointed to as examples of better systems have the same problem as we do: health care costs growing far faster than the economy. They have lower absolute costs, but are on the same unsustainable path. We're both headed for a cliff with no brakes, the fact that they are a hundred yards behind us doesn't change that. We need to focus on fixing the brakes instead of thinking that if we could just backup 100 yards to where they are we'd be OK.

Posted by: ab13 | March 29, 2010 4:26 PM | Report abuse

ChrisDC,

The least regulated part of our insurance market -- the non-group market -- has also turned out to be the worst possible market place for consumers in terms of quality and cost. At a minimum that would seem to suggest that the incentives in the health care sector are fundamentally different from other consumer markets. I suspect we'd see the same kind of perverted outcomes if we privatized our police and fire service. Shear profitability is not how we measure whether those services are providing a good ROI.

I think it's important to realize that there is no, unhindered, free-market answer to providing universal coverage.

A profit-centered approach to the problem says: you make your product affordable to the masses by eliminating costs. And the largest source of "costs" are going to be coverage of the elderly and the sick. The perfect market solution from the insurers perspective is to sell a product to people who ideally need it the least at the highest possible cost.

Posted by: JPRS | March 29, 2010 4:33 PM | Report abuse

"The deficit will be smaller because of health-care reform."

Heath reform assumes a 21 percent cut in Medicare payments to physicians as part of the SGR. Do you really think this is going to occur? Are you going to write a post when Congress passes the "doc fix" and note that those budget assumptions used to pass health care reform we're basically a lie?

Posted by: NoVAHockey

/////////////////////////////

Even if the Dems decide to account for the "doc fix" more honestly and transparently than previous GOP congresses (thanks for the budget "fix" Gingrich!) -- the net result is still at worst a net wash over the first 10 years. The 20 year window still hold open the prospect of serious deficit reduction.

Posted by: JPRS | March 29, 2010 4:36 PM | Report abuse

srw3 -- I'm neutral on how to address the doc fix issue. All I'm saying is it's dishonest include it as a savings as part of health reform when they fully intend to address it at a later date. If you're going to fix it, you can't say it's a savings in March only to have it be a cost by the end of the year. Klein knows this yet he's continuing to claim that health reform is a savings. sure, left alone, it could be a savings. but everyone --- everyone -- knows that that 21% "savings" is a joke. and because he's not pointing it out, he's either lazy or lying. Me, I think he's lying through omission.

Posted by: NoVAHockey | March 29, 2010 4:36 PM | Report abuse

"Borders" on a clinical disorder? I disagree. They are all the way there. It's shocking.

Posted by: lcrider1 | March 29, 2010 5:00 PM | Report abuse

@ NoVAHockey : The bill as written does save money. The doc fix is a separate problem that existed long before HCR was being considered. Why should that fix be inside the HCR bill?

If lawmakers really don't want to add to the deficit, they don't have to pass the doc fix or they can pay for it separately. It is a long term problem.

Posted by: srw3 | March 29, 2010 5:08 PM | Report abuse

@ NoVAHockey : The point is that the doc fix will be considered whether or not HCR passed. It is a separate issue.

Posted by: srw3 | March 29, 2010 5:09 PM | Report abuse

srw3,

If you know the doc-fix is going to happen, and you ignore it in your forecasting, that's being willfully inaccurate. And since enrollment increases under the bill, the scope of the doc fix problem is actually larger post-bill than pre-bill.

As for Ezra's article, how willfully literal can you be? You can be "self-indulgent" to line your pockets (per the article). Its also self-indulgent to fund your personal pet projects (even if the beneficiaries of those projects are third parties) at the expense of more "worthy" goals.

Posted by: WEW72 | March 29, 2010 5:15 PM | Report abuse

"When it is VOLUNTARY, the helpers are happy about it, the helped receive benefits, and those helped are motivated by kindness to help others in turn."

Nice fantasy. In reality. When it is VOLUNTARY, the help is arbitrary, sporadic, and gives the helpers a power trip. It creates fallacious categories of the "deserving" and "undeserving" sick. It underwrites medical Calvinism. You saw that in last summer's town halls, when opponents of reform told people without access to healthcare to call their Congressional offices.

Universal healthcare isn't about making the well-off feel good about themselves. Making it subject to the vagaries of individual charity is elitist by definition.

Posted by: pseudonymousinnc | March 29, 2010 5:16 PM | Report abuse

RoundedFork

Awfully easy to be the party of "we" when you take the money to pay for it out someone else's pockets.

Posted by: WEW72 | March 29, 2010 5:19 PM | Report abuse

@ ab13 : They have lower absolute costs, but are on the same unsustainable path.

I don't believe that this is true. Other countries do have health care inflation, but it is not nearly at the same levels as the US increases. For example, drug prices drive a great deal of health care inflation, but only the US pays full price for name brand drugs. So they are not on the same path as their rates of growth are slower. And given the nature of their systems, they will have a much easier time further controlling costs than the US system.

Posted by: srw3 | March 29, 2010 5:20 PM | Report abuse

RoundedFork

Awfully easy to be the party of "we" when you take the money to pay for it out someone else's pockets.

Posted by: WEW72

///////////////////////////////

Of course, there's more ways to redistribute income than simply through taxation.

Over the past 30 years, the GOP has done an especially good job of redistributing incomes from the middle and bottom of the economy upwards (e.g. through impacts of globalization, financial de-regulation, changes in the tax code, lax enforcement of anti-trust and consumer protection laws during GOP admins).

Both political parties advocate on behalf of pluralities when in the majority. The main difference is that the Dems tend to define "we" much more broadly than the GOP.

Posted by: JPRS | March 29, 2010 5:29 PM | Report abuse

"Dems - Party of WE" one poster said earlier. Actually, it's "Dems - Party of yours, his, hers, theirs".

Posted by: TArbiter | March 29, 2010 5:30 PM | Report abuse

@srw3: "I don't believe that this is true. Other countries do have health care inflation, but it is not nearly at the same levels as the US increases."

Their health inflation is much faster than the growth in their economy. The US is actually middle of the pack when it comes to growth. See here: http://www.businessweek.com/the_thread/economicsunbound/archives/2009/09/where_are_healt.html

Also here: http://www.epha.org/a/1285
From that link: "OECD reports healthcare spending outstrips economic growth by 1.7 times"

All of them are headed for eventual disaster. France, regularly held up as the best, has growth just about as fast as ours (5.5% vs 5.8%). They are expected to have a deficit from the health care program this year equal to 10% of the total budget.

-----"For example, drug prices drive a great deal of health care inflation, but only the US pays full price for name brand drugs."

This hurts your case, not helps it. The US subsidizes the lower drug costs around the world. There is no free lunch, if we start paying less, someone else is going to pay more.

------"So they are not on the same path as their rates of growth are slower."

Not really, as shown above.

-----"And given the nature of their system, they will have a much easier time further controlling costs than the US system."

I don't know why you would think that.

Posted by: ab13 | March 29, 2010 5:46 PM | Report abuse

JPRS says "Over the past 30 years, the GOP has done an especially good job of redistributing incomes from the middle and bottom of the economy upwards (e.g. through impacts of globalization, financial de-regulation, changes in the tax code, lax enforcement of anti-trust and consumer protection laws during GOP admins)."

This line or reasoning always makes my head hurt. Progressives tend to believe that "naturally" everyone should have about the same amount of wealthy. Inequity of wealth is a function of a corrupt, or at least pro-wealthy, system. In reality, show me where rich people literally "take" the wealth of the poor and the middle class... It doesn't happen. The power of the government is directed at the "rich", who pay the vast majority of taxes to pay for the entitlements of the poor.

Your complaints about the last 30 yeasr are actually that the government slowed down its previously existing program of redistributing wealth to the poor. The ultimate entitlement mentality. "The market doesn't make me a winner. Government, give me more money/entitlements."

Posted by: WEW72 | March 29, 2010 5:54 PM | Report abuse

"I personally think food is a higher priority than having a doctor. When can we expect that necessity to be provided by Washington? And at what expense?" Ahh, what a naive youngster, to think that Washington is not involved in providing food (and other than food stamps). Ever hear of the subsidies provided to farmers through the Agriculture Dept? Ever hear of the irrigation provided to farmers through the Interior Dept? Maybe you should look at the federal budget - it's online now - and just look at how much the government spends in those two departments to provide Americans with food and fiber.

Posted by: pojo68 | March 29, 2010 6:01 PM | Report abuse

@ pojo68 :

I know. I've heard of food stamps. Thanks for pointing out the obvious. My overall point is that universal health care for people making as high as 400% of federal poverty is as absurd as providing universal food. Understand?

Posted by: ChrisDC3 | March 29, 2010 6:40 PM | Report abuse

@ WEW72: Inequity of wealth is a function of a corrupt, or at least pro-wealthy, system. In reality, show me where rich people literally "take" the wealth of the poor and the middle class... It doesn't happen. The power of the government is directed at the "rich", who pay the vast majority of taxes to pay for the entitlements of the poor.

Well something happened over the last 30 years that made the incomes of the top 1-5% grow exponentially faster than the incomes for the bottom 95%. Why do you think that was? Don't you think that government policies (or lack thereof) had something to do with this massive shift in income distribution?

And wealth inequality will always exist. It exists in the US and in Europe. It is the size of the disparity that is shocking. The difference now is that the distance from the oligarchs and the rest of society is huge and growing. The question is why income and wealth have gone increasingly gone to the top 1-5% wealthiest people? If this is just "the market system" working its invisible hand magic, then the market system isn't working for the vast majority of people in the country anymore.

Posted by: srw3 | March 29, 2010 6:41 PM | Report abuse

> In reality, show me where rich people literally "take" the wealth of the poor and the middle class... It doesn't happen.

If you want, "in reality", to see rich people appropriating the wealth of others, then you're just being silly. If you think that a high Gini coefficient is testament to a healthy society, then you've got much bigger problems. One of the more depressing glibertarian tropes is to treat wage stagnation and structural economic immobility as a shorthand for people demanding entitlements,

Posted by: pseudonymousinnc | March 29, 2010 6:45 PM | Report abuse

WEW72,

I welcome some degree of inequality of outcomes. And like most Americans I believe that pay and performance should be interrelated. Maybe some theoretical progressive believes what you say they believe, I don't.

I also believe that in recent years a strong case can be made that compensation -- especially at the top levels -- has not been due to any superior level of performance. It's due to the fact that money equals power in a system like ours; and those with the resources to fix rules that favor their narrow interests have done so.

e.g. A person would be hard pressed to defend compensation levels at the top of large financial firms over the past 10 years based on merit.

If a person effectively destroys the net-worth of their company due to poor planning; and has to seek massive external support just to keep the business running -- that person has provided a net cost to the overall economy. Regardless of how many hours they've worked, they deserve no special compensation.

We see some of this too with CEO pay in other industries. Of course there are exceptions like Alan Mulally at Ford; Steve Jobs at Apple; and many others, but certainly a guy like Hank Greenberg, the former CEO of AIG, doesn't deserve one penny of the money that he's received over the years.

Hank Paulson sure didn't deserve to receive a half a billion in tax free compensation for his time spent leveraging Goldman to the hilt.

I see social value in making every generation work to earn their keep.

In the post-Depression era, we taxed the rich so heavily that in places like Newport, Rhode Island, many of the heirs of Robber Baron fortunes, ended up having to turn their family homes over to the national park service simply because they couldn't afford the tax rate on their property any more. In the period after WWII too, we didn't find the country descending into Communism even with those high taxes on the super-rich -- in fact the economy doubled in size and wages in the middle of the economy kept track with GDP growth.

I suspect where we part ways is that you believe a grave injustice was done to the heirs of the Robber Barons. You believe that the rich should be able to fix the rules to their advantage just like they do today in the former Soviet Union.

My view is that the greatest good for the greatest number should be the guiding principle -- because at the end of the day, an economic structure that benefits a few at the expense of the many is an economic structure that is ultimately incompatible with democracy.

Posted by: JPRS | March 29, 2010 6:53 PM | Report abuse

@ pojo68 :

I know. I've heard of food stamps. Thanks for pointing out the obvious. My overall point is that universal health care for people making as high as 400% of federal poverty is as absurd as providing universal food. Understand?

Posted by: ChrisDC3

//////////////////////////

So you think a small business with 7 employees should be forced to either drop its coverage, or fire an employee simply because one of its employees develops cancer?

(meaning that in all likelihood the company's insurance costs are going to end up exceeding the company's total revenue)

Do you think an insurance company should be able to rescind coverage simply because a policy-holder gets an expensive medical condition?

Maybe you don't realize that 400 percent of the poverty line for two people is around $60,000. If a person is making just under that level and qualifies for a $300 a year subsidy, that's too much generosity for your blood!

I hope to God that your employer (or parent) has you on their tax-deductible (indirectly tax-payer supported) insurance plan!

Posted by: JPRS | March 29, 2010 7:13 PM | Report abuse

["Another point I'd like to make about this nonsense blog posting: When can we get past the fantasy that people who oppose government funded health care are opposed to helping the poor get health care?"]

When *you* get past the fantasy that there is another practical way. Government funded health care is simply the only practical way to get everybody the insurance they need. The hell we're going through now thanks to the private health insurance companies is proof of that.

That you persist in the delusion of thinking that a for-profit health care market is workable means one of two things. Either you are very deep in denial, or you really don't want the poor to get health care.

And considering the elitist nature of the right-wing these days, as well as the fact that you must be smarter than a rock, we naturally figure that it is the second (heartlessness and cruelty) rather than the first (ignorance and stupidity).

Posted by: edta | March 29, 2010 8:41 PM | Report abuse

@JPRS: "So you think a small business with 7 employees should be forced to either drop its coverage, or fire an employee simply because one of its employees develops cancer? (meaning that in all likelihood the company's insurance costs are going to end up exceeding the company's total revenue)"

Actually in the current market a business with 7 employees buys coverage in the small group market. The small group market is guaranteed issue with mandated rate bands that limit the ratio of the highest and lowest premium you can charge to any group. And rate increases, while they can be based on the experience of the group, are limited to the change in rates you charge a new customer plus 15%. What that means is that if your theoretical group with 7 employees has a member who gets cancer, they would already be paying a rate that was banded to be pretty close to those of everyone else, and after the cancer diagnosis and subsequent adverse claim experience their rate increase is also limited by the amount they change every other group's rates, including new sales coming in the door. So you can't jack up the rates on all the groups with a lot of claims without also raising your new business rates dramatically. The small group market is pretty competitive, lots of players in every state, and combined with the guaranteed issue environment that keeps groups very price sensitive. The only disincentive to moving around frequently to the lowest priced carrier is any possible employee unhappiness with the disruption of changing insurers (new ID cards, maybe some network changes, etc).

I'm not really sure why you would have given that hypothetical if you knew these facts about the small group market. And if you didn't know those facts, I don't know why you think you'd be qualified to making judgments about the way health insurers operate. You ought to know something about the industry and the regulatory environment they exist in before you're so confidently proclaiming how that market ought to be reformed.

Posted by: ab13 | March 29, 2010 10:16 PM | Report abuse

srw3,

The growing gap between the wealth and the poor, I'd argue, is primarily the result of greater participation in the equity and dead markets.

Decades ago, the average person did not invest, either individually, or through others (e.g. a pension plan). Then Wall Street said "hello" to the middle class. The middle class itself grew in the post WWII boom. Pensions were created, and pension funds. TONS of money was invested in the stock market (and just wait until it comes out as the boomers retire...we are all doomed). The stock market (especially recently), has also become MUCH more transparent, and operates in real-time.

With that changing environment, the people in charge of that money (investment bankers and the like), started to make obscene money. And then CEOs, whose No. 1 priority was keeping their company's stock prices high, started to make obscene money. Then a whole generation of entreprenuers made millions in the IPO bubble of the 1990s. The end result? The top end of the income spectrum got both filthy rich, and had a ton of new members.

Did the revival of a laisse faire regulatory scheme exacerbate that problem? Probably. But the fundamental drivers of the new generation of super rich don't include the GOP. Only punitive tax rates on high earners could have prevented it. And you may well have stifled a generation of innovation at the same time.

And when you get really upset that a bad CEO still made a lot of money, direct your anger at the Board of Directors who approved the compensation, and the company's shareholders, who elected the directors. Then remind yourself that a baseball player makes $25mm a year, and some actors make almost that much for 1 movie. I'd rather have the CEO of a fortune 500 company make that much, personally.

Posted by: WEW72 | March 29, 2010 10:30 PM | Report abuse

It is an indulgence if get premium care and you don't have to pay for it.

Posted by: staticvars | March 29, 2010 11:42 PM | Report abuse

""It's too bad though, because sometimes Ezra seems to want to engage in a more nuanced discussion without assuming bad faith or sociopathic motivations in the people he disagrees with, but all too often he falls into posts like this.""

Robert Samuelson and Charles Krauthammer aren't interested in a good faith nuanced discussion, and they are the ones entitled to choice real estate on the WaPo editorial page. Why aren't you calling _them_ out as the problems here?

Posted by: tyromania | March 29, 2010 11:57 PM | Report abuse

Yes to say that Krauthammer is merely concerned about rationing as someone stated earlier is laughable. Like there is no rationing now or that HSAs don't result in self rationing which is not always good or for the right reasons. Yes, Charles is an elitist and selfish. No you can't rationalize this fact away.

Posted by: Falmouth1 | March 30, 2010 6:39 AM | Report abuse

Ezra,

You said:

"Extending health-care coverage to those who can't afford it would be worth it even in the absence of cost controls."

Do you realize how telling a statement that is? So you would be in favor of health care reform no matter what the cost. What if the cost was a 15% unemployment rate for the next 40 years? What if it was a de facto default on the US dollar through 8% inflation for the next ten years? What if it was less than 1% GDP growth for the next twenty years? What if it required a doubling in the tax rate for middle class Americans? What if it caused the spontaneous decapitation of a random sampling of 107,419 Americans annually?

So instead of "self-indulgent" or "candy", how about this as a descriptor: Grossly irresponsible.

Steve

PS No, I don't believe the CBO estimates, and no, I do not believe that Congress will make the politically difficult choices in the future to contain costs.

Posted by: FatTriplet3 | March 30, 2010 9:38 AM | Report abuse

From Nobel Laureate Gary Becker:

"There's one bias that we're up against all the time: Markets are hard to appreciate."

Capitalism has produced the highest standard of living in history, and yet markets are hard to appreciate? Mr. Becker explains: "People tend to impute good motives to government. And if you assume that government officials are well meaning, then you also tend to assume that government officials always act on behalf of the greater good. People understand that entrepreneurs and investors by contrast just try to make money, not act on behalf of the greater good. And they have trouble seeing how this pursuit of profits can lift the general standard of living. The idea is too counterintuitive. So we're always up against a kind of in-built suspicion of markets. There's always a temptation to believe that markets succeed by looting the unfortunate."

Earlier in the piece Becker says:

"The health-care legislation? It's a bad bill," Mr. Becker replies. "Health care in the United States is pretty good, but it does have a number of weaknesses. This bill doesn't address them. It adds taxation and regulation. It's going to increase health costs—not contain them."

http://online.wsj.com/article/SB10001424052748704094104575144011906222520.html?mod=WSJ_newsreel_opinion

Steve

Posted by: FatTriplet3 | March 30, 2010 9:54 AM | Report abuse

@tyromania: "Robert Samuelson and Charles Krauthammer aren't interested in a good faith nuanced discussion, and they are the ones entitled to choice real estate on the WaPo editorial page. Why aren't you calling _them_ out as the problems here?"

Because I'm not interested in getting into a "he did it first" pissing match. Is the answer to people making weak or bad faith arguments to stoop to their level? Ezra is also entitled to choice real estate on WaPo. Note also that like Kevin_Willis said, Ezra has pretty drastically misrepresented Krauthammer's point.

Posted by: ab13 | March 30, 2010 10:23 AM | Report abuse

"There's an absence of empathy here that borders on a clinical disorder."

No, it IS clinical disorder (no borders here). Both Samuelson and Krauthammer are clinically deranged (rabidly so in the case of the latter).

And if you keep writing stuff like this, Ezra, you'll wind up being fired. A la Froomkin... Right-wing publications do not tolerate dissent.

Posted by: Gatsby10 | March 30, 2010 10:51 AM | Report abuse

ab13,

Of course, if that small business is generating a profit of $20,000 - $40,000 and you increase its rates 15 percent the first year, and to the top of the band within the next year or two after that -- odds are that the business will end up dropping its insurance coverage.

There's also a reason that the small group is capped at 50. If the rates were tied to larger group pools, small group purchasers would get more favorable terms at the outset.

Guaranteed issue limits the ability of insurers to screw their customers, but it still doesn't fully resolve the issue of inverted incentives. The incentives in the system still encourage insurers to seek out those who need their product the least; and it gives them the latitude to turn the screws when a customer starts using their product for its intended purpose.

Posted by: JPRS | March 30, 2010 11:01 AM | Report abuse

FatTriplet3,

8 percent inflation would not cause the U.S. to default -- not even over a 10 year period (e.g. that's roughly the rate of inflation from 1974-1982). A high rate of inflation would probably increase the cost of borrowing and future spending, but it would also likely reduce the pain of paying off existing debts.

The more likely scenario is that the U.S. will see broad economic and federal budget benefits from the passage of this bill -- not the opposite.

Posted by: JPRS | March 30, 2010 11:14 AM | Report abuse

-----"Of course, if that small business is generating a profit of $20,000 - $40,000 and you increase its rates 15 percent the first year, and to the top of the band within the next year or two after that -- odds are that the business will end up dropping its insurance coverage."

So now you've changed your tune from "the insurance will exceed the company's total revenue" to "they'll get a 15% rate increase a couple years in a row and that's too much". Yet somehow that scenario, despite being considerably less onerous, still has the same outcome. Gotcha.

-----"There's also a reason that the small group is capped at 50. If the rates were tied to larger group pools, small group purchasers would get more favorable terms at the outset."

Favorable to whom? Would that lower premium come from the magic low-premium fairy?

-----"Guaranteed issue limits the ability of insurers to screw their customers"

"Screw" their customers? So denying insurance coverage because of uninsurable risks, or not being allowed to adequately price the risk amounts to "screwing" someone? That's a pretty interesting view you've got. When a life insurer refuses to sell a policy to someone with terminal cancer have they also "screwed" that person? If a property insurer refuses to sell a policy to someone whose home is on fire, have they "screwed" that person?

----"but it still doesn't fully resolve the issue of inverted incentives. The incentives in the system still encourage insurers to seek out those who need their product the least; and it gives them the latitude to turn the screws when a customer starts using their product for its intended purpose."

This is logically incoherent. How does the small group environment give them latitude to "turn the screws"? It severely limits the rate that can be charged to any group, and limits the amount their rate can ever be increased. The small group market is actually a pretty good deal for those small businesses.

You clearly didn't even know about the small group laws before, but still think you know enough to talk about this market.

Posted by: ab13 | March 30, 2010 11:25 AM | Report abuse

Nobel Laureate Gary Becker also wanted to privatize Social Security too before the financial crisis. Stuff always looks good on paper to theoretical ideologists. His reasoning is a schoolyard argument.

Posted by: Lee_A_Arnold | March 30, 2010 11:27 AM | Report abuse

.

You are a brave man for saying it out loud, Ezra. I wish you well.


.

Posted by: drindl | March 30, 2010 11:59 AM | Report abuse

ab13,

1. I'll grant that the hypothetical of the cancer patient in the 7 person company is unlikely to exceed revenues (it's plausible, but definitely an outlier -- odds are that kind of business wouldn't even offer insurance in the first place, because they are already priced out of the market).

However, fundamentally the point remains the same -- a major illness in a small business jeopardizes the coverage of everyone in that pool. Guaranteed issue does not remedy the issue of "pre-existing" conditions. It also does not insulate small businesses from being effectively priced out of the market due to the fact that one member in their pool starts actually using the insurance product for its intended purpose.

2. Lower rates come from lower risk. Lower rates are also a function of size and leverage. The larger the risk pool, the lower the cost on a per person basis.
This is not be a controversial proposition.

As recognized within the reform package itself, the primary areas of concern are in the small group and individual markets. If the small group and individual markets were doing a first-rate job of providing broadly accessible and affordable coverage, there would have been no basis for the health care debate. Perhaps from the point of view of some insurers the status quo was OK -- maybe even ideal. Clearly this was not the case for an even larger number of consumers.

3. We clearly have a fundamental disagreement about the place that health insurance should occupy in a health care system.

Your posts seem to suggest that the profit incentive trumps other considerations (e.g. such as the affordability and availability of care).

My view is the profitability of insurers is at best a secondary consideration.

When it comes to something as vital as health care I would prioritize questions concerning cost, quality, and access before the profitability of a payment system.

The needs and concerns of the people should come before the wants and desires of people within the insurance industry.

Especially given the experience of other countries -- e.g. those with a more streamlined payment system; and those with a more heavily regulated ones -- the need for reform within our own system was clearly long overdue.

Posted by: JPRS | March 30, 2010 1:08 PM | Report abuse

JPRS, you very clearly were not aware of the laws that prevent small groups from having to bear the full cost of their risk. When confronted with some facts about it, your response was basically "Yeah, all those things that severely limit their rates are true, but insurance is still expensive". You seem to want to blame insurers for rising medical costs, rather than the people consuming them and the providers supplying them.

-----"a major illness in a small business jeopardizes the coverage of everyone in that pool."

No it doesn't. They are still protected by the limitations on rate increases and the rate bands. Will they pay a higher rate? Of course, but nowhere near the full cost of covering them. Small group is essentially community rated, with very a limited range of risk-related pricing allowed. Those ranges are not the problem with small group, the problem is total cost growth.

-----"Guaranteed issue does not remedy the issue of "pre-existing" conditions."

Yes it does. It does exactly that. It prevents you from being denied for pre-ex, and the rate bands limit the amount you can be charged.

-----"It also does not insulate small businesses from being effectively priced out of the market due to the fact that one member in their pool starts actually using the insurance product for its intended purpose."

The rate bands and rate increase limits do that.

----"Lower rates come from lower risk. Lower rates are also a function of size and leverage. The larger the risk pool, the lower the cost on a per person basis.
This is not be a controversial proposition."

This is not quite true. Adding more people to the pool does not magically lower the costs, it just spreads it among more people. You were questioning the 50 employee cutoff for small group, but pooling them with larger groups does not lower costs, it just shifts them around more. We need to lower medical costs, not just subsidize them more.

-----"If the small group and individual markets were doing a first-rate job of providing broadly accessible and affordable coverage, there would have been no basis for the health care debate."

The reform bill does not address costs in the IM and SG markets, only coverage. Both of those markets could use some changes, but those changes need to be focused on lowering costs, not just finding someone else to pay for them.

-----"Your posts seem to suggest that the profit incentive trumps other considerations"

Nothing I've said suggests that. Profits are important to the extent that without them you won't have any insurers.

-----"When it comes to something as vital as health care I would prioritize questions concerning cost, quality, and access before the profitability of a payment system."

Cheap, high quality, accessible. Choose two. It does us no good to pretend there are not huge trade-offs to make amongst those three components.

Posted by: ab13 | March 30, 2010 1:40 PM | Report abuse

JPRS,

An 8% inflation rate IS a defacto default. I think a de jure default (which is what you were referring too) in the US is very unlikely as all our debts are held in dollars and we can always print money. But an 8% inflation rate means that holders of Treasuries are being repaid in cheaper dollars, so its a de facto default.

I'm glad that you're optimistic about the bill and wish that I could share your enthusiasm. But I can't.

I think the bill contains no serious cost containment and that costs will be dramatically higher than the CBO scoring. Many, many credible economists share this concern. The CBO scoring can be gamed, mostly by requiring it (correctly) to ignore political calculus. Have you read any of Elmsendorf's recent statements on that. He clearly, as head of the CBO, shares that concern.

This on top of an unfunded liability of $17.5 Trillion for SS, Medicare Part A of $36 Trillion, Part B of $37 Trillion and Part D at $15 Trillion.

Steve

Posted by: FatTriplet3 | March 30, 2010 1:53 PM | Report abuse

ab13,

With respect to the per person cost the price difference in large and small groups is not insignificant. A 15 percent increase on a major business expenses is likely to eat a significant chunk out of the bottom line for many small businesses. An adjustment to the upper range of the band would likely be an inducement for many small businesses to drop coverage altogether.

The reality is that the small group market does not function as well for companies and individuals as the large group market does. If a person doesn't understand this, then I can understand why he or she might have trouble understanding why we had a debate on this issue over the past year (I would also wager that the person is probably not subject to the rules that govern small and individual markets -- either that or the person works for HR in a small business and is simply trying to preserve his or her livelihood).

With respect to cost, quality, and accessibility, frankly the decision is more along the lines of pick one or pick two -- at least as far as a system of private insurance is concerned (e.g. chose lower quality and odds are you get a lower cost product that's more accessible; or you can opt for the highest quality at a higher cost and you effectively price a lot of people out of the market altogether).

Obviously there are many drivers of health care costs -- with the provider cost eating up a larger share of revenues for larger purchasing pools. However, I think this is a different discussion topic.

The question that I'd focus on is more along the lines of: "which system of payment strikes the best possible balance between cost, quality, and accessibility for consumers".

If a system of private payment achieved the best balance of those outcomes, then that would be a strong argument for a system of private, profit-oriented, payment. Arguably this is the case for larger businesses. A person would have a harder case with the small group market. In the case of an individual market, there is really no defense. The insurance market didn't chose one or two of the measures -- cost, accessibility, quality -- it pretty much failed consumers on all three levels. Of course, the insurers are simply following the incentives within the market -- they aren't malicious; they are simply indifferent to the needs of whole classes of potential customers.

So the challenge becomes creating a structure that is more responsive to consumer interests and which puts the incentives for insurers in a more socially useful direction. The current reform package addresses many of those concerns.

Posted by: JPRS | March 30, 2010 2:24 PM | Report abuse

FatTriplet3,

I don't really follow the "de facto" "de jure" distinction with respect to inflation.

Either inflation is at 8 in fact, or it isn't at 8 percent. I don't see how inflation could be 8 percent in principle. Maybe I'm just an idiot -- you'll have to spell out the distinction more clearly for me.

With respect to inflation rates, GDP growth matters as well (maybe this is what you're referring too?).

I do think deficits are a long-term issue. I don't think that the likelihood of U.S. default is that high right now -- even after the passage of the health care bill. The markets certainly aren't buying that outcome as a very likely one. The shear size of the U.S. economy is one factor in our favor.

It would be helpful though in terms of GDP growth and debt reduction if the Chinese stopped pegging their currency to ours and let it free-float.

Posted by: JPRS | March 30, 2010 2:36 PM | Report abuse

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