Network News

X My Profile
View More Activity

Stupak's abortion argument: Still more about class than choice

stupakclassJPG.JPG

Matt Miller hits on one of the most important points in the abortion and health-care debate. The practical effect of Bart Stupak's position is not that the federal government will not subsidize abortion by subsidizing health-care insurance. It is that it will not subsidize abortion by subsidizing health-care insurance for poor women. We already spend much more subsidizing coverage that includes abortion for richer women:

This entire debate is ridiculous, because the feds already subsidize abortions massively, via the giant tax subsidy for employer-provided care. Today the feds devote at least $250 billion a year to subsidizing employer-based coverage, a subsidy that skews incentives horribly (but which big business and big labor wouldn’t let the politicians touch this year). A Guttmacher Institute study says that 87 percent of typical employer plans cover abortion, and a Kaiser study found that 46 percent of covered workers had abortion coverage.

As I've written before, the Stupak amendment is as much about class as it is about choice. Imagine if Stupak attempted to expand his campaign to the coverage employed women receive. It would, after all, be the same principle: Federal policy should not subsidize insurance that offers abortion coverage. But it wouldn't have a chance. That group is too large and too affluent and too politically powerful for Congress to dare to touch its access to reproductive services. But the poorer women who will be using subsidies on the exchange are a much easier target.

Photo credit: Manuel Balce Ceneta/AP

By Ezra Klein  |  March 5, 2010; 5:43 PM ET
 
Save & Share:  Send E-mail   Facebook   Twitter   Digg   Yahoo Buzz   Del.icio.us   StumbleUpon   Technorati   Google Buzz   Previous: Your economic problems in graphs
Next: Can't judge a policy by its price tag

Comments

Rich get the elevator, poor get the shaft.

Even in the days of illegal abortion, the well off and middle class could go to Canada or other countries for abortion services, while the poor were sent to back alleys.

The true irony is that abortion is defacto unattainable for many poor and working class women because the number of clinics that perform abortions is shrinking every day. Many states have only 1 or no reproductive services clinics that will perform abortions. Between state laws requiring multiple visits to a clinic, mandatory counseling, waiting periods, etc., abortion is rapidly becoming too costly in time, travel, and money for many women to access.

Posted by: srw3 | March 5, 2010 6:00 PM | Report abuse

Ezra? Anyone?

Can you please point to a site that displays the Stupak Amendment, so we can all see the actual language.

And, I'd still like to hear your thoughts about the impact Stupak and his followers will have on final passage of HCR.

I've always feared the abortion issue could be the real "Tarantino".

Posted by: onewing1 | March 5, 2010 6:03 PM | Report abuse

OOps, strike that request for a link to Stupak's actual amendment. You've already provided it (in your prior coverage of this issue).

Posted by: onewing1 | March 5, 2010 6:06 PM | Report abuse

The Bart Stupid/Blue Dog contingent makes a distinction between direct payments and tax subsidies. They worship at the church of Ronald Reagan, which decrees that you don't really 'owe' the government your taxes, so a tax exemption is not really a government subsidy, like a direct payment for an insurance policy would be. But in the end, it all comes down to the same thing - rich or well paid people = good, poor or low paid people = bad

Posted by: exgovgirl | March 5, 2010 6:19 PM | Report abuse

I wonder if the Stupak amendment mandates 18 years of forced child support from the father? If not, why not?

Posted by: KT14 | March 5, 2010 6:21 PM | Report abuse

Here is an excerpt from my response to an earlier Ezra Klein post making the same point:

"From a policy standpoint, it is obviously incoherent to put in place an amendment that denies abortion subsidies to poor women, but not the affluent. That doesn’t mean, however, that the Stupak amendment is as 'as much about class as about choice,' as Klein asserts. What it means is that abortion foes have resorted to guerrilla war in the absence of any real hope of overturning Roe V. Wade."

The rest of my response can be read at the Innocent Smith Journal:

http://innocentsmithjournal.com/2009/11/09/the-stupak-amendment-opportunistic-but-not-discriminatory/

Posted by: InnocentSmith | March 5, 2010 7:24 PM | Report abuse

Just compromise with the Stupak language if they don't have the votes otherwise (and who knows how many votes he has until the CBO score and language is released).

Most importantly, I'd prefer Stupak's over Nelson's amendment - look in today's Post about the abortion flap and how the Nelson language stigmatizes abortion. If it comes down to giving 30 million people insurance and saving their life because of this preventitive care v. this amendment, I'd choose health care reform any day.

Posted by: legalla | March 5, 2010 7:31 PM | Report abuse

I have to say, I don't know how much more I can take of forces attacking effective health care reform. On the one hand, the health care bill has suffered so much because of special interests. On the other hand, it is amazing that there is still meaningful reform in the bill at all.

I wonder if it weren't for the inefficiencies piled in on so many governent actions, would we have a debt crisis at all?

At least we'd be able to fix it.

Posted by: NickM2 | March 5, 2010 7:44 PM | Report abuse

The President, and pro-life, and pro-choice forces have all drawn this same distinction, Ezra. Because there is a distinction in whether you give me money to do something directly, or tell me that if someone else gives me the money, you won't tax that as income.

I fail to see why you cannot see that there is a difference between the two. Your argument, Ezra, amounts to the following: any dollar of income that Ezra Klein does not pay to the government is a subsidy from the government. Ezra Klein sometimes eats dinner at Komi. Ergo, taxpayers are paying for Ezra Klein's dinners at Komi. If that seems like nonsense, well, it is. And so is the argument that untaxed health plans are paid for by the government.

On this, I agree with President Obama--the tax exemption for insurance plans does not equal federal funding of abortions. On that, the President is telling the truth. Where he is lying is in pretending that the Senate Bill wouldn't alter that calculus.

Steny Hoyer, who announced today that he will work with Stupak on a (doubtless doomed) effort to create a third thing--besides the Senate bill, and besides reconciliation (the rules of which will not permit an abortion fix, Hoyer believes), clearly agrees that the Senate bill will pay for abortions, or else he wouldn't be trying to "fix" the problem.

Posted by: FrBill1 | March 5, 2010 8:01 PM | Report abuse

The notion that "that which the government does not seize is a subsidy" isn't going to get very far outside a few think-tanks. Clever, though.

Posted by: tomtildrum | March 5, 2010 8:04 PM | Report abuse

Let me Google that for you.
http://lmgtfy.com/?q=supak+amendment+text

Posted by: barrysweezey | March 5, 2010 10:09 PM | Report abuse

Without wading into the politics of abortion, it strikes me that if I were pro-life and wanted to stop abortions from taking place, that stopping the federal government from paying for them for poor women(as the Hyde amendment does), or this Stupak language that wouldnt allow health insurance plans into the exchange that cover abortion and thus subsidized by taxpayers would pretty much stop abortions, I mean, are there a large number of middle and upper class women having abortions??

Posted by: zeppelin003 | March 5, 2010 10:23 PM | Report abuse

Ezra, I doubt your argument holds here. Goal for Stupak is to 'stop Fed money for abortion'. If it means to stop first for 'poor woman'; that is a start. Stupak is not saying 'no subsidy to poor woman'. He can say give subsidized coverage without 'abortion coverage included'. What happens in employer covered coverage is besides the point.

And here is the thing Ezra - you want to justify half measured HCR on the basis of political feasibility. You argue that voting for current HCR is best option today since more cost control or Public Option is politically not possible. Then why shouldn't Stupak also think about 'banning abortion' in the same way? You start from one group and then build when politics is conducive.

Me? I am least interested in banning abortion coverage or supporting it. Agnostic about it, do not much want to say since I am not the one who bares the pain of 'giving birth to a baby'.

Posted by: umesh409 | March 5, 2010 10:26 PM | Report abuse

My curiosity about this sent me to almighty Google. This from Guttmacher: http://www.guttmacher.org/pubs/fb_induced_abortion.html

The abortion rate among women living below the federal poverty level ($9,570 for a single woman with no children) is more than four times that of women above 300% of the poverty level (44 vs. 10 abortions per 1,000 women). This is partly because the rate of unintended pregnancies among poor women (below 100% of poverty) is nearly four times that of women above 200% of poverty* (112 vs. 29 per 1,000 women[3,1]


So, the bottom line is as I suspected here that poor women are by far the ones having the abortions in America, and that Ezra's point here is mostly theoretical, in as much as women who simply arent having the abortions arent as affected by the Stupak language as the women who are having them, which I think is the point if you want to ban abortions.

Posted by: zeppelin003 | March 5, 2010 11:07 PM | Report abuse

I think its ironic that Senator Barbara Boxer will have ended up delivering the death-nail to the liberal dream of communist medicine because she could simply not resist using it as an opportunity to reverse the Hyde amendment.

I love it!

Posted by: FastEddieO007 | March 5, 2010 11:30 PM | Report abuse

This is truly crazy convoluted logic.

Because the government decided a long time ago not to tax monies paid by an employer to an employee if that money was being used to purchase health insurance---you've interpolated that into US Tax Dollars are funding rich women's abortions....this is sheer nutz!

Get rid of THAT tax exemption---or give everyone an exemption. Either way.

We all know Democrats have supported keeping that crazy law because it helps to make our healthcare system SO DYSFUNCTIONAL and our dysfunctional healthcare system is the major pre-text for why we need the government to take healthcare over---No we don't. Just stop being so dysfunctional. And don't give someone a tax break, and then claim tax money is being used by them to do something.....etc.,.etc.,.....

Posted by: FastEddieO007 | March 5, 2010 11:35 PM | Report abuse

"The abortion rate among women living below the federal poverty level ($9,570 for a single woman with no children) is more than four times that of women above 300% of the poverty level (44 vs. 10 abortions per 1,000 women)."

Women subsisting on $9,750 per year are very poor indeed, and are most likely on Medicaid today. Subsidies for uninsured women will mostly benefit somewhat higher income individuals, and I don't think using the statistics of the very poorest people in society is very illuminating, if we are trying to project how many abortions will take place under subsidized plans, as opposed to employer provided plans with the Federal tax exemption.

My suspicion would be that the rates of abortion on the subsidized plans (if allowed) would be roughly comparable to what already takes place on employer-provided plans (with the tax write-off).

Posted by: Patrick_M | March 6, 2010 12:45 AM | Report abuse

"We already spend much more subsidizing coverage that includes abortion for richer women"

Your arguments lose a lot of power when you conflate or equivocate spending with "not taxing", because the tax rates are not 100%. People could be using money in flexible spending accounts as well. You're also mixing aggregate numbers with per person numbers, which is confusing.

The basic issue is clear though, he is trying to block abortion for the poor, and that is reprehensible enough on its own.

Posted by: staticvars | March 6, 2010 7:40 AM | Report abuse

At least Obama & Pelosi are not following the advice of the Science Czar John Holdren who recommended in a book from back in 1970 that a government can limit use of resources like medical services by forcing abortions on the population.

I guess Obama & Pelosi aren't as radical as many say. Then again he is their Science Czar.

Posted by: FastEddieO007 | March 6, 2010 9:33 AM | Report abuse

Abortions aren't (for the most part) an insurable event, as the vast majority are directly caused by the choices of the insured. For that matter, from what I've read, abortions aren't all that expensive. From a strictly monetary perspective, an abortion has a huge positive net present value in terms of not having to pay for a child. If some woman doesn't want a child, but isn't willing to pay a few hundred bucks in order to save thousands in the future, why should I be forced to pay for it?

On the flip side, given how high subsidies are for the poor, perhaps the state sees covering abortion for poor women as a positive NPV transaction, and doing so makes financial sense.

At the end of the day, moral considerations matter more than money and a lot of Americans believe abortion to be murder and forcing them to pay for it is probably wrong (of course I can see the same comments being made about foreign interventions by the US military).

Furthermore, I agree with other posters that not taxing health benefits isn't a subsidy. That being said, I'm completely in favor of eliminating the tax deduction - the lack of a tax may not be a subsidy, but it still creates an incentive to spend more on health insurance vis-a-vis other things, an incentive we don't need.

Posted by: justin84 | March 6, 2010 10:21 AM | Report abuse

"Furthermore, I agree with other posters that not taxing health benefits isn't a subsidy."

I disagree.

Whenever the government allows a tax credit or exemption for something, that means higher taxes must be collected for everything else. So, in a very real sense, people who are not mortgage holders are "subsidizing" those who have mortgage interest to write off. Likewise uninsured and self-insured taxpayers "subsidize" the health insurance write off for employers.

"Abortions aren't (for the most part) an insurable event, as the vast majority are directly caused by the choices of the insured."

I disagree again.

Women who abort a pregnancy do not plan to becoming pregnant and then abort the pregnancy. If your argument is that by having ineffective contraception or not abstaining from sex, women somehow choose to have an unwanted pregnancy, that is a little like saying that auto accidents are not accidental, because people choose to drive on the roads where accidents are known to occur, or that they occur as a result of "choice" because there is fault asociated with most accidents.

Even when the drivers ought to have been more cautious, collisions are still just that - accidents, as are virtually all aborted pregnancies.

"At the end of the day, moral considerations matter more than money and a lot of Americans believe abortion to be murder and forcing them to pay for it is probably wrong (of course I can see the same comments being made about foreign interventions by the US military)."

You are correct, Quakers have to pay for military actions and people opposed to the death penalty pay taxes that are partially used to execute prisoners. The Hyde amendment is something of an anomaly in that it forbids the government under any circumstance from ever paying for something which is perfectly legal, and which is a common medical service in the private sector.

Posted by: Patrick_M | March 6, 2010 2:51 PM | Report abuse

Patrick, I agree in terms of effects that the failure to tax an activity is similar to spending money on an activity, but subsidy does not seem to be an appropriate word. The government is not 'subsidizing' me by not charging me more in taxes. Consider a hypothetical economy in which lump sum taxes prevail, and everyone is charged $100 per year. Then, the government stops requiring one person to pay the tax. Is that person having their personal finances subsidized by the government, or are they merely not having a part of their income confiscated? It might not be fair to the other taxpayers, and it might not be the same effect as everyone paying $100 in taxes and he receives $100 back, but I think calling failure to tax a subsidy concedes too much rhetorical control of our incomes to the government.

Another point is that rich women's abortions cannot be subsidized by poor women's taxes - the rich pay nearly all of the taxes. Most poor women receiving net income from the government. If we call a tax deduction a subsidy at all, it is rich women (and men) subsidizing the abortions of middle class women via higher marginal tax rates.

Also, comparisons to automobile insurance make the case that abortions are not insurable events, under the true meaning of insurance. I'm not saying that auto insurance and unwanted pregnancies aren't both accidental, but the size of the claim matters. You may cut yourself accidentally with a knife (minor cut) while cooking, but I think you would agree with me that no one needs insurance for bandages and antibiotic cream.

True insurance covers losses that are catastrophic, difficult to predict, and rare. Driving on black ice and skidding into a $70,000 Mercedes and injuring the driver thereof falls under this category. Driving around and having one of your tires blow out is not - most drivers at some point have a tire go out, it is relatively cheap to fix, and you can predict in advance that the vast majority of drivers will experience a tire blow out during their driving careers. Equivalent examples in the health insurance world are cancer and abortion, respectively. Now, many of us get cancer or heart disease or some other ailment at some point in our lives, but the expense is catastrophic and for people in many age groups cancer/heart disease is very rare. It is difficult to expect most people to be able to save for it on their own, particularly if the cancer hits someone uncommonly early.

Abortions on the other hand are experienced by 35% of women (http://www.prochoice.org/about_abortion/facts/women_who.html), and cost a few hundred bucks. Having health insurance cover abortions would be like auto insurance covering replacement tires. It's more of a prepaid expense than insurance, as traditionally understood.

Posted by: justin84 | March 6, 2010 6:01 PM | Report abuse

"Having health insurance cover abortions would be like auto insurance covering replacement tires. It's more of a prepaid expense than insurance, as traditionally understood.
Posted by: justin84 "

Many advocates of health care reform want health insurance to cover the equivalent of oil changes as well as limitless liability.. They want to be able to opt out of obtaining insurance and still be able to get it after they get sick. I think some of these folks even want health insurance to cover the equivalent of putting gasoline in the engine. And best of all, they want you to pay for it.


Posted by: bgmma50 | March 6, 2010 7:39 PM | Report abuse

justin84,

"Having health insurance cover abortions would be like auto insurance covering replacement tires."

No.

Auto insurance is there in case of collisions, and health insurance is there for when people need the services of medical professionals. An abortion is not routine maintenance like changing a set of worn out tires. The comparison is offensive.

"True insurance covers losses that are catastrophic, difficult to predict, and rare. Driving on black ice and skidding into a $70,000 Mercedes and injuring the driver thereof falls under this category."

It also provides coverage when you hit a $5000 used car, nobody is hurt, but there is $2,000 worth of body damage. Of course there are different price categories depending upon how comprehensive you want the auto policy to be, how much liabilty you wish to carry, and how high the deductibles will be. Health insurance works the same way, from cheaper catastropic only coverage, to very comprehensive "Cadillac" plans.

Most health insurance coverage now is employer provided, and it is reasonably comprehensive, typically with co-pays, annual deductibles, and a coinsurance requirement of around 20%.

But generally speaking, the most common model of health insurance anticipates some level of coverage for most instances when people need to visit health care providers, whether that is for heart surgery, cancer treatment, childbirth, annual checkups, an abortion, or whatever. So that IS the most common model.

(to be continued...)

Posted by: Patrick_M | March 6, 2010 11:55 PM | Report abuse

(continuing...)

"You may cut yourself accidentally with a knife (minor cut) while cooking, but I think you would agree with me that no one needs insurance for bandages and antibiotic cream."

Yes, of course. But if you cut yourself so badly that you need to go to the emergency room and receive stitches, most health insurance policies today will provide some coverage for that expense. Having an abortion is something is done by a doctor in a medical setting, it is not like putting a bandaid on a cut yourself at home. Once again, the analogy is absurd, and rather offensive.

Some here (see bgmma50) constantly argue that health insurance should NOT cover all sorts of things, like wellness, prevention, or (apparently) anything which is not catastrophic. That point can be argued, I suppose. But regardless of what you think insurance SHOULD cover, the fact remains that most employer-provided policies DO cover abortion right now.

So it is true that those who are fortunate enough to receive health coverage from their employer (which is partly enabled by the tax exemption the employer enjoys for the cost of the policy) will enjoy widespread access to a service that the Stupak amendment would deny to those who will gain access to health insurance for the first time as a result of the subsidies to uninsured.

"Another point is that rich women's abortions cannot be subsidized by poor women's taxes - the rich pay nearly all of the taxes."

Cannot?

There are plenty of middle and lower middle class individuals and families who pay income taxes. Many of those people are self-employed or work for businesses that don't provide a health insurance benefit. These people earn enough to pay taxes, but do not earn enough for health insurance to be affordable, and so they currently do without.

The fact that businesses that give employees insurance coverage that includes abortion are allowed a break on the taxes they would otherwise pay in TO the US Treasury. At the same time, individually purchased health care which is subsidized BY the US Treasury must not include abortion coverage. This is philosophically inconsistent, at best.

Posted by: Patrick_M | March 6, 2010 11:56 PM | Report abuse

"Some here (see bgmma50) constantly argue that health insurance should NOT cover all sorts of things, like wellness, prevention, or (apparently) anything which is not catastrophic."

Wrong. I argue that providing taxpayer subsidies for health insurance that covers all sorts of things in too expensive and is a big part of the reason why costs are too high. Also a big part of the reason Obamacare is running into trouble.

I support the guarantee of catastrophic coverage to all citizens. I would support the retention of the employer exclusion in an amount sufficient to provide such coverage, and the use of the funds freed up by capping the exclusion to provide direct subsidies and also a tax credit or deduction to those who purchase individual coverage. I would prefer to leave the tax system out of it altogether, but I realize that's not realistic.

I also support the creation of exchanges that would create a nationwide pool of consumers to purchase enhanced coverage for lower deductibles, lower copays, preventitive care, higher limits, and all the other options so near and dear to the the hearts of Americans who can't wrap their minds around the idea of paying for their annual checkup. But people ought to pay for that stuff out of their own pockets.

Posted by: bgmma50 | March 7, 2010 10:25 AM | Report abuse

Patrick,

I agree that the common model of health insurance is comprehensive. I think there is a lot of agreement from health economists that part of the reason costs are so high is that health insurance isn't really insurance by itself, it is a pre-paid health plan plus insurance. I notice that a lot of so-called insurance is somewhat backwards - if I was part of a family that was expecting a child, under most cases insurance would cover the costs of child birth. However, if anyone in my family became so ill as to push our total claims beyond the $1,000,000 lifetime expense limit (say, $1,500,000 of claims), we'd be hosed. Even many liberal economists, such as Brad DeLong, think that health insurance should only cover health claims above a very high level (in his case, above 15% of income per year).

As for the collision situation, you are right that a $2,000 property damage claim is also covered. I also note that I cannot even consider having a deductible for property damage liability. This is probably because lots of people would pick a $5,000 deductible to lower their auto insurance premium and then after an accident fail to pay, and so comprehensive coverage of PD liability is the least bad option. For a damage to my own car, my comprehensive deductible is $1,000 per claim - so if abortion was considered analogous to auto comprehensive, it might well not be covered.

I don't necessarily want to concentrate on abortion - I'm against all comprehensive insurance. I understand that in some cases people won't go to the doctor if they have to pay, and fail to find diseases early - but in those cases I ask if a person fails to get a checkup because of cost, why on Earth should anyone else have to pay for something the direct beneficiary didn't think was worth the money?

Back to abortion, I'm not against having abortions covered if a family has already incurred fairly significant healthcare costs. I just don't want abortions or other small things covered with comprehensive first dollar coverage.

At the end of the day, I'm concerned with overall health costs, and the proportion of those costs that will uncontrollably inflate the government's healthcare bill. Under government comprehensive insurance, cost will become an ever increasing problem. We already see vigorous push back on cost saving parts of the plan (the breast cancer guidelines WRT CRE, weakening/delaying the excise tax).

If we limited the government's health spending to 5% of GDP, perhaps in a model in which the federal government has each state set up a network of hospitals and other providers, available to anyone who wanted to come, I'd be okay with that. I would even be okay if those facilities provided abortions, provided that the state decided that way was the best use of funds provided in order to best meet the goals of the system.

Posted by: justin84 | March 7, 2010 12:03 PM | Report abuse

justin84, that's very well said. I too, think that comprehensive insurance is a very bad idea. About the only difference between you and I on that score is that I think private insurers ought to be able to offer it and individuals who want it ought to be able to buy it, but there should be no subsidy, no employer exclusion, no tax credits, no tax deductions. In other words, everybody who wants to spend $5000 plus per year for $25 copays and unlimited lifetime benefits ought to pay the entire freight out of their own pockets. I think that would be the end of eomprehensive health care, and good riddance to it. We'd all benefit by lower costs.

Posted by: bgmma50 | March 7, 2010 4:11 PM | Report abuse

"I understand that in some cases people won't go to the doctor if they have to pay, and fail to find diseases early - but in those cases I ask if a person fails to get a checkup because of cost, why on Earth should anyone else have to pay for something the direct beneficiary didn't think was worth the money?"

Than answer is very simple.

If the person has a financial disincentive to prevent illness through ordinary checkups, blood tests, etc., the rest of the pool will pay the much higher price when they get sick.

My own family's plan has fairly high annual deductibles, co-pays, and co-insurance, but the insurance company pays 100% for the annual check-up and for simple preventative measures like flu shots, for the simple reason that it lowers risk and saves the insurer money (thereby lowering rates to the rest of the pool) when everyone has routine wellness and preventative care.

Posted by: Patrick_M | March 7, 2010 7:31 PM | Report abuse

"If the person has a financial disincentive to prevent illness through ordinary checkups, blood tests, etc., the rest of the pool will pay the much higher price when they get sick."

I think it has been fairly well established that preventative medicine may work spectacularly well for the person whose cancer happens to be detected during their annual check up, but for the system as a whole, it is cheaper to pay for the odd case of cancer that is detected in an annual checkup vs. paying for annual checkups for everyone.

However, annual checkups are cheap. So, catastrophic coverage plus half the cost of one annual checkup per person. But I want no part of the younger versions of those McAllen Medicare patients who have spent a lifetime eating garbage and sitting around and now want me to pay for 100% of their Type II Diabetes medications, testing supplies, and equipment for the rest of their lives, and then for the leg amputations and heart bypass operations they need to undergo later when they have refused to test their blood several times every day, take their meds faithfully, and God forbid get off their asses and walk to the grocery store to buy some fruit and vegetables.

Posted by: bgmma50 | March 7, 2010 8:04 PM | Report abuse

"but the insurance company pays 100% for the annual check-up and for simple preventative measures like flu shots,"

A flu shot is $25. I got one at my grocery store last winter. My GROCERY STORE pharmacy was administering them on a walk in basis. Took 5 minutes. No appointment, no doctor visit. Just paid my $25 and got a flu shot. And it's a chain store. Every single one of them in the state was running the same deal. My husband got one at his office for $10, because the employer arranged for some mobile flu van to visit and innoculate everybody. How hard is that?

Posted by: bgmma50 | March 7, 2010 8:23 PM | Report abuse

bgmma50,

I actually am okay with comprehensive health insurance between willing buyers and sellers. My problem is that the government's finances are projected to blow up because of the way it helps individuals obtain health care. That's why I'd be okay even with a British NHS-style of public hospitals available to all, set at a significant but steady level of GDP, because it keeps the government's commitment contained without intruding on the freedom of those who wish to get health care outside of the system.

Patrick,

It isn't clear that preventative care actually saves money. According to the New England Journal of Medicine, encouraging exercise, healthy eating, and the cessation of smoking are areas where prevention can make a difference. However, the evidence is more mixed on preventative medicine. Regular checkups are, for most people, a waste of money, and if you catch cancer early it doesn't mean you save money - you're going to spend a lot of money fighting the cancer. You might beat the cancer, but then you wind up with a hospitalization due to a heart attack four years later, which costs a lot of money itself - especially since four years down the road, healthcare costs will be higher.

Cheap preventative medicine is something people should pay for their own and they should do it for their own good. Checkups probably help people catch conditions early when they are treatable - good for health, but not necessarily cost. I agree that the very poorest Americans will need help for this, but not the middle class. If a middle class family decides that they'd rather go on a cruise then send each family member in for a checkup, then that is their own choice.

Sources here:

http://content.nejm.org/cgi/content/full/358/7/661

also here:
http://www3.interscience.wiley.com/journal/121378262/abstract?CRETRY=1&SRETRY=0

Posted by: justin84 | March 7, 2010 10:38 PM | Report abuse

"How hard is that?"

Not so hard for me, and not so hard for you. But not everyone is quite so fortunate as you and me.

Imgaine that you work as a clerk in fabric shop, and your husband is an orderly in a hospital. You have two kids. You struggle to pay the rent, the utilities, the payment on the used car, and to provide for food and clothing. That $100 for your family's four flu shots at Safeway is beyond your reach after paying the relentless bills. One of your kids comes down with the flu, and it is one of the unfortunate cases that goes to bacterial pneumonia with severe respiratory distress that requires hospitalization and weeks or even months of continuing care and medication. That's expensive.

It makes good financial sense, not to mention that it is far more compassionate and within the purpose and meaning of "health care," to try and design a system that does everything possible to prevent illness.

"I think it has been fairly well established that preventative medicine may work spectacularly well for the person whose cancer happens to be detected during their annual check up, but for the system as a whole, it is cheaper to pay for the odd case of cancer that is detected in an annual checkup vs. paying for annual checkups for everyone."

I keep hearing that from you health care opponents, but I am still waiting to see someone produce supporting data. If it is true, my health insurer is apparently throwing away money when they waive the co-pays on routine wellness and prevention. Again, the plan is structured that way because it is cheaper for them to fund prevention, wellness, and early detection, than it is to pay for the treatment of easily preventable sickness and disease.

I am sure you disagree and that all would be fine if the tens of millions of slothful welfare queens would just "get off their asses and walk to the grocery store to buy some fruit and vegetables."

Posted by: Patrick_M | March 7, 2010 10:39 PM | Report abuse

"Regular checkups are, for most people, a waste of money, and if you catch cancer early it doesn't mean you save money - you're going to spend a lot of money fighting the cancer."

Oy.

"For most people" it may be a "waste" to have their checkups, but you can't know if you are in that lucky majority unless you are in fact checked. You won't know if you are developing a silent condition unless you have a routine examination.

And by the time a person reaches middle age, most of us have at least one issue that bears watching, or take a common medication for conditions like elevated cholesterol or high blood pressure, or there will be some other reason why there is a medical necessity for a regular checkup with blood tests. Routine check-ups make eminent medical and financial sense, they are a "waste" for no one.

This is not all about cancer, but if you don't think that early detection of cancers like breast cancer, colon cancer, etc. are not only life saving but money saving as well, you know nothing about cancer.

Posted by: Patrick_M | March 7, 2010 11:04 PM | Report abuse

"If it is true, my health insurer is apparently throwing away money when they waive the co-pays on routine wellness and prevention."

No. Your employer is paying your health insurer more money for a plan that covers routine wellness and prevention.

Your store clerk and her family are probably covered by state child health insurance, and if one of them gets sick enough with the flu to be hospitalized, they would be covered by the major medical coverage that I do support.

Posted by: bgmma50 | March 8, 2010 9:51 AM | Report abuse

"I am sure you disagree and that all would be fine if the tens of millions of slothful welfare queens would just "get off their asses and walk to the grocery store to buy some fruit and vegetables."

You have a really bad habit of mischaracterizing the things I say, and usually in an attempt to portray me as a racist. I said nothing about welfare queens. The incidence of obesity in the country is appalling, and the rise of type 2 diabetes among children alarming. Do I think they are welfare queens? Um, no. Do I think the solution is to provide them with diabetes testing supplies and medications for the rest of their lives? Um, no. I think the solution is for them to stop stuffing crap in their mouths and get some excercise.

Posted by: bgmma50 | March 8, 2010 10:11 AM | Report abuse

"You have a really bad habit of mischaracterizing the things I say, and usually in an attempt to portray me as a racist."

Point me to a single racial reference is my comments.

"I think the solution is for them to stop stuffing crap in their mouths and get some excercise."

And if people had annual checkups and wellness advice, they would be nagged and counseled by their physician to do just that. We all agree that living a healthy life style, at every income level, will reduce heath care costs.

"No. Your employer is paying your health insurer more money for a plan that covers routine wellness and prevention."

No. The employer is not paying more for a policy that covers preventative care. The insurer structures the policy to encourage preventative care because it is cheaper to pay for prevention than for treatment of advanced stage illness and disease.

"Your store clerk and her family are probably covered by state child health insurance, and if one of them gets sick enough with the flu to be hospitalized, they would be covered by the major medical coverage that I do support."

And for that coverage that you do support, it will be cheaper to "change the oil than to rebuild the engine." To deny all low income people access to health care unless and until their conditions become catastrophic makes no sense.

Posted by: Patrick_M | March 8, 2010 10:53 AM | Report abuse

Has anyone asked Stupak why he's voted over the years for budgets that contain the Hyde amendment, but that's not sufficient when he also has the chance to extend health care to 30 million people? I know it's to get leverage, but if he's the only thing holding up 216/217 votes, it's a fair question.

Posted by: qkanga | March 8, 2010 10:58 AM | Report abuse

Patrick,

As for supporinting data, I cited two articles, one from the New England Journal of Medicine, that suggest that there isn't much evidence that preventative medicine saves money, as opposed to better diet and habits. I believe Ezra also has suggested in the past that preventative care is ultimately about better health, not saving tons of money.

I'll admit that I don't know a ton about cancer treatment and costs at various stages, but I do know that some people who catch cancer at stage 2 fight it all the way to stage 4, and still succumb. I have to think that in cases like that, catching it early ended up being more expensive than catching it near the end. On net, maybe it does save money to catch cancer early, if only because end of life care is very expensive. However, across the board there doesn't seem to be any evidence that preventative medicine saves the system money. After all, health care inflation is rapid and delaying end of life care means that ultimately more will be spent on it.

I agree with bgmma that the money isn't being thrown away. You or your employer is paying extra for the cost of the wellness and preventation coverage. From what I've seen, preventative medicine isn't a slam dunk from the cost perspective.

Also, when I said prevention was a waste of money, all I meant was that there are a whole lot more people who are told they are healthy and there are no problems, compared with people who actually find something via the checkup. An individual might well decide he or she would catch rare but serious problems in advance, if only because treatment is easier early on, and thus the money from their point of view is well spent.

Posted by: justin84 | March 8, 2010 11:04 AM | Report abuse

Patrick,

As for the struggling family, even low paid jobs with both parents working can produce $40,000 - $50,000 annual incomes. ($11.50/hr x 4,000 hrs/yr = $46,000). I put that value into a federal income tax calculator, assumed $4,000 of retirement savings, and found the family is only paying $658 in annual federal income taxes. With FICA and other state income taxes, that family has $36,000/yr of spendable income after retirement savings, or $3,000/month. If they are renting and have a cheap used car, then they probably have disposable income. Now $36,000/yr for a family of four isn't glamourous living, but I would like them to continue to work harder/get degrees to become more productive and increase their income that way, rather than subsidizing their living and removing the incentive to do so.

On the other hand, I would be perfectly happy paying for flu shots for a family of four that only makes $12,000/yr, because I agree in that situation it impossible to make ends meet.

For that matter, subsidizing the $46k/yr family wouldn't bother me nearly as much if I didn't think that health care was already driving the federal budget into oblivion, and the implicit marginal taxes imposed by such subsidies wasn't going to destroy the incentive for said family to get ahead. Far fewer people are going to take out a few loans and take night classes to get a degree if 60%-70% of the extra $25,000/yr expected from higher education is taken away via lost subsidies and taxes.

Again, I'd be perfectly okay with a system of publicly run providers which were capped at a certain percentage of GDP, to which anyone who didn't think they could afford private healthcare could go to. That way means testing isn't an implicit marginal tax, its a spending choice and doesn't discourage increasing one's income, but the poor /lower middle class still have real places to go for their healthcare needs.

Posted by: justin84 | March 8, 2010 11:27 AM | Report abuse

justin84,

I did take a look at your articles but I did not find them to be especially rich in persuasive hard data showing that preventative care does not reduce overall systemic costs in the health care system.

"I do know that some people who catch cancer at stage 2 fight it all the way to stage 4, and still succumb."

Of course that is the case for "some people" with some cancers. But for many others, early detection of many cancers and pre-cancerous conditions leads to a rapid and low cost solution. With a simple visual examination, a physician can identify a tiny pre-cancerous spot on the skin, zap it with a squirt of liquid nitrogen, and very likely prevent a case of skin cancer, as just one of many examples.

Yes, most annual check-ups result in a clean bill of health, but sooner or later in life, virtually everyone will have an annual examination that will turn up an area of concern that can be easily addressed, thanks to the early detection. The small cost of annual examinations that promote wellness and enable early detection makes sense for every indivdual (as you concede), and it makes equally good sense in the aggregate when we all contribute to a risk pool.

"You or your employer is paying extra for the cost of the wellness and preventation coverage."

Saying this again and again does not make it so. Of course, a reasonably comprehensive plan that includes coverage for routine exams is more expensive than a catastrophic coverage plan. But that is not the difference I am describing.

The difference is that the insurer waives the small co-pay, and the patient co-insurance contribution on those cheap routine examinations, tests, and preventative vaccinations, because it is in the insurer's financial interest to pay that small additional amount for those kinds of preventative procedures. The patient therefore has an incentive to seek inexpensive care that promotes the prevention of the development of serious and costly conditions. I don't see such wellness strategies as providing "gold plated" health care to the the uninsured at all.

I am simply saying that modest investments in wellness and prevention, whether in the form of encouraging better diet and exercise, or annual visits to a primary care physician for routine physical examinations, make good public policy and will ultimately help lower the costs of treatment for preventable illness and disease.

I think that the arguments here have become circular, so you and bgmma50 may take the last word.

Posted by: Patrick_M | March 8, 2010 12:05 PM | Report abuse

"To deny all low income people access to health care unless and until their conditions become catastrophic makes no sense. "

Which is another mischaracterization of what I said. Or did you just skip over the part where I said that the children are probably already covered by state child health insurance.

I hereby incorporate in full the excellent analyis of justin84 at 11:27.

Posted by: bgmma50 | March 8, 2010 1:52 PM | Report abuse

"Point me to a single racial reference is my comments."

If, by the use of the term "welfare queen", and falsly attributing it to me, you were not attempting to invoke the stereotype that all Republicans think that urban dwelling black women have 6 kids and systematically rip off the welfare system, then I revise my remarks as follows:

You have a really bad habit of mischaracterizing the things I say, and I would like to make it clear that the term "welfare queen" is one that Patrick fabricated and that I never used.

Posted by: bgmma50 | March 8, 2010 1:59 PM | Report abuse

Patrick,

With regards to saving money through preventative care, there wasn't hard data in the abstracts of the articles. However, take these two lines from the NEJM article:

"Our analysis was restricted to the 599 articles (and 1500 ratios) published between 2000 and 2005 that properly discounted future costs and benefits. We classified 279 ratios as preventive because they refer to interventions designed to avert disease or injury."

and

"Our findings suggest that the broad generalizations made by many presidential candidates [regarding cost savings from preventative care - Justin] can be misleading. These statements convey the message that substantial resources can be saved through prevention. Although some preventive measures do save money, the vast majority reviewed in the health economics literature do not."

The study looked at 279 preventative care procedures from previous studies, and found that the 'vast majority' of these did not save money.

By the way, lots of preventative care isn't necessarily covered. My my health plan, I get a free annual checkup. However, if I needed to get a colonoscopy, that would be subject to the regular deductible and co-insurance of my high deductible health plan. I note that colon cancer screenings are one of the procedures which the NEJM authors note may actually save money.

I will grant you that from an individual insurer's perspective, waving a small co-pay on a preventative procedure may make financial sense relative to having the co-pay, although I stand by my statement that in terms of total costs, the evidence doesn't suggest that preventative medicine saves any significant amount of money. Bgmma and I were arguing from the perspective of the insurer not paying for routine care at all to fully paying for routine care. (more to follow)

Posted by: justin84 | March 8, 2010 3:14 PM | Report abuse

I don't think either bgmma or I oppose paying for preventative care for those with low income. If someone has to choose between food/housing and basic medical care, then I think he/she deserves help from society from a moral perspective, and we are rich enough to afford to help. My argument is not to abolish Medicaid and leave the poor to fend for themselves - I'm against subsidizing comprehensive health care for the middle class. When it comes to the middle class, I am in favor of protecting them from medical bankruptcy, and so I am completely okay with universal catastrophic healthcare in many forms. Where it becomes too much for me is when the household's choice is between a second iPod and flu shots - in that case I think we should leave the choice to the household.

I do admit that preventative medicine makes sense for nearly everyone from a health perspective, but just because it is my view that people are better off doing something doesn't mean that I want society to pay for them to do it, or force them to do it. I don't want to pay so that tax dollars fund retirement accounts for the middle class, even though saving for retirement is a good idea. Nor do I want to pay to support free fruits and vegetables for the middle class, even though better diet lowers healthcare costs. Once we have helped the least well off, I would prefer to let people make their own decisions on personal finance and healthcare, and live with the outcomes of those decisions, right or wrong - especially since paying for all of the 'right' choices will probably be unaffordable in the long run.

Posted by: justin84 | March 8, 2010 3:16 PM | Report abuse

There's something very discomforting about talking about abortion and its availability to certain social classes.

Especially if we haven't reached a point in which other influences that go into that decision have not yet been fully humanized.

And, no, that doesn't just mean providing a social net, it also means supporting young women or certain social classes' choice to reproduce. Rather than the fears, cries, taunts and general lack of compassion often thrown at them.

Abortion should not be for social engineering. (Unfortunately, the statistics already show it is.)

Posted by: cprferry | March 9, 2010 10:49 AM | Report abuse

By the way, the real fear of abortion in the health care bill is that legitimizes it by an opt-out that makes abortion part of every person's base coverage and to which insurers can charge no less than a $1 for that coverage. It's not federal money (except those that are subsidized), but it's a federal acknowledgement that elective abortion is a basic health care procedure (which Hyde Amendment presupposes it's not) and regulates that insurers can charge a rate that by most estimates would actually result in a profit (many economists argue that an abortion-only premium would be $0 if not negative, well below the "no less than $1" that the Senate bill dictates. The result is all health insurers would offer abortion when only 46% presently do, and the only way not to be in the such a plan is to opt-out.

Posted by: cprferry | March 9, 2010 11:35 AM | Report abuse

The comments to this entry are closed.

 
 
RSS Feed
Subscribe to The Post

© 2010 The Washington Post Company