Countdown to Extinction: The 2016 Presidential Election

[drogulus]

It might make sense for you to audit a course on public finance at a local community college.

     I'm not sure I could do any good. If they wouldn't listen to the economists who know this stuff I doubt they'd listen to me.

     
     From the wikipedia on public finance:

    "The main objective of taxation is raising revenue."

     You can't recover from that.

[Todd]

     I'm not sure I could do any good. If they wouldn't listen to the economists who know this stuff I doubt they'd listen to me.

Right.

[Todd]

Bloomberg reports Bloomberg won't run.

[Madiel]

I always get fascinated when people talk about things like socialisation of healthcare without outlining in detail why that would be bad.

There's so much ideology about government good or government bad without considering the specific subject matter. To me, general healthcare is a perfect example of a service that is more effectively provided centrally, rather than requiring each individual to purchase their own doctors and hospitals and treatment.

People proudly declare how the USA has fantastic healthcare, and it absolutely does but only for those who can afford to access it. And need for health services is random, it doesn't correlate to ability to pay for health services.

When people basically don't want government in anything, it's easy to point out things like roads, fire departments, sewage pipes and other infrastructure where it clearly makes sense to provide the service on a collective basis. I would put a large amount of healthcare in the same category.

[Brahmsian]

I always get fascinated when people talk about things like socialisation of healthcare without outlining in detail why that would be bad.

There's so much ideology about government good or government bad without considering the specific subject matter. To me, general healthcare is a perfect example of a service that is more effectively provided centrally, rather than requiring each individual to purchase their own doctors and hospitals and treatment.

People proudly declare how the USA has fantastic healthcare, and it absolutely does but only for those who can afford to access it. And need for health services is random, it doesn't correlate to ability to pay for health services.

When people basically don't want government in anything, it's easy to point out things like roads, fire departments, sewage pipes and other infrastructure where it clearly makes sense to provide the service on a collective basis. I would put a large amount of healthcare in the same category.

Amen! 

[(poco) Sforzando]

I always get fascinated when people talk about things like socialisation of healthcare without outlining in detail why that would be bad.

There's so much ideology about government good or government bad without considering the specific subject matter. To me, general healthcare is a perfect example of a service that is more effectively provided centrally, rather than requiring each individual to purchase their own doctors and hospitals and treatment.

People proudly declare how the USA has fantastic healthcare, and it absolutely does but only for those who can afford to access it. And need for health services is random, it doesn't correlate to ability to pay for health services.

Testimonial from a Republican who voted twice against Obama and then admitted the Affordable Care Act saved his life:
https://www.whitehouse.gov/blog/2016/03/03/brents-letter-president-you-saved-my-life

[Todd]

I always get fascinated when people talk about things like socialisation of healthcare without outlining in detail why that would be bad.

I'm always fascinated by the intellectual dishonesty of those who deny that many Democrats actively pursue socialization of healthcare.  This is almost entirely a phenomenon of the American left.  I have read, and heard, more than one person deny what Sanders proposes is the socialization of healthcare.  As if Medicare for all could be anything else.

Socialization of healthcare, as it would and perhaps will be practiced by the US federal government through expanding power in the insurance market, using Medicare and Medicaid as practical guides, will, by necessity, involve rationing.  It will also involve HHS using its monopsony power to pay prescribed rates for defined goods and services, which may be below the standard price healthcare delivery firms or private practitioners charge, and it maybe even below cost.  This is done to force certain procedures or products to no longer be used.  This is done today.  Another aspect of the socialization of healthcare in the US has to do with the strictly clerical side.  HHS is phasing in mandates to use ICD-10 coding standards for billing purposes, and if healthcare providers do not comply, they do not get paid.  (This has been proposed for years, but is only now rolling out.  It is independent of, but coincidental with, the ACA roll-out.  I've been reading about it since the early-90s; I'm somewhat surprised it is happening now, though I know for certain it will take longer than predicted.)  Now, some may cheer this development, and say its about time that record keeping becomes standardized, but there is an immediate negative impact to smaller providers, who cannot afford specialized staff for coding, even though such staff members do not get paid an exorbitant amount on average, and there is an outsize impact to smaller communities.  These changes will also require investment in IT infrastructure and greater reliance on digital records, with the security concerns that brings up.  So, to put it briefly, the government will use monopsony power to achieve desired prices, decrease or eliminate certain practices, both of which are forms of rationing, and also uses its mandate power to force other, non-healthcare delivery activities to take place.  Single payer coverage would exacerbate these practical concerns.  Some people think these would be bad things, others think they would be good things.

Now none of this is to say that private insurance does not impose rationing of its own, because it does.  However, in terms of reimbursement and services provided, private companies are often, but not always, more flexible, and they do not have the power to mandate, at least to larger healthcare providers.  There is less of an imbalance of power.

One other development, also underway, is that with ever greater government involvement on the insurance side comes the emergence of ever larger corporations and not-for-profit entities on the delivery side.  This, in theory, would allow for economies of scale (one of the most misused economic concepts ever outside of manufacturing and only applicable here in terms of purchasing power) and should make standardization of record keeping and service delivery easier, but I know for certain with one gigantic healthcare delivery firm, well know for its efficiency, that is not entirely the case. 

Now perhaps a purely market based solution would be better, but evidence shows that not to be the case.  Pre-existing conditions are excluded, some insurers exit markets entirely, and so forth.  But a better answer may be something along the lines of allowing individuals the option to self-insure (usually the young and indestructible) or to be able to choose among a variety of plans that meet certain coverage and premium mixes that are more palatable rather than being forced to use a government mandated plan.  And then there are the lies that were told about how ACA would work – people could keep their plans, their doctors, etc, when that was never the case – and that leads one to wonder about promises made about even more ambitious programs.

Personally, I'm not wedded to any particular arrangement.  I have little faith that the US government will or could deliver health insurance efficiently (nor would I want it to) – and its record of healthcare delivery is poor – but I doubt it could be much worse than the private market, with its market failures.  I'm mostly disappointed in the lack of imagination of business leaders and moderate Republicans in using legislative momentum to extract concessions on unrelated business regulations and using this as an opportunity to remove one employee related financial burden for employers, which would have the great benefit of making US labor markets even more flexible.  And workers themselves would benefit by no longer, or at least less probably, being stuck in jobs for health insurance.  But without concessions, Republicans should do everything in their power to block or destroy additional plans for universal coverage.

[Que]

"Socialization" ? That is a rather odd term...

You mean designing it as a (partly) collective arrangement (like in may European countries) or providing it as a public service (NHS in the UK)?

In the Netherlands we have "hybrid" system. Basic health care is mandatory for both sides, so you have to have an insurance and the (private) insurance company has to accept you. Anything outside of the "basic" package is left to the free market. Any unequal distribution of "bad" risks between the insurance companies (clients that elderly, or have a permanent condition) are "equalized" between the companies trough an special equalization fund. People with a low income receive a tax benefit to help pay for the insurance costs.

The system seems to work pretty well....

What doesn't work well are the privatized hospitals: inefficient and poorly managed.

Q

[Madiel]

There is less of an imbalance of power.

Well, you're focusing on the power balance between the private companies and the government. I'm focusing on the power balance between the private companies and the people who actually need healthcare.

Healthcare as a product is particularly ill-suited to market forces because it's a product that you most need when you as an individual are not in a position to bargain. And that's the thing that utterly baffles me about the US system. I've got no problem with private health insurance for elective surgery, or for getting your choice of doctor, or maybe for getting something done faster, but when push comes to shove and it's basically a question of receive treatment or face death/permanent injury, I find it completely absurd that a business negotiation might have to take place in those circumstances. I find it horiffic that a person might have to deal with financial issues in an emergency room.

I also find it completely bizarre that one of the things that Americans have to consider when seeking employment or choosing a job is the health care plan that comes with the job. That's a clear sign that the health insurance market simply doesn't work for individuals. Individuals have to rely on companies to negotiate something for them. Why individuals relying on companies to negotiate is better than individuals relying on the government to negotiate for them, I've no idea. You're worried about the government wanting to keep costs down, but not a corporate employer wanting to keep costs down? I know which I'd be more comfortable with: the government doesn't have a profit motive.

Though credit where it's due. I love the television series Breaking Bad, and it could never have happened without the American healthcare system.

[Jo498]

Though credit where it's due. I love the television series Breaking Bad, and it could never have happened without the American healthcare system.

This wins the thread, or at least the healthcare portion. 

I admit that I have no idea what the US could do now to improve its healthcare system. I do not know how the structures there could be adapted to systems like in European countries (and there are several quite different ones here). But fact is that the US expends more on healthcare as GDP % than all or most other countries and it also has more people without adaequate (or any) health insurance than most comparable 1st world countries and despite the huge expenses a comparably low life expectancy (and a huge poor-rich gap in life expectancy, although this gap is also astoundingly big in e.g. Germany).
To claim that this situation should be anywhere near a local optimum and developing it more in direction of the European models would like make the situation worse strikes me as odd.

[drogulus]

I always get fascinated when people talk about things like socialisation of healthcare without outlining in detail why that would be bad.

     That's the point when you should stop being fascinated. The notion that people need to be informed about the degree of socialism in a particular plan so they can oppose or support it, or that they need to know how socialist they "are" if they do support it has no useful information in it. The details of the plan carry information you need. The other stuff is name calling, the kind of thing you say if you have nothing substantive to offer.

     

This wins the thread, or at least the healthcare portion. 

I admit that I have no idea what the US could do now to improve its healthcare system. I do not know how the structures there could be adapted to systems like in European countries (and there are several quite different ones here). But fact is that the US expends more on healthcare as GDP % than all or most other countries and it also has more people without adaequate (or any) health insurance than most comparable 1st world countries and despite the huge expenses a comparably low life expectancy (and a huge poor-rich gap in life expectancy, although this gap is also astoundingly big in e.g. Germany).
To claim that this situation should be anywhere near a local optimum and developing it more in direction of the European models would like make the situation worse strikes me as odd.

      There are two goals:

     1) Raise efficiency. The U.S. system is too expensive for the results it obtains. Much of that comes down to gouging of the insured, the rest due to the high costs of health care for the uninsured or underinsured. Does the "socialist" label tell you whether efficiency should be a goal?

     2) Cover everyone. In spite of efforts to the contrary ethical notions do enter into politics. My view is this has its strongest justification where what's ethical wins on efficiency, too. Is it more efficient to cover everyone? Yes, that's asked and answered. Does there remain an ethical justification strong enough to counter the imperative to provide health care for all?

     A Darwinian view is helpful. Human beings and human societies will evolve. We might, as the philosophers say ("in principle"), evolve back into dinosaurs, yet this doesn't happen. The future of societies and species always builds on the present. Time can't be run in reverse. The best we can do with social systems is pick out a feature from a past society and find a way to bring it back. Some features can't be brought back, like absolutist notions of private property that depended on the notion that the great bulk of the populace were disposable tools for the deserving view. We think differently now and private property ideas change with everything else.

     An example of private property, almost the founding notion among absolutists, is slavery. This is the paradigmatic version where those who seized slaves have absolute control over those who were seized. Property rights afficiandos today would prefer to call this "states rights" to make the principle go down easier with a little strategic forgetfulness, but its there in attenuated form as the Red States stand on principle to deny health care to their subjects. Are the states acting on behalf of property rights, as vessels for what dare not speak its name? A little history helps here, and more history helps more. Slavery and states rights were argued for via theology (what a surprise!). Yes, it's so, a transcendent being implacably hostile to human beings minus the elect, was, a book said, author of property rights! And you know historians say the slave faction had better theologians than the abolitionists! Oh yes, I'm sure they did.

     Some versions of property rights have ethical justification. I pay taxes, that could violate a property right if I thought the idea applied to money. I know why it doesn't so I have to build my case on other grounds if I decide my taxes are not what they should be. I do that. Now that our slaves are gone (or, that we're not slaves), we're going to have to circle the wagons to protect the rights we have left. No doubt states can be hungry beasts, particularly for property rights that cause suffering for many people who can't exercise them.

[Pat B]

Personally, I'm not wedded to any particular arrangement.  I have little faith that the US government will or could deliver health insurance efficiently (nor would I want it to) – and its record of healthcare delivery is poor – but I doubt it could be much worse than the private market, with its market failures.  I'm mostly disappointed in the lack of imagination of business leaders and moderate Republicans in using legislative momentum to extract concessions on unrelated business regulations and using this as an opportunity to remove one employee related financial burden for employers, which would have the great benefit of making US labor markets even more flexible.  And workers themselves would benefit by no longer, or at least less probably, being stuck in jobs for health insurance.  But without concessions, Republicans should do everything in their power to block or destroy additional plans for universal coverage.

It's always easy to argue for a vague platitude when your opponent has a specific policy, and that has clearly been the R's general strategy since 2010. They thought they'd hit Obama so hard that he'd lose to whoever they put up in 2012. Instead, they riled up their own base to the extent that they mostly can't ask for concessions; they are obligated to seek a full replacement with... something else.

I do credit Burr-Coburn-Hatch for producing an actual proposal, but I discredit them for its terribleness and utter political unviability. It was a stark reminder (to those who heard about it) of how much more difficult things get when you move from chanting "market-driven" to trying to write an actual policy.

Many of their moderates have been primaried or intimidated. No R wants to be known as the one who compromised with Obama.

[Pat B]

I also find it completely bizarre that one of the things that Americans have to consider when seeking employment or choosing a job is the health care plan that comes with the job. That's a clear sign that the health insurance market simply doesn't work for individuals. Individuals have to rely on companies to negotiate something for them. Why individuals relying on companies to negotiate is better than individuals relying on the government to negotiate for them, I've no idea. You're worried about the government wanting to keep costs down, but not a corporate employer wanting to keep costs down? I know which I'd be more comfortable with: the government doesn't have a profit motive.

Another implication is that bigger employers have more bargaining leverage than smaller employers. It is, in effect, a codified way of making it difficult to compete.

ETA: yet another problem is that for people with employer-provided insurance, the interested parties are:
1. Employee
2. Employer
3. Insurance company
4. Doctor or other provider
Which is probably too many, especially when the only party with a real interest in controlling costs (the employer) is completely detached from care/cost decisions.

[drogulus]

I do credit Burr-Coburn-Hatch for producing an actual proposal, but I discredit them for its terribleness and utter political unviability. It was a stark reminder (to those who heard about it) of how much more difficult things get when you move from chanting "market-driven" to trying to write an actual policy.

     I think you know what Repub alternatives are for. They're placeholders. They have a plan! If it was any good they wouldn't have it. When Obama adopted the Repub plan, real because it was filtered through the legislative process of Massachusetts, that left Repubs with nothing but the leavings, a plan suited to Outer Dingbatville where Repubs mentally reside these days. I haven't seen the plan, but I'll bet it's got lots of property rights in it.

     

[Todd]

You mean designing it as a (partly) collective arrangement (like in may European countries) or providing it as a public service (NHS in the UK)?

Sanders' vision, and the dream of a fair number of those on the American left, is for a federal monopsony on the insurance side: that is, the socialization of health insurance.  Basically, Medicare for all.  Other frameworks are available, including the type you describe and the broadly similar ACA.  But in the US system, no matter what, the federal government is already the largest single purchaser of healthcare, and it uses that fact, plus its ability to mandate practices under the law, to set reimbursement rates and to require defined practices in reimbursement (eg, electronic submission for reimbursement using ICD-10 coding standards), which has the unintended/intended (not sure which) effect of forcing some smaller healthcare providers out of business altogether or into larger healthcare delivery organizations.  The US is currently moving toward ever greater government involvement in healthcare right now, and it will not be reversed.

find it completely absurd that a business negotiation might have to take place in those circumstances.

The negotiation happens when purchasing insurance, not when receiving care.  If someone goes to the emergency room without insurance, they must be treated under federal law, and the squabbling about reimbursement comes later.  Billions are written off every year due to uninsured people receiving care this way, which means that the insured are already covering a portion of the uninsured indirectly.

You're worried about the government wanting to keep costs down, but not a corporate employer wanting to keep costs down? I know which I'd be more comfortable with: the government doesn't have a profit motive.

I'm concerned about both.  The difference is that I can switch employers or buy my own insurance.  I cannot switch governments.  Well, unless I move to a different country.  And while it is true that the government has no profit motive, various government agencies do have bureaucratic motivations (budgets, power) and inertia, which can create similar pressures. 

they are obligated to seek a full replacement with... something else.

That was a blunder both with the population of voters and with companies involved with healthcare.  There are now vested interests with billions at stake.  ACA will not die.  Sanders would run into the same reality were he to win and attempt to impose Medicare for all.

[drogulus]

     What Republicans' 'Demographic Death Spiral' Looks Like

Billions are written off every year due to uninsured people receiving care this way, which means that the insured are already covering a portion of the uninsured indirectly.

     Oh, if only there was a way to get the entitled to see their own stake in this process! I guess nobody is entitled to be smart about such things. You have to do the work, not let your property interests do it for you.

     I could act like Mr. Property and do the tunnel vision thing, kill all my neighbors goats or make sure they don't have any, but what if law, and a little of that nasty ethics shit say I have to pay anyway? Why does the world have to be so unfair to the entitled?

     In practical terms, as well as vindicate our sacred rights, why not instruct our party to come up with a way to not pay for health care for the unentitled? Wouldn't that make the issue clearer? If only we could get all the Elect to sing from the same hymnal, maybe we could win!

[Pat B]

That was a blunder both with the population of voters and with companies involved with healthcare.  There are now vested interests with billions at stake.  ACA will not die.  Sanders would run into the same reality were he to win and attempt to impose Medicare for all.

You're talking about (maybe among others) the insurance industry, right? Let's be clear then: that predated ACA by a long shot. Otherwise agree completely. They had a sweet deal in 2010, have a somewhat different but similarly sweet deal now, and will spend a whole bunch of money making sure legislators don't make things significantly worse for them.

[drogulus]

They had a sweet deal in 2010, have a somewhat different but similarly sweet deal now, and will spend a whole bunch of money making sure legislators don't make things significantly worse for them.

     No proper insurance company could do less. After all, we are not Communists.....until I hear otherwise from the Caller of Names.

     Everybody has to decide for themselves how much a sweet deal for insurance companies should be in a health plan that's supposed to be for everyone. Is it better to just pay the "we're not Communists" mafiosi fuck you money and shove them aside? Should we allow them to be part of the solution? Is it safe to do that? Is it sane to do that?

     What I'd do, I'd pay the walk away money and build a good system on available models. Something has to be done to put health care for everyone out of reach of the Red State scumbags. Red State nullification is doing real damage. So I say "you shat all over your own plan and did great harm to your own constituents to destroy the Kenyan Socialist (ah, the power of names!), now you're going to lose your right to do even more damage."

[Todd]

You're talking about (maybe among others) the insurance industry, right?

A variety of corporate interests have a stake in ACA.  Insurance companies get millions of new customers, some forced.  But that's not the only industry impacted.  M&A activity has accelerated in the past few years in other areas of healthcare, especially on the delivery side among larger hospitals and other providers (eg, HMOs).  Some of the requirements of ACA favor larger organizations that can consolidate administrative functions - eg, consolidating and managing electronic medical records, which is a massive undertaking.  I have more specific knowledge about the area where I live, where a good number of smaller providers have closed up shop while the largest providers are consolidating into basically four main providers, and a good portion of those smaller providers (mainly individual practitioners) now are part of the larger companies.  I suspect that trend will continue.  In the last few years, one enterprising delivery company specializing in treating Spanish-speaking Medicaid patients has gone from one main facility to eight facilities, plus mobile units, with contracts with multiple larger providers.  More medium and large entities on the delivery side (and the medical supply side, in certain areas) will also make sure to spend buckets full of money on lobbying since they stand to gain from the now current system. 

[Madiel]

The difference is that I can switch employers or buy my own insurance.  I cannot switch governments. 

What do you mean, you can't switch governments? This is an election thread.

And the notion that you would switch employers to switch health plans is exactly what I find so outrageously bizarre.