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1. On surface nothing wrong with what people think. However this is very thoughtful topic. Unfortunately, appearance of thoughtfulness is a political liability unless it can be reduced to a single line.
   Economically speaking, there are two ways that growth will return. One through more private saving and secondly through alteration in consumption pattern. The bill with its medicare cuts and more coverage for younger one is correct alteration from economic perspective. There are other alterations as well such as free preventives.
   Now moving onto the intuitive point of more for all implies rationing and deficit.
   Let me take that separately. The taxes on indoor tanning service or $20B on medical devices or high end insurance plans is not what is making this bill deficit neutral. What is making it neutral is calculation that there will be lesser hospital/EMR visits once everyone has insurance. It also means that medicare would not be dumped with underinsured and undertreated folks waiting to turn 65 and get coverage. This is an alteration of expenditure pattern, hoping ‘just in time’ expenditure will prevent serious things from happening later.
   The fly in the ointment here is that no one knows whether doing right things now will help later on. I am doing all things I know are correct from health point of view, yet I am not sure how I will turn out after 65. Good luck, if any of you has better idea about me. But Peter Orzag and Obama had to put the assumption and now we have to wait an watch.
   Now onto other aspect of rationing, which is PCP deficiency. Since this is an exercise in alteration, we will have surplus of specialist. There is funding for more PCPs and then there are nurse practitioner, willing to take up the slack. In fact Walmart vendor closed walk-in clinic for lack of volume.
   The intent of HCR is correct at deepest level. Prevention of gaming the system is what HHS has to ensure. What is unfortunate though is that we are facing increasing public health challenges in terms of diluting food nutrition, obesity, diabetes, childhood diseases, mental diseas etc. This tidal wave might just wash away all savings and give new political talking point but offer no solution.
   Let me ask this, if by spending more money on health we waste or ration, do we save money by not spending on health?

2. So I will say the painfully blatant comment that will be either shouted down, rationalized, minimized, or just plain ignored: More and more of the patients in medicaid are not invested in responsible health care choices, but just looking for quick fix solutions to long term problems, and being indigent in the first place to be in this insurance program does not enable them to efficiently problem solve to improve their physical and social well beings and make true progress. And I can say this without hesitation and with complete validation having been treating them for most of my career.
   So now, when this deform legislation unfortunately comes into full fruition, and all these people who do not have insurance, for whatever reasons but I will bet a sizeable portion who are just dollars above the poverty level now to have been denied medicaid prior, you think they will come into the health care pool and make an effort to learn how to swim, so to speak? No, just a further drain on the dwindling “pool” of lifeguards known as health care providers forced to attend to this population that will enforce rationing will take place. So many people out in the waters, without a vest, and no idea how to get to the side!
   Will someone else out there be a bit honest and direct and call it the way it is: our society is not interested in preventative care as a majority, and the current baby boomers, who George Carlin so accurately portrayed them in his 1996 show “Back in Town”, have no interest to try to change things for the better, and they will be the largest consumers of the health care buck these next 15-20 years. And consume they will, with no return for the others who are to just write the checks for this free ride they have grabbed onto these past 60 years! 60 years this generation has just taken and given back nothing of true value to this culture!!!
   Face it, the boomers will suck the system dry, the medicaid population will offer nothing to rejuvenate clinicians, and government will just stand behind said clinicians and just find new creative ways to screw things up even more.
   I wish I could get in Doc Brown’s DeLorean Time Machine and go to 2015 and meet some of these Deform Legislative advocates and see how you are doing.
   You’ll be hiding, denying, or plain just dying!
   Was it foreshadowing what is to come with this site being down this past week?

3. ” Note that there will still be the option to not accept new patients, or Medicaid, or Medicare,”
   Will there? When Medicare first passed it was codified in the law that doctors would be paid fairly. It took all of 5? years until that become an inconvenience and Congress changed the law and forced doctor to accept their fee schedule, now that they whipped out all other insurance for everyone over 65 it was a lot harder for doctors to walk away.
   When public failures insure 20% of the market it is easier to opt out and still have a practice. At minimum they expect 17 million more people into Medicaid and Medicare is suppose to grow substantially as well. Will there be enough private business left to support all the doctors that want to treat only private insureds?
   Will the government allow doctors that opt out of M&M to treat people in the government exchange? If you look at the history of coercion displayed by our federal government its not a wager I would take.
   ” 1) HCR also offers some provisions to increase the supply of physicians, especially in primary care. So relatively soon there will be new supply to offset.”
   A provision in a healthcare bill seldom makes it to reality. If half the provisions turned out the way the politicians claimed they would Medicare would cost 1/10th what it does now. Further most analysis I have seen says the additional claimed PCPs won’t even be enough to replace those retiring due to age let alone being feed up with HCR. I haven’t seen any analysis that shows a credible growth in total number of PCPs in the next 10 years. Unless there is mass bribery, forgiveness of loans, or change in law, nurse practitioners or PAs, we will have a decline in PCPs at the same time we have a massive increase in demand. If you know of anything that shows a different outcome I would love to see it.
   We are telling larger employers that now, more then ever, is the best time to open their own clinic and have primary care on staff so their members will have guaranteed access to what is going to be a very scarce resource.
   “Total volume of care will not decrease in 2014 or 2015. Of that, I am confident.”
   I’ll guarantee you that total volume not only doesn’t decrease but it will substantially increase. The ability to fill that capacity will be lacking so the service being delivered will be impacted in a negative way. I expect PCP to become more of a mill then it already is. Primary care post HCR will be like a trip to the DMV, 3-4 hours standing in line for a 5 minute service. I think tele-medicine both on shore and off shore will blast off as people looks for any means available to supply basic primary care. Wouldn’t surprise me if they allow pharmacists to treat and prescribe at the counter basic ailments.
   Everyone but the very rich are soon going to have either Medicaid or Medicaid like care.
   “Margalit’s hope that the over treated will be less so under reform, while the undertreated get better care, is a hope I share.”
   I think we all do, sadly most of you haven’t realized this bill did the exact opposite. If I want someone to stop receiving unnecessary care the last thing in the world any educated person would do is give them a low annual out of pocket max and pay for the care you want to get rid of at 100%. Once a person hits their OOP it cost them nothing to spend the rest of the year getting treatment they don’t need. Once a doctor, who just had their reimbursements cut 30% according to HCR, gets a patient over their OOP they can treat them like an ATM. No collecting from the patient just strait transfers from Gov Health. The divide between what liberals expect from this bill and the obvious counter outcomes amazes me. The move from 1 million lifetime limits to 5 million lifetime limits led to 5 million dollar claims. Most of which everyone agrees is wasted care. What exactly do you expect the care between 5 million and unlimited to produce? Do you really think now that care will be more efficient and necessary? The bill as passed does the exact opposite of everything you claim you hope it does, and in very obvious ways.
   “People who have a strong felt need for care will be the ones willing to put up with longer waits rather than not bother with scheduling or cancel the appointment.”
   You sure about this? In my experience need is pretty low on the list of who gets treatment. Top of the list is time. Those that don’t have a job don’t mind waiting all day. Those on Medicare don’t mind waiting all day. If I work 8-5 M-F, doctor hours, I don’t have 6 hours to take off to get a flu treated. If I am on public assistance I have all day. This is a common and well known problem, another example of how the bill fails to account for reality. It was written by politicians and academics who have no idea what they are talking about.
   “People who are poor enough to qualify for Medicaid are, well, poor.”
   This sounds like you haven’t read HCR as it pertains to exchanges and what plans are available to what people. Millions of people are going to lose their current small group private insurance and be forced onto Medicaid. If you look at the new income guidelines and who these people are I wouldn’t call them poor by any means. Lower middle class will be the new welfare under this HCR as written.
   “Are you talking about the decision an employer might make that it is in its financial interest to no longer offer insurance once HCR has taken effect?”
   I’m going to partake in a little hyperbole here. Did the millions of peasants under Moa and North Korea choose not to eat and this starve to death? I don’t think you and the general public grasp the degree to which HCR strips employers of their plans, its not a question of the business choosing to drop insurance it’s the fact that HCR makes 70% of current small business plans illegal and they are forced to drop them.
   There are tens of thousands of small employers that buy high deductible plans of $5000 then self fund back to low deductible, $250-$1000. The plan the employees have, the $250-$1000, is legal and meets all the requirements of acceptable coverage. Obama is an idiot though and the way they wrote the bill all that matters is the $5000 plan the companies buy to cap their exposure is illegal. 1/1/2014 all those plans are gone. To buy the exact same benefits from a carrier will increase their cost 20-30%, for the exact same benefits they had the night before. JD when you say employers make the decision do you really think that is a fair summary when Obama just increases your cost 30% with no added benefits because he is a moron? Where do you want the extra 30% to magically come from? So now that those employers are priced out of the market by Obama what happens to their employees….Medicaid.
   “But rationing was always there, as I pointed out and you didn’t deny.”
   I don’t think John denied that rationing exist now, he is saying it will increase as I also backed up in this comment. We will have a significant increase in rationing and it will effect the majority of the population instead of the current minority it does now. We will all share in the misery of public health instead of 20% of us. Ya progress and equality!

4. Healthcare is not a zero-sum game. Increases in one area of healthcare spending (ie, expanded coverage) do not have to be offset by decreases in other areas of healthcare spending. There are other areas of the federal budget that can be reduced to limit overall growth in the federal budget. Reductions in the defense budget and agricultural subsidies easily come to mind.
   Rationing healthcare is nothing nnew. Payers ration healthcare everyday through the medical and formulary policies the implement.
   Rationing healthcare through arbitrary cuts in reimbursement leads to unintended consequences. A better approach is to provide incentives for higher quality care that is more cost-effective. Healthcare reform includes numerous initiatives that seek to do accomplish that.
   Most importantly, one of the richest nations in the world should not divide its citizens into two segments: those with access to the healthcare system by having insurance and those with severly limited access, if any, by not having insurance. We should set societal priorities to first take care of our health before fighting wars that are accomplishing very little or paying farmers to not grow crops in a world of so many starving people.
   Robert Kaminsky, MedSpan,
   Blog: http://medspanresearch.wordpress.com
   Website: http://medspanresearch.com

5. Oh, the employer has the only duty to decide what coverages you and your family Needs.So, I don’t know about you, but even though my employer pays a much much smaller share and the fact that his bottom line is all that matters. — Gary Lampman

   I’m not sure I understand what you are wanting to say. The employer has no “duty” to supply healthcare to anyone. There are a great many persons who are employed via contract vehicle that do not receive healthcare coverage from the employer. I’m not speaking of Unionized labor, I’m speaking more of the Form 1099 crowd.The concept of an employer paying for a percentage of an employees healthcare package was designed as a mechanism for attracting and retaining a talented workforce. Because of this it was called “benefits” package, as in, these are the “benefits” that come for working for XYZ corp. That by no means requires that you “take” the benefits package. What would you say if they attempted to make you elect their benefits? You would most likely attempt legal action against them, citing a “rights violation”. (Now, imagine the Federal Govt. threatening you with punitive measures should you decide to not elect a benefits package)Besides, if you are a salaried employee, you are an “exempt” employee. That means, in most cases, it is “at-will”. You do not have a contractual obligation to stay with XYZ corp and are free to quit whenever you wish. XYZ corp has no contractual obligation to keep you employed or even to provide you with any benefits. I doubt very seriously that you employer’s bottom line is all that matters, otherwise they wouldn’t be offering benefits packages to begin with. Those are notoriously expensive and difficult to operate. Also, they are what is known as a pure “cost center” in that they do not generate any revenue, they only consume it.If you don’t like the way you are being treated by your employer, and assuming you aren’t under contract with your employer, you have the option of finding another employer. One whose philosophy of workforce management might be more agreeable to you. Another option you have is to decline coverage through your employers group plan (or plans depending upon the size of your employer and the regions they service) and seek insurance yourself (self-insured) like the 1099 crowd. A third, and probably more difficult option to implement, is to seek employment in a European country. France especially, since their form of government and economics is heavily influenced by socialism. You would net less money, generally, and pay much larger taxes (in most instances upwards of 28%). But you would have access to free (as in you’ve already paid for it, even if you don’t use it, through heavy taxation) healthcare. You would also be given mandatory paid vacation.

6. Oh, the employer has the only duty to decide what coverages you and your family Needs.So, I don’t know about you, but even though my employer pays a much much smaller share and the fact that his bottom line is all that matters. Is evidence enough that employers are not good advocates for employees. Also,the fact that Health Insurance is employer based and lacking accountability to its members. Also stengthens the argument that contracts between insurance and providers leave members as prey for the Market.
   Oh,I know it will come with a price but at least I will know the rest of the population will be covered..

7. Nate,
   I don’t mean to say that no one will quit and blame reform. Of course, what people say may not correspond to the statistics so I won’t put much stock in individual pronouncements. Note that there will still be the option to not accept new patients, or Medicaid, or Medicare, so any doc who is unhappy with getting new folks or Medicaid or Medicare can just opt out. Yes, volume may go down, but why would any doc quit outright when they could see their old patients more or less as before and stop seeing any patients in programs they don’t like? Is the practice of medicine for private pay patients under reform so horrible that a doc would stop that as well, and go straight to retirement? I think this will almost never happen.
   But let’s agree that there will be some additional retirements due to reform that we can see in national statistics. To points in response to that. 1) HCR also offers some provisions to increase the supply of physicians, especially in primary care. So relatively soon there will be new supply to offset. 2) My statement shouldn’t have been that no doc will retire, but that the number of appointments won’t decline. That’s what matters more in terms of access to care. We like to say that docs are overburdened, and in some ways they are, but there is still slack in the system and some of that slack will be taken up through the increased demand for services after HCR. Broken appointments will be more often scooped up; newer physicians who don’t yet have a full complement of patients will find it easier to get them, etc. Total volume of care will not decrease in 2014 or 2015. Of that, I am confident. Beyond that, I wouldn’t make bets because part of the point of reform is to limit utilization of unnecessary care.
   Margalit’s hope that the overtreated will be less so under reform, while the undertreated get better care, is a hope I share. I have no idea the extent to which that will happen. People who have a strong felt need for care will be the ones willing to put up with longer waits rather than not bother with scheduling or cancel the appointment. But a stronger felt need doesn’t necessarily correlate with a stronger actual need. There are plenty of hypochondriacs and worry-worts out there.
   Nate, as for your point about Medicaid: hogwash. Medicaid is free. Even if you are “in” Medicaid are not forced to use it instead of paying cash, if you want to pay cash. People who are poor enough to qualify for Medicaid are, well, poor. Most of them will welcome it, and the few who don’t can continue to avoid the doctor or pay out of pocket.
   I also don’t see how anyone with private insurance will be “forced” into Medicaid. Are you talking about the decision an employer might make that it is in its financial interest to no longer offer insurance once HCR has taken effect? That is the employer’s decision. Employers who make that decision will still have to contribute to the employee’s health insurance, as you know, though there are differences for large vs. small employers, etc.
   Anyway, John Goodman’s argument was not about these kinds of transitions between plans. We can argue this stuff, but it isn’t what I was responding to. Re-read his points a)-d). He was looking at a higher overall demand due to reform (more insurance, better benefits…not worse benefits) without an increase in supply. And his point was that this will create rationing where before there was none. But rationing was always there, as I pointed out and you didn’t deny.

8. “But the supply of health care practitioners will not decline due to HCR.”
   jd are you really going to claim not a single doctor will retire becuase of HCR? There went your argument, now you can try to reword it and claim not many will retire thus the decline will be small but then you just ceded John’s point.
   “usually through the form of an allowed amount of the good to be consumed, though it can also take the form of price controls meant to curb supply or demand.”
   There are currently millions of uninsured that pay full prince for their healthcare. HCR will force these individuals into Medicaid which pays substantially less which will drastically reduce the care available.
   They are also rationing access to insurance, who will be allowed to have it and who won’t. They rationed access to MA out of existance…except in FL I can’t remember if that waiver stayed in the bill or not.
   If I am on private insurance and HCR forces me into Medicaid I wont have access to the same drugs and treatments I had under my private plan, your not going to call that rationing?

9. I believe I can honestly say that I don’t know a single soul who knows anything about health economics who thinks ObamaCare isn’t going to increase the deficit. — John C. Goodman

   According to a letter from the CBO to Senator Jeff Sessions:
   SourceThe passage of PPACA does both reduce the publicly held debt and increase the publicly held debt. Apparently, the provisions of PPACA that apply to the financial inflows and outflows of the H1 trust fund would act to reduce the federal deficit by (net) $132 billion over the 2010-2019 time period. However, provisions of PPACA as they pertain to the rest of the budget would result in a net increase to the federal deficit by $226 billion over the same time period. The difference is a net increase in federal deficit of $94 billion.Presumably we would need to cut some other budgetary line items or increase tax revenues (possibly a combination of both) to resolve this shortfall.

10. Other reasons for the increased costs, decreased quality, and unexpected deaths:
    http://huffpostfund.org/stories/2010/08/safety-overshadowed
    http://www.huffingtonpost.com/2010/08/04/fda-obama-digital-medical_n_670036.html

11. There’s a lot going on here, that seems hard to answer one part, some observations though:
    1. The history of congress cutting medicare has been documented, and shown that congress sticks with the cuts it promises. There is obviously the exception of the SGR, but that was not meant to save money anyways, and was flawed. If implemented it would drastically reduce income of doctors, versus the near zero reductions implemented by the PPACA. Here’s a summary of the CRS report that documents the history pretty thoroughly, http://www.cbpp.org/cms/index.cfm?fa=view&id=3022.
    2. The issue of limited supply of doctors is a good one, but it is not as if current people without insurance are not already using certain forms of medical care. Yes, more health insurance will push people towards more GPs, but that’s why the health bill has new subsidies for those that choose the GP route, as well as, increased funding for minorities to go to medical school, since that’s the group most likely to go toward GPs. Furthermore, this is an issue that has been created because of the massive amount of cash that can be found in specialized medicine. The way to resolve this issue is to create a more stream-lined process, better info-sharing, more interoperability, changing payment schedules to try and incentivize quality medicine, etc. Obviously the health bill is not the end-all-be-all, but the steps being taken can not just be thrown out because of misplaced fears of higher taxes, and a few more minutes waiting for a doctor.

12. Well, assuming the “haves” are currently over-treated in order to rack up more revenue, maybe with the addition of newly insured, there will be enough demand for proper treatment so there will be no need to over treat, and the same capacity can serve a larger number of users without harmful rationing.

13. Sick Care for the wealthy at the expense of Seniors and Middle Class.Why should a bunch of self serving Deadbeats decide what is best for the 30 million people. who’s opportunities out of reach! Furthermore a far greater burden on society has been festering for decades and the yahoo’s choose to keep digging our nation deeper into debt and denying Coverage to a population who can neither afford or are uninsurable. Oh how easy it is for some!

14. Inchoate said what I was going to say. To elaborate, adding millions won’t increase rationing, but it may change the form of rationing a bit.
    There are two ways to think about rationing:
    1) as a deliberate government control on utilization of some good, usually through the form of an allowed amount of the good to be consumed, though it can also take the form of price controls meant to curb supply or demand. This is what most people think of, and nothing in the bill, certainly not the mere fact that more people will be insured (the only reasons John cites) bring about this kind of rationing.
    2) Rationing is also used much more broadly in economics to refer to any system in which supply of a good is limited and a mechanism must be created to allocate the scarce good. Our current health care system is rationed in this sense, because we limit the supply of doctors and hospitals through various private and public means (licensing, med school enrollments, CON requirements, etc.). Price is often used as a mechanism to “ration” in this sense.
    John Goodman must have had the broader sense in mind. But the supply of health care practitioners will not decline due to HCR. Right now, limited slots are rationed by (a) high prices for the uninsured (they avoid recommended care that they would seek if it were more affordable), (b) waiting lists for higher demand providers and (c) waits or long drives for care in poorly supplied regions. Our average wait to access care is surprisingly long right now, and worse for primary care than many nations with universal health care.
    What is likely to change simply by virtue of the increase in coverage, is that out of pocket cost will be less of a factor and wait times will be more of a factor. The total number of provider visits will not decrease, and in fact it is very likely to increase if Massachusetts is any indication.
    Let’s be honest: the person who is worried about “more” rationing is an insured person who is really worried that those who previously were rationed out of care will now have a more equal footing to receive care and so will compete for the limited slots more and force the already insured person to wait a bit longer. It is a case of the “haves” wanting the “have nots” to get lost.

15. since healthcare is already rationed, PPACA may change how it is rationed but not introduce rationing.
    John G is a clever, enterprising ideologue with many an idea, and a manner less abrasive than Gingrich. Certainly has much more brainpower than most of what passes for conservative leadership in our benighted land. Unfortunately he is not above slumming in semantical ghettoes when it suits his purposes.

16. THE POINT
    Only “poll” that matters is at ballot box. In Missouri yesterday, voters told OWE-bama — you goofed.
    http://www.google.com/hostednews/ap/article/ALeqM5iMLrmlnxO4QRUYVZwQOUyMeXetSwD9HCSE2O0
    A reckoning is approaching for the slick-talking Harvard Law crowd. It will not be pleasant.

17. Not sure I understand your point John. After Harris asks the “public” the questions above and the “public” answers “Yes”, is Harris filling in the box with “No”?Are you saying the poll is a meaningless use of time because we all (or at least you) know the answers already? Could increasing medical costs (approaching 20% GDP) to the “middle class” without any intervention by government be a “tax”? And I’m guessing you’re one of the people appalled by the increases in the deficit due mainly to entitlements, like Medicare, and that you favor cuts to Medicare and/or more taxes to pay for it?