OP-ED

The Conservative Way Forward on Health Care

The landslide Republican victory, in taking the House and electing some strong conservatives to the Senate, can be interpreted as a mandate to rein in government spending, and specifically to repeal ObamaCare, as these issues were clearly behind the large turnout.  There is still a very real possibility the Supreme Court will find the “individual mandate” to buy private insurance unconstitutional.  If this provision is thrown out, it’s hard to see how the law survives, since the mandate is needed to finance it.

Now is an excellent time to construct a conservative alternative vision for true reform of our health care delivery system.  Since most current problems with the health care system stem from government, a conservative plan should seek to reduce its role.

It goes without saying that the Patient Protection and Affordable Care Act must be repealed since, like all the laws passed by this administration, it does precisely the opposite of what its name suggests.   By massively increasing the health care bureaucracy at the expense of actual providers of care, it will make care harder to access and more expensive.   Many physicians will take early retirement and the already great physician shortage will be exacerbated.

The law is too large and complex to waste time foraging for items to salvage.  There is a great risk of leaving behind hidden mandates and rules that will be harmful.  Better to scrap the whole thing.  With Democrat Senators running scared for their jobs in 2012, it is conceivable the Senate would also vote for repeal (Harry Reid notwithstanding).  But not even the most generous view of Barack Obama’s ideological flexibility has him signing a repeal bill, and a veto override is out of the question for now.

It may be possible, however, to enact affirmative measures that make ObamaCare irrelevant.  Here are some common sense, free market proposals, many of which were proposed and discussed, but ignored by the President and the Congressional leadership in the run-up to passage of ObamaCare.

1. Transfer the tax deduction for health care spending from employers to individuals. This would end the absurdity of purchasing health insurance at the “company store,” a practice that limits individual choice and liberty, nourishes a sense of dependency, and promotes overuse of care.  This policy, an accident of WW II wage and price controls, was the “original sin” in health care financing; doing away with it would empower consumers to shop for the best plan for their families, which will lower premiums.

2.  Remove barriers to the interstate sale of health insurance.   There is broad agreement on this proposition.  It would increase choice and competition between insurers and drive down premiums by effectively ending state mandates that drive them up.

3. Deregulate and allow greater contributions to Health Savings Accounts.  These fabulous tax shelters give individuals more control over their health spending, and, coupled with an inexpensive policy to cover catastrophic illness (i.e., true insurance), are all most people need.  By returning most health care purchasing decisions to consumers, spending will immediately be slowed and prices curbed.   This is the conservative, free market, already tested and proven way to “bend the cost curve down.”

4. Follow the recommendations of the bipartisan Breaux Commission and give Medicare beneficiaries a means-tested stipend to buy private insurance.  This solution came during the Clinton era but was too free-market to pass muster with Bill and Hillary.  With Medicare moments from insolvency, there should again be a bipartisan consensus to reform this behemoth.

5. Transfer (gradually) all Medicaid responsibility to the states.  Federal support for Medicaid allows much greater spending than would otherwise occur.  It forces frugal states to subsidize lavish coverage in New York, California, and elsewhere.  States should have complete freedom to organize their Medicaid systems along their own priorities, in exchange for losing, over perhaps five years, the federal subsidy.  This would encourage states to find innovative ways of providing health insurance for the poor, such as individual health accounts, or subsidies to buy private insurance.

The latter two points would allow the mammoth Center for Medicare and Medicaid Services to be mothballed, though Medicare could retain a role as insurer of last resort for those with pre-existing, expensive, chronic diseases.

6. Institute a “loser pays” system for medical malpractice to cut frivolous lawsuits.  The ability to launch a lawsuit (and this applies beyond medical malpractice) with minimal financial risk is the reason behind the explosion of malpractice litigation, with all the associated costs.  Tort reform at the federal level would require the Senate to override the trial lawyers’ veto, which could be a problem.  This reform should be pushed at the state level.

7. Finally, for true patient protection, let’s propose a constitutional amendment to guarantee the individual’s right to privately contract for medical care.  This will eliminate for all time the threat to the private practice of medicine and assure that, no matter what system is in place, patients will always be allowed to spend their own money on care.

The above points are clear, simple and practical solutions. They empower the individual and greatly reduce malignant government influence and unburden the taxpayer.  It is the conservative way forward on health care.

Richard Amerling, MD, is a nephrologist practicing in New York City.  He is an Associate Professor of clinical medicine at Albert Einstein College of Medicine in New York, and the Director of Outpatient Dialysis at the Beth Israel Medical Center.  Dr. Amerling studied medicine at the Catholic University of Louvain in Belgium, graduating cum laude in 1981.  He completed a medical residency at the New York Hospital Queens and a nephrology fellowship at the Hospital of the University of Pennsylvania.  He has written and lectured extensively on health care issues and is a Director of the Association of American Physicians and Surgeons. Dr. Amerling is the author of the Physicians’ Declaration of Independence (http://www.aapsonline.org/medicare/doi.htm).

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75 replies »

  1. “The PPACA OOP limits are much higher than in Switzerland.”
    Depends if your measuring the $ or the %. On a dollar basis you are right on a % basis I am correct.
    “You really believe that?”
    When your argument can’t stand up quack you resort to posting generalities no one can respond to? What part do you question? Rather people can sue insurance companies? It happens every day, or that people can change insurance companies, happens tens of thousands of times every first of the month. Thank you for the inteligent discourse.
    TTT if your going to post try to stick to facts, no one wants to wste their time reading your 1990 gripes.
    ” them using it to bump off people who had pre-existing conditions”
    This has been illegal for almopst two decades so you can shove that complaint not even addressing rather I was ok with it or not.
    “something called a lifetime coverage cap.”
    Let me educate you on insurance. Insurance is charging a premium to cover a risk. Most states require insurance companies have so much capital to cover claims, lets say 30% for argument sakes. What is 30% of infinity? It is also an infinit number. Now calculate a premium that is 120% of infinity divided by 12, how would you like to start paying that monthly?
    Lifetime maximums were a financial insrtrument needed to reserve and calculate risk, reinsurance and the operaiton of the policies. the rationing done by death panels, comparitive effectivness or anythng else has nothing to do with lifetime limits. Does your life insurance policy have no limit? How about your home, auto and every other type of insurance you have ever seen?
    If you don’t grasp the concept of freedom no sense me trying to explain it to you in a blog post. Communism will always be a comfortable home for people like you. If you want a government to dictate the terms and length of your life then move to such a country.

  2. Every private insurance company already has a “death panel.” I don’t know why Nate is okay with them using it to bump off people who had pre-existing conditions or who reached something called a lifetime coverage cap. I also don’t know why the deaths they’ve already caused and continue to cause are less disturbing than the deaths government might cause if it enacted policies that it won’t actually enact because they aren’t in the legislation, but I’m sure it would make a fascinating yarn.

  3. “I can change insurance companies within a matter of days in most cases and I can sue corporations when they do wrong.”
    Now that is funny. You really believe that? Oh well.

  4. LAUGHABLE
    How generous the OWEbama crew is — as long it is NOT their money.
    Always someone else’s fault. Ignore that Canadian provincial officials fly to the USA life-saving treatments. Ignore that OweBama role model Fidel has Harvard-trained surgeons fly in from Spain when he’s sick (got that, Fat Mike)?
    See you in court, OWEbama. Fight your INCOMPETENCE, with our dying breaths.

  5. LAUGHABLE
    Howe generous the OWEbama crew is — as long it is NOT their money.
    Always someone else’s fault. Ignore that Canadian provincial officials fly to the USA life-saving treatments. Ignore that OweBama role model Fidel has Harvard-trained surgeons fly in from Spain when he’s sick (got that, Fat Mike)?
    See you in court, OWEbama. Fight your INCOMPETENCE, with our dying breaths.

  6. “I can change insurance companies within a matter of days in most cases”
    Not in 36 states if you are already sick.
    “Paolo who is this strawman talking about lavish Medicaid benefits?”
    These are the exact words from the “conservative” plan by Richard Amerlang (see point 5 at the top).
    “Obamacare exacerbates this even more by capping OOP at artifically low amounts. Very anti-Swissish.”
    Wrong again. The PPACA OOP limits are much higher than in Switzerland.

  7. “I can change insurance companies within a matter of days in most cases”
    Not in 36 states if you are already sick.
    “Paolo who is this strawman talking about lavish Medicaid benefits?”
    These are the exact words from the “conservative” plan by Richard Amerlang (see point 5 at the top).
    “Obamacare exacerbates this even more by capping OOP at artifically low amounts. Very anti-Swissish.”
    Wrong again. The PPACA OOP limits are much higher than in Switzerland.

  8. I’m all for coping parts of Switzerland systems, for example we can start with people paying 30% of all healthcare out of pocket, that would solve all sorts of problems by its self. When our OOP spending went from 50% to 12% today has cauesd a large portion of our problems. Obamacare exacerbates this even more by capping OOP at artifically low amounts. Very anti-Swissish.
    Before that we can start with the French model of people paying their doctor then getting reimbursed, assignment of benefits was another montrosity we need to get rid of.

  9. Quack,
    I can change insurance companies within a matter of days in most cases and I can sue corporations when they do wrong. Neither option is available when it is the government.
    Paolo who is this strawman talking about lavish Medicaid benefits? Maybe you should have that conversation with them?
    Medicaid is adequatly funded the problem is waste and fraud. If the program was properly and efficently ran we could deliver all the care to all the people that need it and do it for less then we spend today. Just as Education is adequatly funded and Medicare is adequatly funded the problem is none of them are adequatly administered or designed.
    “And if you are truly concerned about spending/benefit restrictions in the exchanges, then look at places where these exchanges exist: Massachusetts, Switzerland, and the Netherlands (not the UK).”
    Which one of those have planned spending billions on Comparitive Effectiveness studies and programs? Your argument lacks relavance, when those systems are allocating billions to vague rationing programs with no oversight then lets discuss how they operate.
    PPACA does cap the tax deductiblity of certain care and make it more difficult to pre-tax other, sounds like a first step to me….

  10. It’s ironic that the same people who complain about Medicaid’s “lavish benefits” will then complain when someone they know doesn’t get some benefit through Medicaid. I guess it’s only lavish when it’s for somebody you don’t know. If you are truly concerned about ALL Medicaid beneficiaries getting adequate care, then support adequate funding for it. In Massachusetts, bariatric surgery is covered by Medicaid.
    And if you are truly concerned about the future of Medicaid, then either support equalizing Medicaid payments with Medicare (as suggested by Barry) or support the transferring of Medicaid members into the exchanges, both of which cost money.
    And if you are truly concerned about spending/benefit restrictions in the exchanges, then look at places where these exchanges exist: Massachusetts, Switzerland, and the Netherlands (not the UK). There is no upper limit to the benefits people can purchase with their own money. There is no limit in the PPACA either.

  11. Hmmm…so it is OK when an insurance company “plays God” but not when the government does? The government is accountable in some small way to the voters. The corporation is accountable only to its board and a few major stockholders. I’ll take the government, thank you.

  12. Here is a real world example to consider, lap band surgery. Medicaid won’t cover it, plans subject to Ohio State regualtion wont. The employee has tried everything, they medically can’t lose weight. If this was 2014 and they were no in the exchange and the exchange said it is not allowed and to protect against people paying for it themself they won’t cover complications or any care after someone has one then this person would have no way of getting the surgery.
    Since this group is about to be self funded we can step back and look at the big picture. They are on a fist full of meds because of their weight, they have a good support system, they follow care protocals, they are an ideal canidate to try it. Long term it makes economic sense to pay for the surgery. Its going to kill this years budget but that shouldn’t be the deciding factor. When government controls healthcare these decisions become financial not medical no matter how much medical justification they come up with to put behind it.

  13. The problem is not comparitive effectivness or even rationing. They are both needed. The problem is when an entity that is responsible for paying for 50% or 100% of care is the one undertaking these endeavers. When Waswhington is presented with a budget crisis and needs to save 100 billion would you trust your life with them making the right decision?
    When Medicare has been over budget for the past 40 years has washington attached fraud, abuse, and inefficnecy? No, they cut reimbursements for good care and bad care.
    When schools are short of money do they reduce excessive pensions or administrator salaries? No they increase class size or eliminate sports or put off buying new books.
    Liverpool Care Pathways was never written up as a law or voted on in the UK. It was developed by a single institution, Beurcrats saw that it could save money and expnaded it across the NHS system. The puiblic never had an opportunity to comment on let alone oppose the new policies.
    Now look what is bveing pushed here in the US;
    Government currently pays for 50% of care and as of 2014 is pushing that to 75-80%.
    Government already has the ability to dictate via public plans how care is delivered and even what care is allowed. When they take over private insurance via the exchanges they will have the ability to disctate to the entire system, opting out of Medicare and Medicaid will no longer get you out from under government direction. There will be no where else to do but underground and back alley medicine.
    The government is setting up panels and organizations that are not answerable or even transparent to the public to start determining what is effective.
    This is almost the exact same path that LCP took. People like you and rbar want to mock Palin and anyone that is concerned about the ability of these non accountable organization to come up with care mandates we don’t agree with and implement them across the system with no public scrutiny or input or option to opt out.
    What about the above is not true or a possibility? Why do we not have a right to be concerned this could happen here? When people attack us for wanting to discuss it with smear and troll labels shouldn’t that make us even more concerned?
    In 2014 what prevents the government from deciding the care you need is not covered and not allowed to be delivered by a provider accepting public payment, now 75% of all care?

  14. Nate, since I have hope for everybody, I will try to answer your questions.
    “Germany has a Fee for service system, if we pass a bill based on global reimbursements why would we be discussing the German model as a comparison?”
    The bill authorizes experimentation with global payments. It is not “based” on it. If you ask me, I have no objection to fee for service.
    Comparative Effectiveness – You wrote here many times about your work and how you help employees use generics instead of brand name meds. This is a form of comparative effectiveness. I don’t think you will object to using cheap drug therapy instead of expensive invasive procedures, if the outcomes are comparable. So you cannot be opposed to comparing effectiveness of various courses of treatments and all things being equal, pick the cheapest one.
    If you are talking about all that QALY stuff, I am as opposed to it as you are, if you indeed are. If memory serves, I think you agreed here with not having others pay for “excessive” measures at the end of life. So you are more CER oriented than I am.
    “When did I ever claim everything would end up just like the NHS?”
    Several lines above the question. Reread your comment.
    “I assume rbar and Margalit don’t want death panels in the US….you do agree they are bad don’t you? Why don’t you discuss how we prevent that instead of attacking anyone that ask the question?”
    From the sound of it, they must be bad, but I have no idea what they are because nobody proposed anything that sounds like execution tribunals anywhere and I read most of the law. Is it a bunch of people reviewing every admission to see if it would be cheaper to kill the patient than to treat him/her?
    How can we discuss prevention of monsters in the closet? What is it you would suggest in the form of prevention? Legislation stating that no hospital and no clinician shall withhold treatment from any person desirous of said treatment providing that said person has enough money to pay for the treatment and has no expectation that the health insurance carrier will foot the bill? Would you feel better if such legislation was passed? I would not.

  15. Nate – If you want to read a left-wing English paper, I suggest you read The Guardian. The Daily Mail and Telegraph are conservative. And if you are looking for stories about replacing the NHS “nightmare” with a US-style system I suggest you stay close to Upper Kentucky. You are not likely to get that opinion from any English paper or political party, left, center, or right.

  16. ” NHS style health care is not the only alternative to our current system.”
    Nice straw man Margalit. No one including me said it was. But when you pass a bill and start heading in a direction similar to one specific system then comparison to that system are valid. Germany has a Fee for service system, if we pass a bill based on global reimbursements why would we be discussing the German model as a comparison?
    What other countries have comparitive effectiveness bodies? What others systems besides NHS have systems in place that you would like to compare these changes to?
    ” it is not a realistic possibility in the US anyway.”
    Up until 1964 Medicare was not a realistic possiblity yet here it is, same for Medicaid. When was a 13 trillion national debt a realistic possibility? Yet we have one. That is the thing with liberals, what your promised is never what you get in the end. Liberals wont write a death panel bill, it will have a nice warm name and be wrapped in promises of better and cheaper care. 10 years later we will have Obame Care Pathyway and be wondering how the hell we got there.
    ” Nate is apparently not really sure whether he wants more cost effective care or not”
    I’m quit sure of what my clients and I want rbar, the difference is I actually deliver on it while the government some how manages to fail almost every time they try. Unlike people like you I know how to deliver more cost effective care and do it every day. We could do an even better job if Washington would stop screwing things up.
    “such as: everything government run will be like NHS)”
    Nice made up argument, what one would expect from a partisian that doesn’t know enough to actually debate the facts. When did I ever claim everything would end up just like the NHS? If you could read you would be able to see the reason I raise the questions now is so it doesn’t end up like NHS. The time to prevent our system ending up like NHS is before it happens. But liberals are incapable of having an honest discussion to facilitate this. You want to dismiss the possibility of LCP happening here as if there is some magical forcefield that stops it from crossing the ocean. Why are you liberals so afraid to discuss the facts?
    I assume rbar and Margalit don’t want death panels in the US….you do agree they are bad don’t you? Why don’t you discuss how we prevent that instead of attacking anyone that ask the question?
    What in the current regualtions prevent the same scenerio from playing out?
    ” Yet, the only place where I hear these nightmare scenarios on European “socialized” medicine is in the US right-wing media,”
    Paolo you must not travel or read much, Daily mail and Telegraph are both English papers, how can you claim the only place you hear about my hooror stories are from right wing US media when the links are left wing European? Perfect example of a liberal argument, no facts all propoganda. Who’s the troll, the person posting facts or the three liberals void of any argument or logic just making stuff up? Or maybe its your geography that is off, maybe you thought UK was Upper Kentucky?

  17. rbar – Amen.
    I travel a lot and have been to almost every developed country in Europe, Asia, and Australia. I have many work colleagues, friends, and even some family living in these places. The topic of health care comes up pretty often in conversation. Yet, the only place where I hear these nightmare scenarios on European “socialized” medicine is in the US right-wing media, where each little incident then gets repeated ad-nauseum by people who have never been outside the US and have no clue about what life is like in the UK, France, or Germany.
    The European health care systems (they are very different from each other) are far from perfect. The UK system gets frequently criticized by other Europeans. People complain all the time (as people do here) about problems, medical errors, waiting times, and other ways to improve their systems. Yet, I’ve never met a European or Australian (rich or poor, conservative or liberal) who wanted to adopt our system. Even the people who have come to the US for treatment (and I have known a few) are generally pretty happy with their guaranteed systems at home and the option to seek additional private treatment elsewhere (usually in their own country). As is the case everywhere, the rich usually get better treatment than the poor, but the poor don’t have to decide between medicine and bankruptcy.

  18. “How about the difference between a fact and pure fantasy?”
    O-bumbler is an expert at that — insulting SCOTUS, deceiving CEOs, angering the Medicare crowd.
    Which is why NO ONE WITH A BRAIN believes him. And he’s launched 10,000+ lawsuits. And Pelosi rejected, out of hand, his panel’s plan for defecit cuts.
    A one-termer, a lame duck.

  19. There are multiple horror stories to tell from Germany, Switzerland and the US. As soon as palliative care is considered, there is room for error (i.e. misdiagnosis of – or within the context of – a terminal condition). If the bar for palliative care (PC) is laid higher (i.e. you try to treat/examine near everything), you have fewer mistakes doing PC while treatment could have been possible (so I would not be surprised if GB spending much less on medical care has more such mistakes, and we have less).
    What most (lay)people are not aware of are the downsides/dangers (apart from cost) of overtreatment (nosokomial infections, bad outcomes of surgery, unwarranted aggressive treatment with poor patient comfort). We definitely have much, much more of this in the US; for example, our system kills or cripples many by doing way to many complex back surgeries. Nate is apparently not really sure whether he wants more cost effective care or not, or he wants money to be the sole decisionmaker (ignoring the fact that even with a single payor system or strong government option, privately paid care for the “100 k 1 week saving” chemo that he claims to be concerned about is entirely possible). I have given up on him, he is a partisan hack trying to dominate the discussion by pulling up anecdotes, pseudoarguments (such as: everything government run will be like NHS) or unprovable assertions (such as “when you come to me, I will give you policy X with deductible Y, entirely affordable”) from his rectum. Once you realize this pattern and consider all his invectives, a sane person would treat him as what he is: a troll.

  20. Nate, for the gazillionth time: NHS style health care is not the only alternative to our current system. Perhaps some are advocating for that type of system here, but I certainly don’t and it is not a realistic possibility in the US anyway.
    Do you have any horror stories from Switzerland or Germany or France?

  21. “He died within two weeks — only for a post-mortem examination to reveal that he died of pneumonia, not cancer — an illness which could have been treated with antibiotics.
    It is a shocking case. His widow Pat described his treatment as ‘barbaric’ and was this week awarded an £18,000 payout over her ordeal.”
    Only under a government system can your murder someone and it only cost you £18,000. Costing someone an extra day in the hospital in the US would cost you more then that with our malpratice system

  22. For those not familar with what Liverpool Care Pathway is you can see the Liberal definition here;
    http://en.wikipedia.org/wiki/Liverpool_Care_Pathway
    To see what happens when politicians and governments pass laws in matters they don’t understand and the consiquences it can have see these;
    http://www.dailymail.co.uk/debate/article-1220221/ROS-COWARD-If-proof-folly-doctors-playing-God-mans-barbaric-death.html
    http://www.telegraph.co.uk/health/healthnews/6127514/Sentenced-to-death-on-the-NHS.html
    http://www.tldm.org/News12/Britain%27sPathwayToEuthanasia.htm
    These are called facts Margalit, they have names, they have familes, and they had lives before people like you decided to play God.

  23. Margalit,
    NHS does exactly what I said now. For once, any liberal, please exaplin why if it is already happening in England we in America should not worry about it happening here. Just once, one of you have the inteligence to actually debate the facts and stop the snarky comments.

  24. “If my family wants to pull their money and buy me some medicine the government says is not cost effective they should not be allowed to prevent me from doing so with force or coercion. When government has taken over a majority of care provision it is only a matter of time before they ration care.”
    “rbar you don’t seem to understand the difference between a fact and something alleged.”
    How about the difference between a fact and pure fantasy?

  25. “There are many points that you don’t answer as well”
    Such as?
    “your attempts of defending the death panel smear while claiming to be concerned about HC cost control are impossible to maintain at the same time with a straight face.”
    How is this? Government has never succeded at controling cost, why do you believe only government can control cost with this histroical record? In America it is not the governments place to determine what care Americans can and can not buy. If my family wants to pull their money and buy me some medicine the government says is not cost effective they should not be allowed to prevent me from doing so with force or coercion. When government has taken over a majority of care provision it is only a matter of time before they ration care. We have seen this exact behavior when Medicare was passed guaranteeing providers fair payment then when the competition and options eliminated the repealled that portion.
    There is a reason liberals and people such as your self cower from a debate on death panels, you can’t win it. History has shown our government act in this manner and other countires have gone down the exact same road. That is why you dismiss the argument instead of even attempting to answer it.
    “but to just point out alleged mistakes”
    rbar you don’t seem to understand the difference between a fact and something alleged. It is not alleged they “lost” the historical temp data when outside scientist tired to peer review their work, its a fact. Its is not alleged the Russian claimate data was made up that has been proven. Its not alleged Soros funds a number of the most vocal AGW advocates. Again your intelectually bested so you attack the method and hide from the facts.
    I can buy a spell checker for my inferior spelling your stuck with your inferior thinking.

  26. DEATH PANELS
    Bwarney Fwrank, Chris “CountryWide Mortgage” Dodd, Fannie Mae, Freddie Mac.
    “I’m here from the government, and I’m here to help.” (Myself. So I can coast to retirement.)
    If O-Bumbler thinks he can sell his BS now — he needs to quit. Today.

  27. DEBT KILLS
    Ask Ireland and Greece. Duh.

    @Frank
    “While liberalism has BANKRUPTED Ireland and Greece, with the USA one click away, thanks to O-BUMBLER”
    Uh, no. The problems in the USA can be laid squarely at the feet of Reagan, Bush 1, Clinton, and Bush 2. Obama, for all that he is a big-business lackey, is trying to fix them (however half-heatedly and without being punitive to business people themselves, much to my dismay).

  28. Nate, I am not going to answer these absolutely stupid republican talking points. There are many points that you don’t answer as well, and your attempts of defending the death panel smear while claiming to be concerned about HC cost control are impossible to maintain at the same time with a straight face. With regards to “mistakes” in the peer review process that you mention – no human process is flawless, but to just point out alleged mistakes and claiming that it proves your point is exactly the trick used by debating creationists and holocaust deniers – Michael Shermer wrote an interesting book about that. Let’s face it, you are THCBs Joad Cressbeckler, with the differences of health insurance expertise but inferior spelling.

  29. Once again avoiding the hard questions,
    “It’s the same nonsensical argument that there are “interests” touting global warming – the opposite is the case (you can build a carreer by doubting manmade climate change with a poor scientific background/expertise, but the opposite isn’t true).”
    Simple question then who is getting Soros’ millions?
    Why every time I ask you a hard question do you run from it?
    I understand the peer review system very well, Unlike you I am also inteligent enough to know it is not infallible.
    Curious do you not know about the East Anglia emails or just like to pretend they don’t exist. I could point out 100 failures in peer review in an hour. Anyone that blindly beleives in peer review just blindly beleives. Not that you even know enough to debate AGW with me but care to explain how you peer review temp data when jones et all lost it? Made up Russian data points are peer reviewed how?
    I’m very aware of the anti AGW lobby and some of the bad science they peddle, it just doesn’t begin to measure up to the tax funded junk science AGW is putting out there.
    The same problem we have with AGW we have with healthcare, bad science and regualtion passed for political purposes. i.e. Kyoto treaty that was the most import treaty ever that accomplished nothing, no one meet their goals but some how us not signing it was the first step to then end of the world.

  30. @Frank
    “While liberalism has BANKRUPTED Ireland and Greece, with the USA one click away, thanks to O-BUMBLER”
    Uh, no. The problems in the USA can be laid squarely at the feet of Reagan, Bush 1, Clinton, and Bush 2. Obama, for all that he is a big-business lackey, is trying to fix them (however half-heatedly and without being punitive to business people themselves, much to my dismay).

  31. The problem with PPACA is that it is NOT liberal. It is conservative to the point of being fascist. People are being legally obliged to buy the insurance companies’ crappy, no-value-added products. The use of state power in the service of corporate power is a criterion of fascism. I despise the Democrats because they are conservatives, not liberals. They are certainly not social democrats like myself.
    A truly liberal solution would have been to nationalize/state-ize(?) the entire healthcare industry. An alternate would have been to regulate the industry like the utilities. Health care workers would become government employees on salary. We could then unionize to protect ourselves, collectively bargain, and strike when necessary.
    The assets of insurance companies, for-profit hospitals and for-profit clinics would be seized and put to use actually providing health care to people. Health care can then be rationed based upon need, not personal wealth (as it is rationed today).
    I write this in answer to the OP. PPACA is not a liberal policy. It is conservative to the point of fascist. Obamacare is just Romneycare write large.

  32. The whole point of conservatism is NOT to go forward.

    While liberalism has BANKRUPTED Ireland and Greece, with the USA one click away, thanks to O-BUMBLER

  33. FATAL FLAW
    ” ,, One of my influences in changing whom I associate with was seeing a PBS report on how the Swiss ..”
    .. are NOTHING like the USA. Like comparing O-bumbler with Jack Welch.
    Stupidest BS ever produced. T.R. Reid ought to be ashamed for being such a tool.

  34. “Pretty sure Florida has an open enrollment date for the self empoloyed end of summer which is guarantee issue. CT also has self employed GI. MI Has there’s. I’ll find another dozen for you.”
    FYI, there are exactly 14 states that have some type of guarantee issue mandate for the individual market. In some cases, it’s only for some individuals, or only for some period of time, or there is some other limitation. In 36 states there is no GI mandate whatsoever.

  35. Once again avoiding the hard questions,
    “It’s the same nonsensical argument that there are “interests” touting global warming – the opposite is the case (you can build a carreer by doubting manmade climate change with a poor scientific background/expertise, but the opposite isn’t true).”
    Simple question then who is getting Soros’ millions?
    Why every time I ask you a hard question do you run from it?
    I understand the peer review system very well, Unlike you I am also inteligent enough to know it is not infallible.
    Curious do you not know about the East Anglia emails or just like to pretend they don’t exist. I could point out 100 failures in peer review in an hour. Anyone that blindly beleives in peer review just blindly beleives. Not that you even know enough to debate AGW with me but care to explain how you peer review temp data when jones et all lost it? Made up Russian data points are peer reviewed how?
    I’m very aware of the anti AGW lobby and some of the bad science they peddle, it just doesn’t begin to measure up to the tax funded junk science AGW is putting out there.
    The same problem we have with AGW we have with healthcare, bad science and regualtion passed for political purposes. i.e. Kyoto treaty that was the most import treaty ever that accomplished nothing, no one meet their goals but some how us not signing it was the first step to then end of the world.
    Why don’t you stop changing the subject and answer for some of the ignorant statements you have made.
    How did Medicare benefit the 13% of seniors it was passed to help?
    Where does Soros money go if no one is getting paid to be pro AGW?

  36. Nate, your comments speak for themselves. You may know a lot about health insurance, but you have obviously no idea about science and the peer review process. The peer review process rewards new/dissenting insights IF they can be scientifically validated. Also, I am not sure if you are unaware of the massive interests lobbying against independent climate science, or if you just pretend to be unaware. From now on, I think that I will see any supposedly “factual” statements of yours in a different light.

  37. rbar when Soros is funding James Hansen what exactly do you call that? Hansen, Mann, all of them only have jobs becuase they push Global Warming. If you want published you better be pro global warming cause we have proof your work would be buried otherwise.

  38. Pretty sure Florida has an open enrollment date for the self empoloyed end of summer which is guarantee issue.
    CT also has self employed GI
    MI Has there’s. I’ll find another dozen for you.
    rbar I see you skip my specific example of how liberals have claimed to be helping people while doing the exact opposit, why is that? You seem to be running from the argument, how then “The best I can call this is intellectually dishonest”
    Democrats when they passed Medicare admitted they hoodwinked the public. Any honest review of the political rhetoric used to pass it compared to the actual bill pass show it was all a lie. How are these facts you avoid intellectually dishonest?
    The same scenerio played out in public education. The Democrats and their Union partners reap billions in personal gains while our children suffer.
    Same played out with public housing, Democrats got rich while generations of poor suffered.
    How do Liberals not gain power when the government nationalises 16% of the economy? Talk about intellectually dishonest. Do you have any idea how many union healthcare jobs they would control. Do you have any idea how many billions in campaign contributions they would kick back. I think it is IL or CA that is trying or has mandated that all visiting nurses must join the union and pay dues. This is all about power for the liberals.
    ” likely no gain in income ”
    Medicare was likly to only cost a few billion.
    PPACA is likly to save money. Funny how the sales job never makes it to reality. Might you likly see the number of physicians curtailed? Might you likly get fewer hours at the same pay under a government program? Might you likly
    ” It’s the same nonsensical argument that there are “interests” touting global warming ”
    So Al Gore hasn’t made millions selling Global warming? Your so full of it rbar. How could you be so clueless?
    ” the opposite is the case (you can build a carreer by doubting manmade climate change with a poor scientific background/expertise, but the opposite isn’t true).”
    Where do you think the money comes from to pay all the Scientist pushing Global Warming? Do you think they work for free? They get grants and jobs by publishing papers claiming global warming is caused by what ever spme special interest wants to attack. Special interest fund it to attack industry they don’t like. Government funds it as an excuse to increase or in the UN’s case charge new taxes.
    make up some more BS for us to laugh at. To think someone actually gave you a degree is scary.

  39. Nate, I believe I know your positions, and there is not much sense to continue arguing. But 2 things:
    “The difference is I want to help the 5-10 million people that really need help, liberals want to take over 2 trillion plus in GDP and dictate to everyone what is in their best interest. I want to care for people you just want the power.”
    The best I can call this is intellectually dishonest. It’s a typical conservative talking point when they try to discredit motive. I have no personal gain in power and – as a physician – likely no gain in income (probably rather a hit) from a strong government run alternative, and yet that’s what I stand for (although I think that the system could be greatly improved without that). It’s the same nonsensical argument that there are “interests” touting global warming – the opposite is the case (you can build a carreer by doubting manmade climate change with a poor scientific background/expertise, but the opposite isn’t true).
    When argue like this (same thing with your silly defense the nonsensical death panel demagogy), I really have to doubt that you have anyone elses interests in mind (other than yours that obviously depends on the insurance business).

  40. Neither party’s extremist positions really offer realistic solutions to the quagmire that is health care now. So why do we keep allowing this pendulum of extremist views to bash us into submission?
    There are moderate viewpoints that can embrace some of the logistical ideas each side offers. But, we aren’t dealing with people who want to negotiate. They just want to pontificate and eradicate.
    Just the kind of thinking for health care solutions (as thick as sarcasm can get!)

  41. To paraphrase Alan Grayson, the conservative plan for health care is: if you are poor, don’t get sick. If you do get sick, die quickly. I think that about sums it up.
    The means by which we provide food, clothing, shelter, hygiene, education, safety and health care for all are debatable. Whether or not we provide them is axiomatic.

  42. “It can be. Just not for a price that 99% of the population can afford.”
    Can 99% of the population afford SR22 rates? If you make the mistake of getting a DUI there is consiquences. With healthcare what percent of cost is lifestyle choices? Why do we expect someone else to pay for bad lifestyle choices?
    Can 99% of the population afford to drive and insure a BMW or Mercedes? Those are safer and better cars does everyone have a right to one? Of course not, why does everyone have a right to excessive healthcare?
    “In an unregulated market, new healthy members of society have no incentive to join existing risk pools (they would just join new cheaper pools consisting of only healthy members).”
    Paolo this just isn’t true. Spend a few years selling insurance and you will see the decision making us much more complex then that. If thi was true Anthem, United, and the Blues wouldn’t exist. In every market there are second tier carriers, they come and go. They will enter a market with low rates, buying business, not cut it and be gone 5 years later. Its usually the sick risk that takes a chance on new carriers. People look for service, network size, someone that pays claims right. People will pay more if they perceive one pool being better then another.
    “This is why unregulated individual insurance is unstable and why most people avoid it if they can.”
    Unstable by what definition? It is growing double digits year after year. Rapid member growth is seldom a sign of instability. Your complaint is the cost, the cost is people waiting until they are sick to buy insurance and the law allowing that. Before the elimination of pre-ex the market was very price stable, not until politicians started distorting the market was there problems.
    “In California, that is, but most states are the same in terms of no guaranteed-issue (they don’t have to take you).”
    Every state I am aware of has guarantee issue open enrollment periods were once a year the carrier needs to take anyone that applies, while expensive considering the issues these people have it is a charity hand out. Further almost every state I have worked in, couple dozen, have chamber or similar plans that allow the self employed to join on a guarantee issued basis.
    Now lets go back to what you actually said in your hybolic rant;
    “Unless you live in MA or NY, or are coming directly from COBRA (per federal law), the insurers are not required to sell you a policy.”
    You contracdict this your self in your second post. Now you add that high risk pools exist. There are also conditional enrollment required of HMOs like I said. I think we both agree you were incorrect in this statement.
    “People have been denied policies for something as simple as seasonal allergies or a single prescription drug.”
    Some states cap the rate you can charge a sick person compared to a healthy person, this artifically lowers an insurers ability to write slightly sick people. You can’t afford your entry level premium to be 2-3 times what a healthy person would acturially pay, none would sign up. If you can only charge a sick person 50% more then the healthiest to create a viable pool you need to start with the healthy then write up to the level of person who’s claims are 50% greater then the starting person. Some seasonal allerigy medications are very expensive. If the carrier was allowed to charge a fair price that represented the cost to them of that allergy medication they wouldn’t need to deny the person.
    “or a single prescription drug.”
    You seem like a more inteligent person then someone that would make an ignorant comment like this. A single drug will get you denied…really? You mean to tell me a carrier won’t write me an individual policy with a monthly premium of $300 if I am taking a single drug that cost $5000 per month. That is just wrong, there is no reason for that. Pretty stupid argument. When people get prescribed a high cost mediccation that is one of the big factors to drive people to shop for insurance that don’t have it. And you think this is a bad reflection of insruance companies?
    “If you are over 40, you are pretty much a walking pre-existing condition by their standards ”
    This is just a lie, look at KFF statistics on age band distribution of individual policies, plenty of people over 40 and even over 50 have individual coverage. Then look at the uninsured age bands and the over 40 set are not hurting for lack of access to insurance. If you make BS up in arguing with me I will hand you your backside. Political rhetoric doesn’t cut it.
    “However, it would be nearly impossible to change plans or insurers, because I am (gasp!) 50.”
    When was the last time you shopped? What carrier actually turned you down or is this all just conjecture on your part?

  43. “Not sure what studies you are talking about but they do cut cost without any doubt. Its beyound being able to argue.”
    The people who choose HSAs are a self selected group. We also do not know the unintended consequences. There are studies that show people will skip care they have to pay for out of pocket that may increase costs later. Also, HSAs, usually, still have an insurance component. As long as you have insurance n the mix providers can cost shift. Hence, if people want to have HSAs, I dont really have much objection, but until we have a real study with a more randomized population followed over a significant time period (I hate these studies that proclaim success after two years) I dont expect much savings from them. Lastly, it will take a huge cultural change and people dont change that quickly. We have some HSA penetration where I work. In my years of practice I have had maybe 5 ask what something costs.
    “Steve why would we want to tax productivity? If you want a nation and GDP to grow wouldn’t you want to remove any disincentive to earn and produce? Why not tax consumption?”
    My preference is for a consumption tax coupled with a large estate tax, but that is not on the table. Given that we tax income, I meant income above, I would prefer that we not distort market or give preferences with tax breaks for insurance or mortgages. I would also tax capital gains as ordinary income. If you look at capital gains revenue, capital gains rates and GDP together, you get a scattergram. There is little linkage other than temporary one year adjustments for tax purposes. The perfect storm of low income and capital gains rates gave us the worst post WWII recovery ever. It certainly isnt doing much now.
    Steve

  44. In other words, it only guarantees issuance of an individual policy if you are coming off of a *group* (i.e. *employer*-provided) plan and either were not offered COBRA or you did use COBRA and used it for the full time period. http://www.bioptron-zepter.com.pl It does also guarantee renew-ability of the plan you get under this guarantee, but doe NOT guarentee the ability to change to a different individual plan. An insurer can deny your application to change to a different plan/insurer. So until 2014, you can be stuck with the same plan you got when you left group coverage.

  45. Nate said “Nancy look up HIPAA then rewrite everyrthing you complained about. From your comment is sounds like your at least one if not two decades behind on your facts.”
    No, you are incorrect, I think you are thinking of the *group* coverage provisions in HIPAA regarding pre-existing conditions, etc. when you are moving to a new *group* plan. I am talking about *individual* plans, for the self-employed and others who do not have access to a government- or employer-provided plan.
    Per http://www.dol.gov/ebsa/faqs/faq_consumer_hipaa.html :
    “The law guarantees access to individual insurance policies and state high-risk pools for eligible individuals. ***They must meet all of the following criteria***:
    (1) Had coverage for at least 18 months, most recently in a *group* health plan, without a significant break;
    (2) Lost *group* coverage but not because of fraud or nonpayment of premiums;
    (3) Are not eligible for COBRA coverage; or if COBRA coverage was offered under Federal or state law, elected and exhausted it; and
    (4) Are not eligible for coverage under another group health plan, Medicare, or Medicaid; or have any other health insurance coverage.
    The opportunity to buy an individual policy is the same whether a person quits a job, was fired, or was laid off.”
    In other words, it only guarantees issuance of an individual policy if you are coming off of a *group* (i.e. *employer*-provided) plan and either were not offered COBRA or you did use COBRA and used it for the full time period. It does also guarantee renew-ability of the plan you get under this guarantee, but doe NOT guarentee the ability to change to a different individual plan. An insurer can deny your application to change to a different plan/insurer. So until 2014, you can be stuck with the same plan you got when you left group coverage.
    Trust me, I’ve been living with the individual market for almost a decade and know the ins and outs quite well. In California, that is, but most states are the same in terms of no guaranteed-issue (they don’t have to take you). States do have high-risk pools, but they have tended to have waiting lists and to have (not surprisingly) very high premiums for limited coverage. (Yes, the temporary high-risk pools created by the ACA have changed things a bit, but it’s only for people have been denied a policy and been w/o insurance for 6 months IIRC)
    I keep suggesting that anyone in Congress who voted against the ACA should give up their employer-provided insurance and see how they do in the individual market. No one seems to have taken me up on that (although I think a couple of new Congress critters said they will keep their existing policy rather than take the govt-provided plan).

  46. “Why is it you don’t beleive health Insurance can be sold to sick people like loans are given to people with poor credit and sick people are sold life insurance?”
    It can be. Just not for a price that 99% of the population can afford.
    “I didn’t realize we stopped having babies in this country.”
    In an unregulated market, new healthy members of society have no incentive to join existing risk pools (they would just join new cheaper pools consisting of only healthy members). Existing healthy members will also tend to leave the old pool for newer cheaper/healthier pools. Hence, old pools will eventually run out of healthy members and costs will spiral up. This is why unregulated individual insurance is unstable and why most people avoid it if they can.
    Only systems (like employer-based) that force new members into the older pool(s) are stable and don’t have this problem.

  47. rbar,
    “and one knows Palin’s reply about death panels, a statement that too few in the conservative camp felt necessary to disapprove.”
    Why would we disprove a true statement? Are you denying parts of the original and passed HCR resemble the beginnings of the liverpool panels?
    “Most progressives/liberals (and probably a majority of americans) feel that there also should be a progressive component to health insurance, i.e. that the better off subsidize health care for those who cannot afford it.”
    Then why have you never proposed or passed a program that actually does this? It is a lie you tell everything you want to pass something that does anything but help the poor. Why didn’t Medicare cover catostrophic illness or fully cover the 13% of the population that needed it? Instead the bill did the exact opposite. Why didn’t Obamacare lower cost instead of drastically increasing it? Every time you want to increase government you claim it is for the poor but you never help the poor.
    ” and also feels that someone with a million dollar RISK”
    I’ll give you the benefit of the doubt that you honestly misquoted me, I clearly said expected claims which is nothing like risk. Expected claims is just that, an acturial sound expectation of actual claims.
    “And we ALL have risks at least in the several 100 Ks: a diagnosis of cancer or an accident suffices.”
    Insurance premium is not based solely on risk, your leaving out probablity. Someone that has not been diagnosied with cancer can buy a cancer policy for a couple hundred a year that would pay 100K, its the probability of getting cancer that effects premium not the risk value.
    The difference is I want to help the 5-10 million people that really need help, liberals want to take over 2 trillion plus in GDP and dictate to everyone what is in their best interest. I want to care for people you just want the power.

  48. And let me add to rbar- conservatives also suck up benefits and protest the cost just like Nate did for Medicaid above. Lives saved isn’t his concern.
    Nate sells his product to companies and the filtering of old, sick & disabled is done by his clients in different ways. This might be giving him impression of his being able to manage the risk and thus the bewilderment’What are all rest talking about. All it takes is a $5K HDHP/HSA and there it goes.’

  49. RN,MPH what specifically about that comment do you disagree with? To this day and more so when it first started public housing was considered compassionate and a great idea. Would you argue public housing has not destroyed generations of poor? A lage portion of the public hosuing turned out to be more a modern day version of savery then a public good.
    The same arguments can be made about both Medicare and Medicaid. In many cases they have done far more harm then they have good, when you consider what could have been accomplished with the resources wasted on both programs it is immoral. You don’t conside 100 trillion of debt passed on to your children and grandchildren immoral?
    Why is it Liberals also shirk from a factual debate and resort to I can believe you give these people a voice attacks? Are you that afraid of having to support your ideology?
    BobbyG I see your doubly impressed. I’ll extend an olive branch and see if your at all interested in a factual discussion. Why is it you don’t beleive health Insurance can be sold to sick people like loans are given to people with poor credit and sick people are sold life insurance? If someone with multiple DUIs can buy autoinsurance why can’t we sell someone with allergies a health insurance policy?

  50. I believe – after reading Nate’s comments – that the whole problem boils down to risk sharing.
    Most conservatives want to share risk – i.e. have health insurance since they realize the risk and feel they can afford it – and a few really think that they may remain uninsured and will not have significant health care costs (at least not until they are eligible for medicare).
    Most progressives/liberals (and probably a majority of americans) feel that there also should be a progressive component to health insurance, i.e. that the better off subsidize health care for those who cannot afford it.
    Nate is (maybe intentionally) cryptic what kind of risk sharing he supports. As someone dedicated to bring down insurance costs for corporate clients (as far as I can remember some old posts of his), he should at least support the former. But then he throws in: “Are you claiming that America as a whole has hit a point of no return (?????) for poor health? If this is true you ignore the fact that all we have to do is limit the care we provide those super unhealthy to bring the cost back to affordable. Do we need to spend 100,000 on a drug to keep someobe alive an extra week?” and also feels that someone with a million dollar RISK (which does not equal actual future expenses, as the insured might be more healthy than expected or die prematurely). And we ALL have risks at least in the several 100 Ks: a diagnosis of cancer or an accident suffices.
    It’s just a simple fact that someone making 36K a year will not be able to cover this risk on his/her own. That’s why most if not all industrialized countries have a progressive component in their system, despite the fact that their health care is a lot cheaper. I assume that Nate would counter: well, this person is to buy a high deductible true risk insurance, maybe with the help of some kind of tax credit, plus a HSA. But are people in this income bracket able to feed this account, and will they try to “save” money by foregoing very reasonable, efficient care (e.g. taking antihypertensives)?
    That some treatments have marginal benefit at very high cost is a different issue that Obama wanted to begin addressing with comparative effectiveness research – and one knows Palin’s reply about death panels, a statement that too few in the conservative camp felt necessary to disapprove.
    To state the obvious, health care can be very expensive. So the question arises, who has to pay? The unfortunate few who get sick? The people able to afford insurance? Or society as a whole?

  51. Jeez… I know that THCB wants to represent all kinds of folks along the political spectrum, but the AAPS are really wingnuts.
    Just one little example, in their Statement of Principles (on their website), they state that Medicare and Medicaid are, in sum, “evil and participation in carrying out its provisions is, in our opinion, immoral.” And that’s one of their more reasonable positions.
    I’m disappointed that this well-respected blog is giving these folks pixels. They really don’t have anything, IMHO, to say that genuinely adds to the real conversation we need to have about our health care system.

  52. Well BobbyG I’ll put my lengthy, 20 years, experience in insurance risk against your credit risk any day. Seeing as how I successfuly gauge and price insurance risk every day and my clients are still in business I must be doing something right.
    To further deconstruct your lack of knowledge of insurance risk;
    ” sooner or later you run out of a sufficiently large stratum of low/no risk people”
    I didn’t realize we stopped having babies in this country. If our birthrate was to drop low enough I guess we could eventually get to a point where there was no healthy people but even that “theory” is ignorant of how insurance works. If you really did have a credit background you should be familiar with impaired risk. It applies in auto, life, credit, and health. There are insurance companies that do nothing but high risk policies. If the entire population was to be classified unhealthy that doesn’t inpair the ability to insure them at all, it only increases the premium to insure them, a very basic concept someone with any background in risk analysis would know.
    ” from whom to cherry-pick”
    I’ll call this one political ignorance instead of educational. Its a liberal fallacy that insureres cherry pick based on health. They cherry pick based on their ability to charge a premium sufficient to cover the risk. When law or regualtion prevents them from charging a premium sufficient to insure the risk they can’t insure it. I would love to write policies for people with expected claims in the millions that wait until they have the liability to insure becuase my premium would be millions plus 15%. Again something that someone with a credit risk background should know, how else do you do subprime loans?
    ” so that they can in the aggregate pick up the tab of those whose severe chronic and acute health risks (and subsequent episodes of bankruptingly expensive care) would “price them out.”
    Are you claiming that America as a whole has hit a point of no return for poor health? If this is true you ignore the fact that all we have to do is limit the care we provide those super unhealthy to bring the cost back to affordable. Do we need to spend 100,000 on a drug to keep someobe alive an extra week? Again this is not a structual short comming of an acturial system its a social failure to make tough decision.
    After the lesson you just took are you still amused?

  53. Nate, at least I know how to spell “actuarial” (and a number of other words you butcher). Moreover, I’ll put my lengthy experience as a former risk modeler (credit risk market)and knowledge of the principles of empirical risk vetting and forecasting up against yours any day of the week.
    The unsustainability comes from the fact that sooner or later you run out of a sufficiently large stratum of low/no risk people from whom to cherry-pick, so that they can in the aggregate pick up the tab of those whose severe chronic and acute health risks (and subsequent episodes of bankruptingly expensive care) would “price them out.”
    I love how you frequently drop by to patronizingly lecture others about how little they know about subject “x.” Very amusing.

  54. “the insurers are not required to sell you a policy.”
    Nancy look up HIPAA then rewrite everyrthing you complained about. From your comment is sounds like your at least one if not two decades behind on your facts.
    BobbyG I don’t think you know what acturial is. The system is impossible to fail because it charges a premium to cover the risk. As long as an acturial system is allowed to charge what the risk dictates in premium it will never fail. Its when you impose price constraints not derived from acturial logic that the system fails. The problem is clearly the priceing constraints not the actuial system. Further I would challenge you to even come up with an example of cherry picking from an acturial system.
    tycotoe of your imaginary 50 million, its never that high at any one time and many of those are uninsured for very short periods of time and chose not to take COBRA how many do you think really can’t afford insurance? The problem is bleeding heart liberals who always stick other people with the bill want a solution for 50 million people. 50 million people don’t need help. 5-10 million do. For once why don’t you actually address the problem instead of creating massive government programs that don’t solve anything.
    Medicare was based on the premise that the 13% of seniors who couldn’t afford a catostrpohic illness shoouldn’t lose everything if they get sick. Liberals being the morons they are passed Medicare that applied to all seniors and limited inpatient days so catostrophic illness still banbkrupted the 13%. On top of that the plan was so poorly designed that 13% has now risen to 19% of seniors.
    Let me correct your ignorant political view, the conservative narritve view is lets do something to actually help the 5-10 million that need it. The liberal narrative is lets F up a system that covers 300 million claiming we are helping 50 million but does nothing to actually improve their sitution. We’ll just make everything worse for everyone like we have since 1965.
    “Can anyone explain the right-wing obsession with allowing insurance to be sold across state lines?”
    Poorly thought out mandates that drive up the cost of essential care with little to no benefit. People want insurance they can afford, if you offered them a policy minus mandates like fertility treatment, chiro, or holistic medicine, that would cost 10-15% less they would take it. Unfortunetly that is illegal in most states if your selling a fully insured plan.
    “Without a provider network in each state, they’re not competitive.”
    I can rent a network in any state with 10 minutes notice. I could probably buy your discount from 5 of the 10 contracts you hold within a day. You totally missed the point and how it would work.
    “1)Better to do away with the tax deduction entirely. We should tax total worth anyway.”
    Steve why would we want to tax productivity? If you want a nation and GDP to grow wouldn’t you want to remove any disincentive to earn and produce? Why not tax consumption?
    “3) Nope. There is no solid proof HSAs decrease costs. All existing studies suffer from selection bias. Mind you, I still like the idea, I just dont expect it to cut costs much if any.”
    Not sure what studies you are talking about but they do cut cost without any doubt. Its beyound being able to argue. If you look at people that have HSAs their behavior changes, not everyone that has one but more then enough to make them valuable. People with HSAs are more willing to switch pharmacies, we see them question their doctor more, they review their bills more. I was looking at an analysis yesterday for a firm that pushes cost savings ideas and something like 20% of total Rx cost could be reduced by changing pharmacies, cutting pills, using mail order, or using generic. 20% of 20% of your total cost is meaningful dollars for changes that have no impact on care. HSA members also use transparency tools more then non HSA members.

  55. “”Can anyone explain the right-wing obsession with allowing insurance to be sold across state lines?”
    I have been through this several times with Avik Roy. It is obvious that just selling across state lines will not reduce costs. Just like pcp, I will not cut Mutual of Utah a break when the come with 100 patients and want a discount. What they really want is to do away with state mandates, but, they dont want to directly engage states on the issue. They dont want to look like big government telling states what to do. As to Dr. Amerling’s plan.
    1)Better to do away with the tax deduction entirely. We should tax total worth anyway.
    2)Discussed. Dumb idea. Need to do away with mandates.
    3) Nope. There is no solid proof HSAs decrease costs. All existing studies suffer from selection bias. Mind you, I still like the idea, I just dont expect it to cut costs much if any.
    4)A voucher system. I doubt this is politically feasible after the right defended Medicare during the election. Most right of center pundits still support the higher paying Medicare Advantage.
    5)Ok by me. Let individual states deal with having their working poor unable to get health care.
    6) Some kind of reform is good. It is unclear to me that the feds can do much. I suspect it needs to be done at the state level.
    7) F*ing stupid.
    Steve

  56. “Can anyone explain the right-wing obsession with allowing insurance to be sold across state lines?”
    pcp – The right-wing phrase of “selling insurance across state lines” is just euphemism for “let insurers choose their legal jurisdiction.” Obviously, they will choose the jurisdiction of the state that is most deregulated.
    It would be more accurate to call this a federal plan to eliminate all state health insurance regulations, but that description probably doesn’t poll too well.

  57. I largely agree with tcoyote’s comments.
    I also think rbar’s approach is closer to the mark. The Medicaid program should be federalized and the payment rates equalized with Medicare’s. Some of the incremental cost at the federal level could be offset by shifting much of current federal spending for education to state responsibility and require states to cover a much higher share of spending for transportation projects, both road work and mass transit. In addition, we could get serious about combating Medicare and Medicaid fraud. We could start by taking 30 days to pay providers instead of the 14 days typical of the Medicare program today. Every provider with the authority to bill either of these programs should have a robust ID card that includes a picture and numeric as well as a biometric identifier and an actual address where the provider practices. Every bill should include the ID information for both the provider who performed the service, test or procedure, and the one who ordered it, if different. There’s a lot of sophisticated analytics technology out there today. We shouldn’t be hesitant to use it.
    Finally, anyone who proposes healthcare reforms lacks credibility if they don’t recommend provisions that will adversely affect them in terms of income, choice, accountability or cost of insurance. For my own part, I would be more than willing to give up the tax preference for employer provided health insurance. I have consistently advocated malpractice reform that would replace juries with health courts and would give doctors safe harbor protection from lawsuits when they follow evidence based standards. I support both comparative effectiveness and cost effectiveness research in making coverage and payment decisions. I would be willing to allow medical professionals to apply common sense in end of life situations in the absence of clear directions from me or my surrogate without having to worry about being sued because they didn’t “do everything.”
    The selfishness of every interest group from hospitals and doctors to insurers, drug and device manufacturers, lawyers, seniors and consumers generally just boggles my mind. The same is true with respect to federal and state finance more generally. Everyone wants the problem solved at someone else’s expense. The world doesn’t work that way folks.

  58. “Conservative Way Forward” is an oxymoron. The whole point of conservatism is NOT to go forward.

  59. This is the same ideology as sayng that we need to scrap Social Security and Medicare, eliminate public schools and get rid of the minimum wage , OSHA and clean air and water laws to make Amaerica great. I have ZERO, ZERO, ZERO belief that there would be any GOP plan if McCain won the election.I was also sick and tired of seeing not a damn thing come out of the GOP after the last attempt by the Clintons and do not wish to wait till I am on Medicare to see the next attempt.
    We have had GOP Senate candidates insult kids with Autism and their parents, run on platforms of dismantling health care and proposing that we use chickens as tender to pay for services like we did in the good old days.
    I was one of those people we used to call a “Compassionate Conservative” who really did wish to reform health care and finaly insure all Americans. My fellow GOPers viewed the uninsured as bums , ni**ers and beaners and had no interest in how many of the uninsured are working Americans. I was told that everyone has health care, “just go to the ER”. No young person needs that guvmint insurance and Medicare is the same as British and Canadian systems.
    This is all the same talking points and cheap AM radio station catch phrases you can get daily.
    One of my influences in changing whom I associate with was seeing a PBS report on how the Swiss, yes those capitalist Swiss create a private system which had Gov assistance for lower income people and still had competition, advanced medicine and technology available.
    http://www.pbs.org/wgbh/pages/frontline/sickaroundtheworld/
    A right wing leader in Switzerland in the interivew said that right after the Clinton attempt , the right and left wings of the Parties agreed on a basic principal of covering Swiss Citizens and figured out a way to make it work. He was stunned at the idea that a US citizen would go bankrupt do to health care and said that this is a completely foreign idea to the Swiss to become destititute because of illness.
    Yup, the GOP hates Obama so much that getting rid of preexisting clauses on my family and getting more of our premiums to cover us is just collateral damage in their war.
    Oh wait, PBS is part of the New World Order conspiracy with Obama as the Anti Christ, so Obamacare is part of the plan according to a lot of my right wing friends.
    Introduce bills to improve the bill and I will take you seriously.

  60. Can anyone explain the right-wing obsession with allowing insurance to be sold across state lines?
    I have negociated contracts with the 10 largest payers in my state. If anyone shows up with Mutual of Alaska, they’ll pay my full list price and try to get reimbursed from the insurer. Without a provider network in each state, they’re not competitive.

  61. Peter, it isn’t just a PCP shortage. It’s a shortage basically in the non-elective specialties that have 24/7 responsibilities- general surgery, cardiology, pulmonology, etc. High earning specialties where you control your own calendar/work schedule are going to be oversupplied, and the urgent need part of the physician world are going to be drastically undersupplied as the boomer docs retire. We’ll all have to remind ourselves to get sick Mon-Fri, 9-5. The rest of the time could be a little scary. . .
    Agree w/ rest of your comments.

  62. “The landslide Republican victory, in taking the House and electing some strong conservatives to the Senate, can be interpreted as a mandate to rein in government spending, and specifically to repeal ObamaCare, as these issues were clearly behind the large turnout.”
    Since the Repugs never did tell anyone what they would cut in government spending (that would really make a difference) and since about 50% of responders want “Obamacare” left alone or expanded, I doubt you could interpret much from the election other than Americans are angry and want their problems solved today at no cost to them. Oh, and seniors can be easily manipulated by fear politics.
    Dr. Amerling’s seven magical points to solve all our healthcare access and cost issues is typical of most “solutions” offered by doctors, which not surprisingly leaves their incomes intact.
    I would love to see #1 enacted immediately. Within a year Americans would storm the gates demanding government run single-pay – the real solution. Unleash all of us to the individual market, please.
    Why would transferring Medicaid to the states solve cost issues when the states now are getting crushed by Medicaid expenses? Allowing states to “innovate” really means allowing them to cut (more).
    Is there some secret out of state health plan that defies actuarial reality which we could all afford if only we had access to it?
    I would love to see how ballistic seniors go when they are given a “stipend” to buy private health insurance – let’s do the election over again with this one on the table.
    “and the already great physician shortage will be exacerbated.”
    No, there’s a PCP shortage, certainly not a specialist shortage. Care to give up some of your income Dr. Amerling to help provide more PCPs?
    “for true patient protection, let’s propose a constitutional amendment to guarantee the individual’s right to privately contract for medical care.”
    Yes, this one is just for patients, how generous of you Dr. Amerling. Is there nothing you wouldn’t sacrifice?
    Notice how none of these things actually attack what doctors and hospitals charge, or their billing methods.

  63. There ‘s a conservative narrative that we really don’t have a problem with the 50 million people who lack health insurance because they are either here illegally, or are voluntarily foregoing coverage even though they have the money to pay for it, or, if you did the 7 things, insurance costs would plummet and EVERYONE could afford to buy it. nancy is dead on right about the cost of individual insurance. it’s flat out unaffordable for tens of millions of people and HSA’s and this other stuff won’t fix it.
    It’s a little like the holocaust denial thing.
    States are cutting the hell out of provider payments with their current share of the costs. Take away the nearly $300 billion in federal subsidies, and you don’t have a Medicaid program. And you devastate the community health centers and academic health centers who are the safety net for the 50 million people and rely on Medicaid as, in many cases, their major payor. Amerling’s hospital would go broke! Maybe he could do dialysis in churches or his co-op’s common room or something. . .
    This all sounds great unless you’ve actually managed anything in the health system. We’re going to see a lot more Amerling type agendas (though I DO like loser pays malpractice reform). I’m sure he’s a capable and caring nephrologist, but unfortunately, his agenda taken together is lunacy, not a replacement for a deeply flawed health reform bill.
    rbar is a lot closer to a sensible alternative, except that paying decent rates for the merged Medicare/Medicaid program would cost maybe another $150-200 billion a year, mostly because of how low the current Medicaid rates are.
    What we’re trying to “fix” is almost as big as Germany and employs sixteen million people. Looks manageable from 50 thousand feet, or even at ground level . . . It isn’t.

  64. I think this is the first time I have seen the words “lavish” and “Medicaid” next to each other.
    Congratulations to the author for actually proposing a plan with enough detail to guarantee that nobody will support it.
    I prefer rbar’s plan.

  65. The for-profit actuarial risk based model for health insurance is unsustainable, it contains the seeds of its own destruction (they’re radpicly running out of people to cherry-pick). Moreover, the Karen bin al Ignagni AHIP crowd has by now proven that they cannot vet risk — both within policy rate setting in particular and in their swell recent adventures in the securities bubble markets more broadly.
    Moreover, they are not Your Friend — beneficent, altruistic entities out there just chomping at the bit to provide you with “affordable” and “effective” coverage were only the regulators to get out of the way. They exist to maximize shareholder value, period.

  66. Almost every time I read a Republican/conservative health care reform plan, it becomes clear that they do not understand what the individual insurance “market” is like for those who do not have insurance provided by an employer or the government.
    Unless you live in MA or NY, or are coming directly from COBRA (per federal law), the insurers are not required to sell you a policy. People have been denied policies for something as simple as seasonal allergies or a single prescription drug. It’s not just things like cancer or diabetes that get you nixed, it’s almost anything they want. Take a look sometime at leaked underwriting documents.
    If you are over 40, you are pretty much a walking pre-existing condition by their standards (hurt your elbow playing tennis? your knee while running? Sorry….).
    I am self-employed and fortunate to have insurance having gotten it right after my COBRA ended 10 years ago. However, it would be nearly impossible to change plans or insurers, because I am (gasp!) 50. And I am healthy, eat well, don’t smoke, at a healthy weight, exercise at least 5 times per week, and have only the occasional health issue. So I am holding my breath until 2014 when I can finally change to a different plan/insurer.
    That’s how much the individual market sucks. How are you going to fix that without (a)keeping the ban on denial for pre-existing conditions; and (b) getting everyone in the pool to prevent the otherwise inevitable adverse selection problem in the individual market and/or exchanges?

  67. I must say that this is the best, most substantial “conservative” plan to replace the current health care law that I’ve yet seen.
    It does not address, however, address the problem of those in our society who cannot, or choose not to, buy private health insurance.
    I’m curious to hear what Dr. Amerling would do with those patients who show up at the hospital door needing care.

  68. Actually, I also agree with #3 as well, sorta. In fact I’m probably gonna go that route next year. It’s worth a LOT more to me in OUR household tax bracket than it would be to someone at the low economic margin.
    But,
    “spending will immediately be slowed and prices curbed”
    Right. That is delusional.

  69. How about that:
    -Merge medicare and medicaid, pay sustainable rates with procedures and cognitive skills rated similarly, adjusted for level of expertise and risk (gradual adjustment).
    -financial incentives for a healthy lifestyle (or measurable efforts toward health such as BP control or weight loss)
    -scrap part D and pay for generics only (except for a handful of drugs of exceptional value), of course everything is possible as self pay
    -services covered based on comparative effectiveness research and expert consensus.
    -supplemental insurance and private insurance (with a voucher covering the cost for the medicare cost for enrollee) possible for everyone, but cherrypicking (weeding out of preexisting conditions) not permitted.
    -malpractice reform: physician error in judgment is safe from litigation, while actual negligence (e.g. not reacting to actual exam result) is not. Two independent experts per case, court appointed.

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