OP-ED

Paul Ryan Still Doesn’t Get It

Republican House Budget chief Paul Ryan still doesn’t get it. He blames Tuesday’s upset victory of Democrat Kathy Hochul over Republican Jane Corwin to represent New York’s 26th congressional district on Democratic scare tactics.

Hochul had focused like a laser on the Republican plan to turn Medicare into vouchers that would funnel the money to private health insurers. Republicans didn’t exactly take it lying down. The National Republican Congressional Committee poured over $400,000 into the race, and Karl Rove’s American Crossroads provided Corwin an additional $700,000 of support. But the money didn’t work. Even in this traditionally Republican district – represented in the past by such GOP notables as Jack Kemp and William Miller, both of whom would become vice presidential candidates – Hochul’s message hit home.

Ryan calls it “demagoguery,” accusing Hochul and her fellow Democrats of trying to “scare seniors into thinking that their current benefits are being affected.”

Scare tactics? Seniors have every right to be scared. His plan would eviscerate Medicare by privatizing it with vouchers that would fall further and further behind the rising cost of health insurance. And Ryan and the Republicans offer no means of slowing rising health-care costs. To the contrary, they want to repeal every cost-containment measure enacted in last year’s health-reform legislation. The inevitable result: More and more seniors would be priced out of the market for health care.

The Ryan plan has put Republicans in a corner. Some, like Massachusetts Senator Scott Brown and, briefly, presidential hopeful Newt Gingrich, are rejecting the plan altogether. Most, though, are holding on and holding their breath. After all, House Republicans approved it — and voters don’t especially like flip-floppers.

Senate Democrats will bring the Ryan plan for a vote Thursday in order to force Senate Republicans on the record. Watch closely.

Some GOP stalwarts say the Party must clarify its message – a sure sign of panic. Former Republican congressman Rick Lazio says the GOP “must do [a] better job explaining entitlements.”

It’s just possible the public knows exactly what entitlements are – and is getting a clear message about what Republicans are up to.

All this should give the White House and Democratic budget negotiators more confidence – and more bargaining leverage – to put tax cuts on the rich squarely on the table.

And, while they’re at it, turn Medicare into a “Medicare-for-all” system that forces doctors and hospitals to shift from costly tests, drugs, and procedures having little effect, to healthy outcomes.

Robert Reich served as the 22nd United States Secretary of Labor under President William Jefferson Clinton from 1992 to 1997. He shares many of his thoughts and columns at Robert Reich, where this post first appeared.

Livongo’s Post Ad Banner 728*90
Spread the love

99 replies »

  1. Just wish to say your article is as surprising. The clearness for your post is
    simply spectacular and that i could suppose you’re an expert on this subject.
    Fine with your permission allow me to grab your RSS feed to stay up to date with drawing close post.
    Thanks a million and please carry on the rewarding work.

  2. I mean great, particularly if you want to lower your blood pressure.
    As such, proper control in weight and intakes of sugar and cholesterol rich foods should be avoided.
    ” The goal here is to allow your forearm muscles to work ‘ but not to overdo it to the degree that your blood pressure spikes.

    Feel free to surf to my web page: how to lower blood pressure

  3. A basic conundrum: Finite resources, infinite demand.

    To shrink the pie, one must either:

    1) Ration access to patients – especially for non emergency and elective services. BTW, whoever plays the payer ( private insurance or the government ) will wear the black hat with the patient when they deny something based on lack of medical necessity. This includes as the Mad MD shares tough calls on who gets what, when and where. Can someone say, ” hospice”?

    2) Reduce unit cost reimbursement to providers – all payer legislation, global budgets, ( oh, and watch a generation of docs retire, fold their tents and our best and brightest go into something other than medicine ) Perhaps UK docs will come here as former Commonwealth docs flood to the UK to accept better levels of reimbursement than their own countries – creating huge nursing and provider shortages

    3) Reduce units consumed by patients through PCP directed medical homes, compliance based designs, clinical oversight, population health improvement and performance based remuneration for all. Must invert the pyramid to restore primary care.

    Having consulted and handled private and public health purchasing across the UK, Continental Europe and the Middle East for many SMEs and large multinationals, the private system is alive and well – everywhere. There is no getting around the perpetuation of a two-tiered system. It will always exist as long as someone is willing to pay for the ability to access care faster than a public system would otherwise accommodate.

  4. ” we can estimate what national health care expenditures will be next year, inefficiencies included.”

    That’s not good enough, government can’t raise taxes effective next month. If they are off 20% then where does the extra money come? What if we are mid recession where does it come from?

    Look at Medicare’s history of projections, if private insurance was half as bad as government at projecting cost they would all be out of business.

  5. Margalit –

    Even if Medicare were a single payer system that covered the entire population, it would not be any easier to accurately predict healthcare costs a year in advance than it is under the current system. If you had that model and tried to make it work within a fixed budget, what do you think would happen if the money ran out by the end of November? The answer is that there would be a supplemental appropriation because we’re not going to let people go without care just as we won’t let people die on the steps of the ER just because they’re uninsured and can’t pay.

    Canada imposes global budgets on hospitals but it rations care, especially for non-life threatening procedures and diagnostic testing. Moreover, a recent article in Health Affairs found that poor people who had complete access to care in Canada with no coinsurance required still had worse medical outcomes than middle income and wealthier people while they consumed more care in the process. So, aggressively and expensively addressing poverty as you would like still won’t produce equal medical outcomes just as throwing a lot of money at poor school districts in New Jersey as our State Supreme Court requires us to do doesn’t come close to equalizing education outcomes either.

    Regarding Medicare Advantage plans, PPACA is gradually phasing out the extra payments over the next several years. Humana, the 2nd largest MA insurer after United, is confident that it can continue to grow and prosper in the Medicare market while earning its target pretax profit margin of 5%. Several years ago, it developed a strategy it calls its “15% solution” which is intended to deliver the standard Medicare benefit package to seniors for 15% less cost than regular Medicare can do it. Strategies include less fraud than regular Medicare, better discharge planning and care coordination, better case management generally and more cost-effective provider networks.

    Finally, there are circumstances under which it is appropriate to pay different providers different rates for the same service, test or procedure. For example, even within the same group practice, a relatively new doctor is likely to be willing to charge less in order to build his practice and gain experience while a 20 or 30 year veteran will charge more.

    Also, even within a tax financed system like Germany’s, to calculate the cost of insuring a particular individual, the Central Fund will use as many as 80 separate factors to calculate the premium to be paid to the sickness fund or insurer that covers that person. People in the U.S. don’t want and wouldn’t trust a one size fits all system. We like to have choices here even if it costs a little more.

  6. So as a tax payer, I am supposed to pay more for each Medicare beneficiary to private corporations because…… ???
    We’re looking to cut Medicare expenses, but somehow now I have to pay for memberships in the Silver Sneakers club for active seniors? Does this have anything to do (again) with keeping the same percentage in profit, but from a larger amount?

  7. “If physicians are all going to be government contractors can we all look forward to public health center quality care or VA before it became a national scandal?”

    Why? Every physician that is not operating on a cash only model, which very few do, is currently a contractor with Medicare and with private insurers. Physicians treat members and the payer pays according to contract terms. Medicare has one contract with everybody (although actual fees vary) and private insurers have different contractual fees. The only difference would be that the doctor at Partners and the solo practitioner across the street would be paid the same amount for the same service. Is that a bad thing?
    I don’t see any public health centers or VA models being necessary as long as physicians are not employed by the government.

    As to employer self funded insurance (or not), from a consumer POV, there is no difference. I pay X number of dollars per month and the “system” takes care of all my medical expenditures. The high deductible plans, which you seem to favor, are more insurance-like, if the employer doesn’t fund the deductible, but since according to you, most do, we are back to prepaid.

    Barry, I agree that the lack of a fixed budget makes this an open-ended entitlement. But if we had Medicare for all, is there any reason not to have a fixed budget (a reasonable one)?
    The fact that variations in care exist is not necessarily a risk. We know they exist and we can calculate and project their effect. Unless there is some sort of new plague coming our way, we can estimate what national health care expenditures will be next year, inefficiencies included.

    Although I do agree with Dr. Emanuel on most things, I do not agree that small private practice, particularly for primary care, is either inefficient or incompetent. I actually think that primary care should be provided in the most disaggregated and independent form possible, so it maintains an alignment of interests with patients instead of whoever owns the medical complex.

  8. “It is prepaid medical services. There is really no risk involved in medical care if you look at it at a national level.”

    Margalit –

    That’s not true. Medicare is an open ended entitlement. Bills come and taxpayers pay them. It does not operate within a fixed budget determined in advance. Medicaid works similarly though both the federal and state governments share the cost. There is also plenty of risk even at the national level. Practice patterns vary enormously whether it’s managing patients with diabetes, heart disease or asthma. There are regional differences in determining under what circumstances to recommend back surgery, hip and knee replacement surgery, heart surgery, etc. Lots of care is either unnecessary, defensive in nature, money driven or an attempt to satisfy patient expectations. Total costs are growing faster than the economy and have been for a long time which is why the system is unsustainable. Even if Medicare were the single payer for the whole system, cost growth would still be unsustainable. Potential administrative savings, which are the single payer approach’s biggest advantage, are substantially overstated, in my opinion and would probably be more than offset by increased fraud in any case. Lower prices per service, test or procedure without a large commercial insurance sector to shift costs to would probably endanger the viability of much of the hospital sector. A single payer approach, according to Dr. Zeke Emanuel, would lock in most of the practice pattern inefficiencies of the current system and probably stifle innovation as well. It’s not the answer. Maybe the Vermont legislation will prove that for us eventually.

  9. ” Which contracts are easier to work with? Which entity allows you more autonomy and has less red tape?”

    You don’t work with Medicare, you do things the way they tell you or you go to jail or lose access to all their members.

    If physicians are all going to be government contractors can we all look forward to public health center quality care or VA before it became a national scandal?

    “What we call health insurance is not insurance. It is prepaid medical services.”

    Again Margalit, there is so much you don’t know. Again most private insurance is self funded, on those cases, which are the majority, the insurance doesn’t kick in until 50K, 100K, or 200K in claims on a single person. How is that prepaid medical services? Now when your genious president passed PPACA caping deductibles and OOP he has turned it into prepaid services, why did you vote for him again?

    ” all pretending to assess and manage risk, which only exists because we fragmented the pool into thousands of artificial sub-pools, is illogical. And expensive.”

    In this system you and Quack dream of, how do individuals pay for their hospital stays and large dollar care without insurance and pools?

  10. “I thought that the “private” version of Medicare, i.e. Medicare Advantage is even more expensive.”

    Do you try to be this obviolous to facts or do you really live under a rock? Have you never compared traditonal medicare benefits to Medicare Advantage? Hint, its cost more becuase you get more.

    Don’t vote because your ignorant of the basic knowledge you need to make an informed vote.

    What’s with you liberals and your apple to orange comparisons?

  11. “hatred of insurance, I assume you feel the same way about life insurance, auto insurance, homeowners insurance”

    What we call health insurance is not insurance. It is prepaid medical services.
    There is really no risk involved in medical care if you look at it at a national level. It’s an expenditure that can be estimated and budgeted just like other budget items (except wars).
    So eliminating all the little inner pools of insurance, all pretending to assess and manage risk, which only exists because we fragmented the pool into thousands of artificial sub-pools, is illogical. And expensive.
    The actual medical care is what it is, at least for now. The surrounding paper shuffling and data crunching and busywork can be eliminated.

    I don’t go as far as Dr. Vickstrom, and I don’t really think physicians should be civil servants, but they should be government contractors. If that sounds onerous, just remember that most physicians are already operating that way both for government contracts and private contracts. Which contracts are easier to work with? Which entity allows you more autonomy and has less red tape?

  12. ‘Until you can reconsile the fact single payor Medicare is more expensive then everything else you should refrain from voting.”

    Interesting. I thought that the “private” version of Medicare, i.e. Medicare Advantage is even more expensive.

    I wonder how expensive Medicare would be if it included all the healthy people currently paying into private insurance. What was the MA excess? 14%?

    Is this the new conservative idea of how to run a democracy “don’t vote because we know better”?

  13. “you don’t need health insurance to live, you need healthcare.”

    True, true. All the more reason to get rid of health insurance. Time to change the paradigm.

    “Health Insurance exist becuase healthcare is so expensive, health insurance didn’t make healthcare prohibitivly expensive. You can thank government for that.”

    Ultimately, we can thank supply and demand for that. Once again, I argue we should change the paradigm of supply and demand. Also health insurance does its part in jacking up the price of said health care.

    “You are still ignoring the fact that 80% of private healthinsurance is non profit so your argument based on profit motive is BS.”

    “Non-profit” in the way the Blues are? I suppose it depends upon what “is” is then…

    Nate, you say I don’t know what I’m talking about all day long, but the fact remains I’m a doctor. I deal with this junk all day, every day. Our “system” is failing. I comprehend that just fine.

  14. you don’t need health insurance to live, you need healthcare. Health Insurance exist becuase healthcare is so expensive, health insurance didn’t make healthcare prohibitivly expensive. You can thank government for that.

    You are still ignoring the fact that 80% of private healthinsurance is non profit so your argument based on profit motive is BS.

    These aren’t assumptions, your making wild and false claims apparently based on a complete lack of comprehension, instead of getting your facts straight you bury your head in the sand chanting falsehoods. Self funded plans don’t have profit motives and they are 50% of all private insurance. Next majority of the fully insured carriers are non profit so they also don’t support your argument.

  15. When you are arguing over assumptions, logical proof has nothing to do with the argument. The current medicopolitical reality is unsustainable and a failure. Time to create a new one.

    I don’t hate insurance, I just think it shouldn’t exist or should exist on a (really) non-profit model. And no, this doesn’t apply to other kinds of insurance. We don’t need them to live.

    AAMOF, I already live on a civil servant’s salary. I am one, and proud of it.

  16. At least you admit facts and reality have nothing to do with your thought process. Now if only we could take away people like you right to vote the rest of us would be ok.

    Curious though, this ilrational hatred of insurance, I assume you feel the same way about life insurance, auto insurance, homeowners insurance? They should all be non profit or not exist at all?

    And when is it you propose providers live on civil servant salaries? $50,000 a year and a pension.

  17. “If providers really think that insurers consume 30% of the premium dollar and provide no value added, there is nothing stopping them from assuming the insurance function.”

    First, I’m a physician, not a provider.

    Second, yes there is something preventing me from assuming the insurance function: I want to do something real, substantial and honest with my life. I have no desire to get money for nothing.

  18. @Mssrs. Carol and Ogden,

    I’m a doctor, not an insurer. I do something real with my life, not shuffle other people’s money around, while taking a cut off the top. I don’t need to pull dubious numbers out of my rectumAhem.

    Which brings me to the point. The Ryan plan is just tinkering with the current system, which is the bastard child of socialism and capitalism. The current system is not working for most people, although it is working for insurance company executives and their shareholders. I am arguing for revolution, not incremental change. No profit motive in medicine for starters, and that includes all players. Take medicine to a civil service model like police, firefighters, etc. We can dispute this, but is ultimately something that is not provable either way. I speaks to your basic assumptions concerning resource management. You all seem to think bleeding off resources to third parties that neither provide nor consume medical care is a good idea. I don’t. You can spew insurance “facts” at me until you are blue in the face, but it won’t change my mind that for-profit, third-party insurance costs too much by its very existence. The insurance companies cannot distract me from the fact that they exist.

    In the interest of intellectual honesty, I should concede that I would be OK with private insurance if they made no profit, and their executives were paid civil service compensation, and that they were regulated to the point to which they provide all the benefits which the government would have provided had it done the job. I’m OK with highly regulated, supplemental private insurance to cover beyond the basics what socialized medicine doesn’t cover.

  19. If providers really think that insurers consume 30% of the premium dollar and provide no value added, there is nothing stopping them from assuming the insurance function. Become an insurer, estimate your claims costs, quote a premium and capture what you think are massive profits currently going to insurers. Oh wait, that’s been tried. It turns out that assuming actuarial risk is not so easy and it’s quite possible to go broke quickly if actual claims costs materially exceed estimated claims costs. Insurers are, in fact, a lot better at assuming actuarial risk than providers are because they have better data and better analytics. If you can do it on a huge scale like Kaiser, it can work, at least in some markets but even their premiums are about in line with their competitors’.

    I think what doctors in particular really want is to be able to practice medicine as they see fit with no accountability, oversight or utilization review and they want their fees to be paid promptly and without question. That might be OK in a world of infinite resources but that’s not the one we all live in.

  20. 36 million enrolled in traditional Medicare

    “A four month “Nightline” investigation into Medicare fraud makes one thing perfectly clear: this is a crime that pays and pays and pays. The federal government admits that a staggering $60 billion is stolen from tax payers through Medicare scams every year. Some experts believe the number is more than twice that.”

    That works out to $1,666.66 per Medicare enrollee per year. Private insurance only cost around $3600 total per year. Private insurance admin at most would be $720. According to ABC news and the government half of what Medicare loses on fraud alone. How can you ignore these facts and continue to insist government care would be cheaper? Oh thats right if you liberals, socialist, and communist took over everything you would click your heals and make all the fraud go away. Why you can’t do that now I will never understand but we shouldn’t worry about facts when we have dogma

  21. Wow the inteligence on here drops to zero on the weekend. Think through some of these comments….for the first time apparently.

    “Private insurance in this country is subsidized by Medicare.”

    ? how, Medicare through cost shifting and administrative complexity increases the cost of private insurance for the population it serves. Now if your saying private insurance premiums are lower then they would be if they covered people over 65 that is true but that is not a subsidy.

    No Medicare does not take the sickest, how many premature babies are covered by Medicare? What’s with you and margalit making all these obviously false comments, decided the truth and facts were to inconvienent to argue with? Are you really that clueless to how Medicare works Quack?

    “After you pay a deductible each benefit period, Original Medicare will cover you in full for days 1 to 60 that you are in a hospital. For days 61-90, you pay a daily coinsurance. Medicare pays for up to 60 additional hospital days in your lifetime with a high daily coinsurance, after you have used up your 90 days of hospital coverage in a benefit period.
    After you use up your 60 lifetime reserve days, Medicare will no longer pay for any coverage until you start a new benefit period.”

    Well Quack how does Medicare cover the sickest people when it cuts off hospital stays? And those expensive Rx, is that Medicare that covers all of those?

    Its becoming very clear that you and Margalit don’t care aqbout the facts or a system that actually works all you care about is the politics and destroying the country. If you just need to make crazy baseless BS up to support the argument and get your political change so be it, you don’t care how poor the outcome, as long as it is more government power.

    Name a socialized system that is so much better then ours that doesn’t have private insurance…..

    ” If private insurance took over Medicare patients, the cost of private insurance would sky rocket and the actual care delivered to that population would fall thru the floor.”

    Once again Quack, BS that has been disproven. Private Insurers already deliver Medicare, exact same benefits, cheaper then Medicare does.

    What else would you like to make up?

  22. Yes Margalit I have actual numbers. Every time I process a claim with a PPO discount I know for a fact I saved them money. When I audit a hospital bill I know for a fact money has been saved. When I write a new piece of business and reduce their premium 10% I know for a fact I saved them money.

    You don’t seem to grasp that not all insurance is written by carriers.

    You also can’t seem to get your head around the concept that it could be far worse then it is now.

    “If employers wanted to slash their health care expenditures, they should support single payer.”

    And there is the home run of ignorance. You admit just above you have no grasp of how insurance works yet somehow your ideological certain single payor would save money. If this was true then Medicare wouldn’t be the most expensive health insurance system in the world now would it?

    Until you can reconsile the fact single payor Medicare is more expensive then everything else you should refrain from voting.

  23. The many socialized health care systems around the world that deliver care at a fraction of the cost of our own argue conclusively against this. The socialized, civil-service systems are much cheaper than our own. Face it.

    Private insurance in this country is subsidized by Medicare, which takes the oldest, sickest and most costly patients off the books for private insurance. If private insurance took over Medicare patients, the cost of private insurance would sky rocket and the actual care delivered to that population would fall thru the floor. Once again, private health insurance in this country is ultimately parasitic, and it’s profitability highly subsidized by Medicare.

  24. Unless you have actual numbers to prove that the cost to insureds has been reduced, all we have is the ever increasing cost curve. Could it be that, as you argued here many times, 5% of more money translates into larger profit? And could it be that all those bureaucratic activities you describe, indeed decrease the portion spent on actual care, but do very little for the overall cost to consumers?

    If employers wanted to slash their health care expenditures, they should support single payer.

  25. “have done nothing to reduce cost and I would venture a guess that they may have contributed to the rising of costs.”

    How can you come off as lucid some days then say completly stupid things like this? Nothing really, PPOs don’t reduce billed charges? Utilization review? Bill audits?

    What’s increased cost is government and clueless liberals making statements like nothing has reduced cost then passing laws based upon that warped view.

    “There is no one in the medical complex, including private insurers, that would benefit from lowering costs.”

    Sorry for the bluntness but you managed to raise the bar on stupidty over your last comment with this one.

    Employers wouldn’t benefit from lower cost, I’m sure they would be shocked to hear that. Most plans are self funded and sponsored by employers, over 50% to be exact so wouldn’t all those people hired by those plans benefit from succesfully lowering cost? That would be TPAs, PPO, UR, etc etc.

    Can’t wait to hear what you come up with next.

  26. ” how do we justify spending all the money on shareholders, executives, physical plant, staff time and secretaries?”

    Because even when paying for shareholders, executives, and everything it is still cheaper then paying civil servants. I’ll point this out to you again, evil private insurance “cost” $360 to $720 per person per year. Medicare cost $700 to $1050.

    Civil Servants don’t save money and this has been proven time after time for 30 years.

  27. “..why not wish for Fairy Guardians that keep us healthy with their magic wand?…….. You want individuals to determine what care they will and will not get only with the consultation of their doctor…. you propose to eliminate all cost control.”

    First of all, all the cost controls that supposedly exist today, have done nothing to reduce cost and I would venture a guess that they may have contributed to the rising of costs. There is no one in the medical complex, including private insurers, that would benefit from lowering costs. Everybody has a nice last resort release valve called patient empowerment, where any unpalatable extras are passed on to employees or other insureds.
    The only group that will benefit from lowering costs are people and the government, both as a payer and as a representative of citizens.

    The biggest damage is probably the destruction of general practice, first by gross underpayment and then by pitting GPs against their patients in various gate-keeping roles, which is about to get infinitely worse now. Even your “beloved” NHS, after trying this industrialized type of medicine, is now turning to its GPs to fix the problems.

    If I had to choose someone to trust with health care, I would much prefer a gazillion disparate professional PCPs, who are empowered to be the guardians of health care, to corporate medicine, corporate insurance, government committees or anything else that is large, monopolistic, powerful, for-profit and therefore sooner or later largely corrupt and never interested in individual people. I am not comfortable being a population.

  28. Which again brings me to my point: how do we justify spending all the money on shareholders, executives, physical plant, staff time and secretaries? Why not just replace them all with a few civil servants and be done with it? If the money is not going to provide actual health care, why is it going in the first place?

  29. “…the cost to run CMS, Congress, Treasury, collection, buildings, and countless other cost”

    We have to run those anyway, so might as well use them. It’s called “economies of scale”.
    How much does it cost the system just to process claims today? Including all payers, all middlemen, all providers (including time on the phone).
    How much goes to marketing? How much goes to benefit design? How much goes to shareholders and other profits (including hospitals)?

  30. “And I believe insurance companies take 30 cents of every dollar for admin/profits,”

    Can’t say I am surprised your opinion is based on ignorance of the facts but no they don’t take 30 cents. 50% of private group insurance is ERISA self funded plans, that would be what 50% of 80% or 40% of all insured people? Overhead in self funded plans is around 10%. That would be roughly $360 a year per person. Medicare loses $700 per person per yer in fraud.

    ” It would certainly be worth the savings, in my mind.”

    What savings, you haven’t demonstrated where a single penny would be saved. I have demonstrated how poor civil service work does increase cost on the other hand. So you are suggesting we pay considerly more for worse service and poorer results. No thanks.

    “instead of the 5 cents of Medicare.”

    Besides doing an invalid comparison, use dollars not percent, you can’t even get the numbers right. Medicare pays private insurers a little under 5% to perform the work they do, not included in your invalid argument is the cost to run CMS, Congress, Treasury, collection, buildings, and countless other cost.

    “Certainly it would go a long way towards a more just and merciful society.”

    Maybe if the left could get the basic facts right they wouldn’t be in such a rush to socialize everything. Do you care about the actual results, in which case you should care about the facts going in, or just the politics of it?

  31. Well, our civil service functions much better than many countries I have visited or lived in. It’s not really that bad if you are not into instant gratification and customer service. It would certainly be worth the savings, in my mind.

    With regards to fraud and tax cheats, that is a law enforcement problem, not one to shill out huge amounts to private companies. And I believe insurance companies take 30 cents of every dollar for admin/profits, instead of the 5 cents of Medicare.

    What I would like to see is primary care, nursing homes and medications socialized, with high-ticket interventions (like open heart surgery and ICUs) privatized. If everybody could be provided with a basic level of care, private insurance for major medical would not be that big a burden. Certainly it would go a long way towards a more just and merciful society.

  32. “Civil servants could do with this with minimal expense: no shareholder dividends, no multimillion dollar executive salaries, no profits to third parties which add no value.”

    Like how civil servants efficently run DMVs, accessor office, turn pikes, and everything else. What’s their success on tax collection, mid to high 70s?

    Medicare and their civil servants thougth they could be smart and save 1-2% on admin fees, and pay for it 5 times over with fraud. Is that what you hope happens?

  33. “Democrats want the government in the exam room and Republicans want corporations to be there. I don’t want either.”

    Why stop there Margalit, why not wish for Fairy Guardians that keep us healthy with their magic wand? Its more praticle then your sound bites.

    Who do you want to pay for this? You want individuals to determine what care they will and will not get only with the consultation of their doctor. Yet you want someelse to pick up the bill for this. Obviously you have not given any thought at all to the consiquences of this system. Our problem with healthcare today is cost and you propose to eliminate all cost control.

  34. “Democrats want the government in the exam room and Republicans want corporations to be there. I don’t want either.”

    Very well said, Ms. Gur-Arie!

  35. @Nate,

    “It’s not insurance companies billing 10 times cost for hospital services, $10,000 a month for life saving drugs, bilking public health programs for 10% in fraud, ordering redundent test, killing thousands with preventable errors, etc etc.”

    Much of this is probably true. But that is not the job for insurance companies. This sort of thing should be taken care of by a civil service board of physicians. They are in a position to know what is and is not necessary; what is and is not correct; not insurance company executives and their secretaries. Civil servants could do with this with minimal expense: no shareholder dividends, no multimillion dollar executive salaries, no profits to third parties which add no value. In my daily dealings with insurance companies, they just reflexively say “no” to everything I order. Period. Where is there value added in that?

    BTW, 35% of my income actually does go to taxes. Could I pay less? I’m sure I could, but I consider it my patriotic duty to pay my taxes, especially when I DON’T like it. Would I prefer that it not go to sustaining fossil fuels, slaughtering innocent people across the globe, corporate welfare and (unnecessary) welfare the poor? Yes, of course. But I do it anyway because it’s patriotic.

    Anyone here every read Maj Gen Smedley Butler?

  36. Sure not what you sound like when your comming forward hand outstretched demanding money. It’s not insurance companies billing 10 times cost for hospital services, $10,000 a month for life saving drugs, bilking public health programs for 10% in fraud, ordering redundent test, killing thousands with preventable errors, etc etc. You question the value added benefit of insurance, they minimize, counteract, and eliminate all of the above, there is your value.

  37. Dr. Determined,
    You’d be surprised, but I do agree “about being realistic and clarifying what quality of life means for a person, not the family members more often than not in prolonging life”.
    This is what it should be and this is where it should stop.
    Democrats want the government in the exam room and Republicans want corporations to be there. I don’t want either.

  38. @DeterminedMD

    Wow. I largely agree with you post, regarding resources and their allocation. You make a very concise and poignant argument.

    With regards to political parties, while I do not defend the Democrats, remember that the Republicans have been just as evil, carrying political water for the filthy insurance companies, the ultimate parasites in the medical field. The insurance companies are the very definition of “no value added.”

  39. What a lame interpretation to what I wrote, at least that is how I interpret your reply, Ms G-A. It is not about asking people to “commit mass suicide at the appointed time”, but it is about being realistic and clarifying what quality of life means for a person, not the family members more often than not in prolonging life.

    This is a sizeable part of Medicare expenses. Your comment above reinforces why this debate is both absurd and annoying to those of us who are championing for change and hope. Not these partisan bylines and echo rhetoric that both parties are guilty of. People in DC are the textbook illustrations of selfishness, greed, and lack of clarity and concern for the pubilc. And as I wrote earlier, you vote for the same, lame, out of touch representatives, you have no right to complain, you are part of the problem.

    Prolonging life just because there is technology that allows some chance does not infer entitlement and unfettered access. That is what cost is about. But, as most do here, focus on what is best for party and personal interest first. Politics and health care are oil and water. That is why I detest so much how the Democrats have cruelly, carelessly, and cluelessly dug such a canyon between physicians and patients.

    I’m done at this thread and site for now until a whopping link intrigues me to come back. Not that most of you really care though.

  40. “Ah, Margalit, you just begged the question: who owns the money? And before you answer, it doesn’t matter what you think, because most of the people who posses it think they morally own it. ”

    People thought that they “morally” owned lots of other things that they are not entitled to own any longer. Of course the new question that begs to be answered is what does “morally” mean?

    It does matter what I think because we chose to live in a democracy. And there is a price for individuals to pay. Sometimes, when the government decides to go to war, it may ask you to contribute your life for the common good or go to jail. Sometimes it may ask you to contribute a few dollars for the same purpose, or go to jail.
    Once we agree that government has a right, conferred to it by virtue of representing the majority of citizens, to ask you to contribute as needed to the common good and to the preservation of the system as we know it, then you have to agree that government has a right to ask you to also contribute money. For some reason, folks seem to be uniquely attached to money more than anything else, and the more you have the more attached you become. Must be addictive somehow. Is there an ICD-9 for that?

    Yes, minorities deserve protection from majorities, and people should have a basic right to enjoy the fruits of their labor without the State ripping those from their clutched little hands. I have never heard of anybody driven into destitution by taxation, and I have never heard of wealthy individuals driven into the middle class by taxation either.

    The argument for progressive taxation is that without the environment, services and labor of others in this country, you would not have been able to earn your fortune. The country provides you peace, tranquility, infrastructure and trained labor. The more you exploit these features and the more money you make, the more you have to pay back, so the country can continue providing the same to you and to future generations.

    For those contending that boomers are selfishly bankrupting their grandchildren because they refuse to commit mass suicide at the appointed time, may I suggest that those selfishly refusing to respond to the needs of the country, whatever those may be at the moment, are damaging future generations in a much more horrific way.

  41. What a pathetic debate. I had several links to give to show those interested the absurdity of listening to Democrats tell us there is no problem, and Republicans telling us privatizing Medicare is a simple solution. Yet, no one has the intestinal fortitude to say what is the problem, although some above allude to it.

    We are not meant to live to 85, 90 or more years as a sizeable population of a culture of this magnitude. And expecting the boomers to admit to this is like asking an active addict to tell others he has a problem with dependency. And most of you usual commenters have no guts to raise this issue.

    Wow, frauds in government representing frauds in the communities allegedly being represented. At least you get the representation you deserve.

    I, however, think it is time to start correcting the problems by starting with a simple premise, incumbents are incompetent and therefore should not get to be reelected. Irregardless of party affiliation. Let’s get some truth and real leadership back in government.

    For those who do not understand what I wrote above, go to the pig latin translation site and maybe something will make sense. Or, just go listen to your toilet flush, that may be more sensible to a lot of you!

  42. That scares me. The ACO concept could save money but not if we force/allow all the competing hospitals to join together. I think the most potential savings came from competing ACOs taking risk to deliver care the most efficently. If we have 1 ACO in an area then we have given them even more power.

    Sometimes I think politicians haven’t really thought through this….

  43. I hear ya Nate.. Whenever new rules are made, an army of consultants make $$.. That said, I think the consultants would make money if they came in and told us that we should not form an ACO. They would just make less as they wouldn’t need to come back and shepard us through the process. They did give us unpleasant news that we probably will have to parter with a local competitor hospital in order to to be a viable ACO. I am assuming the other hospital has their own consultants 🙂

  44. How much would your hospital spend on an ACO consultant if they said ACOs weren’t going to form? They have a pretty vested interest in people thinking there will be ACOs. I bet if you check their contract there is no refund provision if they don’t come to be.

    Many great ideas with bi partisan support die waiting to be passed.

  45. ” I would say “who” should decide what is just and equitable is the government.”

    If a majority agrees to fleece the minority and they do it via government then its equitable, By that reasoning slavery was equitable as it was decided by the majority.

    tax bracket is meaningless, with deduction you could be paying nothing. Net tax rate is the only number that matters. History shows fans of progressive taxes are even bigger fans of deductions, how much was Clinton’s underwear he donated to charity?

    “But I can swallow that better than I can them starving to death in the streets.”

    Nice false argument. The alternative to progressive taxation is not death in the streets, Even during the great depression people weren’t starving in the streets. If that’s your best argument for a preogressive tax then it shows how terrible and unfair of an idea it is

  46. The Medicare patients that I see in my practice get the same quality of care as my non medicare patients. I don’t understand what you are referring to.

  47. Our hospital and their consultants certainly believe ACOs will survive and WILL form. The health systems that have objected to the draft rules have outlined the objections in written detail to CMS. Expect significant modifications to the draft rules. According to the Hospital consultant I spoke with who lives in DC and interacts with members of BOTH political parties on this issue, significant cost containment will occur no matter who is in the White House. It will be labeled something different if the next president is republican, but that will not really matter as the result will be same. Billions must be saved and they will be because they have to.

  48. @Nate,

    If you do not agree with progressive taxation, there is no way for me to prove to you what is just and equitable. I would say “who” should decide what is just and equitable is the government. That is one of its jobs, to arbitrate among citizens. AAMOF, I am in the maximum tax bracket. So I am putting my money where my mouth is on progressive taxation.

    I agree that it is not equitable for us to pay for the livelihood of prisoners and the lazy. But I can swallow that better than I can them starving to death in the streets. But that is where I draw the line, not you. We simply disagree on this. I don’t think it makes either one of us evil, just that we don’t agree.

  49. “, I now see taxes as the price we pay to live in a civil society, and progressive taxes as the price we pay living in an equitable, civil society. ”

    Those for a progressive tax are never really for a progressive tax though, they are for taxing someone else and calling it progressive. Who defines equitable and civil? I don’t think its equitable that I pay taxes to subsidize someone that doesn’t work at all, where is the equality in that?

  50. @Margalit,

    “All that said, for your 95 years old taking a shot at immortality, I would be willing to bear the costs to society, so he can have his way, but not before you tell him squarely that whatever treatments he chooses, he will be dead as a doorknob in 6 months with 0% chances of recovery. No sugar coating allowed…..”

    As a matter of fact, one of my hats is palliative care. In regards to telling ppl the bad news, my nickname is “The Sledgehammer” among the nursing staff. I leave no ambiguity. But people still regularly choose the long, drawn out death; the futile interventions. It’s not rational, but that’s their right, and I uphold their decisions. There seems to be a belief in liberal circles that if we just educate people, all the bad choices will go away, and reason will prevail. I fear I am not that optimistic. I really think that our system is trending towards a few, basic services provided to everybody, with many more options then depending upon how wealthy you are. It may not be right, and it may not be the way I wish it, but I think it is reality.

    @Nate,

    I understand the argument of taxes = body slavery. I even used to agree with it. I used to agree with Rand’s positions on economics. I still agree with her positions on civil liberties. However, I now see taxes as the price we pay to live in a civil society, and progressive taxes as the price we pay living in an equitable, civil society. Strange, many libertarians forget that corporate law is considered an unwarranted intrusion of the government into economics, and that corporate limited liability and corporate personhood should be done away with as well.

  51. “…what makes people truly liberal is the recognition that everybody is entitled to have liberties, even when it costs money.”

    Ah, Margalit, you just begged the question: who owns the money? And before you answer, it doesn’t matter what you think, because most of the people who posses it think they morally own it.

    Your thought is actually is a new religion, young as religions go, only a couple or three centuries old. And it’s charming, don’t get me wrong, the way kittens are charming before they grow claws. But religions which leave out a theory of personal conversion do not work. There has never been a society — even on a spreadsheet — that can make the economics work, because it entails re-defining all the “money” as community property — by coercion. This begins as a sound bite, or a chorus on the barricades. Because miracles do still occur, hope for it ending with only a soviet whimper as opposed to a bang.

    Wealth seems to produce medical technology, and long lives, and birth rates below replacement levels. You cannot give those old people “liberty” as you define it without taking lots of money away from the young people. That they should voluntarily give it up is a dream against nature. They are hoarding it for their pleasures and their own aging parents. Since the need of their own parents is not quantifiable in advance, the force of nature argues against voting for a tax increase. You can’t shame them into it, because their moral obligation to their own family is stronger than your new gospel.

    You need to convert the population to your religion to make the math work. Good luck.

  52. So Margalit is cool with slavery as long as you don’t look at it in a dollar and cents perspective, nice to know Margalit. I’m sure the 95% of African Americas that vote democrat will love to hear how they were supporting entitlement to their masters’ liberities and should be proud of their liberal contribution.

  53. exact opposite. Entitlements are not liberities. When I am obligated to pay someone else’s wants there is no liberty just oppresion

  54. France doesn’t have scary stories becuase they have a market based solution.

    “Private Insurance. “More than 92% of French residents have complementary private insurance.” This insurance pays for additional fees in order to access higher quality providers. Private health insurances makes up 12.7% of French health care spending. These complementary private insurance funds are very loosely regulated (less than in the U.S.) and the only stringent requirement is guaranteed renewability. Private insurance benefits are not equally distributed so there is, in essence, a two-tier system.”

    Two tier system, loosly regulated, 92% private….I would be ready to bet your sick to your stomach right now and about to lose your lunch.

  55. ” for your 95 years old taking a shot at immortality, I would be willing to bear the costs to society, so he can have his way, ”

    And here is why liberals can never design sustainable systems. There is a specific intellectual deficency that makes people liberal, it completly blocks their ability to see consiquences. Margalit you can never ever balance what you just said. Its beyound unicorns and pots of gold to think such a system could ever exist.

  56. Dr. Vickstrom,
    Personally I share your outlook on life, but somehow I feel obligated to respect the views or beliefs of that 95 years old person who feels differently. Just like I don’t want someone forcing me to receive medical care, I have no interest in compelling others to “give up” when they are not ready or willing to do so.
    I think “adequate” is a personal definition, and I think people should be allowed to define their own “adequate” dealing with disease. I also think that many folks are robbed of this choice somewhere in between hospital and nursing home commute. Sometimes it’s their own family perpetrating this injustice, sometimes it’s hospital policy or fear of litigation and sometimes it’s the reticence of doctors to spell things out as brutally as they need to be spelled.
    I think all of us should have advance directives and I don’t see why this is such a big deal and why it cannot be done at the DMV when you renew your license just like organ donation choices. Yes, some won’t feel comfortable doing it, but many will, so it may be worth a try.
    All that said, for your 95 years old taking a shot at immortality, I would be willing to bear the costs to society, so he can have his way, but not before you tell him squarely that whatever treatments he chooses, he will be dead as a doorknob in 6 months with 0% chances of recovery. No sugar coating allowed…..

  57. Guarantee that you will have Medicare in relatively some similar form in 10 years because the party that votes to substantially reform it including largely ending it in its current form won’t win another national election for a generation. Why no one wants to touch it.

    What is going to happen (and the budget overall) is that their is eventually going to be a showdown to between the Gen X/Y folks vs. Boomers who have left a huge tab of IOUs, haven’t saved enough, and want very lucrative retirement benefits. Doesn’t add up.

  58. “MG, everyone has an ideology – that’s how you decide who’s an ideologue and who’s not.”

    This is generally true to a point but Ryan is an anti-tax zealot. He is a true believer in supply-side economics in which he wants no taxes on any from of rent-derived income and a flat income tax if possible. That is really Ryan’s driving emphasis. His concern about the deficit is kind of laughable. He was repeatedly voting for GOP spending time and time again including the MMA Act of 2003 which was the single biggest spending bill of the last 50 years. He’s absolutely fine with deficits and has said so publicly in the past repeatedly. He just wants a low a tax rate as possible. He’s also for big gov’t too when it suits him including massive defensive spending. Represents the absolute worst of GOP thinking today.

  59. “I am a firm believer that it is possible, i.e. there are enough resources, to provide adequate care for everybody in this country. If the Europeans can do it with much less money, we should be able to do it too.”

    Your right Margalit the Europeans have figured out a way to do it;

    Doctors are prescribing drinking water for neglected elderly patients to stop them dying of thirst in hospital.
    The measure – to remind nurses of the most basic necessity – is revealed in a damning report on pensioner care in NHS wards.
    Some trusts are neglecting the elderly on such a fundamental level their wards could face closure orders.

    Dehydration contributes to the death of more than 800 hospital patients every year.

    Read more: http://www.dailymail.co.uk/health/article-1390925/Elderly-patients-dying-thirst-Doctors-forced-prescribe-drinking-water-old-alive-reveals-devastating-report-hospital-care.html#ixzz1NYcWgP4W

    I bet our evil pharma companies will even find a way to mark up and exploit this simple prescription.

  60. @Margalit

    I too believe it is possible, given our current resources, to provide adequate medical care for all in this country, provided we stop wasting our money, both within medicine and without.

    The problem lies in defining “adequate.” For me personally, who was raised in the fatalist/skeptical culture of the upper Midwest, every day I live without agonizing pain and death is a gift from God that I really don’t deserve. I’m just happy to have lived my 40 years so far. But for many of my patients from other places, 95 is just too young to die, and they want every intervention possible. What will the definition of “adequate” be and who will decide it? That is what we are really fighting over on this blog, methinks.

  61. ” If the Europeans can do it with much less money, we should be able to do it too.”

    They can’t, have you been that oblivous to the austerity measiures they are enacting. They have not solved the problem any better then we have.

    Yes you can borrow from future generations to provide great healthcare now, as soon as your population and growth stagnates, a 100% certainity, it all falls apart, the math don’t work.

  62. “Ryan’s plan screwed everyone under the age of 55 with almost no sacrifice by most of the most Boomers. ”

    A 40 Trillion dollar undeliverable promise on the other hand is such a great deal for those same seniors, their kids, grandkids, great grandkids, and the next 10 generations that will be trying to pay it off.

  63. Don’t you think the Tea Party candidate may have affected the outcome of this Congressional race? Noooooooooo . . . the national press had already written the headline for this race: Democrats are “defenders of Medicare”, despite the unsustainable cost trend. It makes me want to throw up.

    Ryan’s plan was a brain dead retread of a failed 1990’s idea from the Ways and Means Chairman Bill Thomas: the forced conversion of Medicare to a voucher program. Not a new idea, but rather a fiscal gimmick: limit Medicare’s rate of growth by simply restricting the size of the voucher and let private insurers do all the dirty work (if they can). By failing to address the NEXT TEN YEARS of Medicare cost growth, Ryan cynically gambled that he could neutralize the emotional opposition of current Medicare beneficiaries. He and the Republicans deserved repudiation: this was a really cynical ploy.

    Even more cynical, and far harsher, The Medicaid idea in Ryan’s plan was also a gimmick, only the risk was shifted to states, who are going broke trying to fund the current program. Let’s pretend that states and health insurers can do what the feds have failed to do: make actual choices that eliminate the rip-offs, inappropriate care, avoidable illness and lousy quality that plague both programs.

    A pox on both parties. They are reactionary cowards pandering to our fears, rather than leading and finding solutions. . . .

  64. I would love to hear the President talk more about mistakenly amputated feet, pediatricians who do unnecessary tonsillectomies, and choosing between the red pill and the blue pill, And he should elaborate on the claims by Lippan and Michael E that we should accept death and stop transplanting kindness in 65 year olds.
    Or, perhaps we could discuss how often public outcry will lead to Medicare-for-all coverage of procedures with low evidence-based scores, the same way that Medicare added annual PSA’s, mammograms and physicals. Or, perhaps, patients should be allowed to get their CA 125 they read about in the Sunday paper, or whole body I would love to hear the President talk more about mistakenly amputated feet, pediatricians who do unnecessary tonsillectomies, and choosing between the red pill and the blue pill, And he should elaborate on the claims by Lippan and Michael E (above) that we should accept death and stop transplanting kindness in 65 year olds.

    Or, perhaps we could discuss how often public outcry will lead to Medicare-for-all coverage of procedures with low evidence-based scores, the same way that Medicare added annual PSA’s, mammograms and physicals. Or maybe patients should be allowed to get their screening CA125 or whole body CT, with the risk of “fraud an abuse” -and the cost- transferred to them, not the doc.

  65. How many unnecessary wars (although they are unconstitutional) are we going to fight wasting all of our resources instead of going in, winning, and getting it over with. Same with fixing health care. The slaughter is almost as bad!!

  66. Your right on, we can’t continue to pay $250,000 for a kidney transplant for a 65 year old with mulitple system problems. Doctor’s need to say NO, and patients need to learn that!!!

  67. MG, everyone has an ideology – that’s how you decide who’s an ideologue and who’s not.

    I’m 55 – not affected by the Ryan plan – and don’t expect to see Medicare survive 10 years. I’m sure I wouldn’t get the same quality of care on Medicare as I do on my current Health Savings Account.

  68. Ryan is an idealogue. Pure and simple. I am not surprised by his reaction in the least to the election result. He sees the world the way he wants to and not for how it generally is. Potentially makes for a great thinker but not a great politician.

  69. Agreed, Dr. Vickstrom.
    I am a firm believer that it is possible, i.e. there are enough resources, to provide adequate care for everybody in this country. If the Europeans can do it with much less money, we should be able to do it too. This is not to say that we must copy any particular system, but it seems that the math can be made to work without abandoning large segments of the population and without rationing necessary and effective care.
    I would be curious to know what the sum total of net profit (including “non-profits”) is extracted from health care every year by those who do not actually deliver care (i.e. clinicians and staff), such as insurers, pharma, devices, hospitals and other suppliers and middlemen.

  70. ” Now if your calling premium cost then yes”

    Yup, premiums are what I care about. As a consumer and an employer that is what I pay. Since private insurers are not able to obtain hold down medical costs, premiums go up.

    ” So it would seem prudent to their survival that they find a way to keep insurance affordable or they wouldn’t have any customers.”

    For their survival they need profits. They do not need the most patients, just the ones that can pay enough to make a profit. Clearly, not everyone can currently afford insurance.

    “Would those be the same ACOs that aren’t being formed because the guidelines are so onerous?”

    They have been revising the guidelines with input from IMG, Mayo, Geisinger, etc.

    “Maybe that just deemed your hospital of such poor quality it wasn’t worth the effrot to try and save?”

    We keep making these damn best 50, best 100 hospital lists. Very annoying. I would like to sleep at night when on call.

    “Just yahoo Anthem, United, Aetna hospital quality initative and you will find thousands of examples”

    Thanks. I did. They are using the same ones Medicare is pushing. Since they are doing them later, it is not changing anything I do. Guess that is why I did not know. You are correct. Now, as long as Medicare keeps finding new ways to improve care, I can be assured that the private insurers will follow.

    Steve

  71. Ryan’s plan screwed everyone under the age of 55 with almost no sacrifice by most of the most Boomers. Only a few selective ones unlikely enough to be 52 or 53 right no would be screwed by Ryan’s plan.

    Sadly Democrats exploited a number of seniors’ largely misplaced fears about Ryan’s plan would effect their Medicare coverage. It was a nice sleight of hand. Democrats learned well because it was exact same thing the GOP did to them in ’10 elections. Hell, the irony in PA is a guy like Toomey ran ads repeatedly in his Senate election that stated Obamacare was going threaten seniors and their Medicare coverage. Of course that was almost complete BS but it didn’t matter. Seniors voted in large number for Toomey and the GOP in PA. That matters a lot just like in did in the NY district election where you have a larger than normal elderly population.

    Ryan’s budget is pure supply-side idiocy ripe with crazy economic assumptions. Its laughably bad. It is why the likes of Romney and Huntsman have saved away from it. They know a piece of garbage when they see one. Gingrich was just foolish to voice his opinion publicly. It basically sunk whatever chance he had in raising any kind of serious money needed for a presidential run.

    This all goes back to the fact that the Democrats didn’t submit a budget in ’10 and Obama’s initial budget this year was so weak and lacking on confronting the deficit. By not putting forth something that was semi-serious, he gave the ground to loons and ideologues like Ryan command the center stage even if their ideas are terrible and don’t address the problem at hand.

  72. “Hand-over-taxpayer-money-to-private-insurers.”

    Why not complete the flow Quack, 85%, or more, of which is immediatly sent to the providers. Under the current system the money sits in the governments bank account and insurance companies write checks on it. Under the Ryan plan the money sits in insurance company bank accounts and they write checks on them. Are you really that concerned about the three lines of text that would change at the top of the check?

    “The Ryan plan is bound to fail from administrators, investors and other third-party parasites gobbling up more and more resources, with less and less for patients.”

    Now we find the real problem, you don’t want any other parasites eating at your buffet. Someone needs to put the parasitic providers on a diet, what third party would you prefer it be then?

  73. “Is this how things work today Nate? Are insurers bending backwards to keep insurance affordable?”

    Yes Margalit it does. That is why you haven’t seen loss ratios plummet. Insurance companies can’t stop regualtion and they can’t stop most consumption, if you don’t like insurance premiums look in the mirror, you are the problem.

  74. @Margalit,

    All excellent points. But many damning points can be made against Medicare as it stands now. It will continue to take more and more of our GDP. I think we have to do something else, but the Ryan plan is not it.

  75. “How much money does an insurance company make on someone that doesn’t have insurance? Nothing, hopefully you realize that. So it would seem prudent to their survival that they find a way to keep insurance affordable or they wouldn’t have any customers.”

    Is this how things work today Nate? Are insurers bending backwards to keep insurance affordable?
    And by “insurance” I don’t mean those decorative “insurance” products that look just fine until you try to actually use them.

    “The Ryan plan empowers seniors to buy coverage that meets their needs. ”
    Translation: The Ryan plan forces seniors to buy coverage that meets their financial abilities.
    Which further translates into extending the rationing by ability to pay, now common in private markets, to the senior population.
    And since Medicaid in his plan is also gutted, there will be no safety net when millions of destitute seniors start dropping out of your profit driven nirvana.

  76. The Ryan plan is fail. Hand-over-taxpayer-money-to-private-insurers. Rand Paul has a real capitalist solution to this: get rid of all government programs in the medical marketplace. Immediately. End of line. I generally respect Paul as a real capitalist and libertarian, except where he joins the white supremacist, forced birthers.

    I am opposed to Paul on principle, as I am a social democrat. However, the current system AND the Ryan plan are bastardized mishmashes of capitalism and socialism, both of which are bound to fail. Medicare is bound to fail from physicians and patients bilking it, from refusing to accept that eventually we must all die of something; from refusing to accept that our resources are not infinite. The Ryan plan is bound to fail from administrators, investors and other third-party parasites gobbling up more and more resources, with less and less for patients.

  77. Steve do you even think about what you type? Obviously not or you wouldn’t write such senseless garbage.

    “They will keep raising costs”

    How is it insurance companies raise cost? Now if your calling premium cost then yes but that premium increase is in direct proportion to the cost of care it is buying. Its providers charging more and consumers using more that increase cost not insurance companies.

    Next clueless comment;

    “and if you cannot afford it, you will not have insurance.”

    How much money does an insurance company make on someone that doesn’t have insurance? Nothing, hopefully you realize that. So it would seem prudent to their survival that they find a way to keep insurance affordable or they wouldn’t have any customers.

    “ACOs.”

    Would those be the same ACOs that aren’t being formed because the guidelines are so onerous? What will a non existant ACO do to control cost?

    “Medicare has a number of quality initiatives currently running. At least at the hospital level, my hospital or any in our area, private insurers have none.”

    Maybe that just deemed your hospital of such poor quality it wasn’t worth the effrot to try and save? The correct answer is none your aware of, I’m sure there are atleast a dozen that effect your hospital. Just yahoo Anthem, United, Aetna hospital quality initative and you will find thousands of examples

  78. “Making seniors buy insurance with a fixed voucher is in of itself a cost containment tool.”

    Well, not really. It seems more likely that insurance companies will keep doing what they currently do. They will keep raising costs, and if you cannot afford it, you will not have insurance. Either that or they will offer plans that do not cover very much.

    “We already know what happens when you pay doctors less for good or bad care, they just perform a lot more needless care to make up the difference.”

    ACOs. Also, Medicare has a number of quality initiatives currently running. At least at the hospital level, my hospital or any in our area, private insurers have none.

    Steve

  79. Desperate Democrats Decrying Dollar Disappearance Drain Debit Limit Dry…Film at 11.

    Reich for President…He gets it.

  80. well if you have a link to liberal PolitiFact then that settles it. Couldn’t find anything on the DNC website or MediaMatters?

    “The truth is always more complicated than good ol’ Nate suggests:”

    So a group does a study not based on PPACA but generic reform ideas and concludes that possibly in the realm of belief generic reform, not PPACA, if coupled with additional private reform could reduce the increase in cost. And thats your argument?

    The Ryan plan empowers seniors to buy coverage that meets their needs. PPACA cuts reimbursement for good care and bad care and does nothing to address any of the problems that got us all here in the first place. Ryan is offering a proposal that could resolve issues and might cost seniors more but there is no guarantee.

    PPACA changes nothing and will reduce care without question. We already know what happens when you pay doctors less for good or bad care, they just perform a lot more needless care to make up the difference.

  81. The truth is always more complicated than good ol’ Nate suggests:
    http://www.politifact.com/truth-o-meter/statements/2010/mar/19/barack-obama/obama-says-health-reform-legislation-could-reduce-/

    And the big difference between Ryan plan and PPACA attempts: reducing costs with a scalpel and not with an axe. Of course you reduce costs if people cannot afford care and avoid going to the doctor, even though they should (although some of this will come back as emergency care when people do no longer treat their diabetes and hypertension). But, as evidence suggests, with high copays and deductibles one reduces both needed and unneeded care (yes, in theory, seniors could try to find out themselves and pay copay for good stuff only, but most patients, especially medicare patients, have difficulty and no desire doing that and do whatever the doc recommends). Let’s reduce care that is of no or little benefit (or even harmful); people who want unreasonable care are still free to buy it.

  82. “And Ryan and the Republicans offer no means of slowing rising health-care costs. To the contrary, they want to repeal every cost-containment measure enacted in last year’s health-reform legislation.”

    How dishonest can you be? Making seniors buy insurance with a fixed voucher is in of itself a cost containment tool. Seniors would buy the plans that control cost and are affordable which would require carriers to find solutions. Note that would be a hundred insurance carriers that do this every day looking for solutions versus 200 liberal democrats that never ran anything successfully in their lives who pay attention to insurance once every 8 years. The voucher would be 100% times more efective then any cost containment in PPACA.

    Second dishonest comment, what cost containment provesion in PPACA? There weren’t any. No lifetime limits? That savings? mandatory preventive, that cost savings? 26 year old dependents, coverage for experimental treatments. You can’t name one cost saving measure in any of PPACA.

  83. Obama has sure fooled enough of them. The changes in PPACA cut reimbursements the same way Ryan’s plan calcualted the voucher.

    “IPAB’s authority is triggered when Medicare’s future spending is anticipated to increase faster than a target rate. The target growth rate through 2018 is the average of the change in the Consumer Price Index (CPI) and the medical-care component of the CPI. For 2018 and later, the target rate is real Gross Domestic Product (GDP) per capita plus 1 percentage point.

    For every year the projected Medicare growth rate exceeds the target, the IPAB will put forward proposals to cut spending by a certain percentage that increases to 1.5 percent of total Medicare spending (after 2017) or the projected excess, whichever is less. But IPAB may only address some providers. Before 2020, it may not target providers for which rates are already cut by ObamaCare — primarily hospitals.”

    Ryan says clearly and specifically how cost will be calcualted, Obama hides behind a newly created IPAB and no one on the left wants to say a word. You claim the Ryan plan will shift cost to seniors, where is the Obama plan shifting them to?

  84. We need to realistically confront death and dying in America. Someday we will mature as a medical profession and as a US culture around this issue-this “elephant” in our living room and in our lives.

    And if we do it ethically and with compassion we will dramatically reduce MEDICARE expenditures.

    Dr. Rick Lippin
    Southampton,Pa

  85. We just need to make sure people know what TRyan’s plan really offers. It will increase overall health care spending. It will require seniors to pay a much higher percentage of their health care costs. It does this while cutting cutting taxes for the wealthy. It would have been difficult to sell the Medicare plan, but it is harder when one realizes that what the tax cuts do.

    I think it is salvageable. You could raise the indexing above inflation to GDP plus 1% as was done in Simpson-Bowles. You could keep the vouchers, but let patients choose between Medicare or private insurance, basically a public option. Also, keep the IPAB so that there is some mechanism to cut costs.

    Steve

  86. ” the fastest growing segment of the popuation is 85 and older and 10,000 Boomers join Medicare every day and advancments are constantly increasing longevity.”

    How does forcing those patients into the private sector solve anything?

  87. Reich is the one who doesn’t get it.

    Most age 65 and older have children who are 20 years younger and some have parents who are 20 years older. Like Bob, get real, the fastest growing segment of the popuation is 85 and older and 10,000 Boomers join Medicare every day and advancments are constantly increasing longevity. And addng 16 million more to Medicaid just increases costs. By the time Obamacare hits 2020, nobody will get anything. Then what will parents tell their kids or kids tell their parents, or ecah other except they’re sorry they were so selfish and listened to obvious misinformed people.

    Meanwhile waste, fraud and abuse keep growing as they are still $1 of very $3 spent on healthcare. Obama promised Tom Coburn they would agressively fight these, but they’re still $800 billion a year and growing. As things get tighter, first Medicaid will be deep sixed, as Medicare keeps getting cut more each year requiring Madicare recipients to pay more and buy Medigap insurance if they can afford it. But as they use to say in the military, [did you serve Bob], not to worry – the poor and socioeconomically deprived will end up as the big losers, so you guys better stay out of their neigborhoods if the entitlement programs go south, if you want to stay healthy.

  88. At least Reich avoid calling anybody who supports the plan a racist like his last post about Romney supporters did.

  89. That “current seniors will not be affected” is hard to explain with anything else than political maneuvering, and it will actually worsen deficits short- and midterm.

    “And, while they’re at it, turn Medicare into a “Medicare-for-all” system that forces doctors and hospitals to shift from costly tests, drugs, and procedures having little effect, to healthy outcomes”. This sentence is a vaguely worded policy proposal that is grounded on an array of facts; it is not, and cannot be, like most major fundamental policy proposals, a factual statement.

  90. True, true. But current seniors know their children will get hung out to dry, and the insurance companies will laugh all the way to the bank. You can’t fool all of the ppl all of the time.

  91. Current seniors will not be affected by Ryan’s plan.
    Furthermore, this statement has no basis In fact:”And, while they’re at it, turn Medicare into a “Medicare-for-all” system that forces doctors and hospitals to shift from costly tests, drugs, and procedures having little effect, to healthy outcomes.”.

Leave a Reply

Your email address will not be published. Required fields are marked *