THCB

Why Do You Care Whether I’m Insured?

If you care a great deal, I’ll give you an account number you can use to make a deposit.

[Note to Self: Send this Alert to the folks at Commonwealth. Also to Nancy Pelosi and Harry Reid. CC Uwe Reinhardt as well. You never know what they might do. They certainly talk about this topic a lot.]

While you’re thinking about the initial question, here are a few follow-up questions:

Do you care whether I have life insurance?

What about disability insurance?

Homeowner’s insurance?

Auto casualty?

Auto liability?

What about retirement insurance? (A pension or savings plan.)

Do you care whether I keep my money at an FDIC-insured institution?

Or whether I bought an extended warranty on my car?

Or whether I bought travel insurance before taking my scuba diving trip to Palau?  (It pays off if you get sick and can’t go.)

I’m sure there are busybodies who would like to run everyone else’s life. But society as a whole has taken a more rational approach. We basically don’t care whether people insure to protect their own assets (at least we don’t care enough to make them do so). But we do care about events that could create external costs for other people.

Through Social Security, we force people to pay for life insurance benefitting dependent children (who could potentially become wards of the state) but not for a working-age spouse. All but three states force people to have auto liability insurance (covering harm to others) but not casualty insurance (covering one’s own car). We basically don’t care whether people insure their own homes, but we force them to contribute to retirement and disability schemes to prevent their accidental dependency on all the rest of us.

Here is the principle: government intervenes in those insurance markets where people’s choice to insure or not insure imposes potential costs on others. Because of our basic human generosity, we’re not going to allow people to starve or live in destitution. So when people don’t insure for retirement, disability, etc., society is going to step in and help (where help is needed) anyway. Implicitly, we have a social contract that socializes the downside of certain risks. If we allow the upside to be left to individual choice, we will have privatized the gains and socialized the losses. When people don’t bear the social cost of their risk-taking, they will take more risks than they would otherwise.

Another way to think about the problem is in terms of the opportunity to become a free rider on other peoples’ generosity. Consider the person who has no life insurance (for dependent children), no disability insurance and no retirement savings program. Because he is not paying premiums or saving for retirement, he can consume all of his income and enjoy a higher standard of living than his cohorts. But if he bets wrong (dies too early, becomes disabled, reaches retirement with no assets), he is counting on everyone else to help him out.

How does all of this apply to health? Considering all of the trees that have been felled to facilitate health policy writing, you would expect an exhaustive literature. But aside from Robin Hanson’s thesis that health care is different (which I’ll save for another day), there is almost nothing!

I’m not kidding. There is virtually nowhere you can go to find a rational, well-thought-out, consistent analysis of why you should care whether or not I have health insurance.

After you finish reeling from that revelation, allow me to partially fill the intellectual void.

If we are concerned that the uninsured will impose an external cost on the rest of us, there is a simple remedy. Impose upon them a fine equal to the expected cost of any unpaid medical bills they might occur. Elsewhere, we have estimated that the full time uninsured get about $1,500 per person in free care, on the average. So the appropriate fine is $1,500.

Note, however, that uninsured middle-income families are already paying higher taxes (probably in the range of $1,500) because they do not have the tax subsidized insurance their neighbors probably have. So far from being free riders, these families appear to be paying their own way. Of course, the extra taxes the uninsured pay tend to go to Washington, D.C., while uncompensated care tends to be delivered locally. This mismatch of revenue and expense is not caused by the uninsured, however. It is the result of government not having its act together.

Note: The above argument applies to middle-income families. It doesn’t work very well for people who have assets—say, $1 million or more, and that’s about 1 in every 30 people. Also, the argument becomes weaker the lower a household’s income. People who cannot afford health insurance anyway are not willful free riders. They are not making choices that impose new costs on others. So there is no obvious social reason to force them to insure. They will need health care from time to time, however.

What is the best way to get health care to people with low incomes and few assets? The answer is not Medicaid. Nor is it SCHIP. Nor is it any other system, inappropriately modeled on the “insurance” approach to health care. More on this in the future.

Bottom line: aside from the need to coordinate government revenue and expenses that relate to the uninsured, it’s not at all clear why you should care whether I have health insurance.

If I have overlooked something, I invite readers to weigh in.

John C. Goodman, PhD, is president and CEO of the National Center for Policy Analysis. He is also the Kellye Wright Fellow in health care. His Health Policy Blog is considered among the top conservative health care blogs where health care problems are discussed by top health policy experts from all sides of the political spectrum.

 

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102 replies »

  1. Yes I care whether you have all of the items you mentioned. Why? Because in this country, people are taken care whether or not they have these thing. The insured pay more and higher insurance premiums because some don’t have insurance. Car insurance? I have to pay over $100 per car every year for the “Uninsured Motorist Fund” in Michigan where everyone is suppose to have insurance but don’t. No job or form of retirement? Well just look at all the transfer payments to the chronically unemployed, even talk about 401K seizures by government to make retirement a reality and more fair for the not-so-well off (chronically unemployed). It seems no matter what we do right, others will do wrong and the rest of us end up paying for their mistakes. So yes I do care if you are a responsible person.

  2. problem is mainly for the poor people.they didn’t get work and for them a better health care is a night mare

  3. What an extraordinarily insightful and indepth response response. You could not be more on target.

  4. I quite agreed with your response, I just wanted to add more comments to your topic of the subject matter. Most industrialized world has free medical care for their citizens. I believe we are doing the same thing, but not enough to cover most poor citizens of this country. I also believe that our government can increase health care clinic in big cities and rural areas, and also provided free medication for our citizen it will help a lot and in the long run it will reduce the health cost. I also believe that the preventive medicine is the key to reducing medical cost. It is true that some patients can see the doctor, but sometimes they have no money to fill their prescriptions. I am sure our government can make provision for generic medicine to cover this kind of cost. It would be the kind of money that is well spent, and the productivity of the work place would increase in the long run. It is a win win situation for all of us if our government can make a provision to increase health care clinics around the country for easy access to medical care

  5. “We seem to understand the danger of farming our defense out to greedy for profit corporations, no-one in their right minds would disband the US Armed Forces, and put it all in the hands of Halliburton, hoping for the best. But in health and education, we appear to have done just that. None of these main ‘tripod’ societal needs should be for profit. Our country cannot afford it.”

    Congrats on the time traveling Destinkeys, how do you like the future so far? Miss 1920 much?

    90% of Education has been provided by government and it has been a major failure, we have to move to private and accountable education before we lose any more generations of kids.

    Majority of Healthcare is also provided by the government, both care and insurance.

    What is this imaginary private for profit sector providing education and health you made up?

  6. Any society rises or falls depending on how well supported it is. No nation can survive without its’ populace healthy, educated and well defended. At least, not ‘survival’ that anyone would want to live through. Unfortunately, in the USA, only the defense of the country is not allowed to fall into the hands of private, for-profit hands (and even that is beginning to happen). In a society of ‘we the people’, our government’s primary job, maybe even it’s MAIN job, is to ensure the safety, health and overall education of its’ populace. We seem to understand the danger of farming our defense out to greedy for profit corporations, no-one in their right minds would disband the US Armed Forces, and put it all in the hands of Halliburton, hoping for the best. But in health and education, we appear to have done just that. None of these main ‘tripod’ societal needs should be for profit. Our country cannot afford it.

  7. “Let the oil companies save the expense of trying to establish their own defense forces, by making them pay the US navy for their services. This will easily bring in a TR!LL!ON $$$ per annum.”

    always amusing watching liberals and their half whit ideas chased over the ledge by equally clueless liberals. If only the ledge was higher the problem of liberalism would be solved.

    1 trillion from protecting oil shipments, really now? The entire oil industry is around 3 trillion a year. Why would Canada pay our navy to protect their pipelines? Why would domestic producers pay our navy for protection? How could someone think there is a billion to be made off protecting oil shipments let alone a trillion?

    Margalit and John you really don’t grasp how far from reality this is? Explains a lot of your opinions actually.

    1 trillion from pot, that number is almost as stupid as the navy collecting 1 trillion. How much are we going to lose from accidents and deaths from people driving high? Or are you claiming Alcohol has no cost? Is smoking pot good for your lungs, i must have missed that study where it lowers health cost long term. And we all know how much more productive high workers are.

    Care to back up the 4 trillion for Iraq war number, that might have taken first place for ignorant comments. Since we are magically undoing the war what about all the jobs created from building tanks and Humvees, all the salaries paid public and private. What would these people have been doing through two recessions exactly?

    And the 34 million people still living under the rule of a mass murder, sorry your life isn’t important our poor need a new xbox and bigger free housing?

    “Universal health care will decrease the burden on large corporations,”

    Yes becuase in clueless liberal land a tax you can’t control is always preferable over an expense you can. Please lets tax business advise from the clown that doesn’t know the difference between a billion and a trillion, what could go wring there?

  8. “If you want to see what a purely free enterprise health care system is like, go spend a few years in Somalia.”

    Sure and if you want to see Government healthcare go to North Korea

  9. If you want to see what a purely free enterprise health care system is like, go spend a few years in Somalia. The Somalians are experts in the arts of waging pointless wars and ignoring sick people who can’t pay.

    Also, regarding the remark supra, that the country took care of sick poor people 100 years ago : the author of that statement would do well to pick up the works of Jane Addams, Lincoln Steffens, or the non-fiction of Upton Sinclair and Samuel Hopkins Adams. They lived through the early 20th Century and described the horrific neglect and mistreatment of the poor and indigent people of those days.

  10. Mr. Lane is edging back to the conversation about what to do with all those poor people. Mr. Ogden worries about the national budget. The big question is how we meet both concerns ?

    We have wasted a TR!LL!ON $$$ on richard nixon’s failed War On Marijuana. Legalizing and taxing the stuff would make a huge difference in our national finances, besides dramatically cutting the income (and ability to buy assault weapons) Mexican gangsters make.

    We squandered $$$4TR!LL!ON in the Bush crime family’s OFF BUDGET Iraq Fiasco II, and continue to waste $1 B!LL!ON/day there for no good purpose. We could make a huge difference in our national finances if we followed our allies out. The savings would be even more if we ended the Bush crime family’s failed Afghanistan Fiasco. In the end, by staying on focus, Obama caught bin laden. Now we can go.

    The US navy ensures both allies and enemies alike of the safe transfer of oil from the ports of the Middle East, Alaska, Indonesia, Mexico and Venezuela. Without this protection, the oil companies would have to arrange for their own security. Let the oil companies save the expense of trying to establish their own defense forces, by making them pay the US navy for their services. This will easily bring in a TR!LL!ON $$$ per annum.

    We spent a couple of TR!LL!ON $$$ bailing out Wall Street, and put several more TR!LL!ONs at risk to prop up ‘vital’ banks. We could have arrested, charged, held in custody as high risks for flight, tried, convicted, and, imprisoned the scores of bankers who engaged in the massive securities fraud that precipitated the crisis, and who put federally guaranteed deposits at grave risk. One felony and one gross misdemeanor. That would have prevented future generations of greed-driven pencil pushers and bean counters from doing it again, although some business men will commit crime no matter what. It’s in their nature.
    The convictions would enable the banks to strip the malfeasor’s of their funds, which B!LL!ONS of $$$ would have greatly aided our national finances.

    Finally, whereas both poverty and wealth appear to be heritable, and whereas the US has contended since 1776 that all men are created equal, and whereas the lack of a Federal Estate Tax tends to make men increasingly less equal, and whereas estates are windfalls for the heirs, and whereas the national finances need annother revenue stream, it is advisable that the nation re-institute the Federal Estate Tax as it was before 2001.

    Do all these things and the US will be so well funded that the cost of a single payor universal health care system will not be a problem. Universal health care will decrease the burden on large corporations, allowing them to expand their work forces, further increasing the revenue stream.

    What won’t work is continually pinch pennies, downsize, coddle corporate criminals, engagein expensive military projects that have no point, and police projects that are counter-productive. To deny health care coverage for Americans because you want to squander money on failed republican policies is worse than immoral, it is stupid.

  11. This is in response to the initial question of why do I care if the next man is insured. I would say “I don’t” if we lived in a society where our actions did not impact other people. I choose to pay for health insurance because I prefer to have the security of knowing that if anything does happen I have the support provided by insurance. However, there are a few that think they are the picture of health and paying insurance premiums for services never utilized is a waste. Then there are others whose jobs don’t offer coverage and purchasing a private policy is far too expensive. Both will cause me a raise in premiums when life happens and perhaps that man that is the picture of health suddenly develops prostate cancer because he didn’t get preventive screenings or the man that could not afford private insurance is in an unexpected accident at work. Mr. Goodman suggests imposing fines on these individuals, which is not practical. A poll conducted by Harris Interactive reported that 34% of Americans have no retirement savings and 27% have no personal savings. Fining people would be a joke; they would not have monies to pay the fine. These are two different extremes, one chose not to insure by choice and one by force, yet the end results will yield the same. Both of these individuals will expect and probably receive treatment at the expense of those that are insured.

    http://www.harrisinteractive.com/NewsRoom/HarrisPolls/tabid/447/mid/1508/articleId/684/ctl/ReadCustom%20Default/Default.aspx

  12. At risk of taking your crown why is it you are always the last comment saved only by some spam? Do you project much John? Speaking of trolling I comment on the subject you run your mouth on trolling, again, project much? 2:26 am you must be really rich with nothing but time to kill.

    Thanks for the healthy dose if iron(y) to start the day

  13. Repeating my comment from another thread in January…

    https://thehealthcareblog.com/blog/2011/04/21/and-the-worst-health-care-system-in-the-world-isae/comment-page-1/#comment-53798

    Wow! Almost ninety comments.
    It’s called The Last Word Game.
    Reason and logic are not part of the equation.
    Whoever has the last word wins.
    For those who haven’t figured it out yet, nate always wins.
    Most trolls are innocent of any sense of reason and he is no exception. He seems to be a deeply wounded individual, incapable of compromise, courtesy or sincere apology. However, I think he must be very successful in his work because, as seen here, he stays on task with unrelenting energy and determination. That level of commitment takes exceptional dedication.
    Okay, sir.
    Your turn…

  14. The political question is not whether skinflints can save a buck, or whether resources are finite. The political question is whether it is in the best interests of the nation to finance a minimum health care program. The host of this blog may feel that destitute people deserve to suffer, but the vast majority of the people of this nation disagree.

    As to Mr. Goodwin’s inquiry as to whether anyone cares if he has insurance, I only care self-centered people act in such a way as to make themselves as inexpensive to treat as possible. You see, their consumption of medical care raises the price of mine. Therefore, Messers Goodman and Ogden, act toward the rest of us the way you hope to be treated. Excercise, good diet, abstinence from unhealthy and dangerous activities will help.

    Before I leave, I should remind the cheapskates who are willing to cut poor people off, read those dollars in your pockets. You will notice that those dollars have the name of the owner clearly printed upon them. While you may (temporarily) manage some dollars, the dollar itself is the property of the US, and always has been. Nations have always retained the right to use the national currency as has been viewed as vital. Individuals must bow to this law, or suffer the consequences.

    If you don’t like it, that’s just too dam’ bad.

  15. Yes, Nate. I do understand.
    I just want people to stop saying “in a world of finite resources, we have to ration care”. I want them to be honest and say “we don’t want to spend our money on your care. Period.” Let’s see how that goes over….

  16. Ever see the M*A*S*H episode when Hawkeye and BJ feign a fight to humor Frank Burns for his birthday and they end up really fighting, and BJ’s beef is Hawkeye has to always have the last word, so when they make up, BJ says “thank you”?

    You’re welcome. NOT! It is not strictly a cash interpretation. May you never know the pain of having a care procedure delayed in a hospital because something was in short supply. Honestly and seriously!!!

  17. so you satill don’t grasp that money doesn’t grow on trees? Money is not infinite, despite the way you spend it

  18. “Pay them [doctors] more and you will have plenty”. My god woman, you are on a roll today!!! Who in god’s name is going to support this in DC? And would any doctor believe the pay would be seen?

    I’m done at this thread because the absurd that does spark some humorous response will degrade to outrage sooner than later. I just leave with this to try to bring back the readers to the point of the posting (you know, what that guy Goodman said at the top about whether you should be concerned about having insurance), it will come to whoever has the access to the LIMITED resources this country distributes will survive. And it will not come down to universal health care, it will come down to who you know, how much you have, and why you should even be in the g-damn line in the first place.

    And NO politician will have any worries, as things stand now. Good day, good evening, and good night!

  19. I am starting to gain a new appreciation for conservative methods of debate. I don’t watch Fox news, so this is rather new to me…

    First Dr. D. who is asserting that because supply is not infinite, it must somehow be limited. Are there only two forms of availability: infinite and limited? Is adequate or sufficient even a possibility?
    How many empty hospital beds do we have? How many MRIs, CTs and all that fancy machinery sitting idle for hours every day? How many fully qualified students are not accepted into medical school each year? How many foreign trained physicians lingering on the sidelines?

    Then Nate, quoting 15 people dead from either artificially created shortages of drugs by speculators, or “manufacturing glitches”, as proof that there is a shortage of health care resources.
    Shortage of PCPs? Pay them more and you will have plenty. Same for rural health. It’s all about the money.

    And then comes the suggestion that asking that wealth be more equitably distributed in this country is tantamount to killing 100% of billionaires and taking all their money (wow!!), and since killing all billionaires and taking their money will not resolve our problems, then by definition, creating a more equitable and prosperous and productive society, like we used to have when America was the uncontested global economy leader (and growing), will not have any effects either.

    Are you guys serious?

  20. per Ms G-A’s 10/10 12:29 comment:
    “Health care resources are not limited in any way in this country.”

    Wow, I don’t even know how to respond to such an extremist interpretation, other than remind at least readers grounded in the reality I seem to share with those who are clinicians that there are not infinite supplies of drugs, supplies, oh, and bodies to fill as providers. I know I have said some questionable outrageous things in my time here, as not everyone appreciates or agrees with my perspectives as a provider, but that above statement is just absurd to read.

    Get away from the computer screen and interact amongst the people, ma’am, you might see that reality is a bit different than what the silicon based life forms are claiming!!

  21. Kill all the Billionaires and take 100% of their money, it was said tongue in cheeck but I could see you actually advocating for it.

    Kill the rich and it pays the bills for one year, what do we do the second year? Ah thats right in Liberal Math you just count them a second time, then a thrid, and so on.

  22. “And one more thing: Health care resources are not limited in any way in this country.”

    15 dead people would disagree with you….if they weren’t dead.

    http://www.cbsnews.com/stories/2011/09/23/earlyshow/health/main20110587.shtml

    PCP resources are limited.

    Flu Shots most years

    Rural areas we have limits on care available

    “The money to pay for those resources is limited because most of our money is extracted from society at large and hoarded away by a small number of thieves.”

    Really? The total wealth of all these thieves would only pay for current social programs for a year or two. Do you notice every time you make these outlandish claims it bites you in the backside? Get the facts not the propoganda.

    I would suggest you watch this, it will disprove a lot of what you believe.

    http://www.youtube.com/watch?v=661pi6K-8WQ&feature=player_embedded

  23. Dr. D.,

    What is it exactly in the sentence “Society should intervene there and help him out” implies that we should place him on a beach and feed him fish all day long?
    Did it ever occur to you that “help him out” could mean teaching him how to fish? Or is the specter of having to throw a few fish his way, while he is learning, too frightening for you?
    Obviously he cannot learn on his own. Is it better to lock him up somewhere and feed him for the rest of his life? Or is it better to invest a little and turn him into a “productive member of society”, a.k.a. those cheap laborers that make it possible for the 1% to harvest boatloads of fish in return for a meal a day?
    Ignoring him won’t make him go away.

    And one more thing: Health care resources are not limited in any way in this country. The money to pay for those resources is limited because most of our money is extracted from society at large and hoarded away by a small number of thieves.

  24. does anyone have data on the number of hours an overpaid american doctor works compared to those in say Greece, France, or UK?

    Would also be curious to see how length of carrier compares and pension.

  25. “I have included a link to an interview with a former Cigna VP”

    LOL could you be any more naive? This fraud has been discredited for years now, how could you still fall for this? Did you even notice what Mr. Potter did while there?

    “I was head of corporate communications and that was the ultimate PR job.”

    He wrote press releases and stood in front of a camera. His knowledge of actual insurance and how the business is ran was right around the same level as yours.

    Now lets call you out on your other lies you seem to have skipped over;

    “These same companies are purging their employer plans that are costing too much,”

    Seeing as how you feel for the CIGNA VP of communications maybe you really have had your head buried in the ground since the 90s. This claim hasn’t been true for 10+ years, why are you bringing it up now?

    ” it is clear that a free market health insurance industry will never work.”

    When have we had a free market health insurance industry and when did it fail to work and in which way?

    You have already walked back a one ridiculous claim about providers working only for the greater good now start walking back the rest.

  26. “…not to the degree most are today [regarding reimbursements alone, Ms Stephanie?]. People here are blurring what people make in income versus how they invest it for further income outside of patient care and then try to say that any doctor making over set amount is just being greedy. Show me the majority of doctors doing daily clinical care in primary care, pediatrics, psychiatry, and other select specialties that have a lot of patient care flow in the office are making larger incomes, when in fact, they are not making more money, they are getting lower reimbursements and are running the risk of poor choices by seeing more patients per day to balance the losses. But, we don’t want to example the specifics to the income stream, because that might take away from the premise being falsely promoted here, eh?

    So, per Stephanie’s definition, what is “paid well” versus “obscene wealth”?

    Careful treading onto this ice flow, Ma’am.

  27. “Society should intevene there and help him out” [the stoner]. Again, you basically are telling us everyone needs to sit on the beach or dock and wait for the fish, then when we call you on it, you then double talk that we should fish for ourselves. Do you read what you write?

    It is about people helping others to help themselves. If you did clinical care and work with impovershed people, more and more are just coming in expecting, not even asking anymore, for handouts and entitlements that they claim they deserve, and people like you advocate for this dependency like it is doing a justifiable service?

    We are in trouble as a culture, folks, and when Obama says we are getting soft, while part of that comment is to deflect attention away from him , he is not too off base in the comment when interpreted by those without a partisan agenda. This minimum wage issue is getting a bit off topic though, so I would advise to step back and read the thread to decide how this relates to the insurance topic, ’cause I don’t fully see the transition.

    Again, that damn gorilla in the room currently just sitting quietly in the chair in the corner reading the paper. You all don’t want to address responsible life expectancy in this culture, do you? People are going to retire at 65 and expect to live off of ponzi pensions for 20 or more years, using up limited health care resources along the way?

    If this is your reality, Ms G-A, I won’t ask what is the color of the sky in your world, because darkness really doesn’t have color, just various shades of gray that darken as the time progresses.

  28. I have never been accused of pot-stirring, but I think I might be guilty of it today! Clearly I have hit a few nerves and will admit to two shortcomings of my earlier post: I failed to link a resource that supports my position and I failed to take into account that folks out here might not be able to have an adult debate without resorting to name-calling. Not much I can do about the latter, so let me try to correct the previous:

    I am not in favor of physicians and other healthcare providers donating their skills purely for altruism’s sake. I believe they should be paid well, but not to the degree most are today. The way the system is set up currently encourages the shift from providing a service to people in order to improve health to encouraging fraud, utilizing technology simply to increase profits, and refusing to care for folks whose “insurance plan” or lack thereof does not reimburse at an acceptable rate. The current health insurance and government reimbursement system has propagated much of this type of immoral behavior among practitioners.

    For-profit health insurers have set the stage for this by doing the same at their level. I have included a link to an interview with a former Cigna VP who apparently has had a change in perspective and is speaking out about business as usual in healthcare insurance corporations.

    By the say, John’s link above to the article about social capital is absolutely dead on. Research has shown that social capital is positively linked to health outcomes.

    http://www.pbs.org/moyers/journal/07102009/watch2.html

  29. To all those who are anguishing over whether or not you should still come here, what with all the “sniping” and “trolling” from those who have the audacity to disagree with you: you really don’t want to miss this discussion. It is of historical importance. You thought Marxism had already been litigated? Well, you would be wrong. We’re still trying to decide, right here on this comment thread, whether the “rich” really own what they have, or whether they “plundered” it; whether the poor are employed, or “exploited”; why we allow the “capitalist” to capture the excess “value” of the laborer; what is the appropriate level of “profit” a business should be allowed to have — and so on.

    Apparently, it actually is 1957.

  30. “Much for the same reason SSI was created,”

    But SSI has failed to do this. It has failed miserably. The poor can’t live on their SSI, the system is broke and future generations will get at most 70% likely much less which means they can’t live on it. The early collection rules allow people to retire to early and collect less then they need, they should be forced to wait until full age. With SSI such a failure why would we undertake another similar program sure to fail just as bad if not worse?

    ” it is clear that a free market health insurance industry will never work.”

    How do you know this? Its never been tried so what do you have to base this claim on? On the opther hand we have countless examples of failed social health insurance so it can be said that public health insurance will never work.

    “No other discipline that exists purely for “the greater good” is a for-profit schema.”

    Healthcare never existed for the greater good, it existed so providers can make a living just like any other business. The only profession that comes close to existing purely for the greater good would be some select groups of monks, nuns, priest etc.

    How is a farmer any different from a doctor in regards to what they provide and its necessitity in life?

    “It’s a business for them and that is propagated by insurance companies”

    Wow, this is a stretch, how does health insurance propagate for profit medicine? Long before health insurance ever existed doctors where making a profit

    “These same companies are purging their employer plans that are costing too much,”

    Anything to back this up? Curious how this happens when small group is guarantee issue. Your a raving nut and full of BS.

  31. I agree with the author’s right to not utilize healthcare coverage. He can also opt to not utilize social security benefits even though he is most likely contributing to the system.
    Much for the same reason SSI was created, America is at the point of transforming healthcare to protect the uninsured and the underinsured. If we look at the provision of healthcare as a moral imperative, it is clear that a free market health insurance industry will never work. If we subscribe to the idea that access to affordable health care is a right of all human beings, we need to remove money from the equation. No other discipline that exists purely for “the greater good” is a for-profit schema. Most physicians talk the talk: They entered the profession in order to help people. Some may even walk the talk by working with people who can’t afford payments all at once or even, providing care free of charge. Most don’t. It’s a business for them and that is propagated by insurance companies and by the spineless politicians who listen to lobbyists instead of individual constituents.
    For Americans who hold to the belief that the provision of healthcare is a moral imperative, it is reprehensible to see what is happening to our fellow human beings. Insurance companies actively working to increase shareholder profit by streamlining their rescission and denial processes. These same companies are purging their employer plans that are costing too much, disregarding the human face of one employee who has been struck by cancer. The thought that simple concern for the almighty dollar drives this sort of immoral behavior is horrifying to most.
    So, if this author does not want healthcare coverage, no one should force him. Like a previous commenter noted, personal responsibility comes into play at some point. However, if you believe that what is happening in the for-profit health insurance industry is immoral, get in line with me to take the dollar signs out of the provision of a human right.

  32. Why does the government want to pay for care? It has been stealing it for 30 years. That must be cheaper.

    Perhaps the goal is not to provide care, but to control care.

  33. It is a crime to file a false police report.

    It is an entitlement to go to the ER and whine, over and over and over again. You should be troubled.

  34. “You don’t want to help?

    I want to help those that need it, not those that are lazy and want everything handed to them.

    “means that you already discounted the possibility of losing money.”

    No it means I was keeping it simple so even a liberal that hasn’t ran a business can answer the question, which apparently still can’t be answered. Basically we found the flawed logic of your plan, it can’t account for businesses losing money. Something very common in life. Take bars and food for example. Appears your plan doesn’t work for the majority of businesses.

    “what type of work is not worth $7.25 per hour?”

    Picking up dog dirt, trash cleanup in the desert and along roads, handing out those annoying advertisements on street corners or sticking on my door, opening mail, stuffing envelopes, hostess, blogger for huffington post, fast food cashier if you can’t count or speak english, or fast food cook if you can’t roll my burrito correctly(almost everyone at Del Taco), people that empty trash cans at the airport while talking on their cell phone the entire time, people at the food court that pick up the trays, weeding, dog walking.

    This is what we lost, people use to work their way up, now they expect the government to hand it to them paid for by someone else.

    “Cruz: Well, that’s right. And that’s an incredibly kind comparison. Marco and I share a very similar personal story, which is that my dad is from Cuba, he was born there, he grew up there, and he was imprisoned and tortured in Cuba as a teenager when he was 17. And he fled Cuba, he came to the United States. When he was 18, he showed up in Austin. Had no money, didn’t speak English, had 100 dollars sewn into his underwear, and he went and got a job as a dishwasher making 50 cents an hour. And he worked 7 days a week and he paid his way through school at the University of Texas. And I’ll tell you, Robert, when I was a kid my dad used to say to me all the time, “when we faced depression in Cuba, I had a place to flee to. If we lose our freedom here, where do we go?” And there’s no question that better explains why it is I’m running for Senate than that question right there.”

    How did we get from $0.50 to $7.25? If people could work for $0.50 an hour and make it through school why do we need $7.25 an hour plus tax credits plus pell grants, plus food stamps, and they still can’t move up?

  35. “every time you help someone you take it from someone else”
    True. And the point is? You don’t want to help? There is a price to maintain a functioning “society” which allows you to create a business, run it successfully and make boatloads of money. And the price is not optional.

    “deduct the value of placing your capital at risk” means that you already discounted the possibility of losing money. That’s why you are entitled to some profit. Interesting Obama jab, but irrelevant.

    Your argument about the $5 can be taken to other absurd numbers such as 10 $1 per hour workers. My problem remains: what type of work is not worth $7.25 per hour? And no, splitting one position into 2 or more does not answer my question, and using a drug addict as an example of productivity doesn’t either.

  36. Wanna read about fishing, literally (and, its financial implications regarding teh latest burst bubble)?

    Michael Lewis’ visit to Iceland in his new book “Boomerang.”

    Tragedy of The Commons and all that…

  37. “Society should intervene there and help him out.”

    How many times and for how many years? I know people that have been dead beat losers for 10 years and will be for 10 years more until they die. How much do you want to steal from the future to waste on these people? Why do you deny the future what is rightfully theirs, opportunity and a fresh slate of their own to either fail or exceed, and waste it on people that don’t deserve it? There is not infinite resources, every time you help someone you take it from someone else.

    “Minimum wage does not make millions of people unemployable.”

    Just becuase you deny the truth doesn’t make it go away. I interview these people every time I have a job opening. There are millions of people not worth $5 an hour.

    “Deduct all other expenses, deduct the value of placing your capital at risk and what is left is what the labor is worth.”

    Your avoiding the question, if the business is losing money then what happens to labor cost? Lets ignore the cost of capital, say I make solar cells, call my company Solyndra for example:), It cost me $4 in material to make a panel I can sell for $3, before any labor cost I am already losing money, so does that mean my employees pay me, or do they work for free, or how are they paid under the Margalit new world order?

    Before you try to dismiss that no business would make something it knows its losing money on Obama gave them 500 million so obviously its a sound business model.

    “If someone making $10 an hour can do the work of three $5 per hour people, the business owner should pay him $15 per hour. As I said above, pay should be based on contribution or productivity.”

    Fair enough, so if I can’t find the $15 per hour person then your ok with me paying three people $5 right? You just killed your own argument. You want people to be paid what they are worth unless they aren’t worth your artifical fllor then you want them to make some minimum. When no business is willing to overpay them you want society to support them for their entire life.

  38. We should fish for ourselves, and the vast majority is trying hard to do that. The problem is that somebody is detonating explosives under our water and scooping up all the floating fish before we get a chance to catch anything. I think explosives should be banned and the perpetrators should be forced to grab a rod and be patient just like everybody else.

  39. Don’t hire the guy “who gets high every day and never shows up on time”. Society should intervene there and help him out.

    Minimum wage does not make millions of people unemployable. It makes millions of people unexploitable. Sooner or later, I hope those third world governments will be forced to act on behalf of their citizens as well. Until then, I for one am not buying any crap made in child labor countries. If you look hard enough, you can find everything with a Made in the U.S.A. label on it and lo and behold it’s not that much more expensive if at all. I wonder how those guys manage. Maybe they don’t mind paying decent wages for decent work.

    Nate, please read my comment a bit more carefully:
    “Deduct all other expenses, deduct the value of placing your capital at risk and what is left is what the labor is worth.”

    If someone making $10 an hour can do the work of three $5 per hour people, the business owner should pay him $15 per hour. As I said above, pay should be based on contribution or productivity.

  40. “I find it hard to believe that any kind of honest work is worth less than $7.25 per hour.”

    You obviously have never ran a business. Do you really think the high school drop out who gets high every day and never shows up on time is worth $7.25 an hour? Most of the jobs sent to China were sent there becuase the remedial labor was not worth our minimum wage. Instead of increasing the standard of living it just makes millions of people unemployeable. Didn’t you say something recently about consiquences?

    “Deduct all other expenses”

    Back to my question, if my product loses money then my employees will pay me to have worked on it?

    you seem to be unaware of how markets work. If someone is a good employee then they have higher value. If someone making $10 an hour can do the work of three $5 per hour people why would a business owner not pay the $10?

  41. This I agree with, “If you removed minimum wages, I bet every job that pays $7.25 today will drop to $5 per hour to increase the owner’s margin, and it will ripple up to other low paying jobs, and there will be no significant increase in these crappy jobs either.” I really see by what I read from select commenters here that your double standards in income stream are disguised antiphysician rhetoric. In my opinion, this country has degraded into flagrant narcissism and antisocial behaviors that are wonderfully disguised by the CEOs of many companies and just fuel the addict behavior that many have, just not in a chemical standard. Money is an addiction, folks, and if you don’t address it as such, addicts are by nature selfish and destructive, and sometimes in the end rather enjoy taking others with them as they fall.

    So, by your writings Ms G-A, we are all to just expect someone to fish for us. Cheap and lazy, and you certainly seem to advocate for this.

  42. It all goes back to how you define value. I think maybe it should be defined the market price of the product you’re selling. Deduct all other expenses, deduct the value of placing your capital at risk and what is left is what the labor is worth. The tricky part is to apportion fair value to each laborer’s piece and it should be based on measurable contribution, not education, intelligence or reputation.
    I find it hard to believe that any kind of honest work is worth less than $7.25 per hour. It benefits society because the poor are part of society too. If you removed minimum wages, I bet every job that pays $7.25 today will drop to $5 per hour to increase the owner’s margin, and it will ripple up to other low paying jobs, and there will be no significant increase in these crappy jobs either.

  43. “Why Do You Care Whether I’m Insured?”

    Get Me Re-write.

    “Why Should I Care Whether YOU’RE Insured?”

    The more salient question.

  44. “I bet the same workers would be paid a lot less for the same exact “contribution”.

    Do you accept that becuase of minimum wage some people will never be offered a job becuase they don’t add $7.25 an hour in value? How does it benefit society to have people eliminated from the job market by government regulation?

  45. who sets this “real” value? And is it really based on what the person has to offer or the ideals of some liberal on what they think someone should be worth ignoring real world measures like education, work ethic, inteligence?

  46. Right now workers are compensated for what they are worth to you, not what the value of their contribution really is. What they are worth to you depends on availability of people looking for work and how hungry they are. If there was no minimum wage in place, I bet the same workers would be paid a lot less for the same exact “contribution”.

    I am not suggesting that capital is not entitled to profit in return for assuming risk. The question is how much profit? There is a difference between employing people and exploiting people.

  47. you either don’t know our military or are redefining the poor to be anyone comming from a household making less then $250,000

    so paying people what they are worth is wrong because it allows them to stay poor, but you advocate goivernment welfare that pays them even less for doing nothing and keeps them poor?

    “obviously not paid anything close to the value it produced”

    This is better then even a Value Added Salary, as you don’t want people compensated for what they are worth or what they add but the end result of their labor no matter their contribution. I know with your ideology these things don’t have to actually work even on paper before they are advocated for but have you given that much thought?

    Curious under this new compensation theory of yours if my business loses money then can I charge my employees for making a product that lost money? Or do I bear all the risk and share in next to none of the reward?

  48. “The poor” served in every war this country ever fought in larger numbers than the wealthy because there are more of “the poor” than the wealthy and because they found it harder to make “other arrangements”.

    Cheap unskilled labor was paid enough to keep it functioning as cheap and unskilled for generations, and was obviously not paid anything close to the value it produced which accrued to the “savvy entrepreneur”.

  49. “supportive of President Obama’s initiative to create jobs by investing in fixing our national infrastructure.”

    If only Obama had such an initiative. I’m not a liberal I know to look past the name of the bill and read how it plans to actually work. Nothing Obama has passed or proposed would do anything to fix our infrastructure.

    How have the poor guarded our borders? Think your making that one up.

    Cheap unskilled labor was paid for their work, nothing was built on their back.

  50. Sorry to interrupt this feel-good session, reached based on the unscientific assumption that it’s your fault if you get sick. Or perhaps you gentlemen are suggesting some means to ascertain if the disease was brought on by one’s reckless behavior or maybe not? Something like a Personal Health Assessment Board, better known as death panel?

    “100 years ago we provided the poor safe borders to live in”

    I would like to point out that for over 200 years the poor have provided you with safe borders to conduct your business activities in, not to mention the cheap unskilled labor on the back of which many pizza empires were built. And if you have no problem with veterans mentally and physically crippled in the process, living in abject poverty, may God have mercy on your souls.

    Finally, I am happy to see Nate, that you are supportive of President Obama’s initiative to create jobs by investing in fixing our national infrastructure.

  51. I think we reached that middle ground they talk about in the news. Kids should never be held accountable for the failure of their parents or being unlucky in birth. We also shouldn’t leave them to suffer with these same parents.

    I think we could also design welfare transitions that were less harsh to wean these people off the public tit.

    I.e. if you “can’t” find work then you report to the trash transfer station and sort recyclables from trash for 8 hours to get your benefits. Most major cities have thousands of condemed houses that need torn down but they can’t afford to becuase they are paying millions of people not to work. That’s the insanity that needs to end.

  52. Charles Murray was a major theorist on getting people to stop being poor.

    As early as 1975, he wanted all forms ot government aid to cease. This would force poor people into the labor market, or I suppose starve.

    Murray’s viewpoint was that there would be some really horrible years, with food riots and mass criminality –when the poor began to realize what they were up against — but after that, things would get better for them and for the nation.

    Two ponts about Charles Murray though —

    a. You can be sure that Mr Murray had no intention of living anywhere near the places where there were going to be riots;

    and

    b. As I remember from his writing, he proposed that we keep funding Medicaid, especially for children.

    Now one can make the point that America could prevent epidemics and conduct public health for a lot less than what we actually spend on Medicare and Medicaid.

    I would not be opposed to a debate on how much responsbility the government should accept for self-contained illnesses in adults.

    If a child has whooping cough, I do want to pay for their care. But if an adult has high blood pressure or diabetes, I can live with myself if I do not pay for their care. Very few individuals enter adulthood with high blood pressure or heart disease or gastric diseases of all kinds, On the whole,
    they have earned their health conditions by their eating and driniking habits. (I am no better, I am just stating a fact.)

    So I could accept an argument that curing the self-contained illnesses of adults should be a lower priority.

    Is this an area for debate?

  53. “As a nation we are not troubled when poor people call the police.”

    Where socialism always fails is in the consiquences of these actions. Have you taken this idea past the poor person going to the ER?

    100 years ago we provided the poor safe borders to live in, and some protection of rights and saftey. Then we started to feed them. Then guarantee retirement, then house them, then educate them, and now you want the public to take on responsibilty for their health. During this time when have any of the measures improved? You think your being compassionate by offering these services when in fact your just making poverty more attractive. Why work when Bob will give you everything to just get bye?

    Notice their aren’t many old communist or socialist states? Oldest one left being Korea followed by China.

    After ER what do you give them next? Does it ever end?

    How about helping people stop being poor for a change so they can pay their own bills?

  54. To Nate:

    I live in Minnesota, which frankly has a German/Swedish socialist heritage in its rural areas, and a Hubert Humphrey-style Democratic heritage in most of its larger cities.

    Public services in the states nearest Canada are a lot more like Canada
    than they are like the American South and Southwest.

    The rates of uninsurance in North Dakota and Vermont are close to Canada’s.

    This is not because Minnesotans (or Scandavians) are angels. Until very recently , they have not had to deal with immigrants of a different race.

    The author Michael Lind has some very good pieces on this dichotomy that I recommend. If America ended at the Mason Dixon line, we would have probably had national health insurance 65 years ago.

    As for paying taxes — it is true that many individuals do not pay income taxes. There is nothing wrong with funding public health facilities through sales taxes, which believe me everyone pays.

    As a nation we are not troubled when poor people call the police. (Most of them are victims of crimes, not perpetrators.) We should be equally untroubled when poor people go to a subsidized urgent care center or a public emergency room.

  55. John Ballard commented above about “I see a trend toward an increase in cold-blooded arguments such as this, buttressed by an equally mean-spirited spray of sniping from a stable of commenting trolls inhabiting these increasingly treacherous pathways.” I would agree, probaby to Mr Ballard I am one of these alleged ‘commenting trolls’, but yet I find often the ‘troll’ label is thrown out by the commenters who are not looking for debate and dissention, but just wanting to hear the choir singing ‘amen’ as large and loud as possible to drown out any reality to otherwise to their preaching.

    Technological advancements in health care have always had pros and cons, yet those who advocate the loudest for EHRs and other computer access for widesweeping application to health care for all seem to have little if no tolerance for dissenting, differing positions.

    Why is that, if my interpretations have some merit? There are probably several plausible and realistic reasons why people are hellbent to get EHRs implemented, and some may have legitimate reasons that are not overtly insidious and nefarious. But, do people who want to engage in healthy debate just dismiss differing opinion as extremist agendas? Often, those who are projecting do so. Besides, why is it those who scream the loudest to get EHRs in place aren’t doing any of the clinical care?

    Hmmm, am I off base in smelling a profit driven motive here?

  56. “The first responder to any car accident is normally the cops and/or the highway patrol,”

    Not sure where you live but if it is in a parking lot and or does not have serious injury in Las Vegas, parts of CA, Parts of OH and numerous other places I have been they wont come out at all. You need to go to the station and file a report.

    “Instead we all pay taxes for them”

    Millions of people, some of the biggest users, don’t pay any taxes to support police and fire

    “we should turn emergency rooms into public utilities, paid for by all and available to all without charge.”

    Does that include the 50% who aren’t paying income taxes now or will they and seniors be given a free ride on this like everything else?

    When you say utility do you mean the smoothly ran utility like we dream about on paper or the mess that actually exist in most cities? The one that takes weeks to see you, hasn’t read your water meter in 3 years, 1 hour waits on hold to speak to someone. No thanks, keep your socialist system I’d rather pay for my ER and actually get decent care when I need it.

    “Right now we have over-privatized the function of emergency medicine, ”

    Really Bob, are you writing this from France? Your trying to tell us Medicaid receipitants seeking care in public hospitals is to privatized? THERE IS NO PRIVATE IN IT! When you identify a boogy man he’s getting blamed for everything no matter what isn’t he?

  57. “we should turn emergency rooms into public utilities, paid for by all and available to all without charge.”

    To control costs (and wait times) it would be better to make PCPs free (tax paid) and ERs charge – except for life threatening emergencies.

    “We do not expect these persons to be paid by car insurance claims. Instead we all pay taxes for them, and have done so in almost all US communities for the past 120 years without calling it ‘creeping socialism’.”

    Same goes for weather disaster response/clean-up/restore. Socialist subsidies are only for the other guy, tax paid government partnerships are for me.

  58. The first responder to any car accident is normally the cops and/or the highway patrol, and they are tremendously important.

    We do not expect these persons to be paid by car insurance claims. Instead we all pay taxes for them, and have done so in almost all US communities for the past 120 years without calling it ‘creeping socialism.’

    In the same spirit — we should turn emergency rooms into public utilities, paid for by all and available to all without charge.

    That would be a practical way of solving the challenge that John Goodman outlines very well. We would help all citizens without being busybodies.
    Sometimes a clear-cut tax is better for society than a maze of mandates and subsidies and exceptions to mandates, etc.

    Now I realize that some patients go from the ER into a long hospital stay, so it would not be as simple as it sounds to just fund ER’s with federal dollars.

    But that is the direction we should move. Right now we have over-privatized the function of emergency medicine, and so we are lurching back and forth over Rube Goldberg solutions of private insurance….which is to be paid for (maybe) by tax credits at this income level or employer mandates at that level, etc.

    Bob Hertz – The Health Care Crusade

  59. Car insurance is for lawyers, repair shops and auto manufacturers.

    Health insurance is for doctors, hospitals, suppliers.

    Without either, the respective segment of the economy shifts dramatically.

    The fate of the individual is unchanged…mortal and inconsequential to the universe. Merely the cash cow unless he has no coverage.

    The politician does not want the baggage so he mandates free care. His problem has been solved by stealing from the rest of us. And we think he is a hero.

  60. Agree.

    I hang at numerous blogs (all using my traceable name). I can tell you that this one is quite, quite mild by comparison. Maybe the signal to noise ratios are suboptimal for various peoples’ tastes (here or elsewhere), but, they’re just words. And, a lot of the signals are quite substantive, and worth one’s time.

  61. I think John, you should come here more and more. Once the voices of reason retreat from the public debate in disgust or despair, the argument has been lost. We, as a society, cannot afford to lose this argument.

  62. Why do you care whether I have auto insurance (mandated)? You care because you see (and experience) the direct results of the other guy not being able to cover your loss. We see this every night on the local news when they cover accident scenes. Get the local nightly news into the ER and other hospital wards to show un(under)insured getting care and asking the cost and how it is being paid for.

    Even feel good news stories about moderate income insured people being treated for catastrophic illness does not ask them how they’re affording to pay for it – because that would take away the “feel goodness” of the story and infuse too much reality.

  63. Thre are people who have great coverage but no dicipline to care for themselves as fantasized by this nurse. People are not in the ER just because they are uninsured. I am in year 30 as a physician in an ER (same one for all 30 years). Nothing should be free anywhere in our society. Even with insurance there are out of pocket costs.

    Grow up, America.

    BTW. Doctors in Greece are on strike. No amount of coverage will get you care if the doc is not there.

  64. Having followed this blog for the last two or three years I see a trend toward an increase in cold-blooded arguments such as this, buttressed by an equally mean-spirited spray of sniping from a stable of commenting trolls inhabiting these increasingly treacherous pathways.
    It’s like reading Dickens or listening to talk radio, an altogether sad commentary on the rotting away of a handicapped social conscience.
    I find my self wanting to come here less and less.

  65. One thing I do care about: your desperate attempt to cover the bald front of your head. Why not get hip, and trim out? You’ll look a lot better.

  66. 1) Self selection.

    2) Mostly Hispanic.

    3) Ever wonder where the sick illegals go?

    Steve

  67. “every citizen deserves access to basic healthcare.”

    I disagree, someone that refuses to work or contribute to society when capable deserves nothing but that which they earn.

    “One way to keep it affordable is to ensure everyone pays into the system.”

    This is how we fund our schools and they are terribly over spent and deliver even worse value for the money spent.

    Its not the place nor the roll of government to manage our lives to that degree, government has never been successful at it in the history on mankind.

  68. Hi Nate — I use “care” in the same sense that you do when you posed the question in your headline. As a society we know that it is to our ultimate benefit that our future generations possess a foundation of knowledge and skills. By the same token, it is to our advantage that we have a healthy and able workforce. This means that every citizen deserves access to basic healthcare. In our current society this translates into affordable healthcare. One way to keep it affordable is to ensure everyone pays into the system. This could be done through taxes (like many other common good services — transportaion, research, schools, etc.) or through every citizen contributing to the nation’s health via insurance coverage.

  69. “…to poor to get sick, holds a lot of truth”

    This is rich…. and a possible solution to the problem at hand: increase poverty rates to decrease health care spending. Looks like we are headed in the right direction after all.

  70. “took personal responsibility and paid for your own insurance.”

    Insurance is not healthcare, if I am willing to pay for my own healthcare why am I forced to buy insurance? More so now then ever why am I forced to buy insurance that covers all sorts of treatments I would never use?

    “why should I care if you have insurance is a fairly easy one — your decision is costing me private and public resources that I wouldn’t be incurring if you took personal responsibility”

    Why don’t we make people buy disability and life insurance then, they also have public and private cost. What about all the money being spent on food stamps, why aren’t they required to take personal responsibility to feed themselves?

    “The best way to bend the long-term cost curve (which is disproportionately borne by federal and state taxpayers) is to have health insurance in the interim.”

    Actually wouldn’t it be to eat healthy and exercise?

    “The reason why I should care about whether you have health insurance is because if it keeps an emergency room doctor from treating my wife for a real emergency because the doctor is forced to take time to care for an uninsured person without an emergency, it undermines the quality of care for which I’m paying.”

    Your own argument then states that you have greater access to primary care then you otherwise would and just above you also said more primary care, earlier detection, etc is good for the public. If all these people now have insurance and try to get primary care it will make the wait at the ER look like the express lane. Where are all these people suppose to get treatment now?

    “Despite its name, CHIP is not an “insurance” program either”

    Interesting comment, then why does CHIP pay insurance companies to enroll kids in their insurance plans?

    “health “insurance” as we know it is not insurance against catastrophic illness”

    Then why did PPACA remove annual and lifetime limits so no catastrophic illness will ever go unreimbursed?

  71. “Poor people who cannot afford medical care are less able to find work and keep it.”

    If this was even slightly true we wouldn’t have illegal immigration. Very common saying amoungst the poor, to poor to get sick, holds a lot of truth

  72. I care because you will show up at my ER and we will have to take care of you, over and over. You will get crappy, or no, follow up and will come in worse. If we are both unlucky, you end up on dialysis and it costs a bundle.

    Poor people who cannot afford medical care are less able to find work and keep it. I suspect you have seen those studies. You probably just forgot about them when you wrote this piece. This means more people unemployed and more we need to support. Or, we can just blame them and let them starve.

    If your answer to this problem is a $1500 fine, why wouldnt more people drop their insurance? Any significant medical procedure will cost more than that. Sounds like free rider NIrvana.

    Finally, there is a moral side to the discussion, but I am not sure that is important to conservative economists.

    Steve

  73. Maybe people making so little (40,000) shouldn’t have children. Maybe we all need to learn to live within our individaul means. Maybe we shouldn’t be coveting what others have earned or have been given.

  74. I tried posting this response to Mr. Goodman on his blog, but the moderator did not accept it. Im hoping that “The Health Care Blog” will allow this response to be published…

    In short, the answer to your question about why should I care if you have insurance is a fairly easy one — your decision is costing me private and public resources that I wouldn’t be incurring if you took personal responsibility and paid for your own insurance. An individual mandate addresses that issue in a way that the simple “users fee” as you propose would not. If we start with your assertion that “…because of our basic human generosity, we’re not going to allow people to starve or live in destitution….”, the answers become quite clear.

    First, we know that people who have health insurance are more likely to receive appropriate care in appropriate settings and well before most conditions become emergencies. Alternatively, someone who does not have health insurance is more likely to seek care in the most expensive and inappropriate setting (emergency room). If the person can write a $2000 check for the cost of a short stay in the emergency room and hospital, great – there is no social cost in his action. However, if that person cannot afford to pay (or chooses not to pay) for those services, the provider writes the costs of those services off as bad debt. Or the provider then seeks to recoup those losses by negotiating higher reimbursement rates with health insurers who in turn increase premiums to policyholders to offset those costs. In other words, someone who chooses not to have health insurance is directly costing me money in higher premiums (either directly or in higher benefit costs in lieu of wages) to offset their decision not to obtain health insurance.

    Second, people without insurance tend to forego needed primary and preventive care that results in longer-term health problems later in life…for example undiagnosed diabetes or hypertension. When that person ages into Medicare, those higher costs are borne by me (as a taxpayer and future beneficiary) when the government must either increase taxes or cut benefits/eligibility to offset those higher (but preventable) costs. Either way, the cost of you deciding not to obtain health insurance is borne by taxpayers and other beneficiaries. The best way to bend the long-term cost curve (which is disproportionately borne by federal and state taxpayers) is to have health insurance in the interim.

    Third, uninsured Americans force our society to limit scarce health care delivery resources for those who are in actual need of health care services. The best example is the use of the emergency room. We know that someone who is uninsured is much more likely to use the emergency room as their usual source of care than someone who has health insurance. At the same time, there are instances when the insured require the use of the emergency room for emergency care. However, when scarce and limited resources are used to treat non-emergency care in an emergency setting, this unnecessary and inappropriate utilization limits those resources to the insured that need those services. The reason why I should care about whether you have health insurance is because if it keeps an emergency room doctor from treating my wife for a real emergency because the doctor is forced to take time to care for an uninsured person without an emergency, it undermines the quality of care for which I’m paying.

    Fourth, it is incorrect to assert that the uninsured do not receive federal benefits for the higher federal taxes they pay (relative to those who access the insurance tax credit.) The federal government pays billions of dollars to offset the cost of uncompensated care through community health centers, disproportionate share hospital payments, bad debt payments, funding for public health systems, etc. While services for the uninsured may be delivered locally, without doubt the cost of these programs are paid for through federal resources. Likewise, your analysis of the uninsured middle-class family does not take into account coverage for their kids through the Children’s Health Insurance Program (jointly funded by federal and state governments). [Despite its name, CHIP is not an “insurance” program either, but a program that pays for care whether there is an emergency or catastrophic condition.] In other words, the higher tax payments of the uninsured middle class (assuming they are paying federal income taxes at all) help to offset the cost of the indigent care services they use. In short, federal taxpayers are paying for the uninsured one way or the other — we are just choosing now to pay for them outside a health plan in the most disjointed manner possible. Your decision not to have health care doesn’t make my costs go away – another reason why I care if you have insurance.

    Fifth, health “insurance” as we know it is not insurance against catastrophic illness (in general) — it is a mechanism for paying for health care services as we need them (with the exception of catastrophic coverage). Premium costs help pay for delivery of services — to talk about “health insurance” in the same way as we talk about “car insurance” or “life insurance” generally mixes apples and oranges. Having said that, if the difference between me paying for car repairs for an accident that was your fault and you paying for it, I would think that “personal responsibility” conservatives would support such a mandate. By comparison if the difference between you, as an uninsured person, going to the doctor to get an early diagnosis of the mumps (rather than showing up and the emergency room after its too late) means my kids don’t catch the mumps, I believe that should be your personal responsibility and not something of which I should have to bear the burden because of your poor decision.

    Sixth, I question your estimate of an uninsured person costing $1500. If the cost of an individual health insurance policy is $3K-8K/year (depending on health care) but the tax penalty is only $1500, how will that incentivize a person to get insurance? Is your $1,500 an annual number or a lifetime number? What if the person is diagnosed with cancer and the costs of them being uninsured increases 100-fold – do they still only have to pay $1500? What about the cost of an uninsured family – does that mean that an uninsured family of four needs to pay $6,000 to cover their social costs of their choice not to receive insurance? Does it take into account the costs of inadequate care in inadequate settings and the higher costs on Medicare and Medicaid that person will incur over the long term? I’m all for the placing the burden of health care costs on the individual (thus my support for an individual mandate), but those costs must be commensurate with the actual costs of that care. $1,500 is an insufficient amount in my estimation.

    Conservatives were right in the 1990s to insist on a tax-incentivized individual mandate as part of their proposal to expand health coverage through the private sector and as an alternative to a “Medicare-for-All” single-payer approach. Why conservatives are rejecting this approach now is beyond me…

    P.S. Since you lament the dearth of research on “why I should care if you don’t have health insurance,” I would suggest the following. I think you’ll find there are more resources out there than you originally realized.

    EBRI: The Economic Costs of the Uninsured: Implications for Business and Government
    http://www.ebri.org/publications/books/index.cfm?fa=eco

    Institute of Medicine: A Shared Destiny: Community Effects of Uninsurance
    http://www.iom.edu/Reports/2003/A-Shared-Destiny-Community-Effects-of-Uninsurance.aspx

    Institute of Medicine: Hidden Costs, Value Lost: Uninsurance in America
    http://www.iom.edu/Reports/2003/Hidden-Costs-Value-Lost-Uninsurance-in-America.aspx

    Health Affairs. “Covering the Uninsured: What It’s Worth”. Wilhelmine Miller, Elizabeth Richardson Vigdor and Willard G. Manning.
    http://content.healthaffairs.org/content/early/2004/03/31/hlthaff.w4.157.full.pdf

  75. Pardon me Mr. Ogden, the safety net is not much to those making over 200,000.00 or more. to the rest of us, its quite a bit.

  76. Assuming 30 million people are living on more then $40,000, 10% of 300 million, each of those people is paying $66,666 annually to support our saftey net which isn’t much

  77. “The safety net provided by society is really not all that much.”

    Really?

    $695 billion (+4.9%) – Social Security
    $571 billion (+58.6%) – Unemployment/Welfare/Other mandatory spending
    $453 billion (+6.6%) – Medicare
    $290 billion (+12.0%) – Medicaid

    2 trillion a year not to mention 100 trilllion of unfunded promises. Not all that much?

  78. 90% or more of this country lives on or below 40,000.00 a year. Many of these are families. Some cannot afford the safety net of retirement plans, private insurance, and some cannot afford to buy a home. Many have probably lost what they had in this last banking/mortgage fiasco. The safety net provided by society is really not all that much. The average senior lives on a yearly income of below 20,000.00 a year. Thank god for Medicare and Social Security, I really don’t know what the 90% of American citizens would do without it.

  79. “Or that all children (not just mine) receive a full education?”

    There is a difference between saying you care and actually caring. We have most inner city schools graduating less then 50%, if you cared this wouldn’t be happening. You say you care so you feel good about yourself despite the reality that we don’t provide educations to all kids.

  80. Right now, the only reason I care whether you have health insurance or not is that if you don’t , I will be one of the people who pays for your life-saving treatment through MY insurance premium or tax payment. That will cost ME money. Money that you could have paid through YOUR insurance premium or tax payment.

  81. Creating a good health plans is obviously very important. it is more valuable to prevent the disease rather than to cure one. We should start from general health education for all level of citizen. It is a long term goal. But i think this a reasonable goal.. 😀

  82. I don’t agree with much that is posted on this blog including many of your comments Margalit, but I do agree with at least part of your statement. The sooner we dump insurance as a mechanism to purchase health care, the better off we will be. Universal health care achieved through the mechanism of third party insurance will be an abomination that will drag this country down for generations. Take a look at medicare part D. You have to be either willfully ignorant or a lunatic if you cannot come up with at least one way to provide medication for our seniors in a way that would cost far less than this ill conceived benefit program. We simply do not have a good track record in this country when it comes to designing massive programs in which the government purchases private services and we should actively avoid any such future programs.

    And I don’t mind the progressive tax system as long as everyone pays something, even if that something is almost nothing. No one values what they don’t sacrifice for – I see that every day in my office. And everyone I have ever met who works in health care understands what I am talking about.

  83. Oh wow!! I agree.

    The health insurance model is antiquated, inequitable and very inefficient for providing actual care. Nobody should have health care insurance. Everybody should just have health care, when needed and as needed, regardless of income and/or any other considerations.

    And such a wonderful progressive idea deserves an equally progressive implementation, i.e. fund it all by progressive taxation.

  84. I had the same opinion as the author until I began working in healthcare. I worked as an Emergency Room nurse for many years and saw first hand how important health insurance is. I would see people who couldn’t afford insurance or even go to the doctor, but would present to the ER with serious medical issues.At one point, these medical conditions could have easily been treated in the primary care setting. I have also seen the other side where uninsured patients would treat the ER as a doctor’s office. So how does that affect you as the patient? 8 hour waits. I can guarentee the author will be wondering about other’s insurance status when in pain experiencing the long wait times that ER are notrious for.

  85. Perhaps for the same reason we care that others wear their seat belts? Or that all children (not just mine) receive a full education? In a fair, responsible and socially progressive society, some laws are instilled for the greater good.

  86. Mr Goodman tries very hard to muddle the waters. Most people in the US, if I recall recent surveys correctly, support universal coverage (and also support EMTALA, the unfinanced mandate to at least stabilize the critically ill, which is another reason to care about coverage). Forcing individuals to have insurance is one way to get there, not the one I would prefer.

    There is a libertarian minority who feels that sickness is an individual risk (that can be alleviated by risk pooling if the individual elects to do so, and otherwise may be taken care of by some mysterious charity that all of a sudden has the resources to pay days and weeks of in patient treatment). Or, if such charity does not materialize, like for the comatose person in the original case scenario at the infamous republican debate: “I say we personally tell that stupid coma guy to suck it! In Morse code hand squeezes.”(Steven Colbert).

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