Talmudic-Like Studies of Republican Health Reform Ideas

After doing Talmudic-like studies of the doctrines on health reform promulgated by Republican health-policy makers and the conservative economists who inspired them during the past two decades, I am devastated to discover that all of those studies have been for naught. We are now told, sometimes by the same prophets of yore, that these doctrines were not only wrong, but outright heretical, which in this context means un-American.

New doctrines are rumored to be in the making, but the first word on them has yet to be committed to new, sacred tablets, mainly because there have not yet emerged any new ideas worth committing to tablets.

Do not take my word for it. Newt Gingrich, one of the Grand Old Party’s aging prophets, said so himself in his recent speech to the Republican National Committee.

Comes now conservative commentator John R. Graham of the Pacific Research Institute, telling us that Republicans seem lost in the desert even in their hit-and-run insurgency against their sworn enemy, the Affordable Care Act of 2010 (ACA).

What is a befuddled immigrant to the United States like me, eagerly trying to become a right thinking American, to make of it all?

My early introduction to the texts coming from conservative thinking on health reform was the Heritage Plan of 1989, Viewed through the prism of the ACA of 2010, its language seems eerily familiar. One provision, for example, proposed a:

“[m]andate all households to obtain adequate insurance. Many states now require passengers in automobiles to wear seatbelts for their own protection. Many others require anybody driving a car to have liability insurance. But neither the federal government nor any state requires all households to protect themselves from the potentially catastrophic costs of a serious accident or illness. Under the Heritage plan, there would be such a requirement” (p.5).

The Heritage Plan also called for income-related, refundable tax credits toward the purchase of private health insurance. Although it did not call for community rated premiums, it proposed means-tested public subsidies and toward high out-of-pocket expenses of individuals and families. It did not spell out the daunting administrative apparatus that would entail. But one can imagine the required new bureaucratic apparatus, replete with auditors to prevent fraud and abuse. Presumably, income-related subsidies would have involved the Internal Revenue Service (IRS) in some ways as well.

Next came a text put forth by conservative economist Mark V. Pauly and like-minded colleagues in Health Affairs. It is worth a reading again. Here’s the core of these prophets’ proposal:

“In our scheme, every person would be required to obtain basic coverage, through either an individual or a family insurance plan. …All basic plans would be required to cover specified health services; plans could, however, offer more generous benefits or supplemental policies. The maximum out-of-pocket expense (stop-loss) permitted would be geared to income, with more complete coverage required for lower-income people, to ensure that no one faced the risk of out-of-pocket expenses that were catastrophic, given their income.” Again, lots of government intrusion into health care, along with links to the IRS.

There then followed a real life health bill based on these ideas, the late Republican John Chafee’s antidote to the emerging Clinton plan. It was called the “Health Equity and Access Reform Today Act of 1993” and had an impressively long list of Republican co-sponsors, among them Senator’s Orrin Hatch (R-Utah) and Charles Grassley (R-Iowa), now fierce opponents of the ACA. As the folks at the Kaiser Family Foundation have shown, many of its provisions of Chafee’s bill have a striking similarity to provisions in the ACA of 2010 and comparing.

I know from personal conversations with former Congressman Bill Thomas (R-California) that in the late 1990s he and his colleague James McCrery (R-Louisiana), both of the House Ways and Means Committee, had crafted in the late 1990s a bill encouraging the gradual replacement of employment-based health insurance with individually purchased insurance. Apparently it could not be sold to the incoming Bush Administration, probably because it called for a slew of new regulations of the health insurance industry and the bill called for more federal money than the much smaller amounts that Bush Administration was willing to spend on expanding health insurance. Although a copy of the draft bill is not publicly available, I would bet that it continued the design parameters typically proposed by Republicans in the 1990s and incorporated in the ACA of 2010.

As late as 2003, Stuart Butler of the Heritage Foundation testified before Congress on health reform. In it he noted that

“Today there is a legal and moral obligation on society to provide some level of health care to those who become ill,” adding “It is also reasonable to expect residents of the society who can do so to contribute an appropriate amount to their own health care. This translates into a requirement on individuals to enroll themselves and their dependents in at least a basic health plan — one that at the minimum should protect the rest of society from large and unexpected medical costs incurred by the family. And as any social contract, there would also be an obligation on society. To the extent that the family cannot reasonably afford reasonable basic coverage, the rest of society, via government, should take responsibility for financing that minimum coverage.”

Finally, as late as May 2009 Republican Senator Tom Coburn (R-Oklahoma), a physician, threw into the legislative hopper Senate Bill S.1099, “The Patient’s Choice Act”. It had seven Republican co-sponsors. Evidently it was hastily composed, presumably as an antidote to the then brewing ACA as a platform from which Republicans could negotiate with Democrats.

Coburn’s bill calls for a benefit package like that given to Members of Congress, state-based health insurance exchanges based on some European models (Switzerland and the Netherlands), auto-enrollment into health plans with a chance to opt out, guaranteed issue, and so forth (see Expanded Summary of the bill here and here). I had commented on that bill in The New York Times in 2010, noting how the bill slouched towards the Affordable Care Act. The insurance exchanges called for in S.1099 all would have to have interfaced with the IRS, with the state Medicaid plans, and with employers – certainly small employers – just as do the exchanges under the ACA –roughly the same bureaucratic infrastructure.

So what are we to make of the spectacle of Republican anti-Obamacare insurgents, busily fielding hit-and-run attacks against sections of the very sacred tracts that their own prophets had promulgated as principles during the past 20 years? On what principles, new or old, are these hit-and-run raids conducted?

The amazing spectacle put on by this insurgency, however, can explain why Republicans now come across as nomadic tribe lost in the intellectual desert on this issue, as is being argued by Newt Gingrich, and also why now even their hit-and-run raids pick on the wrong targets, as John Graham argues. It seems that, like most insurgencies, this one knows what it is against but not what it stands for.

But history tells us that there is always hope. Eons ago the twelve tribes of Israel, under the leadership of Moses, reportedly were lost in the Sinai desert, in a random walkabout of some 40 years. A possibly apocryphal rumor has it that eventually an exasperated Mrs. Moses stamped her besandaled foot in the sand and shouted “I have had it with your leadership, Moses! I’m going to ask for directions.” And so she did, and so they got to the promised land.

Perhaps some day someone in the Republican Party will ask for coherent, principled directions on health policy – and this time follow these directions. Perhaps.

Uwe Reinhardt is recognized as one of the nation’s leading authorities on health care economics and the James Madison Professor of Political Economy at Princeton University. He is a regular contributor to The New York Times Economix Blog.

65 replies »

  1. Professor Reinhardt:

    The discourse on whether the ACA takes it’s origins from GOP DNA is completely beside the point. This entire exercise, indeed, the ACA, itself, is a solution looking for a problem.

    People in need of health care can get health care in this country already, for a fee or for “free” (taxpayer subsidized). Our sidewalks are not awash with hobbled indigents begging for a kidney transplant or chemotherapy. Public and charitable hospitals do not refuse patients because of an inability to pay. The Catholics, Methodists, Baptists, Presbyterians, Jews and Masons all operate charitable hospitals. Doctors give away more of their time than any other profession, to care for the infirm and the needy.

    The delivery of health care in this country may not be the most efficient model, nor is it virtually, in all instances, even effective. But to say that our “system” does not comport with our “social ethic” is just plain wrong and exposes your obvious bias.

    As for your comment that “patriotism in America is dead” then I would submit that your assessment is an accurate portrayal of those who yearn for a bigger, more intrusive, “cradle to the grave” centralized government. It was resistance to such a monster that proved to be the reason this country was founded in the first place.

  2. “Don’t tax you, don’t tax me, Tax that fellow behind the tree”

    R. Long

  3. Bob –

    Not long after the Medicare Catastrophic Act passed in 1988, a large group of seniors literally mobbed then House Ways and Means Committee Chairman Dan Rostenkowski’s car in Chicago. Shortly after that, the legislation was repealed. Seniors balked at the income tax surcharge as the financing mechanism. This is all too typical of Americans who want entitlement benefits but they expect someone else to pay for them.

    This is just another example of why I get upset when liberals try to create the impression that we just need to soak the top 5% of the income distribution and everyone else can have the benefits they want. Moreover, these politicians never define the term “fair share.” I think they believe it is always more than whatever high income people are paying now no matter how much that is.

  4. I just finished Paul Starr’s excellent book ‘Remedy and Reaction’.

    The political history of health reform is even more convoluted than I knew.

    Richard Nixon proposed an employer mandate in 1972.

    Russell Long of LA proposed national catastrophic insurance in 1974.

    The Medicare Catastrophic Act of 1989 called for a monthly premium to seniors of $4.92 plus an income tax surcharge topping off at $2,100 per couple.

    This country is a lot more new-tax-phobic than I thought before reading this book.

  5. Uwe, making a living inside the walls of academia….

    Never to know the mechanics of the real world…

    Ah, these “intellectuals”. “renowned researchers”.

    The only difference they have made is to screw the system up even more in the last 40 years.

    To show you how dishonest Uwe is, think about this. He blames Republicans because they had control more years. So, he assumes correlation. He assumes cause-effect from timeframes. WOW!!

    TALK ABOUT Not even allowed to pass a freshman course with such blanket correlation. Disgusting….

    Yet he is an expert for on healthcare policy. One of nation’s best.

    Total Joke! No wonder system is broke. These losers are driving the process.

    I am sure the typical response of self-defense wrapped in intellectual words will pursue.

    Just remember, you made the most ridiculous statement in history. on a blog!

  6. I suggest it is not trivial to add that none of the legislation passed by congress, signed by president, or, “amended” by supreme court, legally allows the irs to unilaterally decide there will be subsidies in federally established exchanges (in direct violation of the wording and intent of the bill passed). Since the irs’s illegally fabricated subsidies will trigger penalties/taxes to employers to the tune of $700 billion, I do not consider this unconstitutional implementation of The Act to be splitting hairs.

  7. Barry Carol, thanks for this. Sorry for getting defensive. It comes from growing up Liberal in the South.

    We are in broad agreement with most issues, and I agree with your mention of tort reform, a buzzword that needs a response. The popular “trial lawyers” trope gets trotted out repeatedly and the sooner we get safe harbor courts into the system the sooner that pesky matter will be put to bed.

    But related to that is a larger problem of “defensive medicine” which I believe is bigger than a fear of litigation. My gut feeling is that doctors over-treat and over-subscribe for two other reasons (other than mercenary).

    First is what I call professional hubris. Military commanders don medals and strut, politicians tend to be narcissists, preachers pontificate (bishops pronounce the word “God” with an audible upper case “G”) and doctors breeze in with starched white coats, speaking vernacular, writing scrips and ordering tests. These stereotypes are hateful to real professionals, but they do not spring from imaginary places. Denials notwithstanding they are too often not far off the mark. We all can think of personal examples who fit those molds.

    Second it a very human desire to be protected from the emotional responses of family members who take an emotional toll on doctors all day, every day. And it’s never enough to compensate for the few gestures of heartfelt gratitude for success and even more rare expressions of sympathy for the doctors and staff who have truly done all in their power to keep a patient alive and/or comfortable and had to face failure themselves.

    These are not measurable causes for high medical costs. But I am certain that they play as much a part of the final tally as marble floors, potted plants, high-end coffee service in the waiting rooms and 24/7 concierge food service.

    As for IPAB, I was under the impression that it has more policy input than you describe. Limits may have been added during reconciliation, but my impression was that IPAB would be the new Gorilla, calling most of the shots which would be enacted by default, with Congress needing to affirm objections to overcome them. If that has changed, I stand corrected.

    As for taxes, we can save that discussion for a different time. There is plenty of room to reduce costs at the retail level before worrying where to get more money.

  8. John Ballard –

    First, like Legacy Flyer, I don’t have a lot of respect for the Republicans either when it comes to healthcare policy, at least since about 2003. The only decent idea that they’ve offered that didn’t make it into the ACA is tort reform. Selling insurance across state lines would just drive a regulatory race to the bottom. Guaranteed issue without a mandate for people to buy insurance or for employers to provide it (the Nixon approach) can’t work because of inevitable adverse selection.

    I’m a strong supporter of IPAB conceptually but it will have its hands tied behind its back because it can’t recommend reductions in Medicare benefits or increases in beneficiary premiums. Basically it’s limited to offering areas where provider payments can be further squeezed such as imaging and maybe certain cardiac procedures.

    I don’t think my comment about taxation is “liberal bashing.” Liberals just haven’t been honest with the middle class with respect to how much a comprehensive social safety net costs and who is supposed to pay for it. In Germany, for example, everyone pays a payroll tax of about 15%, including about half nominally paid by the employer, for health insurance but the tax only applies to wages up to €45,000. Value added taxes across Europe average 20% and reach 25% in Scandinavia. We don’t have one (yet). A 20% VAT rate in the U.S. would raise about $1.2 trillion annually.

    The wealthy have done well over the last 30 years or so because of the sharp increase in asset values from stocks to real estate to oil and gas to timber. I’ve always said that you can’t get rich in America by working for a salary. Aside from inheriting wealth, you need to be an owner of or partner in a successful business. For corporate executives that means stock options and restricted stock awards. For the rest of us, it’s mutual funds, individual stocks and maybe real estate.

    On the tax burden, the middle class has to pay for the broad middle class and the rich can pay for the poor. Longer term, I think, at the federal level, the middle class will pay payroll taxes and a value added tax but not income taxes. The income tax might eventually be zero on the first $100K of income, 25% from $100K to $1 million and 35% or so above $1 million with essentially no deductions or exemptions except for charitable contributions above 2% of income. State and local taxes will remain the same structurally but will drift upward as a percentage of income.

  9. Ahem.
    I’m one liberal who doesn’t think that all we have to do is keep raising taxes on the top 1% or 5% of the income distribution and we can sustain the current system. And I don’t think I am an outlier. In terms of taxes, it is plain that the system which has crept into use over the last twenty or thirty years has torpedoed any real meaning to the notion of progressive taxation. Whatever the reasons (and they are many), new wealth has been and continues to flow overwhelmingly to the top quintile of the population. The arithmetic is startling.

    But it is wrong to conclude that the desire to rectify an unbalanced tax system is tantamount to imagining that the current system is sustainable. Surely you are aware of the current flap over Howard Dean’s nutty attack on IPAB, the crown jewel of ACA, the famous “death panel” itself, which was conceived to do precisely the opposite of maintaining the current system. There was and continues to be a political tug-o-war between Congress and what used to be MedPac, now displaced by IPAB, over the heart of reimbursement structure of both Medicare and Medicaid. In that contest the jury is still out. And even when the dust settles (and it will, make no mistake about it — IPAB is enshrined in law, no longer up for discussion) the future will remain tenuous as a variety of experiments, bundled payment models and other tweaks a finally given a shot at correcting disparities across the country.

    All the parts of this Rube Goldberg Plan are slowly but surely getting cobbled together, and until it has been given a chance to do something, carping about what it won’t do is premature. So let’s lighten up on Liberal bashing and wait until the main corpus of ACA actually gets in motion. As real problems arise, let’s address them and look for remedies as needed. Your suggestions are positive and have genuine merit, and my guess is that all of them will be approached one way or another once IPAB gets up and running.

    Congressional resistance to Dr. Berwick was robbed the country of one of the most gifted administrator for CMS and crazy talk about “repeal and replace” and “defund Obamacare” continue to poop on he GOP brand. But in time, despite political resistance, what is finally in place (with Republican/ Conservative fingerprints all over it as Dr. Reinhardt points out) is as good as it’s gonna get. We need to give it a chance to work.

  10. Barry’s comment reminds me of a truism I read some years ago, I think the author was Louis Sullivan…….

    and it was something like this:

    “Pick out low cost, high quality, and fast access…….you can only have two of these, never all of them.”

    I was fascinated by Dr Reinhardt’s remark that the Democrats are paying dearly for trying to finance the ACA, unlike the 2003 Republicans who basically put the MMA act on the national credit card.

    Makes me wonder, would the Democrats be in worse trouble if they had just raised income and payroll taxes on any one making over about $75,000 to pay for the ACA………instead of the complex and sometimes sneaky ways they did claim to finance the ACA, ranging from actual income taxes on the rich to dubious Medicare cuts to almost ludicrous revenue raisers like taxing tanning salons.

    Maybe their bill would never have passed with a straightforward tax increase.

  11. Barry,

    Agreed and probably put more clearly and eloquently than I did.

    And please note that Bush and the Republicans (theoretically known for their business acumen) put forth an addition to Medicare that didn’t require Medicare to buy generic drugs, but instead required the government to pay “top dollar”. Gee, what a great idea – Medicare costs are unsustainable, but we add an expensive drug program on top of it.

    It was at that point that I lost all respect for Republican Health Care Policy – what little I had. How do you spell PANDERING?

  12. The rank ordering of medical services, tests and procedures that Oregon attempted a number of years back recognized that resources are finite and somebody has to say no, we can’t give everything to everyone. Numerous other countries that spend between 9% and 11% of GDP on healthcare implicitly made a political decision about how much healthcare each society can afford. It doesn’t necessarily square with how much healthcare people might need or want.

    We could lower healthcare prices in the U.S. if Congress could stand up to lobbyists and allow Medicare to specifically take costs into account in deciding what to pay for and not pay for. This is especially true in the areas of new drugs (especially biologics) and medical devices. Reference pricing, tiered insurance networks and narrow networks could create countervailing power against large hospital systems that have significant local or regional market power. Sensible tort reform could sharply reduce doctors’ perceived need to practice defensive medicine. Paying doctors to help patients work through end of life choices and goals, execute living wills and advance directives as well as provide informal guidance to spouses and adult children would also be helpful. Making the Medicare claims database available to outside analytics firms could mitigate fraud. We haven’t even scratched the surface yet on what’s possible and doable to reduce medical cost growth.

    In this country, the focus has been on expanding access with little attention to costs at least so far. Liberals seem to think that all we have to do is keep raising taxes on the top 1% or 5% of the income distribution and we can sustain the current system. It won’t work.

  13. That was actually not the Oregon experiment I was referring to.

    Nevertheless, an interesting piece of information in its own right.

  14. Your mention of Oregon is worth underscoring.
    The famous but quickly forgotten “Oregon experiment” which happened when the state ran out of funding for Medicaid and awarded Medicaid randomly via a lottery. The result was an ideal control group and another experimental group which could be compared for efficacy of Medicaid.

    NEJM was dry but clear:

    This randomized, controlled study showed that Medicaid coverage generated no significant improvements in measured physical health outcomes in the first 2 years, but it did increase use of health care services, raise rates of diabetes detection and management, lower rates of depression, and reduce financial strain.

    Ezra Klein reported basically the same thing and National Review gleefully jumped on the story a day or two later. (They just love the part about “no improved measurable outcomes” disregarding the parts about lower depression and financial stress… we all know how poor people are always bitching about how they can’t get ahead, right?)

    Here’s the Google link I used that got all three references and others:


  15. Thanks Vik Khanna for your above comments-AMEN to you! We are spinning our wheels in the mud going realy nowhere on Health Care reform and other pressing matters unless we address these systemic problems that you have identified and with which I fully concur.

    I wouldn’t have singled out one Congressman or Senator- They are ALL stuck in a system of there own making at worst or complicity at best. I would also sadly include the White House.

    Dr. Rick Lippin

  16. Amen, Rick. Campaign finance reform is critical, as are redistricting, term limits, and transparency about how government operates. Every single Rep’s or Senator’s schedule should be up on the web daily, as well as spending by their offices.

    These arrogant, thoughtless (see, for example, Elijah Cummings of MD) people live gold-plated lives and slip easily into believing that they are simply above it all and have no need to answer for how they spend what is really OUR time and money.

  17. Barry Carol,

    Thanks for the (limited) support.

    My support for a single payor system may not be for what some would call a true single payor system.

    Basically, I believe that every American should have some kind of basic healthcare available. But, I do not believe we can afford to give “Cadillac” health care to everyone. I support some kind of single payor or Medicaid for all, but this would not cover everything.

    However, I do not think we can force all healthcare to exist within this framework – like the Canadians have. So I would propose that this be a baseline system, which could be supplemented by other insurance – similar to what the British have.

    Now some will argue that this would create a multi-tiered health care system in which poor people get worse care than the wealthy. To this I have two responses:
    1) In reality, that is how it works now.
    2) This is entirely consistent with how we handle other basic needs. In general poor kids don’t go to the same schools, poor people don’t eat the same diet, housing for the poor is not the same, transportation, etc.

    Frankly, I liked the idea that was put forward in Oregon years ago. Treatments would be rank ordered in terms of their cost/benefit ratio and we would fund them up until we ran out of money for health care. So a child would get antibiotics for pneumonia – high benefit/low cost, but a 90 year old demented, diabetic would not be admitted to the ICU – low benefit/high cost.

    This would require some kind of panel (a death panel if you wish), to decide what is most important. I reject the idea that we cannot make judgements about who is entitled to what when it comes to healthcare, but we feel free to make those same judgements (either intentionally or by default) about other things.

  18. I’d go further and say that the “law” being implemented in 2013 is neither the one signed in 2010 nor as amended by SCOTUS in 2012, in important ways (e.g. employer-mandate delay).

  19. Perhaps Dr. Reinhardt can tell us how patient expectations and the inclination to sue in the event of a bad outcome or the failure to diagnose a patient’s disease or condition differ between the U.S. and Western Europe / Canada / Japan.

    Defensive medicine pervades the medical culture in the U.S. but its financial impact is impossible to quantify with any precision because perceived patient expectations and, to a significant degree, financial incentives also influence doctors’ decisions to order tests and perform procedures.

    I think Democrats may have been able to pick up some Republican support for the ACA is they embraced tort reform that provided doctors with safe harbor protection from failure to diagnose lawsuits if they followed evidence based guidelines and removed medical disputes from juries of lay people and substituted specialized health courts with the power to hire neutral experts to sort through conflicting scientific claims. Of course, to do that would have required Democrats to take on the trial lawyers which are a key part of their base.

    I agree with Legacy Flyer’s take except for his support for a single payer system which even the liberal expert Ezekiel Emanuel opposes.

  20. Indeed, let’s review.

    Y’see, people don’t want actual health care, concretely. They want maximal nominal inscrutable “choices,” abstractly. A Bazaar of choices having, in the end, nothing do do with actual health care, concretely.

    “Do you hate children or do you believe they are too stupid to handle any choices in the future”

    I HAVE children, and a grandson. I don’t think they would benefit materially from broad “choices” of contending private defense militia Plans.

    There IS a market for that sort of thing. It’s called Afghanistan. Try it. Report back to us.

    Should you live long enough, Infidel.

  21. This discussion has become a circular argument. No one has mentioned that Medicare does not “ration” drugs or treatments, it only determines how much it will reimburse for such. All that is being “rationed” is tax money, and even that is officially only for 80% of the charges (note — charges are not the same as costs).

    Medicaid actually rations treatments but here again it is a mechanism for stewarding tax money. And until physician payments finally become the same for Medicare and Medicaid — a first step in making the administration of care more equitable, as well as making accepting Medicaid patients attractive for a few more doctors — further scaling of resources will incrementally be passed to IPAB.

    The transition from what we have to anything even a little more rational (note that word rational) cannot be done quickly. Too many pieces to the puzzle. This steaming pile of you-know-what didn’t happen overnite and won’t be cleaned up in a hurry. The famous Private Sector (PBUH) will always have an important role to play, whether that means employers, insurance companies or (oddly enough) providers of the actual care. Other countries have taken a mixture of approaches from cost controls (aimed at curbing the private sector) to insurance tweaks. Canadian Medicare is administered by the provincial authorities and private insurance is taboo, but the NHS in UK is their equivalent of federal, plus private insurance enables a raft of alternatives for those who can afford to pay.

    In the final analysis, the main “rationing” boils down to money. Those who can afford care get as much as they can afford, and those who don’t simply do without. It’s more clearly seen in the case of dental care. The difference, of course, is that medical care is more of a life and death issue, which makes great fodder for politicians, media voices and anyone selling stuff.

    Taxpayers will complain about Medicare, until they get there themselves.
    Then they will complain about Medicaid until Grandma runs out of assets.
    Then they will complain about food stamps until they see their grandchildren qualifying because their parents are not earning enough for “food security.”
    And so it goes.
    The social safety net’s a bitch, isn’t it?


  22. “the law that was passed by congress and signed by the POTUS.”

    First it’s “lawless”, then it’s the “law” passed by Congress and signed by Obama. I see nothing “lawless” about the system of government the founders created.

    You’ll need to win an election to get rid of Obamacare – you know, the legal way. But maybe that’s too much to ask.

  23. Same response. I call it The Act because it is not the law that was passed.

  24. Actually, The Act that was upheld by SCOTUS was not the same as the law that was passed by congress and signed by the POTUS.

  25. Uwe, as I write in my Forbes.com post just posted on THCB, Obamacare is almost identical to proposals made by the American Medical Association under the Nixon administration to avoid the dread socialized medicine of “single payer” favored by those noted communist sympathizers, the Kennedys.

    Meanwhile, there’s a Talmudic solution for your puzzlement. There is a famous Talmudic story about Moses being given the chance by God to see a class on the Torah taught far in the future by a great sage. Moses felt bad because he didn’t understand any of what was being taught — until the teacher cited as his authority “the Torah as given by Moses.”

    So you see, even though there doesn’t seem to be any logical link between the conservatives of the past and the hard right GOP of the present, if you had the vision of Moses — or a direct connection to God — I’m sure you’d see that it al makes sense.


  26. “the lawless manner in which it was proposed, adjudicated, and now being implemented by this administration”

    Y’see, when I don’t get MY way, it’s “lawless.”

    I thought it was now a “law,” One upheld by SCOTUS (also part of the “law” system). Silly me.

  27. Wrong wrong Aurthur.

    You choose your doctor, you choose your hospital, you choose your treatment – just like now.

  28. All is trivial unless we get real campaign finance reform

    Dr. Rick Lippin
    Southampton, Pa

  29. “it is the lawless manner in which it was proposed”

    Take it up with the Supreme Court.

  30. Let’s review. Single payer equals one payer, yes? One payer means only one payer. correct? A root of one is mono, yes? Mono payer equals one payer, ok? One payer means mono payer means monopoly payer, right? One payer, monopoly payer, only government payer means government monopoly payer, right? Monopoly government payer means no options, yes? No options means no choice, right? Why do you believe no choice works best? Why do you believe you should eliminate all choice for anyone else? Do you hate children or do you believe they are too stupid to handle any choices in the future?

  31. Dear Befuddled Immigrant (btw, not even the snarky and chauvinistic French had the disingenuousness and gall to use the term “befuddled” on the Statue of Liberty), Since you have requested guidance on right thinking Americanism, please note Americans, historically, do not abide well any authority (particularly illegitimate) dictating how they will behave. While there are obvious and well documented problems with “The Act” aka PPACA, it is the lawless manner in which it was proposed, adjudicated, and now being implemented by this administration that invalidates everything else associated with it. The Act does not lawfully allow subsidies in federally established exchanges. The IRS cannot lawfully levy taxes on citizens (to the tune of $700 billion). The result of The Act with guaranteed issue, no preexisting limitations, and tax/penalty payer funded subsidies, completely removes the concept of insurance from the system (likely intentionally). All the proposed ideas you site as pre obamacare republican predecessor ideas included the basic concept of insurance. The Act codifies and regulates insurance out of the system. You cannot reasonably equate these two opposing starting points. Finally, your use of the Old Testament as a cutesy literary device to belittle any efforts to disrupt this abomination should cause those around you to fear biblical vengeance. However, there is time to repent and purchase a surge protector.

  32. “In this regard, the right has the workable answer: ration by ability to pay, just how we ration Coca Cola. It really works well, if you can stomach the ethical implications.”

    You must also be one of those “Conservatives” who are lost in the desert. Yes, those pesky “ethical” implications, if only we could just look the other way. Child labor worked pretty well as did slavery.

  33. “That makes you wonder how well a single payer system for all would work in this country.”

    We wouldn’t even get close. Canada is not without its political paybacks, however their health system has been in place such a long time and works pretty well that Canadians for the most part want to protect it.

    Private pay health care has been allowed to make an insidious inroad to keep costs increases down and handle wait times but so far the core system is not in jeopardy. Wait times have been improved and tracked better in the last several years. The article below was in 2006.


  34. The die was cast in the House in the late spring of 2009 when Nancy Pelosi and Waxman shoved aside the Republicans and their own Democratic moderates like Jim Cooper and wrote their own bill HR 3200. The House bill set off the “summer of rage” that led to the rise of the Tea Party.

    By the time Baucus convened his bipartisan group, the Republican reaction against the process was in full flower. It was too late. See my blog on this space on what happened and why: https://thehealthcareblog.com/blog/2009/07/20/a-wild-pitch-hr3200-brushes-back-health-reform/

  35. @legacy flyer (ran our of replies up there)

    Sorry for the lack of clarity. Yes, in all those examples are doing right by the patient is also doing right by society, thus no ethical dilemmas in saying no to the patient, if he/she is asking for something that is useless or harmful.

    The cirrhotic patient is a different type of story, isn’t it? (and I don’t mean organ scarcity).

    As to your series of 4 questions: You would not order that test because it is not good for your patient. How it affects you personally, or the payer, should be irrelevant.

  36. I don’t completely understand what you are saying.

    1) Giving antibiotics to a kid with a viral syndrome treats the mother not the disease. There are complications to antibiotics – some nasty.

    2) MRI doesn’t have side effects (that we know of), but there are co-pays and it puts the patient one step closer to the knife – which is frequently not a good place to be.

    3) There is significant expense to CT with IV Contrast, which have copays. Plus there is radiation, which as we all know causes Godzilla, the Hulk and Spiderman (tongue in cheek but ….)

    4) Elderly people with serious underlying medical problems frequently DO NOT enjoy their stay in the ICU, nor do they necessarily enjoy their life afterwards. Not sure we are doing them a favor by intubating, etc.

    I am not asking for any cover, but ….

    If our society wants docs to save money, it needs to protect them from the consequences of attempting to do so. Or put another way:

    Why would I not order:
    1) an expensive test,
    2) of limited benefit
    3) that I am not paying for
    4) but could save me grief later

    In order to save an Insurance Company money, but increase my risk of being sued?

  37. You are contradicting yourself. All the examples in your second comment are good for your patient. Your advocacy should include doing what happens to be right for society as well.
    Going back to your first example, in your first comment, the alcoholic needing a transplant, that’s where the moral dilemma lies, because what is good for that guy (or a prostitute with HIV, or a crack dealer shot during arrest, or a poor smoker with lung cancer – i.e. poor people who can’t pay for their sins) may not service the bottom line of the corporation insuring him, or government, or even society at large. Are you suggesting that a government bureaucrat should provide you cover to engage in unethical behavior for the “public good”?

  38. Peter1:

    I think more than a few Americans are dismayed that the US Congress has become a bazaar in which one can purchase the affection of legislators.

    That makes you wonder how well a single payer system for all would work in this country.

  39. I am glad you responded as you did, agreeing that this is both an economic and a philosophical swamp.

    Canadians have tried to sidestep this issue by creating artificial scarcity of real resources on the supply side and then looking to doctors to do the triage, just as a medic would on the battlefield. The Brits have done that as well. Americans look askance at than approach.

    Instead we put in place excess capacity in most areas and then look to physicians somehow to ration that excess capacity, a tall order for a profession not trained to do that and, in fact, not inclined to do that.

    So we thunder and thunder against excess utilization and waste in the system and say someone should say know without having any idea how that should be done.

    In this regard, the right has the workable answer: ration by ability to pay, just how we ration Coca Cola. It really works well, if you can stomach the ethical implications.

    But even the right balks when you try the flush them out of the closet on that. I once tried that with the editorial board of the Wall Street Journal. Perhaps I should narrate that story on this blog.

    I think the American Society of Health Economists (ASHE) should create the start up with the 800 number and charge appropriate fees. It would finance their biannual meetings.

  40. I am a physician (in practice since the early ‘80s) and live in the US. I am a registered Democrat, but more of an Independent/Libertarian in philosophy. I support a single payor system as the lesser of all evils, but am fearful of what a single payor system could turn into in an entitled society – more or less what we have now but even more expensive. (“I am disabled by _______ and need ongoing therapy, medication and disability payments.”

    I am well aware of who raised a “hue and cry” about “death panels”. However, studying the “cost-effectiveness” of something doesn’t give a politician the stones to say “No”. A single tragic episode splashed across the national news is enough to make most Democrats or Republicans run for cover.

    Uwe says: “So who should say No?”

    A very good question – and one without an easy answer.

    An analogy to make it clearer where I am coming from: Compare a Doctor with a Criminal Defense Attorney. Most Criminal Defense Attorneys know that a good percent of their clients are guilty. But they are not supposed to just go to court and “roll over”. They have an obligation to the client to get them the best defense possible. They represent their clients in a SYSTEM that makes the final determination of guilt vs. innocence.

    Similarly, Physicians know that not all diseases are curable, not all treatments are indicated, etc. They have an obligation to do the best for their patients – whether or not this is the best thing for the Medicare/Insurance Companies Budget. They are not supposed to just “roll over” and order the cheapest treatment. They are supposed to advocate for their patients.

    What is also thrown into this equation is a toxic mix of; “the customer is always right” and the American malpractice system. What do you do in the following situations?

    1) Mother demands antibiotics for viral URI (not indicated)
    2) Patient with 1 week of back pain demands MRI (not indicated)
    3) Patient with very low probability of PE in ER – should you get CT? (not indicated)
    4) Elderly patient with very low probability of survival – family wants ICU admit and everything done. (patient unlikely to benefit)

    What you need to realize is that “doing the right thing” can yield:

    1) Loss of patient/family from practice. Bad Press Ganey scores
    2) Unhappy patient, hell to pay if something serious shows up later
    3) Congratulations – 99% of the time, you saved Medicare/ Insurance Company a lot of money. 1% of the time you get sued and Kathleen Sebelius will definitely not be sitting next to you in court.
    4) Trouble and lots of it

    It isn’t reasonable to simultaneously expect Doctors to do the best for their patients and for the Insurance Company / Government. Now if all the doctors work for the Government theoretically this problem is solved. But I doubt if this would be popular with the public. Alternatively, we can try to set up some clearer guidelines AND (a unique and unpopular idea for Obama and Sebelius) PROTECT docs who work within those guidelines.

    But, a politician/bureaucrat would have to stand behind the consequences of rationing and accept responsibility for his/her decisions – not use the current dodge – “that is what your doctor prescribed”. And by the way, I think rationing is perfectly reasonable, but the people who benefit; politicians, health care “experts”, and the taxpayers need to step up and take credit/blame.

    By the way, I like your idea of the company with the 800 number. You could work for this company and since you are one of the “economic brains” behind health care reform, you should take a lead role in explaining why unplugging Grandma is good for the economy. Can I get your cell number?

  41. “The failure is bipartisan”

    Ask yourself why it’s bipartisan. Look no further than how politicians get their election funds – bribes from corporate America and rich people. A bribery system of government will fail – and has been failing and will continue to fail.

    Title of Ralph Nader’s new book – “Told You So”

  42. Jeff,

    Was it really stuffed down the throats of Republicans? I recall Baucus making strenuous efforts to bring Republicans to the table, as did Kennedy’s HELP Committee.

    Furthermore, what more could Democrats have done than starting out with a basically Republican design as their main blueprint. Surely Republicans of goodwill could have worked with that, had they seriously wanted to forge a bi-partisan deal. So I reject the stuffing down their throat thesis. What concretely did Republicans bring to Baucus’ table?

    The House was much more old Democratic, but their plan did not get legislated. What got through was the much more Republican leaninng Senate bill. The one weird thing here was that the Dems in the House out in language to pay docs for helping patients with living wills, actually at the beset of a Republican from Georgia or South Carolina. It is an idea Newt waxed mushy on in the Wsh lost. And what was the Dems’ reward for that basically sound and fair idea?

    I agree that what came out of the Congress is a mess, but much of that mess can be adduced to two factors.

    First, given our system of governance, any attempt to expand coverage and to streamline the delivery system will come out messy, after running the gauntlet of committees and moneyed lobbyists.

    second, the Dems’ made the strategic mistake of seeking to finance the bill, which triggered a lot of the nasty taxes in the bill. think how much easier it would have been, and how much cleaner the ACA would be, if it had been a smoothly financed as the MMA 03.

  43. Status quo neither satisfactory, nor morally defensible. . .

    I just don’t understand why the fact that there is ancient Republican DNA in ObamaCare means that the current Republican party is somehow responsible for implementing what the Democrats stuffed down their throats.

    No defense of the current Republican crew implied here. The Republican party is a dying institution. Bob Dole’s comment that it should have a sign on it which reads “Closed for Repairs” really summed it up for me. That would require maturity and reflection.

    But I also think the Democratic party is a dying institution (look past Hillary Clinton at their potential 2016 Presidential roster and what do you see?) that hasn’t had an original idea of its own in two decades. Its base: public employee unions and the plaintiff’s bar.

    The failure is bipartisan, Uwe, not just Republican. The largest political party in the country right now is the “None of the Above” party. Neither of these parties has the vision or competence, nor the public trust, to reform our health system. . . .

  44. Coming out of the desert will be the realization that single-pay works the best – not perfect, but the best.

  45. To Legacy Flyer:

    Do you live in the US or outside the US?

    I ask because you seem so oblivious to the fact that it actually was not Obama, but Republicans who raised a hue and cry when Obama proposed to fund cost-effectiveness analysis and swiftly accused him basically of being a Nazi trying to erect death panels, merely for supporting the idea that physicians should be paid for helping their elderly patients prepare living wills. Newt Gingrich had earlier embraced that idea enthusiastically in a Washington Post op-ed but when the stuff hit the fan delicately demurred.

    So the word “cost” was stricken from cost effectiveness analysis, and PCORI now just does clinical effectiveness analysis. The idea is that if it works at all (is effective) Medicare should pay for it.

    You say we need to develop the capacity to say: No, you can’t have it. You don’t want to burden doctors with that task. So whop should say No?

    Why don’t you found a little company with an 800 number that doctors can call and summon you and your staff to a patient’s bedside, telling him or her “No, you can’t have this treatment (unless you have the money to pay the full cost of it).” I think that could be a lucrative start-up for you.

    I am getting this personal because, frankly, I am a little tired of the brave souls who strut about the world pronouncing that we have to say no without telling us exactly how that would be done in the U.S. context.

    Doctors need help at the bedside. The brave souls should supply it.

  46. Rolling Stones: “You can’t always get what you want, but if you try some time, you just might find, you get what you need”

    We need to (re)develop the ability to say: “No – you can’t have it.”

    – You are a cirrhotic who killed his/her own liver – no you can’t have a liver transplant.
    – You are a 90 Y.O. demented, diabetic. No, you can’t spend your final month in the ICU.
    – You have new onset back pain. No you can’t have an MRI or spine surgery.

    Steely Dan: “I’m a fool to do your dirty work”

    Instead the Government tries to push this duty off onto doctors whose fiduciary responsibility is NOT to save money for the Government or Insurance Companies, but to the patient. And at the same time the Government is trying to get docs to order less tests, prescribe less meds, hospitalize less, the top lawyers in charge – oops I mean Sebelius and Obama – don’t want to protect docs from any of the blowback such decisions inevitably engender.

    The theory behind ObamaCare is pretty standard for tjhe lawyerly thinking process. I remember a group of us in college dividing up the cost of a pizza. The future lawyer among us made the following observation: “If we do this right, everyone will come out ahead”. So OBAMACARE attempts to: improve healthcare, cover more people and reduce its cost – i.e. to make everyone come out ahead. Ain’t gonna happen.

    Good BASIC health care should be given to everyone. But we can’t have the usual everyone is entitled to everything philosophy our politicians favor. Someone – and not the doc – needs to learn to say: “You can’t have it.”

  47. The meaning, Jeff, is that if Obamacare were repealed or is ground to pieces through lack of funding, we end up with the status quo.

    Would that be your ideal?

  48. I share your pain, John. Most health policy analysts I know wrestle in their mind and soul with the issue you raise.

    We know from both theory and empirical observations that whatever markets under capitalist system would do, e distribution of health cared among citizens would be unlikely to be compatible with our social ethic.

    Some countries, Canada and Taiwan, for example, therefore turn the entire health insurance system over to government, assuming that us they will get closest to the distribution they espouse.

    Most other nations have muddled through, one way or the other, and for sheer muddling the US wins the world cup prize. But even here the goal — at least the goal stated for public consumption — is that everyone who needs health care should have it, regardless of their own ability to pay for it, something the market just could not achieve.

    We can have endless debates over the exact mix of private and public activity in health care, and it will always be so.

    The irony is that Obamacare, copied for the most part from the play book of Republicans, should have been the platform for a bipartisan compromise. Sen. Baucus certainly tried. But, if you want to be honest about it, the Republican game was to prevent the President’s reelection, and they sacrificed their own health reform ideas for that futile pursuit. It was never about what might be helpful to the people, especially th millions of uninsured.

    What would Republicans do if, like a dog chasing a car that then stops, they should win the White House and the Congress? To get a clue, read S.1099, or the old Republican plans of the 1990s. they would legislate something like Obamacare, although perhaps smaller. And, to keep it elegant, they might just deficit finance it, as they did the MMA 03, a truly irresponsible act.

    The overarching problem in America is that, the 1 percent or so of brave military people aside, patriotism in America is dead. The behavior we see in governance now is a clear manifestation of it. it is all tribal
    Olivia’s now, just as in Afghanistan.

  49. Like Prof. Reinhardt, I’m an immigrant (also from Canada) and also trying to always become more “right-thinking” (but perhaps in another sense that Prof. Reinhardt intends).

    If I could attempt to mend fences with my own side, perhaps I should note that “conservative” health-policy analysts are unwilling to just throw out calorie-free slogans like “universal access” or “health care is a right”, but really grapple with who should decide how health-care resources can best be allocated.

  50. The Democrats have a semi-coherent, partially thought out plan that elaborately re-arranges the deck chairs on the Titanic.

    The Republicans have nothing coherent, reasonable or even partially thought out.

    Dumb and Dumber II – the Health Care Sequel

  51. Ah, the exploration on how the conservatives lost their compass, but more interesting to me would be a Talmudic-like study on how the House of Hillel turned into a blathering advocate for the positions previously held by the Hose of Shammai.
    In other words, what came first, the liberal chicken turning conservative, or the conservative egg turning ultra-conservative?

  52. This loss of fundamental conservative (but humane) principles meeting the conversion of noble health care professions i to become full for profit business models, equals modern American health care that all too often, leave people who must depend on “the kindness of strangers.” Explaining America’s health care to international observers (or Martians) has become embarrassing. A society that 70 years ago saved Europe and Asia and now can’t save its own people from inadequate health services which consume 1/5th of economic activity and leave 20% of its people depending on the kindness of strangers is tragic. Perhaps we deserve to return to the desert.

  53. This is interesting history, but its meaning? RIchard Nixon, a Republican, proposed a guaranteed income AND national health insurance. By today’s party’s standards, he’s a flaming communist. So are a lot of the aides to President Bush the elder. So what?

  54. As a non-partisan conservative, I have to agree wholeheartedly with Uwe here. Conservatives both in and out of the Republican party have been embarrassingly inept — completely incompetent even — at solving even basic health policy issues even though they have controlled the White House (and, hence, the bully pulpit) 20 of the 33 years since 1980.

    For me, the root cause of the policy hubris goes to the sense of entitlement amongst politicians and their small-brained, big-mouthed pals at all the different (liberal and conservative) think tanks, law firms, and consulting firms that populate WDC, which is where the pols will all work if the ever give up office). The politicians reward themselves with the power of incumbency, which they will do anything to hold on to, including lining their campaign coffers w/money from interests grown rich on the status quo.

    They diminish the quality of debate every time they open their mouths.

  55. Great stuff.


    Etymology: “heresy,” simply “to choose.” (Absent the anti-bandwagon sociopolitical connotation.)

    “My early introduction to the texts coming from conservative thinking on health reform was the Heritage Plan of 1989, Viewed through the prism of the ACA of 2010, its language seems eerily familiar. ”

    JD Kleinke has long made note of this.

    “On what principles, new or old, are these hit-and-run raids conducted?”

    “Principles” and “Republicans” in the same train of thought? Not any more.

    “Perhaps some day someone in the Republican Party will ask for coherent, principled directions on health policy – and this time follow these directions. Perhaps.”


  56. Hamlet:
    There’s letters seal’d, and my two schoolfellows,
    Whom I will trust as I will adders fang’d—
    They bear the mandate, they must sweep my way
    And marshal me to knavery. Let it work;
    For ’tis the sport to have the enginer
    Hoist with his own petard, an’t shall go hard
    But I will delve one yard below their mines
    And blow them at the moon.

    Hamlet Act 3, scene 4, 202–209