Obamacare

Two Views On Health Care From The New Yorker

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Writing in this week's New Yorker, Atul Gawande, a doctor and justly celebrated health care scribe, is hopeful that the health care reform will leverage local experimentation in order to bring down costs:

The major engine of opposition, however, remains the insistence that health-care reform is unaffordable. The best way to protect reform, in turn, is to prove the skeptics wrong…The reform package emerged with a clear recognition of what is driving c

Mild chuckling permitted. Guffawing strictly forbidden.

osts up: a system that pays for the quantity of care rather than the value of it. This can't continue.

…The most interesting, under-discussed, and potentially revolutionary aspect of the law is that it doesn't pretend to have the answers. Instead, through a new Center for Medicare and Medicaid Innovation, it offers to free communities and local health systems from existing payment rules, and let them experiment with ways to deliver better care at lower costs. In large part, it entrusts the task of devising cost-saving health-care innovation to communities like Boise and Boston and Buffalo, rather than to the drug and device companies and the public and private insurers that have failed to do so. This is the way costs will come down—or not.

That's the one truly scary thing about health reform: far from being a government takeover, it counts on local communities and clinicians for success. We are the ones to determine whether costs are controlled and health care improves—which is to say, whether reform survives and resistance is defeated.

Well, one hopes, though I'm not sure there's much reason to. Gawande's notion that the Affordable Care Act might work, although we can't really say how, is superficially appealing to those of us who see benefits in widespread experimentation. But it isn't all that convincing when compared to John Cassidy's more skeptical view, which appeared on The New Yorker's website last week. Cassidy offers a rather blunt assessment:

The official projections for health-care reform, which show it greatly reducing the number of uninsured and also reducing the budget deficit, are simply not credible.

1. The cost and revenue projections rely on unrealistic assumptions and accounting tricks. If you make some adjustments for these, the cost of the plan is much higher.

2. The so-called "individual mandate" isn't really a mandate at all. Under the new system, many young and healthy people will still have a strong incentive to go uninsured.

3. Once the reforms are up and running, some employers will have a big incentive to end their group coverage plans and dump their employees onto the taxpayer-subsidized individual plans, greatly adding to their cost.

The rest of his post expands on these criticisms, and it's worth reading in full. But the contrast between the two pieces and their respective outlooks is worth underlining. Gawande's cautious hopefulness comes down to a belief that, given our system's flaws, something had to be done to change it. The ACA is something. It might work. It might not. We don't really know. But it was better to pass it and try than do nothing. Cassidy, on the other hand, agrees that the system is a mess, but notes that, historically, the types of reforms it enacts have not produced their desired effects, and there is little evidence that should cause us to believe that this time will be any different. I suspect Cassidy and I would disagree on what sort of system would be more likely to work, but on this, I think he  offers what is clearly the more compelling case.

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  1. London, England (CNN) — The UK scientist at the center of the “Climategate” controversy over leaked e-mails has been cleared of hiding or manipulating data by a parliamentary committee.

    But lawmakers who had been investigating the row over global warming science said in a report published Wednesday that climate scientists must publish all their raw data and methods to ensure the research is “irreproachable.”

  2. 2. The so-called “individual mandate” isn’t really a mandate at all. Under the new system, many young and healthy people will still have a strong incentive to go uninsured.

    3. Once the reforms are up and running, some employers will have a big incentive to end their group coverage plans and dump their employees onto the taxpayer-subsidized individual plans, greatly adding to their cost.

    What we need is a libertarian ACORN to publicize the economic benefits of these two actions and assist individuals and companies in taking these actions.

    I’m serious. This is not snark.

    Usually the people who talk about Galting are dufuses but this is a real chance to do it for real. The best way to fight an irrational or unjust demand is sometimes to obey it – literally.

    1. As a small business owner, I will seriously consider dumping our health care plan.

  3. Sorry about the redundancy redundancy.

  4. Ezra Klein thinks it’ll help:
    http://www.newsweek.com/id/235246

    1. Only one more year and change and Klein will no longer be considered a child under the new health care bill.

    2. Ezra Klein has obsessively supported health reform and would have put forth arguments that the reform would help no matter what.

      1. For example, he says:

        “If all goes well, consumers will be able to log onto the exchange’s Website, compare insurance plans, and choose their favorite. That means insurers will have to compete for customers. As any free-market conservative will tell you, that should drive prices down and quality up. If it doesn’t, insurers will have some annoyed legislators to answer to: The bill says congressmen and their staff members need to buy their insurance from these exchanges, too.”

        Sure, I love it when companies fight over informed consumers, but companies cannot engage in price wars for long. There must be innovation and niche filling. There will be no competition and no cost-cutting because of the standard homogeneous plans that the law will require.

        1. Its like he never even realized that this service has existed for a decade at ehealthinsurance.com

          Ezra Klein is heaping pile of douche. HEAPING.

    3. The most offensive part of that article is Klein’s claim that “the market” will now improve quality and lower costs, since insurance companies will be engaging in “good competition” and not “bad competition”.

      Because as long as you call something “a market”, it will magically produce quality improvements and lower costs, even if you have systematically outlawed everything that would create incentives to improve quality or lower costs.

      Klein doesn’t even attempt to tell us HOW quality will improve or costs will decline. He just waves his hand at it and says “good competition” will make that happen.

      People claim libertarians show excessive faith in markets, but at least we can tell you the mechanisms we think make markets work, even if you find them heartless. Klein just uses “the market” as magic words. “Abracadabra – lower costs!” It’s sickening.

      1. No, the worst is this:

        “But because the individual mandate in the bill brings everyone into the insurance market and the subsidies for those who can’t afford insurance on their own put Washington on the hook for costs, Congress will have to get serious about holding costs down in the system.”

        Ezra has just stated that the bill is going to reduce deficits (just so we are on the same page, deficits are what supporters of this bill refer to so they don’t have to talk about spending) by putting government on the hook for medical costs!

        Holy moly

        1. And exactly how is the government going to hold down costs? It’s one thing to say it has an incentive, by what mechanism is it going to do so?

          1. There’s a pretty simple answer to that question: rationing of care through coercion and price controls once single payer is implemented.

      2. He who continues to exercise faith in me, lo will he be rewarded here on Earth.

        He who takes my name in vain [Ezra Klein] will burn in hell for eternity.

      3. “Because as long as you call something “a market”, it will magically produce quality improvements and lower costs, even if you have systematically outlawed everything that would create incentives to improve quality or lower costs.”

        And when it doesn’t, they chalk it up to yet another “failure of capitalism”.

    4. Ezra Klein is an intellectually lazy partisan hack who would believe magic unicorns flying out of Obama’s ass could provide everyone free healthcare if the DNC told him so.

      1. We know. That’s what his next column will be about.

  5. . Instead, through a new Center for Medicare and Medicaid Innovation, it offers to free communities and local health systems from existing payment rules, and let them experiment with ways to deliver better care at lower costs. In large part, it entrusts the task of devising cost-saving health-care innovation to communities like Boise and Boston and Buffalo, rather than to the drug and device companies and the public and private insurers that have failed to do so. This is the way costs will come down?or not.

    The only experiments that ever work are the ones driven by the incentive of a price for failure otherwise their implementation is treated as a nice little harmless experiment with no externalities and not the life and death decisions that have long term consequences where effective action has to occur.

    1. their implementation

      Voros, we should be genetically tested, that homophonal-dyslexia can’t be mere coincidence.

      1. life and death decisions that have long term consequences where effective action has to occur.

        AKA, the conditions that gave rise to the markets in the first place, long before we took them for granted as things to be ‘experimented’ on and leeched for various political purposes.

  6. The reform package emerged with a clear recognition of what is driving costs up: a system that pays for the quantity of care rather than the value of it.

    So much wrong packed into one sentence.

    No recognition at all that what drives costs up are the disconnects between the consumer, the payor, and the provider.

    Instead, we now are reinforcing those disconnects, with bigger mandatory benefit packages, subsidies for insurance, and a general reinforcement of the idea that nobody should have to pay for any part of their own healthcare, ever.

    That’s why this will fail, Atul. All that experimentation with different ways to structure universal coverage is just arranging deck chairs on the Titanic.

    1. Exactly. We don’t get enough value for our dollars in health care; ergo, the answer is to set up a bureaucracy where technocrats can tell us what provides value.

      In a real free market, the consumer is the arbiter of a product’s value. Which is why the distorted, over-regulated mess of the US system cannot be described as free-market.

    2. No recognition at all that what drives costs up are the disconnects between the consumer, the payor, and the provider.

      Costs are rising more slowly in well-run public systems, where there is even less incentive. So that can’t be the main problem.

  7. Gawande’s cautious hopefulness comes down to a belief that, given our system’s flaws, something had to be done to change it. The ACA is something. It might work. It might not. We don’t really know. But it was better to pass it and try than do nothing.

    This is sad but true. It’s pathetic how enthusiastically ObamaCare supporters have been willing to abandon any pretense of logical argument or serious consideration of ways to actually make our system better. It’s one thing to dislike many aspects of the current system; it’s quite another to drop a bomb on it wholesale with no idea of what you’ll do to put it back together. Was it that long ago that liberals were berating conservatives for being anti-intellectual?

    1. It’s unfortunate we’re going to be on the business end of the governmental equivalent of,

      “Hold my beer – I’m gonna try something.”

      1. “….well, shit. That didn’t work. Butcha cain’t criticize a man for tryin’.”

        Grrrrrrrr

      2. Now watch this drive!

  8. What is in this bill doesn’t matter as much as people think; the Greek horse is beyond the Trojan gates, the Democrats in elected office, the bureaucracy, the courts, and in the non-profit sector now run the health care system, and will do whatever they feel like.

  9. Ezra Klein has obsessively supported health reform and would have put forth arguments that the reform would help no matter what.

    That’s unfair. He’d do that unless he was told not to. He’s open-minded.

  10. Reforming health insurance must not only keep American’s healthy, it must also benefit the health of our economy. That is why I supported cost controlling measures that will curb waste, fraud, and abuse. These measures include enhancing oversight periods for new providers and suppliers, placing moratoria on areas identified as being at an elevated risk of fraud, requiring compliance programs, creating a database for law enforcement tracking, and increasing penalties for submitting false claims.

    1. oversight, morotoria, a database, and penalties. I think we will all soon be rich and healthy.

      1. You missed “compliance programs” – welcome 🙂

        1. Damn it just keeps getting better.

      2. I have always held that health care is a fundamental right to all people, and that as a nation we must do what we can to provide Americans with access, affordability, and stability. For too many years, I have heard stories from folks who are either dropped from their insurance plans, priced out of quality coverage, or unable to obtain insurance due to a preexisting condition, such as high blood pressure.

        This legislation provides immediate assistance 90 days after enactment when those who have been without coverage for six months and have preexisting conditions have the opportunity to find coverage in the new high-risk pool, which will eventually transition into the state and regional exchanges. As well, in September, insurance companies will no longer be able to discriminate against children with preexisting conditions; our children with diabetes, asthma and various other conditions will not face a life of fighting with their insurers because of their diagnosis. Furthermore, they have the option to stay on their parents’ health insurance through the age of 26. After the year 2014, none of us will be discriminated against for our preexisting conditions.

        1. I have always held that health care is a fundamental right to all people

          Terrific. We will confiscate your family’s fortune to provide healthcare to the hill people of Laos.

        2. I have always held that health care is a fundamental right to all people, and that as a nation we must do what we can to provide Americans with access, affordability, and stability….

          Okay, admit when you typed this nonsense you were imagining yourself as the character on the magazine cover!

        3. I have always held that health care is a fundamental right to all people

          Hardly fundamental if they constitute an obligation of servitude.

          1. Thank you so much for your thoughts regarding health care reform. It has been a pleasure to hear from so many constituents on such a personal issue, and I appreciate having your insight.

            While I have shared support with many of my constituents for a public option, which I believe would act as a control mechanism for value and competition, the health care reform passed by Congress does not contain a public option. This legislation sets up state and regional exchanges, administered by either a state government body or a non-profit, to serve as a market place for individuals and businesses to purchase their health insurance. States can band together to create regional exchanges as well as enter into compacts to allow insurers to sell in various states. With this legislation, once and for all, we will be able to purchase health insurance across state lines.

            Our nation faces many challenges, and economic recovery is vital if we are to meet them.

            As always, please feel free to contact me or my office if ever you think we may be of assistance.

    2. Evidence that drunk dialing your representative after hours has no positive or negative outcome 😉

      1. I hate arguing with a form letter.

  11. I find it amazing how many campaign promises Obama broke to pass a bill that the supporters say could work if we give it time.

    Lobbyists in the White House making secret deals

    Abortion taking a step back with Obama endorsing the Hyde Amendment

    No importation or price negotiations per PhRMA

    No public option

    1. Today he told Matt Lauer that moderate republicans are going to support him when then realize that he froze domestic spending. Just ignore that 900 billion in new health care spending.

      1. they* not then!!!

  12. Sorry Atul but we “experimented” with risk based delivery of care at the local level 15 years ago. It was a disaster for both the providers and insurance companies. Of course the people who wrote the bill hadn’t reached puberty 15 years ago so they wouldn’t have a memory of that.

    Most of the ideas in the ACA have been tried before and were absolute failures at either providing care or controlling costs.

    Anything that actually worked is looking at increased regulated, reducions or outlawed.

  13. Why does the New Yorker use a libertarian as their mascot?

    1. we have a winner

    2. Because Puddy has Ziggy bed sheets.

  14. Of course you think Cassidy offers the more compelling case, Suderman, you predictable fucking right-wing turd. Go suck Ron Paul’s cock.

    1. I’ll suck his cock, and I don’t even like the guy!

  15. Costs are rising more slowly in well-run public systems,

    That cries out for a citation. Be sure to include data on availability of care in these “well-run” systems.

    Of interest, of course, is that the particular reforms we’re talking about here have along history of increasing, not decreasing cost.

    1. Also include how much these systems pay for drugs and other technological innovations.

      1. They allow the U.S. to do that sort of thing. Oh, wait.

        1. Heh. Precisely.

    2. “Well-run public system” is an oxymoron.

      Feel free to try and produce a real-world example of such a system in a country with low taxes (since if you throw enough money at something, it is possible, though certainly not inevitable, to get decent outcomes if you ignore the lost opportunity costs of the money squandered.)

  16. Citation:

    http://www.kff.org/insurance/snapshot/chcm010307oth.cfm

    Be sure to include data on availability of care in these “well-run” systems.

    Red herring. As per you, “No recognition at all that what drives costs up are the disconnects between the consumer, the payor, and the provider.”

    1. Red herring

      How can anything that you pulled out of your ass still be red?

      1. Bleeding.

  17. Perforations of the rectum and massive hemorrhaging swathing the insulting object.

  18. Check out Whatstherealcost.org, an interactive website with many tools to help you understand the real cost of healthcare.

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