Obamacare

Montana and the Myths of Single-Payer Health Care

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Vermont is already headed down the road to state-based single-payer health care. Now Montana wants in on the single-payer action too:

Gov. Brian Schweitzer said Wednesday he will ask the U.S. government to let Montana set up its own universal health care program, taking his rhetorical fight over health care to another level.

Like Republicans who object to the federal health care law, the Democratic governor also argues it doesn't do enough to control costs and says his state should have more flexibility than the law allows. But Schweitzer has completely different plans for the Medicare and Medicaid money the federal government gives the state to administer those programs.

The popular second-term Democrat would like to create a state-run system that borrows from the program used in Saskatchewan. He said the Canadian province controls cost by negotiating drug prices and limiting nonemergency procedures such as MRIs.

So Schwietzer's plan is to 1) ration care through centrally imposed limits on expensive procedures, which is not exactly a big political winner, and 2) pay less for drugs. It's true that drug companies sell to some buyers at lower prices than others.  But the fact that a company sells something to one person at a lower price does not mean the company can sell to everyone at that price.

Medicare's has frequently tried to fight rising spending through arbitrarily cuts to provider payment rates. If you pay less, you'll pay less, right? Sort of. That approach has downsides, and frequently just pushes costs onto others. For example, thanks to Medicare's low payment rates, Medicare officials report that 64 percent of hospitals lose money on Medicare patients. And what happens then? Well, in some cases hospitals try to cut their own costs. But in many other cases, hospitals simply shift the costs over to private payers, who end up subsidizing the government's lower rates. Even in a single-payer system, we'd likely see costs shifted elsewhere, and then conveniently ignored.

In many ways that's what happens now with Medicare, which ends up hiding a lot of its operating costs, including revenue collection. Single-payer advocates like to argue that wholly government-run payment systems are more efficient because they get rid of the need for profit and reduce administrative costs. Sometimes they even point to America's premier single-payer health care system as an example. But as John Goodman and Thomas Saving argued in Health Affairs recently, administering Medicare is only more efficient if you don't account for its administrative inefficiencies:

What about the claim that Medicare's administrative costs are only 2 percent, compared to 10 percent to 15 percent for private insurers? The problem with this comparison is that it includes the cost of marketing and selling insurance as well as the costs of collecting premiums on the private side, but ignores the cost of collecting taxes on the public side. It also ignores the substantial administrative cost that Medicare shifts to the providers of care.

Studies by Milliman and others show that when all costs are included, Medicare costs more, not less, to administer. Further, raw numbers show that, using Medicare's own accounting, its administrative expenses per enrollee are higher than private insurance. They are lower only when expressed as a percentage – but that may be because the average medical expense for a senior is so much higher than the expense for non-seniors. Also, an unpublished ongoing study by Milliman finds that seniors on Medicare use twice the health resource as seniors who are still on private insurance, everything equal.

Nor is it true that cutting back on administration always saves money:

Ironically, many observers think Medicare spends too little on administration, which is one reason for an estimated Medicare fraud loss of one out of every ten dollars of Medicare benefits paid. Private insurers devote more resources to fraud prevention and find it profitable to do so.

Medicare performs less oversight on its payment system, which is designed to pay first and ask questions later (if at all), than most private insurers. As I reported in my October feature on Medicare fraud, the lack of oversight makes fraud incredibly easy and enables huge amounts of waste. The result is that Medicare now spends almost $50 billion a year—or about 10 percent of its total operating budget—on fraud and other improper payments.

GOP Sen. Tom Coburn is currently pushing the FAST Act, a package of administrative tweaks designed to weed out some of the most glaring, easy-to-game holes in the payment system. But it says something about the program's inherent resistance to fixes that it's bled tens of billions on fraud and other bad payments for years without even the obvious holes being fixed—and that even in the face of $50 billion a year in squandered taxpayer money, typically aggressive waste-hawks like Coburn have resorted to pushing relatively minor program adjustments.

Gov. Schweitzer is right that we need to look for ways to reduce health spending. But we already have a phenomenally expensive single-payer system in this country, and it's the problem, not the solution.

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  1. “Gov. Schweitzer is right that we need to look for ways to reduce health spending.”

    This comment gets tossed out as if it were proven; it isn’t.
    We are consumers of health-care. We buy penis-fixing drugs, pay for botox injections, buy birth-control pills, get drugs for ourselves and our kids to make sure we’re not too antsy or too laid back.
    In short, we *choose* to buy health-care and you might just as well claim we need to look for ways to reduce cell phone spending.

    1. We choose to “buy” these things cuz its not with our money.

      Eliminate not only medicare and medicaid, but all third party payment schemes, and see what we “buy” then.

      1. “We choose to “buy” these things cuz its not with our money.”

        You’re right there.
        In my case, it is my money; I pay my health insurance just like my auto insurance.
        But most people who ‘spend’ that money do it with other peoples’ money.

        1. Do you pay for a family plan or an individual plan?

          Even though I am an owner / part owner of 2 businesses, my health insurance is provided through my wife’s employ. In the interest of full disclosure, though you may be surpirsed, my wife is a fairly well compensated public employee.

          In the 11 years of our marriage, the only time I have relied upon the state’s stinkin’ health coverage was for some dental work ( one tooth removal / implant). Otherwise, I pay, out of pocket, full price, for regular chiropractic (even though its covered for 20 appointments annually) and the dental check-ups and cleanings(which are not covered).

      2. Well, elimination of third party payment schemes would require anti-liberty legislation. The reality is that many people would chose third party payment schemes in a completely free market for at least some level of health coverage. Granted, we should tweak the legislation so as to not favor third party payment schemes or incentivize employer sponsered health care vs. privately obtained, and we should certainly reform Medicare/Medicaid so that we who are using market health care aren’t left subsidizing the greedy geezer thieves, but the concept of insurance has considerable utility and would exist in a completely free market.

        1. Of course I would not support legislation which banned or regulated third party payment schemes.

          However, in a purely free market, I don’t know how viable third party schemes would be.

          1. They’d certainly be viable in one form or another, but would probably look more like high deductible catastrophic plans tied to HSAs (which for my money is the ideal health-insurance regime). Although I’d imagine there would still be a presense of zero copay plans, but if people were responsible for purchasing themselves, they’d likely shy away from those in the realization that the monthly premiums are simply too expensive and its subsidizing a lot of useless and unnecessary car for themselves and everyone else in that insurance pool…

            although I think I sometimes put too much faith in the intelligence of people.

            1. Take health care delivery. In a purely free market, there would be no state licensing regimes, no FDA, no state regulatory agencies, Big Pharma would crumble and allopathy would not have the state foundation / backing with which to indoctrinate folks.

              Under such a scenario, why would there be a need for third party payment mechanisms?

              1. Yes, there would inevitably still be certain treatments that would be cutting edge and more expensive than the average person could afford. A third party catastrophic plan would still be popular. Moreover, some people would still choose to get comprehensive plans that paid for every little expense, as a sort of forced savings plan for medical insurance (a lot of people have not the will power to save for occurances and so choose to have savings plans foisted upon them, whether it be through BoA keep the change debit cards or excessive federal withholdings).

  2. estimated Medicare fraud loss of one out of every ten dollars of Medicare benefits paid.

    That number is certainly way too high, just because Medicare classifies billing errors as fraud.

    And if you know anything about Medicare billing, you know that it is so insanely complicated and incoherent that errors are inevitable.

    The biggest category of billing error, BTW, involves lack of mandatory documentation; IOW, there is no dispute that the patient got the treatment, and no dispute that the treatment was needed. The only problem is that the doctor didn’t fill out a form correctly.

    1. That’s why I try to be careful to say that it’s fraud *AND* improper payment, which aren’t the same thing. As I point out in my fraud feature, we don’t actually have solid estimates on the extent of Medicare/Medicaid fraud. We know it’s high, perhaps very high. But we also know that a lot of the bad payments look more like waste, abuse, error, exaggeration, etc. Fraud’s a big problem, but so is complexity of the payment system (more on this topic in the nearish future).

      1. That’s why I try to be careful to say that it’s fraud *AND* improper payment, which aren’t the same thing.

        Fair enough. But I’m not sure that payment for medically necessary treatment that is actually delivered is “improper” because of improperly forms.

  3. If you want more of it, subsidize it.

    If you want annual double digit increases in the retail cost of a good or service, let the state be the dominant purchaser of the same.

  4. Single-payer advocates like to argue that wholly government-run payment systems are more efficient because they get rid of the need for profit and reduce administrative costs.

    It works for AMTRAK (the no-profits, part, anyway).

    1. Works for us too!

  5. It’s easy for me to say (which is why I keep saying it), but we need to somehow shift to payment for end results, and not just “procedures”.

    If the plumber comes to your house, looks at the three feet of water in the basement, and then replaces the washers in the kitchen sink, he doesn’t get paid. But doctors pull this (only slightly exaggerated) shit all the time.

    1. Pay for results, as opposed to effort? Why…that’s just CRAZY talk, PB!

      I agree.

    2. One legend is that the ancient Chinese had a system in which the client paid his doctor a small regular fee while healthy, but upon falling ill stopped payment until the doctor made him well.

      1. Ancient Chinese secret, mmm?

    3. Although I agree and sympathize with your aims, the medical field is simply too complex for that to be a realistic approach. There is a ocnsiderable amount of uncertainty, and doctors will sometimes have to perform a multitude of processes and steps in order to make a correct diagnosis and fix. Granted, that very uncertainty, combined with the ultimate lack of accountability evident in a single payer system like Medicare, is what permits doctors to game the system. But the more appropriate way to address the problem is to make the patient have some not overly burdensome but high enough threshold skin in the game to be a prudent consumer.

      1. Actually “pay for performance” is the catchphrase of the moment in health care management.

        I can’t believe it but I’m going to have to defend CMS here. They recognize that their bureaucratic nature makes it hard to be efficient. So they are borrowing the efficiency moves the private sector made in the last ten years and enforcing them on clinicians as P4P measures. As the biggest payer, the effect of this will be to force every health care system to adopt the best practices of the top systems. They are at least trying. (Of course this puts all the pressure back on the private sector and the physicians in particular).

      2. Uncertainty is the key. In many cases there is no way to guarantee a cure/improvement, even if the doctor does everything right. There’s simply some non-zero chance of a cure/improvement. Do patients deserve to not pay their doctor simply because they were unlucky?

        No, I’m siding with Sudden. Once you take Government out of healthcare, every person will have some financial skin in the game. Then our medical care spending will drop like a rock. No more people going to the ER with a cough or sprained ankle…

        1. A friend of mine who is Mexican recently went to the ER for some chest pain on a Sunday afternoon. Being Mexican, they presented him with some bill for like $100. After presenting him the bill, they asked if he had insurance. He informed them he did and gave them his information. They proceeded to present him a bill for $150 and then some amount orders of magnitude higher to his insurance company.

      3. So much this.

        Trying to define the “results” that will get paid for is impossible.

        Say you come in with some pretty non-specific complaint. SOP is to run a battery of tests. Should only the test that identifies the problem be paid for? Do you really want to have to come in over and over again so a single test can be run at a time?

        Say the procedure for your problem is successful 60% of the time, and nobody can say in advance that it will or won’t work on a particular patient. Why should somebody who does the work not get paid for it, even though it doesn’t get the result they want for reasons beyond their control?

        And (this is the biggest), a major, major reason for suboptimal outcomes is the freakin’ patient. You can give perfect care, but if the patient doesn’t hold up their end, guess what? Why should the doctor take the hit for that?

        1. Say the procedure for your problem is successful 60% of the time, and nobody can say in advance that it will or won’t work on a particular patient. Why should somebody who does the work not get paid for it, even though it doesn’t get the result they want for reasons beyond their control?

          The reality is that 100% of the procedures will be paid for by the 60% who were cured by the procedure. Instead of eliminating free rider problems, it just shifts them.

          1. The reality is that 100% of the procedures will be paid for by the 60% who were cured

            And I’m sure the government will increase the payment for “successful” procedures by 2/3s to cover the difference.

    4. The human body is far too complex, and current science too primitive, to guarantee medical results. Analogizing it to plumbing is absurd; Life (capital-L) has no metal pipes at nice right angles.

      You’re paying for medical advice and expertise, not an outcome. This isn’t the solution to our health care issues.

  6. As far as the issue of fraud goes, how/where do we draw the line between “fraudulent” and “pointless”?

    1. And that’s the key point. When discussing Medicare, we talk about the 10% fruad figure being overstated because it includes billing errors, but we fail to account for the medically unnecessary procedures which ultimately tally well in excess of 10%.

      1. Of course, Medicare already pays only for treatment that is “medically necessary”.

        Whether its “necessary” or not often turns on risk aversion. If you’re not particularly risk averse, you may not regard certain tests or procedures as “necessary”, but someone who is more risk averse would.

        Who determines the level of risk aversion to be applied to everyone, across the board?

        1. We only pay for treatment when it fits our bottom line and makes our stock go up.

          1. We only pay for treatment when it fits within our department’s budget and keeps our political masters of our backs.

            1. Surely, we’re the superior system. Which is why seniors are clamoring to get off of Medicare so they can have some of our sweet, sweet, sweet private FREE MAHKET sector healthcare.

  7. It’s easier to pay less for drugs when you are a foreign country and can threaten to break patents. That doesn’t work so well for domestic insurers.

    1. And which foreign countries have threatened this?

  8. Single-payer advocates like to argue that wholly government-run payment systems are more efficient because they get rid of the need for profit and reduce administrative costs.

    Jesus christ, they never learn.

  9. make the patient have some not overly burdensome but high enough threshold skin in the game to be a prudent consumer.

    I wholeheartedly agree.

    But that whole, “You can’t second-guess him, he’s a DOCTOR, and he knows what’s best for you,” business should really be subject to much more intense scrutiny than currently is the norm. Doctors should be treated more like plumbers and less like High Priests.

    Similarly, I suspect much of what is called “defensive medicine” and blamed on malpractice attorneys is really just doctors running up the score; and the customers don’t care, because the bill goes to somebody else.

    1. “Doctors should be treated more like plumbers and less like High Priests”

      Both plumbers and doctors should be treated with similar respect. Frankly, I suspect plumbers are treated with greater respect. I work in an ER and endure foul insults, physical threats and threats of lawsuits on a daily basis. I am forced to treat these people despite this behavior. I am forced to treat people 24/7 for even the most minor chronic complaints – try getting a plumber in the middle of the night for even a major problem. I daily face the threat of legal assault for less than perfect outcomes even though I’m trying to solve several medical mysteries every hour with only a few pieces of the puzzle and trying to keep people from dying. I’m faced with this threat of legal assault where there is zero tolerance for a bad outcome even though all patients ultimately have 100% mortality.

      “Similarly, I suspect much of what is called “defensive medicine” and blamed on malpractice attorneys is really just doctors running up the score; and the customers don’t care, because the bill goes to somebody else.”

      No – “defensive medicine” is “defensive medicine.” The costs of defensive medicine are enormous – it includes unnecessary testing, treatment, nursing care/monitoring and documentation.

      In addition to “defensive medicine,” there are additional unnecessary costs due to the third party payer effect. Some of this may be due to physicians pushing treatment of questionable need but is mainly due to patients demanding unnecessary or high cost/low benefit treatment and testing. As you said, the bill goes to “somebody else.” As one might expect, these incentives are synergistic. Third party payers also inflict extra costs with complicated billing which consumes the resources and time (for extra documentation) of health care providers.

  10. Single-payer advocates like to argue that wholly government-run payment systems are more efficient because they get rid of the need for profit and reduce administrative costs.

    I’m embarrassed for whomever makes this argument.

    1. Trust me, it is a very common argument in lefty circles.

      1. Well most of them aren’t rational so my generous feeling of embarrassment doesn’t apply.

    2. Of course! It’s all the government’s fault that the US spends more than any other country in the *world* on healthcare while covering *fewer* people! Abolish Medicare!

      1. Really poor troll.
        F

        1. Don’t you want to END MEDICARE?

          1. Down the rabbit hole…..

  11. it is a very common argument in lefty circles.

    When you work for the government, it’s not about the money.

  12. Yeah, let’s borrow Canada’s health care system. It just denied treatment to a 20 month old child and let the child die.

    1. There was never any doubt Baby Joseph was going to die. Treatment was denied as the bureaucrats thought the procedure to extend his life was “medically unnecessary”.

      http://www.cbc.ca/news/canada/…..oseph.html

      1. If you pay the piper . . .

        1. Exactly. We’re all going to die. I’d rather my treatment options be between me, my doctor, and my free market health insurance. We did used to have that, you know. My sister paid $8 for a pre-natal visit in the 1970s. Not the deductable, that was the cost of the visit. And the doctor had a staff of one to handle the paperwork.

          1. I’m all for free-market solutions to health care, and have first hand experience with our (Canadian) crappy system, but your characterization of the situation was completely inaccurate (“let the child die”) and I felt it needed correction.

            1. Completely inaccurate? The child would have died months ago if it was up to your system. And by the way, thank you, Canada, for Trailer Park Boys.

              1. It just denied treatment to a 20 month old child and let the child die.

                This strongly implies here that life-saving treatment was denied. In reality, his life could not be saved, only very slightly extended.

                I’d rather my treatment options be between me, my doctor, and my free market health insurance.

                In this situation I can easily imagine your doctor and insurance denying the same treatment if the only difference is dying aged 12 months or 20 months, the balance spent in a coma.

                There are many, many legitimate horror stories and criticisms of Canada’s health care system you could make; Baby Joseph is one of the weakest.

                1. Oh come on! Do you know how much we paid to get the right-wing noise machine to scream about that story on the radio and FOX News all day yesterday? That’s good money and you’re tellin’ us it was all wasted??

                  1. Conglomo: Kindly fuck off.

          2. Yeah, your health insurance company would never deny treatment.

            Look, sooner or later, everyone will hit an expenditure cap. People will bitch about that cap being controlled by bureaucrats. They’ll bitch about it being controlled by insurance companies. They’ll bitch that they’re out of money.

            People need to wake the fuck up and realize there is no such thing as infinite resources. People die. Shit happens. Deal with it.

            1. People need to wake the fuck up and realize there is no such thing as infinite resources. People die. Shit happens. Deal with it.

              This. The arguments seem to stem from the idea that everyone on earth is entitled to the very best, cutting-edge, most expensive care available as long as they can draw breath.

              I honestly think the right hurts itself here when they talk about life being sacred and precious (in the abortion and anti-euthanasia rhetoric), because it’s logically consistent to jump from that, to “We must spend $100,000.00 per week in super cancer treatments to keep this person alive for two more months because all life is sacred.”

              If life is inviolably sacred, then there is no dollar value that can ever be placed on any treatment that might help even a little bit.

              1. I don’t think there is an inconsistency with the abortion idea since there is an entire lifetime of potential there, and the termination of the fetus requires active destruction rather than a passive let life happen attitude. Although I agree on euthanasia that has long been one my most passionate issues. A person who is already at the end of their life, who realizes there is little sanctity left in their life, and doesn’t want to saddle their descendents with the pain and burden of care that accompanies a terminal illness should have every right to terminate their own life. I’d be fine with a mandatory waiting period, the patient to bear the cost himself, and some definitive proof that the patient indeed desires death, but it strikes me as a far more cut and dry civil liberties issue than any other out there.

            2. +Terry Schaivo

              Seriously. Have some dignity when your time is up.

          3. Of course, this assumes you can get “free market” insurance. Many people cannot buy it at any price.

      2. Whereas we’d deny him for a “preexisting condition” so our CEO can buy another Mercedes-Benz.

        1. Oh, by the way, Baby Joseph did get treatment here in the USA.

    2. We would *NEVER* do such a thing!

      Hehe, suckers……where’s my stock bonus?

    3. Meanwhile in America 45,000 people a year die from lack of insurance. They don’t get many headlines though.

  13. We already have rationing–rationing done by *US*, suckers! Got the cash? You get to live. Don’t? Tough shit!

    1. And more gov’t involvment will make this situation better? How’d you like to buy a bridge?

      1. Of course it won’t! In fact, let’s abolish medicare and medicaid! Can’t afford that surgery? Tough shit, Granny! Either start eating Alpo, or get measured for a coffin!

        1. HERP DERP. MARKITS DONT WORK GREEDEY FAT KATS. MIKEL MOOR TOLD ME KUBA IZ BETER. HERP DERP.

          1. HERP DERP. PRIVATIZE EVERYTHING. STUPID GUMMINT THE PROBLEMZ, RUSH LIMBAUWGH TOLD ME SO. END MEDIKARE HERP DERP.

    2. Interestingly enough, in the U.S. we have a system whereby you obtain health insurance, and the premium is established based on an honest reporting of your prior medical history. That health insurance may include a high deductible and a lifetime coverage limit, all of which are disclosed to you upfront. You then chose if you like those terms or would prefer to try a different provider.

      Upon discovery of a tumor, you pay your deductible or maximum out of pocket expense plus whatever overages there are (and for a medically necessary lifesaving treatment, I’d endure a significant debt myself if it were indeed that expensive).

      Of course, if you had a previous tumor that wasn’t reported to the insurer in order for them to set the appropriate risk rate, that amounts to fraud so fuck you liar.

      1. Interestingly enough, in the U.S. we have a system whereby you obtain health insurance, and the premium is established based on an honest reporting of your prior medical history.

        Not in my experience, at least not everywhere. Many states, and I believe ObamaCare, require “community rating”, meaning your premium is not tied to your medical history.

      2. ,i>and for a medically necessary lifesaving treatment, I’d endure a significant debt myself if it were indeed that expensive

        Yes, banks are lining up to loan to cancer patients who have an X% 5-yr survival probability (X < 100).

  14. I was thinking about this the other day; for all that government intervention surely makes matters worse, I suspect the main problem with “providing medical and other forms of care for the elderly” is that it is pretty much the ONLY aspect of modern human existence where technology has increased rather than decreased the amount of human labor and effort needed to do it, compared to a hundred years ago.

    Food and clothing are easy, thanks to automation; one machine can spit out more clothes in an hour than a team of human weavers and tailors can make in their whole lives, and food production has made similar gains, so if you point to anybody in the world and ask “How much human work is needed to feed and clothe this person?” the answer is “very little.”

    But with medicine, now, we’ve advanced enough to save lots of people — including very old people — who would’ve died before. That’s good. But now that those old folks are alive, somebody has to take care of them, and so far technology has NOT managed to significantly reduce the labor needed for that. There’s no robot yet that can turn Grandma every couple hours so she doesn’t get bedsores, change her bed linens, help her if she’s fallen and can’t get up … all of this requires a number of people who need to be paid, and technological advances have increased the number of old folks who need such help, yet done little-to-nothing to reduce the number of people needed to help each individual old person.

    1. We need more science, more technology, more wealth. What system is best suited to providing these things?

      1. I fully agree we need for science and technology; I’m just pointing out that right now we’re at a weird spot in their development. Medical care and elder care won’t be nearly such a problem, when robotics advances to the point where any ordinary middle-class family can easily afford to buy a tireless robot maid a la Rosie Jetson. But right now, we’re still a long way from that.

    2. Its not the technology, its the state subsidy. The technology has created the ability for diminshing returns: namely extending life without extending the sanctity of life. In a world without state subsidy, people would chose to perish at a slightly earlier age while living a full and happy life rather than simply wallow around for their last two years as a tremendous drain on societal resources, family morale, and their own diminishing faculties. But because the gummint (read: their great grandchildren) is footing the bill, they chose to extend life for two years for a circumstance that if presented with the bill for, they’d likely say fuckit.

      1. Right. If we abolish Medicare, we’ll charge less. Sure. Right. heheheh…sucker…..where’s my year-end bonus?

        DENIED*! *stamp* DENIED! *stamp* DENIED!

        1. You complete and total lack of understanding of health insurance is sadly not surprising. But health insurers don’t have free reign to simply deny treatments whenever they so choose. There is a little something called a contract; a person enters into a contract with a health insurance provider that specifies certain ailments and procedures that are covered and others that are not. A reasonable consumer of health care will examine the items that are covered, and knowing their own family history as well as their own previous lifestyle choices, will choose the plan that covers the ailments and proceduces that s/he anticipates will be an issue down the road. For example, my family has heart problems and strokes in the men, I’ll be sure to chose health insurance that is heavy on the cardiovascular procedures.

          1. But health insurers don’t have free reign to simply deny treatments whenever they so choose. There is a little something called a contract; a person enters into a contract with a health insurance provider that specifies certain ailments and procedures that are covered and others that are not.

            And yet, insurers will do what they can to find reasons to deny coverage anyway. Private insurers are no more noble and corruption-free than the government, and certainly have strong incentive to find ways to wriggle out of obligations that will cost them huge amounts of money. So we need better technology to reduce the cost of old folks’ care, and until that technology is invented and perfected, we either have to spend enormous craploads of money caring for the elderly, or officially become callous enough to say “No, sorry, you’ll just have to die.” Neither option really works.

      2. In a world without state subsidy, people would chose to perish at a slightly earlier age while living a full and happy life rather than simply wallow around for their last two years as a tremendous drain on societal resources, family morale, and their own diminishing faculties.

        I suspect you’re overestimating how likely people are to apply emotion-free cost-benefit ratios to their own continued existences.

        *Some* of the high cost of medicine definitely comes from outrageous end-of-life extension efforts — if the heart of an unconscious 101-year-old man stops, it’s pretty ridiculous (and expensive) to give him elaborate resuscitation procedures and hook him up to machines that wring another six or seven hours of existence out of him. And, of course, the government outright refuses to let people in terminal pain end their existences if they so choose; Zod forbid people get the idea they, rather than the government, have the right to decide for themselves how long they want to live, or how many drugs they’re willing to take to fight pain.

        But for a lot of old folks, it’s not even that they’re sick or in pain, just old and worn out. They can still live for several years yet, and still have their mental faculties; it’s just that they can’t do those little but important everyday tasks like climb stairs, lift heavy pots and pans to cook for themselves, bend over enough to take their shoes on and off … we already see the problem of old people who really need to stop driving because their vision and reflexes are no longer good enough, yet (unless you live in Manhattan or Boston) “no driver’s license” is practically the functional equivalent of “house arrest,” what with the lack of mass transit options.

        When I was working for some local papers, I had to tour a LOT of oldster prisons (sorry, “nursing homes” and “assisted living facilities”), and I’ve already decided I’d sooner die than eke out the rest of my existence in such cloyingly hellish places. But I don’t know that I’d want to die if I could still do pretty much everything for myself *except* drive a car. Or everything *except* put my own shoes on, and wear clothes that zip up the back. There’s still a couple decades left before I officially get old, and hopefully by then technology will have found ways to get around such simple problems.

        Until then, though, minor little things like that constitute the lion’s share of eldercare problems. “For want of a nail, the kingdom was lost/ for want of reflexes good enough to handle highway driving at 65 mph, the old lady’s ability to live independently was lost, and she now needs a staff of ten to do all the minor tasks she used to handle by herself.”

        1. I’ve already decided I’d sooner die than eke out the rest of my existence in such cloyingly hellish places.

          OK. But let’s see what you decide when the time comes. Life is precious.

      3. “people would choose to perish”

        What planet do you live on?

        In any case, please stay away from mine.

  15. Single payer legal care.

    After all, there’s not a single lawyer out there who does anything worth more than minimum wage.

    (I’ll let you figure out how much of that is serious and how much is sarcasm.)

  16. If the government can just go around setting price controls without any side effects or unintended consequences, why doesn’t he just set the price of all medical procedures and all drugs to be one cent each? No need for insurance if everything costs a penny.

  17. Yeah, your health insurance company would never deny treatment.

    No health insurance company, ever, in the history of the universe, ever, has denied treatment.

    They may decline to pay for treatment, but that is very, very different.

    Its only when you get into a single payer/socialized system that this distinction disappears.

    1. Yeah really helpful distinction. What would be the choice there for the majority of people when payment is denied for the treatment? If the patient is lucky enough get the proceedure they will then be bankrupt. Maybe you would like to explain distictions to them.

    2. Declining *is* denial if a patient has no other resources. And most don’t.

  18. What’s the over/under on Conglomo posting here?

    I’ve got three days. Anyone else?

    1. Each new troll makes me miss the last one.

      Where is White Indian, anyway?

      1. My “paler” brother has gone on…to the Happy Ranting Ground. I hear IT’S in an [AGRICULTURAL CITY-STATE]!

  19. You may not agree with the governor, but when was the last time a Republican tried to enact anything meaningful to solve the healthcare problems, they make plenty of good suggestions but the status quo seems just fine for most of them. Fact of the matter is people just don’t live as long here in the US by anyones statistics.

    1. You wrote, “Fact of the matter is people just don’t live as long here in the US by anyones statistics.”
      Can you put some names and links to “anyones statistics.” Should be no problem, since you imply many.
      BTW: Did you know that a baby born but dies within seconds is still counted as born alive, unlike other countries.
      Stats now please.

      BTW: Man, when did the people of Montana become such pussies, such ninnes? Before this, Montana was considered the land of tough westerns, for me. Who know!?!?….

      1. Did you know that a baby born but dies within seconds is still counted as born alive, unlike other countries.

        Proof now please.

      2. So now Montana’s going over to the dark side? That would explain at least one darkly humorous plot twist in a story intro set in 2063:

        “Board their ship! Take everything you can!”

  20. Is the tax collection aspect a valid complaint? If Medicare vanished overnight, but the government remained otherwise unchanged, how much would the costs of tax collection decrease?

  21. Every other First World country has adopted all or most of single-payer’s key features. Their systems cover virtually everyone. All of them spend at least 1/3 less than we do on health care. All but three* have a lower healthcare-related tax burden. All of them have more slowly rising healthcare costs. And almost all of them get better overall health outcomes by most key measures.**

    How many decades of real-world evidence does do libertarians need to acknowledge that single-payer truly is cheaper, fairer, and just plain better?

    *Oil-rich Norway; Switzerland, where 2/3 of insureds get federal premium subsidies; and the tiny, wealthy banking haven of Luxembourg.

    **Even the UK, which is the third most obese country in the world, spends a measly 8.5% of GDP on health care compared to our 18%, and applies cost-benefit rationing quite ruthlessly, gets better overall results than us.

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