Medicare

Why Medicare Will Always Need Fixing

The limits of the emerging doc fix deal.

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Flick/USCapitol

Over the last 14 years, Medicare's Sustainable Growth Rate formula—the SGR, which was passed in 1997 as a way to keep Medicare spending growing in line with the economy—has scheduled deep cuts to physician reimbursements on 17 different occasions. On each of those occasions, Congress has avoided the cuts by passing a patch—a temporary postponement of the payment reductions called for by the SGR that is always referred to by the same name: the doc fix.

Sometimes a doc fix would last a year or so. Sometimes a doc fix would last just a few months. But no longer how long it lasted, it always ended the same way, with Congress once again staving off deep reductions to physician payments by putting together a financing package—always the biggest challenge—and, usually at the very last minute, passing another one.

The cuts called for by the SGR created an odd situation: On the one hand, it made physicians understandably anxious by scheduling major reductions to their Medicare payments (usually in the range of 25 percent) every year or so. On the other hand, the repeated patches meant that practically everyone assumed, not unreasonably, that Congress would never really let the cuts go into effect.

It was a source of tremendous uncertainty—and yet also a sure thing. And both the uncertainty and the certainty resulted in certain problems.

The uncertainty made trouble for doctors, who hated relying on a weird congressional budget ritual to keep reimbursement cuts at bay; ending the SGR has been the number one agenda item for the American Medical Association for years. At the same time, the consistent overrides also caused headaches for federal budget projections, which assumed that the SGR's Medicare payment cuts would be enacted as required by law.

Neither Republicans nor Democrats particularly liked the SGR. Yet, despite numerous hopeful discussions about how to get rid of it, they couldn't figure out how to agree on and pass a permanent fix. Instead, they opted for the annual(ish) doc fix ritual. This made for a handy illustration of congressional dysfunction, as well as a recurring reminder that Congress wouldn't necessarily follow through on spending cuts it had called for years before.

The SGR, in other words, was government in a nutshell: It didn't work, it cost more than expected, no one liked it, and no one could fix it.

Some people, however, now have hope that this might finally change. 

Since late last week, multiple reports have surfaced suggesting that Republican and Democratic leadership in the House are working on a permanent fix. The details are still being worked out, but the basic plan is to cancel the SGR in favor of some additional means testing to Medicare's physician and prescription drug components. In addition, the plan would institute more cost-sharing in Medigap, which expands coverage beyond traditional Medicare, although the savings here would be minimal; this is mostly designed to nudge seniors into Medicare Advantage plans.

There's no guarantee of passage, but even the possibility that a plan like this might have enough votes to get through the House is a serious upset to the status quo. The doc fix has been a legislative fixture for over a decade now, and most assumed that it would stay that way more or less indefinitely.

Yes, there have been multiple efforts to end the SGR, but these have always stalled, usually because Democrats and Republicans couldn't agree on how to pay for it.

The new proposal attempts to solve this problem in a somewhat novel manner by, well, not paying for it. Not fully, at least, and not immediately. 

This aspect is why the plan has already split the right.Critics complain that it won't be fully paid for in the 10-year budget window that the Congressional Budget Office (CBO) uses to score legislation. Details haven't been finalized, but news reports suggest that the plan would cost about $200 billion over the first decade, but would only offset about $70 billion.

Supporters respond that this is short-term thinking: In the longer term, the savings that would accumulate from means testing would massively swamp the cost of ending the SGR, while at the same time pushing Medicare towards what it should be: a safety net for the needy rather than a universal entitlement. And anyway, the last 14 years of doc fixes prove that the SGR cuts were illusory anyway. This is a small but meaningful structural reform to Medicare in exchange for getting rid of cuts that were never, ever going to happen.

The wrinkle here is that although the SGR cuts never happened as required by law, the doc fixes were almost always paid for with offsets—meaning that something else in the budget was cut to pay for the patch. According to the Committee for a Responsible Budget, this has resulted in a savings of about $165 billion so far, although most supporters will concede that some of these offsets were gimmicks, not real savings. Still, not all of the offsets have been budget tricks, which means that even though the SGR may not be working exactly as originally intended, it is holding down the deficit somewhat. It's not worth tossing out for a deal that isn't fully funded up front. 

So here's the dilemma, and the debate: Accept a hit to the deficit up front in exchange for a small but real long-term reform to Medicare—or reject the deal unless it can be fully paid for within the 10-year budget window? Keep a frustrating but somewhat effective tool for restraining Medicare spending—or ditch it in favor of a small but real long-term structural reform?

I think both sides make decent points; on one hand, it's probably worth holding out for a deal that is fully paid for, or at least reasonably close. On the other hand, a deal that ended the SGR charade, cleaned up the budget outlook, and put a minor-but-meaningful Medicare reform into place wouldn't be entirely awful either.

Whatever Congress does or doesn't do, however, it's worth stepping back and briefly putting all of this in historical context. The SGR has been in place for almost twenty years, and it's been recognized as a problem for more than a decade. That's how long it has taken  to even get to the point where it's remotely plausible that Congress might overhaul a policy that nearly everyone agrees is flawed.

But the history actually goes back much further than that. The SGR itself was a replacement to a previous Medicare payment growth formula—the Medicare Volume Performance Standard (MVPS), which had its own problems. The MVPS, meanwhile, was intended to work in tandem with yet another Medicare physician payment system, the resource-based relative value scale (RBRVS), which replaced Medicare's previous mechanism for paying physicians. 

It's all interlinked and connected, and whatever is done now will likely be up for revision again in another decade or two, after new glitches and frustrations emerge. As long as Medicare exists in its current form and as long as it exerts the sort of overwhelming influence on medical payment and practice that it does, these frustrations, or some as of yet unanticipated variation on them, will be with us. So while I'd like to see reform, and I'd like to see it paid for, and I'd even be pleased if that were to happen, I wouldn't be too excited about these sorts of technical system tweaks, however much they change the status quo, because those policy tweaks will just lead to more policy tweaks, and more bureaucratic responses, and then the cycle will repeat itself again. All of which is to say that even if the doc fix is fixed, it still won't really be fixed. 

NEXT: Reason Nominated for Four Maggie Awards

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  1. Better yet, abolish Medicare. See how easy that was?

    1. Better yet, abolish Medicare. See how easy that was?

      But that would mean one less mechanism to politically terrorize seniors with.

      1. You’re right. The serfs must be kept in chains of dependency.

        1. Yes, as a beneficiary of Medicare I feel so dependent and in chains.

          I much rather would do without Medicare and have private insurance companies charge me inordinate rates, so I could starve in my old age.

          Yes, I’m in chains. And get rid of Social Security to. Receiving that money also puts me in chains.

          1. RodgerMitchell|3.16.15 @ 5:23PM|#
            “Yes, as a beneficiary of Medicare I feel so dependent and in chains.”

            So nice of you to use my money for your medical bills, asshole.

            1. Medicare is paid for by deductions from ones pay, which are collected by the federal government, wisely invested, scrupulously managed then disbursed per contract with the taxpayer.

              1. “wisely invested, scrupulously managed then disbursed per contract with the taxpayer.”
                Would, that it were so.

    2. Lets get those death panels working.

      1. Turd thinks no one chooses, since turd is an ignoramus!

    3. But the fix for that would likely be the reinstatement of Medicare. Or something like it.

    4. Better yet, abolish Medicare. See how easy that was?

      You forgot to click your heels, like Dorothy did.

      Dismantle the ehtire federal government. See how easy that was?

    5. Your idea, is actually better than you and most people realize.

      David Goldhill, CEO of the Game Show Network, author of “How American Health Care Killed My Father” and life long Democrat, writes: “So even with the government paying almost all of their bills, today’s seniors pay a higher share of their income for health care than seniors did before Medicare.” http://www.huffingtonpost.com/…..02229.html

      That suggests abolishing Medicare would reduce health care spending for seniors who are using Medicare! It’s also an indication of how much government has screwed up the health care marketplace with Medicare.

      Still, seniors using Medicare would probably object. So what politicians could do, is replace Medicare with medical spending vouchers that seniors could use to purchase health care insurance or medical care. That would be better than the annual doc fix, or the proposed increase in spending they are considering. This has the advantage of getting rid of government meddling in the health care marketplace with Medicare. But of course, we’d need to get rid of Obamacare as well and move back to a free market, where people pay for their own medical care rather than trying to foist it on the backs of others via government. That is the only moral solution.

      1. Rather than “That suggests abolishing Medicare would reduce health care spending for seniors who are using Medicare!” I should have written: “That suggests abolishing Medicare would reduce out of pocket costs for health care for seniors who are using Medicare.”

        1. Rather than “That suggests abolishing Medicare would reduce health care spending for seniors who are using Medicare!” I should have written: “That suggests abolishing Medicare would reduce out of pocket costs for health care for seniors who are using Medicare.”

          Right, because Huffington Post says so!!
          Medicare’s monthly premium is $105 x 12 = $1260
          Annual deductible is $147 (up to $1407 total) for all but hospital stays.

          My total prescription costs for seven scripts (a heart patient), co-pay + premium = $410.

          So total annual cost is prox $1,800 or …. ummmm …. $150 per month.

          There are higher costs for a small number of seniors, through means-testing. But even for that one must earn a good deal more than the maximum social security income.

          Medicare spends an average of $15,000 per year, per person. So ignore the Cato proposal and all the others who raise tens of millions of dollars by bullshittting a gullible Tribe Lib.

  2. When one realizes that the ultimate government scam is selling a scam government fix to the current government scam, all becomes clear.

    1. It’s scams all the way down

      1. Exactly. Scams within scams within scams. It’s so scammy that there are physicists who are dumping string theory for scam theory, which posits that matter and energy are made up of nested scams.

        1. My General Scam Theory covers all this.

          Are you a subscriber to my newsletter?

          1. Does your General Scam Theory reconcile general scamativty and quantum scamming?

            1. Yes. Plus it gets into anti-scammers, black scams, debunks The Big Scam? and explains the conservation of scams.

              1. Impressive. Does it explain why anti-scammers seem so rare in our universe?

                I’m not sure about the Big Scam not being a real thing. I mean, surely there was/is a Prime Scammer unscammed.

                1. Hah! You believe that Prime Scammer scam! IT’S A SCAM, MAN!

                  1. I see we are in complete agreement.

              2. Are scams particles or waves? How would the double slit experiment turn out in the scamverse?

          2. Admiral! Don’t keep it private, that would be petty, and there could be corporal punishment.

        2. You laugh, but serious physicists are now planning experiments (if they haven’t already run them), to determine whether our universe is nothing but a simulation. If those experiments indicate that all we know IS a simulation, then you might as well call the corresponding field of study “scam theory,” involving scams within scams.

          1. “Computer, end program.”

  3. OT: If you like chubbies (you know who you are) DO NOT CLICK THIS LINK!

    Suki Waterhouse smoulders in next to nothing for sexy new GQ shoot with her rock-hard stomach and long legs on show

    http://www.dailymail.co.uk/tvs…..-show.html

    1. I’ll be in my bunk….

    2. I reiterate the need for a boobie thread. Clearly, there is a wellspring of untapped talent here which could change us all.

      1. What boobies? Based on the rest of her figure, they probably look like two insect bites. Somebody take that child home and fatten her up a little. That can’t be healthy.

        1. THERE COULD BE BOOBIES HERE, THAT’S WHAT I’M SAYING.

  4. “Neither Republicans nor Democrats particularly liked the SGR.”

    I suspect they like it just fine. What better way to extract campaign contributions and other support from the AMA and other health care lobbies than an ever-present threat that Medicare payments may get slashed unless Congress acts to restore them?

  5. I heard on a TED Talk that the way to fix third-world poverty was for the first world to print money and give it to them.

    Curiously, there was no explanation as to why the third-world countries couldn’t, you know, just print their own money to fix their own poverty… but anyhoo, given this Truth(tm), I’m pretty sure Congress can just keep allowing debts to bloom indefinitely. Because TED Talks told me so.

    1. Can I do a TED talk about how free markets could solve many problems?

      1. Sure. AND WHY DON’T YOU TALK ABOUT CREATIONISM WHILE YOU’RE AT IT.

        Basically identical. All full o’ crazy and make believe.

        “free markets” – HAH! Free markets couldn’t exist without government!

        1. Ah, a market denier. You should be ashamed.

        2. HAH! Free markets couldn’t exist without government!

          It does help when there is a mechanism for enforcing property rights and contracts, and to resolve disputes without resorting to violence.

          1. Without who resorting to violence?

            1. The people involved in the dispute. One reason why there is so much violence in the illegal drug trade is that disputes cannot be resolved in court. So parties resort to violence.

    2. Curiously, there was no explanation as to why the third-world countries couldn’t, you know, just print their own money to fix their own poverty…

      Because their money wouldn’t be backed up by promises by the federal government to tax Americans in the future. That’s what gives American dollars and bonds value: Future taxation.

      1. So, the dollar is backed by the full faith and credit of my daughter?

        1. Don’t be ridiculous, it’s not faith based. It’s really backed up by her fear of running afoul of the IRS.

    3. Because a major source/symptom (chicken/egg problem) of Third World countries’ poverty is the fact that their currencies devalue themselves into nothing fairly rapidly.

      Whether that cycle can be fixed by just giving them United States dollars is debatable. Just giving the Greeks euros hasn’t prevented financial calamity there (though the eurozone isn’t akin to a Third World country adopting the USD).

      1. Whether that cycle can be fixed by just giving them United States dollars is debatable

        There’s not much debate. I think it’s been fairly well proven that it won’t fix them.

        I think giving them US dollars which drop in value by the proportion that we print them won’t fix anything either.

  6. Once you get it right, why, Bob’s your uncle!

    “The history of the NHS in England”
    […]
    “The NHS in the 2010s
    The present day NHS is undergoing major changes to its core structure, including who makes decisions about NHS services, service commissioning and the way money is spent.”
    http://www.nhs.uk/NHSEngland/t…..es/the-nhs history.aspx

    1. Everything I needed to know about the British National Health is summed up by the fact that Giles was already doing cartoons making fun of its failures in the mid 1950’s … and he was a Socialist.

  7. I FINALLY understand what this “doc fix” is all about. They did this 17 times?

    America lacks the courage to simply cap (or reduce) doctor’s pay and force doctors see a certain amount patients. In other parts of world, this encourages doctors to recommend patients to undergo expensive surgeries they need. Or may not need, but who knows.

    But the doctors and the nurses union and the administrative staff won’t like working for less pay? Well, they have to do their fair part and pay their fair share.

    1. You got it. The elimination of the doc fix alone puts Medicare back into surplus for decades.

    2. “But the doctors and the nurses union and the administrative staff won’t like working for less pay? Well, they have to do their fair part and pay their fair share.”

      Sarc, right?

      1. I hope not. Who doesn’t want their own slave doctor?

      2. Yep. And did you notice that Weigel was too fucking stupid to figure out that XM was joking and exposed himself?

        1. I thought he was being saracastic too.

        2. Mike M.|3.16.15 @ 4:04PM|#
          “And did you notice that Weigel was too fucking stupid”

          It’s hard not to notice that turd is several bricks shy of a load.

    3. “But the doctors and the nurses union and the administrative staff won’t like working for less pay? Well, they have to do their fair part and pay their fair share.”

      Since they’re part of the medical mafia that profits by shaking us down through regulatory rent seeking, I won’t have a lot of tears for them when they get screwed.

  8. “This aspect is why the plan has already split the right.Critics complain that it won’t be fully paid for in the 10-year budget window that the Congressional Budget Office (CBO) uses to score legislation. Details haven’t been finalized, but news reports suggest that the plan would cost about $200 billion over the first decade, but would only offset about $70 billion.”

    LMAO. So really, I’m supposed to believe that the same Congress that won’t actually follow through on the budget cuts that are called for in the SGR (Doc fix), will follow through on the extra $130 billion 10 years down the road?

    Sure, and can I get a Pony with that promise.

  9. my best friend’s half-sister makes $88 /hr on the laptop . She has been unemployed for 10 months but last month her check was $21616 just working on the laptop for a few hours.

    go — http://www.Tradevalt.Com

  10. Do we need a safety net for the needy? We have Medicaid, Obamacare, and Medicare. It seems to me like they all try to do roughly the same thing.

    It is also obviously that entitlements with phase outs have tremendous economic consequences in how they distort markets. Today, relatively modest income workers making $20-$40k a year can end up with marginal tax rates in excess of 100% because of Obamacare phaseouts.

    Doing the same thing with medicare will create the same problems.

    Turn medicare into social security, instead of health insurance, you get a check to buy it. You can take that check and buy relatively crappy insurance (medicaid quality) or add some of your own stash to it to buy something better. No phaseouts necessary.

    1. “relatively modest income workers making $20-$40k a year can end up with marginal tax rates in excess of 100% because of Obamacare phaseouts.”

      Dependency isn’t a bug, it’s a feature.

  11. If I thought any of them were serious about getting out of this mess, I’d suggest doing something positive now. Like cut the docs 1% this year. And ask us old geezers pay an extra $1 at the doctors office.

    Next year add another .5% and $0.50 respectively.

    But they are not serious, and the money would be wasted as in [Politician: “Look! More income to the coffers! Call uncle Al. I’m going to set up a new department.”]

  12. The doc fix fraud…

    This is just government lying about the costs of their programs. If a company pulled this kind of crap accounting, people would go to prison over it. But rules don’t apply to our rulers.

    If Big Government has no compunctions about using force against you, why would it refrain from using fraud?

    The experiment in self government failed with FDR, and we’ve been reverting to the mean ever since. It relaxes me accepting that I live in a banana republic where rules and laws don’t apply to our rulers.

  13. This is yet another of those articles like “Why we need to breathe air and drink water YET AGAIN each day”…..

    Medicare needs adjustment.

    Insurance needs constant adjustment.
    Life needs constant adjustment.
    Science and Medicine change and statistics reveal things…we adjust.

    The writer acts as if this is a bad thing. Yet he probably never complained when insurance rates went up by double digits each year due to “corporate change” in the profits they expect. He probably didn’t say a word as they dropped people with pre-existing conditions due to “changes” in the actuarial data.

    1. craiginmass|3.16.15 @ 5:08PM|#
      “The writer acts as if this is a bad thing. Yet he probably never complained when insurance rates went up by double digits each year due to “corporate change” in the profits they expect”

      Hi, asshole!
      I’ll bet you figure those rates really did go up because of profits, right you ignorant piece of shit?

  14. This is yet another of those articles like “Why we need to breathe air and drink water YET AGAIN each day”…..

    Medicare needs adjustment.

    Insurance needs constant adjustment.
    Life needs constant adjustment.
    Science and Medicine change and statistics reveal things…we adjust.

    The writer acts as if this is a bad thing. Yet he probably never complained when insurance rates went up by double digits each year due to “corporate change” in the profits they expect. He probably didn’t say a word as they dropped people with pre-existing conditions due to “changes” in the actuarial data.

    1. Long time, no see. PS, you remain an idiot.

      1. YEAH! A traitor to the Tribe. Stone them all to death! Be a True Believer!
        And a belligerant blowhard bully,

  15. The doc fix is the epic political tool.

    It can be used to scare doctors into donating. It can be used to scare seniors into voting/donating. It can be used as a handy talking point: “I saved Medicare”. It can be used to make the CBO score your budget as being balanced in 7 years (ha!).

    1. You forgot, “Promising to eliminate it can be used to make PPACA look revenue neutral.”

  16. When Peter Suderman says, “I’d like to see it paid for,” what is he really saying?

    He’s saying he believes the United States federal government, the sole entity that initially created the dollar from thin air, somehow now can run short of its own sovereign currency, so it needs to ask you for dollars.

    Think about it, because clearly Suderman has not.

    And this guy is a “senior editor at Reason magazine”???

    Yikes!!

    1. Where the fuck do you think the money comes from moron?

      1. The same place the very first dollar came from. The U.S. federal government, being Monetarily Sovereign, creates its own sovereign currency from thin air.

        You, being monetarily non-sovereign, cannot do what the federal government does, which is why you are confused about money creation.

        Look up Monetary Sovereignty and perhaps you’ll understand: http://goo.gl/exlpbf

        1. RodgerMitchell|3.16.15 @ 7:50PM|#
          “The same place the very first dollar came from. The U.S. federal government, being Monetarily Sovereign, creates its own sovereign currency from thin air.”

          I was pretty sure that someone this stupid wouldn’t be capable of typing, but lookie there! The monkey brain can type!

  17. Get government out of the health care business as much as possible. Limit them to limited regulations and financial support to those who need it.

    Obamacare, Medicaid, Medicare and VA hospitals should be abolished.
    People under these programs and those who are financially below the poverty level should be given a yearly amount that they could use to purchase health insurance.
    Keep the federal regulation stating that insurance companies have to cover pre-existing conditions as long as the person had previous insurance.
    Allow people to purchase insurance from any state.
    Deregulate state health insurance markets.
    Unhinge medical insurance from employers in the tax code.

    Getting government out and increasing competition in this way will lower health care costs. It cuts the bureaucracy costs, cuts the fraud costs and improves competition and quality of care.

    1. Yes, please!

    2. Get government out of the health care business as much as possible. Limit them to limited regulations and financial support to those who need it.

      1) How do we elect a President, a majority in the House and a veto-proof Senate to achieve that?

      2) Does a 73 year old senior, living on $9,000 per year Social Security “need it”?

      3) What perectage of the Medicare population could not afford private healthcare at a cost of over $10,000 per year per person?

      1. If you’re 73 and don’t make more than $9000 a year . . . next time you get seriously ill . . . you die.

        Life is hard but no one has the “right” not to die.

        1. You’re even crazier than I thought.
          One more time:

          1) How do we elect a President, a majority in the House and a veto-proof Senate to achieve that?

          2) What perectage of the Medicare population could not afford private healthcare at a cost of over $10,000 per year per person?

          Reality is SUCH a bitch.

  18. He’s saying he believes the United States federal government, the sole entity that initially created the dollar from thin air, somehow now can run short of its own sovereign currency, so it needs to ask you for dollars.

    You apparently don’t understand the difference between currency and wealth. How about we just get the Federal Government to give everybody … oh … $10 million. That way we would all be rich … right? After all the government can’t “run short of its own sovereign currency”. Then we could all retire … right? Opps … that wouldn’t work … who would grow our food, fix our cars, or fix our roof.

    Currency is a tool that is used to represent the wealth. The wealth is the stuff we make, the services we provide. If you increase the amount of the currency you have done nothing to change the wealth it represents. All you have done is make the lowered the value each unit of currency represents.

    1. “How about we just get the Federal Government to give everybody … oh … $10 million. That way we would all be rich … right?”

      Or how about we just get the Federal Government to tax everybody . . . oh . . . $10 million. That way, we all would be poor, right?

      Now that you gave your stupid example and I replied with my stupid example, let me know if you would like to understand how federal finance really works.

      It’s much more interesting than you can imagine.

      1. RodgerMitchell|3.16.15 @ 7:55PM|#
        “Now that you gave your stupid example and I replied with my stupid example, let me know if you would like to understand how federal finance really works.
        It’s much more interesting than you can imagine.”

        Of course it is! You just print money and assholes like you figure we’re doing great!

      2. Still waiting for this ‘much more interesting’ explanation, Roger.

      3. Or how about we just get the Federal Government to tax everybody . . . oh . . . $10 million. That way, we all would be poor, right?

        You really believe that wealth is just a matter of printing up more currency. Man are you stupid.

        Now that you gave your stupid example and I replied with my stupid example,

        You had to reply with a stupid example because your incapable of addressing the merits of my argument. IOW, your unable to explain the relationship of currency to wealth.

        … let me know if you would like to understand how federal finance really works.

        LMAO … you don’t even understand that the currency is related to wealth much less how fucked up Federal finance is.

        1. Seems Roger was willing to drop some bullshit here and wander off to bullshit others.

        2. Greg,
          You can check Roger’s link. Yes, Roger is every bit as stupid as you might imagine and worse. This is a living, breathing human being in the 21st century who truly bleeves that printing a number on a piece of paper has something to do with increasing wealth or value!
          Assholery in the extreme!

  19. What a painful article–so much bureaucracy, hundreds of hours of time with public officials, and for what?

    If only the people who made the SGR wrote it so that following its cuts was mandatory, like the sequester but on an ongoing basis. But then, it probably wouldn’t have passed in the first place, would it?

  20. What a painful article–so much bureaucracy, hundreds of hours of time with public officials, and for what?

    If only the people who made the SGR wrote it so that following its cuts was mandatory, like the sequester but on an ongoing basis. But then, it probably wouldn’t have passed in the first place, would it?

  21. The “real fix” would be to introduce American (monopoly) medicine to the cost controls of the free market. This means the elimination of prescription laws as a first step. Which eliminates the legal monopoly that doctors currently enjoy over access to medical drugs. In effect most medical drugs become “behind the counter, adult signature required”. This changes the medical equation to one where the patient, not the doctor or the insurance company, has the freedom to decide matters for themselves. Other forms of deregulation would be to eliminate state medical licensing in favor of a system of national certification (by a private agency similar to how we now certify electric devices). There is no good reason why we have the legal monopolies in medicine, the law, teaching, etc., that we have now. Except that in the past the professional organizations (labor unions under a different name) got the federal and state governments to grant them a legal monopoly over the provision of professional services. With the rest of us suffering the consequences of higher monopoly prices for service for which we have no alternatives…

    1. We have been getting a little bit of that as health practitioners other than MDs have been allowed to dispense some prescription drugs, and do other doctor-like things too. The restraint of trade has been maintained by broadening the guild by merger with other guilds, which is an improvement from the customer side. Much of the pressure to do so has come from the motiv’n of cost containment by gov’t & big private insurers. Unfortunately this has presented itself with the appearance of diminution of quality by insureds who wind up seeing nurse practitioners, physicians’ ass’ts, etc., so popular sentiment isn’t necessarily on the side of weakening the monopoly or oligopoply.

  22. Not on this subject, but why no column on the late libertarian author Terry Pratchett? Although not as obvious as Heinlein’s, a deep libertarian strain runs through his works and his life, distilled (for me) into one of his most frequent observations, that the worst evil is to treat people as though they were things. By the way, Sir Terry is not dead. He crowds my bookshelves. He has merely stopped writing, and that is sad enough for me.
    Thank you.
    Sherwin Cogan
    scog@cox.net

    1. Do a search; there was one.

  23. The problem with Medicare is more general — it is that it is yet another patch of the patches of the Bismarckian Welfare state.

    1. “The problem with Medicare is more general — it is that it is yet another patch of the patches of the Bismarckian Welfare state.”

      And every application since then has required fixes on fixes as it becomes obvious that handing out free shit encourages people to demand free shit.
      Bismarck might be excused; he was a kraut and presumed all krauts wanted to work. By and large, it’s true; it took Stalin and Ulbricht to make it clear that krauts who were lazy enough not to migrate to the west could be as lazy as any population.

  24. I feel the same way about wt. control. I can stand to avoid eating this only by eating that as compens’n. I wind up still in positive caloric balance, feeling it’s an exercise in self-depriv’n to keep from gaining wt. even faster.

  25. Medicare should be ended and a safety net made available which for most would be Medicaid. Pretty simple if govt wasn’t involved.

  26. Typically poor reporting by Suderman and Reason. Also, check the dates here and you’ll see that Obamacare was “paid for” with fee cuts that had already passed.. The CBO Director explained that in a letter, which was also not reported.

    The sad truth is that Obamacare passed by defautt. Nobody is defending liberty, and taxpayers are suffering for that.

    Like this: If Republicans refused to approve Docfix — regrettably, of course, to “pay for” Obamacare — the Dems would entirely own the collapse of Medicare — as even MORE doctors and hospitals began reffusing Medicare — unless they repealed it themselves. But that means understanding how it works, and applying the strategic sense of a high school student.
    Or this: The administration’s own Medicare Trustees have reported, every year, that budgeted savings are unlikley to occur. But the Trustees Report is also ignored by rightwing pack journalism. So the suffering continues, because even the adminstration keeps saying it’s bogus (but nobody looks)

    This is why we keep losing, over and over. By default.

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