House Republicans' Obamacare Replacement Plan Is a Disaster. Here's Why.

It's health care that matters, not health care insurance.


Paul Ryan
Tom Williams/CQ Roll Call/Newscom

The release of the House Republicans' health care reform plan is the latest reminder that misguided objectives drive many policy decisions in Washington. Unfortunately, it often results in bad policy outcomes with real economic costs.

A lot has been said about the new plan to replace the Affordable Care Act. For example, it would make health care more expensive for millions of Americans. It would create a new entitlement, in the form of expensive tax credits. It would create an "Obamacare cliff" for the presidential election in 2020, the year when many important parts of the Affordable Care Act would be repealed. It might fail and drive us straight into a single-payer system. I agree with all of that.

But at the heart of the Republicans' inability to reform health care is their commitment to this notion that the provision of health insurance is the goal rather than the provision of health care or, more fundamentally, the production of health itself. Though insurance companies love it because it guarantees overinflated profits for their industry, this idea goes a long way toward explaining why the supply of health care remains so expensive.

As my colleague Robert Graboyes rightfully points out in his work, by focusing exclusively on the provision of health insurance coverage, Republicans have been asking the wrong question: "How do we find a way for Americans to consume health care at no cost to them?" Unfortunately, it has produced a series of policy decisions that have removed all incentives for health care consumers to be careful about how they spend money.

According to a Congressional Budget Office report in July, consumers pay for only 11 percent of their health care costs. Everything else is paid for by third parties, whether it's the government or private insurance. That's a problem, because when people's consumption is paid for by someone else, it jacks up demand and drives up the prices and inefficiencies of the subsidized good or service. Why should you consume health care carefully if you don't pay for it? And of course, health care providers have little incentive to keep their prices low to retain their customers (patients) because these consumers aren't paying the full tab.

Graboyes notes that this laser focus on the provision of health insurance coverage has distracted us from a more important health care goal: producing better health for more people at lower cost, year after year. The solution here is innovation. Nothing would affect prices and quality of health care as radically as revolutionary innovation, which we've seen in other fields, such as information technology. To encourage such innovation, we have to free the health care supply from the many constraints imposed by federal and state governments (both blue and red) and the special interests they serve.

"At the federal level, we could speed up the Food and Drug Administration's process for approving drugs and devices. The government could stop impeding the development of specialty hospitals. At the state level—encourage telemedicine, allow nurse practitioners and other non-physician providers to practice independently, eliminate certificate of need (CON) laws, and ease up on restrictive licensure laws," Graboyes writes. That, of course, is just the beginning. The next step is to end the Soviet-style price control so prevalent in Medicare pricing methodology and end hospital monopolies.

This is not what the Republicans' bill would do. Its benefits, such as the removal of most Affordable Care Act taxes, would be overwhelmed by the negative impact of government-encouraged health insurance provision. Though it would reform Medicaid, it would leave the ACA's huge Medicaid expansion untouched, replace Obamacare tax credits with Republican tax credits in the individual insurance market and continue the distortive practice of subsidizing employers' plans through the tax code. The bottom line is that the plan might add to the deficit. It deserves its Obamacare 2.0 label, as it doesn't really address anything. It might even make things worse, according to Michael Cannon at the Cato Institute.

It's time that lawmakers shift the way they think about the role that government should play in health care generally and abandon the idea that their role is to provide health insurance for all. They're obviously not there yet.


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  1. Good article.

    Their plan passed something this morning….i am not too familiar with the entire process but it is no where near going to the overall house and senate correct? Hopefully!

    1. Committee. Still needs a house vote and reconciliation with the senate. There are already insufficient repa in the senate to pass assuming all of team blue votes against it. So it seems foolhardy to keep pushing this forward when it has a constituency of basically just paul ryan, but maybe I just answered my own question.

      1. Thanks. But isnt out of commitee a pretty big deal? I thought there is a lot of work to be done still

        1. Meh. It’s a kot easier to whip 10 members bigged down in the details than fhe whole house. If the freedom caucus bucks this that alone dooms it.

      2. House Ways and Means committee. Still caught up in another committee.

        The Stupid Party stays true to its name

      3. I suspect this bill was tailored to the 4 senate republicans who vowed not to vote for anything that touched Medicaid expansion (I.e., they won’t vote for anything that’s not at least as bad as the ACA) because without their votes there’s no majority.

        It would be ironic if even they still don’t vote for it.

    2. “It’s health care that matters, not health care insurance.”

      Says who? What matters depends on what you are looking to achieve. If you are looking to improve the overall health of the population, then it’s health care that matters (at least more than insurance). If you’re goal is to make sure that people see you doing something visible to demonstrate how much you care, then it’s health care insurance that matters.

  2. Christ, what assholes.

    1. I must have read 500 comments on various blogs in the last couple of days about this pathetic attempt to 1) make Obamacare even worse than it is and 2) get blamed for it when the roof falls in, but this perfect three-word comment is all I ever need to read about the Republican party’s latest drive to the very bottom.

  3. Campaign on repealing it. Govern on tweaking it. Next – act surprised when Obamacare becomes Ryancare and voters punish Republicans because now they own the problem of stupid intervention in a marketplace.

    Anything I missed?

    1. Not at all.
      This will become known as the republican collapse of the healthcare system. Children’s history books will show that all of the destruction headed our way was the fault of repubs and capitalists. All the while, Brak O, just like FDR, will be hailed as the benevolent god that tried to help.

      Trump was either insane or stupid to want this job. Let’s just hope his response to failed politics will not be what Hillary’s surely would have been. That cunt was ready to go full Chavez once the weather turned.

    2. The big mistake was not repealing it before there was a replacement.

      Making repeal contingent on replacement means that if we can’t agree on a replacement, then it won’t be repealed.

      On the other hand, if ObamaCare were already repealed, there would be a tremendous amount of inertia for enacting a replacement.

      Cortez scuttled his ships so that the only way his men could go was forward.

      That’s what was called for here.

      Trump is partly to blame for this. Leaving Congress to devise their own solution is like expecting cats to agree on a goal and herd themselves towards it. ObamaCare got through because of Obama’s leadership. All he had to do was unify his party around his plan. Trump is sitting around waiting for Ryan to do that. It’s time for Trump to be a leader.

      1. I agree except with the trump part. He was one of the loudest voices for repeal and replace. Now the gop could have just ignored (probably safely) but given what happened last year I suspect too many are still scared by him.

        1. We don’t need voices.

          We need Trump to champion a repeal plan like Obama championed ObamaCare.

      2. ObamaCare got through because of Obama’s leadership. All he had to do was unify his party around his plan.

        Not quite how I remember it. The way I recall Obama made some vague promise of healthcare reform during the ’08 primary simply because Hillary had a plan and his advisors felt like he needed one too. Then once elected he let Nancy “we have to pass it to find out what’s in it” Pelosi and other congressional dems do most of the crafting of the bill. He just went out and pitched it (if you like your doctor you can keep your doctor).

        IOW, he didn’t really have much of a plan, but felt he had to make some kind of promise to compete with Hillary, and then once in office felt he had to follow through with something. But it’s possible I’m remembering wrong.

        1. Another ironic fact: Obama’s too economic adviser Jason Furnan had, before assuming chairmanship of the CEA, supported a policy very similar to McCain’s proposed bill, based around a fixed income tax credit for insurance.

          Now, of course, anyone who promotes such a plan is a right wing lunatic. Amazing how much the Overton window has shifted.

          1. *top economic adviser

            1. *Jason Furman

              I hate iPhones

        2. Obama pushed the ACA through Congress through phone calls, threats, and using the bully pulpit.

          It’s not about who thought of it and who proposed what.

          It’s about how it gets through Congress. That requires leadership.

          Trump needs to identify a plan, propose it, and crusade for it. Nobody wants to stick their necks out for no good reason. Stubborn mules won’t do what you want because they’re supposed to.

          Life is like that.

          Development projects don’t process themselves through local government. Developers have to push them through the bureaucracy, through the planning commission, and through the city council.

          The universe trends towards entropy, and half the people you meet live their whole lives in a dream like state. You want something done? You want people to do something? Don’t sit around and wait for them. Make it happen.

          If ObamaCare isn’t repealed, Trump will end up paying for it–whether it’s his fault or not.

    3. Yes, the part where voters punish Republicans.

      If Republicans were that stupid to just tweak when they could repeal it then you would have a point. They’re not. If they repealed it, they’d get hammered. Which is why they’re tweaking it. Selling it to their stupid voters as a repeal is the easy part.

      “I love the poorly educated” — DJT

  4. Obviously, this question isn’t germane to the above topic but, hmm, will the dumb as shit, psychotic Trump The Hump, lying, hypocritical phony Sean “Ugly, Little Chimp Face” Hannity and the rest of the contards now lick the shit from low-life rapist Julian Assange’s diseased asshole? Just wondering.

    1. Not sure why you brought Assange into that. Still got the sadz about the election?

      1. “WakaWaka,” you idiot, I’ve literally never voted for any political office in my life, because unlike you faux libertarians who hide behind the label because it sounds less biased and partisan and more palatable than what you actually are–right-wing, Republican contards–I put my faith in myself, not lying, corrupt, hypocritical politicians and fake news peddlers like Trump The Hump, Rand Paul, Limbaugh and the hacks and toadies at Faux News.

        1. Do you have all of those adjectives and nicknames written down on a sticky note next to your computer, ready for use? It seems a lot to remember.

          1. Ah, come on now, “mortiscrum,” you simply can’t handle the truth. Now go join chimp face Hannity and rapist Assange in an anal threesome.

            1. Your eloquence is outmatched only by your wit.

              1. Why, thank you, asshole.

    2. Obviously, this question isn’t germane to the above topic

      That part was eminently sensible, but then you had an aneurysm.

      1. Well, “Citizen X-#6,” I guess we can now count you in as a Faux News and Trump The Hump lover, and a lover of rapist Assange’s asshole. Are you gay, particularly for Australian weirdos?

    3. Vagina Lover|3.9.17 @ 10:29AM|#
      “Just wondering.”

      Were you born an idiot, or did it take training? Just wondering.

      1. In your case, “Sevo,” your mental retardation is due to your parents’ Down Syndrome. Are you Trig Palin? I don’t think your psychotic mommy wants you using the computer, except to play video games.

      1. Is cake your favorite food, “Cynical Asshole?”

  5. There were two good things about the Ryan plan.

    1) It got rid of the individual mandate.

    If slavery were the most cost effective form of social organization possible, what difference would that make? Slavery is morally reprehensible. Executing welfare recipients might be cost effective, but it’s also morally reprehensible. The national debt is beside the point.

    You know what else is morally reprehensible?

    The individual mandate.

    2) It phased out the Medicaid expansion.

    Medicaid pays a small fraction of the cost of care, and that leaves providers to gouge insurers to make up for those losses. This and Medicare (which reimburses at twice the rate of Medicaid but still doesn’t cover the cost of care) are the biggest causes of the problems in our healthcare system.

    Any “fix” that doesn’t address Medicaid isn’t really addressing the cause of the problem. The Ryan bill would phase out ObamaCare’s Medicaid expansion by 2019, and that is a necessary step to fix our problems.

    I won’t support any bill that doesn’t get rid of the individual mandate because the individual mandate is morally reprehensible.

    I’ll begrudgingly support a bill that gets rid of the individual mandate but doesn’t get rid of the Medicaid expansion because the individual mandate is morally reprehensible.

    The Ryan bill does both of those things. It’s a good bill for those reasons. We’re unlikely to get a better bill, but I hope I’m wrong about that.

    1. You are overselling the amount of medicaid reform.

      1. How so?

        It was to be phased out by 2019.

        If they were on private insurance after that, then that’s a gigantic improvement. It’s one thing to have to pay for people’s health insurance.

        Quite another to distort the market beyond its ability to function through Medicaid.

        Eating candy and being shot in the mouth aren’t equivalent because they’re both bad for your teeth. Yeah, the poor will still cost the taxpayers money under the Ryan plan, but at least they won’t be breaking the system.

        1. Funding is grandfathered in so at best you don’t make the problem worse, but it’s already fatal. Again, the states will NOT lose the expanded barrycare medicaid funding regardless of what this bill intends.

          1. The important thing is that those patients are no longer on Medicaid. However you pay for them, it’s better that what we have–so long as they aren’t on Medicaid. Getting people off Medicaid is the solution.

            Medicaid pays an average of 12.5 cents on the dollar.

            Show me a hospital with a large Medicaid population and not much private insurance to gouge to make up the difference, and I’ll show you a hospital that’s in financial trouble.

            When I worked at the hospital, we needed an average of one private insurance patient for every eight Medicaid patients to break even. Every one of your prescriptions, every x-ray, everything you do in an acute care hospital, you’re paying for all those Medicaid patients in addition to yourself.

            That problem must be addressed–there is no other solution.

            Move those patients to private insurance, and they stop being part of the problem.

            Think of it this way: the purpose of the individual mandate is so that young healthy people will help insurance companies offset the amount of money they get gouged for the Medicaid expansion. ObamaCare in its essence was a means to help the insurance companies survive an expansion of Medicaid. Medicaid is the heart of the problem, and the Ryan plan moves people off of Medicaid.

            1. Medicaid being the option for people who couldn’t possible afford decent health coverage. Just assume that those people won’t go to ERs and make society pay anyway. How much human sickness and death do your principles require before they are fully satisfied?

              1. The aca was sold on savings by these er folks now actually paying which medicaid does not

              2. Hungry people shouldn’t be punished for eating babies – they gotta eat something, don’t they, don’t they have the right to live, too?

                1. What an apt analogy that totally elevates this discussion.

              3. As someone who worked in an Emergency Room doing finance work, I can’t even begin to tell you how many Medicaid patients we saw who’s only issue was a cold or light fever, but we had to see all three of their kids and bill Medicaid for an issue that Motrin, a non-Rx over the counter drug, fixes for less than $20. Of course, since we we’re the E.R. it cost the taxpayer around $600-$1200 per kid. So please, tell me more. The cost curve is so bent it’s a pretzel and neither the ACA or this new RINOcare plan do anything to make care more affordable or more accessable. Period.

              4. Most studies of medicaid’s effectiveness (Tge Iregon study being the main one) actually found no significant improvement in coutcome from Medicaid enrollment of the uninsured.

                Also, most people on Medicaid would just get private insurance absent Medicaid; over half of Medicaid enrollees are coming not from being uninsured, but rather are switching from private/employer plans.

                So rolling back Medicaid doesn’t mean ‘sickness and death’, it means people going into the private market where coverage is more accurately priced.

                Now go play with your toys and the grownups talk.

              5. Looks like there’s going to be more sickness and death with medicaid:


                Oregon Study: Medicaid ‘Had No Significant Effect’ On Health Outcomes vs. Being Uninsured

    2. Republicans are taking the cowardly way out. They want to repeal the mandate but keep the popular coverage requirements, which is of course economically untenable for the insurance industry. As Ms. de Rugy says, one possible way this goes is a collapse of the market-based system, leaving single-payer as the only alternative anyone can sell.

      1. Tony has no idea what he’s talking about, and he doesn’t give a shit about what’s economically untenable for the insurance industry.

        1. I’m also not big on Leninist schemes to achieve what I want via purposeful (or easily predicted) chaos, though if Republican incompetence and psychopathy is how we get single payer, so be it. It’s not happening organically, that’s for sure.

          1. “not big on Leninist schemes” but an advocate of single-payer. Sure, those things are totally dissimilar.

          2. If you’re a Leninist, why do you care what happens to the proletariat? You’re just going to put them against a wall eventually anyway.

      2. As opposed to those courageous donkeys who created a new 200bb entitlement for insurance which results in no appreciable improvement in health outcomes and quite likely even a degradation.

        1. Twenty million people with coverage who didn’t have it before, but carry on with your alterna-facts.

          1. Tony, Obama’s goal was single payer gov insurance the whole time.

            All you have to do is look at great britain’s NHC to see what a disaster all government controlled programs become.
            You were actually correct in your first comment.

            1. GB’s healthcare system is not a disaster. Nothing like our market-based system. More alternafacts.

              1. You are such a blind moron. Bye bye dickhead

              2. These stories are from the past couple of years. I don’t recall any massive undertaking to address these issues, so forgive us please if your word is not enough.



              3. Nothing like our market-based system.

                Yes, the market-based system that’s been catastrophically warped by government-created perverse incentives since 1946. Tony, did your mom have any children that lived?

                1. Honestly the system has been warped ever since we started using a third party to pay for it, both public and private.

              4. We had a market based system?

                Tony definitely not getting his mess.

                1. Meds

              5. In our (the USA’s) system, most of the benefits of free-market forces on health care consumption and health insurance have been muted and distorted for decades. Employer-provided health insurance is one of the dominant parts of our system – and it shields workers from the true cost of insurance and prevents workers from choosing a health plan that best suits their needs. Employers get a tax deduction for the expense, but employees have no tax liability for that part of their compensation. Not much of a true market-based scheme.

                The other dominant part of our system is Medicare – which is essentially a single-payer hybrid. It’s not market based either.

          2. Yea under medicaid and heavy subsidies which fucked over the middle class in premiums

            The aca was sold on those without paying for coverage to lower costs because er bills arent being paid by someone els

          3. Twenty million people with coverage who didn’t have it before

            Most of whom are Medicaid recipients, which is unsustainable in the long run with the Baby Boomers becoming an increasing burden on the Medicare system. Costs for Medicare and Medicaid services combined have gone from $850 billion in FY08 to $1.4 trillion in FY16.

            1. And medicaid reimbursement is bad so the mid class either pays it in tax or in jacked up premiums the opposite of what donkeys said

            2. Pretty sure Tony goes to Brak’s twitter feed every morning to be told what to say.

              He’s not putting these words together on his own.

          4. Like skippy said, no appreciable improvement medical outcome at a higher cost. But at least they a nice pretty insurance card.

            Really for all your crocodile tears, one gleans that you don’t really care about quality of care; all that matters to you is that a piece of paper says the government giving people a thing.

      3. The penalty while an annoyance is kind of meaningless due to its size. It makes sense to go without care and pay penalty….only to sign up if a lot needed.

        Obamacare requires young and healthy folks to sign up which isnt even close to their projections

        The dems sold the aca as being necessary to lower costs by putting people without coverage on it. Problem is it was mainly medicaid and heavy subsidies which of course is paid by tax payers and jacked up premiums for middle class

    3. Yes, Ken. You’ve already mentioned that you’re fine with the Feds running health insurance.

      1. I have no idea what you’re talking about.

    4. This bill is very disappointing. It may include the items you listed but for six years we have listened to the Republicans talk about removing the state barriers to provide for more competition. Considering this bill doesn’t contain that is extremely disappointing. What would it take to get that provision? There are other issues as well, but this was one of their own rallying cries.

      1. It’s also a meaningless bunch of horseshit that exists solely to give Republicans a talking point where there was a mere void before, but it’s okay, nobody expected libertarians to know anything about national health policy.

        1. We know all there is to know about national health policy Tony.

          national health policy is not necessary and does not work.

          If the healthcare markets were allowed to function like a for profit business without massive regulations and controls, it would be far better for everyone.
          And deadbeats would either have to pay for their own health insurance or risk being in debt for the services they would receive in emergency rooms for the rest of their lives.

          1. Citation needed.

            1. Regularly read the London Telegraph to see almost monthly stories about the NHC and its utter failures. They are simple and basically mirror the failures of Canada’s system. The results are shortages of resources, customer neglect and money drying up for certain services.

              Contrary to your intellectual capacity, Cuba also has a terrible system. Surprise dipshit, Michael Moore and Beyance are not smart people.

              Citation provided genius.

              1. Find me a single British person in the world who has ever said they prefer America’s system to theirs.

                1. Austin powers?

                2. http://www.cnbc.com/2015/01/13…..risis.html

                  That a person who believes he/she is getting free shit may not be complaining is poor evidence of success. Those working in the system say it’s fucked up.

                3. Ok, so what a British person thinks about how the British system works compared to the American system is more important than how the systems actually function. Got it.

                  1. Most of the people that send their kids to DC schools think that system works pretty well too.

                    When by any objective measure it’s an abject failure.

                    The same tribalism that leads to nationalism also leads to mindless support for the NHS and muh public skoolz.

                4. Tony|3.9.17 @ 11:16AM|#
                  “Find me a single British person in the world who has ever said they prefer America’s system to theirs.”

                  Find me one Tony post that suggests a kindergarten level of intelligence.
                  You really think that’s some sort of evidence, dimbulb?

                5. Find me a single British person in the world who has ever said they prefer America’s system to theirs.

                  I know a number of British ex-pats living in the US that say the NHS is an abomination that has killed some of their friends and family members.

            2. I’d recommend you look at the work of John C. Goodman and Mark Pauly. Also John Cochran has written good pieces on healthcare. All libertarian-leaning, and give excellent data-based analyses and proposed solutions.

              Also, the ‘healthcare economist’ blog has some decent posts.

              More over, Jason Furman, Obama’s chief economic adviser supported what is now considered a conservative healthcare policy based in fixed size tax credits for insurance (republicans proposed it in Congress but Reid wouldn’t allow a vote; so it’s a myth that they never had an alternative plan).

              But yeah, you’re the expert on health care policy.

        2. While this bill seems to have been created quickly too Republicans could put something out there, how does that have anything to do with libertarians? Didn’t they keep Rand Paul out of the construction? I know it’s a house bill but they didn’t even consult him. He’s a doctor and a libertarian. I don’t get your point about the libertarians.

          1. …quickly so Republicans…

          2. Libertarians have an easy solution, and it is truly the most moral possible one: if you can’t afford healthcare, die in the street. So why bother understanding facts like “across state lines” solves no problem we currently have and exists as a talking point and at most as a pathetic attempt at giving the insurance industry a means to maximize profits while minimizing payouts.

            1. if you can’t afford healthcare, die in the street.

              so you’ve descended from mindless talking points to outright retardation.

            2. I haven’t seen anyone proposing an “afford it or die” platform. There are proposals from libertarians that would make the individual more responsible for their own health care management. but they are not that drastic. Besides, whether it was the health care system prior to ACA or post-ACA, there were people facing treatments, surgeries, or care of some kind that would not be rendered unless they could afford it or some part of it. That included some life saving care so people were dying when they couldn’t afford it.

            3. The insurance industry is not the reason for the high healthcare costs fyi. Small part but if you get rid of them it doesn’t really reduce cost that much

              It is due to govt intervention by using medicare, medicaid, incentivizing employer provided plans and regulations/mandates. Also the actual health care professionals are paid well and it is expensive to bring new things to market

            4. if you can’t afford healthcare, die in the street.

              Oh this is so much bullshit. This isn’t the libertarian position AFAIK. The libertarian position, as far as I understand it, is:

              If you can’t afford healthcare, it is YOUR RESPONSIBILITY to find means of obtaining healthcare WITHOUT COERCION. So: find a benefactor, solicit the help of willing friends and associates, go into debt to pay for it, whatever – just don’t steal money from people to pay for your health care. IF YOU CHOOSE to go without healthcare for whatever reason – can’t afford it, terminal illness, don’t want to bother with going to a hospital – then that should be your choice to do so and no one should force you to get care that you don’t think that you want.

            5. I thought that was the Government solution

    5. You know what else is morally reprehensible?

      Every coercive and redistributionist part of the health care law. And most of the rest of the stuff the federal government does.

      The individual mandate is bad, but I don’t think it’s uniquely bad among all the other health care regulations. Forcing everyone (who pays federal taxes) to subsidize people’s routine health care is at least as bad as the individual mandate.

    6. There’s another aspect of RyanCare that is much less bad than ObamaCare.

      ObamaCare provides subsidies from 100% to 400% of poverty line.

      Under ObamaCare, do you make less than 100% of PL? No subsidy for you, tough luck. Make 100%-250% of PL? You face a huge marginal income tax rate. Make 251% of PL? Your deductibles and oop maximums spike up. Make 251-400% of PL? You’re back to a huge marginal income tax rate?

      Make 401% of PL? Congratulations, you just lost the entire subsidy. In my own case, the marginal income tax rate is about 800,000%. *

      Under RyanCare, the phase out of tax credits doesn’t hit until about $150,000/year, and it doesn’t have a ridiculous cliff like ObamaCare has at 250% and 400% of poverty line.

      * The Laffer Curve suggests that there’s some tax revenue maximizing rate between 0% and 100% of marginal income because marginal tax rates influence behavior at the margin. However, it does not consider the possibility of a marginal tax rate of 800,000%. Has nobody considered the effect of such rate?

    7. Executing welfare recipients might be cost effective, but it’s also morally reprehensible.

      Letting them die by their own stupidity/laziness though is both cost-effective AND morally commendable.

      Any “fix” that doesn’t address Medicaid isn’t really addressing the cause of the problem.

      As long as any segment of the health care “industry” is dependent on tax collection for a noticeable portion of their revenues then the problem isn’t being addressed.

      It isn’t insurance if it covers routine maintenance. If your auto insurance company was mandated to pay for your gas, oil changes, and tire changes the price of gas would be $20 a gallon, oil would be $30 a quart, and tires would cost $2000 each – and your auto insurance annual payment would be $12K. But you’d be getting 80 miles per gallon. And you’d probably not bother owning a car because it makes no economic sense.

      Yet this is exactly the set up 98% of doctors think is a final solution. Economic ignorance is morally reprehensible.

      1. Get your stupid morals off my body, meddling asshole.

        1. Get your grasping fingers out of my pocket, greedy shithead.

      2. Exactly. You wouldn’t own a car, you’d steal one every time you needed one.

  6. Socialism is all that matters.
    This is all so hilariously futile.

    No way in hell a bunch of corrupt desperate useless politicians are going to repeal a brunch of free shit. More impossible yet is convincing a citizenry full of illiterate morons that something is financially doomed.

    These scumbags have no skill or profitable usefulness in real life. They will fight repeal of any socialist program for eternity because they need to retain their worthless jobs.

    America is doomed ultimately because our complacency, due to great wealth generated by capitalism, has rendered us a stupid mass of sheep who expect government freebees and protection from all things painful.
    Until of course, it all comes crashing down. As all economies with over 100% of debt to GDP ultimately do. The wars are going to be cool to watch though as we will be told.

    1. In this case, though, the thing they were going to repeal makes health care lower quality and more expensive for millions of Americans. Likely hurts more than it helps. There is some political capital.

      If it were just free shit, they would indeed be toast.

  7. CON laws and all of that is basically window dressing. Sure NP’s could misprescribe antiobiotivs for colds as well as the best primary care doc out there but that just tweaks the margins. The bigger issue is doc supply which is basically constrained by medicare since that is what funds most residencies. So just import more docs say the open border advocates. Maybe. Some peer countries would be fine for this: canada, a big chunk of europe, but they don’t really have a bug surplus to spare so I’m not convinced that solves the problem either.

    Vero gets to the heart of the problem that americans bear the lowest direct cost sharing of the industrialozed world. But it’s going to be a tough love sell to tell everyone the good news that their copays are going up. A lot. And libertarians will have to get their heads out and understand that a change of this magnitude will require real focus and unrelenting incrementalism. Being easily distracted by kulture war and MIC spending means that you’re a fickle enough ally that no one will listen to you.

    1. Sometimes I feel like I am the only one that recognizes what we actually have is a problem with a lack of health care provider supply.

      1. Last time I looked there were only around 250,000 primary care Doctors in the United States to service 350,000,000 people. Do the math.

    2. Your point about incrementalism is very accurate. You cannot persuade people to shift their views significantly. You can do it in small chunks. Stopping the bleeding from Medicaid would be helpful. And equalizing tax treatment I think is a good thing.

      One thing that has shocked me in the whole debate is how much attention seems to be paid to the demand side of the equation and none to the supply side. Simply allowing medicare to spend outside of the US would probably shift a lot of good supply from other countries to us.

      It seems to me the biggest issue w/ access to doctors is that there aren’t enough of them. Or we are forced to use them when something cheaper and easier will work.

      1. It seems to me the biggest issue w/ access to doctors is that there aren’t enough of them.

        and if we follow the logic trail, how much of that is owed to govt intrusion making the profession less and less attractive.

      2. It seems to me the biggest issue w/ access to doctors is that there aren’t enough of them. Or we are forced to use them when something cheaper and easier will work.

        Mostly the latter.

        Doctors love the fact that government mandates increasing demand for doctors AND mandates keeping the supply low.

  8. The short term solution should be to eliminate Obamacare and the exchanges entirely, grandfather the people who are currently receiving expanded Medicaid while restoring the income amount to its previous level for new applicants and peg that amount to inflation, set a date for sunsetting the provision for 26-year-olds being on their parents’ insurance, blow up the requirement to own insurance, modify the “pre-existing conditions” clause to allow insurance companies to at least have their plans reflect their burden to the insurance pool (if you’re costing everyone else a shit-ton of money to treat your issues, damn right you’re going to have to pay more), and mandate transparent pricing at all medical care providers. You should be able to go on a physician’s website and find out how much they actually charge for, say, a broken arm or heart replacement. The fact that NO ONE on the right or left seems to demand this very simple means of encouraging competition shows how mendacious both sides are about fixing the problem.

    Long-term, current anti-monopoly and price discrimination laws should be enforced so that one person isn’t charged a different price for the same service just because of their insurance company, or lack therof.

    1. Don’t go offering solutions now. America is far better off being angry at what CNN/Today show tells them

      And that is why pols don’t care about solutions. They would much rather risk not getting elected every 4 years than stick their neck out and guarantee showing their stripes.

      Like every bureaucrat ever created, it is far better to stay low and hope than try to exact change.

  9. I don’t see how the “We’re lying about how much we’re screwing the poor to give money to the rich” caucus and the “We’re lying slightly less about how we’re screwing the poor to give money to the rich” caucus possibly reconcile with each other and get anything passed.

    1. Don’t worry, one day everything that’s bad will be good again.

    2. Subscribing to the class warfare meme is one classic mark of a truly useful idiot.

      Well done Tony.

      The scumbags have been using dopes like you for millennia.

      1. That’s basically all this plan does: take benefits and money away from poor people in order to fund tax cuts for the rich. It really has nothing to do with improving healthcare. It does quite the opposite.

        1. Uh it doesnt get rid of medicaid fyi

          1. Don’t bother with this idiot. He sounds like the average angry leftist brainwashed sheep. Devoid of intellectual curiosity.
            Going to be a miserable loser the rest of his life.

  10. In reality, it’s health that matters, not health care.

    1. I should RTFA before commenting.

  11. The plan is a joke and it confirms every bad thing that has ever been said about Paul Ryan and the House GOP leadership. It just astounds me that Ryan thought he could ever get this thing passed or doing so would be anything but a disaster for the country and the Republicans. Worst of all, this isn’t that hard of a problem. If they would just get rid of the coverage mandates and stop forcing insurance companies to insure people with pre-existing conditions, you would solve most of what is wrong with Obamacare. How hard is that?

    The irony of the whole thing is that the Democrats and the media are still spinning this as repealing Obamacare and the Republicans throwing sick people into the street. So trying to compromise and show that they really are okay with some socialism bought them exactly nothing. The House GOP can’t even sell out properly. When you sell out you are supposed to get something in return you fucking half wits.

    1. Pre-existing condition coverage has sunk literally ever program that’s tried it. The reason? Because that isn’t insurance, it’s a finance plan on services that can’t be repossessed for non-payment.

    2. ^This. The most important thing I have learned from this plan is Paul Ryan is as bad as many have told me.
      I had no idea he was this much of an idiot. Wow, just wow.

  12. Paul Ryan’s heart is in the right place. He wants to make healthcare a commodity available only to those who can afford it. The others of course, as his philosophy tells him, are poor because they are immoral, and not just immoral but so immoral they deserve to die slowly. What I don’t get is why he thinks he has to be such a big fat liar about all this. If this is truly the most moral system, surely it can be sold politically. Or does Randian psychopathic horseshit, despite its ostensible appreciation for cold logic, allow for the utter bullshitting of people who are set for the death camps, if only for expediency’s sake?

    1. Healthcare is a commodity. You dont have a right to force people to take care of you

      Anyway i have some medical bills can you help me out so i dont die in the street?

      1. Then protect your own fucking lawn from vagrants. And get off my roads. I’m sick of paying for your upkeep, parasite.

        1. Wait so why do you support the dem party and grand stand about how people need to adhere to the social contract?

        2. Why wont you help me when you preach virtue of helping others?

          Or are you only generous if someone else has to do the work?

          1. He would give more money to poor people except some rich guy is hoarding all of the money and keeping it from him.

            And thus encapsulates the mental economic capacity of a socialist.

        3. Get back to us when you can prove that you actually ARE paying for anyone else’s upkeep.

          1. I am not rich enough not to pay taxes.

            1. Amusing since ‘The Rich’ are already the vast majority of tax revenue in the United States. They quite literally shoulder almost the entire revenue base of the Government. What happens, exactly, when you run out of other people’s money I wonder?

              1. They’ll just print some more!

              2. Really? How much in taxes do you suppose “billionaire” Donald Trump paid last year?

                1. How much did he make?

                  You can’t seem to keep your talking points straight. On one hand you question his purported networth, on the other you suggest he isn’t paying taxes, but if he’s losing money on investments instead of making it then of course he isn’t paying taxes on capital gains. There’s no capital loss tax, genius.

        4. This may be the dumbest talking point in history. If road use were allotted to people according to how much they pay for them, rich people and big corporations would get most of the rations. They pay far more into road maintenance than the costs they impose.

          Roads, like virtually all public services, is a net transfer of wealth to the poor and working classes, who are the ones who are ‘not paying their share.’

          I’d love to make roads pay per use. It’d be great for me. It’s lower income people who oppose the idea because deep down they know roads are basically a free good financed mainly by the rich people and companies they hate.

        5. Since I don’t have a prison or court system, my method of protecting my lawn might not be as humane or involve as much due process as you would prefer. Don’t pretend that crime victims are the only beneficiaries of the criminal justice system.

    2. Clearly the moral choice is to make people care for others that they’ve never met. Besides, once everyone is making $25/hr they’ll have all that extra money to send off to those others in desperate need of medical care.

      1. Look Sparky, if making insurance unaffordable and practically useless for millions of people who previously had both affordable and healthcare they liked is the price we have to pay so that a small number of people with rare or previously existing conditions can get health insurance, well that is just a price other people are going to have to pay. Becasue MORALITY!! And of course because THE CHILDREN!!

        1. As a guy who actually has a real ObamaCare policy (the type that purchased on the infamous Healthcare.gov exchange that progressives rave about) I can confirm that it is far, far worse than the individual coverage I had before ObamaCare.

          Before ObamaCare, just three years ago, I had a quality PPO policy with a wide provider network. It had a high deductible, but would be great if I were get in a carwreck or get diagnosed with cancer.

          With ObamaCare, I pay 50% more in premiums, but have a crappy HMO with the same provider network as the local Medicaid provider and the same high deductible. But it’s basically carwreck insurance. If I were to get a diagnosis of cancer, I’d be on a plane to Singapore because the ObamaCare provider network excludes pretty much every competent oncology option.

          1. In fairness, though, I should mention that the ObamaCare policy does offer free birth control and pediatric dental service to my sixty-year-old wife and myself.

          2. “As a guy who actually has a real ObamaCare policy (the type that purchased on the infamous Healthcare.gov exchange that progressives rave about) I can confirm that it is far, far worse than the individual coverage I had before ObamaCare.”

            While driving to work this morning, I heard on the radio that the Congressional Democrats had proposed an amendment to the GOP bill to rename it the “Pay more and get less plan”.

            Funny I thought that’s exactly what Obamacare did.

          3. What was never reported during the passing of this monstrosity is that something like 75% of the public was happy with both their insurance and their health care. This law fucked 75% of the public to provide benefits to the other 25%, that many of whom didn’t even want.

            1. 75% of the public was happy with both their insurance and their health care.

              75% of the population is healthy and doesn’t spend anything on medical because they are healthy. Literally, the healthiest 50% of the population spends 3% of the medical dollar – an average of roughly $500 per person. Insurance is itself a form of tax for healthy people. The actual healthcare market is irrelevant to them – less relevant than whether to buy coffee at Starbucks or brew at home. Further, because they are healthy and not consumers of medical services, they are completely ignorant of how either insurance or medicalcare actually works in the US – or of how much sickness itself is impoverishing.

              And that ignorance is entirely rational. There is no reason why healthy people should be preemptively engaging in a market they are not part of. But it is insane for that group to then exercise that ignorance in a voting booth and assert that insurance is not taxes but a free market – but taxes are taxes and hence socialist – and that the irrelevant consumers should be the major factor in how the actual healthcare system is structured. It’s insane. This moron majority is why our pols are such morons in turn.

              1. “But it is insane for that group to then exercise that ignorance in a voting booth and assert that insurance is not taxes but a free market – but taxes are taxes and hence socialist -”

                Insurance isn’t a tax because government force is not involved.

                Actual taxes are indeed taxes because government force IS involved.

                And if those taxes are used by government to intentionally force some to subsidize the existence of others that is indeed socialist.

                1. Insurance isn’t a tax because government force is not involved.

                  Force is force. And ‘you must keep paying this excessive amount of money in order to have any claim on someone else to pay bigger bills if they ever happen – and if you stop paying then your death is your problem’ is coercion. Do you really think there’s some big fucking difference here between government saying this and an insurance company saying this? I don’t see much difference at all and certainly not one big enough for a over-simplistic ideological chant as the only response. Health insurance is not the same as either liability or life insurance.

                  Free market re healthcare DOES NOT EXIST anywhere on Earth. It did not exist in any acceptable modern form before WW2 in the US because a)specialists did not exist then and b)hospitals were mostly founded by churches as charities for their congregation (with surplus space – which there was plenty of then – opened up to everyone else – except in the South). If it were so easy to make it happen, then it would have already happened somewhere. Maybe that’s because its more complicated than the boobjob/tummytuck market.

                  1. “Force is force. And ‘you must keep paying this excessive amount of money in order to have any claim on someone else to pay bigger bills if they ever happen – and if you stop paying then your death is your problem’ is coercion”

                    Uh huh.

                    Only ACTUAL force is force. And government has the monopoly on the legal use of actual force.

                    Insurance of any type (health, home auto, umbrella liability, etc.) is a voluntary contractual arrangement between two private parties. There is no force involved absent government. The insurance company cannot throw you jail or stick a gun to your head if you refrain from purchasing their policy.

                    Furthermore your life is your own responsibility – not anyone else’s It is not “coercion” if an insurance company drops you if you refuse to pay the premiums. You are not entitled to something for nothing.

              2. “The actual healthcare market is irrelevant to them ”

                The health insurance market is not irrelevant to them.

                Ask those who had individual insurance policies pre Obamacare if the huge premium increases they had to pay for policies that were of less value in terms of less coverage and fewer provider choices if that was “irrelevant” to them.

        2. I guess it’s easy to shout about morality when you have no intention of backing up your claim.

      2. For idiots like Tony, I would like to get an answer to this question:

        Why should my unborn grandchildren have to pay for the healthcare of someone today who was too lazy or stupid to but health insurance?
        Why should generations of unborn US citizens pay for sorry-ass bums who have a cold?

        1. Because like a thousand other things healthcare is most efficiently dealt with as a social cost rather than an individual one. Because you people are victims of industry lobbyist propaganda, you have somehow convinced yourselves that healthcare is meaningfully, morally different from other collectively paid-for services like national defense, criminal justice, and infrastructure. But it isn’t. It just happens that it benefits the poor relatively more than those other things, so that’s why it, like education and welfare, gets a target put on its back by people like you.

          It comes down to you irrationally hating the poor, thinking poverty and immorality are not only equivalent, but that we need a system to punish that immorality harshly, like some fucking busybody Christian, and why that should be anyone’s problem but your own escapes me.

          1. “Because like a thousand other things healthcare is most efficiently dealt with as a social cost rather than an individual one”

            Get back to us when you can actually prove that.

            Absolutely and definitively.

          2. Wow! You make it so easy Tony.

            I am so glad you spouted that lunacy. You have further removed yourself from reality and proven that you cannot understand even the most elementary of economic situations much less discover value in a free market.

            You deserve to reside in the shithole you will be forever relegated to.
            When you join the storm troopers, try not enjoy wearing the silly uniforms.

          3. When’s the last time you’ve personally done anything for the poor Tony. Don’t worry, I’ll wait.

            1. Asking that question indicates that you’re missing the point by exactly 100%.

    3. Paul Ryan’s heart is in the right place.

      And like you his head is up his ass.

  13. The big government republican establishment presented their plan as an alternative to the bigger government democrat plan. Hopefully Rand Paul, Mike Lee and Ted Cruz (enough to kill this in the Senate) can force some changes.

    1. Or just not vote for it, thus killing the proposal instantly. The Republican’s literally can not pass a plan without them. (Assuming zero Democrats vote for it, which seems safe)

    2. Ted Cruz already showed that he is good at backstabbing.

      He cosigned the same exact tweet as Paul and Lee. When Paul and Lee saw the House bill, they held firm, and balked.

      Ted Cruz held back, said he’ll study it, and then proceeded to the White House with his wife and two daughters to greet the man who insulted their mom and granddad.

      For the love of his country.


  14. this laser focus on the provision of health insurance coverage has distracted us from a more important health care goal: producing better health for more people at lower cost, year after year.

    Totally agree. Why it’s like pols are trying to buy votes and win elections by promising their base tax credits at the expense of the other sides base.

    The solution here is innovation.

    Totally disagree. Every other industrialized country on Earth is able to deliver the basics of healthcare – for more people – at lower cost. They do so not via innovation but by using monopsony power and honestly discussing what is ‘the basics’ (which is gonna get into the notion of what is a ‘right’ and what is not) and what is not. Technical/medical innovation is only valuable once you are well beyond the basics and into specialized services. That innovation can only become part of the basics once it has widespread adoption by which point it is no longer innovation.

    1. At the federal level blahblahblah. That, of course, is just the beginning. The next step is to end the Soviet-style price control so prevalent in Medicare pricing methodology and end hospital monopolies.

      The FIRST step is for the feds to focus exclusively on reform of Medicare and Medicaid. It is insane to suggest that they should do so by eliminating their fiduciary responsibility to both taxpayers and beneficiaries. Stop the useless ideological ranting. Those federal programs should exert MORE control over their piece – not LESS control.

      Medicare is the part of healthcare that deals with the highest volume users, where ‘medical utilization’ will in the end inevitably 100% fail in producing a positive result, where there is no future economic value (everyone is retired already) but where there is a moral/ethical issue (what do humans have a right to expect as they die), and where the concept of ‘preparing ahead of time’ can become the basis for an actual free market but only if those medical issues are dealt with first.

      Medicaid is the part of healthcare that deals with the lowest-price points that will be provisioned – and with the healthcare reality that sickness ITSELF is an impoverishing event and is a big part of any poverty trap. Those sorts of issues also need to be addressed before a free market system can work.

    2. Not true. US has better quality healthcare than any other country on earth when you control for lifestyle choices, accidental injuries, and violent crimes.

      It is purely a myth that European countries have better quality care. The reason the US has a lower life expectancy is because of higher homicide rates, injury rates, obesity, etc.

      1. US has better quality healthcare than any other country on earth when you control for lifestyle choices, accidental injuries, and violent crimes.

        ‘Lifestyle choice’ is not some abstract ethereal decision. It is a consequence – and often a form of ignorant self-medication – of not having generalist doctors and routine/preventative care in this country – and thus not going to that generalist doctor on a regular basis. We ‘go to the doctor’ [generalist] less often than other countries – and yet we spend much more on healthcare overall. Our poor ‘go to the doctor’ at half the frequency of our middle class and above (who are still going to the doctor less than elsewhere) – indicating that that is a consequence of income and the way our system is structured – not abstract freedom-loving ‘choice’.

        And since accidents/violence is essentially a non-factor once people hit 30 or so, it is easy to adjust for. Just look at healthcare outcomes or remaining life expectancy at 40 – or 50 – or 60 – or 70. It is only at age 80+ – the heroic end of life stuff that really jacks up costs – and life expectancy – in the US – where the US system provides more.

        1. Heck, just yesterday I made a bad lifestyle choice that adversely affected my health: I ate too much American cheese, & the sodium put me in atrial fibrillation this AM, which I hadn’t had since 2015. Hope I can snap back to sinus rhythm soon, because I feel like shit when I’m in A fib.

        2. Um no. People shooting each other or running each other over with cars does not reflect the quality of health care.

          2nd, among developed countries there is no correlation between life expectancy and health care spending. It’s not a question of how efficiently the money is spent; rather it is just a fact that there are diminishing returns in health care as in everything else. Does Malta have a more efficient system than Norway since they spend less but have a higher life expectancy? No, they’ve just reached the level of quality where the benefit of additional health care spending no matter how efficient is pretty much negligible.

          1. People shooting each other or running each other over with cars does not reflect the quality of health care.

            I know. But our ‘specialness’ with those two things also ends by roughly age 30. We don’t have gangs of seniors roaming around shooting other seniors gang rivals and texting while they drive. Which is why I said use higher ages (eg remaining life expectancy at age 40) instead.

            among developed countries there is no correlation between life expectancy and health care spending.

            There is when you exclude the US (which spends 50% more than anyone else and gets less than most) and when you look at what countries spend their money on. Countries that spend money on routine care and generalists and clinics get very good results measured in life expectancy. Countries that spend money on cardiologists and knee replacements for 80 year olds don’t get much at all. And the first group of countries spends less than the latter group because generalists and routine stuff tends to reduce overall costs – because the population remains healthy for longer.

      2. Just look at the one big fat issue of obesity. How many people in the US have to actually make an economic choice – do I go to the doctor or do I put food on the table this week? They choose food. And it doesn’t take too many decisions before the food is driving their decisions and affecting their health – and they will never really realize what the hell they are doing until diabetes causes problems because – they constantly have to make a short-term choice about ‘do I go to the doctor or do I put food on the table this week’.

        This is not just stupid people who don’t look like me doing stupid things and the hell with them. This is the inevitable rational way that any pricing system is going to work when someone poorer than a doctor has to decide how to self-ration the time-based services of a doctor. They will never acquire the knowledge (eg eat less of this junk and more of the other food if you want to be healthy long-term) that allows them to make a different decision. And our societal failure to deal with this when it is a small issue (you CAN eat healthier) is what forces a much tougher and more expensive issue (treat diabetes or die you fat fuck) long-term.

        1. Depending on which numbers you chose, obesity-related factors account for 15-25% of health-care expenditures in the US. Smoking-related factors account for another 15-25%.

          Lifestyle choices in the form of obesity and smoking comprise fully one-third to one-half of all our health-care dollars.

    3. “Every other industrialized country on Earth is able to deliver the basics of healthcare ”

      For variable levels of “basics of healthcare”…the US easily wins on any number of dimensions in this problem space. It all depends on the weighting factors one chooses to place on the variables. The OECD, for example, places a hefty weighting factor on Social Protection, i.e., government-provided care.

      1. the US easily wins on any number of dimensions in this problem space. It all depends on the weighting factors one chooses to place on the variables.

        NAME them then. By life expectancy, capability to maintain physical activity v physical disability, actual physical activity, obesity, mental health indicators, happiness indicators, actual foods eaten and most other measures related to ‘producing better health for more people at lower cost’ – whether top-down data by bureaucrats or far more interesting bottom-up surveys (like World Happiness Report) – the US is worse than most other wealthy countries. Considering that we spend 50% more as a % of GDP on ‘healthcare’ than the country in 2nd place; the positive indicators for us should be more glaringly obvious than it was in WW1/WW2 when Europeans were gobsmacked at the height/health of young GI’s and when we could notice it ourselves among 1stgen immigrants v 2nd/3rd gen Americans.

        The reason we aren’t ‘producing better health for more people at lower cost’ is because our healthcare system now is designed completely around heroic treatment of disease. Prolong the lives – and not necessarily even the quality – of the small number of people who are very ill – at virtually infinite cost and avoid ALL serious discussion of this. I suspect this focus actually makes things worse overall – the sick can feel like isolated lab rats, and the healthy can resent both the focus and the costs.

  15. Just like with Obamacare congress is focused on the wrong problem. WHO pays instead of bringing down the total cost of the system. We need to bring competition to the healthcare system and increase supply faster than demand. That is the ONLY way to bring down costs and make healtcare affordable for the nation.

    First, everyone should have to pay the same rate, insurers, government and private indivduals. That rate should be posted, for everyone to see to encourge competition.

    Second, if you want to lower costs, you need to increase supply faster than demand (the opposite of what these expansions to insurance do). That will allow competition to drive these costs down. Remember insurance is NOT healthcare. We need to get rid of all the burueacratic hurdles that are stopping more care. (such as the doctor cap).

    Finally, if you are getting government assistance, you should be doing everything you can do keep the costs down. IE, put down the donuts, and the TV remote and go down for a walk (or workout). Their should be a requirement to be fit medical condition permitting.

    I would also add we need to stop heroic end of life care on the taxpayer dime.

    1. I would also add we need to stop heroic end of life care on the taxpayer dime.

      I agree. I also think there is only one way to actually get there – with a system based on a relationship with a personal doctor. A generalist who knows you and your condition – who you have known for long enough to trust – who knows medicine and can judge what works/doesn’t – and thus who can be honest and be your expert and be conscious/capable when you aren’t anymore. Absent that, we make it impossible for an individual to be a part of that decision (as well as other big medical decision) – which means a bureaucrat/stranger does and we scream ‘death panels’.

      My parents are an example of how the US system works. They have an exec retiree plan that supplements Medicare. They did all the financial pre-prep for retirement/aging. They have access to specialists/diagnosticians and are now increasingly using them. But because they moved a lot and were healthy, they relied on ‘insurance system’ to define their access to primary care. Once they retired, in a new location, they found NO generalist doctors to take them. This isn’t unique. The US has fewer generalist doctors/peep than anywhere richer than Turkey/Bulgaria and their function in the US is like tits on a bull. Our entire system is structured towards disease payment/specialists.

    2. Forbes: “an enormous amount of the health system cost is centered in a very concentrated group of people”

      “According to one study (Banarto, McClellan, Kagy and Garber, 2004), 30% of all Medicare expenditures are attributed to the 5% of beneficiaries that die each year, with 1/3 of that cost occurring in the last month of life…there are other studies out there that say slightly different things, but the reality is simple: we spend an incredible amount of money on that last year and month.

      “It seems that no matter how much money you use during that last year/month, if the person is sick enough, the effort makes things worse. A lot of the money being spent is not only not helping, it is making that patient endure more bad experiences on a daily basis. The patient’s quality of life is being sacrificed by increasing the cost of death.

    3. Their should be a requirement to be fit medical condition permitting.

      And how will anyone verify that they are fit in the libertarian world where no government exists to regulate bodies, inspect people, and … FREEDOM!

    4. “We need to bring competition to the healthcare system and increase supply faster than demand. That is the ONLY way to bring down costs and make healtcare affordable for the nation.

      First, everyone should have to pay the same rate, insurers, government and private indivduals. That rate should be posted, for everyone to see to encourge competition.”

      You can’t have competition in the system when such a large chunk of the healthcare consumed in this country is being consumed by people on Medicare and Medicaid.

      Or, another way to look at it, in order for Medicare to cover the true cost of care, it would triple the cost of Medicare to the taxpayers. If Medicaid paid for the true cost of care, the cost of Medicaid to the taxpayers might rise to seven times its current cost.

      Medicare and Medicaid currently make up some 30% of the federal budget. Triple the cost of those programs, and it takes up almost 90% of current federal outlays–and we haven’t even started to pay for social security or the military.

      Meanwhile, the idea of everyone paying the same cost is politically absurd so long as such a large portion of the healthcare is consumed by politically sensitive old people on Medicare and poor people on Medicaid. The system is set up as it is so that those people pay very little or nothing for their healthcare–because they have no means to pay for it.

      1. in order for Medicare to cover the true cost of care, it would triple the cost of Medicare to the taxpayers. If Medicaid paid for the true cost of care, the cost of Medicaid to the taxpayers might rise to seven times its current cost.

        Sure sounds impressively quantitative.

        3x Medicare equals $1.9 trillion
        7x Medicaid equals $3.8 trillion

        Total of that is $5.7 trillion
        Total healthcare spending public and private in US – $3.2 trillion

        Whoops. Unless your goal here is to drive up healthcare costs with a nice big taxpayer subsidy or pretend that them poor/old people comprise 180% of all medical service utilization.

        1. From this chart, total federal spending on healthcare (Medicaid + Medicare) for 2017 is $1.2 trillion

          Tripling that would cost 3.6 trillion.

          Total sending for 2017 is 4.1 trillion.


          “Unless your goal here is to . . . pretend that them poor/old people comprise 180% of all medical service utilization.”

          I don’t believe you’re grasping what I’m telling you.

          If Medicare pays 27 cents on the dollar, then utilization doesn’t go up if the government starts covering the total cost to providers. If Medicare covered the total cost to providers–on the same patients they already have today–it would triple the cost of the program. In other words, it would triple the cost to the taxpayers–of the patients they already have–if instead of paying providers only 27 cents on the dollar for Medicare patients, they started paying providers 100 cents on the dollar instead.

          Medicaid is even worse.

          If you take every reimbursement rate for every code and multiply it by the number of times those procedures are performed, the number of bed days the patients are in the hospital for each code, etc., you will find that Medicaid only pays about 12.5 cents on the dollar. Hospitals stay in business by gouging private insurers to make up the difference. That is why health insurance costs so much–because you’re not just paying for yourself. You’re reimbursing the providers for all the money they lose on Medicaid patients.

          1. Fine. Just triple medicaid and medicare combined. As you say, that’s $3.6 trillion — which is STILL more than the entire combined amount spent on all healthcare in the US public and private – $3.2 trillion.

            I get your main point – that medicare/medicaid are shifting costs to others. My math stuff was to point out that the cost-shifting is magnitudes lower than you assert. And as long as the fedl govt is paying for med coverage for elderly/poor; they damn well should use their buying power to lower costs – because taxpayers pay those costs. WalMart does the same things to its suppliers – it decides what it will pay and if the suppliers don’t like it tough shit for them. It is only when enough suppliers walk away that it becomes tough shit for WalMart.

            The problem is that those two programs spend money on the wrong stuff and ration the wrong things. They ration access to generalists (thus creating a shortage of generalists overall) – and spend money on specialists (thus driving up prices for specialists to their other customers and encouraging students to become specialists rather than generalists). It is generalists who are refusing Medicare patients – specialists don’t. Every other public system on Earth does the opposite. Every other system does it right. We do it wrong. It really doesn’t have damn thing to do with socialized v free. It has to with do why do we keep sticking our heads up our ass and pretending that we see sunshine.

            1. “Medicare and Medicaid currently make up some 30% of the federal budget. Triple the cost of those programs, and it takes up almost 90% of current federal outlays”

              The point was that it is politically unfeasible for the government to pay the true costs of care. Yeah, I was using round numbers to demonstrate that fact.

              “The problem is that those two programs spend money on the wrong stuff and ration the wrong things.”

              The problem is that those two programs don’t cover the costs of care, and that retards reimbursement and the insurance markets so badly, there’s no way they can hope to function with a growing Medicaid membership.

              Rationing one thing and not another is just rearranging the deck chairs on the Titanic. If half the stock on the shelves is being shoplifted, stocking more of one thing or putting another thing on sale doesn’t even address the problem.

              Medicaid membership needs to come down.

              They might split Medicaid out from the rest of the population somehow–like they do with the VA.

              The only other alternative that might work would be a truly private option, but short of those out there suggestions, there’s no alternative to slashing Medicaid.

              And the Ryan bill gets that ball rolling.

              1. The problem is that those two programs don’t cover the costs of care

                The problem for the US is that Medicare was designed as fee-for-service (the norm among employer plans then) – not gatekeeper or HMO or ‘integrated care’ or any other sort of plan that can manage costs/care. Fee-for-service plans incentivize all the wrong things which is why employers (and the states via Medicaid) have tried desperately to move away from that model. But as long as Medicare is a fee-for-service system, our entire healthcare system will be based on that because over-65’s constitute roughly half the total medical market – and a higher % of specialists/hospitals.

                There is no possibility – ever – of a free market in a fee-for-service system. We did not have fee-for-service before WW2/Medicare either. Hospitals were ‘integrated care’ back then (like Kaiser or Mayo now) – drs/hosps providing for a congregation that shares beliefs about treatment/death/etc and the whole was like a co-op or mutual. That can be a free market model – but bluntly I doubt profit motive is as significant in healthcare as are shared attitudes.

                the Ryan bill gets that ball rolling

                If it passes, healthcare costs continue to explode. In 2020 the GOP will, like Dems now, find themselves in electoral purgatory when the AARP lays into the GOP base. The GOP will have proven it is empty of ideas – and progs will bring on single-payer.

                1. “If it passes, healthcare costs continue to explode.”

                  The biggest reason that costs explode is ultimately because of Medicaid.

                  The Ryan bill rolls back the expansion.

                  Maybe the part you’re not getting is the fact that . . .

                  In the analysis above, it’s important to understand that if Medicaid were paying 100 cents on the dollar, the private sector would not be paying the same rates for private insurance.

                  Maybe that’s the confusion about the size of the spending on the budget vs. the total amount of money spent on healthcare-both public and private.

                  If the size of Medicaid tripled, the insurance companies would be saving that much in expenses. The cost of private insurance is so high now because Medicaid only cover 12.5 cents on the dollar. If insurance companies are profitable now, all that money they get gouged becomes profit in the short term. Over coming quarters, they would start competing on premiums like crazy. The savings would ultimately come to the privately insured.

                  It’s the same thing, really, if the Ryan plan takes people off of Medicaid. All the money providers lose by caring for those Medicaid expansion patients stops coming out of the insurers’ pockets. The fewer people there are on Medicaid, the less money providers lose, the less they need to gouge insurers to cover those losses, the more profits insurers make, the less they need to charge for premiums.

                  The Ryan plan addresses the heart of the problem.

                  1. For fucks sake. The Ryan bill doesn’t do anything except rollback ACA. Your GOP argument is nothing more than ‘everything was perfect before Obama – USAUSAUSA’. It’s crap. Our system has been a cronyist clusterfuck for going on 40 years now.

        2. I was being conservative in assuming that if Medicaid started paying 100 cents on the dollar (instead of 12.5) that it would only triple the cost of the program.

          Meanwhile, most of the healthcare in this country is consumed by older people.

          Anyway, I’m not talking about tripling the number of patients on Medicaid or Medicare. I’m talking about the government paying for the full cost of care. They can’t afford to do that. It can’t be done–not politically. That’s why it was easier for them to go with an individual mandate to try to help the insurance companies cope with being gouged. Force young healthy people who don’t consume much healthcare pay into the insurance companies, and they aren’t as squeezed by providers because of the money they lose on Medicaid patients.

          Again, I think people have a hard time comprehending that the government does not reimburse providers for the full cost of care. They think that because Medicare or Medicaid pay your bill, that means the cost was covered. That isn’t so. Providers get reimbursed for a small fraction of the cost of care. Hospitals that are in bad neighborhoods where there aren’t enough private insurance patients to gouge to make up for all the Medicaid patients fail.

    5. Medicaid is a much bigger part of the problem than Medicare, and the program never should have been expanded under the ACA. Undo that damage first, and then maybe we’ll find the political will to dismantle more of the Medicaid program.

      In the meantime, if hospitals were forced to charge no more than what Medicare pays (27 cents on the dollar) or what Medicaid pays (12.5 cents on the dollar), they’d quickly go out of business for the inability to gouge insurance companies to cover what they lose caring for people on government programs.

      This is one of the facts I wish more people understood. Just because you don’t owe the hospital any more money than what Medicare and Medicaid say you have to pay, that doesn’t mean the hospital is reimbursed for the full cost of care by Medicare and Medicaid.

      Imagine a retailer where 75% of the merchandise is shoplifted off of the shelves. Imagine what that would do to the prices for paying customers who didn’t steal. How would making retailers charge the same amount for the same items solve that problem? That wouldn’t even address the real cause of the problem.

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  17. Veronique is so basically wrong. Nothing is ever recieved for free by means of insurance. A pool of individuals pay a calculated amount against the likelyhood that an event will occur. Works well, except when “mandates” destroy actuarial inputs.

    1. “Works well, except when “mandates” destroy actuarial inputs.”


  18. Instead of the ACA mandate and penalties, instead of the coverage for everything under the sun…

    Define a true meaningful minimum catastrophic insurance plan. Heart attack, broken arm, yes; birth control, breast enlargement no. Offerers of these compliant plans should price them actuarially based on age.

    Structure the above as an HSA with high-deductible plan.

    There is no mandate to own the minimum coverage, but if you expose yourself to lack-of-coverage, then insurers can penalize pre-existing conditions and non-coverage via exclusions and/or jacked-up rates for some period of time, e.g. 2 years. If you show up at an emergency room without coverage, they’ll treat you but be allowed to bill you to bankruptcy.

    However, under HIPAA-like rules, pre-existing conditions cannot be excluded if converting coverage from one company or plan to another as long as it provides the minimum coverage. Continuous coverage is the key.

    At some age, maybe 18 or 21 or 25, young people must convert from their parents plan to one of their own, to establish their own continuous coverage baseline or face exclusions and higher premiums later. Also, by converting at a young age, they have time to build up their HSA.

    Redo taxation/deductability to remove employer-provided plans from the equation and to encourage individual plans for increased portability and continuity while eliminating the 4th party (patient, doctor, insurer, employer).

    1. Why not let the free markets rule?

      Doctors, hospitals can treat who they want, drug companies can sell to whomever at whatever price. Patients can choose not to have any healthcare, or buy as much of anything they need. Bargain with chickens, if the provider accepts.

      A free market will have winners and losers.

      The losers can just die. Or remain sick. Or not get sick.

      There cannot be a libertarian argument against that, can there?

      1. Nope. And I’d be fine with that, too. But that’s been proposed by libertarians over and over already. So how can we get something that would pass broader muster…something closer to 100% free-market-some-people-may-die end than the 100%-everything-covered-by-taxpayer’s progressive pipe dream? I was just spitballing.

        I’m as free market as the next libertarian, but I also wonder how to best prevent a situation where I pay an insurance company for 20 years, then they cancel my policy the day I am diagnosed with cancer.

  19. If you don’t have health insurance for all, you have health insurance for a very few, because most of us are going to have close friends or relatives who are uninsured, and we will have to cover their health care as well as our own health insurance, unless we are willing to let them go without or die.

    Here’s a human and potentially manageable plan from the smartest public policy economist I have encountered, Laurence Kotlikoff. http://bloggingheads.tv/videos/45350 Listen or be stupid.

    1. Before Obamacare, 85% of the US population had insurance. We didn’t have “insurance for all” but 85% is hardly “insurance for a very few”.

      After Obamacare, and hundreds of billions of dollars spent, 91% of the US population has insurance.

      Was a 6% “improvement” (in quotes because lots of people fell that their costs have gone up and their satisfaction with their coverage has gone down) worth the cost?

  20. Good article.

    I am not going to defend the Republicans, but the real issue is that they are being politically aware that the majority of the people in this country strongly believe that the government owes them medical care.

    This is the result of many reasons over a long period of time.

    If we are ever to get out of this insanity, it will take some serious education to get people to understand that you do not need the government, an employer or an insurance company in your way.

    HSAs address the idea of getting the 3rd party out of medicine, but the Republican plan does not emphasize this and I think it should.

    For better or for worse, the Republicans are being politically expedient. They know if they turn over medicine to a free market, they will be toast in the next election. Meantime, the president and many Republicans want Obamacare repealed yesterday, but there is no politically sane replacement. Therein lies the issue.

    1. I am not going to defend the Republicans, but the real issue is that they are being politically aware that the majority of the people in this country strongly believe that the government owes them medical care.

      People believe that government/society somehow owes them life at any cost. That is people expect the $20000/year in HIV drugs to be picked up by society. Thousands of dollars in statins. Heart transplants for hundreds of thousands of dollars. Etc.

  21. Just ran across this nugget:

    On average:
    8% of your lifetime medical expenses are incurred in childhood
    13% are incurred during young adulthood (20-39 years)
    31% is incurred during middle age (40-64 years)
    37% is incurred during ages 65-84
    12% is incurred post age-85

    The average lifetime medical bill is $316,000.

    Ignore the problem that that lifetime number is probably way too high to be sustainable by a free market since a significant portion of it seems to result in postponed death not meaningful life/health. The other problem is that the sickness itself can result in not only increased usage but also decreased ability to earn income to pay for it later – so no financing system can work. And because an ‘average’ itself is near-meaningless because medical expenses are both extremely concentrated and highly persistent, I’m not sure there is any solution at the individual level. No individual can actually know what they need until its too late.

    1. A better way of looking at it is that a large fraction of health care costs is for useless end of life care.

      In addition, another large portion of health care costs is for lifestyle choices, like obesity, pregnancy/abortion, STDs.

  22. All this seems obvious. But opponents of repealing regulation think that doing so necessarily results in a compromise in safety. If regulation proponents only knew the levels at which things are regulated, they might be less reactionary. The fact is that you can repeal restrictions and improve quality of care and safety AT THE SAME TIME.

    In my area of medicine, the great debate right now is whether or not to use computers. That’s not an exaggeration. Every year, we cross our fingers and say “this is the year”, and every year the FDA still fails to move on this issue, while the (mostly private) accreditation agencies are approximately a decade into approval and policy recommendations.

  23. Graboyes notes that this laser focus on the provision of health insurance coverage has distracted us from a more important health care goal: producing better health for more people at lower cost, year after year.

    Is this like a 10 year plan?

  24. Why do we even need a healthcare bill at all? Why is the government in the business of health insurance? Yes, we are stuck with Obamacare, which we should either kill or allow to die. But, why do we need to replace it with anything? Why do we provide tax deductions for employer provided health insurance plans? Why are we so afraid of allowing market forces to function in this space? There will still be people who require care and professionals capable of providing it. Will they be able to find one another without government assistance? There will still be insurers with an eye to providing same in the health care field. Do you suppose they have the necessary knowhow and resources to provide policies for those who want them, as they do in virtually every other area of risk?

    Government interference has complicated this marketplace almost beyond repair. It has succeeded in infantilizing consumers of healthcare and making insurance the focus rather than health care itself.

    Haven’t we learned anything?

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  26. The government still being heavily involved is reason enough why it is terrible. The extra “goodies” makes this a really stupid idea.

    Why government doesn’t try SMALL improvements (i.e, my usual call for allowing insurance sales across state lines to increase the risk pool) before going for massive ones? The small ones might be sufficient to resolve issues, but they want to have their big bill.

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  28. One of the most important things they could do is repeal the portion of the 1997 Budget Control Act that places a cap on the number of funded residency slots. It represents an enormous bottleneck in the availability of physicians, and restricts competition for patients.

    You can generate all the physicians you want in medical school, but if the residency slots doesn’t increase to match the number of students coming out, then you can’t get more practicing physicians.

  29. There is a libertarian argument for some government sponsored health care. FOR THE PURPOSE OF THE PUBLIC HEALTH.

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