Whole Lot of Sense on Health-Care Reform

When you've guaranteed me food, clothing, and housing, as well as medical care, let me know. I'm retiring. And don't forget the beer and television.

Have you ever had government made beer?

Nice new look to the site. It's been a while since I've had time to blog.

I'm glad to hear of your opinion on tort reform. There is simply no reason for reform other than companies saving money.

If a company has a big problem with too many judgement going against it, then it should change whatever it is doing.

On the other hand, I think judges should be allowed to sentence lawyers who bring frivolous suits to jail when they lose. I don't think loser-pays can be fair because a corporation can often bring huge resources to bear at trial. That's the advantage they have regardless. If they can't win with huge resources, then they did something they shouldn't have.

"heart disease, cancer, stroke, diabetes and obesity—are mostly preventable"

So, what will most people die of when those things are prevented? Laxative abuse?

Please check this article from Canadian province of BC (of 4.4 million).
Over 6000 surgeries to be canceled:

http://www.nationalpost.com/story.html?id=1881155

But I don’t trust legislatures to set prices in courtrooms.

Back at ya Don, do you trust juries to set prices in courtrooms?

Reform of our broken corrupt justice system is a utopian dream anyway.

Legislatures have shown themselves to be corrupt, and juries have shown themselves to be corruptible, as well as frequently easily flummoxed by pseudo science and disingenuous jargon such as DK practices here.

Loser pays would be far superior to what our judicial cesspool has evolved into, but I also see lifetime appointments to SCOTUS as being particularly troubling as it allows a man/woman, once appointed, to not only ignore fear of being fired or pressured, but to exercise and exert their personal bias and beliefs into their work without fear of censure or termination. It is obvious that such judges do indeed insert their personal bias into law and justice.

Last and not least, I believe we are nearing a point where lawyers will be an actual majority of the citizenry, at least that's my impression.

Does "loser pays" violate the contract we have with our government? Or is the current system create volatility in the market for justice?

Is justice a market? It has a lot of the features of a market.
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"the contract we have with our government"

I'm trying to think if I have any contracts with the government. Maybe my driver's license? I'm not a government contractor. I don't think so. Government doesn't often need contracts. They just tell people what to do, or else.

I've read through the USC countless times, although I'm no USC scholar. I can't think of any obvious USC prohibition to loser pays.

I do think it would result in judges and juries awarding even more unfair verdicts, just out of sympathy for the financial plight of one party versus another.

Still it is obviously the only fair thing to do--even if the amount the loser pays is just based upon some reasonably acceptable standard cost, and not the Johnny Cochran team costs. A cost that would be a clear disincentive for frivolous cases.

Mackey has all sorts of interesting things to say. But it seems to me that he fails to get at some of the most politically touchy factors tending to drive prices up. An earlier commenter mentioned expanding the ability of NPs and other health care professionals to deliver services currently provided by physicians; but I think we need to be more forthright: professional licensing schemes and hospital accreditation schemes can significantly increase health-care costs, and need to be abandoned. Ditto for pharmaceutical and medical-device patents.
http://liberalaw.blogspot.com/2009/08/state-soc...

I'm wondering how the ability of states to exclude extra-state providers (in the case of medical practitioners and med. insurance) falls under the commerce clause.

Has the federal government given the state permission to do that?

I wondered the same thing, Sam. Here's what I've learned so far:

In 1868, the Supreme Court established that the "business of insurance" was not interstate commerce, and therefore would be regulated by the States.

A later Supreme Court changed course and in a 1944 case determined that the business of insurance was subject to the "commerce clause" of the Constitution.

The McCarran-Ferguson Act of 1945 (15 U.S.C.A. § 1011 et seq.) gives states

"the authority to regulate the 'business of insurance' without interference from federal regulation, unless federal law specifically provides otherwise."

The Employee Retirement Income Security Act (ERISA) of 1974 prohibits state regulation of employers' self-insured benefit plans:

"As interpreted by the U.S. Supreme Court, ERISA permits state regulation of insured employee health plans but otherwise preempts analogous regulation relating to self-insured benefit plans."

Perhaps other legislation since 1974 has further implications for health insurance and the commerce clause, but I'm not aware of any.

Interesting that a guy growing wheat for his own use falls under interstate commerce, while an insurance company selling to someone in another state does not.

I like the idea of injecting some real competition into the system by removing cross-state barriers. Right now, that turns every state into an oligopoly.

It would increase competition, but that is not to say there is too little intrastate insurance company competition. Insurance companies don't mind if a state forces people to buy more insurance, which is what all the state mandates do. In fact, if state regulations allow insurance companies to pass through all the costs, you would expect mandates to increase the number of insurance companies available.

The real benefit would be competition between state governments. If you can't base a competitive insurance company under the rules of one state, those jobs and tax revenues will go to another state. That is what will drive down mandates, and open up tailored policies where people can choose to save money by not purchasing certain coverages.

If he had stuck to his 8 point list, the article would have been better.


But he gets lost in fallacies and blatant lies further down:
"ALL countries with socialized medicine ration health care by forcing their citizens to wait in lines to receive scarce treatments."

First of all, that may be true of Canada & England, but even the English patients cross the Channel to other even more "socialist" countries without waiting lists and lower health costs.
Probably the poor man has never been there but loves this stereotype.

Secondly, my wife is currently on a waiting list in a 100% PRIVATE clinic, for a health treatment that she's gonna pay out of her own pocket.
How can that be explained, Prof. Boudreaux & Mr. Mackey ?

Do you really expect me to believe that american hospitals don't have a certain degree of planning when it comes to operations? So american surgeons sit on their lazy ass for weeks wiggling their thumbs, and then have to cut open a few hundred patients that arrive by chance on the same day?
great system, keep it that way. now I understand where muirgeo gets all the time to post here.

Rationing IS their primary means of cost control. By definition, third-party rationing IS denying care.

When a person rations for himself, as in a free market system,
1. he gets to keep any savings he can find through shopping and negotiating; OR
2. if he doesn't get the service, he doesn't pay for it.

When a third-party rations care, they are telling a person that
1. he gets only what has been chosen for him; OR
2. he is not getting what he thought he already paid for.

With a third-party payer, if the person has a complaint about the rationing decision, then at least he might be able to rectify it through litigation--UNLESS, of course the third-party payer is the government.

Then some people, to add insult to injury, want to combine all of the well known economic problems of monopoly with the other inefficiencies of third-party financing, and the lack of recourse of government responsibility. The result is the worst conceivable type of disaster--a government single payer system.

Viking,

When we make our own trade-offs, do we ration or do we allocate our own resources? Individuals choosing their own levels of consumption is not rationing.

Rationing can only occur when people lose the right to choose their own level of consumption.

This is one of the things that drives me insane about the debate. So what if we spend 17% of GDP on health care? Why is 10% or 5% the "right" number and 17% is absolutely unconscionable?

Should you tell your teen-aged son that he can't spend 95% of his income on a car? What's the "right" level of spending for personal grooming?

We spend lots of money on plastic surgery, infertility treatments and the preemies those treatments produce. We trade money for life saving treatments that weren't available 2 or 3 years ago. We know they're expensive, but our loved ones are worth more than our life savings, having to sell the house, or even bankruptcy. What right does the government have to declare that we're spending too much?

What right does Obama have to declare that it's unacceptable for the willfully uninsured to risk bankruptcy during town hall meetings? We allocate for ourselves. Government rations - and this government means to ration everything.

People (not you) who claim that care is already rationed are inflating the meaning of "rationing" so as to rob it of all meaning. If care is rationed, it's only a question of who is doing the rationing. It's a familiar political deceit.

Mehinks
If a person is extremely poor and has to choose medical care for his wife of for himself, would you call that allocation or rationing? I took economics 20+ years ago.

For his wife or for himself, you're asking? I'm not sure what you're getting at exactly.

It's been a while since my economics classes too. I remember that we talked about how the market "rations" scarce resources.

We "ration" our own resources by making trade-offs. For the sake of argument, let's say there is no public assistance for the poor at all. The man can take an extra job or work out a payment scheme with the doctor (I did that when I was poor and had no insurance) or receive charity or a combination. The point is, he can choose his own level of consumption.

If government rations resources, then this man and his wife will get exactly what government decides and no more. All other avenues to receiving the health care he wants are cut off for him. The government chooses his maximum level of consumption and he can do nothing about it. Unless, of course, he happens to be politically connected, but the poor rarely are.

Obviously, the big difference is when you ration your own resources, you control your level of consumption. When government rations, your level of consumption is dictated to you. You have no control.

Statists love to conflate the two meanings of the word "ration" in order to create the illusion that it's all the same thing. "Trust us, you already have no control over your life", they say.

BTW, there's a whole discussion to be had about the larger effect on the economy when people lose control over consumption. Why work, invest and risk any more than the absolute minimum when you won't gain anything from it? The resulting drop in production means there is less to ration and encourages both capital and labour to flee, further depressing the rations.

"People (not you) who claim that care is already rationed are inflating the meaning of "rationing""

Actually that is me, no need to be polite. I understand the distinction and completely agree with you. The conflation is a rhetorical device to illustrate the universality of scarce resources and the necessity of choice. It focuses attention on the distinguishing element--WHOSE choice.

But because I agree with you, if I use it again, I will put it in quotes.

Aw come on Methinks - does not the decisions as to who lives and who dies is merely based on their ability to pay? So the 60yo has the ability to pay but the 25yo doesn't. Would it not be interesting if the 60yo is hoping the 25yo will die because he wants the younger person's kidneys? Does not 'the ability to pay' means those who make the greatest contributions to society will get the rations so there's no contradiction when a young person dies in favour of the old person? (After all the 25yo could have been a career criminal.)

"does not the decisions as to who lives and who dies is merely based on their ability to pay"

Of the - decisions can for live ability can hoping dies is? Society 'no contradition' could have been career kidneys those criminals?

gecko,

I don't know where you are, but depending on your location, there may very well be government imposed restrictions on clinics' ability expand. Also, an HMO's dominance has an effect on the amount of supply and, of course, if the treatment is new and they aren't able to produce enough to meet demand right now but will in the future. The first two problems are especially bad on the West Coast.

Is it possible for you to fill us in more?

Those were rethorical questions, methinks.

The waiting list concerned is caused - in my opinion - by an artificial restriction on the number of medical specialists in this sector.

Compared to the socialist nanny state (but without this particular restriction) where I was born , she'd have had that operation weeks ago.

Exactly - it's red herring. Everybody rations. Private and public. It's not a matter of if they will, but how they will - and there are advantages and disadvantages to both strategies.

Government rationing = gooooooooooooooooooooood
free market price rationing = baaaaaaaaaaaaaaaaaad

Rationing.

aka dealing with the fundamental economic issue of Scarcity

Scarcity of time, of drugs, of doctors, of dollars, of beds, of transplants.

Health care is intimately economic and moral.

Our governing officials are thoroughly economically errant and morally corrupt.

I want them as far away from health care as possible.

The one thing that bothered me about the article is he further corrupted the meaning of "right to health care". We should all have a right to health care. Just like we all should have a right to free speech or religion. Just because we have the right to something does not mean that the government provides it for us. Actually it means the exact opposite. The government does not issue out loudspeakers or TV ad time or schedule press conferences whenever a citizen feels like making a point. You have the right speech but also the responsibility to speak for yourself. The two go hand-in-hand.
Can you imagine you appauled most people would be if the state started using emminent domain to build humungous cathedrals on the tax payer dime?
I would also like to pose another question, doesn't Roe v. Wade guaruntee people's "right" to private medical decisions, and wouldn't almost any government intervention be a violation of that right?

"Just because we have the right to something does not mean that the government provides it for us. "

And if the government does provide it, then it is, by definition, a government-granted "privilege", not a right.

Rights can never be given, only taken away, or not taken away.

The difference between the right to free speech or religion is that those are rights to act without interference, while the "right" to health care requires forcing someone to provide a service or forcing someone to pay for that service.

I hadn't read the article when I pulled together my 4 points in today's post:
http://hallofrecord.blogspot.com/2009/08/other-...

We both agreed on tort reform; Mr. Mackey rightly includes various measures of insurance regulation reform.

I completely agree with the key paragraph which was mirrored in my post:
"Lousy eating habits and smoking/drugs/alcohol... among other things... will chew up a great portion of the Democratic Party damage control plan because there is nothing in the plan to say to people contributing mightily to their own poor health that they have to change or don't look to anyone else to rescue them when their bodies fail."

One thing he does not mention, but I think would be the single best way to control cost, is to allow physician assistants and nurse practitioners to operate independently of and compete with general practitioners. 90% of GP work could be/is performed by PAs and NPs. If you look at Canada or Mexico, pharmacists can dispense drugs for common ailments. There are so many ways to decrease costs by reducing government involvement, I hope people look beyond the tax code.

That is effectively happening now. Most states require PAs and RNs to function "under physician supervision", but under extreme primary care physician shortages what happens is you get a single physician with a team of 50 PAs/RNs, each of which has his own set of patients. The physician makes a good income because of the patient volume, but the supervision is barely existent.

And that is fine, except that people have a certain thing in mind when they see "Doctor". It is important that a patient isn't mislead into thinking that "Doctor Soandso" with a 2-year post high school degree and long white coat is the expected 4-year college graduate with 4 years of medical school and 3-8 years of postgraduate clinical training, including passage of multiple standardized medical board examinations.

And, by the way, that kind of misleading does occur.

Another way to decrease costs is to abolish the drug prescription laws.

Great list! And a good sentence on responsibility. No reform can be acceptable without that understanding.

The state regulation is tough for me personally. I don't like the idea of Congress telling the states that they can't regulate insurance. That seems to be a state's perogative to me. At the same time - if insurance companies could compete across states, that could completely obviate the need for a public plan (hmmm... although I agree with almost the entire list that one didn't seem to make it on!) - so I definitely see the value, I'm just not personally comfortable with the Congress stepping in like that - although you may convince me :)

But this is very good to see - I think a compromise bill including most of these, and perhaps an expansion of Medicaid and the creation of the IMAC for Medicare could potentially get bipartisan support - and could be done this year. This is a good list that a lot of people could sign on to. Then we can spend more time duking it out over the public plan.

If only it didn't have to start out with yet another reference to the "s" word :)

Since the Feds are already mandating all kinds of things, what difference does it make to make the states do one more thing? Really, we've crossed and burned that "states rights" bridge A LONG time ago. We're really like France where the states are cantons.

Why expand two and poorly run programs (medicaid and medicare)? Why not just replace them with a health care voucher system? Cheaper to administer and harder to game.

You don't have to stop states from regulating insurance companies for this to work. All that needs to be done is to allow a national market in insurance.

"Why not just replace them with a health care voucher system?"

Yes. Two important standards to impose on any welfare system:

1. The patient must receive and and pay the bill.

2. The patient must be able to keep any money that he doesn't save.

These two changes to Medicaid would do much to improve quality and drive down prices.

btw - my understanding is Ezekial Emanuel is a supporter of a voucher solution... given how people have received him so far, that may be a liability!

I can't believe that Dr. Mengele is a supporter of vouchers since he's a supporter of a single payer system where he gets to decide your value to the state and, therefore, any treatment you're entitled to. The man is one of the scariest human beings around.

lol... yes, that's the "how people have received him" that I was refering to.

At least it's a relatively fresh Nazi reference... Hitler and Goebbels are paraded around far too often. You hit the nail on the head - we need more Mengele references to work people up. Mix it up a little. Bernanke as Schacht. Maybe Geithner as Speer. Good intuition, Methinks.

If he sounds like Dr. Mengele, why not call him that? Just because he's a Jew?

I'm a half Jew. I claim exemption from the prohibition on calling bad Jews bad despite their protected status.

Oh, LOL. So funny. Hilarious when True Believers and apologists just brush this "unimportant" stuff off. Ha ha ha.

DR. Mengele in The Lancet, January 2009: "The complete lives system discriminates against older people… Unlike allocation by sex or race, allocation by age is not invidious discrimination; every person lives through different life stages rather than being a single age. Even if 25-year-olds receive priority over 65-year-olds, everyone who is 65 years now was previously 25 years. Treating 65-year-olds differently because of stereotypes or falsehoods would be ageist; treating them differently because they have already had more life-years is not."

Love the logic. So, if you want to deny treatment because you think old people smell funny, that's ageist. But if you want to deny them treatment because they're old, that's not ageist. Dr. Zeke will declare what the value of your life is. Not you. The current legislation limits access to people with disabilities, BTW. Perhaps you just don't know what Dr. Mengele believed and what your Dear Leader now believes and surrounds himself with.

Or maybe you're just dense.

Methinks is it possible for you to have a discussion without insulting people that you talk with? Do you do that at work too?

You're doing the selective quotation that most people do when it comes to his complete lives system approach. The age factor is one of eight principles for allocating scarce medical resources. He openly says that not all principles achieve all ethical goals. He recognizes the limits of each. I notice you decided not to quote "Age, like income, is a “non-medical criterion” inappropriate for allocation of medical resources."

What is the alternative? A market where a 60 year old who has 60 years of savings behind them gets a new lung over a 20 year old that can't afford it? I'm with Don on the free market for organs - but can you honestly tell me that that tradeoff has not only efficiency advantages, but ethical advantages? And don't get into this straw man that I think fiat (either public or private) is more ethical than the market. I don't think that.

Emanuel's article - if you read the actual article - presents a broad spectrum of principles for alotting scarce medical resources, age being only one - and even when he talks about age he recognizes it has huge limitations.

And please, I'd like you to explain to me the difference between Ezekiel's perspective on age in the decision making process, and the QALY system he compares it to. Doesn't QALY take age into account too?

This is very reasonable stuff - and criteria that existed long before Emanuel came around and proposed a slightly tweaked version.

But yes - it does start to get scary when you drag out Nazis and start talking about euthanasia and diffuse those who disagree with you by calling them "true believers" in the "dear leader"

Oh hang on, let me ask you - do you condescend to people at work by prefacing your responses with "ha ha ha", LOL and then take offense when they point out the obvious to you, danny?

aha ha ha! LOL. ha ha.

I chuckle when I think what they say is a little out in left field, yes. That's a relatively polite way of interacting and disagreeing.

I don't think I've ever called a co-worker dense or stupid.

Oh, I see. So, if you decide it's civil behaviour, then it is. You're not my co-worker and I owe you nothing, Danny - despite how wise and important you believe yourself to be.

a ha ha. oh ho ho. LOL.

How did this turn into "if you decide if this is civil behavior it it is"?

Just like a bioethicist writing an article about how to prioritize scarce organs magically became "the government gets to decide who lives".

No, there was no claim to wisdom on my part. I just thought the understanding that calling people stupid wasn't a decent thing to do was common knowledge.

LOL. Ha ha ha. When did I call you stupid, Danny? Wipe your tears and calm your overactive imagination.
There's a fake scarcity in organs, so there's nothing ethical about what Dr. Mengele is saying. He also mentions elsewhere that people with Dementia shouldn't be guaranteed treatment. Fine, as long as the state allows the market to supply the demand for that treatment without interference. That's not the case with this "reform".

Just like a bioethicist writing an article about how to prioritize scarce organs magically became "the government gets to decide who lives".

That's exactly what it is because the government created that scarcity and then Dr. Mengele pontificates on what allocation is "ethical". That IS the government deciding who gets to live. You support Dr. Mengele's conclusions, but that's not what you're saying because when yous say it explicitly, it sounds bad but he's an Obama man, so you can't not support him. Your mental gymnastics are very entertaining.

This is just getting bizarre methinks.

Think about it. Can't you say "insofar as there is scarcity I think this process of deciding for either public or private providers is better than the market" AND say "government restrictions on organ markets create much of the scarcity, so if we liberalize that market we'll hopefully won't have to rely on these processes as heavily".

You do realize I support liberalizing organ markets, right? That's not lost on you, is it? Why are you arguing over that facet of it when I agree with you? Isn't it feasible to agree with you on organ sales and Emanuel on distribution by providers?

Dan, you're very self-obsessed. Try not to think about yourself for a moment.

The conversation isn't about what YOU believe, but what Dr. Mengele believes - and the reason that Zeke Emannuel deserves the nickname "Dr. Mengele".

Isn't it feasible to agree with you on organ sales and Emanuel on distribution by providers?

Only if we ingore everything else Dr. Mengele supports. And what Dr. Mengele supports is the government making all those decisions for you - not "distribution by providers". The market couldn't care less about his pontification. It will figure out ethical allocation without his personal stamp of "ethical purity".

What are you talking about? This is a conversation between you and me about organ distribution. It's not self-obsessed to recognize that neither of us really knows what Emanuel thinks. It's self-obsessed to presume you know.

"Only if we ingore everything else Dr. Mengele supports. "

What possible bearing could "everything else that Dr. Mengele [sic] supports" have on what you and I think about organ sales and distribution decisions?

LOL. Ha ha.

In your head it's clearly all about you. Read the thread, and it has nothing to do with you or your support for organ markets.

I have better things to do now. Ciao.

You used a double negative, that might confuse Daniel.

it was meant to be convoluted, Arrow.

Dan, I don't hire stupid people, so I don't ever have to tell them they're stupid.

A market where a 60 year old who has 60 years of savings behind them gets a new lung over a 20 year old that can't afford it? I'm with Don on the free market for organs - but can you honestly tell me that that tradeoff has not only efficiency advantages, but ethical advantages?

No, of course not. The much more ethical solution is to let you and Dr. Mengele decide what's fair. Of course, you're not for that either. Like Obama, you're for nothing and everything at the same time.

Neither QALY nor Dr. Mengele's plan is any good. It's neither ethical nor desirable.

This is very reasonable stuff

Yep, the government choosing who lives and who dies is very reasonable, Danny. Good stuff.

The government deciding who lives and who dies???

I'm getting confused about what you're even talking about now.

Sure, but state regulation is one of many obstacles to a national market.

A voucher plan sounds great too - don't take my lack of commentary on other options as opposition to other options. I'm just not up on all of them - I'm no health policy expert.

But I would hope they would spend a considerable amount of time planning a voucher system, and try it out in demonstrations first. I'm just saying there are some basic things that could happen in the meantime as a stop-gap. I'm not talking about expanding Medicare - if anything I think an IMAC would put the brakes on it. Expanding Medicaid wouldn't necessarily be the most efficient solution, but it could help to cover people who are losing coverage while we work out a public plan or a voucher system or whatever else. It was very much a "what's practical and not practical to do and what will buy people into a compromise" sort of sentiment.

State regulation is not an obstacle. The Mccarran-Ferguson Act (1945) allowed the states to regulate insurance but retained a Congressional prerogative to do so.

The states are much better at it than Congress would be. Besides that, I would rather have 50+ regulatory experiements going on simultaneously rather than have Congress screw up the whole system in one fell swoop. An example of states making a mess of insurance regulation is New Jersey's abominable auto insurance laws.

The problem is that lawyers inevitably get involved and a lawyer's solution for everything is more regulation.

The idea is not to move insurance regulatory authority from the state to the federal government. That would be an infringement of state's rights.

The idea is to allow states to continue to regulate industries based within their borders, but allow citizens to import insurance products from other states without unconstitutional commerce clause restrictions.

Once again: McCarran-Ferguson gives states the power to regulate insurance. It was enacted because of a SCOTUS ruling in 1944 that insurance constituted interstate commerce when sold across state lines. SCOTUS reversed a ruling from the 1860s that declared that insurance was NOT interstate commerce.

Besides, in 1944/45 Congress had more important things to do than fuss with regulating the insurance industry.

Times have changed. Not for the better, I fear.

It seems SCOTUS was at least partially right in 1944. And if so, then McCarran-Ferguson is only a SCOTUS case way from being declared unconstitutional.

Or maybe the SCOTUS/Congressional disagreement was about USC confusion between the interstate commerce clause and state's rights. The correct interpretation, it seems to me, is to recognize states' rights to regulate insurance companies who export from their states, but not to unduly regulate citizens who import insurance products from other states.

That is, insurance should not be treated differently than any other product.

I do support repeal of M-F. I would prefer Congress did it.

Why not just test a voucher system on the 10MM uninsured who don't qualify for medicaid? Once medicaid is expanded, I assure you, it will never be beaten back.

State regulation is not such a big obstacle. States that regulate less will have more insurance providers housed there. If you have the ability to buy from any insurance provider in any state, any individual state's regulation will become all but irrelevant.

Well, if "we" were serious about actually improving the health care situation in this country, these things are exactly what we would do.

Of course, all of us here know that is not the case. This whole "reform" thing has nothing whatsoever to do with actually making things better. It's all about power.

"Control, Control! You must learn control!"
-Yoda, The Empire Strikes Back

It's all about power. That's the problem. There are lots of really good reform ideas out there that nobody cares about because reform is not the point.

Perhaps the best health care reform would be Congressional term limits.

The point is redistribution of income (aka reparations) and increasing the size of the Democratic base.