My health care overhaul

[Winstonm]

Are we talking here about the known unknowns or the unknown unknowns or the really creepy booga-booga unknowns?

 

Sincerely,

 

Donald Rumsfeld

[kenberg]

Are we talking here about the known unknowns or the unknown unknowns or the really creepy booga-booga unknowns?

 

Sincerely,

 

Donald Rumsfeld

I don't know.

[kenberg]

but if the aim is to do either or both of those things, imo there is only one sure way - complete state-run health care with fees and salaries fixed...

You won't find universal agreement (to say the least) with your "one sure way," and it certainly wouldn't be able to pass congress any time soon. The current bill is the only way to get started with this in a serious way now, whether the bill is perfect (and I don't think it is) or not.

 

Otherwise none of the cost control measures will take effect, and health care costs will continue the trajectory toward outer space. The goal of equal care for all is not practical for now, but Obama's reforms will certainly bring better care for quite a number of people.

I do accept that the Obama plan would substantially improve access to health care for many people, and perhaps on that basis it should be passed. I expect very little will be accomplished in the way of bringing costs under control. This is not because I have thoroughly analyzed the bill, really it is still in preparation and I won't be setting aside 72 hours for analysis when the final unveiling takes place. My dismal expectations are more a general result of experience. Many programs don't meet the claims of the advocates, and in this case the principal advocates are so desperate to get a bill passed that they will agree to almost anything. It would be a miracle for a good bill to come out of such a swamp, and I don't much believe in miracles.

 

It will cost me money, it will add to the deficit, it will do me no good. I sure as hell hope it helps those in need because I don't expect anything else from it.

[y66]

Don can speak for himself.

 

I'm talking about the deficit-neutral unknown, for which Mr. Lobowolf is seeking a counter party for bets he wishes to place, presumably against, as if deficit-neutrality were particularly relevant (what is relevant is how much taxpayers will pay in taxes and in higher health care costs if nothing is done) and as if accounting methods required to measure this objectively are somehow less open to debate than, say, Statutory Interpretations. Another unknown, for which Mr Kenberg seeks comprehension, is how much this is actually going to cost real taxpayers. Granted, that's an important question but so is asking compared to what? The Congressional Budget Office estimates that cost-control measures in the current bills would save the government $1 trillion in the next 20 years, over and above the cost of covering the uninsured. The CBO isn't infallible. But they are objective and I think as good as you're going to get for purposes of assessing the costs of the bills.

[Winstonm]

It will cost me money, it will add to the deficit, it will do me no good. I sure as hell hope it helps those in need because I don't expect anything else from it.

 

Damn, Ken, you sound almost as cynical as me.

 

Here's what I expect - I expect the special interests who pour the millions into campaign chests to insure reelections and who offer to politicians after public service the lucrative revolving-door board-of-directors positions will get the bill they want and the rest of us will be stuck WITH the bill. If it happens to help a few people, that loophole will be closed in committee.

[Lobowolf]

The Congressional Budget Office estimates that cost-control measures in the current bills would save the government $1 trillion in the next 20 years, over and above the cost of covering the uninsured. The CBO isn't infallible. But they are objective and I think as good as you're going to get for purposes of assessing the costs of the bills.

If you're suggesting that this is a less subjective metric, I'd be happy to change my wager offer. I'll take the over. See you in 20 years.

[kenberg]

If a representative can return home and convincingly campaign on the assertion that he has cut government costs by a trillion dollars he will be in fine shape. Honestly this is the very first time I have seen that argument advanced. If it holds up, those who vote aye have nothing to worry about. Forget deeming, forget reconciliation, forget helping the needy, just go with the trillion in savings argument.

 

I remain skeptical, but perhaps it is so.

[y66]

The Congressional Budget Office estimates that cost-control measures in the current bills would save the government $1 trillion in the next 20 years, over and above the cost of covering the uninsured. The CBO isn't infallible. But they are objective and I think as good as you're going to get for purposes of assessing the costs of the bills.

If you're suggesting that this is a less subjective metric, I'd be happy to change my wager offer. I'll take the over. See you in 20 years.

You're on. Double or nothing on that Scott Brown bet, indexed for inflation, payable to heirs, assigns, etc.

[PassedOut]

It would indeed be wonderful if a vote today could really save a trillion dollars, but a lot of water will go over the dam before that total is reached.

 

It's much easier to screw things up than to fix them. Under Clinton the government was set to eliminate the national debt entirely, and we all saw how quickly and easily the Bush adminstration screwed that up.

 

Obama's health care reforms will clearly save a lot of money over present projections, probably a lot more than a trillion if untampered with, but future politicians could screw that up as easily as Bush did ten years ago. All you can really do is set things on the right path now and keep hammering away at how important it is to keep at it.

 

Still, I don't think that the possibility for future screwups should deter us from taking the responsible path now.

[luke warm]

Obama's health care reforms will clearly save a lot of money over present projections, probably a lot more than a trillion if untampered with~~

exactly what does this mean? will the bill increase the deficit or not? i realize the final figures from the cbo aren't out yet, but how can you make such assumptions when even many congressional democrats don't do so?

Altmire echoed other House Democrats who are skeptical of the Senate bill, saying he wanted to strike the provision that exempts Nebraska from paying increased Medicaid expenses.

 

"The only absolute, definitive red line that there is for me is I will not vote for a bill that increases the deficit by even one penny," he said.

[kenberg]

I really think that even such a simple question as "Does it increase the deficit?" is open to many interpretations. If money that would, without the health care bill, go toward reducing the deficit gets used to pay for the health care bill then it may be a matter of semantics but I would not really say that the arrangement is deficit neutral even if on paper the costs are paid for.

 

It is better, I think, to ask "Does it reduce health care costs?". There is a chorus here saying absolutely of course obviously. Perhaps so, but truly I am a bit skeptical. The process has been truly awful. There is an enormous amount of money at stake, this naturally brings out lobbyists in full battle gear to make sure that the savings won't come out of the pockets of their clients, and after a year plus of deals it would be amazing if there were many bucks lying around unspoken for. It's just the way the process works.

 

Whatever the per capita cost of health care is, whatever it becomes, someone has to pay for it. So, what I would like to see is a solid analysis that makes a reasonable projection of what this per capita cost will become. If we can restrain that growth or even bring it down, we will save money. If we do not restrain it then we are only speaking of who will pick up the tab.

[PassedOut]

As I understand it, the house will vote for the senate bill only under the condition that the senate will then pass a number of provisions (based on input from Obama) that will scrub the bill of things like the onerous Nebraska give-away. However, nothing actually obligates the senate to do that after the house passes the senate bill, so house members want to make sure that they are not taken for a ride.

 

Over the long haul, the cost-cutting measures in the bill will definitely cut the deficit substantially. I don't know of any contrary objective analysis from anyone of any political persuasion. And, using the reconciliation process, it's not really possible to modify the senate bill enough to change that. Some house members want to use the added provisions to push deficit reduction in the bill even farther, and I wish them success in that.

 

In addition, some house members worry that the senate bill isn't strict enough on abortions. I hope that the letter from the pro-Life Catholics in Alliance for the Common Good (also published in the National Catholic Reporter) will nudge those legislators toward a responsible vote.

 

Yes there is opposition, but not on the cost-saving aspects. Some politicians (and non-politicians) don't like authorizing the federal government to set minimum standards for insurance policies, nor to force healthy and sick people into very large pools. Some, I'm sure, expect that future governments will screw things up so that the cost savings written into the bill now will never be realized -- and that's actually a serious danger. And there are always a few who don't believe that arithmetic can be used to solve real-life problems. And then there is the rather large bloc in congress who pushed the US back into fiscal irresponsibility and who just can't bear to see the other side do better.

 

On the other hand, cost-cutting can be pushed even further with more aggressive tort reform, and I hope that the republicans keep pushing that even if the current bill passes. Then they too might be able to take some credit down the road.

 

I'm pleased to see that Kucinich has come around.

[kenberg]

The scrubbing of the "onerous Nebraska give-away" will, as I get it, consist of making the same give-away available to all states. Of course we will have to see. Actually, that might not be so bad from my viewpoint. I understand it to be a matter of who picks up medicaid costs, it doesn't actually alter medicaid costs. So "states will pick up certain medicaid costs" or "the feds will pick up those costs" is probably more or less zero sum. The problem was that the feds were to pick up Nebraska's and those of some other favored states. Maybe there could be an argument for it, but no one living in one of the unfavored states was apt to accept it. But again it is, as far as I can see, a matter of who picks up the tab. Actual total costs, picked up by someone, don't get lowered either way.

 

 

I get impatient. Somewhere along the way I decide that I really don't give a flying whatever about Nebraska and who pays their Medicaid bills. But I prefer it not be me. If I have to understand this crap, and much much more, before I can have an informed opinion about the health care bill then it's too much. There is way too much of the "now you see it now you don't" in this thing. Maybe Nebraska will get a special break. Maybe that will be removed. Maybe it will be expanded to all states. Maybe i am going nuts trying to follow all of this.

[luke warm]

Over the long haul, the cost-cutting measures in the bill will definitely cut the deficit substantially. I don't know of any contrary objective analysis from anyone of any political persuasion.

well i'll have to agree with ken on this one, there're just too many unknowns (for me anyway) to make that leap... for example, how would things like this affect costs? from the medicus firm

Physician Support of Health Reform in General

• 62.7% of physicians feel that health reform is needed but should be implemented in a more targeted, gradual way, as opposed to the sweeping overhaul that is in legislation.
   
  
• 28.7%  of physicians are in favor of a public option.
   
  
• 3.6% of physicians prefer the “status quo” and feel that the U.S. health care system is best “as is."
   
  

Health Reform, Public Option, and Practice Revenue/Physician Income

• 
   
  
• 41% of physicians feel that income and practice revenue will “decline or worsen dramatically” with a public option.
   
  
• 30% feel income will “decline or worsen somewhat” with a public option.
   
  
• 9% feel income will “improve somewhat” with a public option, and 0.8% feel income will “improve dramatically” with a public option.
  

Health Reform, Public Option, and Physician Supply

• 72% of physicians feel that a public option would have a negative impact on physician supply, with 45% feeling it will “decline or worsen dramatically” and 27%  predicting it will “decline or worsen somewhat."
   
  
• 24% of physicians think they will try to retire early if a public option is implemented.
   
  
• 21% of physicians would try to leave medicine if a public option is implemented, even if not near retirement age at the time.
  

Health Reform and Recommending Medicine to Others as a Career

• 36% of physicians would not recommend medicine as a career, regardless of health reform.
   
  
• 27% would recommend medicine as a career but not if health reform passes.
  
• 25% of physicians would recommend medicine as a career regardless of health reform.
   
  
• 12% would not recommend medicine as a career now but feel that they would recommend it as a career if health reform passes
  

and even more frightening,

46.3% of primary care physicians (family medicine and internal medicine) feel that the passing of health reform will either force them out of medicine or make them want to leave medicine.

 

We will never know if this figure will be accurate until after the passage of the current bill and its application to the industry, but this gives you an idea of how primary care physicians feel on the matter.

that's a little too close to half of PCPs for my liking

[phil_20686]

Firstly, regarding soaring costs, this is something that is hardly unique to america, all the western countries are worried about it.

 

Economics professors call it Baumol's cost disease (http://prescriptions.blogs.nytimes.com/2010/01/17/an-economist-who-sees-no-way-to-slow-rising-costs/), essentially, labour costs always rise faster than inflation. This is a consequence of technological innovation. Technology makes workers more productive, and so raises the value of a given number of hours work to the economy, and hence the price. Thus any pursuit where the the primary resource is human labour is doomed to ever increasing prices. The most common example is that of an orchestra, since no amount of technology helps someone learn to me a concert violinist faster, orchestras are doomed to become ever more expensive. In medicine there is the same problem, docters take a long time to train and every patient requires a huge number of man-hours of labour to see it through. Until, and ulesss, we build machinery that can allow for significant labour saving in diagnoses and treatment, health costs are doomed to rise. This is somewhat compounded by having every more treatments avaiable, all of which cost money. Perhaps someday we will be able to build robot surgenons, but that day is still a long way away imo.

 

Thus, anyone who tells you they will control healthcare costs without reducing coverage is lying, at least in the long term. Of course none of the above means that there is not real efficieny gains to be made, only that such efficincey gains only delay the inevitable.

 

Secondly, all helathcare systems need a strong body who decides what treatments are cost effective. This is hugely unpopular. It is always hugely unpopular. At least in america you pay for insurance and it only covers what it covers no ambiguity. Here in britian there are endless courtcases over new cancer treatments that are denied patients on grounds of cost. How can a public health care system pay £100k a month for a treatment that gives one pateint 6 months extra life, when it could provide 10 patients an artifical heart with the same money. However, individuals who are near death don;t always see it that way hence legal challenges on the grounds of "I pauid my taxes all my life and am denied life saving treatment....." are fairly common and cost the NHS here a lot of money.

 

 

Thirdly, and finally, the problem all health care insures have is that the same procedure does not necessarily cost the same for every patient. Thus charging a fixed fee per operation is not ideal. Perhaps one pateint can be sent home after one day, another needs a week of supervision. Thus its very hard to clamp down on overcharging unless you have some kind of strong body who can really enact `punishments' based on judgement, rather than definitive proof.

[helene_t]

Support for the public option is even stronger among physicians than among the general public: http://healthcarereform.nejm.org/?p=1790

[kenberg]

While drinking coffee this morning I was scanning a column by Ruth Marcus:

http://www.washingtonpost.com/wp-dyn/conte...0031803558.html

 

I hope even Ms. Marcus woould agree that this is not an in depth fniancial analysis, I don't think it was intended as such. But it brings out a couple of issues that concern me. She discusses some of the savings:

 

Of the $138 billion saved in the first 10 years, $70 billion represents premiums collected for a new long-term-care program, money the government will have to pay in benefits later. An additional $20 billion in savings comes from changes to the federal student loan program.

Raising money through premiums is not saving money or reducing costs. It is allocating costs. I am not trying to be a fussbudget about semantics. We have been repeatedly told that per capita medical costs in the US are roughly twice (or more) what they are in other countries, the UK for example.Let's say I believe this, more or less. Raising the money from premiums won't change this. Or from the student loan program.

 

 

Later in the column:

One big reason for the CBO's long-term assessment of major cost savings involves the excise tax on high-cost insurance plans. This is the tax that, in the face of opposition from labor unions and others, has been diluted to almost nothing -- a measly $32 billion, compared with $149 billion in the original Senate bill -- during the first 10 years.

 

 

Her point was the dilution, but my point again is that this excise tax is a way of raising the money, not a way of reducing costs.

 

Here is why I regard this as important: If the total cost is x dollars, then someone has to come up with the money. Regardless of exactly how this is done, surely I am one of those somebodies. If x is way out of whack with the cost in other countries then it would be really good to address this. Explaining how the costs are to be covered, however important that might be, is not at all the same thing as reducing costs.

 

Phil tells us that all other countries are also concerned about rising costs of health care. I believe him. Still, much of the talk here has been of the much greater cost in the US. We need to get a handle on this.

 

 

Bottom line: To save the consumer money, it is necessary to control the cost. Explaining how the costs are to be allocated should not be described as saving money.

[PassedOut]

To save the consumer money, it is necessary to control the cost. Explaining how the costs are to be allocated should not be described as saving money.

Very true. But there are a couple of things to keep in mind about the reforms and CBO scoring.

 

First, because of the startup costs of bringing 30 million new people into the system, a big chunk of the initial savings will be eaten up during the first decade. The biggest savings (should no intervening government screw it up) pile up after that. The reallocations and other savings you mention ensure that the deficit won't go higher during the startup period.

 

Second, the non-partisan CBO does not give the health care bill any credit for savings that cannot be quantified right now. Even though health care experts of all political persuasions agree that the cost-saving measures in the bill will save plenty of money, no one can be sure which ones will turn out to work best and which ones won't pan out at all. So the CBO simply doesn't score those.

 

Although the CBO doesn't give credit for unquantifiable benefits, it does score the quantifiable parts of the bill exactly as it is written. That includes provisions that, realistically, are almost certain to be changed before they take effect. And the health care bill is not totally free of such gimmicks, as some republicans have correctly pointed out.

 

The health care reforms (unless screwed up later, of course) will definitely generate large savings over the long term, but the short-term projections are more problematic. I'd like to see a much more immediate and aggressive attack on the waste in the system, but even the proposed reforms, gentle as they are, haven't yet been passed into law. This weekend should be interesting.

[cherdanno]

While drinking coffee this morning I was scanning a column by Ruth Marcus:

http://www.washingtonpost.com/wp-dyn/conte...0031803558.html

 

I hope even Ms. Marcus woould agree that this is not an in depth fniancial analysis, I don't think it was intended as such. But it brings out a couple of issues that concern me. She discusses some of the savings:

 

Of the $138 billion saved in the first 10 years, $70 billion represents premiums collected for a new long-term-care program, money the government will have to pay in benefits later. An additional $20 billion in savings comes from changes to the federal student loan program.

Raising money through premiums is not saving money or reducing costs. It is allocating costs. I am not trying to be a fussbudget about semantics. We have been repeatedly told that per capita medical costs in the US are roughly twice (or more) what they are in other countries, the UK for example.Let's say I believe this, more or less. Raising the money from premiums won't change this. Or from the student loan program.

 

 

Later in the column:

One big reason for the CBO's long-term assessment of major cost savings involves the excise tax on high-cost insurance plans. This is the tax that, in the face of opposition from labor unions and others, has been diluted to almost nothing -- a measly $32 billion, compared with $149 billion in the original Senate bill -- during the first 10 years.

 

 

Her point was the dilution, but my point again is that this excise tax is a way of raising the money, not a way of reducing costs.

 

Here is why I regard this as important: If the total cost is x dollars, then someone has to come up with the money. Regardless of exactly how this is done, surely I am one of those somebodies. If x is way out of whack with the cost in other countries then it would be really good to address this. Explaining how the costs are to be covered, however important that might be, is not at all the same thing as reducing costs.

 

Phil tells us that all other countries are also concerned about rising costs of health care. I believe him. Still, much of the talk here has been of the much greater cost in the US. We need to get a handle on this.

 

Bottom line: To save the consumer money, it is necessary to control the cost. Explaining how the costs are to be allocated should not be described as saving money.

Then maybe you should not mix up these two issues?

Saying the bill reduces the budget deficit by 130 billions is not the same as saying it saves 130 billions in health care costs. I don't think I need a WP columnist to figure that out, and I have never heard or read anyone confuse the two issues (but then again, I don't watch TV).

 

The main reason why the bill will reduce health care costs is because via the excise tax, it will start a phase out of subsidizing employer-payed health insurance premiums. This is also a way of raising revenues, of course.

 

I understand you have read the Atlantic-Wire article I linked to a while ago about other cost-cutting elements in the bill. I don't have anything to add to that and I am not sure I would bet my house on whether they will work, but if experts say "this bill contains every cost-cutting idea I know of" then I don't think "this bill doesn't do enough to cut costs" is enough of a reason to be against expanding coverage for about 2/3 of the currently uninsured.

[luke warm]

The health care reforms (unless screwed up later, of course) will definitely generate large savings over the long term, but the short-term projections are more problematic.

savings for whom? i believe that is the gist of ken's concerns... if i, for example, pay more in fees or taxes to cover the costs of this bill, how am i better off? whatever my real health care costs presently, it seems they are about to increase... true?

[PassedOut]

The health care reforms (unless screwed up later, of course) will definitely generate large savings over the long term, but the short-term projections are more problematic.

savings for whom?

The cost savings unquantified by the CBO (and I don't think there is any objective dispute about this) will reduce the waste in the current US health care system, resulting in better overall care at a smaller per capita cost (in today's dollars). The reduction in waste will accelerate over the years. I'd like more, but we need to start somewhere.

 

This unquantified reduction in waste is above and beyond the current CBO scoring, which already shows huge gains in the second decade. I see no reason to fear that a reduction in the per capita cost of health care should result in higher costs for anyone, but I'm not really concerned about that. My concern runs more toward the long-term fiscal health of the country and of the US economy. And, of course, our family's businesses.

 

No doubt a single-payer system, as you advocate, would produce efficiencies beyond those in the present bill. But politically that just won't fly in the US, at least for now. The same with aggressive tort reform. The Obama reforms might actually become law.

 

From the standpoint of the individual, the republicans (as I understood what they were saying) want to put a larger burden on those who do get sick in order to reduce insurance costs for those who do not. The democrats want to spread the costs more evenly. That too is simply a matter of allocation, not of overall savings.

 

Do you disagree with any of this? I see your questions, but I don't see what your own take is on these matters.

[cherdanno]

Of the $138 billion saved in the first 10 years, $70 billion represents premiums collected for a new long-term-care program, money the government will have to pay in benefits later. An additional $20 billion in savings comes from changes to the federal student loan program.

Raising money through premiums is not saving money or reducing costs. It is allocating costs. I am not trying to be a fussbudget about semantics. We have been repeatedly told that per capita medical costs in the US are roughly twice (or more) what they are in other countries, the UK for example.Let's say I believe this, more or less. Raising the money from premiums won't change this. Or from the student loan program.

Btw, it might be worth explaining the details of these 20 billions: There are currently two types of student loans, either direct loans from the government, or loans from private banks subsidized by the government. The latter are much more expensive, with the same benefit for the students. So it seems a no-brainer to eliminate the latter. However, so far the banking lobby has been able to prevent that.

However, maybe partly because it only needs 51 votes via budget reconciliation, the Democratic congress leaders think they have the votes to do this change as part of the budget reconciliation bill. This will save 67 billions, 20 of which are use to cover health care costs/reduce the benefit, and the rest is used to extend the student loan program/pell grants.

 

I am really starting to like budget reconciliation. It seems to make it possible to pass common-sense legislation as this one. The amended bill also contains less "special deals" for specific senators than the original senate bill.

[luke warm]

From the standpoint of the individual, the republicans (as I understood what they were saying) want to put a larger burden on those who do get sick in order to reduce insurance costs for those who do not. The democrats want to spread the costs more evenly. That too is simply a matter of allocation, not of overall savings.

which is why the pool of insured should include everyone, healthy as well as not so healthy... and the premiums should be actuarily determined across the board, with the same policy (benefits) for all

Do you disagree with any of this? I see your questions, but I don't see what your own take is on these matters.

it isn't so much that i disagree with what you're saying, it's that i think you are placing the emphasis on one thing while ken (and others) are looking at a completely different "thing"... if i do disagree on anything specific, it's on the cost per capita for health care decreasing as a result of this bill (the way it's written and likely to pass)... i think just the opposite will happen - *my* cost (and yours, and ken's, and millions more) will increase

 

i like this from the onion...

[blackshoe]

JDonn!! What have you done!? :(

 

In an alarming trend that some are calling a failure of U.S. drug prevention policies, daily marijuana use increased nearly threefold this month among 26-year-old Gary.

 

Researchers at the Department of Health and Human Services are attributing the spike in cannabis consumption to a number of troubling factors, including Gary- related underemployment, decreased motivation, and prolonged exposure to Josh.