Post-mandate Rx: Do-it-yourself ‘death panels’!
The punditocracy generally sees the Obamacare arguments before the Supreme Court going badly for the administration, and in particular for the individual mandate that some say is the heart of health care reform. If the mandate does go under, along with health care reform, that will be seen by some as a victory for individual freedom — but it will also mean a big bite out of our collective wallets. Health costs will spike (and will surely continue to rise) while those who have health insurance will effectively subsidize those who can’t afford it — along with those libertarian freeloaders who want Big Government off their backs but still want the rest of us to take care of them when they fall ill.
At the New York Times’ Economix blog, Floyd Norris has a proposal to keep all those principled objectors in splendid isolation without hurting the rest of us: a “Do Not Treat” List:
Let the health plan continue as enacted, with government subsidies and rules to assure access to health insurance for everyone. But if someone is morally offended by the idea of buying health insurance, he or she should be given counseling about the risks but then allowed to decide.
Persons who decline insurance would be allowed to provide details of how they intended to pay for care otherwise, if they wished to do so, and to name a person who would be responsible for paying for the care if the patient were unable to direct payment, much as many people now have health care proxies.
Anyone who chose not to have health insurance, and not to indicate how they would otherwise pay, would be put on a “Do Not Treat” list. Hospitals could simply refuse to offer any treatment, respecting the person’s wish to make his or her own decisions free of an intrusive government trying to keep them alive.
I doubt many people would sign up for such a system, but it would certainly overcome the alleged constitutional flaw in the current health care law.
Some people might be concerned that such a system would amount to voluntary euthanasia or assisted suicide. But surely they would put aside such qualms when they understood this was necessary to preserve our freedom not to be forced to buy something we do not wish to purchase.
Cool. Hey, you got to have the courage of your convictions. “Give me liberty and give me death!” It’s a great bumper sticker, at least.
The gold standard should be a mandate-free unregulated market for medical services with charities taking up the slack for those who fall through the cracks. Calcutta comes to mind.
I guess individuals without the financial resources or insurance could be treated on a charity basis (not passed along to paying or insured patients, or the government) by Catholic hospitals, strengthening their case that they are religious organizations and need not provide contraceptive coverage.
I am not sure that the individual mandate is dead. The justices on the Supreme Court say all kinds of things in oral arguments. But then they have to settle down and work out a ruling. So despite all that was said in the oral arguments about the individual mandate, I still think that the individual mandate could win approval, perhaps 5 to 4.
I agree that rumors of this mandate’s demise are a bit premature. The main reason for believing it’s going down is the cynical consensus, shared by 75% of the public according to recent polls, that the Roberts Court will always rule on behalf of Republicans if it possibly can. But yesterday’s arguments, or what we heard of them, could be interpreted either way. I don’t know how far legal minds can contort to discredit an idea Republicans themselves promoted until Democrats took it up as well. What kind of precedence would that be?
Ironically, if not for the problem of funding, a healthcare bill without the mandate would be far more appealing to Democrats, possibly even Obama himself, who — after all – campaigned against the idea of a mandate in 2008.
“Hospitals could simply refuse to offer any treatment.”
Doesn’t this already happen today – at least at for-profit hospitals – without the hassle of a do-not-treat list?
The suggestion that the purposively uninsured sign “Do Not Treat” directives is an excellent rhetorical device, very Swiftonian. My fear is that Sarah Palin — and worse, others like her in office — will take it seriously, and promote the idea in Congress (!). You really have to be careful what you say around some people.
American capitalism in action: no pay? no play.
Sounds OK to me. Keep your marxist socialist hands off of my health.
Mr Mac. Do you own an individual policy, paid for by yourself, or are you uninsured? Otherwise your health insurance is “socialist”
JIm Pouwels, re your 5:59 pm post: Are you happy with the refusal to treat? I doubt it, but please be clear here.
It’s marvelous how the socialism label gets hung on every “communal” effort we attempt these days. Why this is no more socialist than the space program, the interstate highways, the Tennessee Valley Authority and rural electrification. C’mon Jimmy, be a citizen of a bigger world.
“Health costs will spike…”
Why is that?
Doesn’t this already happen today – at least at for-profit hospitals – without the hassle of a do-not-treat list?
Jim,
By law, hospitals can’t turn away anyone who comes to the emergency room, and this includes people with non-emergency complaints. If you show up at the emergency room and you have insurance, the bill will definitely be over $1000 no matter what the complaint. If you show up in the emergency room with the sniffles and you don’t have insurance, you’re not going to be able to pay that bill, but you will get treated anyway. And of course hospitals have to charge people with insurance (or with the money to actually pay their bill directly) more to make up for all the people who don’t pay their bills.
I think we could easily do without a mandate for everyone to buy insurance if doctors and hospitals simply refused to treat anyone who couldn’t pay (either using insurance or paying out of their own pocket). In fact, health care costs would go down. However, it means that people with the sniffles, and people with gunshot wounds, would have to be turned away from the emergency room (and in the case of the gunshot wound, allowed to die) if they couldn’t pay.
“If you show up in the emergency room with the sniffles and you don’t have insurance, you’re not going to be able to pay that bill, but you will get treated anyway. And of course hospitals have to charge people with insurance (or with the money to actually pay their bill directly) more to make up for all the people who don’t pay their bills.”
Without contradicting my friend David on his main point, I think the above statement bears some comment.
If you are uninsured and go to the ER, someone will deal with you. However, you WILL be billed the same price someone with insurance is billed, and you WILL be dunned for the money, and if you don’t pay, your credit WILL suffer, and you will be in a world of hurt if you need to buy a car or furnace on credit.
Hence, for many of us uninsured, the ER is the last place we want to end up.
Hospitals do write off the cost of unpaid care as bad debt, but they will raise costs accordingly to try to recoup that money. That simply makes health care even more expensive.
I heard on NPR (or think I heard) from some medical pundit who said that those of us who are insured pay roughly $1,000 a year more than we should have to pay, in order to fund the uninsured who show up for treatment.
Is that true? If that’s so (or even close to so),why aren’t the forces backing the bill making more out of it?
From today’s reports it seems that Roberts and Kennedy are definitely the swing votes and that it might go 5-4 against the mandate or 6-3 for it with Roberts going along to be able to influence the winner opinion. As others have pointed out above those who do not have health insurance will drive up the cost as they will still no doubt use benefits despite any “do not treat” labels because this country rightly insists that nobody be refused emergency medical care.
Nicholas C. –
If an educated person on t his blog didn’t know that hospitals can’t turn anyone away, you can imagine the ignorance of the average citizen. No doubt this ignorance accounts for the displeasure o so many people with the program. They just don’t know how the health care system works — and doesn’t work.
I think the most basic problem is that Americans just dont’ want to admit that they want both the best that American medicine has to offer and that they will have to pay a lot for it, whether in insurance, taxes, or higher costs from health care workers, pharmos, and health care institutions.
In other words, we want a free lunch but are unwilling to admit it.
“The gold standard should be a mandate-free unregulated market for medical services with charities taking up the slack for those who fall through the cracks. Calcutta comes to mind.”
Yeah, unagidon, because the ONLY alternative to Obamacare is Calcutta.
I’d like to see what happens if we just had a ‘one price’ policy. That is, any provider can charge what they want but they have to charge everyone that price. That would cut down dramatically on all this cost shifting and reduce the need for ‘pay every bill’ coverage. Perhaps then we could have individual portable catastrophic coverage and pay for everyday medical expenses just like we pay for cable TV. The more we try to ‘fix’ the health insurance market, the worse things get, single payer (Medicare and Medicaid) included.
Jean, if you are uninsured you will probably be charged more than than those of us with insurance. Medicare and insurance companies negotiate prices more effectively than individual consumers can hope to do.
Bruce –
I think that most of us ol folks agree that the essentially single-payer system called Medicare works quite well with a minimum of paperwork. In fact, if you want to commit political suicide run on a platform that eliminates Medicare or even changes it noticeably. Yes, the government sometimes runs things well.
P. S. — I should add that Medicare doesn’t pay for everything. Some costs can be considerable. But te program does what it does well.
“Yeah, unagidon, because the ONLY alternative to Obamacare is Calcutta.”
Calcutta is what a totally unregulated market that is willing to allow people to die in the street looks like. What’s your alternative to Obamacare? I don’t think it’s great either, but it’s a big step forward. You think we should leave everything alone?
Ah, to be free. But, bear in mind, if you are in or retired military, receive Medicare or Medicaid, have a group health insurance policy, or are a medical ‘free rider,’ your are receiving government subsidized health care, or as some here mistakenly define as ‘socialized medicine.’ Some seem to argue that there is a ‘free market’ alternative. Maybe there was at one time, early in the last century, but I don’t think there is any going back to that, and I don’t know anyone who truly believes and can rationally argue that as a viable alternative.
“By law, hospitals can’t turn away anyone who comes to the emergency room, and this includes people with non-emergency complaints. … If you show up in the emergency room with the sniffles and you don’t have insurance, you’re not going to be able to pay that bill, but you will get treated anyway.”
I confess I am pretty uninformed on this point. So I rushed to volume 25,432 of Wikipedia (I bought the hard-copy edition from a door-to-door salesperson recently) and discovered that there is a federal law known as EMTALA, passed in the ’80′s, that did largely put an end to the charming practice known as “patient dumping”.
The laws covers the following: “An emergency medical condition is defined as ‘a condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in placing the individual’s health [or the health of an unborn child] in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of bodily organs.’ For example, a pregnant woman with an emergency condition must be treated until delivery is complete, unless a transfer under the statute is appropriate.”
The article also notes that there are certain medical conditions that aren’t covered by EMTALA, i.e. patient dumping apparently is still allowed under federal law for some categories of patients, including pneumonia, fever and, outrageously, a normal pregnancy delivery (the last apparently having been determined by a court ruling).
David, where you live, it may be that state or local law would require that ERs also provide sniffles treatments.
http://en.wikipedia.org/wiki/Emergency_Medical_Treatment_and_Active_Labor_Act
Bernard – health care is a basic human right. Everyone is entitled to it, and we’re morally obligated to find a way to deliver it to everyone. I’d add that part and parcel of that moral obligation is to ensure that our systems of delivery are financially solvent.
Probably unsurprisingly, the demographic pool that historically has taken a pass on paying for health insurance, and on whom the individual mandate has in its sights, those who are young and healthy, opposes the individual mandate.
Women, who are also thought to benefit from the Affordable Care Act, also oppose it.
Seniors, who will continue to receive Medicare whether the law stands or falls, also oppose it, possibly because the act is expected to reduce Medicare funding.
http://www.commentarymagazine.com/2012/03/26/opposition-to-obamacare-high-among-women-youth/
Please Jim, spare us all the often parroted “health care is a human right”. Caring for the poor is our Christian duty.
I have mentioned time and again that – if we want national health care plan because we are concerned for the poor – the only wokable solution is a single-payer, basic (minimal) national health insurance plan, paid for by income taxes, sort of like the interstate highway system.
Everyone would have the national plan, and the vast majority would buy individual or group-plan riders to raise their healthcare coverage to whatever level they preferred and could afford.
I do not see why that is so difficult for some to understand.
Please Jim, spare us all the often parroted “health care is a human right”. Caring for the poor is our Christian duty.
Ken,
I don’t think “parroting” the teachings of the Church on a Catholic blog is any kind of offense.
See this, for example:
Or see the Catechism of the Catholic Church:
David – I said caring for the poor is our Christian duty. Interestingly, when Democrats refer to Church teaching (like charity or social justice) all agree it is a good thing, but when Republicans refer to church teaching (abortion, gay marriage), Democrats start worrying about “the coming American theocracy”.
In any case, hysterics who dive headlong into the discussion of national healthcare (or any serious discussion for that matter), with nothing but emotive arguments and simply bleat out over used phrases, do not help matters at all.
David, where you live, it may be that state or local law would require that ERs also provide sniffles treatments.
Jim,
I did some additional Googling, too, and found out I was partially in error. Treatment is not required, but evaluation is. Consequently, if you go into an emergency room with a rash, and you are screened and it is discovered that your sniffles are the result of a sinus infection, the doctor doesn’t have to treat you. But if all you need is a prescription for an antibiotic, at that point, why shouldn’t the doctor just go ahead and write it?
I also discovered that it is not people with sniffles who significantly drive up the cost of ER care. If I remember correctly, about 15% of visitors to the emergency rooms come with non-emergency complaints. It’s the people who come to the emergency rooms with serious conditions (heart attacks and such) who don’t have insurance who drive up the expense.
From what I have read, emergency room physicians are opposed to turning people away who don’t have medical insurance, or cash, because they believe these people will go without necessary medical care.
The fact of the matter still remains that medical care that is provided for people who cannot, one way or another, pay for it is paid for by increasing the cost of care for those who can pay.
I’m personally quite fond of Germany’s and France’ Bismarckian systems, which are *not* single payer, but are universally insured. Prices for medical services are set by the government, and insurers are heavily regulated and not-for-profit. In France, every citizen is issued a health care card. When someone sees the doctor, she simply inserts the card into her laptop and the patient’s entire medical history pops up. After services are rendered, the physician pushes a button and an e-bill is sent to the insurer, who then has 72 hours to pay in full. A similar approach adopted here would eliminate countless costly medical errors and the insane overhead that doctors and hospitals endure in dealing with insurers.
Ken,
This is a Catholic blog. If I were in a political argument with non-Catholic Republicans (or any non-Catholics), I doubt that I would use as one of my argument the fact that Benedict XVI said health care is an inalienable right. But this is a Catholic blog, and you are pooh-poohing Catholic teachings, so it is perfectly appropriate to quote them to you.
If you do not agree that the right to health care is a basic human right, you are not in agreement with the Church. I am certainly not in agreement with the Church on a lot of things, so I have no right to shake my finger and accuse you of anything. But I certainly have a right to point out you are in disagreement with the Church here.
“You think we should leave everything alone?”
Are you serious? Where in the world of logic is being opposed to some (perhaps the biggest) parts of the ACA inevitably lead to the conclusion that your position must be that you prefer “a totally unregulated market that is willing to allow people to die in the street”? I just finished watching Morning Joe, for example, and Governor Dean from VT was castigating the Obama administration for pinning everything on the mandate, which he characterized as a (originally conservative) bribe to the industry in which you are employed (insurance). Is he in my camp too? By the way, when he was running for President, Pres. Obama opposed the individual mandate as well. So I think it’s possible to disagree with parts of the bill and not thereby hold the position that you favor your doomsday strawman.
You ask what I would suggest. Essentially, I would try to design a system something like the Swiss system, along the lines discussed by Avik Roy: http://www.forbes.com/sites/aroy/2011/04/29/why-switzerland-has-the-worlds-best-health-care-system/ (you should note that, as Roy does, the Swiss system has a mandate, although Roy believes it is not essential to the system).
But rest assured, unagidon, whatever system I would suggest to replace the overly-centralized scheme of the ACA does NOT include allowing people to “die in the street.”
“If you do not agree that the right to health care is a basic human right, you are not in agreement with the Church. I am certainly not in agreement with the Church on a lot of things, so I have no right to shake my finger and accuse you of anything. But I certainly have a right to point out you are in disagreement with the Church here.”
Does the Church teach that, because health care is a basic human right (as it does), that health insurance is also a basic human right? If so, does it teach that particular policy riders must also be included in the health insurance?
Cardinal Dolan was on Bill O’Reilly’s show last night. O’Reilly’s final question was whether he would tell Catholics not to vote for Obama. Cardinal Dolan sad he wouldn’t – it would probably make more people vote for him.
http://www.billoreilly.com/show;jsessionid=DF5B646F4A29EC64E8F395275B15194E?action=viewTVShow&showID=3097#4
Does the Church teach that, because health care is a basic human right (as it does), that health insurance is also a basic human right?
Jeff Landry,
No, but the Church does teach that health care is a basic human right. I was responding to Ken, who said, “Please Jim, spare us all the often parroted ‘health care is a human right.’”
See Merriam-Webster Unabridged Dictionary for parrot as a verb:
He was being dismissive and rude, and I was responding to him, not making an argument for any particular policy.
While I think the current system is a mess, i think the chaos of the mandate “going down” would be worse. On the other hand, perhaps, as we bankrupt ourselves and see healthcare further fractured, society will eventually galvanize around different priorities and, through painful processes, a more egalitarian system may emerge… Pie in the sky?
David Pasinski ==
It’s pie in the sky because although people want very good health care, they don’t want to ddedicate a large chunk of their income to it. granted, these are hard times, but even beore the recessionthere wasn’t very much support for supporting a first class health system.
David N, thanks for your support. :-) Ken, my observation is that Christian duty and human rights usually tend to coincide rather than conflict. Somehow we come to the same conclusion – that a single-payer system is where we will, and arguably should, end up. But entitlement affordability is the 900 lb. gorilla in the room.
Ann,
I’m sorry to disagree, but we ALREADY pay for a first-class health system, we just don’t HAVE one. Americans pay far more for health care than any other advanced country. While it is difficult to make ‘apples-to-apples’ comparisons, in almost every statistical comparison we are far down the list — except, I believe, in successful treatment for breast cancer where we are near the top. In almost every other category, though, we are clearly not getting our money’s worth.
For a good statistical report on health care expenditures and results among economically developed countries, see
http://www.commonwealthfund.org/~/media/Files/Publications/Issue%20Brief/2011/Jul/1532_Squires_US_hlt_sys_comparison_12_nations_intl_brief_v2.pdf
‘i think the chaos of the mandate “going down” would be worse”
How, exactly, would the removal of a mandate not yet in effect somehow cause such massive “chaos”?
If the goal of health-care reform is both to extend coverage to as many people as possible and to curb the exploding cost of health insurance, then the individual-mandate is an indispensable feature of reform. Without it, the requirement that insurers offer coverage to people with preexisting conditions won’t work — or won’t work without further increasing the cost of health insurance for everyone.
If the Court rules that the mandate is unconstitutional, the problem could be solve by each state enacting a mandate separately. It seems unlikely that all would, but maybe once the states that didn’t saw the advantages that accrued to the states that did, they would all do the right and rational thing. Short of the mandate, there are other ways the states could encourage everyone to buy insurance when they’re still healthy. (They could, for example, set fixed periods for when people could sign up so that it would be harder to game the system by waiting until one needed insurance.) But none of the alternatives would be as effective as a mandate.
If the Court strikes down the entire Affordable Care Act because of the individual mandate, then we are back to where we started. But time is on the side of a more radical and adequate reform — if not a simple single-payer system, then at least a system with a public option available to everyone, irrespective of income. People would be automatically enrolled in the public system. If they found that system inadequate or ideologically repugnant, they could opt out and buy private insurance. Or they could add private insurance to cover services not covered by public insurance.
Why is time on the side of reform? Because more and more people are going to find themselves without adequate employer-based coverage as more and more employers drop or reduce their coverage because of rising costs. The main obstacles to reform are (a) the fear of losing something one already has in order to help those who don’t have it and (b) ignorance of how the health care system works and how other, better systems work. The fewer people who have good insurance, the less prevalent the fear. The more people who lack insurance, the easier it will be to cut through the complacent ignorance.
Jeff
Fair question… My supposition is that costs simply keep ballooning and revenues do not kerep pace and that some part of the system explodes with new restrictions on services.
“Somehow we come to the same conclusion – that a single-payer system is where we will, and arguably should, end up. But entitlement affordability is the 900 lb. gorilla in the room.”
Those of us who are uninsured share your concern over paying for any kind of health care program b/c the more expensive or convoluted it is, the more likely we are to lose it. (Or, in the case of the current ACA, we may lose it before we have it, though I’m not sure that’s going to be a great big loss if it happens.)
I have never really understood why it wouldn’t have been cheaper and simpler to have offered Medicaid to more people–the bureaucracy is already in place–and required those over a certain income level to pay for the benefits on a sliding scale.
Most of us who make too much for Medicaid but not enough to pay for private insurance can pay something. I save about $100 per month to cover what I will rack up in doctor visits, meds, and tests, etc., and I would be happy to put that money into an expanded Medicaid program in order to receive broader coverage.
And Medicaid is not a Cadillac policy by any means. Many specialists will not accept Medicaid, and it does not pay for “frills” that many other policies do. The fact that we freeloaders would not be feeding from the cream of the system and would have to pay something for our benefits would, I think, help our conservative friends see that we’re not getting too much more than we deserve.
I continue to despair at the quality of posts here (e.g. jbruns idea of ‘socialism” or Jeff prattling on continuously about the evils of Obam,acare.)
It’s good to see some (from a catholic/Christian and I’d add poltical (some hate that because it says government needs to be involved) perspective of the right to health care.
I fear the Roberts court wil strike down the mandate showing their Catholic perspective
Which is why i have another reason to fear for the”dosintegration” oif my Church which sioft pedals the individualism of many members while touting the Eucharistic community.
Mr. Nunz: Perhaps you would despair less if you read more carefully. I have no idea what your criticism is.
Matthew – I pretty much agree with your analysis.
Jean – I’m also surprised that an expansion of Medicaid, or Medicare, isn’t what we ended up with. Perhaps it’s because the Obama Administration outsourced the creation of the programs to Congress rather than putting forth its own program proposals. (Recall that the PPACA wasn’t originally supposed to be what we were going to end up with; the House ended up reluctantly passing what was then the Senate bill because Scott Brown’s election to the Senate made it impossible for the Senate to pass the House’s version of healthcare reform.)
Bob – I’m as SHOCKED that you think ONLY those people who agree with your position have “quality posts” as I am at your continuous inability to type.
@Matthew Boudway, who wrote:
“If the goal of health-care reform is both to extend coverage to as many people as possible and to curb the exploding cost of health insurance, then the individual-mandate is an indispensable feature of reform. Without it, the requirement that insurers offer coverage to people with preexisting conditions won’t work — or won’t work without further increasing the cost of health insurance for everyone.”
Howard Dean flatly dismisses this argument, as did Obama-circa-2008.
Jean – I’m also surprised that an expansion of Medicaid, or Medicare, isn’t what we ended up with.
Jim,
Well, Medicare is a single -payer system. Obama and most liberals would be overjoyed, I can only imagine, simply to extend Medicare to cover everyone. However, do you think the Republicans and the insurance industry would stand for that? Conservatives/Republicans do not want “socialized medicine.” They would like to do away with Medicare if they could find some way to do it.
Medicaid is actually expanded to cover more people in ACA, a href=”http://www.latimes.com/news/politics/la-pn-justices-suggest-medicaid-expansion-is-unconstitutional-20120328,0,3037964.story?track=rss&utm_source=feedburner&utm_medium=feed&utm_campaign=Feed%3A+latimes%2Fmostviewed+(L.A.+Times+-+Most+Viewed+Stories)”>and it looks like that aspect may be struck down as unconstitutional. Since each state is responsible for its own Medicaid program, with only partial funding from the federal government, when the federal government tries to expand Medicaid, it is requiring states to spend additional money on their Medicaid programs that they may not want to spend.
What we ended up with is probably the only plan that had any chance at all of passing, and now it seems very possible that it will be struck down by the conservatives on the Supreme Court.
Jeff, almost all health-care economists agree with that argument. If Howard Dean flatly dismisses it, he is wrong. When Obama dismissed it, he was wrong. When Republicans supported it a decade ago, they were right. And if they had passed something like the Affordable Care Act then, it never would have gone to the Supreme Court — and if it had, the Court would have upheld it. But these historical ironies tell us nothing about the legality of the law, or how it would work without its most important component.
“When Republicans supported it a decade ago, they were right. And if they had passed something like the Affordable Care Act then, it never would have gone to the Supreme Court — and if it had, the Court would have upheld it.”
I just want to note that the Republican Party today is not as it was a decade ago. The Tea Party wing doesn’t subscribe to party discipline for the good of the party – that discipline being a key reason a minority party like the GOP has been so successful since 1980. The Tea Party will defy its own leaders (cf congressional freshman Republicans last year), will primary sitting Republican elected officials of insufficient ideological purity, will run 3rd party candidates in general elections, even when that virtually guarantees that a Democrat will win.
If Republicans under Boehner’s leadership managed to cut a legislative deal with Democrats for Obamacare 2.0, some Tea Party state attorney general would still try to kill it via the courts.
If the faux Republicans really want to do away with “socialized medicine,” what do they propose to use for the military? The VA?
Are they prepared to raise military pay to the point that service people can actually afford private insurance for themselves and families? What about veterans who qualify for VA healthcare?
David, that’s true that Medicaid would be expanded and others would get government subsidies to buy health care if they couldn’t afford it once the insurance exchange is set up.
But, to me, me that’s the most inelegant solution to the problem because of the waste involved. The insurance exchanges will cost somethng to set up and that will be passed along to somebody. Moreover, as an individual purchasing health insurance, I will have to shop the exchange, and if these things work like current Web sits which purport to help you find and compare health plans, this will be an utter nightmare. You not only have to compare coverage and premiums, but you have to determine whether you will have to change doctors and hospitals, and how long you’re locked into the policy, and (if you’re smart) determine what that company’s premium increase history has been.
ACA will also require more staff to determine who’s eligible for Medicaid and who’s eligible for subsidies, and to review cases as economic conditions change.
I also have no idea whether, under the current law, so-called “mini-med” policies will satisfy the mandate. If so, these very inadequate policies, which are more like supplemental policies, will prevent a lot of people from getting broader Medicaid coverage because they have “affordable” health care that doesn’t cover squat.
However, rather than point out that the simpler and probably more cost-effecive solution would be to expanding Medicaid via means testing, conservative are trying to make this about some larger moral issue, like socialism, delays in care, and death panels.
“Jeff, almost all health-care economists agree with that argument. If Howard Dean flatly dismisses it, he is wrong. When Obama dismissed it, he was wrong.”
Matthew, all you’re doing is asserting that some health economists THINK that the argument will work out. But we have no actual evidence to conclude as flatly as you do that the mandate is the holy grail of health insurance reform. Indeed, Dean’s whole argument is premised on Vermont, where he claims they have BOTH guaranteed issue AND lower costs WITHOUT a mandate (I haven’t verified his evidence from this morning, but we’ll see if someone comes out to correct him).
But it is wrong to state as a matter of fact that the mandate will accomplish what you say it will; we don’t know if it will or not, which is why the ACA has an exit mechanism for the states built in starting in 2017, as the Administration argued before the Court on Tuesday. Furthermore, the “cost curbing” feature of the mandate is weakened (as Michael Carvin argued and more conservative health economists have pointed out) because the bill prohibits people from buying cheaper catastrophic coverage and requires the more expensive comprehensive coverage.
I read somewhere that American employers started buy health insurance for their workers back in the 1940’s. In those days, because of the war, there were federal rules and caps on wages for some workers. In order to attract and keep employees, some employers began offering health care as a job benefit.
When my dad began practicing medicine in the early-mid 1950’s, almost nobody in South Dakota had insurance; they simply paid cash. The received the doctor’s care and if they could not pay all at once, they paid a bit each month. Sometimes farmers paid with a side of beef or other meat. The doctor was a well paid and well respected man in the community but he was not uber-rich.
The problem with insurance is that the person receiving the doctor’s service is effectively kept in the dark regarding the charges. If you are paying the doctor in cash, you look each other in the eye, and your ability to pay and his conscience decide the pricing. If you are paying a monthly insurance premium and the doctor bills the insurance company, you do not much care what the doctor charges. Insurance companies on the other hand, invest the monthly premium income and make money that way, and they also must pay claims. Complicated yes, but usually complicated things do not come from God; they come from the other place. God is light and simplicity, not tedium and darkness.
And now the whole insurance game has drifted out of whack, and big government types come running to the rescue.
The dirty little secret is that insurance was initially offered because the government interfered with what the boss could pay his employees. And so a problem the government started back in the 1940’s, the same government now proposes to solve with this ACA nightmare!
I hope the Court tosses all 2,700 pages of this nonsense in the garbage.
Ken,
You seem to be opposed to health insurance in principle!
“If you are paying the doctor in cash, you look each other in the eye, and your ability to pay and his conscience decide the pricing.”
That seems a little naive, though it may have happened in the depression when my grandmother paid the doctor for delivering my mother with eggs and butter after Aunt Mag the midwife ran into trouble.
My doctor usually looks me in the eye and says, “We’ll let this or that test ride this year; maybe you’ll have insurance next year.” Then she sends me the same bill she sends everyone else.
General practioners are often paid a salary by the clinic and have little ability to cut you a break these days–and you can’t even get past the scheduler’s desk at a specialist’s office if you don’t have insurance or agree to pay before you’ve even seen the doctor. I’ts strictly a “show me the money” biz.
A doctor in my town–happened to be someone I knew growing up whose dad was a Lutheran minister–started a specialists clinic for the uninsured here. Once a month, he gets a dermatologist, cardiologist, etc. to donate time to see as many patients as they can on a Saturday. These good docs have taken care of simple skin cancers, consulted about heart problems and the like, but the problem is that their ability to help is hampered by patients’ inability to afford meds and more aggressive treatments.
Also, your history of employer-provided health care is slightly faulty. It was first offered int eh 1920s when it cost less than a tube of lipstick–after all, there wasn’t much medicine could do for you in the pre-antibiotic age–as a way to avoid giving workers, particularly many women who were going to work, raises. It may also have been offered in the 1940s as you say, but the government was not the chief instigator of health care.
I realize people get sick of me talking about this, but my guess is that most of you have insurance and really don’t know what it means not to, or like many conservatives, you want to make the lack of health insurance about values or government conspiracies or something, when it’s merely a by-product of rising health care costs, employers’ inability or unwillingness to pay, and many people who are un- or under-employed.
“When my dad began practicing medicine in the early-mid 1950’s, almost nobody in South Dakota had insurance; they simply paid cash. The received the doctor’s care and if they could not pay all at once, they paid a bit each month. Sometimes farmers paid with a side of beef or other meat.”
I was reading a Lew Archer crime novel recently, written in the ’50′s or ’60′s. (I must have set my Kierkegaard aside for a day or two). Archer gets shot by a bad guy, is treated in the hospital, but walks out of the ward to pursue the bad guy before being discharged or paying his bill. Later, checking his answering service, there is a message from the doctor who treated him, that Archer owes him $170.
I enjoy these snapshots of how things used to be, but istm the key point is that they’ve changed. I’d love to see a system where the hospital charge for gunshot wound treatment is $170, but have no clue how to get us there. Switzerland’s system sounds pretty interesting, but it seems to require that insurers be not-for-profit. How would we get there? Whatever plan we put together, we’re constrained by the reality we’ve inherited. We don’t have the luxury of blowing the existing “system” up and starting over. We have to work with what we’re given and somehow navigate to where we want to go.
I must have set my Kierkegaard aside for a day or two.
Jim,
Du behøver ikke at undskylde for at læse en Lew Archer roman. Jeg ved, når jeg læser Kierkegaard i lange perioder ad gangen, jeg er nødt til at tage en pause og læse noget på engelsk.
Thanks to Commonweal for putting forth E.J. Dionne’s discussion of the SCPTUS hearings.
As was noted once here, this is a catholic blog.
The postures of our SC catholic justices tha Dionne exposes underscore the deep individualism and lack of sense of the right to health care existing in many Catholics today.
Just saw a neat video at NCR (of coursed we know from Bil Donahue that NCR is anti Catholic) from Sheila Gilbert , honcho of St. Vincent Depaul Society, calling on us to sustemically change the way we deal with poverty.
A clear sense of community runs through it.
I see a USChurch whose leadership continues to assert its rights, individualism and pays lip service to the poot the needy and yes to victims.
It’s an all about us Church policy led by His Eminence at NY and backed by a putative Catholic League.
Intertwined with that is political ideology tied to the anti obama conservative side that services its “teaching” power or so it thinks.
I may tyoe poorly, bu tI think I see clearly and I am saddened by what I see our Church divided lurching more and more towards!
I’m not knocking kindly face-to-face doctor-patient relationship stories. (My own family has stories that date back to the late 19th century of such encounters.)
But let’s be realistic about that history and about what we have today. Before the widespread use of penicillin, there was almost nothing doctors could do to help cure patients. Even into the 1950s, there was virtually nothing doctors could do about heart attacks, other than hope the patient survived and prescribe long periods of rest and convalescence. Gunshot victims tended to die before getting to the hospital, so it’s not surprising that Lew Archer’s bill was only $170 (in 1950s dollars) for getting patched up—if he’d been seriously wounded, he’d have been dead or dying by the time he got to the hospital, and the doctor wouldn’t have been able to do much about it.
That, as the saying goes, was then and this is now. We’d all (or at least many of us) like to go back to a simpler, easier, friendlier “golden age”. The problem is 1) we can’t, and 2) times weren’t as good back then as we often remember them.
If Lew Archer were paying that $170 in 2012 dollars, his bill would have been $1,625.
For those who want a reality check about prices in the Good Old Days, go here: http://www.dollartimes.com/calculators/inflation.htm
It’s kind of fun to play with.
My grandmother had a gold crown on a tooth in 1918 that she paid $10 for, and the dentist did a good job; Gramma died with that same crown and all the rest of her teeth intact at age 96. The same job in 2012 dollars would be a steal at $164; crowns now cost about $500 a pop.
Mother said the doctor charged my parents $35 in 1957 (April Fool’s Day!) to deliver my baby brother. That’d be about $276 in today’s dollars (a good deal, but there were no fetal monitors, ultrasounds, etc. in those days, either).
When I drove myself to my first job in 1970, gas was 35 cents per gallon … $2.10 in 2012 dollars, which would still be a big bargain. It’s up to $4.09 per gallon down at Dean’s Deli and Gas (yes, that really is the name of our town gas station).
My first newspaper job paid $9,500 per year, worth $27,951 today, and considerably more than I am making now as part-time adjunct with a master’s degree.
I had a wisdom tooth extracted for $50 in 1981. That’s about $130 in today’s dollars. When I asked about the same procedure a couple of years ago, I was told it would be $500, which would include the fancy chair, “twilight sleep” medication, and recovery room nurse care. He refused to just let me sit in the chair while he yanked it out as the surgeon did in 1981.
” jbruns 03/28/2012 – 7:31 pm subscriber
Mr Mac. Do you own an individual policy, paid for by yourself, or are you uninsured? Otherwise your health insurance is “socialist” ”
jbuns: Obviously my tongue-in-cheek comment was not obvious enough. I have been a long and loud supporter of single-payer health plans. I gladly partake of 2 “socialist” plans already: retiree medical and VA healthcare.
I lived in the UK at the end of the 1960s and had advantage of their National Health Insurance. With its faults (then) it was even then head and shoulders above the rationing program that we have in the US today.
Ken: you said this: ” – the only wokable solution is a single-payer, basic (minimal) national health insurance plan, – ”
What would you include in “basic (minimal)” and what would you exclude? And why?
David, Kierkegaard får mig til at indse, at den bedste form for dansk er en sød rulle
Mr Mac. Sorry I missed it
Jim,
Jeg ruller på gulvet og griner.
Do you people really know Danish, or are you just using BabelFish online to translate this?
Jean,
How dare you suggest I would use BabelFish and pretend to know Danish! I know nothing at all about BabelFish. I am using Google Translate to fake a knowledge of Danish.
Sorry, I’m a skeptic at heart. Probably hard for you to believe that …
Interesting. According to Google Translate, the Danish for BabelFish is …. BabelFish.
So much for accuracy.
{;<}}
An interesting analysis of some plausible left-of-center alternatives if the mandate goes down:
http://www.forbes.com/sites/aroy/2012/03/31/whats-democrats-plan-b-if-the-individual-mandate-goes-down/
The Avik Roy piece that Jeff links to directly above also includes a link to this interesting analysis by Harold Pollack on the possibility, in the event that the Supremes kill ACA, of getting a single-payer plan enacted.
http://theincidentaleconomist.com/wordpress/no-overturning-aca-would-not-smooth-the-way-to-single-payer-care/
The reason single-payer (via federal income tax most likely) is the only workable solution, is that the policy particulars would then be in the realm of public policy and subject to the current preferences of the public. Also, churches are tax-exempt and so the government would not be strong-arming them.
The idea in our society is that the voters generally decide – via our elected representatives (president and congress) – what we do with tax money. Obviously it is not that straightforward, and the ship of state turns slowly, but generally this system works for us; most Americans are happy with our system of government.
This of the Mexico City Policy. When Reagan initially declared it back in the 1980’s, the US cut off funding for UN programs that provided or promoted abortion. Since it was an executive order, Bush sr. kept it in place as well. When voters chose President Clinton, he reversed it and we started paying for UN programs that provide/promote abortion. When Bush Jr. was elected, he re-activated the policy and we did not pay for that during his years. President Obama reversed it when he was elected and now we pay. In short, the Mexico City policy – via the presidential election – is a dynamic reflection of the will of the voters.
This is how health care would work under a federal single-payer system. When Democrats are elected the majority, there would be all sorts of free-bees – bc pills and all. When Republicans eventually get elected, they will trim things back.
Thus the particulars of the national policy would be a dynamic thing; a reasonable reflection of the current will, the current consensus of the voters.
Should add that I ws responding to Jimmy Mac’s good question from 03/30/2012 – 3:54 pm.
Oops – meant to say “Think of the Mexico City Policy . . .” Monday morning thumbs it seems!
President Obama weighs in with constitutional views.
http://www.realclearpolitics.com/video/2012/04/02/obama_supreme_court_striking_down_obamacare_would_be_judicial_activism.html
“Thus the particulars of the national policy would be a dynamic thing; a reasonable reflection of the current will, the current consensus of the voters.”
That can be quite dangerous. Think voting rights for blacks and women. Think conscientious objection. What if there was a consensus for plural marriage – and then 10 or so years later the consensus changed? Think how the SCOTUS changes, stare decisis notwithstanding.
Jimmy – This sort of thing must be a reflection of the wishes of the voters. They after all, will be footing the bill.
Avik also has this piece on how liberals have flip-flopped on the mandate
http://www.forbes.com/sites/aroy/2012/04/02/once-upon-a-time-liberals-hated-the-individual-mandate/
As for Pres Obama’s unfortunate comments today, first I can’t imagine he endeared himself to either Justice Kennedy or the CJ, and second it definitely belongs in the “if W had done that, I can imagine the liberal reaction.”
President Obama sounded like FDR when the Supreme Court struck down the NRA. Socialists do not understand the Supreme Court and the importance (in this country anyway) of the Constitution.
When the President petulantly bleated “they will uphold the mandate because it is right”, I sort of felt for him, but not really. It shows how he and others on the Left, simply do not understand that they cannot ram utopian ideas down the throat of the people.
Not everything is relative and/or flexible.