RANGER AGAINST WAR: Affordable Care Act , 2017 <

Wednesday, August 09, 2017

Affordable Care Act , 2017


Let me explain to you how this works:
you see, the corporations finance Team America,
and then Team America goes out...
and the corporations sit there in their...
in their corporation buildings, and...
and, and see, they're all corporation-y
... and they make money.
--Team America: World Police (2004)

Oh, you build it up, you wreck it down
Then you burn your mansion to the ground
--Hold On
Tom Waits
__________________

Does the legislative branch exist to enact or to destroy legislation? Or is a grand Mobius make-work strip in which everyone is guaranteed a job (either building or destroying)?

Every President wants him some flagship legislation, so we have former President Obama's hobbled Affordable Care Act (ACA).

Almost 7 million people opted-out of the plan last year, incurring a tax penalty in 2017 of $695 or 2.5 percent of household income, whichever is higher. For most, this was not an ethical protest, and came down to how to best disburse limited family funds.

Further, just because you can manage to pay for insurance does not ensure that you will be able either pay for or be seen by a doctor. The ACA will never deliver a high level of care. (Lisa's associate Dr. Lickerman actually read most of the 1.500 pages of the abstruse document, and offers a gloss HERE.)

This is the same legislative branch that wants to put sanctions on North Korea and Russia (our sometime ally ... when convenient.)

In a nutshell, they cannot rule the united States, but they are intent to use their same ineptness to dominate foreign powers.

Both parties agree that any ACA-type arrangement must have an individual mandate; otherwise, the effort fails. The healthy must be forced to buy-in, to subsidize the medical care of the grossly unhealthy. Also, in a nutshell.

For some wide-ranging perspective, the U.S. committed a Cold War against the communism of the Soviet Union because, well, collectivism is a bad thing for Capitalists. (This is also why unionism has always been eyed with suspicion, as it is collectivism writ small.) Capitalism is good; socialism and communism, bad. Ranger-simple, at its finest.

Forgetting for the moment the reality that humans are the common denominator making anything either good or bad, let us consider the ACA  and "skinny" clones, for they are socialism in action.

If we were faithful to our capitalist ethos, we would allow people to be uninsured, and not care whether the old or poor die, or anyone else, for that matter. Capitalism is about profits, and not the welfare of the individual. Free choice is its mantra.

With the ACA, we have confused capitalism with socialism and arrived at a gryphon which defies all of our sensibilities. But we can't be seen as being mean, can we? Spin is all -- just watch evening news if you have any doubts.

When the healthy are forced to subsidize the unhealthy, this is the definition of socialism. Insurance is a capitalistic vehicle; forcing it upon unwilling citizens is socialism.

Interesting that neither party calls it for what it is.


(ed. addendum): In keeping with its dour, wet-rag demeanor, The New York Times coverage continues its hope for this administration's failure on this topic in their editorial board position: "Capitol Shocker: Democrats and Republicans Start Working Together on Health Care By THE EDITORIAL BOARD. But Republican leaders could still block their efforts."

Never miss an opportunity to put the kibosh on any sincere deal-making before it has even begun.

Mystical Judaism believes that in every generation there are 36 righteous people. They are the enlightened. Let us hope we have even a couple in our government.

We know the Times is a wash.

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47 Comments:

Blogger Ael said...

In Canada, we have medicare for all.
It works adequately (although there are warts).

Of course, the "S" word isn't as evil here
as it appears to be there.

Maybe it is time for America to try single payer as well.

Wednesday, August 9, 2017 at 1:47:00 PM GMT-5  
Anonymous David said...

Single-payer public insurance would be socialism. A government mandate to purchase private insurance is something worse: legislated welfare for insurance companies, like the robber barons of medieval Europe.

The Canadian medicare system is a product of a simpler time when the insurance, pharma, and hospital industries were far smaller than they are now. Even if the U.S. wanted to go that route, I don't how it would. Would you nationalize all the hospitals in the country?

Wednesday, August 9, 2017 at 2:33:00 PM GMT-5  
Blogger Ael said...

No need for nationalization.

Canada has private doctors and private hospitals. It is just that there is only essentially one payer: the government.

A doctor does not have to take money from the government, but if they do, they can't take payment from anyone else. So, no double dipping, especially for the same service (cause that erodes the single payer approach). There was a lot of controversy over this, but experience showed that letting in private "topping up" payment messed up the system because it inevitably raised the price of cheaper services and dumped the cost of fixing stuff up onto the public system when the private guys inevitably put patching up any unforseen medical consequences out of scope of their services.

For the extremely rich, there are always doctors who are completely outside the single payer system. And, of course, American doctors are always available, for a fee (or rather large numbers of fees of every sort of magnitude)

We do have private insurance plans, but they mostly pay for stuff outside the medical system. So, private hospital rooms, drug plans (although old folks also get their medications paid for) dental care, eyeglasses and other "nice to haves". As our Prime Minister said decades ago: "In case of illness, no one should be forced to choose between their house and their spouse".

Of course, the singe payer means that private health care providers have to live by the schedule of fees published by the government. But don't Americans already have a schedule of fees? Or are there medicare only facilities?

Wednesday, August 9, 2017 at 3:02:00 PM GMT-5  
Anonymous David said...

Doctors are for the most part private.

More Canadian hospitals, however, are public institutions that are block grant-funded by the government.

The failure of Canadian medicare to pay for out-of-hospital drugs is just one of the relics increasingly showing its age. At the time this probably seemed like it wouldn't matter very much. Nowadays, obviously, it's a different matter.

Even with that, putting in medicare with 10 provinces and a much smaller healthcare industry caused no small amount of disruption and years of committed negotiation in a far more productive political environment. As I say, I cannot see how that would happen with 50 states, crippling levels of political dysfunction, and a far larger medical and insurance industry to have to grapple with. I can't see it being established even in Canada at this point given current levels of federal-provincial dysfunction, and there are only 10 provinces, not 50.

Wednesday, August 9, 2017 at 3:44:00 PM GMT-5  
Anonymous Anonymous said...

Canada doesn't even cover pharmaceuticals. Wait times are crazy. Care is rationed. For example (and there are many many similar examples), a woman with breast cancer gets a mastectomy in the US and she gets breast reconstruction. That's policy at every major US insurance company. The socialized system won't cover the reconstruction. If she wants that - and most women do - that around $15K to $20K out of pocket.

Canada has a great shortage of doctors (one reason for the long wait times for anything but acute emergent care). Plastic surgeons are few. Much that is considered "elective" in Canada and subject to extremely long waits if delivered at all, is normal practice covered by insurance in the US.


The US system delivers a Cadillac and the socialized systems a Yugo. True, everyone gets a Yugo, but it's still a Yugo. The people in socialized systems are just so used to Yugos and thin gruel and their little grey Mao suits that they think it's fine. They don't know what they're missing.

Private insurance companies contract fee schedules with providers as does Medicare and Medicaid in the US. I am not aware of any Medicare only facilities. A lot goes into the fee schedule calculations. One such consideration is the level of fee that will maintain a robust provider network (meaning everyone has timely access to hospitals, family practitioners and specialists). Americans pay a little more for that luxury, but that is what they demand. They also demand timely procedures (like breast reconstruction) that are not necessary to life, but certainly nice to have. America is great country and we demand the best.

You know how many people are actually enrolled in an ACA product? 11.5 million. Half of those already had an individual or small group plan before the ACA - and it was more affordable. This whole hoopla is over maybe 5.5 million people. 1.5% of the population. That's it. But wait.....it turns out that a not insignificant proportion of that 5.5 million actually could be on Medicaid or some other govt assistance program; they just don't know it. So it's it probably more like 1% of the population that the nonsense is over. But they are a very very sick 1%. IMO, they should be on Medicare regardless of age. Problem solved. The rest should be allowed to go back to affordable catastrophic care coverage. No one is going to loose their home over $15 or $20K in medical bills. They can set up a payment plan. they could save a little money each month. No one seems to have trouble breaking out the plastic to buy a new big screen TV or smart phone. Save for healthcare issues. And don't be obese. That is the number 1 driver of serious health incidents, both acute and chronic.

The ACA was not a gift to insurance companies - unless you consider contracting herpes a gift too. The insurance companies all lost big bucks getting involved and many of the major companies are now out of the game for that reason. Those still in are cutting way back on the markets that they're in. Beginning next year there will be many citizens mandated to purchase insurance who can't even if they want to. They will default pay the penalty. Wonderful. They won't be happy with either the Dems or the GOP. Trump is in the clear. He wanted to kill the thing as opposed to have it go through a slow painful death.

I totally agree with Jim. Our politicians are craven idiots and I do not trust them to anything correctly or honestly. I sure don't trust them with my healthcare.

I can already hear the responses in defense of mommy govt. NO Medicare is not cheaper to administer. That is a lie based on cooked statistics. In fact 1/3 of Medicare is fully administered by private insurance. The govt made that move years ago b/c it recognized that it sucked ass at administering it. Of the 2/3 still in the federal government's hands, most of the heavy lifting is contracted out to be done by private companies.

The VA seems to be mixed bag.

avedis

Wednesday, August 9, 2017 at 4:03:00 PM GMT-5  
Anonymous David said...

Avedis,

Your first paragraph contains falsehoods. Certainly where I am currently living, breast cancer reconstruction is covered by provincial health insurance. I just checked. The same is true in the largest province, Ontario. I don't really have the time to check the rest. I've already checked two more than you before making that claim, so I think I'm two up there.

As for Obamacare and insurance companies, you're certainly correct that it is an expensive failure. There is an irony in that government cannot even manage a welfare program for corporations correctly, although I suppose all welfare programs are mismanaged in one way or another. Nevertheless the point stands. If a government were serious about universal coverage, the only rational way to do so would be a government program. Telling people (a) that they must get private insurance and (b) that it must fulfill certain criteria is nothing other than creating a state-protected private market for the intended benefit of insurance companies. The Democrats obviously believed insurance companies would profit from their little welfare scheme or they wouldn't have done it that way. Obviously, they miscalculated.

Wednesday, August 9, 2017 at 5:48:00 PM GMT-5  
Anonymous David said...

As for your second paragraph, according to the CIA, there are 2.48 physicians per 1000 in Canada and 2.55 per 1000 in the U.S. Is that the great shortage you're talking about?

https://www.cia.gov/library/publications/the-world-factbook/fields/2226.html

In terms of the Cadillac and the Yugo, this is undoubtedly true. One of the ironies is that Canadian like to brag that their system is a fraction of the cost of the American system. Of course, they could correct all the wait times, but then it would no longer be a fraction of the cost of the American system. Apparently there is no such thing as a free lunch no matter where you live.

Wednesday, August 9, 2017 at 5:52:00 PM GMT-5  
Blogger mike said...

Medicare is great. But it is wasted on us seniors. Why should 65 year olds and above have free medical care for the geriatric aches and pains that come with age, and yet the more vulnerable infants and children and pregnant women have nothing for their care?

I say transfer our medicare benefits to our grandchildren.

They need it more than we do.

Wednesday, August 9, 2017 at 9:14:00 PM GMT-5  
Blogger Lisa said...

mike,


Healthcare should not be an either-or. You paid into it, therefore, you deserve it. Your suggestion may feel beneficent but you may be fairly healthy and have the good fortune to suggest such a sacrifice. We are not talking "geriatric aches and pains" when we talk medical care; Tylenol is good for the former.

Nor should health care be a Hobson's choice.

We are so wrapped by the AMA and Big Pharma, but surely there is another way. The VA has created a sort of hodge-podge, and something of worth could be taken from that, perhaps.

Thursday, August 10, 2017 at 12:14:00 AM GMT-5  
Blogger Lisa said...

avedis,


You are usually witty, but your best two observations here are:


"True, everyone gets a Yugo, but it's still a Yugo"

+

"And don't be obese."


... true that, but awfully hard in a society which aids and abets gluttony in every wicked iteration.

Thursday, August 10, 2017 at 12:17:00 AM GMT-5  
Anonymous David said...

Lisa

Despite my criticism of his facts, Avedis's two remarks there hit at the truth when it comes to talking about public universal coverage if Canada is an example.

In the Canadian system, if you want to provide people coverage equal to the best money can currently buy in America, the cost is going to be much higher than the current American system. Alternatively, you can be proud of having a cheaper system, but then it will deliver a lower standard of care.

Canadians go with option B because it turns out that a lot of people would rather have lower taxes even if it means poorer healthcare. Go figure. Of course, once that decision has been made collectively, then as an individual, you're stuck with it.

Thursday, August 10, 2017 at 7:04:00 AM GMT-5  
Anonymous Anonymous said...

David,
I stand corrected on breast reconstruction in Canada. Apparently it is done, but far less than in the US. In fact, it is only in the past five years that it has been sort of covered. The wait time is up to five years. A woman in the US has it done routinely as part of the mastectomy procedure. In Canada it is not. Many women in Canada aren't aware that it's available. Again avg wait times over two years and up to five years. And overall done far less.

I know for a fact that reconstruction is not covered in the Australian system. Nor in Britain. I had heard about Canadian women having reconstruction done in the US. So I assumed that Canada was just like the other Yugo makers in regards to this particular procedure.

Remember, that is just one of a multitude of examples of care rationing.

How many Americans know that Canada doesn't cover pharmaceuticals? Our leftists believe Canada is a utopia of free stuff. I oppose that misconception.

avedis

Thursday, August 10, 2017 at 7:17:00 AM GMT-5  
Anonymous Anonymous said...

Oh, and not all physicians in Canada are practicing within the socialist system. I am talking about the number of physicians available to those driving the Yugo.

Lisa, good observation on society encouraging eating more to the point of obesity. Everything all the time. Life in the fast lane. That's the USA.

avedis

Thursday, August 10, 2017 at 7:23:00 AM GMT-5  
Blogger Ael said...

Health Care is not the kind of thing that is best managed by "market forces". There are all sorts of information disparities between vendor and purchaser, not to mention the price inelasticity of ones life.

It, like clean water and sewer, is best when coordinated by a centralized bureaucracy. And like everything else, won't be perfect.


Thursday, August 10, 2017 at 7:48:00 AM GMT-5  
Anonymous Anonymous said...

Ael,

Well, comrade, we could say the same thing about education, food and shelter too. And heck, everyone deserves some walking around money too, eh?

Pretty soon, by that line of reasoning, we are communist China of the Mao days.

avedis

Thursday, August 10, 2017 at 8:40:00 AM GMT-5  
Blogger rangeragainstwar said...

To all,
a quik memory. i went to auburn univ for my masters degree.
we had a dr. in town that charged 3$ for an office visit.IMAGINE THAT1

When Lisa sees a dr. she's actually seeing an lpn and then the dr. signs off and gets paid as the person that did the sick call. he has about a dozen such minions and they see a patient about every 15 minutes(being generous here). so u can see how his bucks add up. this is standard practice, and the bills reflect that she saw a doctor , and not a nurse.
the system is thievery.the govt is a part of it.

now for the dva.
i'm in the choice program and its contracted out and the inefficiency is mind boggling.
i won't even write about it because it's so disturbing.i'm 170% service connected and i can't get chiro/with massage for parachute combat related spinal issues.
my va dr. says that i have copd and so i went to mayo because the va wouldn't send me to a pulmonary specialist.
so i get to mayo and i get a 25 yo chinese or whatever breed of oriental womanhood as a consulting specialist.(key word=MAYO SPECIALIST).
the place is slap full of these clones.this is the mayo clinic.
so what do i do?what good is my hard earned insurance whether va or tricaire?(tricare is contracted out also)

SO i just mention all of this as a side bar.
as i always say-it's all pure bullshit.
does any one to include family members of the legislative branches(state or federal)executive,judicial etc... have to hassle to get treated?why/how are they more valuable than us tax paying suckers?
btw-one of my friends said that i wear my cynicism on my sleeve?
how can i do otherwise?
jim hruska

Thursday, August 10, 2017 at 9:34:00 AM GMT-5  
Blogger rangeragainstwar said...

To all,
my auburn days were in the middle 70's.
jim

Thursday, August 10, 2017 at 9:38:00 AM GMT-5  
Anonymous David said...

Avedis,

Try again (again). Breast reconstruction surgery times are typically less than a year in most provinces. I checked my province. Most are done within two months and almost all within six months.

I suppose that's what you get for making "assumptions."

On the quality of progressive ideas about Canadian healthcare, I do wish people would get a few facts straight before trumpeting how good it would be to import to the States:

1.) For constitutional reasons, healthcare in Canada is managed by provinces within their sovereign areas of jurisdiction. So in this model, you wouldn't have universal healthcare from Washington. You'd have it from your state.

2.) Out-of-hospital drugs are either paid in cash or by private insurance. In most provinces, there are coverage programs for seniors (aka Medicare) and low-income (aka Medicaid). In short, this is pretty much the same as the American system already! Drug costs are lower but that is for other reasons, not universal healthcare.

3.) If you want to transfer the American healthcare system onto the public doll, you'll need a corresponding tax increase. Canada cheats on this a little bit by barely funding its military and security budgets, so that in the end the income tax rates come out similar. At least for the time being, America doesn't have that option.

4.) Never mind what's good under ideal circumstances, would Congress be functional enough to do it today? I would worry about that. What happens to the healthcare system in the ongoing debt ceiling and sequestration affairs? I certainly wouldn't want my kids' lives depending on Congress. You?

Thursday, August 10, 2017 at 9:58:00 AM GMT-5  
Anonymous Anonymous said...

David,
I'm not making this up about reconstruction in Canada.

http://ascopubs.org/doi/full/10.1200/jco.2014.56.2793

https://beta.theglobeandmail.com/news/national/canadian-hospitals-struggle-to-cut-wait-times-for-breast-reconstruction-surgery/article32405950/?ref=http%3A%2F%2Fwww.theglobeandmail.com

Maybe your province is superior. Or maybe they just aren't doing the reconstructions and therefore no wait time. Or maybe they're lying with statistics.

The most Leftist state in the union, California, recently floated a proposal to have universal coverage. It was shot down by the voters. If it won't fly in Cali, it sure won't fly anywhere else, except maybe New Yawk.

Jim,
The mode is to have nurses to see patients. The doctors name is on the door, but he's absent. The typical general practitioner nets around $250K/year. That's in small town USA. In a big city they do much better. Specialists net considerably more. Yet they are always complaining that the insurance companies are contracting at such low reimbursement that they can barely scrape by. The practice of medicine is a racket. If not for insurance companies the cost of healthcare would be through the roof. Unnecessary procedures, straight up fraud, sky is the limit prices......insurance companies keep a lid, as best they can, on all of that. I don't trust the govt to do it - state or feds - because the AMA would be bribing them to put more money in doctors' pockets. Also, the politicians would run on expanded coverage. It would get worse than current fast.

avedis

Thursday, August 10, 2017 at 11:20:00 AM GMT-5  
Anonymous Anonymous said...

Jim,
Can you get the chiro/massage at Mayo? Personally, I'd be pretty happy with a 25 year old Asian massage therapist, or two or three.

avedis

Thursday, August 10, 2017 at 11:31:00 AM GMT-5  
Anonymous David said...

Avedis,

According to that article, the wait times vary from six weeks to five years, not two to five years as you initially claimed. So my province would be the bottom end of that. I can guess which one is at the top end, but it wouldn't really matter for this discussion.

All of this comes back to what I was saying about how, contrary to Canadian propaganda and American liberal dreams, there isn't a "Canadian healthcare system." There are 10 provincial systems. If I needed heart surgery, I might be better off in the province where women have to wait five years for breast reconstruction surgery. If I got cancer, I know for a fact I'm better off in this province (which is probably why reconstruction wait times are also lowest here).

I could go on but there is probably no point. Bureaucracy is bureaucracy and federal-state disputes are federal-state disputes. I'm sure you understand how all that works already without me needing to give more details.

Thursday, August 10, 2017 at 11:36:00 AM GMT-5  
Anonymous Anonymous said...

David,
There was another study where the avg wait time was approximately 2 years. It doesn't really matter. I think you make a good point and it's the point I'm getting at. The Canadian system is far from utopia - and it isn't a national system. It's provincially based.

A state based system in the US would result in even greater disparity of care. There are tremendous differences in demographics and resource levels between, say, Mississippi and California. Or New York and Montana.

My larger point is that people thinking that the solution to what ails the US system is a socialized single payer system, are floating around in a pipe dream.

In fairness, so is Trump with his "across state lines" BS. I think I have mentioned that I am an insurance actuary working in healthcare insurance. We rate (set premium prices) based on geography as well as a host of demographic and industry factors (industry when it's employer group based). The cost of healthcare in New York is way more expensive than the cost of the same healthcare in Mississippi. People need to be aware that insurance premiums are not just randomly set; nor are the jacked up to increase company profits. premiums are based on what it costs to provide healthcare services to members. So New Yrkers would greatly benefit by purchasing insurance at Mississippi rates, but the insurance company would then have to raise premiums for the additional cost of care incurred by all the New Yorkers. Mississippi people would lose out. It would be a mess. It's actually impossible, anyhow. I'm just talking theoretically.

Insurance keeps premiums to the lowest level possible so as to compete in the market. To keep premiums low, companies must negotiate the best reimbursement w/ doctors and hospitals, be on top of fraud detection, deny medically unnecessary care/opt for the most cost effective care. Yet competition is also on quality and access. So some of the cost reducing activities gets reversed by members demanding greater access to a greater number of services.

Also, there is something that outsiders don't understand. If we raised premiums to make more profit, not only would the next company undercut us, but we would only attract very sick people that are willing to pay the high premium because they know they are going to be using well in excess of premium in medical cost. That would start a death spiral. We work hard to find the sweet spot. The mix of benefits, access, premium cost, deductible levels, etc. IMO, the free market is working very well to create a superior product that most people find satisfying.

The problem is the poor. Medicaid eligibility levels are very low. The ACA was supposed to fulfill the need for the notch group between Medicaid and employed with employer group insurance or able to pay out of pocket. But it screwed up totally in incentive structure. It fell into the death spiral I mention above.

avedis

Thursday, August 10, 2017 at 12:33:00 PM GMT-5  
Blogger Lisa said...

avedis says,


Lisa, good observation on society encouraging eating more to the point of obesity. Everything all the time. Life in the fast lane. That's the USA.


I would add, the ubiquitous adverts for diabetes meds featuring fat people who "don't have to give up [their] lifestyle" (copy, verbatim) are grotesque. We are totally off the rails as a society. You can be a rutting pig and we'll fix whatever damage you do, that is what the ads tell you.

And it's not only food consumption that's encouraged. To control any of one's appetitive desires is seen as hopelessly parochial in our liberated times.

We enter the world as trolling amoeba's, engulfing every bright shiny bit (add even those not) with our psuedopods, "more for me" being our mantra. As many generation of parents have highlighted consumption as a good, who will teach the children self-control?

Self-control and modesty are superannuated virtues. There are no more MacGuffey's readers. They would not pass muster for the p.c. crowd; they would be disdained or misunderstood by the others.

The capital involved in fixing broke things makes the world go round.

Thursday, August 10, 2017 at 1:27:00 PM GMT-5  
Anonymous David said...

Avedis,

On that we agree I think. I don't you remember you mentioning your profession but thank you for that level of detail.

In Canada, effectively, the problem of differential costs that you mention is "solved" by adjusting the quality of care. I live just north of the Olympic Peninsula right now. In this province, the vast majority of healthcare services are delivered in a couple of urban centers. This makes providing healthcare cheaper, and as a result, wait times are lower. As I said earlier, I think I could guess for you which provinces have the longest wait times, and it would have to do with them having to provide healthcare across larger, less populated rural areas.

I suppose this wouldn't trouble any progressives in New York or Los Angeles, but it should probably give other people pause for thought.

Thursday, August 10, 2017 at 3:50:00 PM GMT-5  
Anonymous David said...

Lisa,

The next generation will learn modesty and self-control via apps on their smartphone.

Thursday, August 10, 2017 at 3:51:00 PM GMT-5  
Anonymous Anonymous said...

David,
The Canadian healthcare I know the most about is in Toronto. The Olympic area is beautiful. My sense is that Vancouver is quite advanced from a socialist perspective (I mean that in a good way).

Yes. Rationing of care is THE ONLY way to keep costs down. At bottom, health care cost will increase no matter what is done. There can be one off solutions other than rationing that will slow the trend temporarily, but then the increases will return. Why?

Because of new technology (I use the term broadly). More can be done for more people and more conditions. Mostly, this technology is not cost reducing. It costs more. Even if were marginally cost reducing (which it isn't) costs would still increase because of the greater volume of utilization (more treated conditions for more people). In the US, insurance companies attempted to cost/benefit analysis on new tech and deny services where marginal cost didn't = marginal benefit. That was still a finger in the dike for the reason I mentioned. However, also, the members (aka patients) complained that "evil" insurance companies were denying critical care. They were egged on by the doctors. Ok. You want it? You got it. We'll just raise premiums to cover the cost (or raise deductible levels to instill a cost/benefit analysis in the patient at the point of purchase - or both).

So, while the socialized system may have lower costs due to rationing, I wonder how long they can hold that pattern. I also wonder how long the US system can forego rationing.

I speak the truth here that no one wants to tell. Not the politicians, not the doctors and not even the insurance company public relations guys. I've been doing this work going on 20 years and I am in the data doing the cost driver analysis, etc. No one wants to make the hard choices. No one wants to show leadership. Jim is probably right. Someone who can lead a fire team against a prepared position just might have to balls to come out and lay the truth on the line and then get something done.

avedis

Thursday, August 10, 2017 at 5:58:00 PM GMT-5  
Blogger Lisa said...

avedis,

Thank you for speaking the truth, and for bringing your considerable expertise to the table.


David,

You are a wit, too, saying, "The next generation will learn modesty and self-control via apps on their smartphone."

Well, perhaps. After they have learned about "adulting". (But per previous, they will many cycles to undo, for being an adult today is no great shakes.)

Thursday, August 10, 2017 at 6:43:00 PM GMT-5  
Anonymous David said...

Avedis

Alongside better "socialism," Vancouver also has one of the most sophisticated private hospitals in Canada. Read into that what you will.

I wish I had this kind of conversation more often, I really do, because the healthcare propaganda on both sides of the border really gets tiresome after a while. Maybe it's coming from an American family or spending a decent amount of time in both countries but I guess I was never properly infected with the "free Canadian healthcare is the best!!" syndrome that is epidemic here and has taken root among some progressives south of the border.

As you say, in the long-term, the problem is cost. To my mind this doesn't get solved if you have a government bureaucracy making the rationing decisions instead of an insurance company's bureaucracy. Both systems are dipping into basically the same pool of new drugs and techniques, so both systems have out-of-control inflation rates. You could raise taxes, but Canadians don't want to pay more taxes. So, you reduce the quality of care.

Plus there's the other aspect, which is that the Canadian system makes innovation almost impossible. There's a reason Silicon Valley didn't get founded in Moscow, and it's the same reason Canada isn't a cutting-edge hub of breakthrough medical research.

Thursday, August 10, 2017 at 7:53:00 PM GMT-5  
Anonymous Anonymous said...

David,
That's a great comment you just made.You're a reasonable and realistic guy. A rarity.

The US system has it's problems too. I know this. Life is full of trade-offs and there's no free lunch. The problem is that we must decide what the trade-offs will be and everyone has a different opinion. An opinion often all it is. Somehow the cacophony of opinions seems to result in brutally slow and bloody progress, but progress nonetheless.

avedis

Friday, August 11, 2017 at 1:09:00 AM GMT-5  
Blogger Ael said...

I understand the distaste for bureaucracies.

However, I would much rather have a collection of bureaucrats bumbling along trying to get the best care out for the most people out of a politically rationed pot of money than be at the mercy of whip smart accountants whose sole goal is to maximize the revenue extracted from me and mine when I inevitably require health care as I age and die.

Friday, August 11, 2017 at 8:56:00 AM GMT-5  
Anonymous David said...

Ael

People familiar with my comments on military and foreign policy here will know I have a pretty practical approach: does a policy solve the problem you want to solve?

The major problem in healthcare is that we are now stuck in a cycle of exponential growth in the costs of new technologies and drugs. The U.S. can't solve this problem by shifting to a public insurance system, and Canada can't solve this problem by shifting to a more mixed market system, yet that is the debate in both countries.

The one area where Canada actively controls prices, as opposed to rationing care, is brand-name drugs. However, it does so by requiring drug companies to pay the average of the American and European markets. Obviously this route isn't open to U.S. progressives. It's only functional in Canada because we're a small market. If, say, the crossborder online pharmacy really took off, our pricing controls would probably collapse.

So that leaves rationing of care. Don't kid yourself, Canada discriminates based on ability to pay at the cutting edge, too. It's just a much sharper curve than in the U.S., because here it's cash-based rather than insurance-based.

Friday, August 11, 2017 at 10:19:00 AM GMT-5  
Blogger Ael said...

There is little evidence that the escalating costs actually improve health care outcomes. Adding money to medical care does not seem to have substantial impacts on our life expectancy.
Also, health care costs increases as a percentage of GDP do (at least in Canada) seem to be plateauing. It isn't as dire as you speak.

Plus, we do have other options.

Go look at how India dealt with HIV AIDS drugs costs.
It is only the political power of the drug companies that protect them from regulators beating them up over their anti-competitive and unethical practices.

Should the prices they charge ever become a serious political liability, I suspect that the regulators would all of a sudden wake up.

Friday, August 11, 2017 at 6:08:00 PM GMT-5  
Anonymous David said...

Ael

I didn't claim escalating costs improved healthcare outcomes. I only claimed costs were escalating! New generations of drugs are incremental improvements on old ones, yet cost exponentially more.

And I have to disagree with you on the plateau issue. The amount we are spending on healthcare is being constrained. That doesn't necessarily mean the costs associated with given procedures let alone any new breakthroughs are going down. It just means we're having to make increasingly difficult choices between a wide range of things that we cannot fully afford. This isn't only a problem for countries with universal healthcare, but universal healthcare isn't a solution to these problems.

As for telling the drug companies to fuck off with their patent laws, that we'll just pay generic drug makers to violate the patents, then that will be the end of new drug research. Canada is small enough that we might be able to free-ride like India is, but if enough countries did this, they'd simply stop making new drugs.

Kind of the way they already have with some lines that we really need research in but are less profitable, like future generations of antibiotics to replace the ones we've overused and misused to the point that they don't work anymore.

Even the generic issue comes with problems. There are routine shortages of drugs now, including life-saving ones, because the generic prices are being driven so low no one wants to bother making them. Again, this isn't a problem only for universal healthcare, but universal healthcare doesn't solve the problem.

Friday, August 11, 2017 at 9:56:00 PM GMT-5  
Anonymous Anonymous said...

" Adding money to medical care does not seem to have substantial impacts on our life expectancy."

AEL, Like the WHO ranking that are often quoted, life expectancy compares are based on apples to oranges comparisons. For example, when is a baby (or new born) that dies, considered to be alive? The US has broad definitions, whereas Europe has tighter ones. Therefore, many babies that don't make it in the US are counted as a dead person, thus greatly lowering the avg life expectancy of all. Whereas in Europe, they are excluded. That sort of thing.

Only 25% of the metrics WHO uses to do its rankings are actually related to healthcare outcomes due to delivered services. The rest is a bunch of Marxist claptrap. Which explains why Marxists are always quoting these numbers.

So much dishonesty in this area. It scares me. I know about healthcare and can easily see the pure BS that everyone is weaponizing. It makes me wonder about others areas where I have less (or no) expertise. I'm sure they're lying there too and I might even be persuaded by some of the lies.

The Marxist are the far worse than conservatives in their propensity for spewing BS as fact.

avedis

Saturday, August 12, 2017 at 1:44:00 PM GMT-5  
Blogger The Mad Dog said...

"Man surprised me most about humanity.Because he sacrifices his health in order to make money. Then he sacrifices money to recuperate his health.And then he is so anxious about the future that he does not enjoy the present; the result being that he does not live in the present or the future; he lives as if he is never going to die, and then dies having never really lived." -The Dalai Lama

Saturday, August 12, 2017 at 10:11:00 PM GMT-5  
Anonymous David said...

Avedis,

What? Statistics can be misleading? You don't say.

The classic example of this is that people think that because medieval life expectancy was only 30-40 years, you were "old" by the time you were 40 in the same way that we're "old" now in our 70s. Not really. Old people back then were in their 70s, too, and the old painted portraits make them look like they're in their 70s.

It's just that the life expectancy was lower because there were a thousand more things that could kill you along the way, usually before you were five.

I don't know if it's intentional dishonesty from those Marxists of yours. From my experience the echo chambers are virtually airtight nowadays. Once a "fact" slips in, it gets repeated often enough that it becomes Truth, and there is no need to go back and check.

Sunday, August 13, 2017 at 12:04:00 AM GMT-5  
Anonymous Anonymous said...

David,
I always hear that the socialized systems are better at delivering health and one of the "facts" quoted to support is that they spend less but have longer life spans in those countries. Differences in infant mortality definitions and to some extent violent crime deaths (murder)and automobile deaths in the US account for the difference in life span. It has nothing to do with healthcare.

Also, note that the quality of health during the life span is not discussed.

You're right about vapor locks on group think and "facts" . It's getting ridiculous.

avedis

Sunday, August 13, 2017 at 7:39:00 AM GMT-5  
Anonymous Nikolay Levin said...

I leave home for a few days and look what happens.

David thinks the Democrats purged themselves and not the American Communists that Stalin self-servingly asked to ally with the scumbug backstabbing Democrats, Avedis thinks Karl Marx rules the White House, and Lisa talks about Soviet agitprop like the Soviets had anywhere near the propaganda budget or even Hollywood profits of America.

To the latter, if you're angry about all these immigrants clamoring for Americas shores you have only the flashy, unrealistic shows and movies of our country to blame. I don't even think the average American can identify with the lifestyle of the average sitcom anymore, let alone a gullible immigrant from a 2nd or god forbid 3rd world country. But if the small and big screen allowed more realistic fiction than it would create serious image problems among its own native population (Sorry David, I also appreciate Trump specifically in sinking approval of American foreign policy all over the world. The more the Imperialist West is divided and in chaos the better chance China could continue to develop the best supercomputers, quantum communications networks and solar-powered aviation and high-speed rail in peace. Western civilization was in decline no matter who was going to be elected. What difference does it make?)

Speaking of which, robust public transportation and a fair economic system might have something to do with Cubas lower violent crime and fatality rate despite being more multicultural than the United States and being blockaded by the worlds most brutal and powerful colonialist apartheid states in history (Israel and the U.S. are the last holdouts to vote to keep the embargo at the U.N., not even America's puppet island nation/nuclear target practice the Marshall Islands could support the unsupportable). But I guess we were talking about healthcare.

Not only will Cuba now lead the United States (and possibly Canada if it doesn't get its act together) in life expectancy because of the increase of suicide, drug (mostly opium) overdoes and spiraling crime rates but simply because their health system does the most for less in the world. It combines the superior coverage of the public option with intensive medical research that allows the invention of medical discoveries that third-world island nations are not supposed to make. Vaccines in dengue, Hepatatis disease, even HIV transmission (the latter completed with some late-stage financing by the U.S., which is why-like China- even Trumpster can only sanction Cuba so much), a cure for vitilingo and revolutionary discoveries in treating foot ulcers, diabetes and cancers. It can't not be disgraceful that Americans, as the BBC courageously reported, have to sneak into Cuba to get affordable treatment for their lung cancer. But then thats what the recent reintroduction of individual travel sanctions are for.

Speaking of disgrace, I don't see how any rational person would find a country that spends many times more per capita on healthcare and yet leads the industrialized world in medical bankruptcies (thats the biggest reason for American bankruptcy by the way) has a better system... unless your healthy salary relies on its survival that is.

Upton Sinclairs famous quote on not being able to understand things that your salary depends on is pertinent here and so I kindly leave Averdis to turn to David and Ael to say that India was forced years ago to can its generic drugs program by the World Trade Organization. Ditto for its budding solar panel industry, scoring one more reason Western "civilization" is the most malignant cancer this planet has ever seen and you see a fundamental systemic problem and not simply political.

Sunday, August 13, 2017 at 10:11:00 AM GMT-5  
Anonymous Nikolay Levin said...

I'd wager that suicide rates in response to capitalism in collapse (for most of those who actually work for a living anyway) don't completely tell the whole picture. My guess is doctors that are required to work in the countryside and even abroad in the most dilapidated third-world capitalist wastelands on the planet after graduation aren't in it for the money, especially when they find out-as you imagine- the highest possible career salary. Watching doctors in first world capitalist countries become glorified drug dealers for greedy pharmaceuticals might have something to do with it too. And I wish it was just the opiod companies. Even absurd medications like Lipitor have been proven not to reduce cholesterol levels. That would require switching to a planet-based diet, something the corporate welfare kings in the hard lobbying beef and pork industry don't want. Thats nothing compared to the sham drugs designed to be frauds just be taken off the market after the damage has been done.

Although I admit that Trump and Bernie both divide America, although they do so by different lines. Trump divides by races to allow the Bourgeoisie (Exploiter class, Billionaire Class et al.) and the labor aristocracy (Corporate lawyers, private doctors and even gainfully bribed *COUGH* *COUGH* I mean paid workers like you and Avedis) to divide and conquer the greater proles. Bernie (and Seattle Councilwoman and ACTUAL COMMUNIST Kshame Sawant) appeals to the Proletariat (probably should be the precariat nowadays though, the gig economies of the magazine salesman, service worker and even temp IT guy) to claw back a slightly larger percentage of the labor they sell to their bosses (I don't think its a controversial conclusion among economists that after noon, in an average 8-hour day, you're basically working for your boss for free until 4 o'clock). The difference is the antagonism between the classes is natural because their interests are inherently at variance. Class warfare is the norm for capitalist societies, its just waged most of the time by the exploiters against the exploited. Sawant, and less the timid Lockheed Martin giggolo and Demo Party sidekick Bernie are just on the side of the exploited class. I don't buy her reformist Trotskyist road will work but she acknowledges that this health care system is the inevitable result of one group of allied people making a killing off of killing as much as the other group as possible. This isn't rocket science. This is the expected unfolding of our stage in late capitalism.

Anarchists like to say that Karl Marx ripped of the hierarchy hater Pierre Proudhon on analyzing this question. You don't have to be a leftist to see that class struggle has been a central element in societies evolution (or deevolution) throughout history. All you have to be to find out is a student of the world. Americas healthcare system proves this as much as anything.

Sunday, August 13, 2017 at 10:12:00 AM GMT-5  
Blogger rangeragainstwar said...

Mad Dog,

Thank you. That is the essence of our damnation.


Nikolay,

Nice to see you back.


--FROM Lisa

Sunday, August 13, 2017 at 3:33:00 PM GMT-5  
Anonymous David said...

Nikolay,

Good to see you again.

I think I will stand by my remarks about Canadian medicare. The system is adequate for what it does, for the most part, but as I've suggested, the real problem at the root of the country's sagging healthcare system is the same as that in the United States, which should not be surprising because they are basically both variants of state capitalism captured by biotech and pharma industries that are, at least for the time being, profiting from a death spiral of unsustainable cost inflation.

As I've already stated, one obvious solution would be to ignore the drug patents, but then you would need to also nationalize all of the medical research, because the private sector couldn't even pretend to supply meaningful advances without intellectual property protection.

There are indeed many malignant cancers on this planet. Sadly, the Soviet Union had an even worse environmental track record than the United States, and so I do not think we will find our salvation from socialism. Possibly there are too many of us now, and global civilization has evolved too far, for the answers to be found in increasingly stale Enlightenment- and Industrial Revolution-era political ideologies.

As for Cuba, I note that in their last national election, only one candidate stood in each electoral district, and miraculously all of the candidates therefore won. A very nice show of democracy. I wonder if their vaunted healthcare system is also a very nice show.

Sunday, August 13, 2017 at 5:58:00 PM GMT-5  
Anonymous Anonymous said...

Thanks, I don't know about you guys but I've been enjoying the beautiful weather. Although with the school year starting up and increasingly successful recruitment among the radical left taking up my priorities, prepare for even sparser posts from yours truly.

If Big Pharma is so insistent on keeping its patents it should be principled and drop its taxpayer-financed government research grants which is still the dominant source of funding for actually discovering medical breakthroughs and drugs. How predictable that leading researchers are citing a collapse in leadership for research and development by the United States linked with the drop in public research funding in recent decades. The private "research" you hear about is mostly clinical trials seemingly designed to commodify what is public as much as possible and such research is now the primary investment of Pharma corporations focusing on short-term profit. Asia (and Europe) is eclipsing the United States in medical research but I should say that Cuba is a unique model for medicine being socialized and exclusively publicly funded. It is simply fact that there is no better medical inventor per capita than Cuba. Which other country with its budget has accomplished what it does? Imagine what the budget of the United States could do with its example?

I don't know how to put this any better than I have in the past. Brazil wouldn't be well on the verge of losing the largest rainforest in the world to violent ranchers and goldminers, Ecuador wouldn't be suing Chevron for catastrophically intentionally negligent polluting and China and America wouldn't primarily be responsible on their own since 1995 in equaling the production of greenhouse gases since the beginning of human history up to 1994 in twenty years if Capitalism didn't knock it out of the ballpark in terms of causes in total pollution and overproduction. Theres no comparison. This was the era of the Chinese Capitalist economic "miracle" and years after the Soviet Union sold off most of its industrial sector, one that was always much smaller than the combined Capitalist West. But then I'm not surprised that you have no knowledge of how Imperialism historically worked and that ecologically friendly economies in the West are maintained by polluted hell holes with no such ecological controls in the Global South.

Wednesday, August 16, 2017 at 8:09:00 PM GMT-5  
Anonymous Nikolay Levin said...

Whoops. That was just me by the way. Continuing on...

Democracy has a funny history when its not protected by oceans or guarded- at great expense to the motherland- by a global empire. Believe it or not the whole world isn't America or Canada or much of Europe for that matter. Greek historians now cite the iron rule of General Pericles as the only era that made a semblance of Athenian democracy possible. French Revolutionaries, Simon Bolivar's liberated republics and even Lenin's Bolsheviks realized that democracy was only possible when nations weren't threatened from abroad, which under Capitalism is never. Lenin before his numerous crippling assassination attempts abolished the Worker Opposition with cheers from the Presidium because even the most democratic of Communists realized division in a time of civil war is suicide. Legendary Simon Bolivar resigned at the height of his popularity because he lost faith in the way democracy in the wake of the Spanish defeat was giving power to demagogues who stir popular votes from ignorance, something we can relate to now. Maybe too much freedom is a bad thing? If CEOs were curtailed in what they were allowed to do perhaps Western Civilization wouldn't be in a death spiral. One thats unfortunately doesn't look to be temporary.
But then you're society would have to be closer to a Leninist-esque socialism to do that.

While the facts are clear that the locally-based Cuban election system, for all its flaws, is still better and getting considerably so than the American system if America still can't find a viable alternative to the most unpopular presidency in recent memory, you should know that Cuba scores the highest on the World Wildlife Federations list of human development coincided with ecological footprint. Investing in urban organic agriculture and a world-class medical care can do that to a country. If I wasn't conceited I might say Cuba is quite the civilizational model for all its sanctions crimping the full realization of its potential. I know you'd prefer your big houses and gas-guzzling cars though David. I just hope you don't have any kids that might curse your decision to do so. Meanwhile, the Americans that pay to have their healthcare done in Cuba aren't complaining much. If Trump hadn't made it harder to do so by expanding the embargo.

Wednesday, August 16, 2017 at 8:10:00 PM GMT-5  
Anonymous Nikolay Levin said...

If you insist on sources, I guess I can oblige.

https://www.urmc.rochester.edu/news/story/4233/u.s.-slipping-as-global-leader-in-medical-research.aspx

https://www.counterpunch.org/2015/10/09/hope-in-abandonment-cuba-detroit-and-earth-scientific-socialism/

https://www.counterpunch.org/2015/09/18/redefining-socialism-in-cuba/

https://www.counterpunch.org/2017/05/16/the-great-acceleration-and-obliteration/

http://www.bbc.com/news/magazine-39640165

Wednesday, August 16, 2017 at 8:26:00 PM GMT-5  
Anonymous David said...

Nikolay,

I detect a slightly angry edge to your comments. That's fine. I'll accept that. I do think I know a slight bit about the history of imperialism, though. It's my day job, in a way.

On patents and healthcare, okay, but the Canadian healthcare system despite being universal is premised on operating within the framework of capitalism and science-based drug development. Doctors are private but paid via public insurance. Effectively all drugs come from private suppliers. That private industry is currently stuck in runaway cost inflation. As I've said, the Canadian healthcare system doesn't offer solutions to the actual problems with the healthcare system because it is embedded within the same system as yours except for some differences in terms of who pays and how.

I suppose you can say the Canadian system just shouldn't care about new drugs, and that will solve the problem. Which ones should we lop off first? The new treatments that effectively cure hepatitis C, perhaps? They're the ones that probably are responsible for the majority of drug cost inflation in Canada over the last couple years, and after all, you've taken the stance that most new R&D is bullshit. If you're going to strip away the patent regime, you're going to have to nationalize medical research, just the same way that if you were going to strip away private insurance, you'd need socialized healthcare instead. Whether the profit motive is chased by American or European pharma companies really won't matter in the long run. The problem is the system.

On democracy in Cuba, it doesn't surprise me that when populations think they are under threat from outside, they are willing to accept strongman rule from someone who promises to protect them. In fact, I'm not sure why you think it WOULD surprise me. I have yet to find a regime that restricts dissent and political competition against the ruling party WITHOUT claiming that this is a necessary check against external aggression.

Wednesday, August 16, 2017 at 11:52:00 PM GMT-5  
Anonymous Nikolay Levin said...

No David, just frustration. You're lack of scrutiny in reading my links and you're woeful memory is what irks me. Don't worry thats not the only reason why I'm trying to limit my posting :-P.

Cure Hepatitis C, huh? Do you mean the drug Sovaldi that costs $1000 a pill in the United States and $4 in India? That pill? Because the cost hikes demonstrate the clear failure of the Canadian and American healthcare systems. Who can afford that besides the very rich, even with insurance? Perhaps Late-Stage Capitalism is finally choking on its Crises of Overproduction just as Marx predicted, among other things.

Maybe you could adopt that nationalized system you so fear and create a cost-effective treatment for the disease like the late 90's Cuban treatment Interferon (which is still around BTW)? But then you'd have to admit that Socialist medicine is the turtle that bests the Capitalist hare in the race. If you read my University of Rochester article carefully, thats simply the facts. Where does it say I said new research and development is bullshit? I just said that even the biggest corporations are a beast that is focused exclusively on short-term profit and are in fact risk averse. The Capitalists continue the farcical lie that business owners take the risks socialists don't and thus deserve to keep their businesses. Meanwhile they politely ask taxpayers to do the risk of the actual fundamental science research and leave the much cheaper trials to themselves. And yet, spending on warfare is becoming so irrelevant in an increasingly nuclear-armed China centered world that record corruption and bank-breaking boondoggles like the F-35 fighter jet have still not convinced the Capitalist class to dump it and accept the changing of the guard inevitable every few generations; I.E. accepting the inevitable dominance of China. They double it down instead, robbing universities of grants to do medical research. And then you have the obvious results.

Alas. Two interesting developments. Charles Krauthammer and if my memory is correct, a Republican congressman believes a single payer system is inevitable-in about seven years. And. A government-financed liver cancer treatment is being sold to a Chinese billionaire.

http://www.huffingtonpost.com.mx/entry/mark-cuban-salubris_us_598b738ae4b0d793738c6463

Take that of it how you will.

Sunday, August 20, 2017 at 10:32:00 PM GMT-5  
Anonymous David said...

Nikolay,

I do not think the Soviet Union invented protease inhibitors. You are, of course, certainly welcome to prove me wrong with one of your famous links, which I promise, I will read.

That said, bendamustine for cancer certainly was a Soviet bloc invention that I believe now goes for something like $10,000 a treatment, so it's not as if you're wholly off base in that critique.

According to the article on which your Rochester press release is based -- you may be interested to know that I read both -- the U.S. share of world research is declining. This is unsurprising in the broader context, since it began far higher and is still close to half of the world. I do note, though, that it's not as if it's America and then socialists. European drug companies are capitalist the same way they are here. Chinese drug research aims for patent protection the same way its American counterpart does. For better or worse, but probably worse, this is the system we live in.

On the Chinese patenting a cancer drug, well, sure. Whether the patenting company is American or foreign, the fact is that limited government funding goes to basic research that may then be turned into a patented drug by a for-private company. I'm not sure whether the fact that in this case it would be going to a Chinese company makes it inherently more unjust to American cancer sufferers than, say, to an American or to a European drug company.

Monday, August 21, 2017 at 12:51:00 PM GMT-5  

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