Conservative-liberal convergence on healthcare?

Great Debates
21

My main beef with this is that it ignores a large part of the problem- that Americans are spending more per capita for health care than people in other countries are, and the amount we are spending per capita is increasing faster than inflation. It’s expected to be $12,782 per capita by 2016, 20% of GDP. Unless we rein in those increases somehow, no system of providing coverage will be viable in the long term. I don’t see anything in your system to address that problem.

A single-payer system could help with that, because then there’s an entity that has a lot of negotiating power with drug companies, hospitals, and others who set prices. AIUI, that’s why Canada, the UK, and other countries have lower health care costs than we do.

22

Just out of curiosity, are there any liberal healthcare reform plans that wouldn’t result in further income redistribution? Or is that integral to all of their proposals?

23

Do you mean further from the income redistribution from the middle class to the rich that we’ve seen the past 7 years? Or the income redistribution from those who don’t get sick in a year to those who do?

24

Part of what makes our system so expensive is the insane fragmentation of the payment mechanism. Streamline that, and you’ve made at least some headway on cost. Having a single party (the federal government, in my proposal) contracting with the insurance companies gives the government a lot more tools to manage cost. And I think part of what makes it so hard to contain cost these days is that there are too many actors, too many perverse incentives, and too little public attention. By getting the (huge) question of coverage off the table, you free up policymakers’ energy so they can focus on cost. And having a single ultimate payer means that the feds can compel insurers to focus on known best practices, most of which end up saving money.

25

You’ll have to explain better what you mean. Are you saying the plan I proposed redistributes income?

26

I don’t like to think of universal coverage as conservative or liberal. I think of it as an act of decency from a government to its people. If that makes me a socialist, so be it.

Robin

27

I’m not sure I completely understand your plan. So the individual chooses a plan, and the employer (or the employer and the government together, for small businesses) pay for it? In this case, wouldn’t there be an incentive for each employee to pick the priciest plan possible, since someone else is footing the bill? Employers would of course reduce wages, and every employee will get more healthcare than they know what to do with.

28

Basically the government would mandate a minimum plan – similar to what most HMOs offer today-- and they would pay a set amount for each covered person. Any insurer willing to offer the minimum plan for this price could participate. Insurers would be free to offer more than the minimum, in the interest of actracting customers (i.e., insurees).

Employers would not reduce wages, because they would pay, per head, about what they’re paying today, and they would save money through not having to administer the benefit.

29

Well, the only reason I asked is because I’m still waiting for a conservative to weigh in and say, “No, by all that’s holy, your plan would violate the Seven Sacred Principles of Conservatism!” Until that happens, I’ll assume that conservatives don’t have any major ideological objections to the plan.

30

I would be generally characterized as a liberal and I LOVE Becker’s proposals (linked ti in post#7. My only tweaks would be to eliminate cherry-picking - same product same cost no matter who you are, and to add the government provided option as one of the choices that people could opt into - choosing to sign up for a Medicare style plan if it turns out to be cost competitive for the quality provided.

It is a much more dramatic shift then anything Democrats are proposing.

31

Well, I’m a liberal, and I hate Becker’s proposal. That whole business about tax credits and HSA’s drives me absolutely bananas. It means that every year, you have to gamble about how sick the family plans to be in the coming year. “Eldest daughter, are you planning on having appendicitis this year? No? Will you break your leg skiing? No? You’re not planning on becoming depressed, I hope?” Etc. And of course every time there is gambling, there are winners and losers. Guess wrong on how much coverage you need and you end up in bankruptcy court. And as always, the people making the riskiest gambles are the least well off.

As a practical matter, I also distrust plans that create uncertainty in everyone’s mind about who is covered for what. I hate the notion that when you’re confronted with illness, you have to decide – or your insurance company has to decide – whether it’ll end up being “catastrophic” enough that it gets covered.

Now, whether Becker-style plans are broadly unacceptable to liberals, I can’t say. I’m inclined to say yes, not just because of their messiness, but because there’s a strongly regressive component to them. I don’t doubt that most conservatives would prefer Becker-style plans, but the question as posed to conservatives in the OP is, “Can you, as a conservative, live with, and even embrace, what I’m proposing as an alternative?”

32

I don’t know how many have flexible health spending accounts available, but every year we go through exactly what you describe. It’s a bit stressful, but in this case all that is at stake is tax advantaged money. In my bracket this is useful, and I have enough to contribute every month, but there are lots of people who wouldn’t get much of an advantage at all.

Catastrophic coverage would help keep you from bankruptcy, but without real reform I suspect the threshold would keep increasing to save money.

33

That’s basically the system we have here in Israel, except for a few tweaks:

  1. The money comes from Social Security.

  2. The insurers are free to offer supplementary insurance - a better plan - for additional pay.

  3. Insurers cannot refuse anyone who wishes to join the government-mandated plan.

It seemes to work just fine.

34

As I said in the linked thread, I would favor some sort of system in which the government’s role was essentially to pay insurance premiums so that everyone is covered, yet still allow everyone to pick and choose their insurance companies and doctors themselves.

I’ve always opposed government provided health care not because it’s socialistic, but because I’ve felt it would provide substandard treatment - complicated by a maze of bureaucratic red tape - in which people largely had no say in their treatment and the options that were available to them. I also felt that without competitive market forces in play, hospitals, doctors and nurses would have little incentive to care about their charges. Does anybody remember the old Carol Burnett skit in which everyone applauds the robber of the phone company (back when it was a monolith), whose motto was “We’re the phone company…we don’t care 'cause we don’t have to!”? This is how I’ve always envisioned health care under a government-controlled system.

Secondly, I’ve had concerns about the effect of government health care on the motivations of people to become doctors since they would essentially just become government employees. Where would be the incentive to study and work and slave and continue to keep up once in practice, when you have virtually no control over the amount of money you’ll make and how you’re allowed to treat your patients? Thus I’ve always envisioned a future of substandard, only adequately trained, and ill-motivated doctors basically just slogging through their days in order to receive a paycheck, with little real concern over their individual patients because to have such concerns would only be an exercise in futility. Better to disconnect from them emotionally and just do your job…after all, where else they gonna go?

Third, I’ve been very concerned over progress in the development of new drugs, machinery and research under a system of government-provided health care. I’d be very surprised if one-fifth of the advances made in medicine over the last two decades would have occurred had government been financing and/or supervising it.

So it seems to me that the ideal solution would be to try to come up with some sort of a system in which the government provides health insurance for its citizens in much the same way that employers do, but otherwise stays out of it. This will still allow competition and market forces to allow patients autonomy in the selection of their doctors and hospitals and treatment options; it would continue to provide doctors the emotionally rewarding ability to treat patients in the way that they feel is best while still allowing adequate compensation for their hard work; and it would allow for unhampered research and development of new medicines and technology by private enterprise.

Also, under the scenario that I propose there would be no need to have the system tied to employers at all. Everyone would be automatically covered and the insurance costs paid out of a government-collected fund created for this purpose, similar to FICA deductions and payments in regard to Social Security. This would allow for equal coverage for everyone and should keep class-war considerations out of the equation, though I do believe that anyone who could afford to pay out of pocket for treatment or options not covered should still be allowed to do so.

Now, I’ve just come up with all this off the top of my head and I’m sure there are plenty of holes in it…but it does, I think, provide a pretty good explanation of the type of health care I’d like to see in an ideal world and why I’ve objected to government health care up to now.

35

Lily Tomlin. Besides that, I agree totally. Plus, the transition would be horrendously complicated and disruptive. But all in all, you’ve offered an excellent example of convergence.

I believe a substantial amount of research in this area is government funded now, but I think clinical trials might become more difficult. Would research physicians work for universities or the government? I think the basic research wouldn’t be affected all that much, but the reduction to practice might be.

36

You don’t really know how HSAs and catastrophic insurance works, do you? You save money, tax free, in an HSA to spend on any health care needs you have that year. If you don’t use it, you carry it over to the next year. If you have a huge medical expense, that’s why you have catastrophic insurance.

In fact, it’s much better for people than regular insurance, since with regular insurance you do actually take a gamble that the one or two policies you can buy through your company actually covers your catastrophic medical condition. With catastrophic insurnace, you may be out the $5000 deductible (although you can use your HSA funds to pay for it) but you won’t be out the, say, $100,000 you need to cover the operation.

Again, you don’t really seem to understand what “catastrophic insurance” means.

If you support government-run health care, you have the type of uncertainty which you dread. As long as you have a third-party (whether an insurance company or the government) paying for your care, they will have some say about how or even if you receive it. There is only a finite amount of health care that can be dispensed. There has to be some way to ration it. If a third party is paying, they are going to do most of the rationing. The only way to eliminate that uncertainty is to give consumers more control over their health care dollars. At least then the person consuming the health care decides if the procedure is worth it, not someone in an insurance company or a government bureaucrat.

37

Thank you Renob, for correcting one of Sal’s mistakes, I’ll take the other one (And really, shouldn’t you know how something works before you sound off against it Sal?).
What’s wrong with tax credits? Single folks get a $7500/year tax credit, families $15000 to pay for health insurance. Except in some limited areas where government interference has completely fucked the health insurance market beyond recognition, that’s more than enough to cover very, very comprehensive health insurance. I’ve been in this industry for 10 years now, and I have never sold a policy to a family that costs more than $1250/month. The biggest problem is that premiums are going to go up-if the government is giving $1250/month to pay for health insurance, premiums are going to rise to that level. Tax credits are the easiest way to provide universal coverage because the government, through the credit, is now paying for health insurance for everybody.

Also, to augment what renob stated, what’s so “uncertain” about what’s catastrophic? HSAs are blindingly simple. Yearly medical costs below a certain amount (no more than $2600 for individuals or $5200 for families) are paid by the individual, costs in excess of that are payed by insurance. At the same time, you MAY (but are not required to) open a savings account to pay these out of pocket costs and each year you can put up to the amount of your yearly deductible in that account. Any money that goes into the account is tax deductible, it usually earns interest (unless you have a bad bank), it rolls over year to year and at age 65 you can withdraw any money left in that account under the same basic rules as those that apply to IRAs. Where’s the uncertainty? It’s simple, cheap and fair. I just helped a 64 year old man get onto the MHIP HSA, and his premium is only $190/month, far, far less than he would pay for “traditional” insurance.
In fact, consider this example: Marry HSAs together with the tax credit, and what have you got? IF the tax credit were in place now, my client would be paying almost 2300/year in health care premiums, he has a maximum yearly potential out of pocket liability on medical expenses of $2600 (probably not separately deductible anymore with the tax credit in place), for a total out of pocket cost that can’t exceed…$4900/year, for which the government gives him a tax credit of $7500. By God, look what we’ve done! We’ve created health coverage paid for by the Government! Play with the premium numbers slightly to allow coverage for everyone regardless of pre-existing conditions(and there is room for the premium in this example to double and still be 100% covered by the tax credit), and damned if we haven’t just instituted universal health coverage, following generally conservative principles, WITHOUT the government controlling a single damn aspect of the patient’s care. Son of a gun, how about that?
And Voyager, the line I quoted came directly from the linked article, maybe you should read links in full before claiming that they do or do not say something?

38

Not sure about that one, Voyager, as I’m unfamiliar with that aspect of medical research. To my (admittedly layman’s) mind, most of the R & D that goes on in medicine is carried out by pharmaceutical companies and the manufacturers of diagnostic/treatment equipment.

39

We bought our first house because my wife worked on Tagamet, and knew it was going to be a winner. These companies do some basic research (pretty badly, since the big ones seem to have to buy new ideas from the small ones) but most of their R&D budget is spent putting new ideas from government funded research into practice, getting it tested, etc. That’s no small job. Companies can no longer afford to take big research risks (even getting it through the FDA is a big risk.) The split between government support for far out stuff and industry support for productization is a good one, and I don’t see it changing even in a government run system I’m against that, for other reasons.

40

As I mentioned, I use a flexible spending account, for the tax benefits. I’m sure your clients have enough income to make this a good deal. But consider the people who can’t afford insurance now. If they aren’t paying a lot of taxes (and these aren’t people on welfare, who are covered) the HSA becomes basically a savings account. We also have the problem of medical bills, under the limit, hitting them before they build up enough in the account to cover it. This thing helps people like you, your client, and me who are okay anyhow. It won’t help the people who might get driven over the edge by big medical bills.

I read it a third time. They say

  1. Break the link between employment and insurance. Not unreasonable.

  2. Do HSAs.

  3. Medicare is a growing problem. Improve drug coverage, reduce the support for long hospital stays. Both reasonable, but I doubt this is going to save a lot of money, since hospitals have long since stopped being hotels. My father, at 89, had a heart attack and a double stent inserted. He was in the hospital for two nights. At 45, after a blood clot, he was in for months.

You quoted the part about extending Medicaid to cover the catastrophic insurance. That’s fine, but it doesn’t cover preventative care (Ms.Robyn mentioned Medicare, not Medicaid, which threw me). It looks like catastrophic coverage will happen (required of everyone, I hope) so that is a point of convergence. Handling people for whom big bills will be a problem is something else. And thus I withdraw my withdrawal of my objection.