Ms. Ocasio-Cortez, on How to Pay for Medicare for All

The BBQ Pit
481

No it isn’t.

All correct.

Incorrect. Obviously.

Good thing I never said that, isn’t it?

Unless you want to read “we need to cut health care costs” as saying “we can’t cut health care costs”, in which case there is no hope for you.

OK, I pick Canada. How will adopting Canada’s model allow the US to reduce its health care spending?

As I said above, make your case. What cuts are we going to make, where will we make them, and how will you get doctors and nurses and technicians and hospitals and drug companies and people currently on Medicare and people with private insurance and everybody else to accept them? Please be specific.

Regards,
Shodan

482

You argue without justification that the first derivative of healthcare costs are the best predictor of their future path. Why on earth is that more relevant than the level of healthcare costs, especially when they are double what they are everywhere else in the world? Your logic is like a naive Bitcoin investor - it has always gone up in the past, so it must always continue to go up; valuation metrics are irrelevant.

Again, an argument based on the first derivative of healthcare costs, rather than their absolute level.

I’m not going to argue specifics with you unless you justify the basis for your position that it is impossible for America to achieve an outcome that’s closer to what every other country in the world has done. Pretty much every other developed nation has some form of universal healthcare at less than half the cost of the U.S., with substantially better outcomes. Yet with dozens of model systems to pick from, you think it’s impossible for the U.S. to implement UHC without even (say) a 10% reduction from current total expenditure?

Why can’t we do what Canada does? If you’re going to throw realpolitik obstacles in the way, then it’s a self-fulfilling argument that it “can’t” happen. If we don’t have the will to do something, then of course we won’t, just like gun control. But don’t conflate unwillingness to do something with impossibility.

483

The same way it allows every other country that operates universal health care to do so. Market forces - you know, those things you’re meant to be in favour of.

Right now, you’re being played like an absolute fucking chump. You raise more money per head for healthcare on taxes than any other, but you don’t bother to use that huge purchase power to command the best deal. Seriously, for a supposed right wing capitalist, you suck at this.

Instead you turn around to the market, and advise them that as the biggest game in town you’re expecting them to sharpen their pencils if they want some of YOUR money. Buyers market, old man. This is capitalism 101 shit. It’s almost embarrassing that you need a European to explain this.

Explain firmly, but gently, that advertising for pharmaceuticals aimed at the general market is banned. Honestly, why do you think that an advert is a good basis for you to suggest to your doctor the drug you need? Tell the market what you’ll pay for drugs…you can even copy the pricing structures other countries have agreed that somehow Pharmco manages to turn a profit at. Have a little think about the current mechanisms where companies can evergreen patents for medication.

484

The Republicans would have you believe that as the largest and most diverse health care market in the world, we are simply unable to negotiate as good a deal as the smaller, more monolithic markets in Europe or Asia.

Of course, they also think Trump is a good negotiator.

485

Is your claim here is that doctors expend more resources on medicare patients than they get reimbursed for? If so, please cite.

486

That really does appear to be Shodan’s position.

“They make so much profit of us, there’s no way we can stop spending so much on it”

It’s right up there with the way republicans embrace socialist principles when it comes to military expenditure for sheer cognitive dissonance.

487

Yup, socialist defense, funded out of taxes. It’s the kind of thing you’d expect from Scandinavians or the French.

488

I don’t hold that position, and have not stated that it is my position. No justification is necessary.

Now that we have cleared that up, feel free to argue specifics.

This strikes me as a dodge. You won’t justify your position until I justify a position I don’t hold.

We could indeed do what Canada does. Will this involve cuts to health care spending? Where will the cuts be made, how much will we cut, and how do you propose to persuade all the groups I mentioned to accept the cuts?

Regards,
Shodan

489

Glad we got that settled.

Does Canada spend less than we do?

Since you have suggested that we can do what Canada does, then you should already know the answers to these questions.
The non-snarky reality is that the work effort to get us from US —> Canada (or whatever other UHC plan we crib from) is SUBSTANTIAL.

If I suggested that we should build a new train tunnel from NYC to NJ, and we all agreed that it was a reasonable transit plan, and likely a manageable engineering project (since we have multiple tunnels already), asking me exactly where the entrances will be, and how we’re going to get permission to dig is not a productive line of questioning. Those are details that need to be worked out, MUST be worked out for the plan to be successful, demanding those details before the work is done to actually plan the thing is ridiculous.

The amount of care and work that needs to be done to plan the redirection of 8% of our nation’s GDP away from one industry and into other industries is HUGE. None of that work can be done until we have a consensus to do the job, and have both sides of the aisle interested in getting to the end. Right now, we have one half interested in fixing the problem, and one half interested in sabotaging whatever plan is attempted.

490

This is disingenous. If you agree that a Canadian-style system is possible, then we have no argument of principle, do we? If you’re sincere about your claim that you do agree it’s possible, then this debate should be restarted in a new thread entitled “We all agree that Canadian-style UHC is the objective. What’s the most efficient technical implementation for a transition?”.

If you agree on the principle, what are you suggesting hinges on these specifics? Of course reducing expenditure from 18% of GDP to (say) 15% would involve economic pain for vested interests who profit from the profligacy of the current system. But if, as you claim, you accept that it’s perfectly possible to do what every other country does - provide better health outcomes more efficiently with UHC funded from general taxation - then the only real obstacle is the political will to do so.

Ultimately, your argument can only circle back to the same thing. We can’t do what every other country on earth has proven is possible.

491

This is the point! We are talking about a metaphorical world where only one person is obese, and no one has ever been able to lose weight. So to say that the one obese person can just do what the others do does not make sense.

492

I’ve already pointed out the two rather obvious logical fallacies to this line of reasoning.

The first is that you are arguing that precedent for the first derivative of the value is more relevant than the value itself. Why should that be so? Even though US healthcare costs at least double what it costs in any other country (for worse results), you’re arguing that the rate of change must always be positive simply because the historical rate of change has always been positive. That’s analogous to arguing that Bitcoin must always continue going up because it has always gone up in the past, regardless of any valuation metric.

The second fallacy is that you’re claiming that since nobody has ever been in this condition before (obsese), there is no precedent for a specific subsequent set of events (losing weight). But if nobody has been in this condition before, there is no precedent for any subsequent set of events. No country has ever spent 18% of GDP on healthcare. So there’s no precedent for subsequent healthcare costs subsequently falling to 16%; but there’s also no precedent for them rising to 20%, and no precedent for them remaining unchanged. Does that imply that none of these things can happen?

493

The fat person can lose weight. The skinny people cannot.

How is that an argument that the fat person should actually *resist *going on a diet?

494

Yeah, I’m a fan of the big lie. Specifically, I like to claim that if the cost of something goes down you don’t have to pay as much for it. Shodan, demonstrating his oft-discussed intellect, saw the logical inconsistency immediately.

495

Are you suggesting nobody has any Regard for Shodan’s intellect?

496

I have very specifically not argued that. I have in fact said I think we can and should reduce the rate of increase, which maps to the first derivative. You are arguing for making that first derivative not just smaller but negative, and in fact a negative number with a very large absolute value over a short period of time, and you don’t really have any evidence for what that would do to health care delivery and to the U.S. and global economy, because there is no precedent for it.

No. This is either incredibly naive, or disingenuous.

Here’s what I would consider a better analogy, in part because it actually does involve decades of growth (managed vs. not) and public policy.

Are you familiar with the Urban Growth Boundary (UGB) in Portland Oregon? The UGB was a wonderful progressive policy begun nearly a half century ago. The result has been an avoidance of the kind of sprawl seen in other metro areas. Areas outside the UGB line are still green, and the areas inside the line are more carefully utilized, avoiding the kind of “hollowing out” we see in a place like St. Louis, where there are a lot of abandoned warehouses and weedy vacant lots.

So let’s imagine the electorate of the state of Missouri became progressive enough that they wanted to emulate Oregon (this is a stretch as things currently stand, but let’s just go with it for the sake of argument). What you are doing is the equivalent of such a Missouri government declaring “We want to make St. Louis just like Portland, so we’ll just ‘do what they do’ and it will be all taken care of, simple as that.”

But of course in reality you could draw a line on the map around St. Louis and it wouldn’t magically eliminate all the subdivisions and strip malls outside that line, not to mention all the highways and surface roads and other infrastructure. Would you go in there and tear all that stuff down, bulldoze it, and start planting trees in its place? Where would all those people go? What about all the jobs at those shopping centers? Who is going to pay for the massive cost of trying to retrofit a sprawled-out metro area to make it like Portland?

What I would argue is that you can put a UGB around the extent of St. Louis’s current metro and in so doing prevent it from being even worse in another fifty years. And you can work on incentives to make people “fill in” residential space inside that UGB, maybe even slowly offer incentives for the furthest exurbs to convert to being “greener”. But you can’t just “do what Portland does” and get the same thing now that they only have as a result of a long process of making smart urban planning choices since 1973. In a way, it would be kind of unfair if you could, right? Portland and Oregon kind of deserve to have something better as a result of good foresight, don’t they?

497

What was the point of that diatribe? As an example of “two things that are not the same”? Good grief, what a ridiculous straw man. Why not just go with an apple and an orange, it would have been quicker.

If only one country - say Italy - had cheaper healthcare, while most other countries were similar to the U.S., then your analogy might be apt - perhaps Italy really is quite different from the U.S., and “just copy the Italy model” might be naive. But every other country has better healthcare for half the price or less - in a huge variety of countries, with many different implementations of UHC. The U.S. is certainly not so fundamentally different from every other country on earth that our healthcare must be twice as expensive for worse outcomes. We are just doing it wrong.

Of course I don’t mean literally just pick any country at random and copy them naively. My comment was a rhetorical response to the constant special pleading that any kind of change in the U.S. won’t work, or the ridiculous claims that UHC funded from general taxation will make healthcare more expensive. The point is - other countries have proven records of doing this better than us, and our general approach should be to study and learn from other countries, figure out how their systems work, and apply those lessons to the U.S.

498

I find your logic not only unconvincing but kind of bizarre. For a country to be the only one to successfully do something often only means it’s first. Someone was the first to expand suffrage to women, someone was the first to mandate a minimum wage, etc. It is THAT situation where the presumption should be that others can emulate it. Yet you say that’s the one where you might throw up your hands and say “I guess only they can do it”?!? WTF

My analogy with urban sprawl and a UGB is not apples and oranges. It is actually quite apt. Decades ago, progressives saw that a system was growing in a huge, ugly, chaotic way that had negative externalities and wasted resources. They reined it in and kept a cap on growth that has made their system quite different and superior today from one where the growth was left to go unchecked. Now, tell me: am I talking about the UGB, or the NHS? It could be either.

499

So if only one other country had already successfully implemented UHC funded by general taxation successfuly, for half the cost and with better outcomes, you’d be willing to try it in the U.S. But when nearly all other countries have done it… you’re adamant that it won’t work here?

And you claim my reasoning is bizarre?

500

Straw man.

I’m adamant that we can’t just adopt another country’s system this late in the game and expect that it will get our costs down to parity with theirs. (If only a single country had done it, it would presumably be a fairly recent change and therefore “emulateable” in the same form.)

I’m *not *adamant that we can’t have a universal health care entitlement here. I believe it is a human rights imperative that we do. But we need to be more realistic about the cost and therefore aim for a more modest scale. A HDHP/HSA entitlement would be far more affordable, less disruptive, and would not spur most people to use a lot more medical services. And it would not mess with people who have more generous health coverage through their employers.