Thursday, December 31, 2009

The perfect vs. the ideal

Lefties are predictably up in arms about the multi-payer Swiss/German amalgam universal health care bill that has been passed in both houses of Congress (in slightly different forms that will have to go through reconciliation). "We need single-payer!", many cry. There's one problem with that: in all the polls, the Swiss/German style multi-payer system polls higher than single-payer does. As in, 75% approval rating vs. 55% approval rating. And the chances of Democrats getting the spine to choose the less popular option are almost nil, jellyfish have more spine than the Democratic Congress.

So it simply isn't going to happen unless the American people as a whole change their mind. The notion that health care should be a right rather than a privilege has overwhelming support from the American people -- as in, close to 80% support in the polls I looked at. So the Republicans are pushing against the tide in their continual whining that health care should be a privilege rather than a right, there *will* be health care reform that has some measure of guarantee of universal health care for all Americans. But unless more Americans support single-payer than support multi-payer -- and all the polls say this is not the case -- single-payer has as much chance of being passed as my cat has of solving quantum physics problems. It just ain't happen. So we have to look at the possible, rather than the perfect, and try to make it as good as possible rather than the ideal that we'd all like.

There's nothing *inherently* wrong with the basic health care financing architecture set up by the bill. It's not single-payer, but single-payer is not necessary in order to get the benefits we typically attribute to single-payer (reduction in paperwork and claims-processing expenses, reducing in overhead, etc.). Heavily regulating health insurers to limit their profits to a certain percentage, eliminating arbitrary denials of coverage and lifetime limits, preventing them from arbitrarily denying claims, and forcing them to use a common claims-processing center that enforces common claims codes and paperwork across all insurers can get most of those benefits without single-payer. Switzerland, the Netherlands, Germany, and Austria (amongst others) get universal health care this way, after all. The question is whether we're going to regulate the health insurers sufficiently and give sufficient subsidies to the working class and lower middle class to make this setup work. Right now I'm seeing no signs that this is going to happen. We'll have to see, I guess.

- Badtux the Practical Penguin


  1. BT
    My argument for single payer was because I didn't see effective regulations coming from the legislative process that we have, now or in the near future. Done properly there is no reason proper multi-payer can't function fine. As you say there are several models that do just that. But I'm sure that our legislative process will give us regulations that are replete with loop holes for the insurance industry so big you could fly a 747 through them. That's what will make our system only slightly better than it is now and without cost containment.
    Hopefully I'm wrong, but I see no evidence of that.

  2. The only thing wrong with the financing architecture set up by the bill is that it takes 2,000 pages of obfuscation to explain it. This in itself should be a red flag.

    At this point, quoting Maureen Dowd seems appropriate:

    "The minute you settle for less than you deserve, you get even less than you settled for."

    Why should we let the good be the enemy of the perfect? No Formula One team ever won a championship by settling for less than perfection.

    Color me cynical if you will, 'Tux, but I can't help being suspicious of a system that allows a few to reap fabulous rewards at the expense of many.

  3. Uhm, no. The part of the bill that actually sets up the infrastructure would be about 30 typewritten pages if you typed it into a word processor. The "2000 pages" is a) double-spaced lines to allow easy markup, b) very wide margins to allow easy markup, and c) only 500 "pages" of that actually deal with the Exchange and with regulation of insurance companies. The remainder deals with Medicare, Medicaid, and various pork items.

    I haven't read the final copies of the bills as finally passed, but I read previous versions and believe me, it was a) quite readable in a fairly brief amount of time (it would be roughly 200 typewritten pages with normal-sized margins and single spacing), b) in fairly clear legal language that was not in any way obfuscatory unless you are someone who has never read legal language before (I'm quite familiar with legal language because I was in charge of regulatory compliance for a number of educational institutions and had to learn that skill to make sure we were in compliance with the ever-changing Federal and State requirements), and c) is full of pork and loopholes and provisions which weren't well thought out (such as no inflation adjustments for all the numbers! GAH! It's as if inflation doesn't exist in Congress's universe!).

    Well, okay, we know about (c). But my point is that the bill itself makes no attempt to obfuscate what it does. Only fucking retards on Faux Noise and tea partiers who admire Sarah Palin rant on about the size of the bill or claim it's "obfuscatory". It's not. It's a fairly average-sized bill as Congressional bills go, and quite clearly written as Congressional bills go, it says what it is going to do, in plain legal language with no attempts to hide what it's doing. What it's doing isn't always what I wished it did, but at least let's stick with true stuff about the bill, rather than doing the Republican nonsense of just making shit up about it...

    - Badtux the Law Penguin

  4. Count me among those who are not happy about the lack of cost containment in the bill. There are other ways that could have been accomplished. I really think that is needed due to the mandate. The end result of that is that it just gives the insurance companies 30 million new consumers that they can give 20% premium increases every year.

  5. Private insurers pay for under 40% of health care in the USA right now, and have an average medical loss ratio of 10%. What that means is that if they had $0 profit, we as a nation would save a whole whopping 4% of our national health care costs.

    The problem with costs isn't insurers, it's providers. And you're right, we need to address that issue. But first we need to deal with the way that insurers are handling the problem of rapidly escalating health care costs -- i.e., by kicking people out of the system and arbitrarily denying approvals for expensive procedures in hopes that the sick people will die before they have to pay out -- and handle the issue of people who can't afford insurance for whatever reason.

    As for providers, there's an easy way to handle that: Simply pass a law that any provider that accepts any government-provided or government-regulated insurance must accept Medicare rates for all procedures paid for by that insurance. And make sure we have appropriate Medicare rates so that providers will have to tighten their belts rather than keep making us pay for their private jets and third and fourth homes. Doctors don't *have* to accept insurance, after all. They could simply put out their shingle saying "Cash only, please!" There's no reason why some specialists should be making $1M/year or more, other than the fact that they *can* because health care is literally a priceless commodity -- if you don't get the health care you need when you need it, you *die*. It's literally "your money or your life", more akin to highway robbery than anything resembling a free market...

    -- Badtux the Healthcare Penguin


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