The U.S. sometimes brands itself as Land of Liberty (TM). Obamacare cut that way back for individuals and employers, who were now required to purchase products from the insurance industry (and therefore, indirectly, from the U.S. healthcare industry), even if they didn’t want those products. Health insurance companies lost the liberty to deny coverage to those with pre-existing conditions, right? But they retained the liberty to withdraw from the Obamacare exchanges and write coverage only to groups?
What about this latest bill? It seems to restore liberty to individuals and employers, but does it take away liberty from insurers? Are they now required to sell insurance to people who are already ridiculously sick? Or can they withdraw from the individual market, at least, and say “we’re only underwriting groups”?
Neither Obamacare nor the new proposed system gives an American living in State X the liberty to purchase insurance from a company in State Y, correct?
I’ve scanned some news articles and Facebook and nobody seems interested in this perspective. Does that mean it is the wrong perspective? Another thing that seems missing from the articles is the idea that we could spend money on something other than health care. If we spend 17 percent of GDP instead of 20 percent, for example, there are mostly “losers” who don’t get certain health care services. There is no discussion of how Americans might be “winners” because now we have 3 percent of GDP to spend on things that we value more than these additional health care services. Less spending = more losers.
Related:
- my 2009 health care reform proposal (kind of similar to the UK, except that the government doesn’t run hospitals/HMOs directly; citizens don’t have the liberty to refuse to pay taxes, but they do have the liberty to buy whatever health care services they want if they don’t like what they get as a default from the government)
The problem is always Trump. People on your facebook feed hate him so much they think anything he does is wrong or bad. Funny thing is people were making fun of him last week for not repealing Obamacare. They used it as an example of how Trump cannot get anything done. Now those people are whining on facebook about how Trump wants to kill babies or some such thing. Most of these people don’t use obamacare and get insurance from their jobs or unions. I am an Obamacare user. I have a silver plan and it is absolutely horrible. My premiums are 3 times what they were pre obamacare. Last year I had a health issue and learned my insurance didn’t cover many many things. Cost me an additional 10,000 dollars out of pocket. My pre obamacare plan would have covered most or all of this. To sum it up, I am being forced to buy a non working product from a non working website at great expense. That doesn’t sound like liberty to me Phil!
You have, on multiple occasions, pointed out your friends on facebook are the most illuminated and benign cognoscenti. Thus your perspective is clearly wrong.
Since the days of Saint Reagan physicians have not had the liberty to turn away certain patients even if they cannot pay. Nobody has seriously considered restoring that liberty to them. I would guess that most people are more concerned with whether the new law affects their ability to obtain medical care if they need it than how the law affects their “liberty”.
I doubt that many people who lose Medicaid coverage or health insurance (due to lower premium support) if this new bill passes will be stupid enough to consider themselves “winners” because other (richer) Americans end up with a nice tax cut out of it.
@toucan sam: I won’t dispute your description of your Obamacare policy as “absolutely horrible”, but pre Obamacare anyone in the individual medical insurance market with a serious health issue would have faced devastating premium increases at their next renewal time.
I think that absence of promised cross-state sold insurance could be due to insurance companies lobbying efforts, not sure. But if enabled, could it cause insurance companies from states that spend more on health care driving insurance companies in states with less health care spending out of business and then increasing premiums in cheaper states? Extra spending could be due to extra regulation and does not necessary mean better healthcare. I am pro cross-state insurance sales but since states manage health care differently (and they should) and states are big healthcare spenders it could be complicated.
The answers to some of your questions somewhat depend on what you mean by liberty… Freedom from vs freedom to.
Regarding the UK plan, I lived in the UK recently for 1 year, and when I suggested to neighbors that we use a private hospital for the birth of our daughter, they strongly recommended against it. Since most of the country was on NHS, only NHS hospitals could afford expensive machinery – in case of unforeseen circumstances, the private hospital would “ambulance” patients to a (better equipped) public hospital.
Effectively, public hospitals will end up buying all the latest and greatest, and the budget-constrained private hospitals, which need to charge a lot for this equipment, will not be able to cover their costs (as patients in need will simply choose the less-expensive public hospitals in these cases), and eventually stop buying them. FYI, I did not read your paper, just want to point out this comment.
Talking about liberty and freedom in relationship to healthcare is nonsense. Just like talking about liberty and freedom in relationship to driving laws, or flying laws.
You have some driving liberties and freedoms, but you are not at liberty to drive a new car with a gas tank that is designed like that of the Corvair. Just as United Airlines is not free (or at liberty) to fly a plane anywhere it wants, any time it wants.
I have used the UK health system, and while it is not perfect, it is at least as good as we have here in terms of benefits and facilities, and way better than what we have here because everyone is covered. The emergency rooms are empty because everyone has a primary care doctor. The drugs are free for kids, and reasonable for adults. And the average American (up to at least the 95% quartile) would be much better off with a UK style system.
That’s a good point, FL. People in the UK (and every other developed country) live with the peace of mind that health care is available regardless of how much money they have in the bank. Very few would prefer the “liberty” that we Americans will enjoy if this bill passes the Senate and is signed into law. In addition to that, the British pay 40% less than we do for health care.
Why is it nonsense to talk about liberty with respect to laws or regulations? Please explain. Bureaucratic regulation is hardly the bedrock of motivation.
My experience with single payer health care (Sweden) is that you normally end up stuck in queues with appointments weeks apart in different places. It’s definitely more the case that hospitals share equipment and personnel over a region than the case that all public hospitals have a lot of fancy equipment. It can be quite time consuming to pursue your complaints. (I had an anecdote here about my parents, but I’ll skip it.)
Our yearly amusement is when the centrally planned system runs out of beds in the maternal wards and women in labor get transported to various remote hospitals in panic. You had nine months to plan this, girls. (The health care bureaucrats are usually women.)
Well, Vince, more precisely we live in the complacent knowledge that access to a health care queue is available. You can too, just migrate to Canada and enjoy it to the fullest.
Tom
We don’t want you up here. The weather sucks, there are too many mosquitoes and black flies, and you can’t bring your guns. Gas is more expensive and the dollar is in the toilet. We have long wait lists for elective surgery, and you probably won’t make a buck if you’re a cosmetic surgeon. So don’t even think of crossing the border. We’re already working on the wall along the 49th.
We value “peace, order and good government” over “life, liberty and the pursuit of happiness” so you’ll be miserable and have no freedom.
So basically, you’re all screwed. Until you can elevate health care to a right of at least equal stature to the right to keep and bear arms.
@Tom: Although many Americans do not have particularly convenient access to care, it is true that for most Americans (especially people with expensive fee for service insurance coverage) access to care is more convenient than under other systems. Of course, dealing with the complex billing/coverage system may offset at least some of that advantage. More importantly, the excess capacity which makes this possible (present for several reasons) is one of the cost drivers which makes American health care more expensive than in other systems. Therefore, making American health care less expensive, which this posting implies Americans should do instead of complaining about winners and losers, will almost certainly involve trading away at least some of that convenience.
While I don’t think it makes sense to complain about people focussing on winners and losers in the context of discussing legislation which mainly creates winners and losers, I do agree with the implication in the posting that, ultimately, bringing the overall cost of U.S. health care under control is the more important consideration.
There are three basic approaches to financing health care:
1) Single payer
2) Obamacare/Republicare
3) No money no care (free market)
Choice (3) is the one which maximizes “liberty”, but no one wants to go there. The two choices currently under consideration (Obamacare/Republicare) both involve significant and similar restrictions on liberty. This is why the analysis of “liberty” is not receiving much attention. Republicare Phoenix Edition swaps out Obamacare’s individual mandate + exchanges for assigned risk pools. In this case, the change is merely part of the sleight of hand intended to distract from the primary change which is cutting benefits to fund a tax cut. However, let’s consider assigned risk pools as a serious policy proposal. First off, assigned risk pools are an odd direction for Republicans to go since exchanges are the more market oriented approach. More critically, assigned risk pools add a huge new mechanism for cost shifting to a system where cost shifting is already a major driver of obscene administrative costs. Of course, the actual impact will largely depend on how these pools are administered by the states, but no one seems to have given much thought to how that will be done.
Risking the stability of the existing system for such a poorly thought out and most likely inferior policy doesn’t really make sense even for people who really want those tax cuts. I think the more likely explanation is that Phoenix Edition is intended to placate the Republican base but then not actually happen so that swing voters don’t have anything to get upset about.
I am sorry but this latest version of Republicare is just more the same BS. They are not trying to make HC better or cheaper or anything. This is about $$$ only and poor people be damned. Congress and the insurance companies want to kick out poor sick people and let them die or do without care. It will be interesting how they propose to handle and pay for emergency medicine for the uninsured if this new mess passes…..
The resurrection of the unpopular AHCA definitely means that the US will spend a lot more time talking about health care over the next couple years! I liked your 2009 proposal for universal basic coverage plus a second private tier. You may also want to read The Lessons of Obamacare, by Sarah Kliff and Ezra Klein. You’re correct that Obamacare was essentially the status quo with universal coverage: one of the lessons that the Obama administration took away from the failure of the 1990s health-care effort under Bill Clinton was that the public wouldn’t accept radical changes.
I don’t know if “liberty” is the right way to look at the AHCA. I’d suggest there’s two perspectives here: populism and good government.
1. Populism: One of Trump’s promises to his supporters during the Republican primary was that he wouldn’t cut Social Security, Medicare, and Medicaid (unlike his Republican rivals). A lot of his supporters rely on these programs! So this is a pretty major betrayal. This is common with populist leaders: they come in blasting an ineffective elite and promising the moon, and then it turns out that their promises are impossible to achieve. What Democracies Can Learn from Greece’s Failed Populist Experiment. “Rambunctious outsiders often have no solutions to offer. But their obvious failures will not guarantee their demise.”
2. Good government: I think there’s basically three possible options for US health care. (a) The pre-Obamacare status quo. (b) Universal public health insurance primarily funded via taxes, as in most rich countries. (c) Romneycare/Obamacare, which is a compromise: universal coverage through private insurance companies.
There were two particularly interesting points in the Vox article. One is that the fundamental problem with US health care is high prices: cost control is ineffective. (In most countries, cost controls are imposed by having a single buyer which negotiates prices. In Canada and Singapore, for example, the government sets prices. In Germany, all private insurance companies in a single state negotiate as a cartel.) Obamacare successfully “bent the cost curve” (reducing growth in health-care spending), e.g. through regulating how much insurance companies could spend on overhead, but didn’t really tackle the problem of high prices directly. (In your 2009 proposal you bring up the idea of cost/benefit analysis; definitely a good idea.
A second point is that what people mean by “affordability” is “low out-of-pocket expenses” (premiums, deductibles, co-payments). Deductibles and co-payments are intended to reduce demand (keeping overall costs low), but people hate them!
Option (a), the pre-Obamacare status quo is bad in both respects. Rising premiums cause health people to drop their insurance and hope they don’t get sick; so the pool of people with insurance gets sicker and sicker, and thus more and more expensive; private insurance companies do everything they can to deny claims. The AHCA is a big step back towards this situation, which is why it’s unpopular.
Option (c) was Obama’s attempt at a workable compromise. It helped somewhat with the overall cost of the system, but didn’t tackle the root problem of high prices directly; and people still hate high premiums and deductibles. It’s more popular then option (a), but not enough to get Republican support. So it may not be politically sustainable.
If the AHCA succeeds, I think the Democrats conclude that option (c) isn’t workable, and move on to option (b): public health insurance, funded through taxes. As someone in a country with such a system (Canada), I have to say that it works far better than the US health care system: we have good health care at a significantly lower cost than the US system. A Reddit discussion between me and a Canadian libertarian, from a few weeks ago.
“Why is it nonsense to talk about liberty with respect to laws or regulations? Please explain. Bureaucratic regulation is hardly the bedrock of motivation.”
Government regulations make markets and capitalism possible. Life would be impossible without laws, courts, zoning regulations, health and safety regulations, food and drug regulations, FAA regulations, etc. They all theoretically impinge on someone’s “freedoms” and “liberties” — e.g the freedom of a car dealer to sell you a lemon, or a drug company to sell you a bad drug, or the farmer to sell you bad pork — but on the other end of those regulations are my freedom to know that the car will work, the drug won’t kill me, and the pork isn’t spoilt. Whose freedom trumps whose?
I prefer American health care because in other systems I would not receive care. When a valid treatment for your condition is “watch and wait, plus maybe some painkillers”, guess what cheaper systems do?
America has a lot of those people, way more than other systems, and that is also why health care costs more here. We Do More Stuff. And I am talking about conditions in which surgery or specific therapy is effective, more so than “watch and wait”, just, you know, far more expensive.
America also gives a hoot about truly disabled children and adults to an extent that is completely not the case anywhere else, occasional token examples notwithstanding.
The genuine diversity of the American population and its history with health care mean cheaping out will not improve outcomes, and will worsen them, but of course less money would be spent. So there’s that.
Practical Conservative:
You are astonishingly ignorant about the US system in terms of actual outcomes.
Highest $/unit health benefit in the world.
The rich are well taken care of, as they always are. The rest? Not so much. Liberty is a meaningless term when you are poor and sick, or worse, working poor and sick.
Gordon, that’s disappointing news — I thought Justin Trudeau more or less threw the doors open. I’m sure a lack of guns etc is no objection however.
As I understand it, a big practical problem with Obamacare was skyrocketing premiums, for less attractive insurance plans than before to boot. In practice, this seemed to lead to previously insured middle class becoming uninsured. Hardly a desired outcome.
FL, it seems naive to immediately step from ‘no regulations bad’ to ‘current regulations divinely inspired’. I’m sure you realize there is a space of possibilities here with varying outcomes, which means we would do well to analyze them rather than taking them for given.
Nor does it seem prudent to rely on the good will of the sacred bureaucrat to express the will of the people in its ultimate form. In fact, peeking into the sausage factory may damage one’s faith in this respect. We can take Phil’s various aeronautical tales as examples, or the bill that had to be passed to know what’s in it, FDA, EPA, or many more.
The bureaucracy too is part of the political system and is populated by individual actors with their own agendas.
>As I understand it, a big practical problem
>with Obamacare was skyrocketing premiums,
Premiums in the individual market were “skyrocketing” for a decade before Obamacare. I know, I paid them. That said, it was known that premiums would go up with Obamacare. Before Obamacare, an insurance company could drop someone whose claims got too expensive. There is, of course, a very significant cost associated with taking that option away from them.
I will concede that in some states Obamacare is not entirely stable at present and that increasing the “fines” for failing to carry insurance would probably be necessary to stabilize it.
>for less attractive insurance plans than
>before to boot.
High deductible catastrophic coverage is what things look like when you implement the Libertarian desire to make things more market oriented and get consumers skin in the game. As I said previously, by replacing exchanges with government administered assigned risk pools Phoenix Edition increases, not decreases, direct government involvement in the administration of health care.
>In practice, this seemed
>to lead to previously insured middle class
>becoming uninsured. Hardly a
>desired outcome.
Most middle class people are insured via employer based group plans which were largely unaffected by Obamacare (except for for the very popular ban on lifetime caps, imperilled by Phoenix Edition, and the mandate to allow children to remain on policies until age 26). The decision to leave this chunk of the health care system more or less alone, although popular, was a major reason Obamacare could not do more to reduce the cost of the overall system.
I like Karl Denninger’s proposal somewhat better than Phil’s.
https://market-ticker.org/akcs-www?post=231949
The problem is that none of this is politically viable. Because of the political realities I think we need to just get it over with and go full NHS. Buy some HMOs, roll them into the VA system, and say: here are the free hospitals and clinics. You just show up here for treatment. No billing.
Gee Tom, change your mind much? Now some regulations are good?
Your comment that regulations are typically the result of some random bureaucrat with an agenda is total BS.
I would argue that most regulations are there because there was some event — a large fire (think Chicago), a stock market failure (think creation of the SEC), a massive health problem (think Thalidomide), a major air disaster (think Turkish Airlines Flight 981) — which caused people to force the government to rethink whether there were enough regulations in place so that corporations who put $$ before people (think United Airlines, Enron, or anyone in the coal industry today) could be reigned in before they did any more damage.
FL, so you make me an anarchist now? And you’re the fascist then, I suppose.
To answer your second assertion, more precisely I base my comments on a field of political science. Figure out the rest yourself.
https://mises.org/library/who%E2%80%99s-bias-against-free-market-healthcare
Gordon MacDonald, the specific health care scenarios I was discussing are not ones in which other countries have better outcomes compared to the United States. You’re the one who is ignorant about the diversity and complexity of American health care and how very many complex health issues it caters to that are simply ignored in other nations. But they have so few people with them compared to America that ignoring them doesn’t hurt their statistics.
Folks: A gentle reminder about the ideal comment… it is just as effective to say “This is what I think and why” as “This is what I think and why and Commenter X is a pinhead.”
Gordon: I don’t understand your perspective on the U.S. “The rich are well taken care of, as they always are. The rest? Not so much. Liberty is a meaningless term when you are poor and sick, or worse, working poor and sick.”
A poor American is entitled to Medicaid and is able to visit any hospital for any procedure and have taxpayers reimburse the hospital and relevant doctors. So a poor American and a rich American get exactly the same care at, e.g., Mass General Hospital (“the massive genital” as some of my doctor friends call it).
You can argue over whether MGH is in fact providing good care, but whatever they do provide is the same to rich and poor. If it is an emergency situation, the patient need not even have bothered to jump through the bureaucratic hoops to get onto Medicaid. (http://kff.org/health-reform/state-indicator/total-monthly-medicaid-and-chip-enrollment/ says that 75 million Americans are officially enrolled in Medicaid and the equivalent for kids)
(Nothing MGH does moves the statistical needle, of course, compared to lifestyle, diet, genetics, clean water, vaccines, etc.)
[The same situation is true in dentistry. My dentist friends actually seek out the poorest patients, e.g., by opening offices in failing towns and poor neighborhoods. These are the folks who need the most work and Medicaid pays at reasonably attractive rates. Parents don’t take care of children’s teeth, for example, so a dentist might be able to do $10,000 of work on a 4-year-old.]
@philg: It may be that rich or poor presenting at Mass General get the same care, but there are many Americans who don’t live near a Mass General (and all medical care is not hospital care) so that alone does not support your claim that “a poor American and a rich American get exactly the same care”. Of course, @Gordon has not supported his claim that the poor are not taken care of either.
I would go along with the claim that most urban poor Americans have access to decent to good care with the caveat that the gaps/complexities/irrationalities of our existing system are generally going to be much more burdensome for the poor than the rich.
bobbybobbob: “Because of the political realities I think we need to just get it over with and go full NHS. Buy some HMOs, roll them into the VA system, and say: here are the free hospitals and clinics. You just show up here for treatment. No billing.”
You could be right. Another way forward would be the “public option” that didn’t make it into Obamacare: people could sign up with private insurance companies, or they could just sign up for government-provided health insurance, something like Medicaid or Medicare, with monthly premiums and relatively small co-pays. Private insurance companies would presumably compete not based on price, but based on some kind of higher-quality service (e.g. broader networks of doctors and specialists).
Philip, Neal: I think it’s people in rural areas and who aren’t poor enough for Medicaid who will suffer the most. This is exactly why Trump said he wouldn’t cut Medicaid: his supporters rely on it.
The Vox article talks about how Obamacare’s Medicaid expansion got little publicity compared to the insurance marketplaces, but has worked surprisingly well. Apparently there’s a significant number of people on the marketplaces who would prefer to enrol in Medicaid, even with premiums. According to the CBO’s analysis of the March version of the AHCA, the AHCA will result in 14 million people losing Medicaid coverage.
“I think it’s people in rural areas and who aren’t poor enough for Medicaid who will suffer the most. This is exactly why Trump said he wouldn’t cut Medicaid: his supporters rely on it.”
To clarify: Obamacare raised the threshold for Medicaid eligibility to 300% of the poverty line. Trump and the Republicans are rolling this back, so there’s a significant number of people who are eligible for Medicaid today who will not be after the rollback. This is a major betrayal of Trump’s supporters. After promising not to cut Medicaid, he’s cutting it by nearly $1 trillion.
@Russil Wvong: When I said “most urban poor Americans” the word “most” was intended to convey lack of precision due to my ignorance of the actual numbers. I did not intend it to mean “nearly all”.
Obamacare narrowed the gap between “most” and “nearly all”, but it is (probably) still too large. I agree that Republicare Phoenix Edition will make it worse which (I think) is the moving in the wrong direction especially since the only real benefit is a tax cut for the rich.
Repairing Obamacare, expanding Medicaid, a “public option” (as described in #30, or expanded direct governmental provision of care (or some combination thereof) are all potential interim measures to try and close the gap between “most of the poor” and “nearly all of the poor”. This is complicated by the need to also address the somewhat different needs of Americans who are not poor, not rich, and can’t get employer based group insurance. However, I can’t see any of these solutions effectively dealing with the underlying problem of runaway healthcare costs.
New house bill results in more liberty in comparison to older ‘affordable healthcare’ law because it repelled individual mandate that taxes fact of human existence. To be sure it was most politically feasible fiscal half-measure that could be passed and it was destined to fail in raising revenues it brought liberty score of the older law to an unbelievably low record, probably not matched anywhere in the world.
@dean: The government can always levy a tax and purchase insurance on your behalf, so the individual mandate is basically a tax. For individuals, Republicare Phoenix Edition replaces the “mandate” tax with a different tax (or perhaps an obligation to pay debt) to fund assigned risk pools. Net effect on “liberty”: zero. Under Obamacare (in fact even before Obamacare), insurance companies had the liberty to participate or not in a highly regulated medical insurance market. With Phoenix Edition, they would have the same liberty to participate or not in a highly regulated medical insurance market with somewhat different rules. Net effect on “liberty”: zero. What about people with pre-existing conditions? Under Obamacare they had the “liberty” to select an insurance policy from those offered in an exchange (and this design imposed a modicum of market discipline on insurance companies). With Phoenix Edition, these individuals would be at the mercy of whatever the government bureaucrat running their assigned risk pool thinks is best for them. Net effect on “liberty”: negative. Add it all up and Phoenix Edition’s net effect on “liberty” is negative.