Rational Arguments

Rep. Ryan is disappointing me.  He has a defense of his “Roadmap” up.  Specifically, he wants to talk about how his plan will affect Medicare.  In his own words:

We do not have a choice as to whether Medicare will change from its current structure. It is being driven to insolvency. An honest debate requires a serious discussion of how Medicare will avert its collapse and be made sustainable. Unfortunately, but not surprisingly, the Democrats’ political machine has attacked my contribution to this debate, making the false claim that the only solution put forward to save Medicare would “end Medicare as we know it.”

The CBO has said that my reform plan, “A Roadmap for America’s Future,” would put Medicare on a sustainable path. The plan protects and preserves Medicare for those enrolled now and for those who will become eligible in the next 10 years, while reforming the program to ensure it will be there for younger generations. Future seniors would have access to the same coverage I enjoy as a congressman.

OK.  First of all, no one is arguing against the fact that Medicare has to change from its current path to be sustainable.  But part of the reason that path was made worse was because of the huge unpaid for addition of Medicare Part D, which was not passed by the Democratic machine.  ARGH.  Look, he’s made me make a partisan argument.  Unforgivable.  Deep breath.

Rep. Ryan, your plan for Medicare is not crazy.  It’s not corrupt.  It’s not morally wrong.  But I’m sorry, it absolutely would end Medicare as we know it.

Medicare right now is a defined benefit plan.  Everyone knows exactly what they are going to get from the government and that’s what happens.  Every year, the government (CMS) figures out how much it will cost to give those defined benefits, and it pays the bills.  There are pros and cons to such a plan, but that’s Medicare as we know it.

You would like to change Medicare to a defined contribution plan.  In that plan, everyone knows how much money (in a voucher) they are going to get every year, and then they go out and buy insurance.  Every year, the government sets how much it is willing to pay, and gives out the vouchers.

A defined contribution plan is NOTHING like a defined benefit plan.  Going to a voucher system, is a total change from Medicare.  It’s the “end of Medicare as we know it”.

Medicare right now is the equivalent of Canada’s single payer health care system.  You want to end that; you want to privatize it.  It’s a radical change.  Own it.  Deal with it.

Your proposal would be a much greater disruption of Medicare than anything in passed in health care reform recently.  Yet many of your colleagues have said that any cuts to Medicare would be horrible.  Did you share this view with them earlier this year?  I ask, because I’ve always felt that the demagoguery about cuts to Medicare was foolish.  I’m not sure you’ve always been consistent.  A wonk would clarify that.

The irony is that you keep talking about the CBO as if they were the gold standard of knowledge in terms of how reform will affect the budget in the future.  Did you share this feeling with your colleagues when they were debating health care reform earlier this year?  I ask, because I’ve always felt the CBO was credible.  I’m not sure you’ve always been consistent.  A wonk would clarify that.

Another irony is that what you are proposing, giving the elderly money or vouchers to buy private insurance, sounds much like the exchanges recently passed in the PPACA.  Right?  How is it different?  Did you share your feelings on the value of this type of setup with your colleagues when they were debating health care reform earlier this year?  I ask, because I’ve always felt the exchanges seemed like something conservatives would always support.  I’m not sure you’ve always been consistent.

A wonk would clarify that.

Last week I wrote about those crazy people in Vermont who were campaigning against each other by claiming their opponent wasn’t enough of a single payer supporter.  Now, Vermont’s socialist (literally) Senator makes the news:

Sanders, speaking at a health care rally at the Hetty Green Park in downtown Bellows Falls on Saturday afternoon, said that he and other members of Congress would also introduce legislation that would roll back to 2014 the current 2017 restriction for states to apply for a waiver in order to implement their own systems. He said Democratic Reps. Dennis Kucinich of Ohio and John Conyers of Michigan would be co-sponsoring the legislation with him.

But Sanders said that if Vermont opts for a single-payer system, as most of the Democratic candidates for governor have pledged to enact, he will take the state’s case directly to President Obama.

I’ve met Senator Sanders.  He’s an impressive guy, and I don’t get the sense he scares easily.  I don’t doubt he will do this.  He may not get the legislation passed, but I am sure he will campaign hard to get the HHS waiver if Vermont decides to go at it with a state-based single-payer system.  And that’s not a pipe dream.  This is from back in April:

By a vote of 91-42, the Democratic controlled House passed its own version of legislation passed earlier by the Senate. Both bills call for designing a single-payer system, in which a government agency would administer and make all payments for health care.

The House version calls for that as well as a parallel design of a system with a public option for health insurance, meaning a system in which a health insurance program offered by the government would compete against those offered by private companies. The House’s version also would expand previously enacted reform efforts.

Either system would require federal approval.

The Senate focuses on single-payer as the goal, but also calls for two alternative designs. Differences will have to be worked out in a conference committee of three members from each chamber, and it’s not clear what Gov. Jim Douglas, a Republican, will do with the bill.

Heidi Tringe, the governor’s deputy chief of staff, said Douglas likes parts of the bill but has “strong concerns” about others. He has not said if he would sign it, veto it or let it become law without his signature.

You’ve got a state House which overwhelmingly passed the bill, a state Senate which is open to compromise, a Republican governor who’s not totally opposed, Democratic opponents for governor who are climbing over each other to show their support, and a US Senator committed to getting the federal approval they need.

I get that the media like their news to fit into a nice narrative.  Right now that narrative is that there is an epic battle between those on the left who support the ACA and those on the right who want to repeal it.  I get that Vermont and its single-payer people don’t fit that narrative.  But that doesn’t mean we should ignore it.  There are interesting things going on in the far northeast.

You hear all this talk about whether or not people approve of the Affordable Care Act, and you start to believe that somehow the exact center of the country lies somewhere between those who feel the Act was the end of freedom as we know it and those who feel it was the answer to all our prayers.  Then a reader sends you this:

The gloves are off in the fight for the Democratic nomination for governor. Former State Senator Matt Dunne is calling out Senator Peter Shumlin for what he says is a troubling misstatement.

Peter Shumlin first said it two weeks ago in an online questionnaire, then again this week in a mailing to voters: “I am the only candidate who sponsored a single-payer health care bill.” Dunne says that is simply not true.

“The facts are that I also sponsored a single-payer health care bill,” Dunne told reporters outside the Statehouse Wednesday.

He did. During the 1993-1994 legislative session when Dunne was serving as a State Representative he co-sponsored a bill that would have created a single-payer system. He wants a public retraction of Shumlin’s claim and is requesting that Shumlin send out another mailer with the correction.

Wait…  what?  Are you kidding me?

One Democratic candidate for governor, Matt Dunne, is upset at another Democratic candidate, Peter Shumlin, because he Shumlin claimed that Dunne did NOT support single-payer health care.  Did you get that?  They are fighting to show which of them is the more fervent supporter of single-payer health care reform.

Watch the TV, and you’d think that voicing anything less than total hatred for such reform would be the kiss of death in modern politics.  Not so in Vermont.

Vermont is still a state, right?

While the health care debate has abated somewhat in the US, it is still ongoing in Canada.  On Monday, there was a debate, on whether people “would rather get sick in the U.S. than in Canada”.  One of the participants was Howard Dean.  The Globe and Mail interviewed him before the debate:

People tend to forget that you already have some socialized medicine in the U.S., as well as a large single-payer system.

Medicare is not socialized, not in the U.S. and not in Canada. It’s a single-payer system. Despite what is often said, your system is not socialized, it’s a single-payer insurance system. The Veterans Health Administration, however, which has 25 million people in it, is a truly socialized system – it’s government-owned and government-operated and it’s worked very well. In fact, the VHA is the No. 1 rated system in the country, according to patients.

Health-care reform dominated the headlines for a long time. Was it successful?

We didn’t pass reform. All we did pass was putting more money into what we already have. It’s successful in a sense that 1) we got a major bill passed, which is something for a new administration; 2) we created a system that’s going to force reform because of the financial realities; 3) a great many more people are going to have coverage. But this system is still not nearly as effective and efficient as the Canadian system.

You’re a physician. There is an assumption physicians don’t like a universal system because, with less competition, they come out losers.

I know a lot of American physicians who would much rather practise under a Canadian model. There is less malpractice, more actual health care, and a lot less bureaucracy like insurance forms to fill out. I think it depends on why you went into medicine. If you want to make a lot of money, the Canadian system is not for you; if you really like to take care of patients, the Canadian system is well suited.

What’s the single most important lesson that Americans can take from the Canadian system?

It covers everybody with a relative lack of bureaucracy. I know Canadians think there is bureaucracy, but you haven’t seen anything until you work in a system with several hundred insurance companies that all do something different. American hospitals have a whole floor occupied by a billing office. You don’t have that in Canada.

Conversely, what’s the most important lesson Canadians can take from the U.S. health-care system?

I’m afraid I’m not sure there is one. There is more cutting-edge innovative technology, but the cost of that is to pay 70 per cent more than Canadians do for health insurance. Canadians will have to decide if that’s a lesson they want to learn.

Bottom line, which system is better for the patient?

I’ve spent a lot of time in both countries and there is no doubt that you’re better off getting sick in Canada.

I don’t have much to add to the content Dr. Dean offers here.  I agree with it.

But why is it that politicians only seem to be able to speak honestly and clearly when they aren’t talking to Americans?  Where was this guy during the health care reform debate?  Instead we got confusing and confounding stuff like this and this and this and this, ending with this.

If you read this blog, you know that I think that single-payer health care systems are fine and dandy.  So when I say that Medicare has issues, it’s not because Medicare is such a system, but because we set it up poorly here.  It’s a bad risk pool, it’s underfunded, and we don’t really raise the rates when we need to.

That said, this is another reason things are not going to get better anytime soon:

Of all the people in human history who ever reached the age of 65, half are alive now…

Homo sapiens is ageing fast, and the implications of this may overwhelm all other factors shaping the species over the coming decades – with more wrinklies than pimplies, more walking frames than bike stabilisers, more slippers and pipes than bootees and buggies, and more grey power than student power. The longevity revolution affects every country, every community and almost every household. It promises to restructure the economy, reshape the family, redefine politics and even rearrange the geopolitical order over the coming century.

If that fact doesn’t blow your mind, I hope it at least makes you pause.  The Medicare population is only going to get larger.

(h/t Will)

Rachel Ryan describes her experience with the French health care system.  She’s shocked at how good it seemed:

I walked into the Centre de Santé – Réaumur’s emergency health center at noon and was admitted within twenty minutes.  Ten minutes later, I was meeting with the doctor.  After a thorough exam, diagnosis, and prescription, I was sent up to the 7^th floor to have blood work done, simply to “verify.”  The total cost of the visit was €44, plus the additional €12 I paid at the pharmacy to fill two week-long prescriptions.  If I had been covered by French national healthcare, la Securité Sociale, the total cost of the hospital visit would have been €0.

Though the term “bedside manner” is completely foreign to the French, the overall experience was pleasant, given the circumstances.  The doctors could not have been more attentive, the hospital was clean, and the wait was negligible, as were the costs.

Nevertheless, I left skeptical, thinking, “it can’t be this good, what’s the catch?”

Yes, there must be a catch, because it’s just not possible that the French system isn’t bad.  Right?  I mean, that’s what we’ve been told over and over again.  Single payer systems are just… horrible.  Right?

So, of course, she finds the flaws:

Le Parti Socialiste (Socialist Party), who – as of last month – gained a sweeping political majority in France’s regional elections, is now advocating a further increase in taxes in order to offset rising healthcare costs. Le Parti Socialiste is proposing an increase in the bouclier fiscal (~ tax limit), which currently states that “direct taxes paid by a taxpayer may not exceed 50% of taxpayer’s revenues” in Article 1 of the Internal Revenue Code.

While there is no doubting that the overall level of care and minimal costs are aspirational, the French universal healthcare system is not without its drawbacks.  Just as the U.S. is currently suffering from a lack of sufficient, available healthcare and money, so is France.  Though the French system offers many short-term and long-term benefits, it is clearly not without its short-term and long-term costs.

So the problems are (1) taxes are too high and (2) the system is too expensive.

The issue I have with discussions like this are the use of subjective words.  There’s a lack of context.  Taxes are too high?  Well, how high are they?  Since the French bundle pretty much all health care into taxes, even if their rates are higher than ours, we’re not adding in health care costs.  Since the average family insurance plan in the United States is over $13,000, I bet this would nearly double the federal income tax burden of most Americans.  But, since we keep medical costs private, we get to claim our tax rates are lower.

The second problem is even more laughable.  Their system has a problem with costs?  The cost of the French health care system, per person, is just under half of ours.

Half.  50%.  I don’t know how else to say it.  If your only legitimate complaint is that a system that costs less than half of ours is too expensive, well, then you don’t really have any complaint at all.

Yeah, that title is a bit bizarre, but I have no other way to describe stuff like this (italics mine):

The Heritage Foundation’s latest world ranking of economic freedoms shows the U.S. falling farther than any other large economy in the world. The foundation says the TARP Program, the auto industry bailout and the stimulus package, among other factors, have caused the country’s economy to go from “free” to “mostly free.”

The U.S. now ranks eighth in the world on the group’s list.

Factors like business regulation, the labor market, monetary stability, property rights and corruption are used to determine the rankings.

Terry Miller, director of the Center of International Trade And Economics at the Heritage Foundation, says the U.S. ranking may continue to fall.

“Certainly looking at the government policies that have been followed over the last year, since our last data cut off, I’m very concerned,” Miller told TPM, adding that health care reform was likely to further hurt our economic freedom.

OK, first of all, I love how the Heritage Foundation has operationalized freedom.  Awesome.  But the kicker is who is more free than us.  We’re #8 in the world.  Want to guess who is #7?

Canada.

Yes, a country with a single payer system is more free than the US.  More free. MORE.  And the Affordable Care Act, which is not even close to anything like a single payer system is going to drop us even further down the rankings, according to the Heritage Foundation.

If we’re not careful, soon we’ll be even less free than the UK (#11) with their national health care system, which is totally socialized.

Like I said… irrational.

I know it’s become de rigeur for some to call the Affordable Care Act “socialism” or even “Armageddon”.  But it’s not even close.  Do you want to know what truly radical reform would have looked like?  Look at Taiwan.  They have a single payer system, where premiums are set at 4.55% of income.  Because of increasing costs, they are talking about raising the premium rate to 5.17% of income.

Recognize that while it’s a single payer system, their tax rate isn’t much more than the Medicare tax rate, and their system covers everyone, not just the elderly.

Anyway, people are still upset about the increase.  So they are going to change it.  Check out how:

According to Yaung, the premium rate for the second-generation system will be lower than at present because premiums will be calculated on a broader income base.

Under the new scheme, premiums will take into account a household’s total income, including wages, stock dividends, rental income and other unearned income.

Their solution was to make the tax even more progressive.  They will tax not just on earned income – but wealth, but other sources of wealth as well.  This will, of course, impact the wealthier citizens far more, allowing those in the middle and lower class to pay even less of a share.

Imagine what could have been.  And stop crying wolf.

A reader responds:

In your Feb. 1 post, you claim that Rep. Price’s authored bill, H.R. 3400, is “the Republican proposal” for health care reform.  It’s one of several that has been sponsored by Republicans, and most importantly isn’t the one that made headlines this fall from such a “grim” CBO review. That bill was H.R. 4038.  Your post misleads your readers and implies that: there has only been one Republican proposal, and that this is it.  Maybe you made an honest mistake, but words are important and your biases rarely hide themselves. In your words, I look forward to you correcting the record.

First of all, I always love when someone tells me my “biases rarely hide themselves” – as if they’ve caught me trying to hide my preference for a single payer health care system.  Or my disdain for rhetoric.  Or my impatience with politics over policy.

Let me say it for the zillionth time.  It’s not hidden.  I think that the available data and evidence show that such a system would be much more cost-effective.  I think that the media (and others) have done a terrible job of describing the details of proposed policy.  I think that too many people want reform to succeed or fail only because they want Democrats or Republicans to “win” or “lose”.  Even worse, I think that some people want it to succeed or fail merely because of personal feelings for politicians, which is so petty it makes me sad.

If you think I’ve got some other “bias”, please do let me know.  I’ll address it here, in the open.  I’ve got nothing to hide.

As to the idea that HR3400 is not “the Republican proposal”, it’s the one that Rep. Price was talking about when he spoke to President Obama.  It’s the one he said had more co-sponsors than any other health care reform bill in the house.  It still doesn’t.

Although it does have more co-sponsors than HR4038, which has only 23.

But if it makes this reader feel good, then I will say – again – that there has been more than one proposal.  I have talked about them in a number of posts.

None of this changes the fact that the health care reform bill with the largest number of co-sponsors is HR676 – Medicare for all.

Here’s one mistake from last Friday’s Q&A, which has been all-the-rage this last weekend.

Rep. Tom Price said (emphasis mine):

Mr. President, multiple times from your administration there have come statements that Republicans have no ideas and no solutions, in spite of that fact that we’ve offered, as demonstrated today, positive solutions to all of the challenges we face, including energy and the economy and health care. Specifically, in the area of health care, this bill, H.R. 3400, that has more cosponsors than any health care bill in the House.

He’s correct that HR 3400, the Republican proposal for health care reform, has more co-sponsors than the Democrats’ bill.  But he is incorrect that it has more co-sponsors than any health care bill in the House.  Know which health care bill has more?

HR 676.  The United States National Health Care Act or the Expanded and Improved Medicare for All Act.  It’s a bill for single-payer insurance.

It has 87 co-sponsors.

Since the Republicans are obviously proud of their number of co-sponsors, I’m sure they are going to be impressed by this fact.  I’m also going to assume that Rep. Price isn’t lying, and that he just doesn’t know.  I’ll look forward to his correcting the record.  And I’ll look forward to the media reporting any of this to anyone.