How TO Pay for Health Care Reform

By Solomon Kleinsmith | Related entries in Bad Decisions, Bipartisan, Congress, Economy, Fiscal Responsibility, In The News, Independents, Legislation, News, Politics, Polls, Spending

In my last post I detailed some of the roadblocks that have kept the Democratic leadership in Washington from finding a way to pass a major health care reform bill with a public option. They’ve whittled the cost of the bill down a few hundred billion dollars by negotiating concessions from drug companies and hospitals, as well as settling on a provision that would have employers pay a fee for each employee they do not already cover. The two main proposals to fill the budgetary gap have stalled, and are possibly dead in the water. So what other options are there?

How can we PAY for Health Care in America Now?

Past the constant calls for saving money by eliminating wasteful spending, which never seem to materialize into actual legislation, we need to find new forms of income to pay for this bill. They seem to be failing at convincing enough senators to support taxing benefits and the more affluent, so what else is left?

For the most part, we pay for our governmental services through income taxes (both individual and corporate), property taxes and consumption taxes. Property taxes are used for other things and rightfully shouldn’t be on the table here. The two proposals that were trotted out for discussion by the Democratic leadership were both taxes on types of income. What remains are consumption taxes.

In a way, consumption taxes are the most fair. For instance it makes perfect sense to tax gasoline and tires to pay for roads, as those driving on those roads need those things to do so. So doesn’t it make sense to tax those behaviors that create high health care costs? The American people seem to think so.

Kaiser Family Foundation poll

Kaiser Family Foundation poll

A poll by the Kaiser Family Foundation, from back in April, found that reforming health care is one of the public’s highest priorities, that a majority of Democrats and Independents believe that we need reform now and that a majority support taxing unhealthy behaviors as an acceptable way to pay for some of these reforms. When asked it they would support raising taxes on “items that are thought to be unhealthy, such as soda, alcohol, junk food and cigarettes,” 61% approved (39% strongly favoring, with 22% somewhat favoring the idea). I’m a huge fan of proposals that kill two (or more) birds with one stone, and I think this is a textbook example of such.

To fund a health care program, it makes much more sense to tax behaviors that lead to health problems than it does to tax income in general. By doing so we can, in one fell swoop, put more of the costs of the system in the hands of those who are causing the most problems, lower the consumption of these products AND help pay for universal health care. We already have taxes on cigarettes, alcohol and items deemed luxuries like jewelry, hotel stays and amusement parks. So why not extend similar taxes to the most unhealthy ‘food’ items in the market? (I put food in quotes because one could argue that high fat and sugar content items like pop, potato chips and many fast food items can hardly be described as food)

First on the cutting block is alcohol, with 68% of respondents strongly or somewhat favoring raising taxes on it to help pay for health care reform. Smoking is more demonized in our country, but alcohol related health costs actually outweigh those related to smoking. The Marin Institute lists several alcohol related health care costs, among them $175.9 billion on alcohol related problems, also saying that they bring about “$184.6 billion dollars per year in health care, business and criminal justice costs, and cause more than 100,000 deaths.” This being the case, I see it as nothing but reasonable to levy a higher tax on alcohol, possibly in relation to which forms of it result in the worst outcomes, that is equal to the cost to society it incurs.

Still with a few hundred billion dollars to go, we come to tobacco. I was a bit surprised that a higher cigarette tax was supported by fewer than the increased alcohol tax, but this may be because tobacco products are already taxed at a high rate. Florida alone loses $20 billion dollars when you compare the taxes it collects to the money it pays out, amounting to nearly $7,000 per smoker. A study released by the CDC in 2002 showed that “For each of the approximately 22 billion packs sold in the U.S. in 1999, $3.45 was spent on medical care attributable to smoking, and $3.73 in productivity losses were incurred, for a total cost of $7.18 per pack.” These numbers are sure to have risen since then, and with somewhere in the neighborhood of 30 billion packs of cigarettes sold in the US last year, it seems more than fair to tack on at least another few dollars per pack.

Whether or not this fills the gap entirely, we also should look at taxing the most unhealthy food items. A study at University of Victoria (British Colombia) found that all income groups would benefit, although more so near the top of the economic spectrum, from a tax on junk foods that sent money towards health care programs. I would suggest that this disparity would be less pronounced in the US, where many people near the bottom of the economic spectrum have much more to gain from such an arrangement, given that it will help pay for health insurance that many of them currently do not have.

Put all of these together, and you might piece together enough to get over the hump. At the very least we could make it easier to pass one of the income tax ideas by lowering the amounts they’d have to raise through it.

One might argue that this would cause people to consume less of these products, thereby reducing the income from the levies. My response would be that we should then increase the taxes to keep up with the costs. This would hopefully create a cycle where more people would consume less, making the purchase of such products even more expensive, driving more out and lowering costs to treat those people over the long run. Herein lies the killing two birds with one stone situation.

One might also argue that this is a regressive tax. In effect it will be that way, at least at first. It is the lower end of the spectrum that spends a larger amount of their overall income on food. They also tend to eat less healthy foods. However, nobody forces them to choose to purchase these particular food items. Nobody should force them to quit, but if they want to continue to lead an unhealthy lifestyle, the rest of society should not be forced to subsidize it.

If people want to smoke, drink or eat themselves to death, then they can make a down payment on the hundreds of thousands of dollars the government will pay to take care of many of them during the last months of their lives. If we can save some of them from that fate by enacting the proposals mentioned above, thats even better.


This entry was posted on Tuesday, July 14th, 2009 and is filed under Bad Decisions, Bipartisan, Congress, Economy, Fiscal Responsibility, In The News, Independents, Legislation, News, Politics, Polls, Spending. You can follow any responses to this entry through the RSS 2.0 feed. You can leave a response, or trackback from your own site.

70 Responses to “How TO Pay for Health Care Reform”

  1. Papa Ray Says:

    Hey, not so damn fast. No body asked me about this crap. I can say that my friends were not asked either, but I can tell you what we would say.

    We don’t want any damn government help. We would say to eliminate most of the government agencys or cut them back to where they did more good than harm. Minorities have been on the gravy train so long in the U.S. that they think it not only their right but want it to serve steaks and lobster. Now they want everybody else to get on board?

    I’m sick of this crap.

    Papa Ray
    West Texas

  2. Papa Ray Says:

    “If people want to smoke, drink or eat themselves to death, then they can make a down payment on the hundreds of thousands of dollars the government will pay to take care of many of them during the last months of their lives. If we can save some of them from that fate by enacting the proposals mentioned above, thats even better.”

    Better? you need to quit smoking what ever it is and stop drinking altogether. What a load of progressive BS.

    It’s our right to do with our lives as we want. As far as someone else paying for the results, yea that is the progressive way. Forget it, Myself and those I know take personal responsibility for ourselves and our families, we don’t need nor want any government help.

    That is the trouble with this damn country right now. No one takes personal responsibility any more.

    Papa Ray

  3. Solomon Kleinsmith Says:

    “It’s our right to do with our lives as we want. As far as someone else paying for the results, yea that is the progressive way. Forget it, Myself and those I know take personal responsibility for ourselves and our families, we don’t need nor want any government help.”

    I’d be more than happy to work in a clause where people can take themselves out of the government health care system entirely, avoid paying into the system, but would literally be turned away at hospitals if they did not have the cash to pay copays at the moment they are admitted and would never receive help from medicare, medicaid or social security.

    There are a very small number of people that would literally rather die in a case like that, but the vast majority would rather have a fallback should they not be able to afford health care. You may be one of those people, or you may think you are until you get cancer and your insurance premiums are more than your life savings. Regardless, I’m all about freedom of choice.

    However, with the system that has been enacted today, society currently pays for the health care of a large portion of the populace. You can of course disagree with it, but this being the case, we have to pay for it somehow. If you have a better way of paying for it, I’m all ears. (no sarcasm)

  4. John Burke Says:

    Aha! Now you’re onto something: health care costs are being driven through the roof by fat, lazy people who eat, drink and smoke too much. But the solution is not merely to tax fast food, tobacco and booze. The obvious solution is to deny health care services to these fat slobs who are too stupid to stop smoking and too self-indulgent to stop drinking (not to mention using all manner of dope), while paying 100% of the costs of care for the good people who work out, run, play tennis, eat only organically grown vegetables from Whole Foods, leave the room whenever there is a hint of stake smoke, and…well, OK, maybe we can make an exception to the no alcohol or booze rule for an occasional glass of fine wine or a weekend joint.

  5. phin Says:

    See your problem is you’re thinking too small. If you’re gonna give bureaucrats this amount of control over you and then compound that initial stupidity even further by handing them even greater powers through taxation, then you might as well go all the way.

    The solution is rationing, which is always what government bureaucracies do best, other than waste taxpayer money that is (in that they are without peers). In this case, the government “allows” each citizen to consume a certain amount of food each day, week, month, whatever, after all most people don’t get fat solely on junk food and/or pop sodas. ALL food is fair game. It’s the calories that matter and what type of calories you consume. So it should be calories that are taxed. If you surpass your daily/weekly/ whatever allowance of calories, well we’ll leave it to the bureaucrats to come up with the appropriate penalties. My guess is: denial of service. Problem solved. Let all the fat, drunk, lazy people die. It’s what they’re doing in Europe with their old people.

  6. Solomon Kleinsmith Says:

    I can’t tell if you’re being sarcastic for comic effect or are just building a terrible straw man argument, haha

    Reminds me of how liberals were comparing Bush to Hitler. I mean the guy was a terrible president, but no Hitler for heaven’s sake.

  7. michael reynolds Says:

    Interesting that Solomon makes a perfectly sensible argument and the only responses are, to put it charitably, not in that same vein.

  8. ExiledIndependent Says:

    I think that what we’re seeing here is a a nanny-state death spiral (yeah, Justin, I said it).

    Solomon, while your logic is sound, it makes the (IMO faulty) assumption that the kind of healthcare reform the government is trying to pay for is the right thing to do, we just need to find a way to pay for it. Yes, the uninformed masses want “healthcare reform.” But those polls don’t ask what that means to them. Additionally, I wonder what the overlap would look like between people who want “healthcare reform” and people who already have healthcare. People are greedy. They want things that they don’t have to pay for. And the uninformed think that the government can magically give them free tummy tucks with no consequences in the broader financial system.

    Since this is usually the point where people trot out the heartrending story of a personal friend who was denied medical insurance during a time of crisis, let’s be clear that that is not what Dems are talking about. We’re not talking about emergency, unusual situation coverage with government as a last-resort provider. We’re talking about an approach that will eventually become a single payer system for every person in the country that will have a chilling effect on innovation, access, and quality of service. So again, while your logic is sound, it’s solving for the wrong problem.

  9. Paul Says:

    The “health care system” is in danger of imlosion! And we may not be able to stop it. fi

  10. kranky kritter Says:

    Ok, here’s a few serious and sensible questions in response to Solomon. Let’s notice first of all that what’s being suggested here is a sort of hybrid moral-economic argument. Because normally the rationale to engage in what have been deemed healthy behaviors is a moral one, not an economic one. But the connection is being made that those afflicted with a moral failing that leads them to indulge in unhealthy behavior should be taxed because they are costing the rest of us money.

    So, who has the actual “count everything” data that proves this?

    Suppose person A smokes 2 packs per day and drinks lets say three 6 packs of beer per week, Suppose further that this person gets lung cancer and dies when he is 61.

    Now suppose that person B neither drinks nor smokes and lives to the ripe old age of 85.

    • First, are we really sure that person A consumed more healthcare service in dollars than Person B?

    •Second, how much more did Person A contribute in already-existing sin taxes on beer and cigarettes?

    •Third, how much did person A contribute to social security and how much did Person B collect above what he or she contributed?

    This argument is routinely dismissed as not serious or absurd by supporters of the sin tax approach. Dismissal sure shows up as an optimal strategy when you don’t want to address a strong argument, doesn’t it? Here’s the thing. Make a moral argument against behaviors like drinking and smoking and the benefits of a healthy lifestyle, and I can accept your premise.

    But when you extend the argument to try to make an economic case that more sin taxation is warranted because the sinners in question are a net drag on government financing, and a different standard applies. The standard that applies is that you count everything and you show me your data.

  11. Mike A. Says:

    This post just reminds me of just how sick I am of government intervention. As a nation, I propose we:

    1. Stop all military pensions immediately. These pensions were NOT generated by free-market (save, invest and grow), but are merely communistic redistributions of wealth (my wealth) to those living off the taxpayer till!
    2. Based on #1, we need to stop all social security and medicare payments. Again too much redistribution going on.
    3. Privatize the military. Let the free market determine wages and benefits for those putting their lives on the line for us. Due to their efficient inventory control techniques, I believe WalMart would be very effective, and provide the lowest cost/unit.
    4. It follows from 3 to privatize the local police force, highway patrol, fire departments, etc, etc.
    5. Make all primary education free market. It’s worked so well for secondary education. This would encourage those from other nations to send their children to our primary schools, creating a shortage and driving costs up dramatically. The profits would be incredible.
    6. Make all water processing plants private ownership. The $50 a month I pay for access to clean, safe water is far too expensive.
    7. Continue to privatize our highways, and extend the privatization to our local roads. Pay as you go!

    In short, our government is a complete failure and should not be trusted with any of our money. There are no success stories to point to to support their involvement in any aspect of our lives.

  12. Scott67 Says:

    ExiledIndependent:
    “We’re talking about an approach that will eventually become a single payer system for every person in the country that will have a chilling effect on innovation, access, and quality of service.”

    My (private) insurance company bureaucracy is worse than ANYTHING I have ever had to deal with in any government agency. They are certainly doing a good job of wasting money, preventing access (to innovative treatments), and restricting my ability to seek quality of care. This myth that large insurance companies are better than the government is just that, a myth, which is based on a knee-jerk reaction that the government is always worse. It may be, but until someone measures it, I won’t take it on faith (either way).

    My hometown opened garbage services to private companies through a competitive bidding process, and let the current government-run trash collection agency bid as well. Guess who won hands down? And my trash is always picked up (the guys even put the lids back on the cans). And Indiana’s privatized welfare system is an utter failure: http://www.southbendtribune.com/apps/pbcs.dll/article?AID=/20090710/News01/907100393/1052/News01.

    Back to the topic of the post:
    I agree we shouldn’t just focus on food. What about industries that pollute the air and lead to health problems? Automobiles are pretty dangerous too. We could probably go on and on. So I agree with those of you who say this is a slippery slope and the taxes would probably not be based on sound science or health policy.

    Still, beyond saying there’s no problem with health care in the US, what positive suggestions do you have for improving it? After all, we’re ranked pretty low in quality of care internationally.

  13. kranky kritter Says:

    Wow, Mike. You go girl!

  14. TheTaxxMan Says:

    Exiled Independent, you are on the mark: “while your logic is sound, it’s solving for the wrong problem.” Government spending is out of control and adding more taxes isn’t going to fix that. Our government leaders need to be more accountable for the outrageous disregard for fiscal responsibility.

    It’s easy to stand on a political stump and say we need health care reform for all Americans. Paying for it is another matter. And people love the idea of getting something for nothing. What about those who’ve scraped their hard-earned money together to pay for insurance? They’ve made a conscious decision to support their family by earning it. Are they going to pay taxes for something they already have? If they want to eat junk food or drink a little beer, why should the currently insured citizen have to pay for someone who has made their own decision not to have health insurance?

    I don’t disagree with the notion that we need health care reform. I just think it’s time congress comes up with a way to pay for a plan without leaning on taxpayers. Much in the same way most taxpayers have come up with a way to pay for insurance within their own household budgets.

  15. ExiledIndependent Says:

    Scott, does your insurance company have to compete with other insurance companies across the country? Do you have the option to choose a different healthcare provider? Do you have a savings account specifically for healthcare expenses? If the answer to any of these is “no,” then there are areas to explore beyond a government single payer system.

    My point isn’t that there aren’t problems. My point is that the solution the government is considering is the wrong solution.

    And to KK’s point, a Logan’s Run solution is the real winning idea. My 93 year old grandmother (non-smoker, healthy livin’) is costing the healthcare system a heck of a lot more than my grandfather did who died in his early 60s (smoked, ate lots of high-fat foods).

    And Scott, you *have* healthcare, you just want more access and quality at the same or lower cost, right? Could you accept that for the money you pay, this is the quality you get? Would you be interested in paying more to get better services?

  16. Tully Says:

    First, as I keep requesting , define “health care reform.” (What, still no takers?)

    Kranky is asking the right questions there. The inherent assumption is that taxing such behaviors (or conditions — obesity, for example, is often NOT related to behavior but to genetics) will save money overall, but that’s a highly questionable assumption. EX: Someone who dies of liver failure from alcoholism at age 50 is not going to cost the system a dime in future Medicare or SS, and barring liver transplant (generally not available to alcoholics) their pre-death treatments are highly unlikely to come to as much as they would for someone who lives to age 85 and consumes 20 years worth of Medicare before dying of congestive heart failure. (Priced statin drugs lately? Bypasses?)

    But it’s a path of least resistance to use people’s moral objections to certain behaviors as an excuse to tax the behaviors. The scapegoat principle is timeless. As my late grandfather (b.1882) used to say, “Don’t tax me, don’t tax thee, tax that fellow behind the tree…”

    One might also argue that this is a regressive tax. In effect it will be that way, at least at first. It is the lower end of the spectrum that spends a larger amount of their overall income on food. They also tend to eat less healthy foods. However, nobody forces them to choose to purchase these particular food items. Nobody should force them to quit, but if they want to continue to lead an unhealthy lifestyle, the rest of society should not be forced to subsidize it.

    A VERY regressive tax. Never been really poor, eh? It is indeed an unhealthy “lifestyle.” Yep, no one forces poor people to buy cheap foods with high caloric content. Why, instead of feeding a family of four on $5/day with a pound of burger, some white bread, cheese, and peanut butter, they could all have a nice healthy organic arugala salad! It’ll be a little small and not provide enough calories to last them more than an hour or so tops, but…point being, poor people eat high-calorie high-fat foods for a reason. Namely, they dislike starving so they purchase as many calories for the dollar as they can. And cheap calories tend to be high-fat and high-carb.

    We already tried prohibition once. How did that work out for us? Oh yeah. Not so good. Raise taxes on booze high enough, and people start making their own. I’ve done it myself. Not rocket science. Raise taxes on tobacco high enough, and you facilitate smuggling. Already happens today between high-tax and low-tax states and no-tax reservations. The actual impact on alcohol/tobacco consumption is questionable. Just as the idea that banning abortion would make abortions stop happening is highly questionable — experience around the world is that such schemes fail miserably to stop the targeted behavior.

    I’d also point out that I do NOT accept so-called “economic studies” produced by issue-advocacy groups, which the referenced smoking-cost study is. I’ve seen far too many “studies” commissioned from hired-gun consultants by issue-advocacy players of all kinds, and find them universally highly suspect and always tailored to produce the results the client wants.

  17. Tully Says:

    Thanks for bringing up Logan’s Run, EI. :-D

    I was going to use it as an example of “health care reform,” since no one wants to say what they really mean by “health care reform.” “Health care reform” can be almost anything, including a whole lot of things I assume most of us do not want. But ask people in a general way if they want “health care reform” and they fill in their own balnks and say “Hellz yeah!” Heh. Be careful what you wish for, and remember that the devil is in the details.

  18. John Burke Says:

    MReynolds scolds commenters — presumably including me — for not taking Solomon’s proposals seriously. OK, here’s my serious response:

    – Taxes on tobacco and alcohol are already high, and it’s not at all clear that jacking them up more would produce much revenue. As matters now stand, with cigarattes at $5 a pack or more, bootleg cigarettes far outsell the taxed product in many parts of the country, and cigarette smuggling is an increasingly lucrative business for organized crime. Some in Congress have proposed bringing booze taxes up in line with inflation. That would be fine with me, but it just doesn’t yield much revenue to cover a hugely expensive plan, and it’s a political non-starter anyway. Perhaps most importantly, no one has a clue as to whether imposing even sky-high taxes on booze would reduce health problems related to excessive drinking. Drunks will get their fix, just as addicts do, and there is always the organized crime route to supply cheaper, untaxed beer and spirits (it did that very efficiently in Prohibtion).

    – Taxes on supposedly unhealthy foods — sugary sodas and fat-rich fast foods, in particular — will unquestionably be terribly regressive, lead to interminable quarrelling about which products should be taxed, and become an impossible political problem for advocates of such an approach. That’s why New York abandoned the sugar-soda tax idea almost as quickly as you can say, “Things go better with Coke.”

    I am semi-serious (in my post above) about going directly to the actual source of the problem of high costs associated with certain unhealthy behaviors. Life insurance companies have for decades charged smokers higher premiums. Why not hit them with higher health care premiums (in private or public plans)? And why stop at smoking? The rest of us (most, anyway) are very comfortable paying higher premiums or taxes or copays to enable coverage for people who work for $8/hour at big box stores or suddenly lose their jobs and get struck by cancer or hit by a car. No problem.

    But really, why SHOULD the rest of pay for the serial, utterly predictable health problems of some hugely fat guy who smokes and drinks too much and waddles his way into the doctor’s office every other week with new developments in his unending troubles with high blood pressure, diabetes, arthritic joints, etc. etc. When this indolent slob needs open heart surgury (as surely he will) and a double hip replacement at the age of 55, what exactly is the exalted “principle” by which the rest of us should pony up the hundreds of thousands of dollars in costs?

    Worse, what about the clown who is drunk or high every weekend and finally racks up his car, sending him to the hospital and rehab for weeks? If he harms someone else, he’ll be liable, but we’re all liable for his hospital bills.

    Granted, it’s not easy to sort out the behaviors from the illnesses, and the legitimacy of the costs. But it’s not altogether impossible.

    We could start by rewarding preventive care — for both the care giver and the patient. If you scrupulously get an annual check up, it ought to be free (appallingly, despite all the baloney tossed around about how critical preventive care is, Medicare does not pay a nickel toward well-patient check ups).

    Equally important, if you have a free check up coming to you but don’t go, you ought to suffer a penalty — say, a surcharge on your premiums that keeps getting higher as you miss more annual checks but is reduced or eleiminated when you finally comply.

    Along the same lines, people who adhere to a doctor-prescribed regimen to lose weight, improve their overall conditioning through exercise, etc. should get a reward — a modest one — in the form of reduced premiums or elimination of copays for certain services.

    Equally important, bad behaviors should result in some monetary sanction, too. Smoking or drinking excessively should mean you pay higher premiums (it’s not all that hard to find out; life insurance companies already do; if you lie, you risk losing coverage altogether).

    And expensive treatments should impose some sort of obligation on the patient to do his/her part. For example, if you have a $100,000 heart operation and go straight out and gain 20 pounds and keep smoking, your premiums should go up and, perhaps, your deductibles and copays for future care as well.

    One more example, a DUI conviction should trigger an automatic review of health care services incurred going forward with a warning that essentially self-inflicted injuries will result in your paying some appropriate financial penalty.

    The reason why I’ve never been able to agree fully that “health care is a right” is that so many people decline to do much of anything to sustain their own good health. To use an extreme example, if a guy puts a gun to his head and puts a bullet in his brain but fails to die, does he realy have a ‘right” to societal payment of millions of dollars in emergency care, ICU care, long-term rehab and/or palliative care?

    The objection will be raised that lower-income people — those more likely to lack coverage today — would be hard-pressed to pay added premiums of any kind as penalties for bad behaviors and/or are already not obliged to pay anything for Medicaid services so that rewards in the form of reduced payments by them can’t be offered. Maybe so, but that still leaves about 250 million people who can be incented or sanctioned.

  19. togakangaroo Says:

    I’m not necessarily against this plan but it WILL have unintentional consequences. I live in New Orleans for example, and taxing and discouraging people from drinking can stop our recovery cold.

    Also, when I’m waiting in line in Walmart behind someone with a grocery cart full of Fago and junk food they’re usually a) not the brightest bulb and b) have deeply ingrained food habits. You’re really going to need a how-to-eat education push that gets to these people before you really can tax junk food, otherwise it will certainly be horribly regressive. This will be absurdly difficult.

  20. Scott67 Says:

    I really like Tully’s point about defining health care reform. For some it seems like it is simply “save money.” Well, I’ll take a stab at it. Health care reform should:
    1. Make people healthier (as measured by something, perhaps life expectancy). Funny that you don’t see people talk about that very much. Is it too obvious?
    2. Increase the efficiency with which you make people healthier. This means that we get an average per capita increase in health outcomes at a lower average per capita expense.
    Note that I write ‘average,’ which means some people could get less healthy.

    Now the question is whether “sin taxes” help with either, I guess. I’m not sure…

  21. rob Says:

    The per person cost of long term care dwarfs those often associated with poor habits (lung cancer, diabetes, liver disease, heart attacks, etc).

    Taxing bad habits that kill people off early may have unintended consequences.

    Perhaps the folks with bad habits are doing everyone a favor.

    Morbid food for thought.

  22. theWord Says:

    Rob
    I’m sending Cheney a case of cigarettes and Twinkies. :-)

  23. Tully Says:

    Just a general point here…

    However, with the system that has been enacted today, society currently pays for the health care of a large portion of the populace.

    As things stand today (it wasn’t enacted this way, it evolved into this mess) “society” (which is ALL of us) collectively pays for ALL the health care used by the ENTIRE populace. Definitionally. Unless there’s some source of extranational subsidies I’m unaware of. What we’re arguing over is what overall level of expenditures and services should be provided, how they are to be distributed and apportioned to the consumers of same, and how those total expenditures are to assessed against said consumers.

    There is no outside source to pay for it. Saying “the government will pay” just adds another level of politically-driven admin to the collection of those monetary resources from the only real source of them, the consumers.

    “Don’t tax me, don’t tax thee, tax that fellow behind the tree…”

  24. Tully Says:

    tWord, send him beer and avoid hunting with him. Also, stay out of cars driven by Ted Kennedy. Most especially, never go hunting with Cheney when Kennedy is driving.

  25. rob Says:

    He strikes me as more of a meat’n potatoes boozehound than a twinkie-eatin’ smoker.

    But perhaps old dogs can learn new tricks.

  26. kranky kritter Says:

    We could start by rewarding preventive care — for both the care giver and the patient. If you scrupulously get an annual check up, it ought to be free (appallingly, despite all the baloney tossed around about how critical preventive care is, Medicare does not pay a nickel toward well-patient check ups).

    Equally important, if you have a free check up coming to you but don’t go, you ought to suffer a penalty — say, a surcharge on your premiums that keeps getting higher as you miss more annual checks but is reduced or eleiminated when you finally comply.

    This is just word of mouth, but I recently heard one apparently knowledgeable healthcare expert say that we all should face up to the fact that various forms of preventive care, while they lead to better health, are not net money savers. This woman says that while we’d like to think that devoting more resources to preventative care would save money, that’s a canard. The desirability of preventative care is, to reprise a previous point, a moral argument.

    It has had an economic argument attached to it, but according to the person I saw on TV, the numbers have been crunched and re-crunched, and it just aint so. Tully, have you heard anything like this?

  27. michael reynolds Says:

    Let’s not genuflect too much to “the numbers.” Lies, damned lies and statistics. It’s a question of what you choose to count.

    Do we count just the cost of care? How about the cost of lost productivity from major illness? How about the costs of a system burdened by resource-consuming too-late care that raises costs for others competing for scarce resources? Are we counting the time spent by family caregivers and that lost productivity?

  28. kranky kritter Says:

    The reason why I’ve never been able to agree fully that “health care is a right” is that so many people decline to do much of anything to sustain their own good health. To use an extreme example, if a guy puts a gun to his head and puts a bullet in his brain but fails to die, does he realy have a ‘right” to societal payment of millions of dollars in emergency care, ICU care, long-term rehab and/or palliative care?

    I don’t think such alleged moral rights exist in space waiting for us to discover them. I think they’re no more or less than what we declare and protect and provide as a culture and as a country.

    Neither doctors nor other Americans seems poised to let people like the one in your example die because we’ve decided they lack an inherent right to care. So I think it’s currently a right by default.

    In other words if the question is this:

    Do we think Americans deserve a virtually unlimited right to all conceivable healthcare measures regardless of their ability to pay?

    Then I think the answer collectively, so far, has been pretty much yes. What I think you are touching on is the general notion that America works best when rights come with related responsibilities. In your view then, the right to healthcare should be tied to the responsibility to take care of yourself physically, and this responsibility should not simply be moral. It should also be measured, monitored, and enforced.

    While this has a certain appeal in theory, my gut says that this would quickly become a kafka-esque nightmare.And a multi-ball political game. And subject to routine abuse by large companies paying bonuses to people whose job was to find ways to add surcharges for a wide variety of iffy actions. It sounds like a substantially $h!ttier word to live in.

  29. John Burke Says:

    “This is just word of mouth, but I recently heard one apparently knowledgeable healthcare expert say that we all should face up to the fact that various forms of preventive care, while they lead to better health, are not net money savers.”

    The thing about this is that you can count in dollars and cents the added costs of an annual screening check up, so that you have a quantifiable increase. But you only have guesstimates, which vary, about how much dough was saved as a result of heading off more serious illness and more elaborate care. However, you really don’t need hard financial data to know that controlling hypertension with relatively inexpensive drugs prevents more serious illnesses, including heart attacks, strokes, and diabetes, any of which would cost far more than a few pills. You don’t need hard financial data to know that pre-natal care reduces birth complications and post-natal pediatric care, And so on.

    Plus, you have to pair preventive care with affirmative patient obligations — or at least incentives for patients. If the deal is that losing weight, strengthening your body through exercise and giving up smoking will get you lower premiums, while not doing so will result in higher out-of-pocket costs to you, you’re more likely to do something to increase your health.

    At least, that’s worth a try — but conspicuously, all such proposals never even get discussed seriously. Too many fat, indolent voters who smoke and drink! Talk about special interests — the Fatso Lobby.

  30. michael reynolds Says:

    In fact, let me make that specific rather than general. Let’s say I don’t enjoy undressing for my doctor. (Actually, I think she enjoys even less.) So we miss a small skin cancer when it could be treated for under $1,000.

    It becomes a much bigger problem and eventually runs up medical costs of $100,000. And then I die anyway.

    In the year that passes from too-late diagnosis to my morphine-eased death, I can’t work. My wife can only work half as much as she would ordinarily. My kids come out of private schools into public, which is tough for my LD daughter, so she loses a degree of lifetime productivity. All of that flows from me not getting a check-up.

    He says, as he puffs a cigar while sitting on his fat ass.

  31. Solomon Kleinsmith Says:

    “We’re talking about an approach that will eventually become a single payer system for every person in the country that will have a chilling effect on innovation, access, and quality of service.”

    Sorry maestro, you can’t put words into MY mouth anymore than I can into yours. I’m not for single payer, I’m for a public option and NOT forcing anyone into anything, which is what Obama campaigned for and I’m hoping for. On top of that, I think you’re dead wrong that we’ll get single payer, at least not anytime soon. There isn’t anywhere near enough support for it, in the House, Senate, White House, or populace. Left wingers want it, but they’re about the only ones.

    “My (private) insurance company bureaucracy is worse than ANYTHING I have ever had to deal with in any government agency. They are certainly doing a good job of wasting money, preventing access (to innovative treatments), and restricting my ability to seek quality of care. This myth that large insurance companies are better than the government is just that, a myth, which is based on a knee-jerk reaction that the government is always worse. It may be, but until someone measures it, I won’t take it on faith (either way).”

    A good point. Its a silly charicature of reality to pretend that government does nothing well. It works well in some situations, and not well in others. Its been shown to keep health care costs down, but tends to provide service that does not keep up with the higher grade insurence. People who have no insurance would much rather have SOME, and people who have average level insurence can CHOOSE. Like Medicare, people can also supplement their insurence if they wish on the private market.

    “First, as I keep requesting , define “health care reform.” (What, still no takers?)”

    In the context of this post, health care reform means this particular bill, including a public option.

    “Kranky is asking the right questions there. The inherent assumption is that taxing such behaviors (or conditions — obesity, for example, is often NOT related to behavior but to genetics) will save money overall, but that’s a highly questionable assumption.”

    Actually I’m not making that assumption. My reasoning for thinking that this should be the way we pay for healthcare was described very clearly above. It will help people’s HEALTH in the long run, if they decide to consume these things less, but there are too many variables to know how this would effect the costs of any particular individual. And you argue for my point by stating the obvious, that some people will get illnesses regardless of behavior, one reason why it would be absurd to find some way of actually taxing obesity, among other things.

    “But it’s a path of least resistance to use people’s moral objections to certain behaviors as an excuse to tax the behaviors. The scapegoat principle is timeless. As my late grandfather (b.1882) used to say, “Don’t tax me, don’t tax thee, tax that fellow behind the tree…””

    What is shameless is your straw man. I thought Tully was a hard core debater, I’m fairly dissapointed so far, I have to say. My argument has nothing to do with morally objectionable behavior, only about looking for ways to fund a bill that can pass and seems fair. You even go off the deep end and start talking about prohibition later on. Are you TRYING to use every major logical fallacy in your comment to see if I notice, or are you not recognizing that you’re doing it?

    “A VERY regressive tax. Never been really poor, eh? It is indeed an unhealthy “lifestyle.” Yep, no one forces poor people to buy cheap foods with high caloric content. Why, instead of feeding a family of four on $5/day with a pound of burger, some white bread, cheese, and peanut butter, they could all have a nice healthy organic arugala salad! It’ll be a little small and not provide enough calories to last them more than an hour or so tops, but…point being, poor people eat high-calorie high-fat foods for a reason. Namely, they dislike starving so they purchase as many calories for the dollar as they can. And cheap calories tend to be high-fat and high-carb.”

    This would be a good argument… if it were true. I’ve been unemployed and/or underemployed for the past EIGHT MONTHS. I can tell you with concrete certainty that you can eat quite healthy on a small budget. Peanut butter is not bad for you in moderation, and neither is beef, if its lean and/or depending on how its cooked. Chicken filets are MUCH cheaper however, and better for you. Whole wheat bread is really not all that much more expensive than white bread, although white bread isn’t exactly terrible for you. Eggs are cheap as sin, and are again something that are great for you unless you eat too many and/or have certain health problems. I eat cereal out of the bag, using powdered milk. Canned juice is RIDICULOUSLY cheap.

    And lets not ignore vegetables… you’re argugula red herring is obviously absurd. Carrots, lettuce, potatos, onions, garlic, apples… and more… all very cheap. I get some pretty awesome deals at the local farmers market as well. You are mistaking cheap calories with cheap PROCESSED calories. Healthy and cheap foods are there for the taking, many people just choose to ignore them.

    “I am semi-serious (in my post above) about going directly to the actual source of the problem of high costs associated with certain unhealthy behaviors. Life insurance companies have for decades charged smokers higher premiums. Why not hit them with higher health care premiums (in private or public plans)?”

    I agree with you, why not? I would have included such an idea if I had written a ten page report rather than a single blog post of a length that people will actually read, heheh. If they have enough money to pay for cigarettes and/or other bad habits, they can find enough money to pay extra for their healthcare, even if its given to them by the government. It would be more difficult to find a way to do the same with eating habits… I don’t know enough about that to know whether doctors could easily, cheaply and accuratelydiagnose the cause of a particular person’s obesity (for example), especially in the face of someone who would assuredly lie if it meant their health care costs would go up.

    And several people made comments to the effect that everyone dies eventually, and the last short while before death is the most costly. Unhealthy behaviors lead to a shorter amount of time that an individual is a productive member of society. Some diseases, like diabetes, are largely preventable and massively costly to the system over long periods of time. Also, other diseases make people die in more expensive ways. The longer someone lives, the higher chance that they will continue to add to the economy, and die accidentally. Someone dying from lung cancer will spend months in acute care, running up bills into the millions. The difference between a guy who drinks himself to death in his 50′s or dies from some other ailment later on in life, is that in between he added to the economy. Late adulthood tends to be the most economically productive period of life.

  32. kranky kritter Says:

    However, you really don’t need hard financial data to know that controlling hypertension with relatively inexpensive drugs prevents more serious illnesses, including heart attacks, strokes, and diabetes, any of which would cost far more than a few pills. You don’t need hard financial data to know that pre-natal care reduces birth complications and post-natal pediatric care, And so on.

    It doesn’t sound to me like you are necessarily comparing the right costs. You also appear to be cherrypicking. Testing for high blood pressure is easy and cheap. But in many other cases, various screening tests are very expensive, and the number of problems identified via the extra care consumed is low. If we provide lots of extra neo-natal care, are we in fact sure that the total cost of that extra care is LESS than the total cost for later treatment of problems not caught sooner? Again, I don’t question the health benefits, i question the math.

    Your counter argument amounts to a claim that measurement is difficult, plus two examples where preventive care may be worthwhile.

  33. kranky kritter Says:

    My argument has nothing to do with morally objectionable behavior, only about looking for ways to fund a bill that can pass and seems fair.

    ROTFLMAO! I think you actually believe this, too! Not sure whether it’s funnier if you do or if you don’t.

  34. kranky kritter Says:

    his would be a good argument… if it were true. I’ve been unemployed and/or underemployed for the past EIGHT MONTHS. I can tell you with concrete certainty that you can eat quite healthy on a small budget. Peanut butter is not bad for you in moderation, and neither is beef, if its lean and/or depending on how its cooked. Chicken filets are MUCH cheaper however, and better for you. Whole wheat bread is really not all that much more expensive than white bread, although white bread isn’t exactly terrible for you. Eggs are cheap as sin, and are again something that are great for you unless you eat too many and/or have certain health problems. I eat cereal out of the bag, using powdered milk. Canned juice is RIDICULOUSLY cheap.

    And lets not ignore vegetables… you’re argugula red herring is obviously absurd. Carrots, lettuce, potatos, onions, garlic, apples… and more… all very cheap. I get some pretty awesome deals at the local farmers market as well. You are mistaking cheap calories with cheap PROCESSED calories. Healthy and cheap foods are there for the taking, many people just choose to ignore them.

    Some very good points there, Solomon. But realize that you are expecting behavior modification simply based on taxes. My long experience working in grocery stores suggests that there is a lack of both understanding and will.

    In general though, I agree with Tully that unhealthy foods tend to be cheaper on a per-calorie basis. I have an almost encyclopedic knowledge of unit prices on this stuff. One thing I think you are doing is presuming a level of nutritional and food prep knowledge and skill that is higher than what exists.

    I think that education geared toward the economical purchasing and preparation of healthy low cost meals is a splendid idea. I am not a particularly healthy eater, but I think that you, like I spend most of our grocery store time on the perimeter, ducking into the aisles mostly for staples. When I was doing the instant mash back in the day, I bagged thousands of orders. People devote a much higher fraction of their grocery purchases to prepared foods than you probably think.

    Maybe we can tax that away, I kinda doubt it.

  35. John Burke Says:

    Reynolds has a great example with his $1000 skin cancer that grows into a $100,000 treatment and a negative Reynolds-family impact on the economy (I’d add along the lines of Solomon’s comment above that if Reynolds lived a lot longer, he’d pay a big chunk of Medicare or Obamacare and income and SS taxes, not to mention health insurance premiums, etc.).

    But this example reminds me of the one, big obstacle to a system-wide focus on well-patient screening and active preventive care: many primary care physicians couldn’t distinguish between a potentially lethal early skin cancer and a golf ball, while many others would simply not spend enough time to be that thorough in examining a patient in for a check up. And that’s assuming that you even have a primary care physician!

    The possibilities for significant “reform” have always been and continue to be limited by the shortage of physicians, generally, and the paucity of primary care providers in particular. Docs want to pursue the specialities that pay the big bucks, and medical schools and the AMA are loathe to expand the number of docs or to facilitate the empowerment of nurse practitioners and physicians assistants to examine, diagnose and treat patients.

    I the past 40 years or so, scores of colleges in America have launched law schools, feeding a steady stream of new law practitioners into an economy demanding them (for some reason, alas). But during roughly the same period, the AMA, Association of Med Schools and others actively discouraged expansion of medical schools and numbers of graduates. I fact, there were NO new med schools opened during the 23 year period from 1982 to 2005 — and only a few over the past several years. The result? The US now needs to produce at least 30% more med school grads per year, starting right away (but it’s not going to start right away) to fill a need for 125,000 or more new docs over the next 15 years (a really short time frame for a profession that takes up to 10 years’ training).

    There is already an acute shortage of primary care docs in many locations — and in the wilds of Middle America finding the right specialist you need is often tough.

    That’s without adding 40-50 million people to the insurance rolls who will then presumably pursue more primary and specialized care.

    And the doctor monopoly also continues to severely limit what other practitioners can do.

    So while a preventive approach to health care makes a lot of sense — both in terms of cost and better outcomes — it’s simply not going to happen without a major expansion of medical training, big incentives for docs to enter primary care, and a larger role for nurse practitioners and others.

    Needless to say, that’s a project that should start today and federal support and money for it should be included in any “health care reform bill” worthy of that name.

  36. Justin Gardner - Political Pulse - Health Care: How To Pay For It & How Not To Pay For It - True/Slant Says:

    [...] how to pay for it… To fund a health care program, it makes much more sense to tax behaviors that [...]

  37. Tully Says:

    What is shameless is your straw man. I thought Tully was a hard core debater, I’m fairly dissapointed so far, I have to say. My argument has nothing to do with morally objectionable behavior, only about looking for ways to fund a bill that can pass and seems fair. You even go off the deep end and start talking about prohibition later on. Are you TRYING to use every major logical fallacy in your comment to see if I notice, or are you not recognizing that you’re doing it?

    Um, excuse me, but did you or did you not propose taxing those behaviors, and cite public approval for such “sin taxes” as being basic to passing them? (You did.) Is it or is it not true that such taxes generally result in less new revenue than projected from static projections while also resulting in increases in assorted forms of both tax evasion and organized crime? (It is.) No straw man. As I said in the other thread, I’m VERY skeptical as to funding claims. Seen such schemes fail over and over. You want to use that kind of funding, please demonstrate how much funding you believe will be produced and justify those projections using standard econometric techniques. We seem to agree that such taxes ARE highly regressive, but you seem to think that the taxes themselves will materially reduce the behaviors so as to produce a net funding surplus. Experience suggests otherwise, and a boatload of unintended consequences to go with.

    This would be a good argument… if it were true…You are mistaking cheap calories with cheap PROCESSED calories. Healthy and cheap foods are there for the taking, many people just choose to ignore them.

    Nope. I’ve condensed your total statement there for space purposes, not to leave anything out. I’m overtly assuming that “there for the taking” is not an endorsement of five-fingered discounting procedures. Sorry you’ve had money troubles — been there, done that. But you’re right, and you’re wrong. One can indeed eat fairly cheaply and fairly healthy IF one has time, mobility, market access, and really works at it. I do that myself, including buying meat in bulk and cutting it myself, and growing a fair amount of our produce (though I’m on strike against growing zucchinis, as they seem to be readily available for free in Aug/Sept…). I once spent a year or so actually homeless (living in car and on friend’s floors and such) a long time ago, which inspires me daily to never be there again. What is temporarily acceptable for a young healthy male with no obligations is not acceptable for a family. Though I’d be happy to offer tips on the nutritional content of beer, and fresh salsa and corn chips.

    BUT…go to the heart of any major urban slum and look around for your beloved farmer’s markets and good cheap produce. Good luck with that. Check the local stores there (if any) and compare produce prices and quality to large suburban supermarkets in more affluent areas. Go the local food low-income pantries and see what they offer for “packages” as staple foods. Compare the caloric content on a per-dollar basis of those foods actually readily available in very-low-income areas and compare same to the actual reported incomes and diets of the people who live there. I think you’re in for a very rude surprise. Namely, that my statements are literally true. I don’t make this stuff up. Sadly, I don’t need to.

    Some diseases, like diabetes, are largely preventable

    Hoo boy. Just not true. Diabetes is largely inherited . What it’s not is untreatable, and the earlier diagnosis is made and treatment begun (and actually followed) and the fewer exacerbating conditions (like obesity) are present, the less lifetime risk of extensive damage and associated health care costs are incurred, by reducing those associated damages exacerbated and/or caused by the condition.

  38. Tully Says:

    Kranky, for cost-effectiveness of preventative medicine you may be thinking of the cost/benefit studies on prostate cancer screening. Specifically IIRC, the C/B of routine PSA’s in men over 50.

    (Bonus psychic catcha for this one: “or mast”)

  39. Solomon Kleinsmith Says:
    My argument has nothing to do with morally objectionable behavior, only about looking for ways to fund a bill that can pass and seems fair.

    ROTFLMAO! I think you actually believe this, too! Not sure whether it’s funnier if you do or if you don’t.

    I’ll get to some of the other comments in a few hours. This one is easy and quick…

    I don’t have to BELIEVE anything about my argument, because I made it and I know what thinking it came from. To YOU this is a moral argument, and you can make it one if you like. However, you do not have the ability to make it one for me.

    Its an if then question. IF we going to pay for this particular bill somehow, what can:
    1- PASS
    and…
    2- Seems most fair.

    1- It has a good chance of passing, because of public support.
    2- Seems most fair, even more fair than other proposals.

    I repeat… I described in detail why I think it is most fair to tax these behaviors. I don’t care about what people think as far as those things being moreally objectable. My argument is we should tax the things that cause the costs. This is not a moral argument, it bascially amounts to:

    A, B & C cause X. So instead of taxing everyone, or soaking the wealthy, how about we tax A, B & C?

    If you see a moral argument there, you are projecting.

  40. ExiledIndependent Says:

    Solomon, I’m not putting words into your mouth. If you are under any illusions that a government “option” won’t quickly devolve into a single payer system, you’re being willfully oblivious to one of the most obvious unintended consequences of the government’s plan. If it’s more affordable (at first) than private options, it will destroy competition from the private sector. Ultimately a government option that is less expensive that a private option will result in a single payer system. And that will limit innovation, access, and quality as the government tries to cope with hundreds of millions of “customers.”

  41. michael reynolds Says:

    KK:

    various screening tests are very expensive,

    Blood pressure, visual skin examination, prostate check and PSA, cholesterol test, liver enzymes, urinalysis, reflex test, and a patient history can all be done for chump change and can reveal about two dozen extremely expensive illnesses. In fact, add them all up and it’s what, $500 dollars? To give a doctor an early indication of everything from diabetes to stroke to melanoma?

  42. michael reynolds Says:

    Exile:

    I don’t get how a government plan limits innovation.

  43. ExiledIndependent Says:

    Michael, the only way to support nearly 300 million people on a government-run medical system will be to greatly reduce the costs of every element in the system: medical technology, pharmaceuticals, buildings and structures, practitioners, etc. When the government finally becomes the only healthcare insurance game in town, they then dictate the prices they’re willing to pay for these systems. Since they won’t be able to pay drug manufacturers (for example) very much, AND since they’re the only customer in the US that the drug companies will have, there will be very little financial incentive to develop new drugs, treatments, etc. It’s the Wal-Mart effect, if you will. Same thing goes for device manufacturers like GE and Welch-Allyn, and HIS providers. So the innovation that these companies engage in–motivated by evil evil profit–simply won’t be financially viable.

  44. michael reynolds Says:

    Exiled:

    So we all need to spend billions on health care to incentivize Big Pharma while the rest of the world takes a free ride on the US consumer. That’s a very good argument for the role of government, and a compelling proof that the free market is not always best solution.

    Right now Big Pharma spends its research dollars less on curing disease and more on curing baldness, impotence and wrinkles. Their incentive to create, let’s say, a single pill that cured all cancer is nil. Their incentive to create a $10,000 course of treatment that didn’t entirely cure cancer is greater. Right?

    I mean, if you go to Merck and say “Hey, I have a med that will cure cancer, and it’s incredibly cheap and easy to make!” And another guy walks in the door and says, “Hey, I have a med that will partly mitigate the worst effects of cancer without curing it, but it will cost 10 grand a year for a 5 year course of treatment!” who do you think Merck talks to?

    So right now we have a system where we throw money at the free market in the faint hope that they will spend some tiny portion of it trying to cure diseases while they spend the bulk of it researching diet pills and erection pills. And this strikes you as a good way to run things?

  45. Solomon Kleinsmith Says:

    Some very good points there, Solomon. But realize that you are expecting behavior modification simply based on taxes. My long experience working in grocery stores suggests that there is a lack of both understanding and will.

    You’ve been trying to put those words into my mouth, but thats not really what I’ve been saying. Nor is it anywhere near the point of this post.

    I do in fact believe that putting a higher cost on these foods will cause them to be consumed somewhat less. Who knows how much less? Its all really conjecture. It would help if there was a public information campaign, on the level of drinking and driving, talkig to folks about how they’re hurting themselves, which someone else mentioned above and I think is a good idea.

    In general though, I agree with Tully that unhealthy foods tend to be cheaper on a per-calorie basis. I have an almost encyclopedic knowledge of unit prices on this stuff. One thing I think you are doing is presuming a level of nutritional and food prep knowledge and skill that is higher than what exists.

    I could care less what the calorie per dollar ratio is. My contention is not that you can get plenty of calories and nutrients to live a healthy life on living on, for example, unemployment, as I did for several months. Do I need to explain to you why caloric intake is nowhere near a problem for this country?

    Um, excuse me, but did you or did you not propose taxing those behaviors, and cite public approval for such “sin taxes” as being basic to passing them? (You did.) Is it or is it not true that such taxes generally result in less new revenue than projected from static projections while also resulting in increases in assorted forms of both tax evasion and organized crime? (It is.) No straw man. As I said in the other thread, I’m VERY skeptical as to funding claims. Seen such schemes fail over and over. You want to use that kind of funding, please demonstrate how much funding you believe will be produced and justify those projections using standard econometric techniques. We seem to agree that such taxes ARE highly regressive, but you seem to think that the taxes themselves will materially reduce the behaviors so as to produce a net funding surplus. Experience suggests otherwise, and a boatload of unintended consequences to go with.

    I cited public approval to support my contention that there could be enough support for it to pass a proposal through the Senate. Using the label ‘sin tax’ is merely what other people have called it. I don’t think its wrong to kill yourself slowly, its your own life and body. I never made a moral argument. You can assume one by reading in to what I say, but you would be incorrect… Hence calling you out on the straw man argument.

    And if you’re going to argue that a bum can’t get enough calories from healthy sources, then I wouldn’t argue with that. But very very few people have a hard time finding enough calories in their diets… its nutrients that are lacking.

    … and you can quote wikipedia in your contention that diabetes isn’t preventable, but I’ll go ahead and go with the American Diabetes Association’s contention to the contrary:

    Is it possible to delay or even prevent type 2 diabetes from ever developing? Yes it is. There is a lot you can do yourself to know your risks for pre-diabetes and to take action to prevent diabetes if you have, or are at risk for, pre-diabetes.

    http://www.diabetes.org/diabetes-prevention.jsp

    Tangent…

    Right now Big Pharma spends its research dollars less on curing disease and more on curing baldness, impotence and wrinkles. Their incentive to create, let’s say, a single pill that cured all cancer is nil. Their incentive to create a $10,000 course of treatment that didn’t entirely cure cancer is greater. Right?

    This would make sense if the way research worked was you had a goal, say a pill that staved off cancer for a few years longer than drugs do now, and then just inserted a billion dollars and several years worth of time and energy from scientists. The reality of it is they are constantly spending billions of dollars on research, and they never really know what is going to come out of that research. If you think a company would hold on to an actual cure for cancer, you’re bonkers.

    It would make so much money in the first few years out that it would easily recoup any amount they sank into R&D, as it would be replacing treatments that run into the hundreds of thousands and millions per patient. They don’t have a choice but to put what they find to market. Also, much of the research on these kinds of things happens at university labs (I had a buddy who worked in one in grad school). They aren’t as motivated by money, but more by publishable research… and I think they would be assured a high place in history if they found an actual cure for cancer.

    You also can’t really blame companies for spending tons of money finding pills to make people skinny or get their hairline back. There is a demand for it, so they fill that demand.

  46. kranky kritter Says:

    Solomon, I think our core point is that a so-called sin tax on healthy food would in practice certainly be regressive. Do you dispute the contention that taxes such as on twinkies and beer and cigarettes are economically regressive in effect, leaving aside their putative benefits? I think we should clear that up.

    I am delighted to acknowledge that it is indeed possible to eat a healthy diet on a low income. I would bet that Tully would do likewise. Regrettably, that this is possible does not do much to make it even semi-likely. To eat healthy on a budget requires a fair amount of will, knowledge, time, and skill. I directly observed grocery purchasing behavior for over a decade. I’m currently convinced that taxes such as those you propose will be highly regressive, and it’ll take quite a bit of evidence contrary to what I have observed to make me believe otherwise.

  47. michael reynolds Says:

    they never really know what is going to come out of that research.

    You also can’t really blame companies for spending tons of money finding pills to make people skinny or get their hairline back. There is a demand for it, so they fill that demand.

    How can both statements be true? You assert that research has no particular goal and that it does.

    Also implied is that Pharma reacts to profit and that it doesn’t, that it would trade a business worth billions — treating cancer — for a business worth millions — curing cancer.

    I’m not a conspiracy nut. I don’t think Mulder and Scully will discover that the government has a cure provided by aliens that it’s holding out on.

    I just wonder by what logic the current system — which amounts, according to Exiled to requiring American consumers to spend hundreds of billions on medicine (defined broadly) in the hopes that a sufficiently large amount of that money will find its way to useful pharmaceutical research — can be the best system.

    It’s not a question of blaming business for behaving like business. It’s the question of whether the business model makes the best sense for this sort of research.

  48. kranky kritter Says:

    Blood pressure, visual skin examination, prostate check and PSA, cholesterol test, liver enzymes, urinalysis, reflex test, and a patient history can all be done for chump change and can reveal about two dozen extremely expensive illnesses. In fact, add them all up and it’s what, $500 dollars? To give a doctor an early indication of everything from diabetes to stroke to melanoma?

    Sounds great Michael. But have you actually done the math? Have you added up the total cost of all that chump change? Have you use the incidence rates of these various afflictions in order to actually calculate whether all that extra preventative care is actually cost effective, or not?

    As I said at the outset, I saw someone who sounded very knowledgeable (and FWIW seemed credible and nonpartisan) say that when you crunch the numbers, preventative care is a cost driver, not a cost saver.

    I am happy to acknowledge that various forms of preventative care are inexpensive and can reveal serious and expensive health problems. But that doesn’t mean that in general it’s cost effective.

    For example, if a given test costs $100, then it costs 1 million dollars to give the test to 10,000 people. Suppose the incidence rate is 1% and 100 people come up positive. Did detecting the malady save $1000 per patient in treatment costs? I don’t know. But this is a very rough sketch of how you would determine whether it was in fact cost effective.

  49. kranky kritter Says:

    Oops…10,000 per patient for the 100 patients who tested positive.

  50. michael reynolds Says:

    KK:

    A very rough sketch. Because you’d need to calculate lost productivity for those who were sick, plus the ripple effect through family and businesses affected by the illness.

    Let’s say we start with a single case of malignant melanoma that might, diagnosed early, have been successfully treated for $1,000. Treatment alone for a metastasized cancer could easily run up bills of say, $200,000. Let’s say the patient is a head of family and makes 100k and by dying early his family loses 20 productive years at that amount. Let’s say the spouse couldn’t keep up with her career because they have kids and the patient needs help, so the spouse’s own 100k a year income is halved for the next five years. Let’s say both spouses were important to their employers and represented a major investment in training. More cost. At that point we’re in the low seven figures — all because a patient didn’t get a $500 check-up.

    This is hardly an unrealistic scenario. When I see a statistic that includes all of that then I’ll be intrigued. Statistics are all about what you count, and what you choose not to count.

  51. Tully Says:

    IOW, you DID say those things and make those arguments, but are claiming that you personally do not attach any moral suasion to the argument, even though moral suasion is the basis of the approval numbers. Heh.

    I could care less what the calorie per dollar ratio is.

    Poor people sure do. Did you check the link? There’s piles of research along those lines. Poor people eat high-energy-density foods because they’re cheap and available. Not even in question, a long and copiously documented fact perfectly in line with utility maximization of income by said poor. You propose, essentially, to tax the poor to modify their behavior, by raising the prices of their most cost-efficient and easily available calories in order to get them to eat fewer calories. You propose to raise the price of food in a way that will fall hardest on those least able to afford it. (It’s almost surreal that one of the major problems of America’s poor is that they get too much to eat.)

    It would help if there was a public information campaign, on the level of drinking and driving

    Um, they were pounding it into kid’s heads when *I* was in grade school, and that was back when we still hadn’t landed anyone on the moon. From having kids I know they still do so, even more so. Every poverty program I’ve ever been involved in emphasized it over and over. Every food pantry I know of passes out the pamphlets with every care package. Short of forced re-education sessions…

    And if you’re going to argue that a bum can’t get enough calories from healthy sources, then I wouldn’t argue with that. But very very few people have a hard time finding enough calories in their diets… its nutrients that are lacking.

    Who’s throwing out straw men there? I never said any such thing…unless you wish to characterize all poor people as bums. If you do, that’s entirely your own assignation and I’ll be happy to call it elitist claptrap. And no, it’s not nutrients that the poor are generally lacking. Nutritional deficiencies are blessedly rare in America, thanks to things such as the enrichment of even cheap white bread and KoolAid. It’s not what’s lacking, it’s what they get too much of. Namely, carbs and fat.

    Re: diabetes — That the full manifestation of an inherited condition can sometimes be prevented or lessened by the diagnosed existence of an earlier stage of the condition does NOT mean that the condition is, as you said, “largely preventable.” No, it’s not. ONE form of diabetes (Type 2 adult onset) is sometimes delayable or even preventable from becoming the more serious full-blown form of the condition. Note from the very site you try to selectively quote that this cannot be done at all until pre-diabetes itself is diagnosed, that pre-diabetes is itself a serious and inherited early-stage form of diabetes. I think the fair-minded will find those facts compatible with what I said above about diabetes. Anyone crunching the numbers on the phrase “largely preventable” as related to diabetes would question your statement. “Largely” implies “to a major extent” and that’s just not true.

    You claimed well beyond the realities there. And it sill begs the question of cost-effectiveness of prevention. For individuals that reward is high, but how does it quantify for population? Numbers, please.

  52. Tully Says:

    PS — You are making an EXPLICIT “moral argument” when you say “seems most fair.” “Fairness” does not exist in vacuum as a criteria. It presumes and implies moral criteria.

  53. Tully Says:

    Right now Big Pharma spends its research dollars less on curing disease and more on curing baldness, impotence and wrinkles. Their incentive to create, let’s say, a single pill that cured all cancer is nil. Their incentive to create a $10,000 course of treatment that didn’t entirely cure cancer is greater. Right?

    I mostly agree but cancer is a bad example. There are hundreds of different forms of cancer (at least) all constituting different diseases. A single “cure for cancer” is like a single “cure for viral infection” or a single “cure for autism.” Not realistic for treating conditions that have similar symptoms but multiple diverse causations.

    Cost-effectiveness and outcomes of annual PSA/prostate screening: Believe it or not, questionable benefit as compared to less-frequent screening. Just sounds wrong, doesn’t it? But true according to Johns Hopkins. Notable quote: “…no good clinical research exists to confirm that PSA screening in general reduces deaths from prostate cancer…”

    The best “preventative care” is really just regular primary care with a doctor familiar with the patient’s medical history. That good old annual checkup and look-over exam, with not all that many tests required. We need more primary-care physicians. LOTS more.

  54. michael reynolds Says:

    Tully:

    “Cancer” is a place holder for exotic orphan diseases I don’t want to look up (that kind of research ruins one’s day) and a grab-bag of more common diseases.

    I can believe that less frequent is probably just as good because the majority of prostate cancers are slow-growing. I think they push the yearly because there you are in the office getting an annual anyway. So why not bend over and cough?

    I agree: regular exam. It’s cheap and it can find a host of problems. Just caught a basal cell carcinoma — not at all threatening, but it could have been a melanoma — on a visit for an entirely different purpose. (Cool little scar on my chest. I’m thinking of going to a plastic surgeon and have it turned into a third nipple.)

  55. kranky kritter Says:

    Mike,

    Cheerfully granted that it’s a rough sketch. I am all for counting everything.

    I don’t think it’s reasonable to conclude that until someone can give you conclusive and unassailable data you’ll just stick with your preconceptions.

    We all have a tendency to muster anecdotal scenarios that support our conceptions. I’m as guilty as anyone else. Like I’ve said before, I think you can make a bitchin’ moral argument for preventative care. But if one is fair-minded, then it’s reasonable to at least suspect that the presumption of economic benefit is very questionable. More preventative care means more care provided, which means more dollars expended. Unless the additional expenditures result in greater reductions elsewhere within the system, the economic argument for preventative care is unsound.

    My take on healthcare reform is that overwhelmingly the main problem is cost. You can never make something better, faster, and cheaper at the same time. At best you can pick two and the remaining variable goes the other way. If you want to seriously reduce one, then the other two BOTH go the other way.

  56. michael reynolds Says:

    You can never make something better, faster, and cheaper.

    Computers.

    NASA flew to the moon with less computing power than my little $1200 MacBook. And they didn’t even have music.

  57. Tully Says:

    “Faster” in this case refers to speed of development and delivery, not physical speed of the item itself — physical speed of the item is part of “better.” We get things better and cheaper and faster over time thanks to technological breakthroughs. You can’t force those to happen, nor reliably predict them.

    The rule of thumb for engineering development is “Better, faster, cheaper. Pick any two out of three.”

    When was the last time we went to the moon, despite our quantum-leap better computers? Has moon flight gotten better or cheaper, or is it happening faster? Can I go visit?

  58. michael reynolds Says:

    Tully:

    I’m an Apple user. Don’t tell me Steve Jobs isn’t getting products out faster. By the time I unwrap the latest gadget it’s already the “old” version.

  59. Tully Says:

    Apple & cheaper sure don’t go together, Michael….

    But I’ll skip the “better” argument there, as rabid Apple fans are like religious zealots. With torches.

  60. Jimmy the Dhimmi Says:

    Computers are bought and sold on the free market, with cut-throat competition, and cost is reduced due to innovation in new technologies that make the old technologies cheaper.

    There are no government mandates on how the computer industry should provide products and services to their consumers, nor is there any government-managed computer manufacturer.

    In addition, while costs on older technology are constantly being reduced through market forces, the newest technology is always expensive when it comes out. A high end PC 10 years ago might cost $5,000 – about the same as today’s high end PC’s.

    The problem with health care is that nobody uses last year’s model. You don’t take medicine to manage a disease, resulting in horrible side effects, if there is a cure available. If you need an MRI, you get an MRI, not one of those old clunky X-rays from the 1980′s.

    Technically speaking, health care costs have actually fallen through the floor. If you want to get the best health care treatments available – in 1985 – they would cost you practically nothing today.

  61. michael reynolds Says:

    Tully:

    It all depends on what you count. I count the time I would spend on hold to Windows tech support people who I can’t understand once I get through. And I have to count the cost to my mental health of screaming, “Why? Why? For the love of God why don’t you work?” All that waiting and rage is costly to me.

    Don’t mess with the cult: we’ll hack your computer and make all the icons prettier.

  62. Tully Says:

    What Jimmy said.

    Funny, all my computers are Windows-OS units and none of them give me any trouble at all. Of course, I built them all, so I know good hardware was used and they were properly planned and competently assembled. And I did all the OS installs myself, so I know they’re not factory-kludged with worthless registry-clogging paid-sponsor bloatware or inappropriate cookie-cutter installs. And I declared the house a no-Vista zone before it was even released and left everything on XP, which means everything actually works and runs well.

    And if anything does go wrong, I don’t have to call anyone’s tech support in Bangladesh (I *am* the tech support — that’s why I build them right to begin with) and unlike an Apple/Mac product, I can quickly fix it myself using reasonably-priced standardized high-quality parts easily available almost everywhere.

  63. Solomon Kleinsmith Says:

    How about this… you pretend you know what I meant by something, and then also pretend that I keep arguing about how you’re seeing something between the lines that I didn’t put there? Sound good? Awesome :)

    And no, it’s not nutrients that the poor are generally lacking. Nutritional deficiencies are blessedly rare in America, thanks to things such as the enrichment of even cheap white bread and KoolAid. It’s not what’s lacking, it’s what they get too much of. Namely, carbs and fat.

    We must be living on different planets then… because I took a Human Nutrition Course last year that argued the exact opposite. We consume FAAAR too many calories in a day than we need, and are not consuming some of the vitamins and minerals we should have in our diets to be healthy. The worst of it has been mitigated by enrichment of things like white bread, rice, pasta and whatnot, but I just fundamentally disagree with you if you think that eating less calories and consuming more essential vitamins is not what doctors have been telling us needs to happen.

    And as far as the bum comment, thats not a straw man. Just laziness on my part… trying to stay active in here, write posts and keep up with the rest of my life. Insert homeless in there and move on. If this hinders the seriously minute amount of people who have the opposite problem than the rest of us (aka too many calories) then they need to have better access to food banks and other programs. If you let the smallest minority dictate policy like this, no program would ever be initiated.

    And regarding diabetes, like I said before. Argue with the ADA if you want. I’m going with what they said over you. So sue me.

    And by fairness I’m not implying right or wrong. Again you read between the lines something that isn’t there. I explained what I meant and you just decide to ignore it, in that the consumption of those things lead to the problems that lead to the costs.

  64. Solomon Kleinsmith Says:

    You are making an EXPLICIT “moral argument” when you say “seems most fair.” “Fairness” does not exist in vacuum as a criteria. It presumes and implies moral criteria.

    You keep digging yourself into a hole…

    Check your dictionary man. Words don’t just mean one thing. In the dictionary you can find several lines that describe the different ways you can use the word. The following illustrates this well:

    From Dictionary.com -
    8. Consistent with rules, logic, or ethics: a fair tactic.

    This obviously isn’t concerning rules, because its a proposal for something new, so we are left with logic or ethics. You would like to think that I HAVE to be making a moral/ethical argument here, whereas the sentences and paragraphs that follow lay out a logical argument for why this idea makes the most sense. I actually use that phrase more than once… yet I do not ever make a moral judgment. Your repeated attempts to make it seem so really are peculiar. You’d have to completely ignore the rest of the post to come to the conclusion that I’m making a moral argument… Do you always get this obnoxious when you lose an argument?

  65. The Stig Says:

    I am astonished.
    I am from Sweden and I have lived here for 3 years. I am scared to get sick and lose everything that my wife and I owe. I did get a cyst in my jaw just a couple of moth ago and now I am fighting with the insurance company for ??? rely dont know. Something must change, for me who come from a country there I can chose my doctor or hospital and the government pay that by our tax.
    But they dont tell me where to go, it is my choice.
    So my question to you all that is screaming about a healthcare reform is:

    1. What right has anyone to make billions of dollars on sick people?
    2. Does anyone know what the word social responsibility is?
    3 If you are at a dinner and 10 people attend, why shall you not split the note, everyone has eaten but only you and me pay, that’s not fair or?
    4. How much of my dollars that I pay to insurance is used to propaganda against the healthcare reform?
    5. How is it possible for almost all western countries to have a grate healthcare but to a cost that is half of what we have in Usa?

  66. Nick Benjamin Says:

    Speaking of Sweden I have cousins there. One had a degenerative liver disease. Over his lifetime he had several liver transplants. It was probably not the most efficient use of health care dollars, but they did it anyway.

    I just don’t think that would happen to him if he was American. Even if it did it would have been a huge hassle, and probably would have seriously interfered with raising his three kids.

  67. health insurance for individual Says:

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  70. Donklephant » Blog Archive » Health Care Reform Redux Says:

    […] how to try and pay for this health care reform, so it doesn’t lead to more debt. I suggested one way to help pay for some of it, but I am not aware of the idea of taxing the consumption of unhealthy things as a source of […]

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