I hear what you are saying about that sweet spot. There really is a razor thin edge between reflexive defenders of the left and reflexive defenders of the right. You can’t say anything bad about Obama without drawing out a left loon, and you can’t call Sarah Palin a lightwieght without making righties veer ballistic.

And thanks again for that article. I really enjoyed it, have recommended it to a few folks, and it has also provided some cross fertilization in my head. For example, in Frank’s post above about climate change, there’s mention of the need to share data. IIRC, that came up as an important part of bringing down overutilization. In fact maybe sharing data has some sort of uber-importance.

I stumbled onto Donklephant several months ago by googling Tully and single-payer to see what he had to say on the subject lately. (I remembered a number of Tully-dominated discussions about single-payer on CF well before the health-care reform debate really got cooking.) If my other blog continues to fall off, I’ll probably end up here more frequently, which may culminate in yet another one-blog phase for me.

It’s hard to find blogs that aren’t 1) nearly or totally without comments or 2) filled with a thousand idiotic comments. I’d say this one could use a bit more action, but that it’s still within the good range for quality and quantity of posts and comments.

I can’t get CF to load with safari, besides, it was dried up in my view.

It’s always good to know that old friends from the blogosphere are still out there, so right back at you. I have to tell you, though, that you’ve probably told me you used to be bk at least three different times after I’ve shown up out of the blue following a long hiatus, so I’m well aware of your former handle, Bri. (Oh, the Centerfield days, when I was a wide-eyed centrist in search of a political identity.)

BTW, a lot of the explanation of their lower costs probably boils down to lower administrative costs. Always remember: having 50 insurance plans to choose from means your Doctor has to know how to bill 50 insurance plans. That’s not free. Add in the 15% administrative costs the best private plans are saddled with and you’ve explained a lot of the difference in medical spending between the two countries.

Agreed. It fosters middlemen and I’m sure it adds substantially to cost. The article WHQ cites suggests that there’s a lot of doctor-ordered overutilization in the highest cost regions. I found that article to be a pretty convincing account. It just rang true to me.

Keep in mind that right now Harry Reid has 56 votes. He’s missing Landrieu, Nelson, Lincoln, and Lieberman. AFAIK only Lincoln and Lieberman are publicly committed to voting against cloture. The other two have been very careful to use the passive voice, and say things like “the bill will not pass in it’s current form.”

Here’s the Progressive scenario. Stupak is put in, appeasing Nelson. Lieberman is bullied back into sanity by being informed that if he actually helps kill the bill, or force it into reconciliation, he’ll lose all his committee assignments and thus be largely irrelevant. Lincoln realizes that if she actually votes against cloture she will lose in the primary, therefore she shuts up. Besides she’s got some Committee spots she likes too. That leaves Landreiu who may be bribable.

That may prove to be a rosy scenario. There are others. Perhaps they could start calling the public option a co-op. Worst-case they add a trigger a la Olympia Snowe and then they can lose a Dem.

BTW, there’s no way Stupak kills the bill completely. The pro-choice wing hates it, but most pro-choice Dems do not think that abortion is the most important issue in the universe. Otherwise Pelosi would have lost more votes on the left.

Good to hear from you BTW. I used to be bk at centerfield.

I think this health care reform debate has been a real fiasco for the Democratic party and the country. It’s hard to believe all the infighting among Democrats to pass something which was touted as a major Democratic goal in the last election cycle. It’s also disheartening to see how little Obama has wanted to take any substantive stands on what he wants to see in a bill.

I’m not sure the Republicans will necessarily benefit among moderates over this because I think the Republican brand is still poison and the shadow of the Bush era is still with us. But, I predict that if congress & Obama continue to look as unimpressive as they are now by next year, that we’re going to see dramatically reduced voter turnout, and 2010 will be decided by which party has the most hardcore supporters…. but with the Republican base seemingly also done with the Republican party in favor of ultra-right-wing 3rd party candidates, who knows who will benefit in 2010??!

BTW- I predict that the financial reform debate might go a little more smoothly than health care reform, but cap & trade is going to be a real fireworks show to try to push through in the midst of 10% unemployment, regardless of what happens with health reform.

It’s eye opening for anyone interested in the sort of structural changes that would be necessary to give us the same or a better quality of health care at lower costs, the types of things not sufficiently contemplated in the current congressional debate AFAICT. There’s quite a bit of discussion relevent to the idea of rationing. The question is, are you simply denying care to save costs regardless of the effect on outcome or are you effectively managing risk and prioritizing the allocation of resources… er, um, rationally?

http://www.newyorker.com/reporting/2009/06/01/090601fa_fact_gawande

Let me ask, do you think the nations you mention are “just as healthy” as us because their healthcare is just as good? You can’t blog a foot on the internet without finding a rant about how unhealthy our lifestyles are compared to the rest of the world.

Largely that’s because those bloggers like to ignore the unhealthy things everyone else does. For example we’re not in the top 10 smoking nations. The French love their wine. The Brits are notorious for drinking massive mounts of beer, but the Irish drink more.

Regardless, the Canadian lifestyle is virtually the same as ours. And they spend less on health care, but still get comparable results. Depending on how you define “ration” they do less than us — in terms of primary care in Canada there is no rationing at all. And Canadians have better access to specialists than many Americans. It’s true that if you’re Paris Hilton you can pay the best Doctor in the country to drop everything immediately, whereas the Canadian Paris has to wait in line like everyone else, but the simple fact is most of us aren’t Paris Hilton.

BTW, a lot of the explanation of their lower costs probably boils down to lower administrative costs. Always remember: having 50 insurance plans to choose from means your Doctor has to know how to bill 50 insurance plans. That’s not free. Add in the 15% administrative costs the best private plans are saddled with and you’ve explained a lot of the difference in medical spending between the two countries.

FWIW, I wouldn’t question the notion that we pay more because other nations ration care, set prices, and so on. My guess is that we pay an early adopter tax both because of our vast (but crumbling) wealth and higher demand. America is the biggest and richest market for new expensive healthcare.

Let me ask, do you think the nations you mention are “just as healthy” as us because their healthcare is just as good? You can’t blog a foot on the internet without finding a rant about how unhealthy our lifestyles are compared to the rest of the world.

Isn’t it more likely that our greater use of healthcare is due in large part to additional consumption, which is related to a lower rate of rationing of healthcare and our poorer health (at least according to many folks)?

Or do you NOT believe that Americans practice less healthy lifestyles, have poorer health because of that, and consume more healthcare because of that?

I don’t doubt that we can lower the cost of services by increasing rationing and using more and more price controls. We know that it can be done, because Canada, France, and England already do it. What I doubt is that we can control costs without diminishing the current quality of healthcare in America.

I’m for participating on blogs in the healthcare debate with my eyes open. Let’s face it, we’ve evolved as a nation to such a difficult point in large part due to indulgence, both personal and cultural. Many of us live in unhealthy ways (I know I do), and fundamentally we believe that we have the right to all care that mitigates the negative effects of this unhealthy behavior. We also believe that our lives are so sacred that we all have to right to all measures which will prolong our lives, if we so desire. [Not everyone believes these things of course, but as a culture, it’s the ethos we express through our laws, healthcare practices, and so on).

I don’t quarrel with this ethos on a moral basis. It’s a pretty high level of morals which prizes human life so highly. But as a practical matter, as an economical matter, and as a physiological matter, it’s hard to miss the fact that the moral ethos is an indulgence whose ongoing viability is reaching its limits.

So I think we should face rationing nead on, so that we undertake additional rationing practices that are, well, rational. Many folks think that Americans should have the right only to whatever care they have had the foresight to accumulate resources to provide. Others believe in a shared collective burden to do the best we can for everyone. Any basis for a compromise will involve establishing a baseline for a reasonable shared collective burden above which extraordinary services are given only to those who have made personal provisions for it.

Even though it begins collecting money soon and doesn’t begin payouts until much later, 2016 according to reports? Call me skeptical. Besides, later balance still rests on the success of later cuts. I wonder how much the dollar will have dropped in value by then.

For one thing last I checked spending started a few years earlier than 2016. For another the second decade — the one where it shaves $600-odd billion off the deficit — doesn’t start until 2019.

Your argument is economically illiterate. The rates paid in other nations may or may not be comparable to ours for tons of different of reasons. Your simple argument may be appealing to folks who don’t understand economics, but it doesn’t pass my sniff test.

Great point. Let’s try the major reason: cost of labor. Cost of labor is closely tied to cost of living, and you’ll note London, Copenhagen, and Japanese cities easily beat NYC:
http://www.mercer.com/costoflivingpr#Top_50
And whereas 1/6 of the British population lives in London, and 1/10 of Danes live in Copenhagen, only 4% of America lives in NYC.

Maybe things are more expensive in the US. The way economists test for that is Purchasing Power Parity. In other words they convert French spending to how much it would buy in the US (Purchasing Power Parity) and compare that to how much we actually spend. In theory that gets rid of artifacts caused by exchange rates.

So what does PPP say? It says that we suck. Our free-market system has a federal government that spends more in PPP than any government but Monaco, Luxumborg, and Norway. As you may expect from that data, in 2006 we spent a greater proportion of our GDP on health care than anybody:
http://www.who.int/healthinfo/statistics/en/

In other words the Brits used 8.4% of their economy to pay for every health procedure they needed, while we used more than 15% of our economy, and they are just as healthy as us.

As for the CBO analysis go back and read their take on the senate bill. Most of the deficit reduction starts 10 years after the plan is passed. So the CBO say’s that one works on a pay-go basis.

Even though it begins collecting money soon and doesn’t begin payouts until much later, 2016 according to reports? Call me skeptical. Besides, later balance still rests on the success of later cuts. I wonder how much the dollar will have dropped in value by then.

As for Medicare growth cuts, I would like to point out that Canadian Medicare pays Doctors less than we do and it seems to be working fine. So do the Germans, French, and British.

I would like to point out that I can buy a new luxury mcmansion in South Dakota for less than the cost of an old 2 bedroom starter house in Newton MA. Therefore, I should be able to pay much less for that Newton house than is being asked, and it will work out fine.

Your argument is economically illiterate. The rates paid in other nations may or may not be comparable to ours for tons of different of reasons. Your simple argument may be appealing to folks who don’t understand economics, but it doesn’t pass my sniff test. Lots of doctors already don’t take medicare. Current reimbursement rates are sometimes a problem. If you had an elderly mother like me and sometimes had trouble finding her a doctor depending on the need, you would probably understand this better. Thankfully at least we live in a densely populated region.

As for reconciliation this would not be the first time it’s been abused. The GOP used it to pass their tax cuts, and actually had to replace the Senate Parliamentarian to get those to go through.

…

I love the notion that reconciliation would poison the Senate.

The GOP side of the aisle has as its single goal to hand a defeat to Obama. The same goal in all legislation going forward. It is now their core ideology, their raison d’etre, the only approach they are allowed to take by their lunatic base.

But reconciliation would poison all that.

Whatever. My prediction stands, which is that it’ll be very difficult to get to 60 with the public option included. After moderates balk, progressives will balk more at taking it out and they’ll lead a charge to use reconciliation.

As I said, it’ll be up to democrats to decide whether its worth it. And poisoning is only a small part of it. Congress is a tradition-bound place, and reconciliation will be an affront. Mike if you think the atmosphere can’t get worse, you’re quite naive.

But as Nick points out, It has happened before, and the republic survived, right? So again, let me stress that it will be up to progressives to decide whether this reform is worth it. And I am not talking simply whether the reform is a worthwhile thing. I am talking about the political costs. If the bill goes through via reconciliation, it will mean that a very tenuous majority composed almost solely of progressive democrats pushed through a fairly drastic reform that is a very big new entitlement. The reform will be unpopular with some or even many Americans, and progressive democrats will have literally nowhere to hide.

All the credit or blame (depending on your PoV) will go to progressive democrats. If that’s what progressives want, then fine, good on them, I guess, for finally growing a pair. Hopefully, there won’t be any whining, crying, or complaining when it comes time to harvest what they’ve sown.

For one, it will be practically a given that passing this reform via reconciliation will lead to greater cuts in the democratic ranks come 2010. Looks like a yummy nail in the coffin of cap and trade, for starters.

My long term worry about reconciliation is that congress could be on its way to setting a precedent that new majorities can ram through stuff they really want using this end around. I don’t blame either side, I just blame politics. Reconciliation is potentially addictive to politicians. First its once in a while, then it’s once a session, then it’s 2 or 3 times, then next thing you know the way things get done has fundamentally changed and out stability is undermined. I think that’s worth worrying about.

The GOP side of the aisle has as its single goal to hand a defeat to Obama. The same goal in all legislation going forward. It is now their core ideology, their raison d’etre, the only approach they are allowed to take by their lunatic base.

But reconciliation would poison all that.

I appreciate that progressives want that public option real hard.

At very least, their insistence on it has served to draw fire away from the more “moderate” reforms the bill envisages. By framing this as a debate over reform plus public option or reform without public option, they’ve quite successfully forced opponents to concede the ground they wanted, viz. reform with or without the public option. Granted, some still oppose the whole effort, but they haven’t been the loudest voices. Most of the debate, it has seemed to me, has been centered on public option, yes or no. So the clamor for the public option may be overreach, but may also be a sacrificial pawn.

Yes, well, what sort of trigger she would support can be negotiated. The CBO projections are going to change anyway since the bill will be amended in other ways. Time? They can set another “deadline”!

They could change the deadline. But they really don’t want to. Under the current timeline they only have a few months to do Cap & Trade, and financial regulations reform. To do the trigger they’d hacve to write it, with input from Snowe (a few days), get it scored by the CBO (more days), send it around the Senate so any of their other 60 people could propose changes….

@Superdestroyer,
Estimates are always wrong. The Medicare actuary dude got into a lot of hot water in 2003 with his high estimate for the cost of Bush’s drug plan, and it’s turned out to cost less than Dubya said it would. The thing is estimates are all we got. The CBO’s all we got.

It’s a given that if we don’t do something major our budget is screwed. Period. This is something major, and the guys who do the estimating think it will fix most of the problem.

@kk
I think you’re a bit too pessimistic on the bill’s chances to get to 60. They’re at 56. Worst-case scenario they kill the public option completely and they get to 60 (Lincoln, Landrieu, Nelson, and Lieberman, plus Snowe, minus Burris). Lincoln is tough, but a primary threat may moved her. Nelson actually thought of the Opt-Out, and Landrieu has never said she personally opposes the public option. She’s said it won’t get to 60. Lieberman is hardest because nobody knows what that guy is thinking. But a lot of people, including many who know him well, seem to think his threat to vote against cloture is a bluff.

As for reconciliation this would not be the first time it’s been abused. The GOP used it to pass their tax cuts, and actually had to replace the Senate Parliamentarian to get those to go through.

As for the CBO analysis go back and read their take on the senate bill. Most of the deficit reduction starts 10 years after the plan is passed. So the CBO say’s that one works on a pay-go basis.

As for Medicare growth cuts, I would like to point out that Canadian Medicare pays Doctors less than we do and it seems to be working fine. So do the Germans, French, and British. For all the crap the Brits throw at their National Health Service the day after a prominent Tory blasted it on Fox News Labour called him a traitor, and the top-dog Tory referred to him as “eccentric.”

It should be noted that all the costs that affect us also affect the Europeans. The French especially — their population is in decline, and that only happens if most of your country is really old.

So IMO your assessment that we can’t cut cost growth, even 2 points, is a bit pessimistic. I’d also like to point out that if we can’t cut cost growth Medicare is bankrupt in 10 years. That’s bankrupt as in “totally out of money,” not bankrupt as in “expenses are higher than costs.” So basically you’re arguing that, to protect the benefits people receive five years from now we should guarantee that nobody receives any benefits in a decade.

I appreciate that progressives want that public option real hard. That’s why we hear progressive congressfolk complaining that moderate dems “shouldn’t” be driving the debate. But “should” has nothing to do with getting to 60, and progressives will have to swallow that sooner or later, or go home for christmas with an empty sack. Or use reconciliation.

The only way this bill gets through at current costs and in current form is if Reid opts for reconciliation. That’ll poison congress for most other efforts, so the dems must decide if its worth it. Especially given that the GOP would then be guaranteed to use reconciliation in at least one painful showy place the next time they get a majority. Anything that makes this procedure veer towards common represents a fundamental change in how congress operates.

Nick has consistently relied on the CBO estimates in claiming that this plan would be a deficit reducer. Right or wrong Nick, many folks are not buying the projections, for several important reasons.

One is that the CBO analysis’s time frame perspective includes collecting money for the plan for awhile before beginning payouts. This means that the plan is not in balance on an annual pay as you go basis. In my view, if a plan isn’t in balance on a pay-go basis, then it’s not balanced. I am not down with concealing the unbalanced nature of the plan and putting off dealing with the need for the plan to be balanced on an annual “collect x, spend x” basis.

Two, many folks, not just conservatives, are concerned that the planned cuts in the cost growth rate for medicare reimbursements are very unrealistic. It would be wonderful if we could keep medicare cost growth to a few percent per year. But if insufficent provider reimbursements threaten the viability of participating hospitals and doctors, the plan will fail pretty quickly, and possibly foster a crisis where folks on medicare can’t find someone willing to treat them. Or it pushes the costs out onto all the federally unsubsidized healthcare consumers, namely, middle class folks and businesses. it’s easy to demonize businesses, but anyone who has worked for a big company over the last decade knows that high growth in healthcare costs has led to wage stagnation.

Here’s the thing for me. I support in principle the idea that low income folks deserve healthcare, and that it’s a moral failing of our system that poor folks have little more than emergency access in many instances. But the ruthless math says that the money for providing care has to come from somewhere. Progressive supporters are trying to sell this plan by telling the people who think are going to pay more under the reform plan that they won’t be paying more. And progressives just aren’t convincing that group.

I for one am completely unconvinced. I expect that if the plan passes in its current form, we’ll have lots of trouble with medicare provision, and that costs for folks in plans not subsidized by the government will rise at a troubling rate. Nothing progressives have said about this bill gives me any reason whatsoever to think I am wrong about that. You can cite the CBO accounting till you are blue in your keyboard fingers. Or claim saving via fraud reduction.

In the end, this is a demographic issue. The raw numbers of folks who will be getting subsidized care is going to create too bug a cost be covered by mandated ceilings on reimbursements and reducing fraud. So the only way it passes with 60 votes from the senate is if it includes a convincing story about its cost and who pays. That story has to convince senior citizens, doctors, hospitals, and at least some folks with incomes above the median.

It is hard to take the CBO estimates seriously since Medicare and Medicaid cost estimates were not within an order of magnitude of being correct. Subsidizing health insurance to below market costs will encourage people to purchase it and will cause more people to demand the subsidy.

If you read the progressive wonks, they all want single payer, tax payer subsidized insurance so that the medical insurance companies can be put out of business. That i s why the current bill is designed to fail by covering fewer people than planned and by costing much more than estimated.

How can health care spending go down given the push for open borders and unlimited immigration, the lack of tort reform, and the push to pay for every fad remedy?