I wonder why health insurance eligibility isn’t handled the same way life insurance is; why not allow insurance companies to market a product that provides guaranteed eligibility to “young invincibles” for a small cost that rises based on their age, but ensures they have coverage at group rates if they do get sick? The 20-something worker can decide if $20 a paycheck is worth that coverage, and the insurance company has an easy sale that evens out the actuarial charts (oh wait, government doesn’t have any of those charts).

The person to ask is an actuary. They can tell you how much that would really cost. Every extra bit of consumer flexibility is going to cost more.

But in general I like this sort of sliding scale, and would like to see it incorporated into a government plan that offers 3 or 4 levels of coverage from bare bones to cadillac. Your age when you opt into the government safety net plan determines your coverage. So if you opt into the bottom ;level bare bones at 20, you have a lower premium than someone who opts in at 27 or 32. And the same thing goes for climbing the quality scale, If you opt up the quailty scale when you get married at 28, you pay a higher premium than someone who opted in at that level when they were 19.

One connection that I think is important is the connection between ending recission and mandating coverage, say to avoid a fine as in Massachusetts. You can’t abolish recission without mandating coverage, That allows free riders at the expense of subscribers.

I know some say that mandating coverage raises constitutional issues. That could be easily worked around by using tax policy. Instaed of mandating coverage, maybe you’d fail to qualify for a refundable tax credit if you didn’t have insurance. The size of the refundable tax credit could phase in at a low point, and could be used both to encourage subscription to some coverage and to soften the blow of any tax of high-end healthcare benefits.

As for political influence on the panels I’d have to point out we currently have the opposite problem. Remember that recommendation on mammograms? Medically it makes sense because false positives in 40-something women are extremely common, each false positive leads to major stress for an entire family, stress is unhealthy, and you don’t save many lives. Politically changing that recommendation in the middle of a bitter debate about health care was extremely stupid.

The trouble with using for-profit companies to restrain costs in the current market is they have very little incentive to do so. The HMOs tried that a few years back. Cost controls were terrible PR, and gained them no business. Since the buyer of the insurance (an employer) thinks of the policy as an extra couple grand in compensation he gives his employees they don’t waste time fighting to get a good deal. Employees tend not to think about their plans unless they’re sick, or it gets on TV for excessive zeal in cost controls.

@Nick, you aren’t in the least bit concerned about the influence of politics on a government panel assessing “comparative effectiveness”? Such a panel will invariably recommend treatments or drugs that are less effective but produced by a larger corporation (and, btw, bigger political contributor) than a similar panel by an independent insurance company that is trying to restrain costs.

Nick’s faulty reasoning isn’t worth the time it would take to respond; the idea that this is “the most Conservative possible solution” is quite simply ludicrous. Still, from Nick’s self-professed vantage point in the liberal base[ment], myopia is to be expected.

At least I have reasoning.

Apparently all you have is faith that there is another, more conservative, proposal that would work, somewhere.

Until I see this proposal I will remain skeptical.

It is in no way necessary to propose alternatives to criticize a given bill as a bad one. That’s a ludicrous position.

Glad that it’s not my position, then. You said necessary, I didn’t.

What I said was that you should be willing to make prescriptive suggestions or admit that you don’t have any, if you want to be considered to be interested in good faith constructive dialogue.

So I’m glad that you have admitted that you don’t have any, because you lack the expertise. I agree that it’s acceptable to say “I think x is the wrong solution, but I don’t know what the right solution is.” Since you’ve done this, thank-you.

Who said it was your burden?

Nick did, both in the comment to which I was replying and in his reply.

Do you have any ideas you think are sensible or don’t you? In my opinion, any person that harshly criticizes a given approach should be willing to make prescriptive suggestions or admit that they don’t have any.

It is in no way necessary to propose alternatives to criticize a given bill as a bad one. That’s a ludicrous position. Like most Americans, I lack the expertise in healthcare and macroeconomics to propose specific reforms, and it would be silly to pretend otherwise. That does not mean that I am not equal to the far simpler task of recognizing the problems in specific proposals.

Nick’s faulty reasoning isn’t worth the time it would take to respond; the idea that this is “the most Conservative possible solution” is quite simply ludicrous. Still, from Nick’s self-professed vantage point in the liberal base[ment], myopia is to be expected.

One of the things that most frustrates me about this debate is that Obama gets lots of criticism for being liberal, but any bill more Conservative then the Senate bill simply would not work. You wanna ban pre-existing conditions clauses you have to overcome the adverse selection death spiral (ie: healthy folks don’t buy insurance because it’s a bad deal for them, so prices go up, so the healthiest folks left don’t buy insurance, eventually only the sickest want insurance and they’re paying $10,000 a head). To do that you need a mandate. You do the mandate and you need subsidies for the poor and middle class. Which means you need taxes to pay for the subsidies. Take any part of the program away and it all goes kablooie.

There are alternatives to this approach, but none of them are more Conservative. The NHS model makes every Doctor a government employee. Single-payer socializes most of the health insurance sector. You could implement a program that had a 100% subsidy for everybody, but that would require even higher taxes (for more subsidies), and would be a giveaway to everyone in the country.

Given that we have to solve this problem in the next decade or go bankrupt, and the most Conservative possible solution just failed because Conservatives hated it, in the long term I don’t see much upside for the Conservative movement. There’s short term upside. You’ll win in 2010, and have a much better chance in 2012. But long-term real reform will come, and when it does it will cost a lot more then ObamaCare did because health costs will be higher.

It isn’t my burden to propose alternative reforms.

Who said it was your burden? Do you have any ideas you think are sensible or don’t you?

In my opinion, any person that harshly criticizes a given approach should be willing to make prescriptive suggestions or admit that they don’t have any. At least if they want to be considered to be interested in good faith constructive dialogue.

For me anyway, that’s a big part of what I seek by blogging, good faith constructive dialogue. I like to presume that most of the people I talk with believe that they have positive insight. And I want to understand that positive insight.

Simon[,] You forget, I AM the Democratic base.

Don’t be so hard on yourself.

I am telling you they have to pass health reform or they will not get my vote. Period.

I don’t believe you. Period. You’re a smart guy, Nick; you understand that in the next Congress, you will be represented by a Democrat or a Republican, and since you’re a member of the base, you want to be represented by a Democrat. If the race isn’t close, you may keep your hands clean, because it won’t make any difference, and tell yourself that you’re not voting on principle. If the race in your district is as close as Brown-Coakley, however, you’ll vote for the Democrat, because you don’t want a Republican winning.

Obama, OTOH, kicked McCain’s ass.

Usually we’d reserve that idiom for an overwhelming victory—we wouldn’t say the Giants kicked the Bills’ asses kicked in Superbowl 25, we’d say that the year before, the 49ers kicked the Broncos’ ass. In terms of votes cast, Obama won by a comfortable margin, 52-45. Nothing more. Now, you could say that he kicked McCain’s ass if you accept the validity of the electoral college as the battleground for elections, as I do, but most of the hard core Obama sycophants reject the electoral college and have been moaning about it for years. You can have a blowout victory by recanting the heresy that Presidential elections should be decided by nationwide popular majorities, or you can maintain the heresy and concede that Obama won a narrow majority.

As far as other ideas for reform, you got any?

It isn’t my burden to propose alternative reforms.

I wonder because ten years would put us into 2020, which is an election year, during which we know nothing will happen because the sitting President will either be a lame duck or running for re-election.

I believe that the high probability of healthcare costs doubling in less than a decade will focus the minds of both the public and its putative leaders, So I can envision a lot of different routes unfolding though I wouldn’t dare handicap the likelihood of any of them. Here are a few different ones:

• With a substantially diminished majority, Obama and the democrats pass a few bills to nibble round the edges at things like ending recission. In the vaccuum caused by the failure of federal reform, various states slowly adopt their own programs for low-income folks. And over time, congress makes changes here and their to help support the states that do this.

• With a substantially diminished majority, Obama throws down a gauntlet (or makes a straightforward appeal) for the GOP to come forward in good faith for a lengthy televised public debate on heathcare, leading to another effort at broad reform. This reform also fails despite the best efforts of mostly older congressional vets, but it provides the sketch for an overarching reform that comes later.

• Due primarily to a still foundering economy, Obama is a one-term President. Republican President X is also a 1-termer for the same reason, as efforts at a market-based healthcare reform also fail. In 2017, the new democratic President passes a hybrid reform.

•Mitt Romney beats Barack Obama in 2012, and then in 2013 helps congress to craft healthcare reform that looks a lot like what Massachusetts did. Hardcore conservatives never forgive him for it, and liberals refuse to give him any credit for it even though it ends up being a lot like the bill that failed in 2010.

• Sara Palin is elected President in 2012. The heads of 15% of Americans immediately explode, solving unemployment and decreasing the demand for healthcare enough to cause deflation. Unprecedented full employment leads to an immediate balancing of the budget and a sufficient surplus to provide free healthcare to all Americans with incomes less than twice the poverty level. The constitution is amended, and Palin serves 5 terms.

I will just say one thing. The Democrats have been to this dance before. They supported the Bush tax cuts when they polled well. They opposed them later on. They supported the Iraq war in the beginning. They opposed it later on. The leaders who were most associated with those flip-flops (Clinton and Kerry) have not had much electoral success. Obama, OTOH, kicked McCain’s ass.

This will be the exact same dynamic.In June HCR polled well. So the Democrats supported it. In January it polls badly. You’re advocating the Democrats do a Kerry about-face.

—————

As far as other ideas for reform, you got any? And please don’t give me any crap about uniform national regulations on health insurers. You coulda had that with the Exchange. But you said no.

I got plenty. Except Wyden-Bennett (which is non-ideological)_ they are all to the left of ObamaCare. And if the people freaked when Obama put 10% of the country in an exchange it’s pretty hard to see why they wouldn’t freak at putting everyone in an Exchange.

If [KK is] right the Dems will lose their majorities in November. If I’m right they have a shot.

Why? You think their base is going to desert them? Those folks haven’t had a thought that wasn’t spoon-fed to them in years. They’ll show up, no matter what, because they have no choice. They’ll take what they’re given. (For illustration, consider Blue Mass Group’s base-directed post in the run up to the Massachusetts election; the headline gives you the flavor: “Yes it sucks. Yes you have to vote Coakley“). That leaves the election in the hands of the middle, and the middle is precisely where the Democrats will, as KK says, just hemorrhage votes if they try to ram Obamacare through.

Moreover all serious attempts at health reform are doomed for at least another 10 years.

No: the kind of misbegotten, heavy-handed statist sledgehammer “reforms” of healthcare that progressives want may be doomed, but that’s a good thing, isn’t it? Both for opponents of Obamacare and people who want to talk seriously about reform. Getting this ludicrous new entitlement-and-mandate boondoggle off the table opens the door to serious reform proposals. Before you can have a serious discussion, let alone consider compromises, you have to break, demoralize, and ideally exclude entirely the kooks. And quite frankly, anyone who thinks that Obamacare is a fiscally serious idea is a kook.

As for the reason they haven’t done it yet, I’m thinking that’s because they want to know what they’ll get out of the reconciliation bill.

The Senate bill has passed. If the House agrees and Obama signs it becomes law. Period.

Right. And that’s where the insufficient unanimity comes in. The house won’t vote to pass the senate bill as is. Don’t think dem leaders didn’t take the house’s temperature on this. They did. That’s why dems are taking the position that waiting for Brown to be seated is the “right thing to do.” It’s the right thing to do because they don’t have another feasible option.

I wouldn’t call that “ramming through” I’d call that normal procedure in Congress.

Doesn’t matter what you call it, or what I call it. What matters is how it would be received by the public.I’m sure it would feed populist discontent. The reason they aren’t taking this vote is that they don’t have the votes. One reason (among many) why they don’t have the votes is the perception of dem congresscritters that it woul put them on the unpopular side of public sentiment.

As for your statements on the speed of Brown’s confirmation remember that we’re not really talking about the bureaucracy. We’re talking about Gov. Deval Patrick and Secretary of the Commonwealth Galvin.

Pretty sure that there are more than 2 people involved with the mass of mechanisms and filings. The rank and file will do their jobs quickly to get it to the desks of the honchos. Deval Patrick is an ambitious guy who has become pretty unpopular locally and will be up for re-election soon. He’s not going to stick his neck out right now and slap the faces of the 52% of MA voters who chose Brown. You can’t imagine the jubilance many local folks are expressing. Patrick holding up Brown’s seating would be political suicide.

Look Nick, you may not realize it, but the sh!t has already hit the fan. Take care to notice that the behavior of democrats in the immediate aftermath involves trying not to get any on themselves.

Stubborn determination to pass the current bill as is has been judged to be a terrible move by most democrats. Might as well face it. Pelosi might be tone deaf, but some of the other folks know how to carry a tune. And the tune goes “welcome Scott, glad to have you aboard, looking forward to working with you.”

Health care reform does 3 things…guarantees coverages, lowers costs and insures everyone.

This bill does none of the above……..How is this health care reform?

Actually it does all three. Universal coverage is guaranteed by mandate, except for a tiny slice of people who really don’t want it. The cost controls are way too wimpy, but given the political firestorm they set off it’s not hard to understand why they’re so wimpy.

@Simon
You’re right that $500 a day is inflated. All providers inflate list prices because insurers negotiate a discount from the list price. Except for Medicare, which has it’s own price list (called a Fee Schedule).

Your conclusion that the problem is excessive federal involvement is wrong, tho. The problem is that the states setup insurance markets that incentivize stupidly high list prices. The current health care bill will help mitigate the problem somewhat because under it almost everyone will be insured, and not pay the f*cked up list price.

As for the “mea culpa” thing I have to point out that didn’t work very well for John Kerry. And that all 219 Dems who voted for the bill have nightmares involving the phrase “With it before he was against it.”

Doomed Says:

every intellectually honest person in this country knows we need to do something about health costs or we’re screwed

Actually the ONLY reason thats true is because the US government continues to become more and more heavily invested in the health care market thus making them the largest customer of the services the health care industry provides.

It may not be the ONLY reason, but I can offer an anecdote in support of that thesis. A family member recently had some problems which required us to look at residential treatment programs. One of them, which is in-state, charges circa $500 per day, with a suggested three to twelve month stay. So the range of potential tabs is $15,000 to $182,500, in a state where the median household income is $47,448 p.a., and most insurance programs don’t cover that kind of long-term care. Accordingly, the daily sticker price of this program is 3.8 times the total daily income of the median family in its market (47,448 / 365 ? $130), or, by way of comparison, nearly four and a half times the normalized daily cost of Harvard Law tuition.

The price is shocking because it appears artificial. It cannot be the market price for those services, because, all else held equal, it is almost inconceivable that any customer from their purported market could afford such a price. And, unsurprising if only anecdotally, none do: I am told that their clientele is exclusively drawn from medicaid.

You put those two things together and alarm bells start to sound. It seems to me that “$500 per day” is not a real (i.e. market-set) price. It’s the arbitrary number that they invoice medicaid for their services. Personally, I think there’s a false claims act suit lurking in the long grass around these facts, but for now, the point is simply that government’s involvement distorts the market. This service provider can get away with charging a ridiculous fiat price because it can levy it from the government. If it couldn’t, either the price would fall, or the company would fold and another that could charge a realistic price would step into the market opportunity thus created.

every intellectually honest person in this country knows we need to do something about health costs or we’re screwed,

Actually the ONLY reason thats true is because the US government continues to become more and more heavily invested in the health care market thus making them the largest customer of the services the health care industry provides.

No ones complaining about exorbitant housing prices. Why? Market driven and the government does not buy houses.

Automobile prices are going thru the roof….the US government is not going broke because of that.

The reason is because the US government does NOT subsidize the price of houses. the price of Big Mac’s, the price of fishing poles, the price of 95 percent of American products.

They DO subsidize health care. Thus escalating prices have a direct impact on the bottom line of the US government.

Their solution is to insure 45,000,000 MORE>>>MORE>>>>MORE>>>>americans who cant pay for their own insurance and pretend this will FIX health care.

Nothing is free. Americans realize that when they see the crap in this bill. This is not health care reform.

Health care reform does 3 things…guarantees coverages, lowers costs and insures everyone.

This bill does none of the above……..How is this health care reform?

*By “I” I mean Matthew Yglesias, and by “just thought of” I mean just read his blog.

Nick:
re “I don’t see an upside to them killing the bill”: that’s easy. Voters hate this bill. If my representative comes back to his district and says “you know, guys, I voted for this thing the first time around, but I realized after Massachusetts that the people were against it, and decided to vote against it when it came bacl,” he has a chance. If he comes back and says “I ignored the canary in the coal mine,” he’s going to be buried.

In my experience voters don’t think like that.

The guy who changes his vote made two admissions voters hate. First he admitted he doesn’t really know (or care) what’s best for his district or the country. He cared about what would save his job. Second he admitted that he had no idea what the people of his district thought about the health care bill. There is no room for this guy to maneuver. He can spin it a bit, but the spin’s pretty weak.

The guy who votes for HCR both times has an honest disagreement with most of the people of his district. He has a coherent position, which he can explain to the people of his district. He’s got some great openings because a) every intellectually honest person in this country knows we need to do something about health costs or we’re screwed, and b) the year-long process demonstrated exactly how difficult it is to find a solution everyone can live with. Moreover while support for the bill is under 50%, in most polls much of the opposition comes from the left. They’re probably not going to vote for the GOP.

I bet most Congressional democrats would prefer to be the second guy.

As for seating Brown, you’re talking legal details. I’m talking simple political calculus. And politically there isn’t much difference between Franken and Brown.