And amen to the part about how most folks stop caring about cost as soon as they discover a procedure is covered. That’s where a huge part of the disconnect lies. In the abstract, we care that our premiums keep rising at unsustainably high rates. But at the itemized level, we generally don’t care as long as its covered. That’s a big root exposed there. We feel that we care deeply in general about cost increases, but at NO particular specific instance do we care and act on it.

Kranky, its even worse than that. Consumers are usually prohibited from knowing the costs, so even the ones who care deeply cannot find out. At most you get an estimate of your “share of costs” because the contracted rate between the care provider and the REAL consumer (the insurance company) is a negotiated rate that is none of your business.

The medical field is no longer adhering to free market principles in most areas precisely because of government interference. It hasn’t for a very long time.

IMO this is substantively true. It may not be the only reason, but it’s a very big part of the problem. For whatever reasons, the system has evolved to the point where it constantly responds to incentives that we can’t discern or are even perverse.

And amen to the part about how most folks stop caring about cost as soon as they discover a procedure is covered. That’s where a huge part of the disconnect lies. In the abstract, we care that our premiums keep rising at unsustainably high rates. But at the itemized level, we generally don’t care as long as its covered. That’s a big root exposed there. We feel that we care deeply in general about cost increases, but at NO particular specific instance do we care and act on it.

(Note, the preview is bolding sections of the text, and I have no idea why — please ignore the bolding if its present when I click submit).

The medical field is no longer adhering to free market principles in most areas precisely because of government interference. It hasn’t for a very long time. Wage controls in the post war era led to health insurance as a benefit to make one employer more attractive than another. While that seems like a normal market reaction (it is), it also has the end-result of insulating insurance from the most powerful cost control … choice by the individual. It wasn’t a problem at first because most health insurance was an indemnity plan … you paid the doctor and got reimbursed, usually at about 80% of the original charge. Consumers thought about the costs then, and doctors and other medical personnel reacted to the reality by
keeping their costs in line.

Subsequent reforms, such as HMOs implemented in the 1970s, “full payment deductible” plans, etc., have only exacerbated the problem. Consumers no longer care, or even ask, how many blood tests are conducted as long as “its covered” with their $15 co-pay.

Where the medical field is truly exposed to market forces prices drop like a rock. Lasik surgery was $4,500 a few years ago, and today its $1,200. Its not “required” to be covered by insurance, and the prices keep going down. In order to attract customers, the practitioners have to be more efficient. They still meet all the necessary regulations for safety and effectiveness; they still have all the same malpractice insurance, etc. The only difference between this elective surgery and non-elective surgery is who is paying the bill.

Advances in technology, a downward force in nearly every field, don’t reduce prices in medicine. Except in elective areas, where the consumer of the procedure is faced with the choice of what to do with the money.

The same CAT scan ordered by your doctor for a problem will be billed to your insurance or Medicare at $2,400, but I can schedule a full body CAT scan … read by a radiologist … for about $800 on the competitive “preventative medicine” market. There is no difference in the scan itself, in the labor to provide (including radiologist report), or in any portion of the end result. But the fact that I control my wallet means the company providing the scans has to attract my business by providing more value for the dollar.

For my wife’s medical issues this past year, I could not even obtain an estimate from the hospital about the anticipated charges. We were not entitled to see the contracted amount because we are not the consumers. So while the scalpel was used on the patient, the consumer was Aetna Insurance. It was only after the surgeries that we saw the bill, and alerted Aetna that “lateral” and “bi-lateral” mean two different things (there was double billing on the bill).

Why did we care to see the bill? Because we’re responsible for a portion of the bill. Had we belonged to an HMO we would have never seen it.

Government has proven it cannot control prices. The only thing that comes close, the only government medical program that has come in under CBO estimates, was the much-maligned Medicare Prescription Drug Plan that uses a pseudo market idea of competing insurance companies. When I examined the best plans for my mother, there were over 40 companies offering the coverage. Many of them were national plans, including the one she choose from AARP.

So here’s a challenge: can you discuss this issue without cursing, personal attacks, guilt by association and other debating techniques? Or am I still a “tool” who is thought to be a “moron”, a “dumb schmuck”, who is “owned” by the same people who “own Rep Paul Ryan”, spouting “free market crap”?

I just want you to write some that isn’t a conservative cliche.

I can respect a conservative argument. I am tired of “let the market solve the problem” when there is no such thing as a free market and the market we have has failed miserably at everything except enriching those who are already rich.

You either don’t wish to address it, you are intentionally ignoring it, or you are blind to the reality that is the fatal flaw of all free market supporters.

A free market requires many players, it requires the ability of players to easily enter or leave, it requires an engaged, informed consumer.

The right–and by this I do not mean the libertarian segment you seem to lean toward, but the corporatist, greedy, power-hungry elite that preys on the libertarian leaners and the social conservatives who have been duped into thinking they are going to outlaw abortion–has made danged sure that the market will never work in the consumers’ favor.

That group is laughing at you every time they see you and others like you post “free market” crap like this. That group owns Rep Paul Ryan. That group owns right wing propaganda machines like Faux News who feed the conservative base this nonsense and they laugh so hard they cry when some dumb schmuck stands up and says keep the government out of medicare, or stop socialized medicine.

I don’t want you to leave, Frank. I want you to stop being a tool for the people who, if you are not one of them, hold you with such contempt that they think you’re a moron for espousing their lines.

Heck, I know you don’t believe it, but I respect you more than they do.

Or, you could just skip the articles you see with my byline.

You might like the DailyKos better. Might be less uncomfortable for you.

a) death panels, death panels, death panels–if I just keep lying about death panels, enough dumb schmucks will believe it.

b) pluck out one piece of unproven statement (government cannot run prisons as well private sector–which is not proven, only that they can short term run them cheaper–but ignore the private sector cannot even clean a school, so maybe they cannot run it better)

c) restrict freedom, restrict freedom, restrict freedom–if I just keep saying freedom, enough dumb schmucks will believe it.

d) call the government a monopoly when the problem is the private industry in the debate–healthcare–is exercising near monopoly powers and that is the problem, and they want to continue that and will fight to the death to continue raping the middle class while the right wing cheers them on

Airing right wing nonsense is not airing views. I welcome libertairan and conservative voices who are going to come here and present rationale, conservative ideas–leave the cliche’d sound bites and talking points at the door.

gerryf – yes, a form of rationing goes on, mainly due to coverage limits, pre-existing condition exclusions, etc. However, that type of rationing is less serious than a political body deciding who lives and dies, if treatment is given because of lifestyle, which drugs will be approved based on which pharmaceutical company has the best lobbyists, etc. I am always surprised that the left, with its sharp edged criticism of America’s past policies, really believes that government can do a better job of deciding health issues than the individual. And yes, Ryan does state that, and his bill helps address that issue.

I’m not sure how showing that government cannot even run a prison more economically than a state bolsters your case. Why give government a virtual monopoly in another area where it has even less experience than that of traditional government power: restricting freedom.

As to fortune cookies, guys, if you want the usual echo chamber, go visit Huffpo. Donklephant is all about airing many views. We would do well with more libertarian and conservative voices here, not less.

Just FYI, I stop reading whenever I see this phrase because 58 Dems is not a filibuster-proof caucus, and I have a hard time taking any political writer who doesn’t understand that fact seriously.

rachel, perhaps you should start reading more. The Democratic caucus is comprised of all Democratic senators and the two independents who “caucus with them”. Between July 7 and Aug. 26, the DC had 60 members; when Sen. Kennedy passed away, the number dropped to 59, and was restored to 60 when Kennedy’s replacement was sworn in on Sept. 24th. From that date until Feb. 4, 2010, the Democratic caucus had 60 members. See Wikipedia or any of the other references to it by using Google.

I don’t think that the method has even that much sense to it.

See what I mean about that irony thing? The guy whose plan you are touting is the first to say rationing is already going on, but to defend his plan you trot out the argument that any other idea will result in rationing.

And then there is

how can anyone compete with a subsidized, tax-payer funded public option?

Let me see. Within 50 miles of my house, we’ve got private companies running prisons, mass transit, school transportation, school maintenance, school lunch programs, public parks…

All of these private enterprises have come in, offered a better price and squeezed out subsidized, tax-payer funded public options.

Now, I would argue that at least some don’t offer the same quality (if my kid whose room most are afraid to enter looks at his school and say it’s not as clean as it was last year, well, some quality has dropped off).

But now, suddenly private business cannot compete with a government plan? This is the same government that conservatives love to say is rife with waste and bureaucratic bloat?

What cannot compete is a private system with bloated profits and CEOs with gold plated toilet seats that gladly take your monthly premiums and drop you the second you get sick.

You’re not even making sense.

It’s like your sitting there with a bowl of GOP cliche fortune cookies and you just pull one out and type in the results.

Meanwhile, we have solid examples everywhere in the western world that work based on a single payer system. It’s simple. It works. And the level of outcome is superior for the majority of people and at far less of a cost. This is fact.

And remember,

“Rationing is going on right now.”
–Rep Paul Ryan

The healthcare industry is anti-competitive now, and the current bill does nothing to stop that. In fact, it makes it worse with a sweetheart deal to the insurance companies. What would real competition look like?

It would start with the reforms JimS has acknowledged are good ones, eliminating the anti-trust exemption, and nationalizing the standards so insurance can be sold across state lines.

But further than that, breaking the monopoly of medical schools (same number today as in the 1970s) so more doctors can be produced, public listing of prices so consumers can choose services openly and without having to be shocked at what their co-insurance amount is, allowing more retail clinics for urgent care, etc. Putting the consumer in the driver’s seat will lead to many of these reforms. Right now, who cares what it costs if you are not paying for it?

Look, it’s really simple. A true free market could have a positive effect on restraining healthcare increases. If there was such a thing as a free market.

A free market requires many players and consumers. The ensure that, players must be able to enter and leave the market. Consumers need to be engaged and informed.

Everything about the healthcare industry precludes that, from the high cost of entry, to the deliberate attempts by the players to confuse the consumer, and the consumer’s general lack of knowledge.

One of the best ideas to introduce market forces was to have a public option. Anyone who truly believes in the market’s ability to work should have been supporting the public option, which would provide real competition for the entrenched healthcare industry.

Instead, they fought tooth and nail to prevent competition because—why.

Anyone who is being honest knows the answer. The rest if hogwash.

I have no doubts that personal behavior related to health differs somewhat from other economic behavior, because the needs and the stakes are different. But I also doubt that this means that behavioral economics declares that market principles therefore cannot be applied at all.

Personally, I don’t expect markets to “fix healthcare.” I do think that judicious application of market principles can help to control costs. Whatever market we end up with (and as long as people are making different choices and paying different prices, there’s some sort of market going on, good, bad, or indifferent), it has to be run in way that it recognizes the range of priorities that the people need, because the tail can’t wag the dog.

I’m not interested in a HC market with improved freedom and efficiency if it doesn’t provide lifetime access at a lifetime affordable cost, and so on. But I’m not interested in less free market that provides such guarantees without truly controlling actual total costs.

The problem from my viewpoint is the reliance on applying classical economic models to health care, an area in which they are doomed to fail miserably. Those who push hard for using the markets to fix health care ignore the findings in the field of behavioral economics, which runs counter to much of what classical economics assumes about human behavior in an economic system.

I don’t agree with them insofar as believing that a market-base approach can’t have positive effects. I think it can, and I think that de-coupling HC coverage from employment will have positive effects. (as would taxing subsidized HC as income) I do doubt that most people will like being placed in a position of choosing not to get healthcare treatment in iffy situations because of cost issues, but over-consumption is definitely a part of our overall problem. And it’s a part that must be faced if we are serious about cost containment.

My question about Ryan’s ideas is what does he plan to do to provide coverage to poor and unemployed folks. We know that if legitimate competition and consumer choice can be harnessed, that can help to control future costs, at least somewhat. But all that would do is help keep HC affordable for people who have decent income in the first place. What about poor, unemployed, and borderline poor folks with incomes wholly insufficient to afford decent HC?

IMO, any plan that focuses primarily on keeping prices manageable for folks who already have insurance that they can afford and ignores everyone else is tantamount to class warfare.

Poor Americans deserve reasonable access to non-emergency care. Perhaps not extremely generous coverage, and perhaps coverage for which you must run some sort of tab that would require scaled payback if and when your circumstances change. But I think that establishing some sort of public provision for the currently uninsured and those who may become uninsured due to things like job loss or catastrophic accident or illness is a moral imperative. It is for me, anyway.

The filibuster proof Democratic caucus…

Just FYI, I stop reading whenever I see this phrase because 58 Dems is not a filibuster-proof caucus, and I have a hard time taking any political writer who doesn’t understand that fact seriously.