Jane Haddam’s WordPress weblog

Sunday Sunday. Or Maybe Sundae

with 11 comments

So it’s Sunday, and things should be pretty calm around here, with Bach, or Mozart, or Charles Mingus. 

But that’s not going to happen, so some notes on the comments on the last post.

1) Michael’s post was a perfect example of exactly what I was talking about.

The shutdown was Christmas in October for the Obama administration on the subject of the launch of the ACA.

A lot of things went wrong–and continue to go wrong–with that launch, and none of them had to do with the shutdown.

But when the screwups continue to cascade, the administration can go, “look! it was the Republicans who wouldn’t open up the government and give us money!”

In reality, h owever, not that much of the government every actually got shut down, and the administration had considerable discretion in what it decided to call “essential” workers and what it didn’t.

We’ll leave for a discussion at another time the administration’s decision to reduce rations to troops in the field to two meals a day while funding NPR with$1.4 million.

But the fact is that HHS was not subjected to shutdown austerity at all.  It was kept fully up and running and operational all through the sixteen days of the shutdown. 

Granted, it couldn’t get any more money, but we’ve already spent about a billion dollars trying to get this thing operational, and you’ve got to wonder why that wasn’t enough.

2) No, it WASN’T because the system had to be in compliance with HIPPA.

Or, if it was, the attempt failed.

One of the biggest issues with the system at the moment is exactly that your personal information is not secure. 

The way this thing was set up, if you’ve put your information out there, it’s pretty much up for grabs. 

3) Admitting the obvious–that this thing has been badly implemented–is not the same thing as saying you’re opposed to government provision of health care.

4) Neither is pointing out that this particular bill was a very bad bill–a VERY bad bill–on about fifteen different levels.

It was, in the first place, corporate welfare for insurance companies on a grand scale. 

It was, on top of that, the most blatant example I’ve ever seen of the complete betrayals of democracy.

Instead of passing the actual law, what it did was to go “the secretary will decide” on literally thousands of different questions.

In other words, it gave Katherine Sebelius the impression that she’d inherited the divine right of kings, and she’s been using her power that way ever since. 

That’s the real issue behind the “contraceptive mandate.” 

An issue like that should have been debated in Congress and only passed by elected representatives. 

Instead, it will go to the SCOTUS, and if the SCOTUS lets it stand, that will be the end of freedom of religion in the US. 

Because freedom of religion doesn’t mean going into the privacy of your home or church and believing things and praying.

It means living your religion day by day, identifying yourself with it and using your actions and words to set an example of how that religion is to be lived.

And no, don’t tell me that this means religious employers will be allowed to “deny access” to birth control to women who don’t believe as they do.

There’s no denial of access involved. 

The condoms and the diaphragms and the pills will still be in the drug stores.  Consultations between doctors and patients will still be private.  You’ll still be able to get a prescription for birth control pills–or even the morning after pill–and go get it filled.  You’ll just have to use your own money.

And since most birth control is dirt cheap, the use your own money thing won’t deny anybody access either.

5) Anecdotes aren’t evidence, and that anecdote isn’t even an attempt at evidence in the direction of how awful it is that the US doesn’t have “unversal health insurance.”

I’m sure some people don’t go to a doctor or a hospital because they don’t have the money. Some people don’t go because they have to be forced at knifepoint to go under any circumstances.

But lots of people do go, even when the money is tight.  The largest difficulty with that is that doctors and hospitals are not allowed–get that, NOT ALLOWED–to charge patients anything less than Medicare pays.

But on top of that–why is NOT going to the doctor or the hospital when it isn’t necessary a bad thing? 

Since the people in the examples given were all right significantly after the event, then the visits would not actually have been necessary.

6) Canada may or may not provide health care for “everybody,” but the ACA won’t.

The administration’s own estimates are that it will cover only about half the people who were uninsured at the time of its passage, and will not–without further legislation–ever cover any more. 

The issue is  not the “working poor.”  The issue is people who do not work for giant corporations, who own their own small businesses or work freelance, and who therefore have to buy their insurance in the individual market.

Every single plan available to me will  be at least twice as expensive as the cheapest insurance available to me as of January 1, 2013. 

Of course, it will be that much more expensive because it will provide me with all this new, extra coverage!

The problem is that I don’t want any of the new, extra coverage. And I don’t get a choice whether to buy it or not.

7) I have always been a big fan of single payer, and I am now, but I am not naive.

What we should have had was a system that got rid of Medicaid and put everybody into what is now the Medicare system.  The roll out would have been a lot smoother, the confusion would have been a lot less, and it would have been operational a lot more quickly.

But there is no chance in hell that we will ever have a system here that BARS private medical care.  Any public system we erect will have at least some competition from doctors and hospitals that choose to operate outside the public system (that is, not accept government funded patients, as some places don’t accept Medicare patients any more) and some patients who will choose to pay out of pocket for everything rather than deal with waiting lists, restricted choices of doctors or health care plans that carry coverage for things they don’t want or even actually object to.

Actually, that was already happening long before the arrival of the ACA. 

At least some of the people who don’t have health insurance in this country are the very richest among us.  Concierge doctors take only very limited numbers of patients, who either pay entirely out of pocket whatever the doctors may ask for or pay a premium (around $7500 to $10,000 a year) over what their insurance companies pay.

In return, they experience no waiting times for anything, and in the most expensive practices, they even get housecalls.

Most hospitals these days are perfectly happy to take cashier’s checks for prime private rooms with no waiting and first-in-line access to surgical facilities, MRIs, cat scans, and the rest of it.

 Any government system will not only not fix this, it will accelerate the trend.

In England, the government provides that NHS and does not much regulate private insurers, so in that system, the middle class has been steadily bailing for private insurance plans for decades.


Written by janeh

October 20th, 2013 at 10:41 am

Posted in Uncategorized

11 Responses to 'Sunday Sunday. Or Maybe Sundae'

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  1. A:” No, it WASN’T because the system had to be in compliance with HIPPA.”

    B:”Or, if it was, the attempt failed.”

    I must note that the truth value of B, that the attempt failed,does not negate the possibility that attempting to comply, across multiple states, multiple independent data systems of independent agencies while insuring compliance with individual state insurance requirements etc., etc., etc. was in fact the cause of the failure.

    Nor does it mean that the act is itself worth saving, that it will or is capable of in fact producing the intended result.

    What we can know is that the ACA is essentially the same system as originally proposed by the conservative Heritage Foundation and implemented by Romney in Mass. – without bankrupting Mass.

    Is it working as well as it was supposed to in Mass.? Reports are, surprise, conflicting – but the whole thing did not crash and burn upon implementation so we can know that at a state level – which is where the ACA was supposed to primarily work – the mechanics of running it are feasible.

    And, on the national scale, what was the big difference between implementation of the Mass. system and the implementation of “Obamacare”??

    Republican obstructionism.

    Further, while HHS may have been “fully funded” during the shutdown, and certainly before, not the Secretary, not even the President, is fully free to just reallocate the HHS budget any way they choose.

    Yes, in one part they get a block of money ‘a’ to accomplish the missions ‘x,y,z’ of the agency and the secretary gets to allocate, through whatever process, where the money goes. But a some number of the programs the agency is tasked with administering are funded separately by specific acts of congress, and the Secretary can’t raid those budgets to shore up another project that’s running into problems it needs cash to solve.

    Which not to say that the ACA as written can or could have opened better – but the odds would have been a whole lot better without conservatives at every level doing everything in their power to delay, disrupt and sabotage the entire effort.

    “Anecdotes aren’t evidence, ”
    Well, true, but no one here seems to pay any attention to numbers, or only responds with, yes, anecdotes, and, well, as anecdotes go that was a well written and rather complete one.

    That did, along the way, include some actual numbers. Which ARE evidence, even when embedded inside an anecdote.


    “Some people don’t go because they have to be forced at knifepoint to go under any circumstances.”

    And those are the people who end up with the wholly preventable, and extremely expensive diseases to treat when they are finally forced by said illness into a doctor’s office or an emergency room via an ambulance ride after the heart attack or collision with an uninsured driver while driving their care with liability only insurance or whatever.

    Then, never having contributed a dime to healthcare, they become massive consumers of healthcare indeed.


    “..why is NOT going to the doctor or the hospital when it isn’t necessary a bad thing?”

    Well, the partial answer is that while severe diseases are still rare, so quite often it will indeed be the case that a doctor’s visit “isn’t necessary”, it is nevertheless the case that, e.g., early detection of some cancers can result in a complete cure. If that small irritating blemish is in fact a skin cancer, then removing early it is almost 100% effective against any further problems.

    Nearly every death from skin cancer is a direct result of not seeing a doctor in time because it seemed to the individual that it “(wa)sn’t necessary”.

    And of course once they realize they’re sick with a disease that requires serious medical attention so they don’t die post haste, suddenly they’re very, very happy to see doctors and hospitals. But at this point the care is very, very expensive – and the new health care consumer sure as hell can’t afford to pay for it. And it gets complicated as hell at that point.


    “The issue is not the “working poor.”

    I suspect they would disagree, vehemently. At least the ones with families. Many low income individuals of course are young and healthy, still under the delusion that they are both immortal and immune to disease and accident, and,yes, they tend to now want to not pay for any health insurance, even when they’re working for an employer that offers reasonably priced health plan alternatives. But any insurance plan is a bet between policy holders and the plan providers over whether or not the individual will need a payout. For the plan provider to remain viable he needs to be taking in more money than he is paying out, i.e.,by necessity some if not most people are paying for something they will never need, or will have paid more for than the benefit they receive. That’s the insurance game.


    I also agree that simply expanding Medicare to everyone (and retiring an aircraft carrier or three if necessary to pay for it) would be a far more intelligent alternative.

    But perhaps the only way the U.S. will ever get both parties to actually focus on an actual solution would be for the ACA to fail and get repealed — and then we just wait for the ongoing income/demographic shifts plus spiraling health care costs to finally break the system. If enough nominally middle class white Republicans start finding health care unaffordable maybe they’ll finally decide that something can be done.

  2. I will continue the discussion started in “liberal, Classically”. Michael, I have a quite extensive math education, including statistics and interpretation of experimental results. One of the basic lessons is don’t compare apples to oranges.

    The table of life expectancy with the US at number 33 uses only 1 parameter. Why do you think comparing the US to Denmark or Singapore or The Netherlands is significant? Those are geographically small
    countries with populations much smaller than the US.

    The table I constructed uses two parameters, population and life expectancy.

    Size matters. Australia has 22 million people. More than half of them live in 5 cities (Sydney, Melbourne, Brisbane, Adelaide and Perth). You can get good medical care in any of those cities. If you happen to live in a town of 1000 with the nearest GP or dentist 2 hours drive away, then you have problems! We have had a Medicare system for over 35 years and we still haven’t solved the problems of providing good rural health care.

    Cheryl, the mix of private and public hospitals may actually reduce waiting time. People with private medical insurance can use the private hospitals for non-urgent care and free up beds in the public hospitals. (Examples of non-urgent include cataract surgery, hip joint replacement and enlarged prostate)


    20 Oct 13 at 3:27 pm

  3. What can I say? Jane’s right. Michael, in his firm conviction that people are incapable of making their own decisions about their own lives, tends to evade issues.
    Note, for instance, Obama was offered pretty much a blank check on swapping the sequester around, which would have let him funnel even more money into the web site. He threatened to veto any such law. And while the Romney program didn’t “bankrupt Massachusetts” it more than doubled the cost of individual insurance policies. Obamacare is on track to do worse. Everything which would increase costs was added to the program, and cost control measures were watered down and postponed. And of course Federal control of the citizenry will increase.

    For what it’s worth, I expect eventually they’ll get the web site fixed–but all the administration’s special friends are doing VERY well out of all this.

    As for privacy, if you want something to be private, don’t put it in an Internet database–as the Army and the NSA most recently could tell you.


    20 Oct 13 at 3:31 pm

  4. “…while the Romney program didn’t “bankrupt Massachusetts” it more than doubled the cost of individual insurance policies.”

    >>”Using data for average health-insurance premiums from the federally sponsored Medical Expenditure Panel Survey (MEPS), this report suggested that, up until 2008, these reforms led to a relative increase in health-insurance premiums. This report was cited numerous times by opponents of Romney and helped fuel the belief that Romneycare caused health-insurance premiums to skyrocket in Massachusetts (even though Cogan et al. did not make this claim).

    However, new data has come out from MEPS covering through 2010, and this data tells a rather different story. It instead suggests that Massachusetts’ health-insurance premium growth declined relative to the nation as a whole in the years since Romneycare has been enacted. From 2006 to 2010, employer-sponsored health-care premiums for a family rose about 19% in Massachusetts, while they rose about 22% in the U.S. as a whole. Compare that to the period between 2002 and 2006, when Bay State family premiums increased 40% and US family premiums rose only 34.5%. Family premiums went from growing faster than the national average to growing slower than it.

    Family premiums have seen the greatest reduction in growth since Romneycare; individual premiums have also slowed their rate of growth, though by not as much. In the four years before the passage of Romneycare, individual premiums in Massachusetts increased 32.7% in the Bay State, compared to 29.1% for the U.S. During the four years after its health-care reform, Massachusetts saw individual premiums increase 21.7% while U.S. premiums climbed 20%. The gap between the two growth rates narrowed after the passage of Romneycare.

    Furthermore, for both family and individual premiums, the rate of growth fell below the national average in the period between 2008 and 2010. And the average family premium actually declined from 2009 to 2010.

    Another way of looking at the cost of health-insurance premiums is to compare the average Massachusetts premium to the average U.S. premium. Here, again, the data suggests that the health-insurance premium gap has not exploded after the passage of Romneycare. In 2006, the average family premium was 8% bigger than the average U.S. premium; in 2010, it was only 5.3% bigger. The individual premium in Massachusetts rose from 108% of the national average in 2006 to 109.6% of the national average in 2010. That is an increase, but it should also be kept in mind that the individual rate’s size relative to the nation as a whole fell from 2009 to 2010 and was even larger relative to the national average in 2004, long before the passage of Romneycare.

    Numerous other states, from New Hampshire to Illinois to Florida, have higher average family health insurance premiums than Massachusetts does. By 2010, Massachusetts had the third-lowest average family premiums in New England (Vermont had the lowest, and Maine’s family premium was $30 less than Massachusetts’). Often held up as an example of a successful “red state” model on health-care as well as other issues, Texas has been less successful at slowing the growth of premiums than Massachusetts. The gap between these two states has shrunk since Romneycare has been enacted. The average family premium in Massachusetts was about $600 more than the average family premium in Texas in 2006 ($12,290 vs. $11,690). In 2010, the difference between average family premiums had declined to less than $100 ($14,606 vs. $14,526). So if health-insurance premiums are skyrocketing in Massachusetts, solid rocket boosters must be attached to Texas’s premiums.”

  5. Me again. I was going to write about how my preferred solution–an expansion of Medicare–differed from Jane’s single payer. But I realized that it wasn’t important. The IMPORTANT thing is to maintain a private health sector with unregulated profits. To understand why, perform a little thought experiment.

    Imagine a biochemist coming to the CEO of an Obamacare regulated health insurance program. Our biochemist has just invented Miracle Pill. Taken once a year, it cures everything from the common cold to old age. It would retail for a dollar a pill. What does the CEO do? (Remember, as Michael F has explained, I am a machine for maximizing profits.) What I do is kill the biochemist and bury him in the back yard. I am allowed a fixed percentage of revenue as profit. If I make medical care radically cheaper, even expanding my market share isn’t enough. If the cost of healthcare seriously declines, so do my profits.

    Now imagine the same biochemist with the same pill showing up at Health and Human Services. What does Sebelius do? (Remember she, like any government bureaucrat, is a machine for expanding her power and selling favors.) She, of course, buries our scientist in the HHS parking lot. If healthcare costs less than lipstick, her entire bureaucracy is doomed.

    Third time is the charm. Imagine our biochemist arriving in the office of a venture capitalist with unlimited potential for profits. The first year, he sells the pills for a million dollars apiece to Donald Trump and his close friends. The second year, he sells them to everyone in the West for $1,000 each. The third year, he gives them to the entire Third World for $50 each, paid for by UNICEF.

    Alas! The political world is filled with people who would be more concerned with our venture capitalist’s “obscene” profits than with the lowering of healthcare costs to almost nothing.

    Let’s try very hard to make sure someone has an incentive to invent and market Miracle Pill. It tends to get lost in the argument over “free” sex change operations.


    20 Oct 13 at 4:53 pm

  6. I don’t live in the US, don’t pay taxes to the US, and don’t use its medical facilities. Therefore I have no reason to follow the details of the ACA.

    But I did spend 40 years working with computers and given what I have read of the ACA requirements, I would not have submitted a bid on the system.

    The requirements are a programming nightmare and could serve as a textbook example of a system which will be very difficult to implement.


    20 Oct 13 at 6:02 pm

  7. John (and Robert), I don’t think a parallel public/private system improves matters because(a) that there are limits on the number of physicians and surgeons of all types, not all of which limits are imposed by the governments, and where there are shortages, the public system will lose out and (b) the private system can make more money by cherry-picking the simple and profitable procedures and leaving the extremely expensive ones to the public system, thus putting up public system costs on a per person basis, and causing managers to try to cut public costs without realizing (or perhaps admitting) why they are high. I have somewhat less faith in the private sector than Robert does, although also less faith in the public sector than Michael does.

    Mind you, the US approach to health care for everyone seems to be set to become the worst of all possible worlds, if it isn’t already. And I know you can get excellent health care in the US without being extremely wealthy – I have and have had relatives living there who have gotten health care, and no one in my family ever was wealthy, although most of us have avoided poverty. It’s just that the procedures by which you obtain this health care seemed unduly complicated and expensive even before these latest changes.


    21 Oct 13 at 6:28 am

  8. I might dispute “faith” Cheryl. I do believe that absent a government preventing it, certain things are true, among them that (a) someone will do ANYTHING for money, provided it’s enough money to be a decent return on investment and the buyer insists on what he wants, and (b) that the stupid and inefficient will eventually run out of their own money and be unable to waste any more. I think both those can be proven, or are inherent in the definition of a private sector. But neither of these things is necessarily true of government agencies.

    Note I did not say that, for example, absent government the private sector will deliver things promptly and efficiently, or even that it is inherently more efficient than government. There are reasons for anti-trust laws and for “infant industry” measures–and reasons they’re hard to get right.

    Michael, that was an interesting comment last, but it didn’t refute my initial statement–that in the first two years of RomneyCare the price of insurance on the individual market roughly doubled. You–or rather HuffPost–are using the big company policies to hide the damage done to freelancers, and using a longer timespan to include later cost control measures not included in the initial plan.

    For what it’s worth, I’m sure eventually even the Federal government will make the website work, and that if there still is private healthcare in the United States in ten years, the cost control measures Obama and company postponed and watered down will be implemented. Whether this will be called proof the initial structure was always right, the gutting of ObamaCare or calling in the adults to fix Obama’s mess will depend more on who implements the measures than on what measures are implemented.

    I’ll guarantee you this, though: the longer the law and the larger the supporting bureaucracy, the more buying a cabinet secretary, senator of US Rep becomes a good investment. Large complex government is inherently corrupt–which means it is NOT the friend of the powerless.


    21 Oct 13 at 7:27 am

  9. Cheryl, I take your point that parallel private and government medical systems do not necessarily improve matters. But unless we want to live in a totalitarian state, where only the “benevolent” government system is by law allowed to exist, it is still better for those who can afford it to use the private system and leave the government system to those who can’t or for whatever reason, don’t wish to use private medical practitioners.

    Here in Oz, at least, the government’s Medicare system is roundly despised by everyone who has ever had dealings with it except for a minority of idealogists who hate private enterprise of any description.

    I’ve used both private and government hospitals and have had nothing but excellent care in both. But the government hospitals are relative pig-sties compared to the private hospitals and most of that seems to be due to low staff morale and shoddy supervision, compounded by union obstructionism.

    I’d sell my house rather than rely on the government system should the need ever arise.


    21 Oct 13 at 8:25 am

  10. We’re fortunate in our public system, then. I’m surprised that the Australians don’t lobby as vociferously for improvement as the Canadians do – but perhaps the easy availability of the alternative reduces their motivation to improve the public one.

    Canada does have private medical care – but the general rule is that practitioners have to choose one or the other – most physiotherapists, for example, and all dentists are in private practice. So are some doctors hired by certain organizations (the semi-government group that runs the program for workers injured on the job springs to mind, and insurance companies hire them too). Private practice also includes those who have (or want to) open specialized clinics that cater entirely to the private individuals, healthy youngish people who want joint replacements, or (IIRC) people who get their hernias fixed at a hernia hospital in Ontario that was grandfathered in.

    No one seems to think they can make a profit from running a private general hospital, not without having the government pay for the care of the more expensive patients – and, moreover, doing it with the staff that can’t be lured away into the private sector.

    You get a blend of public and private care in personal care homes and nursing homes, too. In the current incarnation, all the personal care homes are private businesses, although inspected by the government and run in close association with the local hospitals. There’s some variation in prices and facilities. If you need more than Level III care, as we call it here, there are specific criteria, you CAN go to a private business, but most people go public, and the local facilities – one of which I know very well – are fine if not fancy. The two private options are (1) not for anyone without vast sums of money and (2) somewhat more affordable (although much more expensive than the public option), but allegedly not capable of providing good care, largely due to economizing on staff numbers.

    Private health care doesn’t always work well, and isn’t interested in trying in cases where they can’t make much of a profit, if any.


    21 Oct 13 at 10:20 am

  11. Oh, and if I do end up with a prolonged stay in our public nursing homes, I might well sell my house to pay for the cost. The rule is that you pay your way until you have no more assets (with some exceptions like money for a funeral and, I think, if you have a surviving spouse who needs it, the house), and then the government pays until you die.

    I don’t have a spouse and I’m not one of those people who plans on giving all my assets to my relatives and then presenting myself to the home as penniless, so I’d expect to pay out my savings and other assets for my care, should that turn out to be necessary. That’s what they’re for.


    21 Oct 13 at 10:24 am

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