Monday, January 31, 2011

Open Health Care Thread

This post is to transport a conversation that was happening over on facebook. I'll post the immediate comment and then my response to it, and then we'll go from there. This post is really about asking questions of those who oppose the recent health care law and/or government health care in general.

The basic question: what do you propose instead to solve the problems of health care and provide coverage for the 15% of Americans who don't have it?

Here's the previous comment:

Where do you get your 15% of uninsured number? I would like to verify that stat as there are many numbers flying around out there. You want ideas, here are few that pop to mind. I may adjust them as I think about and research them a bit more.

Secondly, I agree with Durham that opening state lines would increase competition. Just look what Geico has done to the auto insurance. Right now there are 3-4 insurance groups in MN that we can choose from. Next, I would make insurance portable. Meaning that I should be able to purchase a plan and move it with my family, no matter who my employer is. We could also group "like" families together in coops to purchase group plans, Those that want GOlD plans with small deducts could be in a group, those that can only afford high deduct/hsa would be grouped together. Those that are in poverty, could be grouped in another group to buy discounted basic coverage insurance.

I am not a huge fan of the way MN has it MN Care, but it is an option for those out there who cannot get/afford other insurance.

I would also like to see a menu at the Dr. office. When I have to decide on care, I would like to know what it is going to cost me/insurance. Under either system, the patient rarely knows the cost of procedures until the bill arrives.

TORT reform could go a long way to curb expenses. Dr. would be able to buy insurance for less, therefore charge less for services and still make money. The medical field is not a cure all, it is a practice that does the best it can to help people stay/get healthy.

You stated that there are only 2 options: Either we provide MORE care to the uninsured, so that they can get cheaper preventative care and treat things before they become emergencies. You're on the record as being opposed to this. Are you still? Or we deny people care. And that means, quite literally, letting them die. This is not true. This is where charity, churches, and non-profits come into play.

Again, it boils down to choices. The choices we make have an impact on our lives. I like the choices I have under the current system. I do not think the "change" coming is going to benefit the majority of the people."
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Here's my response:

The 15% number comes from all over. For example, http://www.gallup.com/poll/121820/one-six-adults-without-health-insurance.aspx. It's actually higher than 15%.

How would opening state lines lead to competition? In reality. I understand it in theory. But in reality there are some issues. I asked Durham a bunch of questions in response to this claim about eliminating state lines. Here they are: I'm curious about this assertion. What do you have to back it up? What is preventing a company from selling insurance now that would be different if it were sold across state lines? What would a "low cost" plan look like? Are there some out there now? Aren't there essentially national companies now that operate in most states just under slightly different corporate forms, in order to comply with the different laws of each state? Wouldn't eliminating state lines just allow them to merge and then we'd only have a few super huge insurance companies that could prevent all competition?

Plus, health care insurance is so expensive to finance that it is almost impossible to start up a health insurance company. You need hundreds of million of dollars in reserves. And if you're going to operate on a national level you'd need significantly more. Even if you had national competition you'd be looking at nearly 0 new entries into the market. That means what we've got now is what we'd have then, right? So how does that make it better? Except that it gives the insurance companies that already exist more power and ability to control doctors and keep out competitors.


I would make insurance portable. Meaning that I should be able to purchase a plan and move it with my family, no matter who my employer is.

I completely agree with separating insurance from employers. But how do you propose to do this? The reason it isn't happening now has more to do with cost (no one can afford insurance on their own, they need their employer's help) and with insurance companies not wanting to insure people who are individually purchasing, except at high rates and low coverage. In fact, right now there's a federal law that allows you to keep your coverage if you pay for it, but that law only runs for a short time after you lose employment. So I'm curious about how you would suggest we bring about this change?

We could also group "like" families together in coops to purchase group plans.

Um, have you read about how individuals can join coops to purchase insurance under the new health care law? You know why that doesn't exist now? Because insurance companies won't allow it, since it gives consumers more power. Insurance companies like selling to individuals because then they can offer bare bones coverage at high prices, since the consumer has little buying power. Employer plans are much better than individual plans for just this reason; employers come with a nice little pre-set risk pool and more money, making it worth it for the insurance company to offer better deals. You need some way to organize a coop and direct that money, and that's one of the big things this new plan does. How would you do it differently?

Those that are in poverty, could be grouped in another group to buy discounted basic coverage insurance.

When you say "discounted basic insurance" what do you mean? Who would give them a discount? Especially considering the poor generally have worse health and cost a health insurance company more money in payouts. Who would pay for these plans? I'm curious about what you envision here.

I would also like to see a menu at the Dr. office. When I have to decide on care, I would like to know what it is going to cost me/insurance. Under either system, the patient rarely knows the cost of procedures until the bill arrives.
Again, not a bad idea. But if you have a menu at the doctor's office that shows the standard charge, how will you know what discount your insurance company is getting? How will you know your copay? Will a menu really help you know ahead of time what your bill will be? And maybe more important, will it change what services you get? "Well, I need a bypass, but that's too much, so instead I'll just get some stitches..." ? A menu makes some sense, but since we aren't operating in a cash-for-services environment, it might be a little pointless, right?
TORT reform could go a long way to curb expenses. Dr. would be able to buy insurance for less, therefore charge less for services and still make money.

I really like some tort reform ideas. I think the best one is the idea of expert courts, where a judge trained in medical issues handles the trial, instead of an uneducated lay jury who can frequently just feel sympathetic for a victim of doctor mistakes, even if the doctor did everything they should have. I also think error reduction should be focused in other areas, besides using lawsuits to keep doctors in check. So yeah, tort reform has some merit. But we're talking about something that costs about 3.6 billion a year in a 2.3 trillion dollar industry. That's like 1.5%. If we got rid of all medical malpractice suits we'd still save only 1.5%. If you're paying $15,000 a year for insurance that'll save you just $225. Now that's nothing to sneeze at, sure. And I'm all for it. But it's not a solution (and remember, my example is if we make doctors 100% immune to all malpractice suits). Especially since malpractice payouts aren't increasing like health care costs are.
This is where charity, churches, and non-profits come into play.
Well, I've talked about this before. But I'm curious. Where do you think this money will come from? Total U.S. charitable giving reached a record high in 2007 at $314 billion. Total health care expenses per person in the U.S. were $7,290 in 2007. (That was the most reliable data I could find. It was at $6700 in 2006 according to the WHO. They've gone up since.) We'll round total U.S. population down to 300 million. If just 15% of the population is uninsured, then that's 45,000,000. If those 45 million each spend the 2007 per capita amount on health care (and mind you the poor are generally less healthy and spend more on health care) then that would mean they cost 328,050,000,000.
Or about 15 billion more per year than all charities combined raised in their best year ever.

That's just the reality. That's what the uninsured cost. So I reassert: you have two options. You can either give them better coverage through the government so that they can get cheaper preventative treatments or you can tell them tough luck and let them die. Which do you prefer?

34 comments:

aaron said...

Matt,
Does that 15% take into account those people that do not have insurance because they choose not to?? At this moment, I know 3 individuals and a family of 4 that are without insurance by personal choice. Also, I am certain that number counts the millions of illegal immigrants who are here - ILLIGALLY. so, I am guessing that number more to be like 10%. This overlook throws off most of your other comments.

You also seem to miss the idea that TORT reform could bring down DR. insurance costs, which would save more money.

Are you looking for ideas? or just discussion/argument points?

Matthew B. Novak said...

No, I'm looking for real ideas. I want to know how these proposals are actually supposed to work.

No, I get the bit about tort reform driving down the cost of insurance to doctors. The number I looked at there was if doctors were 100% immune from all malpractice suits. That would mean they wouldn't be spending any money on insurance. If that happened and there were no medical malpractice payouts then the total savings to the entire medical profession would be about 1.5% of our total health spending. Of course, we can presume that malpractice carriers are charging doctors more than they're paying out total, so I guess the total would be higher than 1.5% in savings. Let's presume malpractice carriers are making a huge 50% profit. So basically, Doctors are paying the 3.6 billion that gets paid out in malpractice claims and another 1.8 billion to buy insurance. That would push us to 2.25% of total health care expenditures. So we could presume that, at best, if no doctors were ever sued for malpractice, that we'd save 2.25% of our total health costs. And that's using numbers that way overstate the possible savings.

Yes, that 15% includes those who choose to not be insured. I don't think it includes illegal immigrants. After reviewing several various sources it looks like that number is American citizens. If you can find otherwise, please let me know. You said you were certain illegal aliens were included, and I'm wondering what you base that certainty on.

There's a lot of unanswered questions from my previous post that I'm hopeful you'll be able to get to. Specifically the selling across state lines and how that would reduce costs in reality, the issues of co-ops (since those are a major portion of the Affordable Care Act) and the charity bit.

And I'm really very serious about these questions. I'm a partial defender of the new health law, but I think it's got problems too. I keep hearing about all these other "real ways to control costs" but I've heard very very few specifics, and I'm eager to hear more about how they would practically work.

aaron said...

http://www.mrc.org/bmi/articles/2007/Health_Care_Lie__Million_Uninsured_Americans.html

http://www.heritage.org/Research/Factsheets/OBAMACARE-Hurting-Those-Who-Need-Health-Care-the-Most

http://www.mrc.org/bmi/articles/2009/Fact_Sheet_Americas_Uninsured.html

http://politifact.com/truth-o-meter/statements/2009/aug/18/barack-obama/number-those-without-health-insurance-about-46-mil/

Matthew B. Novak said...

Aaron -

I was hoping to have an actual conversation here, not have openly biased websites thrown at me. MRC and Heritage... c'mon. You'd be upset if I were citing AirAmerica or other extremely liberal sources. And you certainly wouldn't take those as truth. Can you really expect me to trust your sources? They admit their bias. Why do you trust them?

And I'll take the politifact one. Which, you might note, rates the claim as "mostly true." It should also be pointed out that "non-citizen" isn't synonomous with "illegal alien." There are lots and lots of legal non-citizens. Many on their way to citizenship, most who are contributing members of society, all of whom are just as deserving of health care.

But let's please return to the real questions. I'm serious about wanting to know how these other approaches are supposed to work. I'm not arguing for the new health care law here. I'm just inquiring about the other alternatives that are being claimed. You listed some. I had questions. Are there answers?

aaron said...

Matt,
Do not ridicule me for providing facts. I just threw some quick posts out there to show that there are other sides of the debate. I see that the gallup poll does not list "non-citizens" in the study. So I can assume that they did not ask that question when polling, which would mean that their number does in fact include them. They are not citizens, so therefore I do not believe that we should provide them education, healthcare, house, etc.... we have enough trouble providing those to citizens let alone non.

Also, the poll does not allow for the figure of those who have chosen to not have insurance. Therefore, you must agree that the number of 16.4% is a high figure based on these two accounts.

Secondly, opening up state lines would increase competition with other insurance companies. BCBS and Medica would not be able to split MN, but compete in a national market for business. How would that not bring costs down?

MN does have a few co-ops that are working. Health Partners and PEIP just to name two.

So, tort reform would only save 2%, but isn't that a step in the right direction? Let's not reroute the whole train because 4% of the people are not getting what some see as a "right."

I am not saying that I have all the answers, after all, I am not a business man, lawyer, or insurance salesman. I am a teacher, I know the ins and outs of education. If you want to talk about ways to cut there, I can have that conversation. Please do not shut down our ideas just because you think they may not work. After all, we just sold the our children's futures down with a healthcare bill that is based on tweaked numbers and thinks that may work.

Durham said...

I wasn't going to actually say anything on here but something you said really annoyed me, Matt. You made the challenge "After reviewing several various sources it looks like that number is American citizens. If you can find otherwise, please let me know." you get a response and then you call BS on the sources. Now you might have a clue on why I wasn't going contribute to the discussion. The next question of whether the figure includes illegal aliens is and adjunct question. I mean, hell, you asked more than one question but then respond as if you only asked one.

Honestly though from everything I've heard from you on the Health Care law, you are only paying lip service to its having problems. Every opportunity I've seen you've defended it to the death, with nary a criticism, other than your catch all disclaimer, tagged on the end, "but I think it's got problems too." Though this opinion may not be endorsed by its author.

Matthew B. Novak said...

Aaron

I don't mean to be shooting down just for the sake of shooting down. I'm just trying to grapple with the realities.

So, for example, you mentioned tort reform. I didn't shoot that down. If you look back, I said "I really like some tort reform ideas" and "If you're paying $15,000 a year for insurance that'll save you just $225. Now that's nothing to sneeze at."

But I want us to be realists at the same time. We can certainly take a step with tort reform, but to act like it is a solution isn't realistic. I think that's something we can agree on. We're both pro-tort reform and both realize that it won't come close to getting us where we need to go.

As for the sites you linked to: I've got no problem with you demonstrating that there's more to the claims than their face value. But the flip side of that coin is that you can't expect people who are admittedly biased to be given full credit (seriously, look at their "about" statements... they're trying to only support conservative positions. That's their mission.). I was under the impression that you were using those sites as proof that it wasn't a big number of uninsured Americans. If you're just using it to show that it's somewhere less than 15%, well that's fine. Maybe I misunderstood what you were trying to accomplish with those links. I think the politifact site is probably the best reference on that, since it's not a biased source and it does what it can to balance the claims of both sides.

Matthew B. Novak said...

Aaron (part 2)

On the cross-state insurance idea: You wrote BCBS and Medica would not be able to split MN, but compete in a national market for business. How would that not bring costs down?

And I guess this is where my original questions come back to play. Won't these companies all just merge into very large insurance companies, and thus there won't really be any more competition? For example, right now it looks to me like Blue Cross/Blue Shield operates in 39 states. Naturally, those 39 individual health plans are all going to group together to become just 1 plan. Most large insurance companies are similar.

So I guess what I'm saying is, what makes you believe selling across state lines will actually create more competition? It seems to me like it'll just create mergers that will make very large companies that will have an even easier time keeping competition out of the market.

I also wonder a lot about provider networks. Right now insurance companies keep costs down by negotiating to direct their customers to certain "in-network" doctors who agree to charge a lower price in exchange. (This is a nice way of putting it... actually the insurance companies pretty much coerce the doctors into this by refusing to pay for their patients if those patients go out-of-network. Thus, doctors end up with less money and have to charge more to make up for it, leading to part of the problem with rising costs.) What will happen to provider networks if this happens? How can an insurance company from Mississippi create a meaningful provider network in Minnesota? Or will there be giant nationwide networks that will need way more adminstration? And won't that give insurance companies more power to lower their payments to doctors, again forcing doctors to increase their costs to make up for it?

You can see why I'm doubtful about how this would work in reality, right? I get the theory. It just doesn't seem to play out when we consider realistic outcomes. Any thoughts about this? Do you know of any studies that have projected what would happen if we sold across state lines? I haven't heard of any, and all of the arguments I've heard for it are theoretical "competition breeds price control" arguments that obviously don't seem to be realistic here.

Can you say more about the co-ops? I don't know much about them.

Finally, your positon on legal immigrants is a little concerning to me. But this post isn't about that, so I won't go there. Suffice it to say, I hope you don't mean to be as extreme as you sounded there.

Matthew B. Novak said...

Durham -

Yes, I called BS on some of the sources. Because they were admittedly biased. Check out the sites' own mission statements. They're not places that are trying to accurately report, they're trying to advocate for conservative positions. That's their goal. If that's their goal, then their numbers on this will be suspect. Likewise, I didn't use numbers presented by the Democratic party. I went to Gallup because they're nonpartisan.

You'll also notice I didn't call BS on the politifact site, because they don't have that same goal. They're trying to get to accuracy. It turns out that gallup didn't ask about citizenship in their questions, and I didn't argue that they did... I accepted the politifact finding that they didn't ask those citizenship questions. That's perfectly legit. I excpect that same kind of attempt at accuracy from other participating in honest discussion. You can't cite a biased source and pretend it's 100% accurate.

As for my problems with the health care bill? You want to know some? Check out part 3 of my big health care post. You know, the one you read and commented on back in March. http://www.philosofickle.com/2010/03/health-care-post.html

You've heard some of my problems in the past. I go into them in detail in that post and you even said they were ideas worth exploring.

If you want me to say more after you revist that post, I'm willing to.

aaron said...

Matt,
Again, I post some support and ideas, and you argue that they are no good and will not work. You use words like theory and doubtful about reality, but yet you are supporting a whole bill that is deeply rooted in theory and no actual numbers or reality. That seems a bit two sided to me.

In theory, the obamacare will work and insure everyone one. That is a good theory......but in reality":

When employers face a minimal penalty for not offer insurance, wont they pay that small fine instead of paying $1000's in health benefits? What would that do to all those people who have employee sponsored health insurance? They will most likely fall into the uninsured pool and have to buy from a "pool" using money out of their own pocket.

Along those lines, the bill calls for all to carry insurance or be fined (minimally) and it also says that anyone will be able to get insurance no matter what their pre-existing conditions may be. In reality, won't business savvy people just not buy insurance, pocket those costs and pay the small fine. Then when they face an incident when they need insurance (cancer, heart problems etc.) they will go out and buy insurance to cover those costs.

It is easy to sit back and bash others ideas about alternatives and argue theory vs. reality. However, I suggest that if you are going to do that, then you should do it for both sides.

I believe that MN does a great job of assuring insurance to most of our citizens. I am not saying that it is perfect, I am not saying I support, but I think they do a good job. In fact, lots of MA healthcare ideas are said to have originated from the Mn system.

I am sorry that I do not have more to offer on the co-ops here in MN. I recently went to a seminar about health insurance and learned a bit, but not enough to be real educated on it.

Matthew B. Novak said...

Aaron -

You use words like theory and doubtful about reality, but yet you are supporting a whole bill that is deeply rooted in theory and no actual numbers or reality.

Actually, there have been numerous projections done on the costs and expenses of the new bill. The best one is probably the CBO. They did a very detailed look at the numbers. The savings claims are based in realistic projections, not theoretical claims like "competition breeds price controls."

That said, I'll admit that I have some concerns about the way things will play out. The idea that fines may be set too low, for example, is one that is hard to project. It's a lot more complicated than just "insurance costs more than the fine, so pay the fine" since there are significant tax consequences and other factors in play, and some of the fines are set not as hard numbers but as percentage of income and the like. And the program relies on other sources of income and cost savings to make up some of the difference in enrolling purchasing payments, so there's a lot going on with that.

It's probably also important to note that most people get their health insurance through their employers. It isn't like employers can just suddenly cut out insurance entirely; employees wouldn't stand for that. They've got contracts and they have an ability to negotiate their payment. Right now, most people have negotiated to have the benefit of insurance. That doesn't change because of this bill. But for the employers who decide to go a different direction, you can expect that employees will demand other compensation, such as increased wages, etc. Then, those people can buy insurance through the co-ops and private market (since they should have more money in their pocket if their employer switches out insurance for higher wages). If they decide it is better to go without insurance and pay the fine, then they can do that. But that would of course mean that they couldn't just go to the doctor whenever they wanted, they'd first have to go through all the enrollment burdens, etc. And personally, if I find a lump or something, I'm gonna want to get it checked out right away. I don't want to have to go through the burden of identifying and then buying insurance and waiting for it to kick in, etc. Or what if there were an emergency? I get in a car crash and need to go to the doctor but don't have insurance? I'm gonna be liable for that still, plus paying the fine on top of it. So I think most people will still buy insurance.

Matthew B. Novak said...

(continued) The nightmare scenario is if somehow almost all businesses decide to cut insurance (which economic analyists have said is unlikely) and then everyone who got cut decides not to buy it (again, very unlikely). It's possible. And I have some concern that we'll come closer to the scenario than analyists project. But if we're being realistic, that's just not how the world looks right now.

Anyway, I guess the point is, I'm trying to be realistic about all of this. Health insurance isn't cheap. It isn't suddenly going to become cheap under the Affordable Care Act. There's a lot of problems with health insurance and the system we have. Those problems aren't going to magically go away now. But I also have a very good sense of how bad the problems are and how much worse they were going to get without anything being done (that's a function of my education. I got a lot of exposure to these problems when studying health law. I'm no expert, but I'm not exactly uneducated on the problems (I did get an award for health law!)). And so for me it's about comparing where we were before, which was "super bad and getting scary worse" to where we are now which is "bad, and getting worse much more slowly than before, with a chance for just treading water."

That's why I'm serious about wanting more ideas. Because we aren't truly getting better. We're just avoiding catastrophe. I want us to actually get better.

aaron said...

health insurance is expensive because it is a very wanted commodity. There is no way to get around it. I do not think that selling my control and self stewardness to the g'ment is worth any savings in insurance. I agree that something is wrong and needs to be fixed. But its like tearing down the whole house because the appliance are bad.

As many good ideas as I see in Obamacare, I see a whole more bad. Like I said in my last point, I do not agree 100% with MN healthcare, but we seem to be doing pretty well. After all, this is like any other issue that should be dealt with at the state level, and feds should stay out.

I like my choices and say. I am wiling to pay a bit more to have them. If the feds are so worried about that 10-20,000,000 uninsured, then they should expand medicare to cover them. That would solve that problem.

As I have said before, federal government should have little to do with daily life and choices. They should concentrate on securing the country, military, foreign affairs and taxes. The rest lies with the states.

As I have said

Matthew B. Novak said...

I do not think that selling my control and self stewardness to the g'ment is worth any savings in insurance.

This is an interesting point. I know we've discussed your particular situation before, and you're in a very rare spot, because you have more flexibility with your employer than most people. Most people don't have "control and self-stewardship" of their insurance; their employer does. So for many people this actually gives them more control over their insurance situation.

If the feds are so worried about that 10-20,000,000 uninsured, then they should expand medicare to cover them. That would solve that problem.

That's pretty much exactly what this bill does. You're ok with that part of it? And you were standing up for co-ops before. I'm confused about what you don't like in the bill. Is it seriously just the mandate and that you think the fines are too low? What else don't you like?

I do not agree 100% with MN healthcare, but we seem to be doing pretty well.

I'm curious about how much you know about Minnesota's system. Are you aware that medical assistance (the program that covers most low-income individuals in the state) is a joint state-federal program? If you think Minnesota does pretty well, you really probably need to be giving credit to the federal system too. Plus, Minnesota has more laws regulating health care companies than a lot of states. We prohibit for-profit health care, for example. I guess what I'm saying is that it might not be a federal approach, but Minnesota's system isn't exactly "small government".

I also think it's a telling condemnation of the federalist "leave-it-to-the-states" system that so few places have copied Minnesota's approach. Leaving it up to the states to find the best approach has left most states without the best approach, and U.S. citizens with worse health care as a result.

The federal government should concentrate on securing the country, military, foreign affairs and taxes. The rest lies with the states. As I have said.

You have said this. A lot. But I've never heard the follow up to "why" that should be so. Maybe this isn't the place to discuss it, but I'm very curious about why you keep returning to this foundational belief statement and what it is based on. My foundational belief statement runs much more along the lines of "we should do what works to make people better off." And if that's using the federal government, then so be it. If it's states, then so be it. If it's no government, then so be it. I care about the result. Your foundational statement seems to focus on the process...

aaron said...

I like my freedom, plain and simple. I like to run my life and make my choices on my own based on the best of my knowledge. I do not like people poking into my business/life.

"I know we've discussed your particular situation before, and you're in a very rare spot, because you have more flexibility with your employer than most people" How am I different than most? my employer pays $ to my health insurance. I can chose from 2 plans, take it our leave it. Same as most I guess.

Did it really take 2700 pages and trillions of dollars to expand medicare? Could have done it with a couple million and left everyone else alone. Again, so a few can win, the rest must give. Not my style.

About the feds. Have you read the 10th amendment I post a few days ago? I believe it says something to the tune of the states having the power.

It is obvious that this conversation has come full circle. We are again on the opposite sides of the table. All though it may be fine to converse from here, we will never see eye to eye.

Matthew B. Novak said...

You're different from most on the health insurance bit because you have a choice of 2 plans. That alone is a choice that most people don't have. Most people have a single "take it or leave it" plan.

I reject that we will never see eye to eye. That position is near the pinnacle of obstinance. You should want to change my mind, and I yours. But more importantly, I should want to change my mind and you yours. That is, when presented with a reality that does not conform with our previous views we should be willing to test that new reality and amend our views to reflect the world around us. To say "we will never see eye to eye" means that one or both of us is permanently unwilling to amend our views. I can't accept that position. I'm willing to change my mind if reality doesn't match up with my previous perspective. Are you?

(I don't mean this to sound insulting in any way. It's a very earnest question. My guess is you just tossed out the line "we won't see eye to eye" without giving it too much thought. So now I'm just asking you to think about it a little more. Whenever I see a comment along those lines I have to think back about the previous conversation and whether I stood my ground too strongly. I don't think I did this time, but I certainly have in the past. I guess I'm just asking you to do the same.)

AGJ said...

I think that it is funny that all of this came from one post that stated:

"Thank God, a Federal Judge has decided that the entire Health Care bill is Unconstitutional."

Yet no one is arguing the statement. Instead it seems that everyone is up in arms about what works and what doesn't.

Again, I will state this - the Bill has been deemed unconstitutional by a federal Judge. Is it?

Should the National (yes, I put national instead of Federal) Government supersede State's Rights and issue a bill that requires all Citizens to carry health insurance.

For all of us sit and argue whether or not one policy would be the best for everyone is beyond our constitution. This is not a matter for the Federal Government to step into - unless of course it is a National government.

Matt - you have good arguments, but they seem to be playing off of the chords of your heartfelt sentiments and situation. A situation that we can all agree is terrible and needs to be addressed in some manner.

Aaron and Durham, you lose the argument as you continue to allow this to be an argument of National Policy. It is not.

Matt, there are so many things that you have stated that I disagree with - I don't know where to begin. According to Alphonse Soady, "if you do not know where to begin, start at the beginning".

So let's start with the Constitution and go from there. There were limits imposed on the Federal Government, and a very few allowances granted. Health Insurance was not one that was granted.

So from there we can start. Your turn.

AGJ said...

Aaron, you stated that: "health insurance is expensive because it is a very wanted commodity."

In that you are very wrong - you need to start looking into supply-side economics. That is the beauty of our purported economic system (minus the influence of Keynesian politics). The products deemed marketable will succeed in an open-market forum and thus more sources will come on line.

Just look to the field of Car insurance - even Geico and Progressive are being undercut.

I will try to put this into a different context:

What are the true worries of the US in terms of the outcome in Egypt and the rest of the Mideast and African Countries in turmoil right now? Do we really want to spread democracy (we haven't for the last 30+ years)? No, we are concerned about the oil we consume (5-10% from the Suez and local arteries) coming under control of peoples that do not like us.

Health Insurance is a commodity - like it or not. Therefore, supply will dictate the price, not demand.

Matthew B. Novak said...

The Bill has been deemed unconstitutional by a federal Judge. Is it?

Actually, 1 federal judge deemed the bill unconstitutional. 1 deemed only the mandate part of the bill unconstitutional. And 2 said it was constitutional. You can make an argument against the bill, but given the last decade of precedent it appears that this would fall under the commerce and taxation clauses and thus be constitutional.

There were limits imposed on the Federal Government, and a very few allowances granted. Health Insurance was not one that was granted.

Yes, there were limits. But the Constitution also says that the federal government has the power "to make all Laws which shall be necessary and proper for carrying into Execution the foregoing Powers, and all other Powers vested by this Constitution in the Government of the United States, or in any Department or Officer thereof." So, for example, if providing health care regulates interstate commerce, then the government can do whatever is proper to see that regulation out.

Or we could even look at the general welfare clause, which gives the federal government the power to lay taxes and spend for the general welfare. Various sources argue different meanings of this clause, but for much of U.S. history (including under Washington and Adams, right away at the beginning there...) it was viewed as an independent power that gives Congress wide discretion when it comes to providing for the general welfare. And since the health of the nation and the financial burdens related to that health are clearly in the interests of general welfare it sure seems like this should be found constitutional.

It would take a very radical deviation from precedent to say that this bill was simply unconstitutional. It takes a slightly less radical departure to say that only the mandate is unconstitutional. It falls in line with precedent to say this is constitutional. And it takes a complete lack of respect for the Constitution to say that the health care bill is unconstitutional because "health care" isn't an enumerated federal power.

Matthew B. Novak said...

As for supply-side economics... I understand it to be much more about macroeconomic theory than the microeconomic/specific market you're applying it to here. That is, in a specific market both supply and demand are going to be highly relevant. Aaron is exactly right that the extremely high (indeed, unlimited) demand for health care (and thus health insurance) is a significant driver of the problems in health care. I got your back on that one Aaron.

aaron said...

Matt, you did not "have my back" you agreed to something that is quite obvious. As to seeing eye to eye, I could argue your whole paragraph there. Anyone who has been reading these posts can see that you have not amend any of your views, but instead only pointed out when I have. Again, you have 1000's of words, but all of dispute and confrontational.

As for the welfare of the public. This does not mean welfare for the public. Why do so many people get that wrong?? Again, you talk about healthcare cost being a burden? Yes they have risen, but so has usage, technology and treatment. Why would they not rise? When people are going in for early mammograms, colonoscopies, and prostate tests there is a high cost associated with those. Of course our costs would go up.

As I state it, the new car industry should also fall under the same public welfare. I mean, to buy a new car now is a much higher cost than it has been in the past. Since transportation and the its' financial burden are a concern to the public, then it should probably be regulated by the feds...... I THINK NOT

AGJ- I have been arguing about national policy. Have you read all the posts? Again, car insurance is sold across state lines...my very argument of why we need to open boundaries. I feel it would drive costs down.

Matthew B. Novak said...

I completely agree with separating insurance from employers

I really like some tort reform ideas.

I'm really very serious about these questions. I'm a partial defender of the new health law, but I think it's got problems too. I keep hearing about all these other "real ways to control costs" but I've heard very very few specifics, and I'm eager to hear more about how they would practically work.

If you're paying $15,000 a year for insurance (tort reform will) save you $225. Now that's nothing to sneeze at."

You'll also notice I didn't call BS on the politifact site, because they don't have that same goal. They're trying to get to accuracy. It turns out that gallup didn't ask about citizenship in their questions, and I didn't argue that they did... I accepted the politifact finding that they didn't ask those citizenship questions.

I'll admit that I have some concerns about the way things will play out. The idea that fines may be set too low, for example, is one that is hard to project.

Health insurance isn't cheap. It isn't suddenly going to become cheap under the Affordable Care Act. There's a lot of problems with health insurance and the system we have. Those problems aren't going to magically go away now.


Those are all quotes from me from this thread. Please, don't dismiss me as "confrontational". That doesn't conform to the reality.

Matthew B. Novak said...

Aaron -

As for the Constitutional issues... please, explain for me what the power to tax and spend for the general welfare is supposed to mean? I'm not disagreeing that there are limits on the federal government, but I'm genuinely curious as to your interpretation of this clause, since you're claiming quite emphatically that others are getting it wrong.

And yeah, I agreed to something obvious on the demand/supply issue. But I was agreeing with you against someone who was dismissing your position. There's no need for the hostility.

aaron said...

Matt- My remark was only to point out that you were backing the obvious and not "agreeing" with me. There was no hostility. Please do not continue to try and make me out as some crazed savage.

As for as your question. I believe Article 1 Section 8, as I read it says:

The Congress shall have Power To lay and collect Taxes, Duties, Imposts and Excises, to pay the Debts and provide for the common Defence and general Welfare of the United States; but all Duties, Imposts and Excises shall be uniform throughout the United States;

Then it is followed by 17 points of power. I take these to be guidelines by which to measure the defense and welfare.

So, I ask you, how does healthcare fall into any of those 17 categories?

Matthew B. Novak said...

Well you told me I didn't "have your back" and then called me confrontational. It's not hard to read hostility into that. Obviously it wasn't intended, so no harm no foul.

You're obviously taking the narrow view of that clause. That view isn't how we've read it in the U.S. for the past 80 years, or how we read it under our first decade.

There were lots of disagreements among the founding fathers about whether that clause gave an independent spending right. Basically, there's never been agreement in our country as to that point.

I know it's wikipedia, but there's an instructive (and relatively short) discussion on it there... http://en.wikipedia.org/wiki/Taxing_and_Spending_Clause

But all of that said, how would this not be regulation of interstate commerce? And maybe even more importantly, if you start selling health care across state lines, then it becomes 100% clearly interstate commerce, and then you're just inviting federal regulation.

AGJ said...

Again, as I am not willing to go back on every argument made by either side. The original statement was in nature of a federal judge ruling the entire bill unconstitutional as it REQUIRES all citizens to purchase a product that is not required to exist in the United States - at least in layman's terms.

Again, this is a States issue, not the national government's. Massachusetts has their version of it, why does the rest of the country need to adopt a similar bill just because a few tricks were played in the house and senate?

C'mon Matt - you stated to me on numerous occasions that this was not a perfect bill - but it needed to pass anyway. In almost every aspect this bill goes against the 'general welfare clause' of the people as it contains so many earmarks and pork-barrel projects that do not pertain to most of the US citizens.

As it pertains to the interstate commerce clause - how in the hell does it? It negates most interstate transactions by propping up a national bank of health insurance. How is that commerce? Commerce is me purchasing a product/service from another entity... interstate is me purchasing a good across state lines. This bill erases state lines and jumps into the national government supplying the service/product.


And how does it fund such a program? By taking over the federal school loan program to help in the funding of it? How wrong is that? Now the bill cuts out banks and lending agencies from their own markets. It now 'taxes' (unfairly) those that want to take a loan to fund their education. Ridiculous.

How? How can you truly back this? On what moral ground?

If you want my resolutions, I will give them to you. You will not like them, but I will give them to you. Just remember, I have just as much to lose, if not more, than you do.

Matthew B. Novak said...

you stated to me on numerous occasions that this was not a perfect bill - but it needed to pass anyway. In almost every aspect this bill goes against the 'general welfare clause' of the people as it contains so many earmarks and pork-barrel projects that do not pertain to most of the US citizens.

You know, there are problems in this bill. But it needed to pass because it is overwhelmingly better than what existed before it. You can't debate this in a vaccuum. And what existed before was full of pork and earmarks and left tens of millions without insurance and tens of millions more at risk of losing it and everyone paying too much and watching their costs go up. This bill isn't perfect. But it's better than what there was before. That's part of why I started this thread: I wanted to hear what else could make things even better still. We've agreed throughout the thread on some things that we'd like to see and some concerns we have (tort reform; are fines set at appropriate levels?). Not that that's pertinent to the basic topic of your posts, which is the constitutional question.

Commerce is me purchasing a product/service from another entity... interstate is me purchasing a good across state lines. This bill erases state lines and jumps into the national government supplying the service/product.

Well, your definition doesn't quite fit the definition applied by the SCOTUS. But it's close enough. The idea is that Congress can regulate "commerce" or economic activity. The definition has been generally expanded to include activities that are not themselves commerce but have a substantial effect on commerce (because in order to regulate commerce you have to be able to regulate the things that affect commerce). The Court has also held over the past century that when a type of activity itself has a negligible effect on interstate commerce, but when, in total the effect of everyone's activity has an effect, then those actions can be regulated. So you buying something locally might not be interstate commerce, but everyone buying the same kind of thing will end up having an effect on interstate commerce and therefore that transaction can be regulated.

Thus, in this case, the purchase of health insurance is obviously economic activity/commerce. And yes, it's being bought intrastate, not interstate, but there is certainly an effect on other states. For example, the type of product on sale in MN can affect the health care quality of the state which affects total state expenditures on health and worker productivity and the odds that people will move here and all sorts of other interstate activities.

The really interesting question isn't whether purchasing health care affect interstate commerce (it does), but whether not-purchasing health care is commerce. Personally, I can see the argument both for and against. For: you're making an economic decision, that decision has an effect on others in the market, therefore it is a relevant economic activity that can be regulated. Against: you're opting not to participate in a certain type of commerce, so it shouldn't be regulated. Both are reasonable arguments.

Personally, I say we just do away with the mandate and let anyone who wants to avoid health care coverage avoid it. They don't have to pay a fine or sign up, but if they get sick we can still allow insurance companies to deny them coverage. If you buy insurance or pay the fine, then they can't turn you away for pre-existing conditions. But if you want to opt out, you take the risk. That'll make the program much cheaper.

Matthew B. Novak said...

Just remember, I have just as much to lose, if not more, than you do.

Do you really? Do you have two siblings who aren't all that far away from hitting their life time maximums and being booted from insurance? Because that's who I'm thinking about when I praise this bill. Quite literally, my siblings risk loosing health insurance because they are sick and need to use it. Unless you're willing to sign up to pay for all of their bills once they get kicked off of their insurance, please, let's not talk about what we stand to lose.

How can you truly back this? On what moral ground?

You want to talk moral ground? On what moral ground can you deny coverage to millions of people? On what moral ground can you tell your cousins that the insurance companies should be allowed to kick them off? On what moral grounds can you justify spending more money than just about every other country in the world? On what moral grounds can you stand by and be satisfied with lower quality care than much of the world? On what moral grounds can you tell senior citizens on fixed budgets that if their prescriptions cost between $2700 and $6000 that they've just got to pay it themselves? On what moral grounds can you tell people with life-long diseases that they effectively can't ever leave their job because if they do they will give up all of their health insurance and never get onto a new program? On what moral grounds can you justify insurance companies turning significant profits while forcing doctors and taxpayers to pick up the costs of the people who actually need care?

That's my moral ground. Those are the things I feel it is my moral obligation to work towards. A system where everyone can get care. A system where wealthy investors don't profit off of someone else's health care denial. A system where we all shoulder the burden of bad health that so unfairly falls on some and not others.

Call me crazy, but I base my morality on Jesus. You know, that guy who went around handing out free health care and told us that everyone was our neighbor, who we were supposed to "love as ourselves."

aaron said...

Matt- On what moral grounds can you justify insurance companies turning significant profits, really?? DO you know what the average insurance profits are?? -3-4%. Is that really significant?

You talk about Jesus, do you really think that he would support this? He did go around handing out free healthcare. He help those he saw needed it. He did NOT rely on the government to do anything. In fact, he did the opposite. I think we should all be more like him. I strive every day to do so.

I do recall that he said, those who do not work should not eat. I believe that would throw out all of our entitlement programs. Taking care of others is suppose to be done by us. Through charity, which is a free will giving of ourselves, time, money or property.

Morality a funny thing to quote, as we each define ours differently based on our beliefs and experiences.

But I do believe we all have a dog in this fight. Whether it be siblings, parents, grandparents, or children. It was my understanding that this program was suppose to be best for all,

You tell Alex that he cannot argue this in a vacuum, but then you continue to do the very thing. How can you tell what the future holds? The government numbers, twisted, double counted and skewed only go out 10 years. The first 4 collecting money, then using that and concurrent money being used to fund the next 6 years. What about after that?? Smells like another SS, Medicare, Medicade problem to me.

Nope, I do not like it, it is not constitutional, and it will not insure all. By the best figures, there will still be 5-10 million people not covered. How is that a fix?

Matthew B. Novak said...

Aaron -

You might want to check your facts before your post them. http://abcnews.go.com/Health/HealthCare/health-insurers-post-record-profits/story?id=9818699

We're talking about record profits, no matter what percentage they are.

And personally, I can't justify any profit in health care if it costs someone a life. I'd love to hear the moral argument for "it's ok for a person to die so that someone else can have more money." It should all be non-profit, just like Minnesota.

How can you tell what the future holds? The government numbers, twisted, double counted and skewed only go out 10 years. The first 4 collecting money, then using that and concurrent money being used to fund the next 6 years. What about after that??

You do realize why those numbers are being run that way, right? It's because the program wisely said "we need to build up some funds in order to implement this" and so the first 4 years are about building the foundation, and then after that it kicks in. That is, it's paying for what it needs to pay for, not borrowing from other areas like so much of what got us into a fiscal mess; it's more responsible government spending than you usually see. What you should look at, if you want projections for savings, is the fact that savings actually increases as we go along. That is, year 10 has more savings than year 9, has more savings than year 8, etc. The idea is that this is going to continue saving us in year 11, and 12, etc. Lots of projections have gone out 20 years (not the CBO, they're not allowed to officially go out, but unofficially even they've projected more) and they show continued savings.

This isn't about me arguing in a vacuum. This is about you not looking up the facts.

As for charity: you've seen the numbers. I am entirely baffled how you can continue to espouse charity as a solution when the numbers demonstrate conclusively that in no reality is charity going to provide enough.

And if you want to talk about it, let's talk about realistically. Are you going to cover my sister's health care bills when her insurance company kicks her off because she's "spent too much"? Seriously. I want an answer. What is to be done about that situation? It's just 1 person I'm asking you about. Solve that problem for me, and then I'll give your advocacy for charity all the credit in the world. 1 person. Go for it.

aaron said...

So, this is personal. Not at all what you led up to believe in your earlier posts.

Matthew B. Novak said...

Where did I say this wasn't personal? I said I was actually looking for ideas, and that I'd seriously consider them. I've done that. I never said it wasn't personal. Of course it's personal; it's health care. It affects persons. You've talked about how you like what you have; that's a personal reason too.

I still want an answer to my question. What is to be done when my sister gets kicked off of her health insurance because of the lifetime maximum? I'm asking you to solve one person's problem.

aaron said...

Matt,
As i have stated before, i am not an insurance man. I do not know much of the way things work. I do know my own insurance and of other options that are offered. I do not know the ins and outs.

I feel bad that your sister, my cousin, is about to hit her max. I am not sure of her options. I would guess that she would need to join a State Risk Pool or PCIP. Again, i am not sure, that would seem to me more up your line of work.

It saddens me that there are people out there who hit a max and then lose their insurance. I do not think that it is right, there should be some sort of a net to help these people. However, i do not think that Obamacare is the correct answer. There has to be some other answer that can provide these people with healthcare so that they can continue to live long and prosperous lives.

Matthew B. Novak said...

So what's the answer? That's what I'm asking you.