Wednesday, March 23, 2011

The Short List - March 23, 2011

  • In Libya, as the air strikes have been successful, managing the allies has not.  If you haven't,  read the account of the four NYT journalists captured and brutalized by the Libyan government.  The New York Times explores the diplomatic no-man's-land for ambassadors from the Middle East with governments in turmoil.

  • Elsewhere in the region, six people were killed by government forces in Dara'a Syria.  Jordan's King Abdullah II is blaming the country's prime minister for the lack of political change.

  • A report by Human Rights Watch claims the Ugandan police are guilty of torture and killings of their own citizens.

  • The Justice Department has sued on behalf of a former Illinois math teacher who quit after her request to complete the Hajj, or a Muslim's pilgrimage to Mecca, was denied.

  • The Affordable Care Act, often derisively referred to as "Obamacare," was passed a year ago this week. While legal challenges persist, even as calls for repeal have quieted, Republicans have failed to clearly articulate an alternative that would cover as many people.


Colin said...

Republicans have failed to clearly articulate an alternative that would cover as many people.

Why is insurance coverage the goal, particularly given that third party payments serve to drive up costs? Shouldn't the goal be the improved affordability and quality of health care?

Jason said...

Coverage is the goal because health care costs can be cataclysmic for families. We should always try to make healthcare more affordable and of higher quality (though those two goals can oppose each other), but open heart surgery, or radiation treatment, or brain surgery will always be expensive endeavors with price tags likely outside the limits of disposable income for the average family.

Colin said...

You're right, it can be expensive, and everyone should have insurance to guard against catastrophic and emergency events. But ObamaCare's approach isn't to encourage such insurance, but rather comprehensive insurance that covers everything. After all by 2018, all health insurance plans must cover approved preventive care and checkups without co-payment. This is akin to mandating that auto insurance, which makes eminent sense, also cover oil changes and other routine maintenance. Why is this a goal?

Jason said...

To clarify, comprehensive insurance would cover catastrophic events.

And the insurance is comprehensive precisely to encourage preventative care, which helps control costs to the system overall.

And to return to my original comment, what's the Republican alternative plan that will provide people coverage and access in the same numbers as the ACA?

You want to throw stones at the ACA, fine. There are flaws in the legislation, but what's a legitimate alternative that ensures people access (and coverage) to healthcare?

Republicans have had about two years when healthcare reform was consistently on the front burner, either trying to gain passage, or repeal but have failed to advance an alternative.

Colin said...

And the insurance is comprehensive precisely to encourage preventative care, which helps control costs to the system overall.

People perform maintenance on their cars, houses and other items all the time to ensure they don't deal with more pressing problems down the road. It is strange to assume people will do this, but won't pay for preventative care absent its mandated inclusion in their insurance.

As for the GOP, I know of at least three plans that have been advanced -- by Senators McCain, Coburn and DeMint -- although I don't know how they measure up on insurance coverage. But again, I don't see why that is the relevant metric. Seems to me the goal of health care reform should be to, you know, improve health care, which involves things like health outcomes, access and cost. Insurance is a means, not an end.

Jason said...

For the individual consumer, the ACA measures outcomes, increases access, and (according to the CBO) not worsen the cost. Yet, I would assume you don't support the bill.

Also, I'll say this until I'm blue in the face, healthcare is not like automotive service or home repair. Failure to have your car serviced, whether by choice or circumstance, ends in a broken car. Failure to have your body serviced, whether by choice or circumstance, will end in death or the emergency room. The markets are not comparable.

Colin said...

For the individual consumer, the ACA measures outcomes, increases access, and (according to the CBO) not worsen the cost. Yet, I would assume you don't support the bill.

What does it matter that outcomes are measured? Given that the thrust of the bill doesn't take effect until 2014, how do we know access will be improved? As for the CBO, you may want to note a new report it issued Friday which revealed that the estimated cost of subsidies from 2012-2021 has been increased 8.6% ($1.04 trillion to $1.13 trillion) due to revisions in the assumptions. I doubt this the last time this will happen.

Failure to have your body serviced, whether by choice or circumstance, will end in death or the emergency room. The markets are not comparable.

Exactly! So given the grave consequences of not servicing one's body, why must a consumer pay for this via insurance rather than out of pocket for it to be used?

Colin said...

To follow up on the discussion about health insurance vs. actual health care reform, as I see it improved health care involves at least the three following areas:

* Cost. Health care costs are on an ever upward trajectory. I want to spend as little as possible to achieve maximum health.

* Choice/quality: I want as many doctors to choose from as possible, as more choice means more quality (and should also help with cost).

* Innovation. I look forward to the day I can swallow a pill that contains some nanobot that eats all the cholesterol in my system, thus allowing me to eat all the cheeseburgers I want.

In light of this, why should I pay particular attention to insurance coverage? Why is that the metric for determining policy success or failure? This is why I see it as a mistake to raise taxes, spend more, add more people to insurance rolls and declare success. How does Obamacare get us closer to the three items I outlined?

Jason said...

To your first comment:
- You said measuring outcomes was a key part of healthcare reform. The ACA measures outcomes. You defined that as a key metric, that's why it matters.

- Based on the information we have available, access will improve. Access has already improved for recent college grads who can now stay on their parents' insurance until 26.

- I've noted the CBO report, and that's frustrating, but a reason to fix the bill. Again, I never said it was perfect, but when it was passed it was independently shown to bend the cost curve downward.

- And if you're not of circumstance to afford a doctor? What would you do then? What's the backstop? You can choose not to have a car, and thus avoid maintenance costs, but you can't choice to have a body. Additionally, if you are of circumstance and means to receive primary care and the primary care physician has reason to believe you have a serious ailment, then you almost certainly need insurance to cover the increased cost of specialized services. But what insurance company will grant a policy to an individual who has a pre-existing condition?

To your second comment:
Cost - I agree, but how do you do that? The ACA, when it was passed, bent the cost curve down according to independent assessments. If underlying assumptions have changed, then let's address specific parts of the bill.

Choice/Quality - First, it's dangerous to put these two in the same line as people might choose a worse doctor with a better bedside manner. Second, plenty of people don't know how to pump their own gas. How could you plausibly expect people to gather enough serious and discerning information about several physicians to make a fully reasoned choice about the one that has the higher quality? There are information asymmetries in healthcare that simply screaming "Choice!" don't account for.

Innovation - I fail to see how the ACA stifles innovation. However, it's clear cutting NIH funding will stifle innovation (one can only quarrel with magnitude, and we have), but you support cutting their funding. Private industry does not hold a monopoly on ideas, and particularly in medicine private industry is driven to make money. Viagra has been quite profitable, but I would dare say hasn't done much for the social good.

We pay attention to insurance coverage because that is the base metric of access. You would no doubt argue for out-of-pocket only, give the money to the people policies. That would be a dramatic paradigm shift in the healthcare industry. It would also lead to crippling debt for those that are born with pre-existing conditions and therefore never accepted into an insurance pool, which is the only way they could pay for their medical bills because, again, cost is going to come down only so much.

Colin said...

Re: Health care outcomes, I am concerned about their improvement, not their measurement. In fact, there is reason to think that these measurements could actually negatively impact healthcare:

Re: Access, we have also seen companies that provide health insurance exit the market (eg Principal Financial), which I am not sure anyone anticipated, so the overall impact is not at all clear. Also, insurance coverage and access are not the same. I have obtained health care in the past even when I lacked insurance. In fact, it would be seem that reduced reliance on insurance would help reduce the whole "in network" phenomenon and thus increase choice and access.

Re: Costs, it is false that the health care cost curve is bent downwards:

As for how costs can actually be reduced, the answer lies in both regulatory reform and simply supply and demand. We need to get away from this model where insurance pays for everything, as when someone else foots the bill there is no incentive to shop for the best price and practice cost control. Unfortunately ObamaCare does the opposite and further promotes the use of insurance. We also need to ease regulatory and licensing requirements so more health care professionals can practice. My girlfriend would have to take 6 months off from work and become re-licensed if she were to move to CA, even though she is already licensed in CO. Makes no sense. Also, allowing the sale of health insurance across state lines would cut down on insurance costs. It would cost the government nothing, and yet strangely this was never even considered by Democrats.

Jason said...

- Healthcare Outcomes - You're arguing with yourself. You said you want to improve outcomes. In order to know you have improved outcomes you need to measure. If there are complaints about the metrics, then let's talk about the metrics, but it seems a flimsy reason to dismiss the ACA entirely.

- Licensing - Are you arguing for a federal medical licensing standard? I could get behind that, depending on the details.

- MinuteClinics - While $59 is "eminently affordable" to you and me, it is folly to assume that $59 is affordable for everyone. Additionally, and add this to the list of "why healthcare isn't like other markets" should we be aspiring for simply the lowest cost for healthcare? Again, if I buy the iPod knockoff and it breaks, that sucks. If I get checked out by the doctor that got all Cs and barely graduated for the Bahamian International For-Profit Everyone Graduates Medical School and he misses something, I could die.

- TV Ads - Commercials on TV tell me I can lose 100 pounds in 2 months if only I buy their product. It's dangerously naive to believe television advertising, with physicians quoting cherry-picked metrics of success would do anything more then exacerbate underlying information asymmetries. If you think that's a good idea, I should tell you about the class action law suit you might be eligible for.

- Insurance - Again, you argue for a dramatic shift in the healthcare market model. You have failed to adequately address information asymmetries in the healthcare market that disproportionately favor the healthcare provider, rather then the recipient. You have also failed to address how someone with pre-exisiting conditions would survive without insurance.

Colin said...

* Outcomes: No, it does not follow that the only way to improve outcomes is to measure them, or that if one opposes a centralized effort to measure outcomes that one has contradicted oneself.

* Licensing: A federal licensing standard is the last thing we need. We already have licensing out the wazoo. Rather we should recognize licensing as a restraint on interstate commerce and a form of protectionism, and allow someone licensed in one state to practice in another (license portability). Failing that, federal law could bring clarity to the area of telemedicine, allowing doctors to regularly consult with patients in all states.

* MinuteClinics: Wait, how many people do you think can't afford $59 per year ($5 per month) for a checkup? Mind you, that's less than my monthly cell phone bill. Even if I accept that these people exist in any appreciable numbers, the more obvious solution is a government subsidy -- a FAR cheaper solution that mandating that person purchase health care insurance which covers checkups. Practitioners at the MinuteClinic are all board certified, so your scaremongering about ill-trained professionals is misplace

Colin said...

* TV ads: My position is not that people should make decisions based on TV ads, but rather that markets produce information. I would love a health care market where professionals compete against one another and advertise their credentials, which would no doubt take many forms, including the web.

Instead of your hypothetical doom-mongering, what about actual observed reality? How about the fact that Lasik eye-surgery, where we find competition and advertising, costs have declined and quality has improved? Or for-profit heart surgeons in India that charge $2,000 for open-heart procedures vs. $20-100K here in the US?

What reason is there to believe that profits -- while synonymous with quality and low prices everywhere -- would lead to poor-decisions and disaster in the health care market?

Colin said...

* Insurance: No, I *have* addressed information asymmetries, noting that markets produce information. In any case, there is absolutely nothing in Obamacare that reduces or eliminates such asymmetries, so I am not sure what your point is.

I have also pointed out that pre-existing conditions are another argument for reducing the role of insurance, not expanding it. Right now to get health care in this country you need insurance -- everything flows from that. But if you have, say, heart issues, why should that mean you can't get insurance against cancer? Or gunshot wounds? Or any other emergency/catastrophic care? It makes no sense.

The best solution for those with pre-existing conditions is to encourage competition that drives the cost of procedures down and encourages the development of a more dynamic insurance market (which in turn means breaking the employment-insurance linkage and moving towards an individual market).

Also, just as a programming note, it seems my comment in which I first raised the issue of MinuteClinics doesn't appear, and yet obviously you saw it as you responded to it. F'ing blogger...may want to consider another type of commenting platform.