Monday, March 22, 2010

Die, Freedom!

It's embarrassing for a political junkie to admit, but I completely passed on the "health care reform" debate and votes this weekend.

Part of this was having two active and busy kids (and part of a third, with Christine's little guy the Poet coming over Sunday afternoon to give her a break), part of it was wanting to stay on top of home and house business.

But a big part of it was simple disgust.

This issue has become a Ministry of Silly Walks, really, and I've long since gone past irritation through anger to revulsion and into indifference at the ludicrous posturing over what is really a very minor adjustment in the U.S. medical system.

The reality is that the fundamental dysfunction - the idea of making a profit off giving medical treatment to the sick - is unchanged. The fee-for-service and for-profit health care business will, therefore, continue to swell up and swallow more of the nation's wealth. The well-duh realization that pretty much the whole rest of the world has reached - that sick people don't and won't "shop" for bargains, that the disjunction in knowledge-level between the medical "provider" and "consumer" is so huge as to be unbridgable and prevents even a smart guy like me from "shopping" for medicine even if I wanted to, and that the complete lack of external controls, either regulatory or market-based, on medical costs virtually ensures that they will bubble until they grow beyond sustainability - has utterly escaped us.

No, this is a band-aid on a tumor, and although it will help a relatively small group of Americans get medical insurance it stays well away from doing anything to actually help reform the for-profit system.

What I did get out of this mess, however, is the degree to which the U.S. party system is broken, and that because one of the two parties has become flat-out, no-holds-barred, bug-fucking crazy. Let's elide the usual political bullshit (John Boehner’s argument, for example, that you won’t be able to keep your health insurance under this plan is just a lie. But we've come to expect this sort of lying by now.) and look at some of the top GOP quotes on the health-care issue (courtesy of Alterdestiny):

Tom Price (R-GA): "If health care passes, "We lose our morality. We lose our freedom."

John Shadegg (R-AZ): "This bill will destroy freedom and do damage to the very fabric of our society."

Marsha Blackburn (R-MN): "Freedom dies a little bit today."

Devin Nunes (R-CA): By passing health care reform, Democrats "will finally lay the cornerstone of their Socialist utopia on the backs of the American people. For most of the 20th century people fled the ghosts of communist dictators. And now you are bringing the ghosts back into this chamber."

Waa...hunh? Obama is Stalin? Forcing people to buy expensive insurance is the COMINTERN? (Guess nobody told the auto-insurance KGB, hunh?) Freedom dies when poor people get medical coverage? Baby Jesus weeps when insurance companies don't get to kick people off their insurance when they get cancer? (Oh wait, they still do - there's nothing in here that prevents rescission.)

I do believe that these gomers are talking out their fourth point of contact. They don't REALLY believe any of this "freedom is dead" rhetoric. The problem is that there's a whole bunch of mouthbreathers out there that DO believe it, and this sort of playground bullshit gets and keeps them worked up.

You can't keep a republic when a third of the citizens believe that passing civil legislation in a majority-vote fashion means "We lose our freedom."

I've said this before, but it bears repeating. One of the deadliest things a republic can do is allow one group or faction to put it's interests not before the interests of others but before the interest of a functioning republic. If one side stops accepting that the other gets a turn at the helm, then there is no solution but conflict, and if one side stops accepting the results of that conflict as played out with votes then it must be played out with guns and ammunition.

Based on this sort of language a fraction - hard to say how large, but given the relative importance of the sort of people like Limbaugh and Coulter who say just the sort of things I've quoted above it is substantial - of the GOP, circa 2010 is already most of the way there.

And where is the alternative? Where is there a place for the "conservative" who doesn't want to hector people about profit!abortiongaysgunsandGod?


(Cross-posted from GFT)


  1. "one of the two parties s become flat-out, no-holds-barred, bug-fucking crazy"

    You've identified part of the problem, Chief. The other two parts are:
    1. The bug-fucking crazy party is still capable of developing consensus and acting on it while
    2. The other party has disintegrated into near incoherence.

    The fact that the Democrats were unable to launch an effective media campaign to support their policy change is a very bad sign of times to come.

    That the House Democrats were reduced to the ridiculous and bizarre action of approving something they didn't like so they could also approve something the Senate will automatically reject is an even worse one.

    That the Republicans obviously plan to demonize the healthcare plan for the next 8 months (before the it will have a meaningful effect on the average family) and use it to utterly destroy the Democrats in the polls is worse yet.

    And that the Democrats don't see this coming is the worst of all.

  2. The profit principle is no problem in the medical sector as long as the sector is tamed (regulated) well. Health care also doesn't "swallow" national wealth; the trend towards a greater percentage of medical services of the GDP is just as natural as is the shrinking share of the food sector.
    Medical services are services just as a haircut - the demand is merely greater (for good reasons).

    The Health care reform debate in the U.S. looks to me like a symptom of -sorry- ignorance. A developed country with a good knowledge of other developed countries could not have debated that silly. The reform actually falls short of Germany's health insurance project of the late 19th century (which was developed by the royalist-archconservative Bismarck!).

    The low level of political discussion with lots of talking points pundits on air instead of lots of rational beings is not exactly a shining example (I can see CNN International).

    One party seems to have problems with losing power in elections (if not with losing elections in general!). They questioned the legitimacy of a legal and legitimate majority government and got away with it for a year (how dumb is that?).
    Their policy seems to be 100% obstruction, fearmongering, hatemongering and no own attractive plan at all.

    That's pretty sad, especially given the not exactly stellar picture of the (only) other party.

    Even worse; U.S. domestic policy doesn't even come close to address the enormous sustainability deficit of the U.S. economy and public budgets.
    The utter inability to fix even a most obvious symptom (Wall Street excesses) is telling.

    German policy isn't much more able to address challenges, but at least we've got many solutions already in place that are still lacking in the U.S..

  3. Chief,
    I think that we always fight the wrong battles and the wrong wars.
    There are , as Sven points out, other really serious ,key issues that need addressed, and that are urgent and survival related. I too,in disgust have not wasted an ounce of energy on this topic.
    The key topic imho is energy, and energy dependence, of which we waste not an iota of national policy. Us old farts have coursed thru so many energy crisis and at the end of each EXACTLY NOTHING ever changes.
    Then theres endless wars/deficit/loss of jobs and myriad other key points. this all points to one conclusion-both parties play the exact same game. It's all illusion/smoke and mirrors and we the people buy the crap.
    It's safe to say that whatever either party does,ever,the taxpayers are getting screwed and others are riding their backs and making large profits.
    If America were a true democracy then the health care issue wouldn't even be an issue or a concern. A healthy economic system would dictate a healthy health care system. Like Sven points out the Germans have had this since Bismark,and i don't mean Dakota territory.
    Just look at Cuba that we villify. They seem to have a firm handle on the topic.
    Vibrant economies dictate vibrant health care and that is our disconnect. We want top quality health programs while we are no longer vibrant.
    As always we're a day late and too many dollars short. We have become unproductive as a societyt and we're trying to pretend that this isn't the case.
    This entire scenario is exactly like the elections in AFGH/ IRQ- they are meaningless b/c they are not operating in reality.
    Like the old lady said-wheres the beef?
    It's clear where the beef ain't.
    When the parties give us what we don't need , can't pay for ,and can't use then we have passed into the twilight zone.

  4. Chief,
    I think that we always fight the wrong battles and the wrong wars.
    There are , as Sven points out, other really serious ,key issues that need addressed, and that are urgent and survival related. I too,in disgust have not wasted an ounce of energy on this topic.
    The key topic imho is energy, and energy dependence, of which we waste not an iota of national policy. Us old farts have coursed thru so many energy crisis and at the end of each EXACTLY NOTHING ever changes.
    Then theres endless wars/deficit/loss of jobs and myriad other key points. this all points to one conclusion-both parties play the exact same game. It's all illusion/smoke and mirrors and we the people buy the crap.
    It's safe to say that whatever either party does,ever,the taxpayers are getting screwed and others are riding their backs and making large profits.
    If America were a true democracy then the health care issue wouldn't even be an issue or a concern. A healthy economic system would dictate a healthy health care system. Like Sven points out the Germans have had this since Bismark,and i don't mean Dakota territory.
    Just look at Cuba that we villify. They seem to have a firm handle on the topic.
    Vibrant economies dictate vibrant health care and that is our disconnect. We want top quality health programs while we are no longer vibrant.
    As always we're a day late and too many dollars short. We have become unproductive as a societyt and we're trying to pretend that this isn't the case.
    This entire scenario is exactly like the elections in AFGH/ IRQ- they are meaningless b/c they are not operating in reality.
    Like the old lady said-wheres the beef?
    It's clear where the beef ain't.
    When the parties give us what we don't need , can't pay for ,and can't use then we have passed into the twilight zone.

  5. Wow, chief, I really don't know where to start.

    My first inclination is that the GoP's and FOX's lil'Frankenstein creature has gone rogue and is no longer sticking to its raison d'etre which is to be the voice of the mob to their social/political agenda.
    Of course I mean the Tea Partiers who have embraced racist and ad hominem hyperbole to emphasize the fact that they are not only loosing their minds but that their reason for being is being undermined as well.
    It's almost as if their saying under their breaths as they scream their souls, "how f~cking dare you be so damn start acting like me so I can rationalize my irrational fear and hatred of you!"

    But as for the flaws in our system...oh man, I hate to be the bug in the ointment but it's just not that simple...despite the two party system we're burdened with, I think the reality is regardless of our two party system, or seven we would still have the disadvantage of having myriad of individualistic people motivated either by ideology or greed.

    The thing that strikes me is that for the Republicans it seems full and complete political power is their cup of tea...not to actualize any agenda that is beneficial to the people of the United States overall, but rather to garner for themselves plum board appointments for services rendered in office.
    The Dem' be perfectly honest, is acting more like a four party dog dems who are really just Social conservative Republicans who realize that the only way to get elected in their district is to call themselves "democrats."
    Then you have the moderate Democrats who are tight rope walkers, trying to do the right thing for everyone while still gaming the system so they can remain in office because, of course, no one understands the DC like they do.
    Then there is the greens, who are split between "lets be rational people about the bed we're sleeping in" and those who are tweakers.
    And then finally, the ultra left wing who are really just as nutty as their Republican counterparts.

    Throw in corporate America and the truth is no matter who is in office the fact that they are human means they have a price which, by G-d, heaven, and the American dollar corporate America will find out what their price is, meet and purchase at that price if not more, and then own that person before he or she is able to log on as an official elected representative of whatever seat they won.

    The bottom line is we need a Constitutional clause similar to the one that separates church and state for state and business.

  6. I'll take a devil's advocate position here.
    I think that the USA just took a small step towards political sanity. Another small step was the dust-up with Israel.

    I suspect that the GOP is losing their constituency. Their response, to go loud and crazy, is a losing strategy. It moves them into the arms of the nutbars and away from the political center. This is not the way to win elections.

    I wonder how the November elections will play out?

  7. I'm glad you think that we've taken a step towards sanity, AEL, I agree. The problem is that I expect a large backlash towards insanity to come of this.

    My personal best guess is that the November elections will see the Republicans collect 75-100 seats in the House and possibly capture control of the Senate as well.

    The Republicans have gamed this very well with their negative strategy. There were always two outcomes:
    1. The bill passes and they can rally the base (plus the tea-baggers) to repeal it in the November elections
    2. The bill fails and the Democratic party implodes from disappointment

    Either way the Republicans win. The only fly in the ointment is that the Republicans are going to have a terrible time governing after the 2010 elections because they've whipped their base into an anti-government rage. But they should be fine if, as I suspect, they only want to control the government and not actually govern.

    I made a mis-statement in my earlier post, by the way. I said that there was no way that the Senate would pass the House's version of health care reform. That was before I understood that the Democrats only need 51 votes to pass it (per NPR). They should be able to manage that although it will add fuel to the Republican fire this fall.

    I think I'll skip watching TV from September until after the elections.

  8. I want to emphasize here that I am saying nothing about the merits of the bill itself - as Sven points out and as I mentioned in the post - that goes about 1/10th as far as pretty much the entire rest of the industrialiazed world at accepting that there is no such thing as a "market" for health care. The thing is a natural monopoly and will always behave as such unless thoroughly regulated. This isn't fucking rocket science, and the fact that we're still debating this just emphasizes the degree to which Stupid and Willfully Blind play in our national character.

    No, all I'm fulminating about here is the broken-ness of the political party system. The Dems can't play politics (because they have either 200 "messages" or none - they really are the Party of Fail), and the GOP can't govern (because they can't understand that you can have low taxes and small government or you can have enormous geopolitical power and influence but you Can't Have Both.

    But the former is a Fail of Omission. The Dems are just fucked up like a football bat. The latter is the product of deliberate and self-inflicted moronity. The GOP has intentionally defined itself as the Party of God, Guns, Gays, Abortion and Tax Cuts. There's no way to govern when you can't tax yourself to pay for what you want, you have to spend your time fiddle-fucking in people's personal lives trying to regulate what kind of sex they can have or how much pray they can inflict on others.

    The Dems are flopping around on the floor spazzing. But the GOP has truly left the building and is running around the bus station in full-blown-bull-goose-looney mode.

  9. Sven,

    In 1975 the cost of health care in GDP terms were about equal in the US and Germany at about 8.5%. Today, Germany spends 10.5% of GDP, and that percentage has remained steady for the past 15 years. The US, on the other hand, now spends 16% of GDP on health care today and that is projected to increase to 20% by 2019 and on into the future.

    There's currently a 6% GDP difference in spending between Germany and the US. I seriously doubt that Germany would be better off if it took an additional 6% of GDP out of the rest of your economy to buy more health care. Health care really is swallowing our (the US) GDP, which is what happens when costs rise 2-3 times GDP growth.


    I don't understand what you mean when you talk about the problem of the "for profit system." Fee-for-service isn't strictly a "for profit" system - after all, it was created by Medicare.

    I think your most of your fire against the GoP is on target, but have you listened to Democrats? They've been fibbing up a storm on health care as well.

  10. Andy: Most of the Dem's rhetoric is designed to blow smoke over the hole this puts in the federal budget. That's expected - the Goldwater/Reagan Revolution has forever changed the political reality of paying for what you want. The thought that you might actually expect Americans to pay taxes for things like wars, environmental protection, food inspections and health care? Get real!

    But nobody. No Body. On the left side of the aisle is talking gooney shit like "Freedom is dying". That's just crazy talk, and, worse, the sort of crazy talk that kills republics. When your political opponants carrying out their campaign promises is "killing freedom" sanity has left the building.

    And give me a break. Fee for service is as old as medicine. You see the barber, he pulls your tooth, you pay him. You get a clyster, you pay for it; get another, pay for it, too.

    The difference is that there really was no significant "health care system" until the mid-century. Most people got little medicine, most of what they got was pretty primitive, and mostly what they did was get old, get sick, and die. My grandfather died at 26 of what today would be a minor chest ailment. The baby who would have been my uncle died of a simple birth defect that would have been cured with an outpatient surgery today.

    When scientific medicine started to take off in the middle 30's and 40's - and especially when the big technologic discoveries began to be made in the 50's and 60's - there were really two ways for U.S. medicine to go.

    One way would have been to imitate the Mayo Clinic system and the public health systems of most industrialized nations. This would have meant that health care professionals would be primarily salaried, that treatment would have focused on preventive and well-patient care. This would have been fairly bad for old people and people with catastrophic ailments; geriatric care and high-end, high-risk treatments would have gotten the short shrift. Costs would have been quite low, and the primary means of rationing medical treatment would have been based on age and medical prognisis. The costs would have been fairly transparent, too, in the form of direct taxation and payouts. The bureaucrat involved would have been a government one, whose primary benefit from your health care would be a healthy, working taxpaying citizen.

    The other is the way we did go: by keeping the fee-for-service setup and making much of our medical system a profit generator based not on outcomes produced but treatments applied. And this coupled with a payment system based on hiding the costs as employer "contributions", and making the bureaucrat one whose principal interest was the balance sheet (if nonprofit) or corporate earnings statement (if for-profit) of his or her employer virtually ensured that costs would continue to rise well past the actual value of the services provided.


  11. (con't from above)

    Most of your comments suggest that you are rather of a free market believer, but in this case I think it doesn't take a genius to realize that some "markets"; things like food preparation, air travel, power generation, medicine, can never be truly "free". In some cases, like airlines and commercial food manufacturers, the pressure to cut corners to make profits is just plain dangerous. I save a couple of thousand by skimping that inspection and a couple of thousand people get e-coli or couple of hundred auger in outside Des Moines. In the others, it's a question of competition. How do you set up a "market" for hydroelectric power? Or kidney transplants. You're dying of kidney failure - you're gonna "comparison shop" for the best AND cheapest renologist? How t'fuck do you KNOW what is "the best"? And is cheapest always the best in this case?

    Nope. Changing from the old barber-surgeon fee-per-tooth to a salary system, and tightly regulating the "medical market" - to include a large public insurance pool - is just common sense. The alternative is what the GOP suggests; keep the current system and let costs ration medical care.

    If we're going to ration - and everything is rationed, there's no "free resource" beyond air, and perhaps not even that - I don't have the stomach to ration based on the idea that poor people deserve to get sick and die more often.

    There's got to be a better way. This bill isn't it, but it's closer than what we had before.

  12. Andy, look up the development of overall private consumption and compare it with the development of health care costs. The difference between both countries will be much less in that comparison.
    Both national economies have taken very different paths in general.

    Btw, it's astonishing how ******** some Americans still comment on the Health Care stuff. I visited a (known right wing) MilBlog a few minutes ago and that **** seriously called the U.S. health care system (as if there was only one) the "greatest health care system on earth".
    Is that sheer ignorance or sheer arrogance?

    WHO and OECD seem to disagree with him, just as do all foreign nations without plans to adapt their system to the example of the U.S. one.

  13. @FDChief:
    Where is this obsession about rationing coming from?

    There's not really such a discussion or problem in Germany. We have sometimes small warning calls about the looming threat of a two-class medical care, but that's it. Present differences in med care re limited to luxury topics like how many beds are in your hospital room and the like.

    We don't ration our elderly to death, and our life expectancy beats the U.S. one by more than a year.

    I understand that this "rationing" narrative came up a couple months ago - I think it came with the stupid "death panels". It's political smoke.

  14. One can hope that sane people once again think rationally in November. Personally, I'm not holding my breath.

    At a recent gathering of friends, most of whom were educated professionals, I was astounded at the poor level of understanding of what exactly Obama wanted in health care reform. Strangely enough, most of what they said mimicked GOP talking points: death panels, socialism, "I'm not gonna pay for health care for illegals, welfare recipients, etc."....

    And these people are supposedly, ahem, college educated. I can't even imagine what Joe the Plumber thinks.

  15. Just one more bucket of gas on the fire that's going to burn us all to cinders. I can't really say much that hasn't been said already, except to mention that it seems that when anyone says that the far left is just as loony as they far right, they neglect to add that (educated guess here) for every far lefty in the USA there are 5-10 loony rightwingers.

    The whole Fox News/Rush/Beck thing is like crystal meth to these people, and they have been so absorbed by it for so long that they wouldn't recognized reality if it bit them on the ass... which it is certain to eventually do... probably far too late to be able to change anything.

    Maybe this volcano in Iceland will give us something to really worry about. One can dream.

  16. To be frank, it's difficult for me to address the abject stupidity of a large portion of the American population when it comes to the whole health care mess. First off, since 95% of the voting population has never experienced any other form of health care delivery first hand, how do they come to any conclusions about national health care, national health insurance and the like?

    Canada? 87% of the population is either satisfied or highly satisfied with the health care system in their country. Europe? Similar numbers. And, EVERYONE has access to all levels of inexpensive health care under these systems, and enjoy life expectancies equal to, or greater that that in the US.

    Where does US "health Care Delivery" money go. For pharmaceuticals, some companies spend more on marketing than research and development. Hospitals spent over $1.2 Billion on advertising in 2008. There are 90,000 pharmaceutical reps in the US, one for every 6 doctors!

    In short, it is a huge industry, and while some elements are supposedly not-for-profit, hundreds of billions each year are either profits or expenses related to turning a profit.

    I am trying my best not to allow my feeling for the general population to be one of contempt, but this latest go-around has really made that difficult. If I did not have children and grandchildren, I would be willing to just let the "system" collapse and let the great unwashed try to climb their way out of it on their own.

    It's too beautiful a day here to think about the American cess pool. I'm gonna ride my Vespa and enjoy life.

    Cheers to all.

  17. Al-

    "It's too beautiful a day here to think about the American cess pool. I'm gonna ride my Vespa and enjoy life."

    Agree totally. My wife's more interested in the whole "debate" than I am and she's not even American!

    Weather here in Portugal's nice as well. Spring is here and I spread some fertilizer in the garden this morning . . . which is as close to this subject as I care to come at the moment . . . ;-)>

  18. Chief,

    That's just crazy talk, and, worse, the sort of crazy talk that kills republics.

    I only partly agree and think overselling is just as bad or even worse. The right is engaging in "crazy talk" but at the end of the day, it's just rhetoric. Making promises that government can't keep seems to me to be a greater threat to the republic than some crazy talk.

    The American people have been told two narratives - one is that this new law is socialism and freedom-killing, the other is that this bill solves our most pressing health care problems and has fixed the health care system (obviously there are a handful of honest brokers on each side). Which is more dangerous? Neither is good IMO but take a look at Greece for what happens when government overpromises and underdelivers.

    On the origins of fee-for-service, you should listen to this, which is the shortest, best explanation I've run across.

    Most of your comments suggest that you are rather of a free market believer

    That all depends on what you mean by "free market believer" which is one of the most mis-used terms today and is quickly becoming the new "liberal" - an epithet divorced from its original meaning.

    My general philosophy is that individuals should have choices. To give you an example of what I support in terms of "market" approaches to government services, take the food stamp system. In my current state (and I think in most states), people receiving food aid get a kind of debit-card which they can use to buy food. Beneficiaries can buy whatever kind of food they want almost anywhere that sells food. I think it's a good system. An alternative, bad, system is one where the government either provides mix of predetermined food every month or micromanages what you're allowed to buy. I consider the current system an effective "market" approach because individuals have the sovereignty to make their own decisions based on their own circumstances about what to buy within a set of broad and reasonable rules. In my book, that's good government policy.

    Also, as I've said before, I also subscribe to the principle of susidiarity. Additionally, I've become more skeptical over the years of federal-level policy because federal level programs too often become vehicles for rent-seekering. Even if one believes that centralized technocratic solutions are the best choice for a implementing given policy objective, it seems to me the reality is that policy is too often driven by interest groups and not technocrats looking after the best interests of the people. The adverse effects of interest groups ranges from AIPAC, to defense contracting to public employee unions. So even though I think the federal government can and should have a role in many areas, I remain skeptical that the feds can do so competently.

    On health care specifically, I think it's important to point out two things: First is the difference between health care and health care coverage/insurance. They are often conflated in discussions on health care policy and, though they are obviously related, they are ultimately different in terms of policy. Secondly, our health care system is not a market system. Every part of it is highly regulated and it lacks fundamental requirements for a market to operate. Our health care coverage system is balkanized - some parts are partly market oriented and other parts aren't.

    So what does a "free market" mean in terms of health care? I don't really know. Here's what Arnold Kling, a libertarian economist, thinks we should do with the health care system. Is that a "market" based solution? Kind of I guess.

  19. The bill that just passed Congress only addresses the question of health care coverage and not health care itself. Like you said, it doesn't address the fundamental problems in our health-care system and it's likely to make many problems worse. For example, with an additional 32 million people with coverage, utilization of health care is going to rise. This law does nothing to increase the supply of health care, nor does it address the problem that many communities are underserved. Providing coverage for a benefit people can't use isn't good policy and increasing utilization on an already understaffed system is going to have some serious negative effects.

    Anyway, I'm rambling now.


    So at what level does health care spending begin to negatively affect the economy as a whole? 50% of GDP? 75%? If you think the US can spend twice what other countries do on health care and remain competitive I think you're kidding yourself, particularly since a lot of that spending is paid by employers and comes out of their operating costs. That reduces their capital and their ability to invest and is one reason (among many) that I think the US needs to get employers out of the health care coverage business.


    It would be interesting to hear what you and your neighbors and friends think of the Greek financial crisis.

  20. "Neither is good IMO but take a look at Greece for what happens when government overpromises and underdelivers. "

    To be fair, the Greek problem is a VERY different one: The lived beyond their means. Just as the Americans do.
    There's no policy - neither left nor right nor green nor whatever - that can sustain a nation living beyond its means.

    Health care costs are not a problem in themselves. Health care is a service, and services are being consumed. The optimum share of health care of the GDP depends on the costs of alternative consumption, the marginal rate of return for medical spending and the populace's preferences.
    60% GDP health care costs can be optimal if the population is completely nuts about living as long as possible.
    5-10% is apparently reasonable nowadays in a developed country.
    Nevertheless, keep in mind that doctor services aren't that much different from hairdresser services. It's not waste nor a problem. You can have too little or too much, but it's effectively both about a consumption of services.

    Also keep in mind that some countries have artificially low health care costs because the pharmaceutical industry is allowed to rip off American consumers thanks to poor regulation there. It's thus being able to refinance its business out of proportion in the U.S..
    I did a very primitive calculation last year and arrived at .5% GDP in the case of Germany for this effect. It may be very different than this, but it's certainly a significant effect.

  21. Andy-

    The vast majority of the Greek people accept that the bill has finally come due and we will all have to bear some part of the burden, either through higher taxes, lower public sector wages, or both, if you are a public sector employee. The current center-left party came into power on a platform of correcting the reckless fiscal policies of the previous center-right party. Unfortunately, thanks to some very creative "Made in the USA" financial chicanery, it was not clear at the time of the elections how bad things were.

    As in the US, it was the conservative leaning party that elevated cutting taxes and increasing spending to an elegant art form. And, it drew votes - up until last year.

    Fortunately, the private and personal sector is not as debt addicted as in the US, so while banks have tightened credit availability, it's not stunting our lives to the extent that it has in the US. While unemployment has risen to about 10%, that is not as great a proportional rise as in the US, and with universal national health care, as well as way fewer people having mortgages, it is not as devastating.

    Yes, people are pissed at "The Government", but they also tend to realize that they bought the low tax, high spending fiasco, and in the main are mature enough to realize that it their debt that they allowed and enjoyed while the ride lasted.

    Our friends who have small businesses have been cramped by the tightened bank credit, but they will do OK, as they are not as totally dependent upon credit lines as is so common in the US.

    There is a significant cultural difference between the Greeks and Americans. Greeks are problem solvers. Way too many Americans are problem fighters.

  22. jim's comment about Cuba reminded me of the last time I was there.

    Cuba has a lot of obvious poverty.

    However, every village had a two story house (i.e. doctor's house where the main floor is the clinic and the upstairs was where the doc lives). Also, every village has a school, with a bust of Jose Marti proudly displayed.

    A look at the CIA factbook reveals that Cuba has as good a literacy as the USA and very nearly as good life expectancy.

    It seems strange that an impoverished and brutal dictatorship can supply basic services to the population nearly as well as the richest democracy on the planet.

  23. Al,

    Thanks for that. Obviously, I don't put complete faith in the media reporting on what's going on in Greece.

    FWIW, I think we'll have an epiphany caused by crisis here in the US as well. Our politicians and our wealth are able to stay the day of reckoning for a while longer, but not forever.


    I'm not saying health care costs are a problem by themselves. Obviously any service is going to cost something. The problem is that the cost of that service is rising at 2-3 times the rate of inflation and has been for several decades. The result is that we are spending more on a GDP basis for healthcare than anyone and the trend for the forseeable future is up, up up. That is a problem and negatively effects the US economy. I don't see how it can be argued otherwise.

  24. AEL,
    IMO the Cubans altho poor have universal health care b/c of national prioritization of assets. It's called national strategic planning. We focus on wars and external contrived problems and they focus on internal use of assets.
    Which leads to the question-which system is more liberal-in the long run.

  25. Andy-

    The health care problem is not just cost, but lack of access. All those nations that spend half or less per capita and less of their GDP for reasonable health care systems provide UNIVERSAL ACCESS - to include well care, physicals, colds and preventive care. Come to Greece and skin your knee, and a readily available, nearby National Health Care doctor will treat you for free, even though you aren't a resident.

    Greece has a mixed public/private system. Insurance is under 100 Euro per month for 90% coverage, to include all prescribed meds, to include aspirin. If the Doc says you need it, your insurance pays for it. Since National Health Care facilities are free, except for purchased supplies (crutches, etc) and room/board in hospital (which insurance covers), private providers must be competitive. Ardy & I went to a private dermatologist today (the NHS dermatologist comes every two weeks to our island) and the bill for the two of us was 50 Euro ($67 US) for 30 minutes total of her time to treat an insect bite on Ardy and check a suspicious patch of skin on my bald head. To remove that patch cryogenicly will be another 30 Euro. So, figure for me, 55 Euro for the removal. What would that cost in the US? When I had it done 15 years ago, it was $200.

    Further, the insurance processing system here is so simple it is brilliant. Greek insurers issue a multipage book to their insured. Each page is an insurance claim form/prescription form. The doctor fills out the form for providing service and keeps the white copy, leaving the yellow NCR paper copy in the book for audit purposes. The Doc simply submits the white copy as his/her bill to the insurance company. No billing clerk required, and in the case of some insurers, the white form can be deposited in the bank for immediate payment, and the bank forwards it to the insurer. If the Dr prescribes meds, that is also done on a page of the book. That page is then presented to the pharmacy as both a prescription and an insurance voucher. Each package of meds has a bar code label that is removed and placed on the form as proof of dispensing, and the form then becomes the insurance claim. Again, no special billing clerks required. The insured pays 10% and the form delivers the other 90%. Drug prices are fixed and about 60% of what we paid in the US for the same drugs.

    Now, I realize that Greece only has a population of 11 Million, but if the US used a similar simple program for insurance processing on a state by state level, only 6 states would have a larger population, and two of those are under 13 million. Instead, the doc we went to in the States was in a group practice of 6 Docs, and they employed 4 billing clerks, along with an equal number of administrative types for other paperwork. The doc we went to today, just like the solo practice GPs I went to in the 40's and 50's, had no administrative staff. The overhead for processing payments in the US system is staggering, and much of it is due to the cost of dealing with the insurance industry, be it public or private insurance.

    Our system in the US simply sucks.

  26. @Andy:
    "I don't see how it can be argued otherwise."

    The topic is complicated. High health care costs are worse than less costs for the same service, but high health care costs are not poison for the economy. It's simply as if the people had different preferences.
    In other words: 15% GDP for medical treatment is poor for the national welfare, not for the national economy (and not much for individual companies).

    Keep in mind that this health sector stuff keeps hundreds of professors and doctors researching it. It's not simple enough to be fully accessible to everyone who's interested in it.

    - - - - -

    Germany's system is that you have a credit card-like thing that you show at the doctor or hospital if you want treatment or a check. You also have to pay 10 € in cash per quarter of the year every time you visit a doctor without a referral. The latter shall prevent people from consulting too may doctors.

    The health insurance fee is 15% of income, or about 130 € if there's no income (per month).
    There's an alternative health insurance system for choice, but that's a complicated story.

  27. To all,
    I'd like to make a prediction.
    Several States have already started the legal process to challenge the Constitutional power that is lacking for Congress to pass this law.In effect the argument is that Congress cannot force anybody to buy anything. If a person doesn't want insurance then that person is not engaged in interstate commerce therefore Congress cannot force them to do so.
    This is interesting and seems to hold water.
    If , and i say if the matter makes it to the Supremes then we'll see a real shut down for Obama. His slam on the Judges at the State of the Union will come back to him in spades.
    That's my prediction.

  28. "....will come back to him in spades."

    Ooohhh, that's a funny.
    But if they come back to him won't that mean he can draw to an inside straight of spades, and thus win?

    Or does it mean that his most ardent, natural consistency will run the brother outta town?

    On some related topics:

    John Robb's latest is a doozy. He quotes a survey that says that 24% of a SUBset of polled Repubs think Obama is the Antichrist.

    Bruce Bartlett on Fortune mag (based on a Frum poll of DC Teabaggers), indicates most of them think they pay 40% plus of Fed Taxes.

  29. Al,

    All true. As I said before, we have a balkanized system that is completely inefficient. And this new legislation just adds another layer of complexity into the mix.

    I also suspect that Greece doesn't suffer from our fee-for-service system where providers get to lobby Congress to add new chargeable services into legislation. That's actually what the "death panels" were really about - it was language inserted into the bill to allow doctors to make advice about end-of-life treatment a billable expense under Medicare.


    If health care costs were static, or rising near the rate of inflation, then Mankiw would be right. The problem is we have to pay an additional 2-6% each year simply to provide the same benefit. How long can that go on?


    You may be right, but the legislation could be altered to be clearly constitutional. The feds could extort the states into enforcing a mandate. The feds used the same strategy to make the drinking age 21 and the speed limit 55 - they simply said if you don't make those changes in your state law then we'll cut off federal highway funding. I don't see any reason the feds couldn't make a similar offer the states can't refuse regarding a mandate.

  30. Andy: The Kling piece reminds me why nobody with a functioning hindbrain elects "libertarians"; because they are the political equivalent of golden retrievers. Noisy and energetic with the attention span of a two-year-old and the intellectual heft of a bowl of jello. His notion of some sort of "fire insurance" for health care is the whackiest nonsense I've ever read, and I've read the comments at "Powerline". And he lost me completely at the part where he recommends a government panel to "educate consumers" on health care "shopping".

    Jim: The states are full of shit. The state of Florida forces you to buy auto insurance and tows your car if you don't. The state of Oregon requires me to pass a test to get a license to work and fines me if I don't. What's the difference here?


    Look, I have no real interest in selling this bill. I think it's impact will be minimal. I think the U.S. majority-private-largely-fee-driven medical system will continue to consume an ever larger part of our disposable income without returning us any real benefit beyond what the rest of the industrialized world gets for considerably less money. I think the notion that calling this pimple on the medical elephant's ass "the death of freedom" is utterly mad.

    Andy's last link makes the point of my original post better than I ever could.

    Look, you may not agree with what the Dems were trying to do, or what they did, or how they did it. But the bottom line is that the Dems would have been a lot better off politically (if all this guff about how much we loves us some of our "best in the world" health care were true) if they'd left that sleeping dog lie. If they were doing it "for political gain" do you think they'd have fucked it up so throughly? Let all the usual ling bastards spin them on "death panels", give up all the really "progressive" (i.e. what a Belgian or a Japanese or an Australian would take for granted) parts of the thing and end up with this camel?

    No. The Dems - fucked up and clueless as they are - still contain a minority of people who believe in the old tired New Deal idea of government; that it's there to help you do things you can do on your own, and that harm you when you can't. Among the rest of the political whores, corporate shills and out-and-out powermongers, what drove this was the notion that people shouldn't have to be sick because they can't afford to pay for medical treatment.

    You can argue that that is a stupid idea. But at least it IS an idea.


  31. (con't from above)

    As far as I can tell, the people who fought this fought it...well, I honestly have no idea why they fought it the way they did. They clearly had no notion of "fiscal responsibility", since they had just spent the last eight years putting wars and tax cuts for the two-yacht families on the national credit card. They clearly didn't believe the nonsense about "freedom" and "big government" since they had just put a massive Medicare drug entitlement on Sam's VISA card AND used "don't touch my Medicare" as a club to beat this with.

    The thing they seemed most upset about was that this thing seems designed to give tax dollars to poor people. So, I don't know, maybe they just don't like poor people. I agree. Poor people wear funny clothes and talk loud and stuff. Some even smell funny.

    The people who fought this seem to have a political field of view that is bounded by Glenn Beck's deal about "America is Good". And if you want to change something in America (that DOESN'T involve making it legal to imprison someone for providing abortions or being Muslim) you must be a godless Hitlerite Commie.

    THAT's their "idea".

    Oh, and tax cuts.

    So I'm pretty sick of the Dems and their foolish inability to get three people heading in the same direction. But, right or wrong, they at least HAVE a direction that DOESN'T involve ginning up a land war in Asia.

    The GOP?


  32. Andy-

    One really doesn't see the madness of the insurance billing process in the US until you try to help an overseas insurance agent make sense of a US hospital bill for them. I had the opportunity to do so several months ago. It was a real "complicated" case. An neighbor, who lives half the year here and the rest in the US and has elected to be is covered by private Greek medical insurance (pays 90% inside the Eu and 80% outside for 90 Euro/month), was driving in the US and hit by another car that ran a red light. She had been hospitalized for 3 days for that when she suffered an inflamed pancreas, resulting in another 5 days in hospital. Her bills for the vehicle mishap were covered by the other driver's insurance company, with which the hospital already had a claims relationship. Thus, they immediately began the claims process upon admittance for direct payment from the US insurer. However, since the pancreatic problem was not due to the mishap, that would not be paid by the US insurer, and the hospital would not accept direct payment from the Greek insurer. Thus the woman has told that she would have to pay for the panreatic problem out of pocket and seek reimbursement from her Greek insurer. No problem, the woman thought. She'd just get a bill once the two courses of treatment were sorted out, pay up and get her typical speedy settlement from the Greek company.

    Of course, there was all sorts of wrangling between the hospital and the US insurer. Was this pain pill for the vehicle injury or for the panreatitis? Was day 3 in hospital primarily for the accident injuries or the panceatitis? And so on. So months went on while she received 10 page itemized monthly statements labeled "THIS IS NOT A BILL. Your bill will be presented for payment when insurance coverage is finalized." And, of course, these statements showed the amount charged for every little item ($1.25 Tylenols, for example), what the insurance company "allowed" (only $.60 for each Tylenol) and what was not accepted by the insurance company. A little over a year later, she got a letter from the hospital that advised her that the insurance had been fully settled and requesting some $14,000 as her "responsibility" for the services rendered.

    So, she mails all this to her Greek insurance agent, as she was in the US for 6 months when the letter arrived. Since the insurance agent is a good friend of my cousin, I get the call to try to explain the two inch thick stack of papers so they can pay the woman. First surprise to the Greek insurance agent was that the insurance company "Allowed" significantly less than billed for virtually every item on the statements, and the hospital appeared to accept that as payment. Second surprise was the "billed" price of things like Tylenol, as well as the inflated and accepted "Allowed" price. However, the woman was being billed full price for the items not connected to the auto accident, and was expected to pay that full price. In short, if the US insurer paid for a Tylenol associated with the accident, the hospital was happy to receive $.60, but the woman was expected to pay $1.25 for each Tylenol associated with her pancreatitis.


  33. Part 2

    Now, the problem is that the “THIS IS NOT A BILL” itemized statement does not explain what happened to the thousands of dollars billed, but not “Allowed”. The insurance agent had added up all the items for which there was not an offsetting insurance entry, and that did come very close to the amount requested in the letter, but she also added up everything, and subtracted what was accepted from the US insurance carrier, and it appeared that the insurance company was paying 55 cents on the dollar, while the woman was expected to pay full bore. Lastly, the hospital never really gave the woman a clearly identified bill ( all the itemized documents were marked “NOT A BILL”), but just a letter stating the amount due. I suggested that the Greek insurance agent call the hospital for a final itemized bill, and she got a summary computer statement that identified the “Total Charges”, “Insurance Paid” and “Patient’s Responsibility” amounts, but no accounting for the charges that had been written off. Of course she was infuriated that her company was expected to pay significantly more for her client’s care, but she also wanted to close the claim. Rather than send the insulting bill in to the home office and possibly create delays for the insured, she called the hospital again and asked if they could produce a simplified bill that did not make it appear as if the US insurer got a “discount” that wasn’t offered to the patient, and subsequently the patient’s Greek insurer. The response was some abuse and being told that such an invoice could not be produced. So she called the home office for guidance, and they told her that dealing with claims from the US was a nightmare and to simply have the woman pay her share of the bill, get a simple receipt for the amount paid and submit that with the “THIS IS NOT A BILL” crap. So the woman goes to the hospital, and pays by check, requesting a receipt. After a while, she gets another iteration of the 10 page document, showing the amount received in payment, but not identifying who actually paid it, and still leaving thousands unaccounted for. So, in fear that it might not suffice, she asked for a simple receipt that states that the hospital received from her, by name, the $14,000 as payment of her responsibility in full. She was told that no such mechanism exists. Fortunately, for her, the Greek insurer was willing to reimburse her the 80% on the basis of the “Payment Received” entry on the 10 page statement.

    One last item. Those 10 pages had about 35 entries per page. Every insurance payment entry had to be manually matched and entered against one of those 300 plus items. Major clerical task that contributes great cost, but absolutely no quality to health care delivery. And why do we have this huge overhead and confusion, because it takes 10 pages and 350 entries to document "Fee for Service"”care.

  34. I can play the role of the disturbing outsider as much as I want - this discussion is still very American. No discussion about health care could ever look like this in Germany.

    We're simply lacking this obsession with a "small state". Instead were discussing along the lines of "sustainability" or "cutting costs" (~saving money while getting the same services).

    Germany's problems can all be summed up as distribution problems. There's no such problem like people going bankrupt because they lack insurances to compensate for bad luck in a car crash or illness. Our consumer protection is way ahead (don't get me started on U.S. food security norms) and my overall impression is that we organised/regulated away most problems faced by the Americans.
    Today it's really only about distribution here; the rich still get too much, the state* and the working poor don't get enough (*: the state is still having deficits, but new legislation bans deficit spending almost completely in a few years). Ironically, some of our imbalances are due to a very economy-friendly social democratic government's (Schröder, few years ago) agenda.

  35. @Jim, about constitutionality:

    Look up this:

    The Militia Act of 1792, Passed May 8, 1792
    First paragraph.


    It's safe to assume that the ones who wrote this bill knew the constitution that they themselves wrote five years ago very well.

  36. A while back…no, more like twenty five years ago…I had an incident.
    The incident, for all intents and purposes, was stupid, but that’s how we end up in hospitals anyway, stupid stunts end with stupid injuries.
    I was no exception, but in my case…well, I could have prevented it…so much for the mind of a young man.

    I fell asleep on the beach…in the full noonday sun…with no shirt on…for about three hours…maybe more…not sure.

    I also had no health insurance at the time. A job, but not much money...and it was summer, I had started a new job, was on probation period…so…yeah…a bad alignment of stupidity and judgment with bad consequences.

    Severe second degree burns across my back and shoulders…it was so bad that skin was peeling, crackling, and bleeding…popped blisters were oozing, and the only thing I had to stave off the worse of it was t-shirts and my room-mates codeine Tylenol…it was bad.
    Room mates begged me to go to the hospital, but without health coverage I figured I was on my own…self-treatment, taking care of myself…I can do this…day two…I had a fever.
    Yep, time to go to the hospital and hope for the best.
    Pretty much all of my paycheck was spent on rent, which left me, and I still remember this…1.95 for food for the rest of the week, plus whatever hand outs I could get…which usually was a 1lb bag of rice, a block of cheese, and…well…whatever I could fish out of the garbage bin from behind the grocery store…and I collected aluminum cans….$0.25 a pound then…and I could sometimes buy milk, or a nice treat like a box of mac and cheese with the proceeds from the cans and dumpster diving.
    I had no car, I walked to work, and now I had to go to the hospital…fortunately, my room mate took me…but I had to call in sick to work…apparently my boss didn’t believe me when I said I was ill, and demanded I supply proof when I came into work the next day, or don’t bother coming in.
    I told him I would bring a doctors note.
    I registered at the emergency room desk, I had a towel over my shoulders since I was self-conscious about the condition of my back.
    I was asked how much money I could give…and I think I had two dollars in my pocket, which I handed over…that was suppose to be my dinner for the week…was going to buy two boxes of mac and cheese with that, and a couple top ramen soups…but treatment trumped food at that moment.
    I sat in the emergency room of Valley Medical for quite some time, until finally a doctor pulled me in. I took off my shirt, he examined me, prescribed anti-biotics, and then looked at me and said, “you need to be more careful.”
    Then he advised me to lay down on the table as he was calling in a nurse. I could hear him outside the door, “take care of him, he’s in bad shape.”
    She came in, saw my back, and I will never forget the tenderness she used to wash my back.
    She was the kindest person in my world at that moment, and to this day I thank G-d for her.
    The next day I went to work…my boss looked at the doctors note, and said, “this is bullshit.”
    I said, fine, and removed my shirt with pieces of me falling to the floor, and turn around so he could see my back.
    His boss, who heard him derisively laugh at me, came out just as I turned around.
    The GM told me to put my shirt back on, that I was obviously still not well enough to work, so go home, get better, come back when you’re feeling good.
    I really didn’t like exposing myself like I did, but people are people, and some of them just take the road to stupidity to new and daring depths.

    For me, I’m glad the health care reform was passed…personally; I think single-payer is the only way to go, but I remembering what I went through is enough to illicit compassion out of me for anyone who is seriously sick and needs help ASAP.

    That is why I support I this amendment…even in its imperfect state it’s still better than nothing.

  37. Sheer-

    Most of the people who are either against, ambivalent toward or non-committal about health care reform of any sort have typically never been without a reasonable coverage plan. That the devil of pre-existing conditions being cause for refusal of coverage has existed for many years illustrates what a foul system we have allowed to exist.

  38. BTW, I highly recommend these two programs on our health care system. They are the best thing I've found that explain a lot of the complexities without jargon. They're an hour each and will cost you $2, but it's worth the investment:

    Part one

    Part two