• Why we get frustrated

    Aaron and I are very interested in an honest, good-faith, evidence-based dialog on how to reform our health system. In order to make progress, we must also keep in mind what’s politically feasible. Compromise is necessary. But in the current climate, it seems impossible. Ezra Klein just expressed his understanding of why.

    In a world where the two parties’ top priority on health care was providing answers for the uninsured and cost control, an argument over the best way to do health-care reform would be a very healthy thing. But that’s not what we’ve got. We’ve got the Democratic Party, whose top priority is to try and solve our health-care problems and who’ve shown their commitment to that by moving steadily rightward over the last century in a bid to pick up Republican support for some sort of solution, and the Republican Party, whose top priority is that we shouldn’t do whatever the Democrats are proposing and have proven their commitment to that by abandoning previously favored policy proposals as soon as the Democrats demonstrated any interest in adopting them.

    And that’s the fundamental problem here: It’s easy to compromise when both sides are committed to solving a problem, because the appeal of solving the the problem is enough to persuade both sides to make concessions. That’s why Democrats gave up on single payer, on an employer mandate, on a public option. But it’s impossible to compromise when one side is uninterested in solving the problem, as they lack the incentive to make any concessions. That’s where the Republicans are on this, and it’s why they’ve not been interested in joining onto a bill even when Bill Clinton moved to the right and adopted the core of Richard Nixon’s plan and Barack Obama moved even further to the right and adopted the core of Mitt Romney and Bob Dole’s plan.

    Taking the debate in the comments on this blog as further evidence, I am in general agreement with him.  I’m sure not everyone sees it this way and will tell me so in the comments. However, if you can put aside whether you see it this way or not, perhaps you can at least recognize that this is the source of frustration for many who care deeply about health care and our system(s) of financing it. For some of us, this is not politically motivated posturing. We’re not happy with the nature of dialog. We yearn for something more healthy and productive.

    You know what would help? Stop the meta-debate. Just cut right to the politically feasible compromises. Cut out the accusations of obstruction, threats of repeal, obsession with legal challenges, claims of illegitimacy, and so forth. You can wag your finger at me and say the same thing. You can be frustrated too! Go on, vent. And then let’s move on.

    How do we move on? How do we just get right down to work? Perhaps one way is to just lay our cards on the table. What are our goals? Universal coverage? Cost control? How are they to be achieved in a believable fashion? What are we to do if your goals and mine conflict (as if either of us had any power to do anything)?

    It should be clear that my chief goal is addressing the deep problems in our insurance markets. I think people who would prefer to be insured, or insured in ways not tied to employment, are not and for reasons that can be addressed. (The ACA is very slow to address some of the issues here, but is a start. I would have preferred something that moves faster. It couldn’t pass.) Addressing these problems will move us closer to universal coverage, or even achieve it. But, to me, that’s not a goal in and of itself. However, I am concerned about “gaming” the system, which is the justification for a mandate or something that serves the same purpose. (There are alternatives here.)

    I also have some concerns about cost, but I’m not convinced we are ready to “bend the curve,” or that we really should. Yet, there are deep problems related to how health care is financed. I am absolutely committed to identifying and removing “waste” and inefficiencies from the system, but view these as likely shifts of the curve, not long-term changes in its rate of growth. I will note that “waste” is not well-defined.

    I’m among the skeptics in the believability of the ACA’s cost controls or revenue generators. Alternatives or enhancements I’ve considered on this blog (competitive bidding, all-payer rate setting) don’t seem politically viable, not yet anyway. My skepticism doesn’t go so far as to claim the ACA can’t begin to address issues of cost, in addition to going a long way toward addressing some insurance market failures.

    I live in Massachusetts. I supported the reforms here when they were backed by a Republican governor. If I thought repeal or removal of the national law made sense, I’d argue for the same for Massachusetts. Instead, I’m supportive of the ways Massachusetts is trying to build on its reforms and to address the related and unrelated cost issues.

    If I thought striking the mandate would better remedy problems in insurance markets or better address cost issues, I’d support just that. I just don’t see how doing so would help. But I’m willing to listen to alternatives or enhancements. In fact, I think they’re required.

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    • This blog routinely posts a graph of CBO budget forcasts, etc.
      In both of them, public health care costs go up way faster than anything else of the graph.
      My chief goal is making that not happen. My chief goal is keeping federal spending at ~18% of GDP. I do not need to worry about the political feasibility of this objective, because there is no alternative; either spending reverts to and stays at 18% or the federal government eventually collapses. This cannot be done without controling public health care costs. You can engage in all sorts of accounting tricks and cuts elsewhere but eventually the overwhelming majority of all health care spending must be private.
      I want every single healthy person in the United States to have catastrophic health care coverage. I do not want risk-pooling with those who are healthy subsidizing the care for those who are not. Insuring those who are already sick is the same as insuring a house that has already burned down or insuring a care that has already been stolen.
      I am deeply, incredibly frustrated by the attempts of those of the left to manipulate the public by saying that this will kill your grandmother or by stating that “[any solution must] help [Ms] St Pierre” and exacerbating an already huge problem with the seen costs and unseen benefits that plague market economies.
      I accept that there are healthy people who wish they could afford coverage, but instead of subsidies and mandates, I would prefer to cover them by making the country more like the state with the least regulation (Alabama last I knew) where premiums are almost a quarter of what they are in Massachusetts (there’s other effects at work here, but a 75% decline in premiums is pretty hard to explain).
      I see health insurance as fundamentally no different than home-owners insurance, or car insurance, or life insurance, or any other financial product (each of which I can not only buy across state lines, but from other countries). I find it incredibly frustrating that I can be treated by a doctor in Singapore (where my actual primary care physician lives), diagnosed by a radiologist in India, and treated with medicine manufactured in Taiwan, but god-forbid if I try to fund it all using insurance from a company outside of Arizona the entire global health care system will collapse.
      I find it frustrating that depite the fact you never hear about the crusing burden caused by exploding costs of bread (in the United States at least), or about the vicious milk monopolies that leverage the fact everyone has to eat in order to drain every ounce of money out of them that they can, we still choose to act as those somehow with medicine all the normal laws of economics break down. I find it frustrating that we even talk about the problem of pre-existing conditions, with the whole less than one percent of the population actually affected by the exclusisons, as the reason why there is a fundamentally broken system that needs to be completely re-designed.
      I think we could do much, much better if we put the entire burden of health care costs of the shoulders of the people actually receiving the care. I admit that this would involve a liquidity problem not easily addressed for those that need very expensive emergency care (see the support for universal catastrophic coverage mentioned above). Insurance, however, should be that, insurance, protection against events that are beyond your control and uncertain. My annual checkup should not be covered, pregnancy should not be covered, chronic conditions already present should not be covered, mental health conditions already present should not be covered, pre-existing conditions should be covered, end of life care should be covered. I am perfectly fine with you paying for a plan that covers these things, but I do not want them mandated, even if that would make them more affordable for you.

    • “… politically feasible compromises…”
      I don’t think there are any. As Ezra Klein pointed out (and as ‘Different Aaron” illustrated though his incoherent rant), one side is not interested in ANY compromise. They are not interested in solving the problem and will offer a hearty word salad defense which only makes you confused.
      The ACA suffered greatly by all of the compromises intended to accommodate the Republicans and the final bill is pretty much what they were proposing in the past but they still did not support it since they are not interested in compromise, only capitulation to some odd god of free-market, save the rich capitalism.

    • You misunderstand.
      I want purely free-market, virtually zero government involvement whatsoever (settle lawsuits, police fraud, etc).
      Others want fully-public, universal, single-payer.
      Compromise would be anything between those two points.
      There are things in between those two points that I would be willing to accept, the PPCA is not one of them.
      My, “This Far, but No Further” point doesn’t happen until somewhere around Singapore.

    • I think we have at least two options:

      1. Massachusetts can start showing the rest of the country that they can offer universal coverage at a monthly insurance rate comparable to Canada/Switzerland. My best guess is that this rate is about $700 per month. If they can do this by tweaking their system, the rest of the country will follow since this will result in significant savings for businesses and goverment entities.

      2. Sens. Lindsey Graham (R., S.C.) and John Barrasso (R., Wyo.) recently introduced the State Health Care Choice Act. The State Health Care Choice Act would let state governments choose whether or not to participate in various aspects of Obamacare, including: the individual mandate forcing citizens to purchase health insurance or pay a fine, the employer mandate forcing businesses to provide health insurance or pay a fine, the mandated expansion of state Medicaid programs and the federal mandate determining what qualifies as an ‘acceptable’ health-insurance plan. This plan is very attractive to many states since they do not have the money to expand Medicaid and several states have passed referendum against the Individual Mandate. This probably will encourage states to develop their own approach to controlling health care costs.

      Since Massachusetts has not achieved any cost control success with their plan, I am betting that Option 2 will become law.

    • “I want purely free-market, virtually zero government involvement whatsoever ”

      There is no model for this working anywhere.

      Steve

    • As a conservative, I too share the frustrations of Austin, Aaron, and some of the other commenters here. I too would like to see some of the problems in the insurance market corrected, so that we move toward more universal coverage.

      I also agree much of the paragraph that begins “You know what would help?” But you know what else would help? If liberals would stop mischaracterizing my side as the party of no. It would help if informed, thoughtful people like the authors of this site disassociated themselves from uninformed tools like Ezra Klein. What gets me the most frustrated is when we try to have a debate about the merits of PPACA (or something else), and liberals say that my argument is illegitimate because I’m just a simpleton who doesn’t like Obama and wants to tear down Democrats.

      So, a “politically feasible” alternative is the objective. Great, I’ve got a few ideas: 1) Eliminate the tax break for employer provided health insurance. 2) Subsidized high-risk pools for those with pre-existing conditions who cannot buy insurance. 3) Permanent Medicare solvency (through a variety of fixes). 4) Expansion of HSAs. And it all starts with repealing PPACA, which is looking more feasible by the day.

      • @pipster – I sure hope nobody has called you a “simpleton.” I do not find your comments about Klein very helpful (read the comments policy please).

        I support your suggestions numbered (1), (3). I have no problem with (4) provided low-income individuals are protected and there is some value-based design. I have the most trouble with (3) as a permanent solution. Seems like there is plenty of room for compromise, if not agreement.

        Then there’s the politics. (1) is not going to happen right away but the Cadillac tax phases it in (yes, slow, but better than nothing–let’s makes sure it isn’t eroded). (3) is a political third rail, but I’ve made suggestions and the law does have some worthwhile experiments (just a start, I know, but better than nothing). (4) and (2) are the most difficult. I’m not sure how to make them fly more broadly.

        I share your frustration that the law is not as swift to implement broadly agreed upon reforms (among economists, at least) like removing the employer-based tax subsidy and curbing Medicare costs. It isn’t as if those who crafted the law didn’t want to act on those more swiftly, they did. It was just not politically feasible at the time. Maybe it will be later, but I doubt it. Which party seems like they really want to move more swiftly on either of those and in a manner that is any more credible than what we’ve seen? (Don’t point to Rep. Ryan’s plan for Medicare. I’ve already explained how it won’t do what he wants it to do and illustrated something better. Need I link to it, or do you know what I’m talking about?)

    • @pipster – How do you view the effectiveness of the high risk pools which already exist?

    • I get very frustrated with the direction of the debate as well. Far too many people who are closer to my opinion on the proper direction of health reform rely on bad arguments and/or play loose with the facts. And far too many people who disagree with me quite a bit on reform spend a great deal of time arguing against those people and their weak arguments.

      There are a great deal of reasonable people on the “right” (I don’t really think this a strictly left/right issue and those terms are too broad to be really useful here, if you wish just imagine I said “greasers/socs” or “Packers/Steelers”) who go almost completely ignored by the Ezra Kleins and Jon Cohns of the world, who choose the easy targets of hypocritical Republicans in Congress or terrible Mona Charen op-eds rather than engage the tougher arguments.

      I think if you ignored all the noise and got an ideologically diverse group of health policy wonks in a room we could hammer out a reasonable compromise in a couple of weeks. If that compromise is not politically feasible then we need to focus on doing what we can to change that, not implement bad reforms because they are “better than nothing”. Doing things politically that give people free stuff and defer the tough decisions to the future will always be politically feasible. That doesn’t mean that is what we should settle for.

      • @AB – Honest question: who should I read on the “right”? I’ve tried. I’ve really, really tried. I used to read Avik Roy. Then I noticed he ignores too much evidence. But I tried! I do like Reihan Salam and Bruce Bartlett. Neither are focused on health but they do touch on it. Any other bloggers worth following? I will try what you suggest. But I will drop people who misinterpret or misunderstand the literature. That’s my only test.

    • @bill – Good question. Not sure if you’re referring to high risk pools that existed pre-PPACA (which I know very little about), or post-PPACA. If the latter, the amazingly low enrollment to date is really something that should give everyone pause. Maybe there aren’t that many people out there after all who have been turned away for pre-existing conditions. Maybe the lack of coverage in this country isn’t nearly as bad as everyone assumes. And maybe we shouldn’t overhaul the entire health care system just to get a few thousand more people insured.

      @Austin – Apologies, but I don’t find Klein very helpful either. His goal is not to inform, or educate, but to delegitimize. The irony is that he does exactly what he accuses Republicans of doing. I really don’t understand how you could pay attention to him but ignore Avik Roy.

      I’m a bit more optimistic than you on the feasibility of the four items I propose, especially if packaged as a whole. #3 is clearly the most difficult, politically, but the issue of debt and unfunded entitlements is obviously coming to a head right now.

      As for whom to read on the right, I have a few suggestions. Of course, Avik Roy is at or near the top of the list. National Review has thoughtful commentary, with minimal snark, and an entire blog dedicated to health care: nationalreview.com/critical-condition. I enjoy NR largely because you find debate *among* the right, including differing opinions from libertarians, social conservatives, fiscal conservatives, etc. (Note: contrary to popular opinion, the right is not monolithic.) At the high end of the snark scale is InsureBlog. The main blogger over there is an insurance agent and has good perspective on that part of the market. And though they cover more than health care, patterico.com has had excellent analysis of the various court proceedings and the legal arguments. The main blogger there is a prosecutor in the LA area, I believe.

      • @pipster – I just realized that I prefer to read folks that I can extract value from relatively efficiently. It doesn’t matter if I think they’re mostly correct or not. It matters more how well they lead me to improve my thinking and understanding. I’ve given everyone a fair shake. I stop reading those who I find mislead me more than not (by which I mean, I check what they say against the research; if they’re consistently wrong they’re not helping me — see http://theincidentaleconomist.com/wordpress/medicaid-bashing/ , just as an example [note, here, that I wasn’t ignoring Avik!!!])

        I’ll check out nationalreview.com/critical-condition . If it passes my tests, I’ll stick with it.

    • Perhaps a politically feasible good first step on health care would have been smoothing the entry into medicare. Opening the program to more people but charging them premiums based on income and introducing a deductible that goes up with income level.

      But the democrats chose to swing for the fence.

    • BTW the state laws on doctor and nurse licensing and what licenses are required to do what lead me to think that health care costs might be better addressed at the state level because the states can make health care too expensive through the licensing. Alternatively the SCOTUS could declare such licensing a restriction on interstate commerce.

    • One more point the market is addressing the 2 problems with health insurance.

      Problem one is that to many people get there insurance through there employers and so have coverage gaps on job lose. The solution is that fewer companies are offering insurance.

      The other problem is too low deductibles make for inefficiency creating a cost problem. The solution is that companies are raising deductibles and dropping coverage. When they drop coverage people usually opt for higher deductibles.

      These are painful and difficult solution in the short run but IMO they will payoff in the long run.

      Politicians cannot make such painful changes because voters prefer low deductible if they think that someone else is paying and they do not understand that they pay either way.

    • Hola-

      A couple of points/questions/thoughts…

      I took a look at Avik Roy and the NRO health care site. Roy seems to be ok, can’t comment on Austin’s concern about Roy’s ignoring some evidence though. The NRO on the other hand, perhaps its me and my political leanings, but I don’t see it as being particularly helpful. Perhaps it is to a liberal as Ezra Klein seems to be to a conservative. Plus, I get halfway down the page and there is an ad for “The Politically Incorrect Guide to Socialism.”

      @pipster (and actually anyone else who might be able to help on this): Is there a difference between the high risk pools and catastrophic insurance coverage? I find the idea of a high risk “pool” somewhat interesting. The way I was taught, the idea of a pool is that multiple individuals with varying degrees of health at any given point in time could fund coverage, thereby ensuring that the really sick would not bear the full extent of their costs by themselves. Also, the costs of the really sick are essentially inevitable as almost everyone needs at least some very expensive care at some point.

      By eliminating the employer tax subsidy (I’m kind of agnostic on it), theoretically employers would drop coverage, leading to the main driver of pooling in the US to go down. So, it seems like kind of a double whammy by doing both of those resulting in a total segregation of sick and healthy.

      Lastly, pipster, regarding this:

      “Maybe there aren’t that many people out there after all who have been turned away for pre-existing conditions. Maybe the lack of coverage in this country isn’t nearly as bad as everyone assumes. And maybe we shouldn’t overhaul the entire health care system just to get a few thousand more people insured.”

      There are three maybes in here. I don’t know the answer or data on the first one. As for the second maybe, according to Kaiser, as of 2009 18.9% of the nonelderly population were uninsured ). It might be a value judgement as to whether thats bad. As for the third maybe, “a few thousand more people?” I don’t know if you can come onto a blog about frustrations in the quality of arguments over health care and make such a statement.

      But this goes to a greater question, can we actually have this debate in such a way that both sides see the other as honest? Is it actually possible? Every day I grow more skeptical of it. Hope I’m wrong.

    • @CG-Thanks for the thoughtful reply. In answer to your first question, I was using the term “high risk pool” to refer to a state (federal?) program that is exclusively for individuals who are not able to obtain insurance due to pre-existing conditions, and are not eligible for some other program (e.g. Medicare or Medicaid). As a conservative, I have no problem using tax dollars to subsidize citizens who want insurance but cannot get it.

      As for the uninsured population, I put a lot of trust in KFF, and use their research almost every day at work. However, when PPACA establishes a program that an estimated 4 million people are eligible for, and less than 10,000 sign up, I think we need to call a time-out and re-evaluate some of our initial assumptions. (KFF doesn’t seem to have any data, but numerous articles cite total enrollment at 8,000 in mid-December.) I stand by my statement–if PPACA ends up covering a few thousand more people than were covered previously, this is not worth blowing up the entire system. What am I missing? What’s wrong with the quality of this argument? Seriously, help me out here, I don’t get your complaint.

    • I think sign-up for the high risk pools is low because the rates are high (150% of standard rates) and many people don’t know about them. Also, they are only for people who have been without insurance for 6 months and these people have either given up on trying to get insurance and/or don’t have current medical expenses.
      I am eligible for the high risk pool but since I don’t have any current medical expenses, I have decided not to purchase the insurance. I know that I will be able to buy the insurance if and when I have significant medical expenses. Until then, I can save the $1150 per month that the insurance will cost. (moral hazard in action)

    • I would have to agree with most of Different Aaron’s comments. I think the more the gov’t tries to get involved with healthcare (or anything for that matter) the worse off the bulk of the population will be. The roots of this healthcare problem go back to the start of employer sponsered insurance plans and Medicare. Both took the cost factor out of healthcare decisions for patients. Both also drove costs skyward as Medicare would say that treatment X was worth Y even if Dr. A. was charging less than Y for X treatment. Dr. A then realized that he was missing out and raised his fees. Medicare made it illegal to charge Medicare more than people with other insurance, so everyone paid more. Medicare had to increase fee schedules every year to keep up with inflation (or so the arguments were) and costs contuinally go up.

      Additionally, when new technology comes out (DVD, BluRay, microwaves and also CT scanners, MRI, PET scan, artificial hips, etc) it is usually expensive to produce as there is an unclear market for it. As people start to use the new product costs always come down as they did with BluRays, microwaves, etc. In medicine, Medicare says “ok if it costs this much to recoup costs on a new MRI then we will pay this”. Fast forward 20 years and MRI’s shouldn’t be as expensive but with Medicare taking the free market concepts away, the costs never go down but always up.

      This is obviously a multi-faceted problem, but I see a fairly simple fix. Eliminate Medicare, Medicaid, any mandates on anything and try to move towards a cash business in medicine and watch prices plummet for everything medical. Charities exist for a reason and will fill the void for those still unable to pay for their own medical care (of course there would be growing pains at first). I’m not real optimistic that this will happen unless the federal gov’t structure collapses, which is more likely everytime they decide to spend more money than we have. Anyway, there’s my two cents.

    • @Eric,
      Yeah, it’s funny how the industries with the most government involvement (health care and education) have the highest prices and the worst performance.

    • @Eric “I think the more the gov’t tries to get involved with healthcare (or anything for that matter) the worse off the bulk of the population will be.”

      @pipster “Yeah, it’s funny how the industries with the most government involvement (health care and education) have the highest prices and the worst performance.”

      I don’t really need to read any further. This tells me that your ideology is driving your arguments and that you would be unpersuaded by any real world evidence that went against your ideology. For instance, if I were to point out that all of the OECD countries (other than the US) have heavily government regulated, controlled (and even managed) health care systems and that they manage to provide their populations with better health care, access and outcomes at less than half (per capita) of what we spend in the US, would you accept this real world well documented evidence or would you continue with your “government bad; free market good” diatribe.

      (Why are the ideologues afraid to use their real names?)

    • @pipster: I might have misunderstood the statement. Did you mean a few thousand more will be covered under the whole of the ACA or were the few thousand more only in relation to the high risk pools?

    • As a physician, I know firsthand that the gov’t knows nothing about what physicians do on a day to day basis, but that doesn’t stop them from interceding more all the time and constantly making my job harder by putting up more and more hoops to jump through, most of which have nothing to do with actually helping patients. You want to know why our healthcare costs more?
      – CMS (medicare and medicaid) regulations that hospitals have to abide by that no other insurer requires. At our local hospital (where I’m currently Chief of Staff) during a Medical Staff meeting I asked what percentage of our bylaws are basically required by CMS. The estimate was 70-80%. And every year CMS decides to change a few requirements to justify their job. Then we have to go through and change the bylaws (as does every other hospital in the country). This adds enormous administrative fees to the system and does absolutely nothing to provide care to any patients.

      – Other countries ration care…period. Those who can afford it come here to get care they cannot get in their home country. I have spoken to physicians who trained in England, and basically if you wanted your non-life threatening problem taken care of within a couple years (gallstones, hip replacement, etc.) you paid for it out of your pocket.

      – We innovate more. Most new drugs and medical devices are developed here in the U.S. This costs money that companies have to recoup.

      – Litigation costs tend to be higher here where the American Bar Assoc controls more legislators than organized medicine. These other countries at least tend to have malpractice environments that are better than they are in the U.S.

      So no, I’m not simply blinded by my ideology, I kind of have a little knowledge of the subject. And by the way, I went to quite a liberal University and come from a family of Democrats, but experience and keeping an open mind have allowed me to see that the gov’t and their bureaucrats rarely make anything better.

    • Everyone chill, enough of the snark and accusations about ideology. Its kind of silly because, well, honestly who isn’t making these determinations at least in part on ideology.

      @Eric:

      1. How do you know CMS changes regulations to justify their job? Is it possible there is a reason for a change that you would know in your position? And what does it matter if its your bylaws?

      2. Yes absolutely other countries ration care. England spends about $4500 per capita less than the US. But does that mean we get what we pay for? My guess is that you agree that we don’t but would disagree as to why.

      3. We absolutely innovate more. But, and this is a big but, I think we innovate more precisely because we pay more. I wonder if a drop expenditures would not also lead to a drop in innovation?

      4. I don’t even know what to say anymore about litigation costs. The estimates I’ve seen show some increase but not a lot, and certainly not enough to be a main driver of overall cost growth. I think there is a legitimate gripe that the wrong cases end up progressing into litigation, but, if you are interested in the rights of an individual, would you ever want to curtail that their legal remedies?

      Lastly, honest observation, and I don’t mean to throws stones or hurt feelings: I feel like doctors especially believe they are in a special place to diagnose (no pun intended, or did I…) problems in the health care system as a whole. While a physician’s opinion is obviously relevant and valuable, is it possible that yours is just one view that must be included along with those in hospitals, nursing, insurance, pharma, etc.? In other words, does your position give you a simple perspective or does it give you the right to say that your opinion is the one that matters most? Does that make sense?

    • @CG–
      Both, I guess. I was referring to the high risk pools directly, but I think the point still holds when applied to PPACA as a whole. One of the primary arguments for PPACA was that coverage would be extended to lots of people who didn’t have it previously. This uninsured population can broadly be divided into two categories: those who qualify for coverage of some kind and don’t have it, and those who don’t qualify for any coverage. The high risk pools (and, in 2014, the guaranteed issue mandate on insurers) are intended to address the second group, a group which appears to be a whole heck of a lot smaller than we thought. So, what about the first group? Theoretically, the individual mandate will push some of them to get coverage, but there is a chance that employer dumping will actually *enlarge* this population. So how many more people will be covered by insurance in 2014 than were covered in 2009? Might it be measurable in the thousands?

      We’re probably not going to agree about that issue, primarily because nobody knows exactly how this is going to play out in the next few years. But that leads into my larger point, which is way more important: how big is the problem, really, and is PPACA an acceptable price to pay to fix that problem? The enormous disparity between the projections for the high risk pools and the actual enrollment to date is a strong indication that some of the initial assumptions were incorrect. When the degree of uncertainty is high, isn’t it more sensible to make some small, incremental changes and see how they affect the system?

      @Mark,
      If you want to have a substantive debate about this issue, that’s great. But my original involvement in this discussion was prompted by Ezra Klein’s quote above. If, like Klein, you believe that my argument is invalid, then I’m not going to engage any further. OK, fine, I admit it. I’m an ideologue. But so what? You still haven’t proved that I’m wrong.

    • The reason I said that CMS makes changes in requirements simply to justify their job is that they will nitpick on language and make us eliminate the word “nosocomial” and change it to “hospital acquired” which means the same thing. So then someone has to go through and find every place in every policy where the word “nosocomial” appears and then change it to “hospital acquired” then bring the policy to the next meeting and have it approved. This is only one real example that I’ve dealt with first hand recently, there are many others. I can think of no other reason to change this wording other than to justify their job as it changes absolutely nothing anyone was doing.

      The reason it matters if these things are in our policies and bylaws is that CMS requires it! It really wouldn’t matter, but then it gives them another thing to ding you on and potentially decertify your facility and then quit paying you or pay you less. So essentially you imply that you agree with me when you say “What does it matter if its in your bylaws?” It only matters because a gov’t bureaucrat says it does.

      Physicians (at least ones in private practice that deal with patients, insurance, CMS and sit on hospital committees) are in a unique position to see the problems from the inside. Employed physicians that see patients but do not deal with the billing, collections, etc. have less insight, at least in my opinion. But precisely for some of the reasons I listed above, there are fewer physicians in private practice all the time because it’s harder and harder to keep up with all the regulations. Of course other people have other insights into the healthcare issues, and there are certainly physicians that don’t agree with me. However, many of them work in academia or don’t practice full-time clinical medicine, which skews their perspective too.

    • @pipster: When it comes to high risk pool enrollment, I wonder if you are taking the low enrollment and then assuming its because there aren’t people out there to fill the rolls? I think it was suggested earlier that it could also be due to the cost of the pools scaring potential enrollees away. As for the whole of the ACA and its potential cut in the uninsured, you won’t really ever know, but I don’t know if thats a reason not to act. All you can do in any situation is make your best guess.

      If there always a high degree of uncertainty, and you think that means we should only make tweaks to see how they play out, how do you square that with your stated goals of eliminating the employer tax subsidy etc? That seems like an equally gigantic shift in policy?

      @Eric: I think you are assuming that there is no reason for the change. As an attorney, it looks to me like there was a change in the law or regulation which then caused a cascade of changes to occur. Regardless, thats an easy thing to change in the bylaws and shouldn’t take a lot of time. Also, you are assuming that under the law, “hospital acquired” and “nosocomial” do not have separate, specific definitions. That could profoundly affect a regulation. Just because in normal parlance they mean the same thing, they don’t necessarily mean the same to CMS regulations.

      As for the question about physician insight, I think my main point was this: a physician in you ED will have a good deal of knowledge about the ED but the quality of the knowledge degrades when you ask about the hospital as a whole. A chief of staff would have better knowledge of the hospital as a whole, but perhaps not as good for all of the hospitals for a community. CMS might have best knowledge about the system as a whole, but less so about the specifics.

      Think about a nurse who is complaining about their income and wanting more. That nurse only knows what certain other individuals in a hospital make, perhaps some of the nurses in other hospitals too. But, you as an administrator know the books for the whole hospital and know that she falls into the average for salary and, besides, there isn’t any more money. From her point of view, a decision to deny her a raise is without merit given her level of information but is wholly justified given your information.

      I guess what I would like to impart is, don’t assume that certain moves in CMS are without a point, its possible that we don’t understand why and haven’t asked the right questions. Don’t interpret this to mean that your opinion does not provide value, just that we all should pause before saying someone else’s moves/positions are valueless.

      Lastly, about your comment related to physicians leaving as a result of regulation-exhaustion, do you have data on this? I’m asking because all of the physicians I know who have complaints about bureaucratic workload say its insurance based, they don’t mention the feds.

    • @CG There just isn’t enough time to delve into multiple other specifics about CMS requirements for hospitals but there are many policies that do involve more than just a slight change of wording in a bylaw. One year cleaner X is acceptable, then the hospital acquires a surplus after getting a good deal from a supplier. Then CMS decides that now cleaner Y has to be used and you can no longer use cleaner X anymore. The hospital then has a bunch of cleaner they can no longer use and have to completely redo cleaning practices, etc. This actually happened in our hospital.

      Look up “subsidiarity” if you haven’t heard of it before. Basically it means that decisions should be made at the most local level possible. CMS and their top down approach leads to inefficiencies and disjointed management as the people making decisions are so far removed from where patient care actually occurs. This principle, I think, should apply to more than just healthcare. I think it would be best for the feds to stay out of much of our lives and let the states basically have 50 experiments going on to solve any given problem, including healthcare. We could all learn from Mass. and their healthcare system and rather than forced implementation nationwide, let each state decide how to tweak it.

      As far as physicians leaving private practice, I’m referring specifically to the fact that many are selling out to large groups and hospitals and becoming employed because the cost of doing business, part of which stems from federal requirements but also from insurers too, has become more than they can manage. I have seen specific data as far as the numbers leaving private practice to become employees but I’m not going to waste the time to find it right now (patients to see). Others are quitting medicine altogether but honestly I think that has probably been over-hyped.

      I didn’t mean to insinuate CMS was valueless, but really, I think most hospitals would provide as safe of care, for lower cost, if the feds just got out of the way.

    • Subsidiarity is something I agree with in principle but I think we have to be careful in the lengths we go to implement it. A modern age has necessitated a great degree of interdependence. Every state can experiment away but there are some that will stagnate dragging the whole of the country down. At some point certain standards found through experimentation could help the whole.

      The idea of 50 separate experiments is a great one, we need more experimentation. I’m not sure why it hasn’t happened more in health care. (If anyone has examples besides Massachusetts and TennCare I’d like to see them.) I’d argue that the ACA provides for experimentation through various waivers. I would like to see Wyden-Brown implemented too so that the waivers could come earlier. The ACA will provide a floor in terms of coverage and cost, and if states can do their own thing while maintaining that floor, they are free to do so. Frankly, I wouldn’t mind seeing more federal encouragement in that direction.

    • Can you get any more self-serving than the following statement:
      “We’ve got the Democratic Party, whose top priority is to try and solve our health-care problems and who’ve shown their commitment to that by moving steadily rightward over the last century in a bid to pick up Republican support for some sort of solution, and the Republican Party, whose top priority is that we shouldn’t do whatever the Democrats are proposing and have proven their commitment to that by abandoning previously favored policy proposals as soon as the Democrats demonstrated any interest in adopting them.”

      How about reducing insurance/legal costs and bringing down insurance costs to the same as it was in 1960 (adjust for inflation of course.) That might help to reduce costs by what 25-50% just by itself.

      Nah – can’t have that.