Health Care Discussion

Sep 2017
5,088
6,078
Massachusetts
Cutting off the money was the language you used previously.
The idea is to decrease the money to per capita levels comparable to what people get in urban and suburban areas. If, after that reduction, rural people are comfortable with the level of services their fair share can buy them, great. If not, make the savings available to help them move to a more efficient geographic location. If they would rather give me the finger, that's fine. They just shouldn't expect to keep getting a disproportionate share of my money.

Your idea also seems premised on two completely baseless assumptions that 1) "helping them transition to cities" would be a net money saver compared to the status quo
There's ample data to suggest it would, given the higher productivity of people who live in urban areas, and the efficiencies of dealing with people in more concentrated settlements.

2) the only assistance people would need to be plugged into an equivalent urban quality of life would be initial.
I"m open to the idea of spreading the money across time a bit more. But the idea would be that even a medium-term expense would be preferable to the perpetual expense of having these people (and their kids and gradkids and so on) living in a geographically inefficient configuration.

I haven't seen any data or economic analysis that suggests that literally transplanting rural people into cities would save money....
At this point, it's only based on suggestive data....figures showing the net flow of funds from urban areas to rural ones, and figures showing the higher per capita costs of providing government services in rural areas (as well as figures showing greater health problems like obesity in rural areas, and greater per capita greenhouse gas emissions). Whether facilitating a more rapid process of urbanization would be a net positive remains to be proven. So, I'd be happy to shift these subsidies in a controlled-experiment way. For example, have two matched sets of states, where one tries my idea and the other sticks with the failed status quo, and see if my idea winds up an improvement over ten years. If so, roll it out nationally. If not, abandon it.
 
Feb 2011
16,401
5,711
Boise, ID
Why not go the other way and, instead of making cuts to Medicare, we just expand it to cover everyone?
If it were feasible, simple, effective, and not that disruptive, sure, obviously do it. Things that seriously call into question whether MfA would be any of those things are:

1) The idea to abolish fee-for-service and replace it with federal global budgeting
2) The idea to eliminate private insurance companies from existence (despite the fact CMS contracts with insurance companies to administer their own programs as it is).
3) Elimination of all patient cost-sharing
4) Strong resistance from employees and unions with Cadillac employer- or union-sponsored insurance who really don't wish to lose it (this seems to be Hillary's biggest identified barrier, for example)
5) Funding it with a huge list of the most aggressive tax increases proposals in American history.

These are all very complicating factors.

Keep in mind, every other wealthy nation on Earth has a higher-quality medical system than ours which costs significantly less than ours. They all do it with a form of universal health coverage, many of which amount to a Medicare-for-all system. Why not just go with what works, rather than experimenting with solutions that have never been shown to work, the way you're suggesting?
What am I suggesting that has "never been shown to work?" Just because some relatively small countries have mostly-functional single payer does not mean "it works" in all imaginable scenarios. There is zero modern precedent for a nation with anything like the U.S. system's characteristics making a sweeping and drastic flip to single payer from a mixed multi-payer system. The U.S. is much closer to being able to establish a form of multi-payer UHC, realistically, than adopting some sweeping fantasy version of single payer like Bernie's plan.
 
Apr 2012
57,332
42,148
Englewood,Ohio
This is something to think about why I feel moving people is not the answer.

One of the biggest catastrophic ideas I have ever seen is when Congress decided to imtroduce bussing instead of spending that money to repair neglected Schools. I was in the middle of that one. Wrote Letters to the Editor. The idea that people would allow their children to be bussed several miles away instead of attending their neighborhood school.

If you think this was simply white flight you are wrong. Those who could afford to move to the suburbs did. I have had many discussions with friends of all colors. We all agreed. In my area both the city and school system fell apart in a few short years. All you had left were those who could not afford to move.

You can not manipulate people. It does not work.
 
Feb 2011
16,401
5,711
Boise, ID
The idea is to decrease the money to per capita levels comparable to what people get in urban and suburban areas.
Specifically how are you suggesting we "decrease the money?" Pass a law that requires denial of reimbursement to providers for services based on where they live? Repeal sections of the Balanced Budget Act of 1997 concerning Critical Access Hospitals? As I've shown, rural facility closures are already accelerating as it is, without the austere cuts you are advocating. So as the services dry up and health care deprivation sets in, how are you proposing we "increase the money" to "lubricate" their transition to cities, which was your plan for them? Do you help them sell their $90,000 $70,000 $50,000 $40,000 double-wide mobile home? What housing situation have you prepared for them in the nearest city? How far will the proceeds from their flash sale get them in a high-cost city?

If, after that reduction, rural people are comfortable with the level of services their fair share can buy them, great. If not, make the savings available to help them move to a more efficient geographic location.
How do you quantify "the savings" you're talking about from having "decreased the money?" From a policy perspective the things you're saying aren't even remotely intelligible.

There's ample data to suggest it would, given the higher productivity of people who live in urban areas, and the efficiencies of dealing with people in more concentrated settlements.
There's no data to suggest that a massive, coercive, nationwide relocation effort to high-cost urban areas from lower-cost rural areas which must be aided by public support would be an efficient maneuver. And the reason there's no data is because things like this are not attempted by countries which have any respect for individual liberty (which BTW you personally proclaimed to, in a different thread).

I"m open to the idea of spreading the money across time a bit more. But the idea would be that even a medium-term expense would be preferable to the perpetual expense of having these people (and their kids and gradkids and so on) living in a geographically inefficient configuration.
You have no financial data showing that the geographically inefficient configuration has a greater societal cost than the costs of having to support a mass influx of rural people in cities. The intentional destruction of rural economies would destroy huge chunks of these people's wealth. No financial data exists that could demonstrate your plan to transplant them would be an overall move toward efficiency. If it ended up being a net societal savings, it would probably be at the expense of destroyed wealth of rural families, loss of their chosen way of life, inflamed political resentment, social unrest, spike in crime and substance abuse and other social problems. Leaving them alone in their admittedly technically less efficient per-capita geographic configuration is probably the lesser of two evils, compared to your thought experiment.

At this point, it's only based on suggestive data....figures showing the net flow of funds from urban areas to rural ones, and figures showing the higher per capita costs of providing government services in rural areas (as well as figures showing greater health problems like obesity in rural areas, and greater per capita greenhouse gas emissions). Whether facilitating a more rapid process of urbanization would be a net positive remains to be proven. So, I'd be happy to shift these subsidies in a controlled-experiment way. For example, have two matched sets of states, where one tries my idea and the other sticks with the failed status quo, and see if my idea winds up an improvement over ten years. If so, roll it out nationally. If not, abandon it.
I'd be interested to read about it, if such an experiment could ever be conducted legally (which I doubt). I do find it funny though that in the middle of this paragraph in which you attempt to appear objectively curious about the outcome of an experiment, you nonetheless declare the null hypothesis "failed," as if no outcome could convince you otherwise. Smells like some research bias!
 
Sep 2017
5,088
6,078
Massachusetts
If it were feasible, simple, effective, and not that disruptive, sure, obviously do it.
Our healthcare system has been a bloody mess for decades, so expecting a "simple" solution is unrealistic. But Medicare for all is effective and feasible. Something like it has been done in many other large countries, each of which spends significantly less than us on healthcare with measurably better public health outcomes.

Now, granted, it would be less disruptive if we moved to a Germany/Switzerland-style non-profit health insurance system, with mandatory coverage and tight government controls on costs. I'd be fine with that. But I'm not willing to suggest that a move to a Medicare-for-all-style system is not feasible here, when quite a few of our peer nations have successfully made that transition. There's even an obvious glide-path to get there, by lowering Medicare eligibility ages over time, which would gradually transition the population away from our dark-ages system. For example, every year, lower the eligibility age two years, until you get to 18, then cover everyone. This would give current insurers a long time to transition away from relying primarily on basic healthcare coverage, to instead rely on providing above-and-beyond coverage, similar to the private plans that exist in many other socialized healthcare systems (e.g., the state coverage will cover a spartan shared hospital room for the minimum medically recommended state, while the optional supplemental insurance would upgrade you to a private room with nicer amenities and get you an extra day or two).
What am I suggesting that has "never been shown to work?"
Our system is the least socialized healthcare system of any wealthy nation, already. What you're suggesting, in cutting back on Medicare, would make it even more radically unsocialized. It's never been shown that a system can produce good public health results at reasonable costs even at our level of privatization, so why expect that moving still farther from advanced-nation norms would suddenly start working? Why not, instead, go with what has been shown to work time and again, instead of a shot-in-the-dark experiment on a plan we have every reason to expect won't succeed?

Just because some relatively small countries have mostly-functional single payer does not mean "it works" in all imaginable scenarios.
It works across a surprisingly large assortment of countries. That includes relatively small ones. It also includes what amounts to the largest economic block in the world: the EU, which in many ways functions as a single healthcare market (since both doctors and patients are free to move around the block). When it comes to socialized medicine, we're talking about countries as vastly culturally and economically different, one from another, as Canada and Japan, Australia and Belgium, Switzerland and Greece. They've all found success with systems well to the left of ours. To see that and think "well, then let's move to the right" is just plain weird.

There is zero modern precedent for a nation with anything like the U.S. system's characteristics making a sweeping and drastic flip to single payer from a mixed multi-payer system
Every country that has a single-payer system started with a multi-payer system. They all transitioned successfully. Why imagine the US is uniquely incompetent to do so?
 
Likes: Dangermouse
Jan 2014
16,243
6,200
south
This is something to think about why I feel moving people is not the answer.

One of the biggest catastrophic ideas I have ever seen is when Congress decided to imtroduce bussing instead of spending that money to repair neglected Schools. I was in the middle of that one. Wrote Letters to the Editor. The idea that people would allow their children to be bussed several miles away instead of attending their neighborhood school.

If you think this was simply white flight you are wrong. Those who could afford to move to the suburbs did. I have had many discussions with friends of all colors. We all agreed. In my area both the city and school system fell apart in a few short years. All you had left were those who could not afford to move.

You can not manipulate people. It does not work.
and I understand that only too well - even though it was after my time in secondary school (and, of course, we lived in the South which was delayed). besides, there was little choice as the number of schools was limited and we lived in the country, which means we took the bus no matter what school you attended. we need to take this discussion past the cost factor and focus on having a healthcare system based on "in situ" conditions. once a viable system has been designed, then the cost factor will come into play.
 
Likes: MaryAnne
Feb 2011
16,401
5,711
Boise, ID
Our healthcare system has been a bloody mess for decades, so expecting a "simple" solution is unrealistic. But Medicare for all is effective and feasible. Something like it has been done in many other large countries, each of which spends significantly less than us on healthcare with measurably better public health outcomes.

Now, granted, it would be less disruptive if we moved to a Germany/Switzerland-style non-profit health insurance system, with mandatory coverage and tight government controls on costs. I'd be fine with that. But I'm not willing to suggest that a move to a Medicare-for-all-style system is not feasible here, when quite a few of our peer nations have successfully made that transition. There's even an obvious glide-path to get there, by lowering Medicare eligibility ages over time, which would gradually transition the population away from our dark-ages system. For example, every year, lower the eligibility age two years, until you get to 18, then cover everyone. This would give current insurers a long time to transition away from relying primarily on basic healthcare coverage, to instead rely on providing above-and-beyond coverage, similar to the private plans that exist in many other socialized healthcare systems (e.g., the state coverage will cover a spartan shared hospital room for the minimum medically recommended state, while the optional supplemental insurance would upgrade you to a private room with nicer amenities and get you an extra day or two).
These are just regurgitated talking points from generic pro-MFA articles you've probably read. I listed five specific major policy barriers to MFA (at least the most recent iterations of it), and you deleted them from the reply so that you wouldn't have to address them.

Our system is the least socialized healthcare system of any wealthy nation, already. What you're suggesting, in cutting back on Medicare, would make it even more radically unsocialized.
Your previous attitude was the archetypal stingy conservative "don't tax ME to pay disproportionately for YOUR health care!" attitude. Suggesting Medicare cuts was only half-serious alternative way of applying that same attitude. If you want more socialized health-care, rather than less, then the previous attitude you applied to rural people is not going to fly. "Not with my tax dollars!" is an anti-socialized medicine type of attitude.

It's never been shown that a system can produce good public health results at reasonable costs even at our level of privatization, so why expect that moving still farther from advanced-nation norms would suddenly start working? Why not, instead, go with what has been shown to work time and again, instead of a shot-in-the-dark experiment on a plan we have every reason to expect won't succeed?
I'm not suggesting moving farther from other advanced nations. Multi-payer UHC is not a shot-in-the-dark experiment. It's a path toward progressive socialization of our health care system that does not require addressing the serious pitfalls I listed in my previous post.

Every country that has a single-payer system started with a multi-payer system. They all transitioned successfully. Why imagine the US is uniquely incompetent to do so?
Because the U.S. has a uniquely and extremely expensive health care system from the outset, which other countries that now have single payer did not have when they implemented it. There are zero examples of a country with unique health care system features like ours making a sweeping shift to single payer. That's not to say single payer could not possibly work, but it would require directly addressing the pitfalls I listed which are problematic aspects of the most recent MFA proposals.
 
Sep 2017
5,088
6,078
Massachusetts
Specifically how are you suggesting we "decrease the money?"
Gradually reduce the subsidies until they're on par with those in other areas.

As I've shown, rural facility closures are already accelerating as it is, without the austere cuts you are advocating.
Yes. And rather than fighting against that tide, at huge and permanent cost, put our efforts and money into bringing the patients to where the providers can service them efficiently, rather than trying to keep the providers distributed inefficiently.

Do you help them sell their $90,000 $70,000 $50,000 $40,000 mobile home? What housing situation have you prepared for them in the nearest city?
See earlier in the thread -- I already discussed that in detail.

How do you quantify "the savings" you're talking about from having "decreased the money?"
Well, for starters, we can keep an eye on the net flow of funds, which currently tend to go from urban states to rural ones, and from denser portions of states to more rural portions. We'll know we're achieving greater efficiency when such disparities decline.

From a policy perspective the things you're saying aren't even remotely intelligible.
You're confusing your own mental limitations with the unintelligibility of the subject you're confronting. It's really not that hard to follow.

There's no data to suggest that a massive, coercive, nationwide relocation effort...
Nobody has proposed that. Try to focus.

You have no financial data showing that the geographically inefficient configuration has a greater societal cost than the costs of having to support a mass influx of rural people in cities.
As I said, all I have now is the suggestive data, showing the net flow of funds and the higher cost per person of supporting government services in rural areas. It remains to be seen if facilitating urbanization, rather than fighting it, will improve the situation. But that's something we can test, rather than just assuming it wouldn't work and throwing good money after bad on the current status quo.

you nonetheless declare the null hypothesis "failed," as if no outcome could convince you otherwise.
I'm not saying that the experiment would succeed. It's possible that as big a failure as our current system is, facilitated-urbanization would be an even bigger failure, which would mean going back to the status quo, as shitty as it is. But, yes, I am a forthright enough person to label the current status quo a failure. We're suffering a sizable net flow of funds to rural areas and yet still winding up with terrible rural outcomes -- higher obesity, shorter lifespans, worse infant mortality, greater per capita pollution output, worse productivity, etc. I don't know whether my proposed solution can help to reduce those problems, but it doesn't take a genius to see that they are, in fact, serious problems and that our status-quo approach hasn't succeeded in eliminating them.

In theory, conservatives should be supportive of my approach, since the idea of government interference creating counter-productive incentives is right at home for them. The idea that the well-meaning politicians flowing disproportionate welfare money to rural areas to prop them up could actually be hurting those people, as well as the nation, long-term, is an idea that should fit comfortably with their worldview. But for too many conservatives, their ideas aren't economically principled. Instead, they're tribal. They see those rural people as their tribe, and they understand the rural lifestyle to encourage Republican voting, and so they support welfare to prop up rural areas indefinitely.
 
Likes: Dangermouse
Sep 2017
5,088
6,078
Massachusetts
These are just regurgitated talking points from generic pro-MFA articles you've probably read.
No. They're carefully researched and considered ideas. The whole reason you have to dismiss them as "regurgitated talking points" is because you can't find a response to them in the talking points you lean on.

I listed five specific major policy barriers to MFA (at least the most recent iterations of it), and you deleted them from the reply so that you wouldn't have to address them.
I admitted it wouldn't be simple, but pointed out it wouldn't be realistic to expect something simple given what a mess our system is. Yet every nation that has moved to something like Medicare for all has encountered similar issues and overcome them. And, even we have done it, with regard to Medicare itself, which has the same considerations, albeit only for a portion of the population.
Here's a little thought experiment for you. Let's say we have a time machine and travel back to the early 1960s, and you encounter a Reagan type, who is insisting the proposal for implementing Medicare just can't work. He presents a list very much like the one you presented (most of which items would work as well -- which is to say as badly-- in arguing against Medicare in the early 1960s). Would you believe him?

Now, granted, the first move to Medicare covered only a portion of the population, and so this would be a larger move. But, at the same time, that's something we did without a framework to build on, back then, whereas now we can just expand on an existing successful program. So it would arguably be easier.

As for your list:

1) Abolishing fee-for-service and replace it with federal global budgeting

With Medicare, there's still some fee-for-service, and there would be with Medicare-for-all.

2) Eliminating private insurance companies

With people age 65 and older, there's still private insurance, and there would be with Medicare-for-all. It would just be supplementary to the basic coverage through Medicare.

3) Elimination of all patient cost-sharing

With Medicare there is some patient cost-sharing, and there would be with Medicare for all.

4) Strong resistance from employees and unions with Cadillac employer- or union-sponsored insurance who really don't wish to lose it

You could allow such plans as supplementary, just as those with Medicare currently can get supplementary coverage. That's consistent with what happens in other Medicare-for-all-style systems... basic coverage is provided by the government, but people can get additional gold-plated coverage on top of that, with more conveniences and little luxuries, as well as additional procedures covered. With the money the employers and unions save on covering for basic insurance, they can provide even better supplemental coverage.

Explainer: why do Australians have private health insurance?

5) Funding it with a huge list of the most aggressive tax increases proposals in American history.

There's a strong tendency among wingnuts and their enablers to treat every tax increase as catastrophic. Whenever I hear about the biggest or most aggressive tax increase proposals in American history, I'm reminded of Bob Dole's rhetoric, which described the Clinton tax hike of 1993 as the biggest tax hike in American history. But it ended up working out quite nicely -- being followed by the most rapid general prosperity increases in decades even as we went from record deficits to record surpluses. I don't get terribly spooked about the whimpering about tax hikes. The US has radically low taxes by the standards of wealthy nations, and can stand to raise them a bit.

I'm not suggesting moving farther from other advanced nations.
If we cut back on Medicare without an equally impactful increase in some other form of socialized medicine, it would be a move farther from other advanced nations. But, granted, if it was part of a move to something more like one of the well-tested multi-payer systems seen succeeding elsewhere, that could be good. I'm not married to single-payer or multi-payer. I think both can work.... and either would be better than what we have, much less what we had in the dark days before Obamacare.

There are zero examples of a country with unique health care system features like ours making a sweeping shift to single payer.
Yes, and with every single successful transition made to single payer in history, the critics could have said the exact same thing before it happened. Every country is unique, as was every health care system. They all overcame their unique challenges. I think we could, too. It wouldn't be the smoothest path, since the Swiss model is easier to emulate. But it would arguably be worth the extra effort, since single-payer systems tend to wind up cheaper than multi-payer ones.
 
Likes: Dangermouse
Feb 2011
16,401
5,711
Boise, ID
Gradually reduce the subsidies until they're on par with those in other areas.
What are "the subsidies?" Any specificity at all would help.

Yes. And rather than fighting against that tide, at huge and permanent cost, put our efforts and money into bringing the patients to where the providers can service them efficiently, rather than trying to keep the providers distributed inefficiently.

See earlier in the thread -- I already discussed that in detail.

Well, for starters, we can keep an eye on the net flow of funds, which currently tend to go from urban states to rural ones, and from denser portions of states to more rural portions. We'll know we're achieving greater efficiency when such disparities decline.

You're confusing your own mental limitations with the unintelligibility of the subject you're confronting. It's really not that hard to follow.

Nobody has proposed that. Try to focus.
These notions are obviously unprecedented in modern times, and you're presenting them in impossibly vague and inconsistent ways. There's zero policy coherence.

As I said, all I have now is the suggestive data, showing the net flow of funds and the higher cost per person of supporting government services in rural areas. It remains to be seen if facilitating urbanization, rather than fighting it, will improve the situation. But that's something we can test, rather than just assuming it wouldn't work and throwing good money after bad on the current status quo.

I'm not saying that the experiment would succeed. It's possible that as big a failure as our current system is, facilitated-urbanization would be an even bigger failure, which would mean going back to the status quo, as shitty as it is. But, yes, I am a forthright enough person to label the current status quo a failure. We're suffering a sizable net flow of funds to rural areas and yet still winding up with terrible rural outcomes -- higher obesity, shorter lifespans, worse infant mortality, greater per capita pollution output, worse productivity, etc. I don't know whether my proposed solution can help to reduce those problems, but it doesn't take a genius to see that they are, in fact, serious problems and that our status-quo approach hasn't succeeded in eliminating them.
What is "our status quo approach" that you're referring to? Actually letting people live where they decide to live? Is that what you mean by "status quo approach?" The same argument could be made about the urban poor, or really any pocket of poverty anywhere. I could point out all sorts of depressing stats about the urban poor, and sweepingly declare "the current approach is not working!" Very convenient argument.

The failure you're trying to point out is people who have problems. Many are not intelligent or educated, they're impulsive, emotionally reactive, mentally ill or have some sort of significant behavioral disorder, plenty have substance addiction problems, came from abusive households and are in turn creating abusive households, they're pretty much unemployable or barely employable at best, some are reclusive and do not handle interpersonal interactions well at all, which is why some of them sought out places to live at the fringes of society, so that they are less likely to assault or kill somebody. These problems are not a symptom of geography, they are symptoms of people's personal problems. Transplant these people and their problems go with them, and the transplant might even exacerbate some of those problems. And when you concentrate enough people with these problems into an area, the area itself looks like an abject failure, which your political opponents would flip right back on you. But the poor outcomes are just a reflection of the complex social problems of the people themselves, which are difficult to treat, cure, solve or eliminate, regardless of where they live.

Rural areas might be the best overall possible place for a lot of the people that live there, despite the health care delivery and infrastructure inefficiencies.
 

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