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27 June 2017


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This speaks to something central to the healthcare debate that very few politicians seemed to be speaking about even back in 2008: the biggest problem with healthcare is that it is too expensive and the costs have been growing too fast, without covering satisfactory benefits as measured by health outcomes, not just whose's going to pay the bill. The biggest problem with Obamacare was that they pulled a bait and switch act without seriously addressing the cost question, making a crisis of some sort all but assured sooner or later. While I am skeptical about the current Republican bill (nothing specific about the Republicans--I was just skeptical about Obamacare, and a lot of Devilry will be in the details no matter who's running the show), confronting the cost question one way or another is something that has to be done anyways and politicizing it, especially through misrepresentation as the Democrats are doing, seems despicable.

The Twisted Genius

The cuts are due to not taking into account the increased number of Americans who will become eligible for Medicaid, the increase in medical expenses and just inflation in general. The result is less medical care for less Americans. The situation is the same with the minimum wage. Granted the wage has risen over the years, but it has nor kept pace with inflation so the result is lower buying power. The question is a matter of priorities. Do we want to strive for good medical care for all or the top earners keeping more of what they earn. I personally think we should be striving for a base level of medical care available to all through a single payer system.

Lee A. Arnold

The real issue is that both GOP bills throw millions of people out of coverage. On Obamacare, the CBO points out explicitly that Obamacare is not "hopelessly broken". It is an easy fix.

Seamus Padraig

All I really have to say on this subject is: we need single-payer.



You mean millions of Americans no longer mandated by law to buy coverage will chose not to do so?

Eric Newhill

Lee A. Arnold,
Sorry, but you're wrong. The ACA was poorly designed and, as a result, it is hopelessly broken. There was way too much hopeful thinking and too little theory employed in it's design. Actually, a lot of what the program was built on is directly contrary to proven microeconomic and actuarial principles.

In 2018 there will be states in which no insurance carrier is offering the product. None. On other states, the product will be offered in only a few geographies - known as "rating areas". So people seeking coverage will not be able to purchase it.

That's broken and that's dying quickly.

I do not know how the ACA could be fixed short of the federal government kicking $billions over to the insurance companies to cover their losses on bad - and increasingly worse - risk. That won't happen. The Republicans won't spend the money and the Democrats would get it all wrong and scream that the evil insurance companies were getting fat off the program. So not politically viable. What else? I sure can't think of anything. If you can, you're the only one.

Eric Newhill

You're essentially correct, but so is KHC.

Why are we going to have an increasing number of Americans on Medicaid? That is a sad thought. We should be addressing that issue instead of surrendering and bolstering the safety nets.

KHC is right that the real problem is never ending increase in the cost of healthcare. Soon to be 20% of GDP. If we stop throwing money at the situation, perhaps someone will start working on the root cause. There is a lot of real cost reducing opportunity; much low hanging fruit. At some point we have to stop the cost increases. How much of GDP do you think is the red line in the sand? IMO, we're there now.

Dr. K.

Harper are you on Obamacare? If your boss tells you your wage is guaranteed to be the same after 20 years is that a pay cut?

Lee A. Arnold

The other OECD countries pay 40% less on healthcare than the U.S. -- BUT healthcare costs for all are growing anyway. One way to cut costs in the U.S. is a single-payer to eliminate private insurer overhead (about 20% of your premium). That still would not touch the excessive cost in the U.S. on the healthcare provider side, including pharmaceuticals, etc. (although a single-payer should be able to bargain-down the prices on some of these things). Most people don't know it, but Obamacare has a host of provisions to work on long-term cost reduction on the healthcare provider side, and some would take years. Some of these things (like rectification of all health records into the same system format, so information flows faster) goes unnoticed (except by doctors, who are made to pay the cost of that transition).


This argument constitutes "bouncing the rubble". The numbers on the margins relate to marginal issues.

The problem with healthcare costs is simple to understand but politically difficult to address. Powerful institutions are making too much money off it to let it change. That statement is way more radical than I usually go, but it seems to be true. A sector that eats up 19% of GDP is too large to tolerate that kind of slop. This quote uses comparison with other countries that have comparable quality health care to clarify the whole issue. You don't have to agree with the author's detailed arguments to see that he has pointed at the elephant in the room:

Per capita spending, health care, 2015
United States: $9451
Canada: $4608
France: $4407
Japan: $4150
United Kingdom: $4003
Miraculous Finland: $3984

Those are among the world's most remarkable data. According to those remarkable data, $5000 per person per year disappears into the maws of our "health care system."

Especially in a week like this, those are among the world's most instructive data. But how strange! All this week, as in all other weeks, our big news orgs will refuse to present or discuss them!




The health care reform "debate" for decades is just distraction and political gamesmanship. The real issue, COSTS, are never addressed as it is politically unpalatable. The lobbies who are making a killing don't want costs to be reduced. That's why there are no questions asked why does the US spend double what Germany, France and Canada per capita. There's no debate how do they provide Healthcare to all their citizens at half the cost of what we spend?

While our politicians go around in circles, Healthcare expenditures double every 8 ywars.

Jonathan House

About half of the physicians in the US support single payer.

Here is one of many sources for that assertion.

I am one of those physicians who support single payer. In my opinion and experience, insurance companies intrude into medical care, government insurance, much less.

Full disclosure so my views can be put into context:

I don't see Obamacare as hopelessly broken but as a potentially fixable compromise adopted by Obama et al either because he/they didn't have the courage to fight for the better solution - i.e. single payer - or because he thought it was the best he could get.

Back a few years, I thought of the health care policy H. Clinton proposed (she explained its limitation as the best that could get through congress) as a policy of "all power to the insurance companies."

Eric Newhill

Lee A Arnold,
You are quoting nonsense. For profit insurance companies run at 80% to 85% MLR and not-for-profits run at around 88% to 92%. How can they possibly be then be spending 20% of premium on "overhead" (whatever that is supposed to be? Do you imagine that the federal government doesn't have "overhead" - assuming that means audits, claims processing, various other forms, network contracting, etc?

The other OECD countries pay less for healthcare because they ration it. period. Fantasies like yours are one reason I oppose single payer. You think you're going to get the Cadillac most Americans enjoy today when, in reality, you will get a Yugo. A single payer delivering a Cadillac would cost more than what we spend today.

Eric Newhill

Jonathan House,
Sure. You want to be able to perform any procedure you want to and you think that the feds will allow that under a single payer system. Wrong. Apparently you do not see a lot of Medicare or Medicaid patients. If you would say what you do.

Also, would you really be happy with Medicaid or Medicare reimbursement rates? I know a lot of physicians and facilities that gripe endlessly about govt reimbursement rates. Some won't even see Medicaid patients. You must have an unusual practice.


Actually the comparison is worse than that. Government (federal, state, local) in the US spends as much per capita subsidizing our "free enterprise" health care system as those countries spend to cover everyone.


No, it is not hopelessly broken. In the states where there are now very few or no insurance companies on the exchange, those are the same states that were dominated by one or two companies prior to the ACA. People will still be able to buy insurance, just not on the exchange. In this case Obamacare has mostly failed to fix a problem that existed before it did. Given barriers to entry, this is not terribly surprising, plus the current uncertainty.

I have run the business side of a 100 person group for many years, Chair a department and have helped write policy for our Congressman (R). The ACA did not suffer from a lack of theory, but probably too much. It was aimed mostly at improving access. (I hope that you are at least acquainted with the idea of the iron triangle or there really is no point in trying to explain stuff.) It also did a number of things to address quality, which I spend a lot of my time on now. We offer services we never could have in the past, at least partially because of Obamacare.

That said, you and others are correct that it poorly addressed costs. It did cater to the insurance companies. We don't get nearly as good a ROI as we should on our health care dollars. Those could be addressed within the framework of the ACA, but I am not bonded to it. If the GOP can come up with something better I would be grateful. The Senate plan does look like that plan to me, but maybe they will modify it. (I don't think single payer is the magic answer. It could cost a lot more if not done well. Many other countries have lower costs, quality just as good and they do not have single payer.)




This is correct. American healthcare costs are unaffordable; $38,000 for a family of four when the median income is $52,000. It is also contrary to the basic rights of Americans to life, liberty and the pursuit of happiness.

The sole purpose is graft. Moving money from the middle class and poor to the wealthy. Pay the fees, go in debt, or die. The only way to cut costs is; 1) restoring the public health service, 2) passing Medicare for All, 3) enforcing anti-trust and price gouging laws, 4) jailing the crooks, and 5) provide preventative health care for everyone.

Lee A. Arnold

I am in favor of a single-payer system. But sorry you are wrong about Obamacare. Right now the total fix is small, $5-10 billion and some regulation changes. Read page 6 of the CBO score of the Senate bill, released yesterday.

Social Security, Medicare, Medicaid -- ALL of these needed start-up tweaks for years, and they still need the occasional adjustment. This is normal.

Look, people in healthcare economics KNEW that the first few years of Obamacare would need occasional subsidies to stabilize the premiums until everybody was inside the system. This was written into the law, as the so-called "risk corridor" program.

Two big things prevented the adjustments: 1. Many red states refused the Medicaid expansion. 2. The Dec 2014 omnibus bill restricted the risk corridor outlays. The Republicans' intended purpose in both actions was to make Obamacare fail. They said so, at the time.

It might help to step back, and look at the big picture. The Democrats wanted to start-up a single-payer in 2010, via the offering of the "public option" (a public insurer, available in the state markets).

The Democrats had 60 votes in the Senate to pass the whole bill, but 4 of the Dem Senators would not vote for a public option -- for the stated reason that it would lead to putting the private insurers out of the healthcare market (Joseph Lieberman, one of the 4, said this explicitly. Remember, his state capital is Hartford, once the insurance capital of the U.S.) And of course NOT ONE of the 40 Republicans would vote for Obamacare, even though it is structurally Romneycare.

So, the Democrats opted to try to get healthcare for everybody, anyway. And let the chips fall where they may in the future, knowing that it would be very hard to take healthcare away from people, once they have it.

Again, this approach was stated explicitly by healthcare policy wonks, at the time. Because most voters do not have the time nor inclination to follow the intellectual ins-and-outs of policy debates. But they understand facts in their lives, & in their neighbors' lives. And Obama understands this tactic very well, much better than most. Future historians may treat Obama very well on this issue, because his strategy is probably going to lead to healthcare for everyone.

Look at the GOP's current dilemma: Everybody knows the Republicans want to take healthcare away from tens of millions of people, to give tax cuts to the richest. It is the starkest, plainest terms of the debate. (The canniest Congressional Republicans saw this disaster coming back in 2010; they said so at the time.) And whether the GOP passes its "Obamacare Lite" or not, the Democrats are finally going to be able to make the single-payer into a winning voter issue.

Lee A. Arnold

That is the beginning reason for younger people, followed later on by the reason of less Medicaid than ACA, and less of other subsidies. Among older people, a big reason is because the premiums increase sharply. See the CBO score of the Senate bill, for example the analysis on p. 4, and Figure 3 on p. 16.


Thank you TTG.

Let's say you have a ten year old who is growing at some rate every year, and you decide to cap his growth at a future height/weight. You would need a surgical saw for the cutting.

Price controls and fully socialized medicine and regulatory smarts and cheaper medical school would get it done, but, alas, in our cruel plutocracy, the 1% and select "makers" call the economic shots. I read today POTUS is back at the Trumpcare table, no doubt dialing the next attempted bill closer to his promised "lower premiums, lower deductibles, lower-co-pays and much better coverage."

Will we ever have a political party that advocates a Sanders domestic policy aimed at the working and middle class, joined with a 'Buchanan' foreign policy aimed at zero adventurism and zero magical thinking?


I wonder if Finland has better healthcare outcomes?


WHO ranks Finland number 31. US is number 37. Rankings of individual criteria are pretty comparable, except that high costs cause the US to lose out on efficiency ratings.


dilbert dogbert

There is an old political saying that goes: "What Goes Around Comes Around". The Democrats are paying some blowback over "Death Panels". Politics is not Tiddly Winks.

Sam Peralta

What is there to wonder?

Just compare the ratio of those suffering obesity and diabetes among the two populations.

But...just like the Democrats who can't accept responsibility for their election loss, many Americans don't want to accept responsibility for their health.

This is what the Nanny State has wrought.

Sam Peralta

If your boss tells you your wage is guaranteed to be the same after 20 years is that a pay cut?

Yes it is. If your health care costs are rising 9% each and every year and your wages are not, then ...

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