Atrios rarely goes to the trouble of making an actual argument, and this time it looks like he's lifted his talking points from a column Krugman wrote a few weeks ago.
Atrios is very hard left. He has never, so far as I am aware, criticized anyone for being too far left. He also doesn't view his political enemies as three-dimensional human beings; he seems to believe people are ultimately defined by their politics and if their politics are bad, they are bad people at every level. He also has this weird fetish about seeing his political enemies tried & jailed.
The core belief Atrios shares with many on the left is that it is only the collective that can provide economic security. He seems literally incapable of thinking otherwise, of even evaluating the theory behind market-based solutions such as HSA's. The idea that an individual can influence thier economic destiny is literally unthinkable to him.
The age of the collective has passed; it's unfortunate it left people like Duncan Black behind.

Terry,

I know. But Duncan Black really isn't my audience.

Mitch,

Having worked in HealthCare Insurance as an analyst, auditor, sr. auditor, comptroller, supervisor and Manager of claims units, I think I have at least some abiltiy to speak to the problems.

First, from 1960 to 1973 Health care inflation was 2300%. The reason was pretty simple, health care was relatively inexpensive at the time (for examplet the bill for my birth was $200), and health insurance was getting broadly developed essentially created a condition where the patient/family was not impacted by cost increases. A key component to constraint is that the patient needs to be able to feel and thus place pressure, when costs go up.

From 1975-1995 various cost control measures, such as Second Surgical Opinion (SSO), Pre-Certification (Pre-Certs), and eventually HMO/PPO's were implemented. These dropped the inflation rates dramatically. The idea for HMO's (initially) paid doctors a per person participation fee for providing healthcare to the participant. Copays were designed (originally) to simply give the provider a stipend up front until their participation fee was received. These evolved into an organization which both paid participation fees and received steep, contractually binding discounts for medical services. There were NO out of network benefits (originally).

PPO's (Preferred Provider Organizations), and PHO's (Physician Health Organizations), combined HMO features with out of network benefits, but again, they had steep discounts for in-network participating physicians.

Well, what essentially happened is that these discounts put doctors in an increasingly unacceptable economic position. First, if part of an HMO they were often employees, paid at a rate below what they desired. Second, if part of a private practice, costs related to authorization tracking, protocol tracking, an general pressures to adhere to protocols in contractiction to thier own desires on how to provide appropriate care.

These pressures caused doctors to begin leaving HMO's in the late 90's. In addition, an aging population has put HUGE pressure on the medical system. The organization of Medicare is such that Hospitals get reimbursed through Medicare for unreimbursed care, consequently, Medicare (along with the impact of aging populations), gets the bill as people become less able to pay for insurance. Because of pressures to pay higher fees to physicians, and the need to pay for more care, HMO fees (as well as PPO fees etc..) started escalating dramatically in the late 90's, a pattern that has not abated, only increased, and the reason is..

The number of uninsured people has skyrocketed. This is absolutely, 100%, no question, no debate, the largest impact to healt care costs, and it is unfortunately a viscious circle. The costs for unreimbursed care (as described above) is passed along to the rest of us, either as part of taxes, or as part of participation fees (the smaller the participation base, the higher the fee, just like insurance). The higher costs go, the fewer people can afford it, the fewer can afford it, the higher it must go.

The result of these two factors (aging population and uninsured/unreimbursed care) has been that health care has gone from 5% of GDP in 1985 to 17%. Malpractice has been a minor pimple on the overall cost picture, and much of it was driven by poor cost modelling by the industry itself. Malpractice charges premiums based on expected costs as well as past experience, in essence several years in advance. In short, MP Insurers were NOT charging for the very few large awards in the early 2000's, because those awards will be argued for an average of 5 years and are not incurred until paid. They were charging for poor cost modelling in the middle 90's, when MP rates were set too low. There weren't any hallmark awards, just higher than expected.

The bottom line is, Savings accounts, and the current Medicare Drug plan unfortunately feed more money into an already highly inflationary environment. Just like the problems of the 60's, more money, without some control, will only cause even greater inflation. Given the supposed Fiscal prudence (which is completely false) of this administration, you'd think they know that simply throwing good money after bad.

The reality is that health care is a critical "demand" utility, like heat, power, etc. The need is so great, and people's will to do as much as they can to survive (especially for their children, or parents who may not be able to make independent decisions), that holding people hostage for fees is certainly possible. I have a relative who paid $25k to travel to Mexico for Laotril treatments, (she died anyway). Suggesting that a market solution will solve the problem flies in the face of logic, in that there are many people willing to cooperate to take advantage of subtle loopholes as long as they don't see the light of day. Simply giving pharmacutical companies more money won't cause them to not also charge more. They spend 14 times as much on advertising as they do on research (advertising for things like Viagra).

No, instead some form of oversight is warranted. Putting it in the hands of the industry to solve has not worked (it's failed for more than 40 years). Our health care system is lagging dramatically behind the rest of the world yet we pay FAR more per capita. You can argue that SOME folks get great care, and they do, and yet many of the most important advances are increasing coming from other arenas, and our AVERAGE expense is still far higher. If our exhorbitant fees paid for something, maybe it would be worth it, but in truth it pays for little more than making drug companies very, very profitable. They make profits elsewhere, and thier argument that our expenses pay for other country's drugs, is both a lie (they make money in other county's), a deception (those where they ARE in fact charitable could be paid for much more cheaply), and potentially a defrauding act (we never agreed to subsidize drugs in Bulgaria).

We MUST find a mechanism to cover all people. The solution will probably require some form of government oversight, perhaps including making doctors/nurses etc.. employees of a unified organization, but our current path is broken beyond description, and simply putting MORE into a broken system is stupid. Arguing that putting more money into that broken system is a realistic solution is not just stupid, it's assinine. Without any sort of restraint, what exactly Mitch, do you think is going to happen?

PB

"In short, it may be the last great hope for America's private healthcare system - the best system in the world in terms of not only providing quality healthcare, but also the flexibility and innovation to respond to unforseen challenges like epidemics."

This statement is empircally false. The U.S. system spends more per person in gross terms and as a percentage of GDP than any other civilized country. In return we get far less service and far worse health outcomes than other countries.

As for responding to epidemics try this little thought experiment. Would you rather go through a bird-flu epidemic in a country were all of your neighbors had access to medical care or one where more than 25% of your neighbors had no access to health care.

Citing the U.S. health care system as a model of free market efficency is like citing Soviet agriculture as a triumph of central planning.

"This statement is empircally false. The U.S. system spends more per person in gross terms and as a percentage of GDP than any other civilized country. In return we get far less service and far worse health outcomes than other countries."

That makes nice recycled DFL spin - but how are the "service" and "outcomes" being measured?

I mean, you said 'empirically' false; show us the data.

I work in the health care business, and I'm telling you such data don't exist.

"As for responding to epidemics try this little thought experiment. Would you rather go through a bird-flu epidemic in a country were all of your neighbors had access to medical care or one where more than 25% of your neighbors had no access to health care."

I'll take option 3: a healthcare system that isn't hidebound by bureaucracy. If you think Canada or Sweden are going to be doing any better in the event of an epidemic than we are, it won't be because they're medicine is socialized, but because their public health agencies have a LOT more power than ours.

"Citing the U.S. health care system as a model of free market efficency is like citing Soviet agriculture as a triumph of central planning."

It makes a cute bit of spin, and it's a DFL talking point, but it doesn't stand up to detailed scrutiny. Not that you've provided (or, likely, know) any data that could lead one to such scrutiny.

Terry, you wrote:
"The age of the collective has passed; it's unfortunate it left people like Duncan Black behind."

I fail to see how this is unfortunate. Sounds like nothing but good news.

"Would you rather go through a bird-flu epidemic in a country were all of your neighbors had access to medical care or one where more than 25% of your neighbors had no access to health care."

Shall we examine SARS as a case study in epidemic response? What were the death rates in the US and Canada, again?

As of April 12, 2003, the World Health Organization (WHO) reported 2960 cases of SARS worldwide, with 119 deaths, giving a death rate of 4% from the illness[i].
Of these, Canada reported 101 cases and 10 deaths; a death rate of 9.9%. Note that 90% of reported cases and 100% of deaths occurred in Ontario. Contrast this with stats from our nearest neighboring country which reported 166 cases but with no deaths.

In the United States, no deaths have been attributed to SARS, but according to the WHO and the CDC, 11 new probable SARS cases were counted in the U.S. from Tuesday through Wednesday, bringing the national total of cases to 52.
Thursday, May 1, 2003 Posted: 2:49 PM EDT (1849 GMT) Source: CNN Health dot com

I believe this puts Doug firmly in the Silly camp.

I mean, you said 'empirically' false; show us the data.

I work in the health care business, and I'm telling you such data don't exist.

The U.S. spends twice what most countries do on health care in total $ terms.

http://www.nationmaster.com/graph-T/hea_hea_car_fun_tot_per_cap

We spend about one third more as a % of GDP

http://www.nationmaster.com/graph-T/hea_tot_exp_as_of_gdp

OK, so we spend alot, what do we get for it.

We are #31 in life expentancy at birth

http://www.nationmaster.com/graph-T/hea_lif_exp_at_bir_yea_tot_pop

We are #27 in number of hospital beds.

http://www.nationmaster.com/graph-T/hea_hos_bed

We are #19 in number of accute care beds.

http://www.nationmaster.com/graph-T/hea_acu_car_bed

We are #27 in access to Rx Drugs

We are #14 in number of nurses.

http://www.nationmaster.com/graph-T/hea_nur

Maybe there is a kleptocracy in Africa somewhere with a less efficent health care system.

Sorry here is the link on access to precription drugs

http://www.nationmaster.com/graph-T/hea_dru_acc

Thanks Rick, and frankly Terry, whatever part of healtcare you work in, it appears it's a bunker, because this data has been out there for YEARS, and is not disputed by anyone. In 1999, the US was 19th in life expectancy and 26th in infant mortality, as tabulated by WHO and confirmed by US Census. As a percentage of our GDP, and cost per capita, it has skyrocketted since 1995, really even since 1990.

Bottom line, it's broken, saying these figures dont' exist when they are so readily available, is simply ignoring fact.

PB

Further, why supposed "fiscal" conservatives advocate throwing good money after bad into a highly inflationary system with no brakes on it, just isn't fathomable, well beyond the fact that they are only supposed fiscal conservatives.

What it seems really is that this administration is in bed with the pharmacutical industry and is simply redirecting public assets into their pockets, because there is ZERO logic in throwing money at this system, none, without some means of constraining inflation, and unless this administration is profoundly stupid (which it isn't) it knows this..

PB

If we really pull together, I'm sure we can get to #1 in infant mortality.

Rick et al,

Nobody is arguing that there isn't a problem. I work in the healthcare business at the moment, too - and there are serious problems.

The statistics you picked, without context, are fairly meaningless and misleading without some additional background. If we are #31 in life expentancy at birth, what are the factors in reaching that number? Who are 1-30? Tiny nations like Andorra; small ones like Finland with homogenous populations, lower crime rates, lower problems with out-of-wedlock pregnancy (which are inherently riskier, and cause a lot of problems for US infant mortality).

We are #27 in number of hospital beds and 19 in acute care beds - So? What's the vacancy of those beds? Many communities are overbuilt! I'd be much more interested in a study of mortality caused by the ratio of beds per person. The link you cited shows no such information.

We are #27 in access to Rx Drugs - defined how? Again, I'd be interested in seeing studies that went beyond correlation to causation.

The number of nurses is, in fact, the only truly troubling statistic (besides infant mortality) that you cite, and the only one truly germane to the topic.

Now - how about comparing the *entire populations* of the US, Germany, Canada, the UK and Sweden on:

1) Mean survival from diagnosis of various types of cancer (breast, prostate, endocrine and some of the other biggies)?

2) Morbidity and Mortality for chronic degenerative diseases like Diabetes.

3) Morbidity and Mortality caused by delays in treatment for diabetes, kidney disease, cardiopulmonary and liver disease and so forth (the delays inherent in the rationed-care systems in Canada, Sweden and the UK cause a LOT of diseases that'd be serious but routine in the US to become VERY serious during the routine wait for treatment).

4) Level of research into developing new treatments (especially antibiotics, antivirals, and treatments for serious diseases) expressed in patents, products and the relative impact of same on mortality of selected diseases.

I don't have access to those right now - but I'll see what I can find. I suspect they're considerably better - and know they're more germane - than the stats you've cited...

As to PB - your post rates a longer response than I can manage at the moment. More later.

Mitch,

Your potpourri of "relevant" health statistics are apparently just off-the-cuff hodgepodge of your own desires.

The reason infant mortality and life expectancy are used, is that they are seen as vastly the best indicators of general health within a society. Many of the objections, like minority population percentages, are merely cannards. Australia, which has high inidiginous population percentages, has terrifically better infant mortality and life expectancy statistics.

My suggestion is that you try really hard to defer to experts on the topic, like WHO, rather than acting like some sort of arm-chair quarterback. It belies your ignorance of the issue, unfortunately.

Most of your questions are simply spurious complaints amounting to obfuscation. The two key indicators are in fact chosen PRECISELY because they broadly address context very well.

At the top of the list of life expectancy is New Zealand, (as I recall) followed by Switzerland, then Australia, Norway, Sweeden, and a host of other European nations. The same is generally true for infant mortality. (sorry, Japan also is in the mix), but we're lagging behind places like Brazil, and are tied with places like Pakistan (again, as I recall).

That you would question the meaninfulness of these measures points out how tremendously empty your understanding is. As for "working" in teh Healthcare industry, sure, Mitch, you're a web-page designer - I'm sure you are working with underwriters setting morbitity rate tables, or, as I did, work for a half-dozen years doing day-to-day complaint/contract interpretation of policy and impact on costs... once again, it's the psuedo-informed prostelitizing Mitch.

Peeb,

Tell you what - the next time you feel like saying "Mitch doesn't want to engage in a discussion", pick out the many, many snide, condescending insults in your post above, and eat them.

What is the point of "discussing" something with someone whose only motivation is to show how much dumber everyone else is than he?

Oh, you're wrong, as I'll show you when i get a moment or two. But until I get that chance, get over yourself.

Now, go and rewrite your post above in the form of a civil argument.

Mitch,

Tell ya what, go look in a mirror. Given your past history of starting off replies as snide, and uncivil to posts which were civil, what perchance, did you expect?

The bottom line is suggesting that infant mortality and life-expectancy are meaningless unless placed in context and then offering up your "garage logic" of other measures pointed out how little you appear to know about the subject. Those two measures are in many ways seen as the gold standards of health care evaluation. Perhaps they are wrong, but they are seen as right for MANY MANY good reasons, as opposed to stuff we can just throw out at a whim.

BTW, feigning offense, as a way to ignore facts is convenient, but hardly conversation. I called you ignorant, and pointed out your deceptive wording by saying you "work in healthcare." It WAS disingenuious at best, as your experience in Information Technology isn't quite the same as dealing with 10,000+Health Claims per year and discussing at great length the problems facing doctors, nurses, and the industry. Sorry, bud, but then I guess maybe you shouldn't go about crowing like cock-robbin. I call that like I see it, you want me not to call BS, don't spread it.

I gave up on you seriously wanting a debate quite a while back Mitch, if you changed stripes, I'm all for it, so please, tell me, what will simply dumping money into a program through tax credits, or through public tax dollars, do to help a system that can merely raise its prices when the money supply increases, and would be compelled by market economics to do so.

So then, what do you think throwing money into an unregulated system will do? (BTW, unregulated means that there are no oversights costs, not unregulated as an industry, so please don't misunderstand or misrepresent the question.)

I'm all ears, and as long as your post is civil, and discusses the point, I'll happily engage in the discussion with you.

PB

as for ignorance, Mitch, I'll place my experience against yours anytime. Once again, Mitch engaged in penis sizing.

Please tell me why I'm wrong, I'd be happy to hear it.

PB

PB-
I think you're getting off base here. I criticized Duncan Black's attack on the the idea of HSA's. I'm not qualified to defend the current way that medical services are delivered in the US, but nevertheless I'm confidant that it works for most people most of the time, just as it does in any other wealthy country.
You rely on statistics that do not control for the level of services available or the percentage of immigrants in the population (documented and otherwise), use them to pronounce our health care system broken, and then prescribe as a solution that it should be managed by the same bureaucrats who run your local Post Office and DMV under the oversight of a congress you no doubt believe is corrupt and demagogic.
When you compare an existing medical services delivery system to an ideal one, the existing one will lose every time.

Terry,

I'm not describing an ideal system to a broken, exiting one, I'm describing existing WORKING systems to a broken existing one. I'm comparing what nearly every OTHER westernized nation has realized, to what we have, in our over-propogandized that we won't have choice (as if we did in 1990 or after), etc.. from the AMA, the single largest political actor on th American stage. They didn't want radical solutions in 1990 (or 1993) because they feared it would kill the golden goose, now there simply isn't a decent fix that won't be painful, but the examples of working, in place systems are very, very available. The indiginous populations of both NZ and Australia are considerable (I have NO idea if they are more than the US, I suspect they are MUCH more considering Native Americans constitute something like .5%, but .. who knows). So Terry, I'm comparing working systems, to ours (the non-working one).

Regardless, the Off-point part is that while Mitch would have us worry about "lefty" spin on healthcare, he rather disingenuiously describes himself as working in the field and then defends a program that simply throws money into an uncontrolled, highly inflationary system.

The point is that this guy seems unable to distinguish between allegory and emperical reality, writing about his 'friend' who had nothing in his fridge, and then debating the merits of a stupid system like HSA's somehow being some sort of 'fix'. They are nothing.

Now Mitch, before you get your undies in a bunch (or rather, to try to loosen them slightly), I did research on the inflation in healthcare back in the 80's, at the time there were reports of high inflation in the 60's (2300% number), and while there are substantive reports available now, I cannot find anything supporting 2300%, so I willingly retract that although...

http://www.kff.org/insurance/7031/print-sec1.cfm

suggests pretty clearly we had steep inflation in premiums during the period, and further that our dollars are being spent heavily on the upper end of the spectrum (somewhat putting lie to claims of over-indulgence of welfare mommas), but as you likely would have never come up with much on your own, I'll throw you that bone. I'll also throw you another, GDP Healthcare costs were 7% in 80, not 5% in 85, gosh, my darned memory.. yeah, and it's still TRIPPLED in 25 years, despite "market" application of forces. The medical industry is the single largest industry in the U.S. and its pricing structures are virtually unregulated... hmmmmmm... The only real controls are that you can't charge more to someone with insurance, than someone without (except as charity). The price Medicare pays is determined from the base R&C for the region (essentially - that's slightly generalized, and I can expand on it, if you need me to). Read the article though, it describes the multitude of problems, and nothing in it supports the notion, which you SHOULD run from anyway if you actually believe in market economics, that simply pushing more money onto an uncontrolled system high in demand, is a good thing.

Yet.. you defend it..it's a wonder, but not really, because time and again you've proven your willingness to defend ANYTHING the power-brokers in your party trowel out. Rather than stand for something, you blather anything. Grover Norquist even thinks the Prez has gone tooo far with the wire-tapping issue, but not good ole Mitch. Nope, he BS's us with stupid anecdotes about his beer drinking, fast food buddies as if our health care crisis is about 40 somethings who eat too many potatos... Profound ignorance has a little competition.. named Mitch. Perhaps next you can describe how Infant Mortality and Life Expectancy, despite being universally accepted measures of healthcare delivery are stupid measures, and after that, you'll describe why the world is flat, and what sand looks like when you bury your head in it, I've always wanted to know that.

And if you think this is partisan and spiteful, let me remind you it was YOUR VP who told a Senator to "go F#@K yourself" so I think the example is pretty well set, cry your aligator tears elsewhere.

Bottom line, the "fixes" proposed (HSA's and Medicare Drug Rx) are sops, they are meaningless eyewash on a HORRIBLY broken system. In 1993 my father asked me if I thought single-payor, Hillary Clinton's proposal, was worth supporting, I said "no" it's a band-aid on a system which will break in 10-15 years.

Your "salvation" proposal is crap, and it was obvious crap when it came out. Single-payor doesnt address universality, because it focused on administration expenses which account for only somewhere between 15 and 30% of the inflation in the system, so it was crap too. Tax deductions simply feed MORE money, public money, into the system.. Gosh, that seems like Haliburton all over again, or maybe just the same idiotic solution as our "Energy" policy (btw, cutting general revenues in order to direct those revenues to targeted private concerns constitutes indirect subsidy). Tell me, how does giving more money to the hungry lion, make it less hungry?

Your post said almost nothing substantive, perhaps you could start now?

PB

Just to be clear Mitch, I was contrasting your proposal to Single-payor, I realize you don't support it. Nope, you support dumping public funds into private systems.. nice solution that.

Oh, and Mitch, one other thing that articles (as well as MANY others) pointed out. The pharmacuteials industry is the most profitable in the country (only banks recently compared and GOSH we needed to pass a bankruptcy bill to protect them)... I mean, it's not as if GWB is in BED with these businesses or anything, anyway..please enlighten all of us oh great purveyor of truth on Healthcare, how exactly will credit/debit cards and tax breaks restrain an inflationary system. What checks against that inflation exist? In market terms, what happens when the consumer has more to spend and supply is stretched.

Credit cards, savings accounts that give you tax write-offs cure nothing. I'm not quite sure how a piece of plastic makes me better able to pay for my medicine if I'm on a fixed income, and I'm not sure exactly how a measely tax write-off when I'm already paying a pretty low rate as a senior, helps, but mostly I'm really confused why Merck, or Pfizer won't just up the rate on my Plaxil once they figure out I have a little more to spend.

Mitch, your post chastened the left for a lack of vision, yet you seem endlessly to see only one cure for any problem, tax breaks. We've had tax breaks for health insurance since the late 80's, it sure has fixed the system, hasn't it? What we need to do now is give FURTHER breaks to the most profitable industry in the country, rather than consider whether those profits are perhaps an indication of a system out of control.

PB

Uh, PB, you didn't really answer my argument other than to say that you think that Oz & NZ have better systems for their indigenous people. Meaning that it's free to them I suppose. Wonder what other group of people gets less than they pay for if the indigenous people get more than they pay for?
You sound confused.

Peeb,

There is a reply on the way, in which I will ignore your petulant, fact-free browbeating.

While you're waiting, why don't you page back through some of your old threads, and find the places where I challenged you to provide facts that were never forthcoming. It'll keep ya occupied.

Mitch, why don't you do the same, and find all the times you failed to actually address the point.

PB

First, as for confusion, you complained about immigrants, Congress, and idealic to existing systems. I compared our existing system to other existing systems.. it hardly was confused.

Second, immigrants are hardly the problem, go read the article (where it talks about what percentage of the population gets what percentage of the expenditures), but further, our undocumented population is smaller than the native populations of New Zealand or Australia.

Third, Congress certainly is corrupt these days, but that doesn't mean we can do nothing, nor does it mean it is incapable of starting something worthwhile. By this logic I suppose we should just disband Congress, but as you don't agree with me that it's corrupt (I infer that since your comment was sarcasm), I'd suggest YOU think they COULD do something meaninful. The problem is their idea of meaninful is a. tort reform and b. tax cuts funneling money into an uncontrolled system.

Sorry, had to chop this up.. apparently using continue followed by the word to, is "bad" content.

TX and OK both have tort reform, yet malpractice rates went up 85% and 76% respectively (as I recall)because Malpractice rates are set to predict YEARS worth of activity, and not as a reaction to a few headline cases.

No, the "solutions" proposed here for Healthcare are smoke and mirrors. Tort reform protects INSURANCE co's far more so than doctors (whom it protects almost not at all) and does nothing to solve the uninsured/unreimbursed care problem.

Health Savings Accounts and Stored Value Cards Cards (as if a stored value card somehow means I don't actually PAY the bill - is it free money?), do nothing but reduce general fund tax base and direct the funds to a healthcare system overrun with patients, and in desperate need of paying customers to pay ever more for an ever increasing uninsured population. In market terms, that means we're throwing money into a high demand system, already under huge pressure, what results when you have high demand and increase the ability to pay...gee, does "inflation" sound right?

We have a population (both insured and uninsured)which is aging and needing more care. Not sure how an HSA is gonna make someone who can't pay the bill in the first place somehow able to pay, when he doesn't pay taxes worth worrying about, nor how it will make those who can pay, somehow not have to pay for that care?

The solution proposed is laughably stupid, it simply fuels the problem further, it makes it worse, it's not even a band-aid, it's gasoline.

Oh.. and Mitch.. go issue orders to your kids, I think I can do with my time whatever I believe is worthwhile... but my response to you is this, you post, I reply, if you don't reply reasonably quickly, I move on. You see, just like you said, I neither have the time, nor inclination to read everything you post in reply, or wait by diligently for you to do so (as if I should wait in rapt attention for your words from "on-high").

Beyond that, by and large Mitch, what you post, is niether new, nor interesting. Like your post here, it's mostly filled with drivel, falsehoods, and unproven or unprovable obfuscations. (like "we have the best system in the world").

I sent you an e-mail on public education in response to your list of constitutional issues, would you care to let your readers know if you responded? I very clearly identified myself, and VERY clearly indicated I sent it to you because the subject (and response) was simply much larger than was fair for them to have to read.

As you took about 4000 words to make your original post here, I guess that doesn't matter to you, but since others complained, I figured it was the polite thing to do.

PB

Only PB could possibly say, "the bottom line is" and then follow it up with another three paragraphs.

Then his comment to Mitch, "what you post, is niether new, nor interesting" (with too many commas).

Physician, heal thyself.

Badda, when you actually ADD something to a thread, you'll be worth taking seriously. It's easy to snipe, far more challenging to put your opinions out there to be laid bare. As a result, and once again, Badda I don't take what you say as worth considering, seriously or otherwise.

Hey Mitch, you recently said you respond to every point I make.. now that's either a lie, or you have a really, really bad memory.

Let me refresh it for you..

I asked you to reconcile having claimed the wiretapping was legal under FISA, you haven't.

I asked you to define which pilot job in the Navy requires ENSIGNS to have masters degrees after "fingers" posted that senior officers need advanced degrees (an issue never in doubt but not at all an explanation for why your YAF friend is still in school). You haven't responded (at least at last check). The point was that your friend was rather inartfully deceiving the Nation. Your comparitive response to the overall topic was to seriously ask who would be more likely to decieve, some YAF dweeb, or the Nation, which is obviously far more likely to be called out on it. Oh, that's another one you didn't respond to, as I recall.

I asked you to reconcile why the Libs should be castigated for calling WP chem weapons (which I chastised them for), but the President shouldn't be for wrongly calling Ricin a bioweapon (unless you think any naturally occuring agent which has the potential to be used as a weapon is a "bioweapon" - aka rattlesnake poison). You didn't answer.

and frankly, there are SOOO many others that you didn't respond to, I probably could write another three paragraphs :).

So Mitch, if you want to start tallying up points not answered, your score is also pretty high. But as I said, I have neither the interest nor inclination to respond to every comment you make. Unlike you, I actually try to consider your whole argument, rather than chopping it into bits so that I can ignore the context, declare it wrong without proof or valid response, or rudely/crudely dismiss it with sophomoric buzzes, again without response or do you consider saying BZZZT Wrong - and Irrelevant responses? You see, most people think of actual C O N V E R S A T I O N as involving real I N P U T and I D E A S from both sides, rather than ideas from one side, and juvenile and dismissive non-response from the other.

So Mitch, care to again say how you've "responded" to every single post.

I'll throw you a bone though, I really only want you to respond to the question I've now asked OVER AND OVER, yet you haven't been able to for 24 hours, specifically, how will throwing money into an unregulated/uncontrolled, high demand, and highly inflationary system, "fix" anything?

Address that, rather than childishly chopping up my posts and even more childishly declaring it irrelevant without validation or saying BZZT. You see, I actually THINK you're smarter than your responses to date have indicated, and I occassionally get a little irked at your laziness/condescension shown because I know you can do better. Give it a try, please?

PB

"I don't have access to those right now - but I'll see what I can find. I suspect they're considerably better - and know they're more germane - than the stats you've cited..."

First - wow lots of emo to scroll through.

Second - Love to see those numbers soon. Without an iota of research, I am willing to bet not one, not two, but three Guiness beers at the Dubliner that if you have diabetis your chances of being diagnosed and succesfully treated are higher in Germany, Canada, Sweden, and the UK than in the U.S. Please note that this actually stacks the deck in your favor. The UK is a very efficient but notoriously underfunded system. Germany actually has an employer based model that is not that good compared to the rest of Europe.

P.S. this just in the most socialized, most public sector of the U.S. health care system, the VA actually beats the private sector hands down in quality of care.

http://healthypolicy.typepad.com/blog/2006/01/va_more_than_fi.html

PB: "Once again, Mitch engaged in penis sizing".

GH: Your wife says Mitch and I BOTH beat you.

Next!

Once again, Mitch's sychophants prove the apple does not fall far from the tree when it comes to engaging in purient commentary.

Thanks Geoff, nice come back actually :). I did smile, my wife has been eyeing the Enzyte commercials lately..

And Rick, don't look for facts from this crowd, what they claim as facts are almost always merely regurgitations of other blog trash.

PB

"I don't have access to those right now - but I'll see what I can find. I suspect they're considerably better - and know they're more germane - than the stats you've cited..."

Wow, you KNOW they are more germane.. how would you KNOW that? Considering Infant Mortality and Life Expectancy are the hallmark standards, that's quite a statement, you KNOW better than WHO, US Census, etc.. who study this, as well as the AMA, which accepts these standards as evidenciary of healthcare delivery.

That's some kinda knowledge you all on the right have, apparently God is speaking to you.. it doesn't appear you're actually relying upon independent investigative facts..

We're still waiting... Mitch??? ya out there bud? Care to reconcile calling this the "best system in the world", or maybe just the question posed half a dozen times, how will throwing money at this problem solve it?

PB

"And Rick, don't look for facts from this crowd, what they claim as facts are almost always merely regurgitations of other blog trash."

Uh. . . huh. And PB's commentary is always the shining beacon of truth and nonbias, not just the rambling, dodgy, pointless narratives it appears to be.

Good Lord, PB, get over yourself already.

*knows better than to expect that*

"And Rick, don't look for facts from this crowd, what they claim as facts are almost always merely regurgitations of other blog trash."

Ergo - the three Guiness incentive program for verifiable data.

OK, I have a bit of a lull. Let's try to address the 45 column inches of questions (and, in some cases, context-free blather):

"First, from 1960 to 1973 Health care inflation was 2300%. The reason was pretty simple, health care was relatively inexpensive at the time (for examplet the bill for my birth was $200), and health insurance was getting broadly developed essentially created a condition where the patient/family was not impacted by cost increases. A key component to constraint is that the patient needs to be able to feel and thus place pressure, when costs go up."

So far, so good. And the constraints were removed from huge swathes of the healthcare consumer population; fee-for-service healthcare, Medicare, Medicaid and other systems not only kept the costs of usage hidden, but basically encouraged a level of usage heretofore unseen.

The public sector health system was, of course, among the leading offenders.

Onward:

"From 1975-1995 various cost control measures, such as Second Surgical Opinion (SSO), Pre-Certification (Pre-Certs), and eventually HMO/PPO's were implemented. These dropped the inflation rates dramatically. The idea for HMO's (initially) paid doctors a per person participation fee for providing healthcare to the participant. Copays were designed (originally) to simply give the provider a stipend up front until their participation fee was received. These evolved into an organization which both paid participation fees and received steep, contractually binding discounts for medical services. There were NO out of network benefits (originally)."

Right. Again, so far so good. The health insurance industry began to introduce means of managing utilization and cost - directing people into networks, channeling through primary care physicians, etc.

"Well, what essentially happened is that these discounts put doctors in an increasingly unacceptable economic position. First, if part of an HMO they were often employees, paid at a rate below what they desired. Second, if part of a private practice, costs related to authorization tracking, protocol tracking, an general pressures to adhere to protocols in contractiction to thier own desires on how to provide appropriate care."

Right. That is a perfectly capable history of managed care.

"These pressures caused doctors to begin leaving HMO's in the late 90's. In addition, an aging population has put HUGE pressure on the medical system. The organization of Medicare is such that Hospitals get reimbursed through Medicare for unreimbursed care, consequently, Medicare (along with the impact of aging populations), gets the bill as people become less able to pay for insurance. Because of pressures to pay higher fees to physicians, and the need to pay for more care, HMO fees (as well as PPO fees etc..) started escalating dramatically in the late 90's, a pattern that has not abated, only increased, and the reason is.."

Right. And true.

And - try to absorb this, peeb - *way* beyond the scope of my post.

We'll come back to that.

"The number of uninsured people has skyrocketed. This is absolutely, 100%, no question, no debate, the largest impact to healt care costs, and it is unfortunately a viscious circle."

The circle is no doubt vicious and viscuous.

The point in my post is not "do we need some means of insuring the uninsured". It's a defense of the notion of the HSA and HRA. Of which more below.

" The bottom line is, Savings accounts, and the current Medicare Drug plan unfortunately feed more money into an already highly inflationary environment."

And it's here you're partially wrong. I don't know when you left the Healthcare biz, Peeb - it's been a few years, I know - but your statement indicates you might be a little unclear on how HSAs work (and I'm not writing about Medicare Part D at all - I think it's an atrocious idea). The idea behind the HSA is to feed LESS money into the system than previous plans. The employer buys a *high deductible* account rather than a traditional low deductible plan; there is less money in the form of employer and employee-paid premiums.

" Just like the problems of the 60's, more money, without some control, will only cause even greater inflation."

But your central premise is wrong; the HSA doesn't supply *more* money. It feeds, at the most, the *same* money. Furthermore, it introduces a very tight loop for imposing constraints on costs; people who are managing their own health care have an impetus to negotiate costs with providers, to curb usage, and to stay healthy. For their part, providers have an impetus to contstrain costs; they get paid for routine office visits in *cash* - no forms to fill out, no staff load, no nothing. Many doctors give *steep* discounts for HSA and HRA payment.

There's another impetus; the HSA money belongs to the consumer; if the user builds up a ton of it, it's part of their retirement plan (as in deed many HSA users treat it).

"Given the supposed Fiscal prudence (which is completely false) of this administration, you'd think they know that simply throwing good money after bad."

You're rambling, Peeb - you're departed the context of the discussion. The Administration isn't financing HSAs.

"The reality is that health care is a critical "demand" utility, like heat, power, etc. The need is so great, and people's will to do as much as they can to survive (especially for their children, or parents who may not be able to make independent decisions), that holding people hostage for fees is certainly possible. I have a relative who paid $25k to travel to Mexico for Laotril treatments, (she died anyway)."

As did most people who relied on Laetril. It's possible - and well outside the scope of this discussion. Here's the difference; if one wants to find a high-deductible plan with HSA that covers alternative treatments for diseases - if that's something one values - then it's MUCH more affordable than in a traditional Fee For Service plan, and unlike an HMO it can actually occur.

" Suggesting that a market solution will solve the problem flies in the face of logic, in that there are many people willing to cooperate to take advantage of subtle loopholes as long as they don't see the light of day. Simply giving pharmacutical companies more money won't cause them to not also charge more."

Very true - but HSAs DO NOT "give" anyone "more money". Again - it's essentially the same money, sometimes less, and managed much more carefully (if the consumer is doing their job).

"They spend 14 times as much on advertising as they do on research (advertising for things like Viagra)."

Which in turn make profits, which benefit shareholders (many of whom are union, municipal and private pension plans) AND finance further pharmaceutical research - which is something at which the US DOES demonstrably lead the world.

"No, instead some form of oversight is warranted. Putting it in the hands of the industry to solve has not worked (it's failed for more than 40 years)."

Arguable, and at any rate *not in the least big germane* to this post.

" Our health care system is lagging dramatically behind the rest of the world yet we pay FAR more per capita. You can argue that SOME folks get great care, and they do, and yet many of the most important advances are increasing coming from other arenas, and our AVERAGE expense is still far higher. If our exhorbitant fees paid for something, maybe it would be worth it, but in truth it pays for little more than making drug companies very, very profitable."

Wow. You came perilously close to the crux of the issue - but then swerved away. Unrestricted utilization of services and pharmaceuticals (facilitated by the lack of constraints on usage) HAVE caused healthcare costs to balloon in the past forty years. There has been, in effect, no free-market discipline in the *utilization* of healthcare for a generation or two. There has been no impetus to manage costs.

And when unconstrained money (from fee for sevice and public assistance) combined with the limited supply of providers, the price of care predictably zoomed, well out of range for the poor - who, you correctly note, are themselves driving up costs for their unreimbursed usage.

" We MUST find a mechanism to cover all people. The solution will probably require some form of government oversight, perhaps including making doctors/nurses etc.. employees of a unified organization, but our current path is broken beyond description, and simply putting MORE into a broken system is stupid. Arguing that putting more money into that broken system is a realistic solution is not just stupid, it's assinine. Without any sort of restraint, what exactly Mitch, do you think is going to happen?"

You want a cure for all that ails the healthcare system? It's way beyond the scope of my original post, but there's elements there. The point - of the HSA and of my post - is that they provide a *real* form of market discipline on healthcare utilization for the low-price, high-volume services that have been driving up the costs of healthcare so drastically; a proper high-deductible "Catastrophic" plan backing up the HSA (or deductible) would give, at considerably lower cost, access to care for *real* emergencies.

As to the rest of your posts, PB (among others), I'll try to get to them later today (my lull is ending shortly); I'll try to get to some of the other points (ignoring the gratuitous abuse that you seem to regard as your peculiar franchise, Peeb).

In closing; you (and Atrios) seem to be completely unclear on how the HSA, and Consumer-Directed Healthcare in general, actually work. Perhaps some research is in order.

"And Rick, don't look for facts from this crowd, what they claim as facts are almost always merely regurgitations of other blog trash."

Er, this from a guy that can't even stay on a single subject coherently, much less answer direct challenges to most of his facts.

"Ergo - the three Guiness incentive program for verifiable data"

Perhaps if you didn't drink so much, healthcare wouldn't be such an issue.

But I'll get to that in a bit.

Kermit and PB: I couldn't possibly speak to anyone's condition, but PB reminds me of my first husband. Always right, always a blowhard, always browbeating, very verbally abusive, but NEVER, EVER at fault for ANYTHING.

I've been reading Mitch for a long time, PB. While you make the occasional good point, buried in a lot of bluster, you are without a doubt the biggest asshole I've ever read in any comment section anywhere. You are thin skinned, petty, and judging by your spelling not very smart. But its your style that reminds me of my ex - all browbeating, rambling, quick to insult, but always able to rationalize everything to make him smell like a rose. To him, anyway.

I have no idea who you are, PB. But I think I know you. And if you are in person anything like the prick you are here, I feel sad for you.

I put my ex in jail. You, I merely tune out.

"As for "working" in teh Healthcare industry, sure, Mitch, you're a web-page designer"

Um, no. I'm not.

" - I'm sure you are working with underwriters setting morbitity rate tables, or, as I did,"

Nope. I just work with users - y'know, the actual consumers of the healthcare product.

Oh, yeah - and I can read.

"work for a half-dozen years doing day-to-day complaint/contract interpretation of policy and impact on costs... "

In other words, you're the guy who kept sending my claims back. Bastiche.

RickDFL: Your questions are leading me into some other research; your answer actually will rate a post later this week.

"RickDFL: Your questions are leading me into some other research; your answer actually will rate a post later this week."

Yipee - I feel like I finally got that 'deluxe apartment in the sky'. Look forward to your ringing endorsement of single payer.

Ok Mitch, you do ergonomic analysis of computing systems (primarily web systems), you disingenuiously describe yourself as working with the "users", by users of course, Mitch means those who use computing services... I guess that's the same as dealing with doctors, patients, and regulators for a dozen years... or not..

Anyway..

>OK, I have a bit of a lull. Let's try to address the 45 column inches of questions (and, in some cases, context-free blather):

Well Mitch, all you actually had to do was answer the ONE question, could have saved yourself a LOT of time. I pointed that out to you.

>"First, from 1960 to 1973 Health care inflation was 2300%. The reason was pretty simple, health care was relatively inexpensive at the time (for examplet the bill for my birth was $200), and health insurance was getting broadly developed essentially created a condition where the patient/family was not impacted by cost increases. A key component to constraint is that the patient needs to be able to feel and thus place pressure, when costs go up."

Actually, inflation in the 60's was highest on premiums of any point in the last 40 years... but I digress.

So far, so good. And the constraints were removed from huge swathes of the healthcare consumer population; fee-for-service healthcare, Medicare, Medicaid and other systems not only kept the costs of usage hidden, but basically encouraged a level of usage heretofore unseen.

That statement is both in part true, and in part not. Medicaid did very little to change healthcare consumption. The current state is that most Medicaid recipients do not see the doctor hardly at all except through emergent care.

The public sector health system was, of course, among the leading offenders.

Actually, the utility rate of the private sector as a percentage of expense has nearly always outpaced public... utilization in the private sector has increased at a pace equivilant to public (and most of the time exceeded).

Onward: (perhaps you'll say something relevant to the point ?)

"From 1975-1995 various cost control measures, such as Second Surgical Opinion (SSO), Pre-Certification (Pre-Certs), and eventually HMO/PPO's were implemented. These dropped the inflation rates dramatically. The idea for HMO's (initially) paid doctors a per person participation fee for providing healthcare to the participant. Copays were designed (originally) to simply give the provider a stipend up front until their participation fee was received. These evolved into an organization which both paid participation fees and received steep, contractually binding discounts for medical services. There were NO out of network benefits (originally)."

Right. (Well, gosh thanks, but, candidly, I doubt seriously you can accurately judge that as being either right or wrong, your experience and comments belie a knowledge level beneath what I've just described).

Again, so far so good. The health insurance industry began to introduce means of managing utilization and cost - directing people into networks, channeling through primary care physicians, etc.

Actually, that happend MUCH later than the original programs, again, you don't appear well informed. HMO's started in 1987 (in Minnesota btw).

"Well, what essentially happened is that these discounts put doctors in an increasingly unacceptable economic position. First, if part of an HMO they were often employees, paid at a rate below what they desired. Second, if part of a private practice, costs related to authorization tracking, protocol tracking, an general pressures to adhere to protocols in contractiction to thier own desires on how to provide appropriate care."

Right. That is a perfectly capable history of managed care.

Gee, thanks, but again, I doubt you actually have the facts in hand to judge it - sorry, but your comments don't support such a conclusion.

"These pressures caused doctors to begin leaving HMO's in the late 90's. In addition, an aging population has put HUGE pressure on the medical system. The organization of Medicare is such that Hospitals get reimbursed through Medicare for unreimbursed care, consequently, Medicare (along with the impact of aging populations), gets the bill as people become less able to pay for insurance. Because of pressures to pay higher fees to physicians, and the need to pay for more care, HMO fees (as well as PPO fees etc..) started escalating dramatically in the late 90's, a pattern that has not abated, only increased, and the reason is.."

Right. And true.

Again, gee, thanks.. see above.

And - try to absorb this, peeb - *way* beyond the scope of my post.

No, try to absorb this Meeotch, it is the PRECISE fundamental you MUST understand to understand why we are where we are and why your poposal is completely NOT the solution.

We'll come back to that.

Well, you will, but I'm afraid I've given up hope of you understanding this.

"The number of uninsured people has skyrocketed. This is absolutely, 100%, no question, no debate, the largest impact to healt care costs, and it is unfortunately a viscious circle."

The circle is no doubt vicious and viscuous.

The point in my post is not "do we need some means of insuring the uninsured". It's a defense of the notion of the HSA and HRA. Of which more below.

Well, unfortunatly Mitch, then your post misses the POINT of the entire healthcare dilema.

" The bottom line is, Savings accounts, and the current Medicare Drug plan unfortunately feed more money into an already highly inflationary environment."

And it's here you're partially wrong. I don't know when you left the Healthcare biz, Peeb - it's been a few years, I know - but your statement indicates you might be a little unclear on how HSAs work (and I'm not writing about Medicare Part D at all - I think it's an atrocious idea).

Well then, we agree on something. it is

The idea behind the HSA is to feed LESS money into the system than previous plans. The employer buys a *high deductible* account rather than a traditional low deductible plan; there is less money in the form of employer and employee-paid premiums.

And the employee gets to put $2000 into a tax free plan and pay for the deductible programs (and some other, limited costs) themselves. Actually Mitch, I'm fully aware of HSA.

" Just like the problems of the 60's, more money, without some control, will only cause even greater inflation."

But your central premise is wrong; the HSA doesn't supply *more* money. It feeds, at the most, the *same* money.

Incorrect, it feeds dollars that previously went to general fund, into the medical system. While that could be said to be an offset against the employer premium, the fact is, the employer premium ALSO goes up.

Furthermore, it introduces a very tight loop for imposing constraints on costs; people who are managing their own health care have an impetus to negotiate costs with providers,

THAT is the flaw, they have NO power to engage in such negotiation, you see, the law REQUIRES that a physician charge exactly the same, regardless of insurance. So unfortunately, it seems it is you who does not understand the law and thus, insurance/state health regs. If you llke, I'll be happy to give you a call and explain it, but essentially, if Dr. Jones agrees to a cheaper fee for Bill, he just agreed to it for EVERYONE, and guess what, Dr. Jones has no impetus to agree. Healthcare is a demand industry, people pay what they are billed. They can TRY to negotiate, but they'll have little, if any, luck.

to curb usage, and to stay healthy. For their part, providers have an impetus to contstrain costs; they get paid for routine office visits in *cash* - no forms to fill out, no staff load, no nothing.

While I agree administrative costs exist, it certainly doesn't mean they are going to lay off staff, and regardless, admin costs amount to about 15% of the inflation in the system. You are curing the wrong problem.

Many doctors give *steep* discounts for HSA and HRA payment.

Really? They give different prices for cash payment, very doubtful. Now they can of course negotiate a rate with the HSA, but that's not the public, that's the program, and it's no different than an HMO, and oh, btw, the "cash" incentive you are talking about, it's been done, it's called a "copay" in HMO parlance, and it had the same idea behind it. It failed because the cash contribution was insufficient (over time) due to inflation, the same problem will happen here.

There's another impetus; the HSA money belongs to the consumer; if the user builds up a ton of it, it's part of their retirement plan (as in deed many HSA users treat it)

Well, there is some ambiguity in the law about whether it can be used as such as I recall, but it still doesn't address the fundamental problem. You are simply taking money from general fund, and pushing it into a highly inflationary market.

"Given the supposed Fiscal prudence (which is completely false) of this administration, you'd think they know that simply throwing good money after bad."

You're rambling, Peeb - you're departed the context of the discussion. The Administration isn't financing HSAs.

Yes it is, HSA's are a tax-free savings account, which means less tax to the system. Care to try that again.

"The reality is that health care is a critical "demand" utility, like heat, power, etc. The need is so great, and people's will to do as much as they can to survive (especially for their children, or parents who may not be able to make independent decisions), that holding people hostage for fees is certainly possible. I have a relative who paid $25k to travel to Mexico for Laotril treatments, (she died anyway)."

As did most people who relied on Laetril. It's possible - and well outside the scope of this discussion. Here's the difference; if one wants to find a high-deductible plan with HSA that covers alternative treatments for diseases - if that's something one values -

Ok, you've again shown an ignorance of any program. In the US, no "alternative" treatments are covered, for two major reasons. First, medical necessity and investigational/experimental are the two limiting factor on plan liability, i.e. if it isn't accepted by the FDA, it isn't paid, this keeps insurance programs from paying for "crystal therapy", and Mitch, please try to understand this, if it isn't medically necessary, it's not acceptable as a decuctible expense and you can't pay for it out of your HSA fund. Second, Medicare acceptability under prosthetic acceptance also guides payability, and generally, if it ain't medically necessary or is considered experimental and investigational, it won't get accepted by the FDA or Medicare Prosthesis approval.

then it's MUCH more affordable than in a traditional Fee For Service plan, and unlike an HMO it can actually occur.

This is utterly false, see above.

" Suggesting that a market solution will solve the problem flies in the face of logic, in that there are many people willing to cooperate to take advantage of subtle loopholes as long as they don't see the light of day. Simply giving pharmacutical companies more money won't cause them to not also charge more."

Very true - but HSAs DO NOT "give" anyone "more money". Again - it's essentially the same money, sometimes less, and managed much more carefully (if the consumer is doing their job).

Err, see above, this is false, it gives them back tax dollars, which they then sink into the system.

"They spend 14 times as much on advertising as they do on research (advertising for things like Viagra)."

Which in turn make profits, which benefit shareholders (many of whom are union, municipal and private pension plans) AND finance further pharmaceutical research - which is something at which the US DOES demonstrably lead the world.

Yeah, and pharmacuticals are the MOST profitable companies on earth, and your US DOES demonstrably lead the world comment, we would call that an extremely poor efficiency ratio in business parlance, our expenditures on research and advertising netting a very poor total PRODUCT enhancement output, but hey, you wanna defend pharmacuticals, be my guest.

"No, instead some form of oversight is warranted. Putting it in the hands of the industry to solve has not worked (it's failed for more than 40 years)."

Arguable, and at any rate *not in the least big germane* to this post.

Actually, it's the crux of the issue, the solutions suggested by the industry have failed utterly because their goal is profit, not robust, universal care.

" Our health care system is lagging dramatically behind the rest of the world yet we pay FAR more per capita. You can argue that SOME folks get great care, and they do, and yet many of the most important advances are increasing coming from other arenas, and our AVERAGE expense is still far higher. If our exhorbitant fees paid for something, maybe it would be worth it, but in truth it pays for little more than making drug companies very, very profitable."

Wow. You came perilously close to the crux of the issue - but then swerved away.

Actually Mitch, I don't think you understand in the least the crux of the issue, and your paragraph below reinforces that opinion. Given that I'm reasonably able to claim being an expert, I'm going to say I have the right to judge whether you grasp the programs and process. You don't seem to have a full grasp.

Unrestricted utilization of services and pharmaceuticals (facilitated by the lack of constraints on usage)

Ahh, the OLD SAW, it's not the fact that we just have too many people using the system too much.. Sure Mitch... the fact that we have an aging population and have tremendous amounts of problems with not having paying customers, it's that we just have too many folks going too often.. That's silly, and dead wrong. In fact, especially in lower incomes, utilization rates have FALLEN as insurance coverage disappeared for them. You appear to fully not understand the issue.

HAVE caused healthcare costs to balloon in the past forty years. There has been, in effect, no free-market discipline in the *utilization* of healthcare for a generation or two. There has been no impetus to manage costs.

This is such an extreme misunderstanding of the reality, I don't know it warrants comment. Let's agree though that decoupling the patient from the cost picture is a HUGE problem, unfortunately, it is not the primary problem, or more correctly, it's a portion of the hole problem. If we had pressure in the 70's , i.e. kept patient pressure on clinicians to keep costs in line, we probably could have avoided SOME of our current problems. However, that does NOT deal with the ballooning population, and now that prices are so high, the HSA will do nothing to help someone who can't afford the bill in the first place, suddenly afford the bill. Doctors can discount, for charitable purposes, but most don't. Consequently, there are massive numbers of unreimbursed bills. Those fees fall on everyone who CAN pay. The HSA does NOTHING to address this built in escalation, because, AGAIN, the individual cannot effectively negotiate, only the plan can.

Mitch, your solution is not a solution. It merely offers a tax credit savings account, it's nothing.

>>And when unconstrained money (from fee for sevice and public assistance) combined with the limited supply of providers, the price of care predictably zoomed, well out of range for the poor - who, you correctly note, are themselves driving up costs for their unreimbursed usage.

This sstatement is false (or mistated on the first part) Fee for service is not unconstrained, and is incorrect in the second ,public dollars did not EVER constitute more than half the total medical dollars.

" We MUST find a mechanism to cover all people. The solution will probably require some form of government oversight, perhaps including making doctors/nurses etc.. employees of a unified organization, but our current path is broken beyond description, and simply putting MORE into a broken system is stupid. Arguing that putting more money into that broken system is a realistic solution is not just stupid, it's assinine. Without any sort of restraint, what exactly Mitch, do you think is going to happen?"

You want a cure for all that ails the healthcare system? It's way beyond the scope of my original post, but there's elements there.

Actually Mitch, it's entirely wrapped up in your post, because your proposal is something which will WORSEN the problem, you must address non-covered persons, and a ballooning population. Both of these drive inflation, your proposal is nearly nothing, and and further, only serves to channel money from taxes (or other bills) into medicine at an increased rate.

The point - of the HSA and of my post - is that they provide a *real* form of market discipline on healthcare utilization for the low-price,

They do NOTHING of the sort. You clearly don't understand the situation. Patient's cannot negotiate individual bills, cash in hand is an incentive to discount, but the inflationary pressures of uncovered bills and increasing age (and thus need for care), are not aleviated in the slightest, and the nominal pressure of cash in hand (btw, you still have to file a claim, so your lower admin fee is only true in that a referral MAY not be needed). HSA's require documentation of charges to satisfy the deductible.

high-volume services that have been driving up the costs of healthcare so drastically; a proper high-deductible "Catastrophic" plan backing up the HSA (or deductible) would give, at considerably lower cost, access to care for *real* emergencies.

I agree with the "catastrophic" approach, in general, but HSA's are not quite that, in that they only account for 2000 per year, and the only "new" benefit is it's tax deductibility. You have to have the money to put 2000 in the program, (so it doesn't help the uninsured really much at all), and then you have to not incur charges such that you can roll over enough to pay for the difference between your costs and the catastrophic coverage. Since the average cancer treatment now costs 60k, and a castrophic policy may have a deductible as high as 10k, it would take a normal person somewhere between 5 and 10 years (assuming 500 to 1k per year of incidental medical fees), to have enough in the acocunt. Further, nearly always folks have serious illness late in life, so this fund would be used for that, thus dumping more money into an unconstrained system.

As to the rest of your posts, PB (among others), I'll try to get to them later today (my lull is ending shortly); I'll try to get to some of the other points (ignoring the gratuitous abuse that you seem to regard as your peculiar franchise, Peeb).

Abuse runs on a two way street, but you seem unable to see that.

In closing; you (and Atrios) seem to be completely unclear on how the HSA, and Consumer-Directed Healthcare in general, actually work. Perhaps some research is in order.

Actually, Mitch, you need to do some of your own. There have been some terrific research papers written on this, you need to avail yourself of them. I pretty well understand the HSA, and in some ways, it appears I understand it better than you, but what is very clear, is that I understand the pressures on the system, and their origin, FAR better. It appears you think this is mostly needing to put negative pressure on utilization (as well as give the patient the ability to negotiate) - and as listed above, they don't get any such ability, and as for overutilization being the issue, you need to go read a great deal more on utilization rates.

PB

Here is some help:

http://www.thehealthcareblog.com/the_health_care_blog/2005/12/internationalqu.html

Short story. U.S. Medicare heart patients do slightly better (2%) over short term, but the same over long-term (1 yr).

Of course this a a very advantagous comparision for the U.S. b/c Medicare recipiants are the one-part fo the U.S. population with a universal health care program.

So, we spend twice what canada spends per person,

http://www.nationmaster.com/graph-T/hea_hea_car_fun_tot_per_cap

and even when you screen out the uninsured, the U.S. still gets about the same level of health care.

Kind of like driving cross town to pay more for gas.

Because the combination of Mitch's and my verbosity is unfair to the readers, I want to summarize..

Mitch claims..

Paying in Cash, and having the patient pay, will give the patient leverage to negotiate.

What the law requires.. Healthcare providers may NOT change their fee based on the existence, or lack thereof, of insurance. Consequently, no real leverage exists, including deciding to cut fee because of cash because this means you gave a discount not available to a standardly insured patient.

Mitch Claims - the primary issue is overutilization and decoupling of patient cost from the bill (including publicly funded programs like Medicaid).

The facts are that low incoome families utilization DROPS when they cease having coverage, and MUCH more importantly, utilization is tied to age. Utilization rates are not markedly different today, than in 1970 (or 1990) for the same age/income group, the issue is that you have MANY more older people, as medical expenditures are somothing like 66% on folks over 65, that's a problem.

Mitch Claims HSA involve no new money.

Fact: They involve money the family otherwise would have paid in tax, and direct it to the medical industry (it's a 2000 per year tax free savings fund).

Mitch claims it could pay for "alternative" treatments like Laetril.

Fact - unless the laws change HSA's will be governed by the same rules as Health Care Reimbursement accounts. These accounts require the service to meet minimum healthcare acceptibility standards, including not being experimental or investigational, as such, Laetril would be denied.

Mitch claims this deals with the problem by re-engaging the patient in the process through having them use cash incentive.

Fact: As described above, clinicians cannot simply discount for cash. They CAN do so for indigent status, and Hospitals often do, but they then file for unreimbursed coverage (hospitals) under Medicare, so you pay for it anyway.

Further, how will someone without coverage, who can barely save $10 per week, somehow suddenly come up with $2000 per year. The HSA does nothing to resolve the other major problem, namely, most of the uninsured aren't uninsured because they WANT to be and otherwise could afford it, they are uninsured because they cannot afford it. While catastrophic policies are cheaper, and thus they may become insured, it still doesn't deal with the day to day expenses they cannot pay for, because they a. don't have the cash, and b. the catastrophic policy won't pay.

For these reasons, it appears Mitch both doesn't know enough of the law, insurance and state health regulation, or appreciate that taxes deferred into a private industry in fact inject more money. It also appears he does not understand the cheif challenges regarding utilization stem from aging patients, and that the primary financial burden stems from unreimbursed care.

While he does hit on a point that making the patient directly related to the doctor is key, the HSA does not effectively do that. To do so, the entire system needs an overhaul. HSA's merely throw more money out of the general coffers at a problem, don't actually give the patient negotiating power, and fail to deal with our crisis of age and affordability.

PB

Allison remarked: "I have no idea who you are, PB. But I think I know you. And if you are in person anything like the prick you are here, I feel sad for you."

Great post. I have a hard time understanding Mitch's fascination with ol' pb. Me, I just "snipe" as Bill so eloquently put it. But pb is a case study to be sure. To go on endlessly in what one poster called Tolstoiian fashion, well, one an only be fascinated, right?

Well Gee Allison, since you don't know me, and would make that comment, I'm not sure who the "prick" is (Mitch, me, or the other really nice folks posting here) but it appears you may have your own demons.

Realistically Allison, I insult these folks far less often than they do me, and I use words like "appear" and "seems" so as to suggest it is both my opinion only, and not certain.

Since I recently agreed to refrain from ad hominem attacks on Mitch, I'm not going to start here either with him or you. If that doesn't fit your "prick" paradigm, maybe your paradigm is broken.

Regardless, Mitch's assertions are flawed, in that they assert negotiating power where little to none will exist (due to laws), buying power from people with inadequate income, and inserts money from the tax stream into an unregulated, high demand environment. Negotiating power, as a patient, even if they could, would require that buyers were in demand, which they are not. Finally, over-utilization is a false charge. In certain fields (podiatry, chiropractic) it was, once upon a time (around 85-90), but no longer. HSA's probably aren't going to do much harm, they'll help a few people a little, create a little inflation, but they certainly won't do much good either. In the end, they won't do much at all, as their scope is just too small. Few reasonable people choose really high deductible plans because saving is too hard. If saving is too hard, so is HSA saving, and candidly, 2k isn't worth a piss in a poke in dollars for any significant dollars.

If that comment was too prick'ish for you Allison, I suggest you not wait around for the really kind things that are said to me.. for example, the folks that say they'd rather kill me than talk (not just to me, to anyone they deem a liberal - which by current definition, I'm not).

PB

That should be "for any significant illness".

Save your research Mitch the White House just conceded defeat.

http://www.nationalreview.com/comment/cannon200601260821.asp

"Healthy, Wealthy & Wise, a new book by economists John Cogan, Glenn Hubbard, and Daniel Kessler, is rumored to be influencing President Bush's State of the Union address. . . .

In a world of much health-policy quackery, the authors examine the health-care sector and deliver a precise diagnosis. "The problem," they write, "is not that market forces cannot work in health care. Rather, public policies have prevented health-care markets from functioning properly.""

Translation, we can not find any evidence that the U.S. private health care sector is better or cheaper. But our theoretic model tells us it must be so, so we will keep tinkering with it.

Reminds me of Kruschev running around the U.S.S.R. in the 50s trying to figure out why the peasants couldn't grow any grain on the collective farms.

Reading a book is "conceding defeat?"

And how did you get in the loop for the text of the SOTU?

Look - before you and Peeb hijacked the post with your sloganeering about single-payer healthcare, I was pretty well limiting things to a discussion of HSAs in and of themselves - attacking Atrios' assertions.

This thread has grown far too long, and my week far too busy, to answer each and every point (and I'll acknowledge you and Peeb's inevitable "Look! He's quitting! He can't answer! We win! W00t w00t!" in advance. It's wrong, but I'll acknowledge it so you can save your wrists and my bandwidth); I will write another post soon, probably over the weekend.

Suffice to say that while *this* post never attempted to address the whole complex issue of providing insurance for *every* American, my next one will. Oh, yeah - and you and (especially) Peeb's various points were about equally valid and conveniently self-serving.