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Sunday, August 2, 2009

Madville Times Poll: Public Option or Not? Vote Now!

Hey! The latest Madville Times poll (see upper right sidebar!) is toodling along nicely. I'd like to know what you think of the "public option": do you want health care reform legislation to include a government-operated health insurance plan offered on the market alongside private insurance plans? I'm not asking if you want government to take over health care or health insurance (though I will gladly argue that we'd save lives and save money if we did). The public option, as constructed in H.R. 3200, simply means you could get insurance from your boss, buy a policy from DakotaCare or Blue Cross, or buy into a version of Medicare from Uncle Sam.

Poll closes tomorrow morning before breakfast, so vote soon!


  1. I think health care needs much reform... and the public option isn't a bad idea. Public/private schools co-exist just fine here in the states, and public/private hospitals work great in Australia.

    But just to keep our government consistent... why don't they let us have a "private option" when it comes to mail delivery? Why can't UPS and FedEx deliver letters and put them in residential mailboxes? Maybe they could get the mail here from Phoenix sooner and cheaper... but we'll never know unless the government lets them.

  2. Another thought... should we have a public option (or single-payer takeover) of automobile and life insurance?

    What makes health insurance different? If the government is going to force us to have auto liability insurance (in all but 3 states), where's their profit-free public option?

    Kind regards,

  3. Health care differs fundamentally from auto insurance. In my opinion, the whole idea of "insuring" health care is misguided.

    When we get auto insurance, we pay for coverage in the event an unforeseen disaster occurs. We don't expect our auto insurance to pay for flat tires or engine damage (unless accident-related, of course).

    The same goes for homeowner's insurance. I need to have the "roto-rooter" people come out here tomorrow to unplug the floor drain in the laundry room. I don't expect my homeowner's insurance to pay for that.

    As for life insurance, I guess we all die sooner or later, don't we? Maybe "insurance" isn't the correct word to describe policies of this type.

    But health care ... I believe this is a fundamental right that should be extended to every American citizen from cradle to grave. We should have a reasonable, equitable, dedicated tax to pay for it. Deductibles should be minimal, and premiums should not exist at all. (In my opinion.)

    As for the Post Office vs. the other carriers, I've found the good old U.S. Mail to be just as reliable as the private carriers -- and usually cheaper.

    Now about that tax for health care again: Just saw a Fox News poll in which 96 percent of the respondents have said they do not want to see any sort of tax increase to pay for health care reform. None. Nada. That's extreme even for Fox. I suspect that this poll says something a lot deeper than "No new taxes." I think a lot of folks indirectly (and perhaps even unconsciously) told their government, "We don't trust you," when they clicked on the "No" button.

    That's a problem!

  4. Thanks for the reply Stan, but you didn't exactly elucidate why you believe health care coverage is a 'fundamental right' but auto liability coverage is not.

    Item A covers you in the event of an unforeseen auto disaster and item B covers you in the event of an unforeseen medical disaster. Living and owning a car both involve costly risks, and what we call insurance is the creation of a financial risk-pool to spread the risk over a larger population.

    Just like auto insurance doesn't cover elective enhancements like installing a remote starter or backseat DVD player... health insurance doesn't cover electives like plastic surgery or LASIK. (Single-payer plans, like Medicare, don't either.) Both just cover the risk-based items.

    47 states insist that you must have liability insurance if you drive a car... which, in essence, translates into the notion that drivers have a 'fundamental right' to have their car restored if some other bozo hits them. There aren't that many states insisting on health insurance and saying that human beings have a 'fundamental right' to have their body restored if they fall down a flight a stairs and break their arm.

    So I'm just wondering why the insurance that is already mandated in most states doesn't have a public option... if public financing would be so much better than corporate profits.

    Kind regards,

  5. And let's take the parallel one step further from the philosophy of the "public option" into that of "single-payer"...

    What should my auto-liability premium be based upon? My likeliness to have an accident with another car, or my adjusted gross income? If I have 10 accidents a year and live in Washington, DC I am much more likely to have an accident than a driver with no accidents living in Sioux Falls (ibid). It seems like the one who is more likely to pull money out of the risk-pool should be the one who puts more money into it, yes? Or would you contend that the driver who is most able to pay for car accidents should be forced to put in enough money to cover thousands of other people's accidents?

    What's fair?

    Kind regards,

  6. David,

    Good points, all. What's fair to everyone? Good question. I don't claim to know.

    I think that health care is a fundamental right that should have nothing to do with insurance at all. People should contribute to the "risk pool" according to their ability to pay, and should benefit according to their need. Pure socialism, I admit, so let's use that word as Paul Wellstone would have (and actually did, in a written reply to a letter I wrote him long ago when I was a rock-ribbed Republican).

    That said, I do not wish to pay taxes to support other people's willful, self-destructive behaviors such as abusing drugs and alcohol, smoking, bungee jumping, swimming in the ocean, eating cheeseburgers, failing to work out for at least 30 minutes a day ...

    By golly, I've argued myself right into a trap, haven't I? Well, it ain't the first time.

    Someone help me out, please!

    Now I guess I'd better figure out which lawyer I should call the next time I get really, really sick.

    Wasn't it Jimmy Carter who said, "Sometimes life isn't fair!"? Doggone right.

  7. My quick take: I'm actually all for a public option on auto insurance. If the government is going to intrude on the market by mandating, the government might as well intrude on the market by offering a public option.

    On practical differences:
    --Auto insurance has a certain natural upper bound for costs: you can total your car. You can't really total your body.
    --Auto bills aren't bankrupting people at nearly the rate of medical bills.
    --The free market appears to be working in auto insurance. It's not working in health insurance.
    --I don't hear much about auto insurance companies denying coverage for pre-existing conditions or dropping customers when they get in an accident. Maybe I'm wrong about that...

  8. Hey Stan,

    The interchange with Wellstone sounds interesting... any chance you posted it online?

    I work in vision care employee benefits, which isn't technically insurance, but is always sold alongside health/dental plans... and so I talk about health care quite a bit just by going to work. My brother just got a medical doctorate (currently in his Psych residency) and had plenty of eyebrow raising stories of how hospitals work the system when he was doing his rotations... His wife is a pharmacist, my dad is an optometrist and so I feel that I pretty much have all sides of the story.

    My conclusion: Whatever health system you have can be abused.

    The current system is abused by doctors ordering unnecessary redundant checks and prescribing name-brand drugs rather than generics. (Unless, Michael said, the patient states he doesn't have prescription drug coverage, in which case the doctor will immediately prescribe the generic equivalent and say something like "this is almost as good as the one I would have prescribed.")

    A lady with a high deductible health plan passed a kidney stone... and afterwards felt no pain, yet the doctor recommended a CT scan "just to make sure" there wasn't anything left. There wasn't, and that cost her $1800.

    The dermatologist absolutely refuses to remove a mole if the patient insists on not spending the extra $200 to send it in for a biopsy. He told Mike that "it just isn't worth it" to only get $200 for the surgery and not the other $200 from the lab. But, of course, the answer given to the patient was that they will only do what best for her health and that they could be liable for malpractice if they don't do the lab.

    And there is a healthy concern about malpractice lawsuits. An optometrist that I work with had to pay for a woman's broken arm because she filed a suit stating that she fell and broke the arm because she was wearing new glasses the eye doctor gave her two weeks prior. (According to that reasoning, anyone who wears glasses can sue their OD if they get in a car accident.) The OD's insurance said it was better for the doc to settle according to her terms than damage his reputation with malpractice headlines in the local paper.

    So there's some anecdotal evidence of the current state of affairs...

    1) Malpractice reform, capping the amount patients can sue for, would drive malpractice insurance premiums down, but on the other hand, if the doctor was drinking on the job and, say, caused you to go blind in one eye, it only seems fair that you should be able to sue him for the balance of the federal debt.

    And there's no guarantee that doctors would stop ordering extra tests just because their malpractice exposure is limited. It's still good business for them (and, as they say, it makes sure that your health is taken care of to the best of their ability).

    2) Single-payer... the abuse here (at least it's abuse in my mind) is that citizens get the same health care coverage for different amounts of money. The kind of guy that Michael sees in the psych hospital has a drug problem, or worse, a drinking problem... no job, no degree, and is looking to score some oxy. He spends two weeks in the hospital at $1K+ a night and the rest of us just foot the bill?

    Just like with auto insurance, why should people buy their health coverage according to their ability to pay, rather than their likelihood to use it? The only way an 'ability to pay' model can succeed is when participation is forced. Just try to get people to sign up voluntarily for a plan that asks them up-front for their adjusted gross income.

    And, let the record show, that in my discussion of single-payer I did not use any arguments regarding quality of care. You'll have to ask Matt Havlik about his experience with military/veterans health care for those anecdotes.


  9. 3) Public option. This one depends entirely on whether or not H's plan will play fair or not. If the plan has to recruit participating hospitals and negotiate their discounts, then it's just another player and won't really change the game all that much.

    But, being the government, they can cheat (ala USPS) and do things like make it mandatory to accept their health plan at all hospitals and discount all claims sent in by 40% (that is, the plan only pays 60% of the amount charged on the claim).

    If they cheat, then the competing health plans won't survive. H's plan can mandate a larger discount than they can negotiate, and so their premiums aren't even in the same ballpark. Unless... H's premiums are based on income rather than standard underwriting. In that case, wealthy citizens will stick with private plans... and the risk pool for H's plan will be skewed... they'll have to pull funding from other taxes.

    In a way, a cheating plan could pretty much accomplish what I think is the best solution... mere government regulation of medical prices. Perhaps along with the public option price discount mandate would be a clause stating that the hospitals have to give private insurers the same discount.

    Anyway... I have work to do, so I'll just have to leave it here.

    Kind regards,

  10. cheat à la USPS? Excuse me, but can you show me evidence of any private vendor clamoring to provide daily pickup at every house in America for occasional envelopes at 44 cents a pop?

  11. Hi Cory,

    How about this?



    UPS is willing to pick up and sort bulk mailings (catalogs, envelopes, etc) and can get it in town quicker that USPS... but has to hand it off to the USPS for delivery as per the rules of the cheatin' system.

    Kind regards,

  12. David,

    Ach! That exchange with Paul Wellstone took place way back in the late 1980s when I lived in Minnesota and did all my writing on a "Brother" electric typewriter! I didn't even have a computer, much less Internet access.

    As I recall, I was upset about the cost of health insurance. Paul wrote back and said (verbatim, if memory serves), "The answer is socialized medicine ..." I thought he was nuts then. Now I would tend to agree with him.

    I'm concerned about the weaknesses that could be inherent in a true socialized medical system, such as long waits, limited or nonexistent appeals processes, and perhaps even denial of end-of-life care. But these are all hypotheticals. From among the countries that have socialized medicine, we ought to model our system on the one that produces the highest level of satisfaction and trust among the people. That shouldn't be too hard to figure out with a few good polls; I suspect Sweden or Denmark might be the best. Germany is also supposed to be pretty good.

    I'm also spooked at what could happen to the tax system here in the good old USA if such a system is adopted. With the multi-level taxes we have already (federal, state, county, and in some cases even city), the addition of a brand new value-added tax (VAT) to pay for health care could drive some people's total tax burdens to near 100 percent. And make no mistake: If we get a single-payer system, there will be immense pressure for a VAT, which could inflate prices of all goods and services by as much as 20 percent and make our Byzantine tax code even more complicated. Even the poorest of the poor would have to pay this tax, and it would strike them hardest in terms of the proportion of income it would represent.

    The evolving battle over this issue is interesting, indeed. It's as if two amoral monsters are engaged in a life-or-death struggle where they eat parts of each other and, somehow, only get bigger and stronger and meaner with each passing year. Meanwhile, my soulmate in Arizona talks about emigration ... maybe the ultimate solution for those who can do it! I have to agree that doing nothing at all is not an option; however, there do exist some options that would be even worse. We must avoid running hard aground in our desperation to avoid drifting out to sea ...

    I voted "Yes" on the public option.

  13. Stan, I wish I hadn't been such a closed-minded Republican when Wellstone was alive. I should have paid more attention to the man.

    [David: UPS wants bulk mail... but do they really want to do the bulk delivery to every house on every block? And do they want to add daily mail to their portfolio as well? I'm not versed on the topic, but I can imagine that if UPS took the bulk mail delivery, USPS couldn't sustain normal local delivery. Is there room for more than one player in this market?]

  14. Stan, I think your vision of amoral monsters is on point and probably helps understand the root of the problem... let me try to sketch it formally:

    1) Our sense of compassion insists that any unhealthiness among us should always be treated, and treated to the highest standard of care.

    2) Doctors, or perhaps I should say hospitals, recognize that because of (1) they can charge exorbitant prices and push lots of extra testing. This is facilitated by health insurance companies, because the 3rd party payer means that the hospital can raise prices and not directly offend the patients. The extra testing is also facilitated by the malpractice situation... they legally need to do 'everything possible' to defend themselves in case they are sued.

    3) On the patient side, (1) fosters a belief that somehow we have a right to the highest level of health, and this is not something we need to invest in, but something that we simply deserve to have freely. By and large, people don't feel like they should prepare for medical catastrophes... and many medical catastrophes aren't their fault to begin with (ie leukemia). With automobiles, when a catastrophe happens and it isn't your fault, the other driver is required to restore the situation. But when leukemia is at fault, it can't pay the bills.

    So whenever someone draws the short stick everybody feels like the person's health should be restored (1) but no one feels like they personally should have foot the bill. My brother outright recommended to me that if I was stuck in such a situation I should just default on my bills to the hospital. (That happens a lot.) Another option is to go the malpractice route and roll the dice with a jury.

    Either way, the hospital is ethically obligated to treat whoever comes in. (Well for serious diseases, anyway... I guess they aren't ethically obligated to remove my mole when I protest the biopsy charge.)

    4) So the result is that doctors have to treat the patients... they cannot turn away 'customers' that might not pay. But in turn the hospital can charge whatever it wants, order loads of peripheral tests, and prescribe the name-brand drugs. Patients aren't likely to turn down their doctors'
    recommendations, and even though the patient holds the final trump card ('just don't pay')... if the patient pays for just a fraction of everything that was recommended, the hospital profits something.

    For the most part, I don't think that the quality of socialized medicine is all that bad. I think Australia's model is the most appealing to me: public hospitals and private hospitals. If there is an issue in quality you can simply pay to go to the private hospital... and since the government sticks to its own facilities, if you're concerned about the government having control over your body (like pro-choicers) you can simply go to the other hospital.

    Kind regards,

  15. Hi Cory,

    I don't know to what extent UPS wants to do mail delivery... but either way, I don't see any reason to have a law decreeing that the USPS has a monopoly.

    Either (a) UPS can do a better job than USPS... in which case the law is hurting consumers, or (b) UPS can't do a better job in which case USPS would have a de facto monopoly rather than a de jure one.

    Apart from the bulk mailing, I could also see this happening... "UPS, I have a package that I need you to take to the college." When UPS arrives, "Oh and here is some mail for people at the college, too."

    They might not get into residential delivery, but perhaps business mail... Lots of businesses (Madison Vision Clinic, for one) get UPS deliveries every day.

    But again, what sense is there in a law that is at best maintaining the status quo and potentially harming consumers?

    Kind regards,

  16. "There is no way to justify our present public monopoly of the post office. It may be argued that the carrying of mail is a technical monopoly and that a government monopoly is the least of evils. Along these lines, one could perhaps justify a government post office, but not the present law, which makes it illegal for anybody else to carry the mail. If the delivery of mail is a technical monopoly, no one else will be able to succeed in competition with the government. If it is not, there is no reason why the government should be engaged in it. The only way to find out is to leave other people free to enter."

    —Milton Friedman, Friedman, Milton & Rose D. Capitalism and Freedom, University of Chicago Press, 1982, 29

  17. Again, I don't know the exact law, but it seems to me that if I really wanted to, I could go to Fed Ex, hand them a package containing a letter for you, and have them deliver it. The only difference is that they can't put it in your mailbox. And maybe that restriction is reasonable: if people are sending me checks and private documents, maybe I don't want just anyone to be able to come fish around in that box.

    But fine; if you and Milton Friedman will give me a public option on health care in return for a private option on mail, I'm all in.

  18. Hi Cory,

    I'm against vote-trading, but I'm not against the health-care public option, at least in principle.

    Ultimately it will come down to the details and how fairly this plan will play in the marketplace. What are your thoughts on the following?

    A) Should hospitals be required to participate with the public plan? (Otherwise, public plan members could just go to the V.A... right?)

    B) Should the public plan 'premiums' be determined based on a member's probable cost in using their health benefits or based on their adjusted gross income?

    C) If the public plan doesn't collect enough 'premiums' to cover their claims and operating expenses, should it be allowed to siphon money from other categories (NASA?) of the federal budget to make ends meet?

    Kind regards,

  19. Sorry to keep you waiting, David!

    A. Required to participate? If a patient has insurance, that insurance should work where that patient seeks care. Allowing hospitals to reject patients using Uncle Sam Insurance defeats the purpose of a public option to create universal affordable access.

    B. I understand some folks will cost more than others. But I hesitate to break someone just because he or she comes down with a disease or is hit by a bus. I'm incline toward the latter option you give (as, I think, is H.R. 3200), but I am open to a business argument that such a plan is utterly unworkable.

    C. The Brits set a budget and say that's that. If we can get money from other pots without destroying other programs, I'd consider it... but I don't have an easy blog answer for that one.


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