Thursday assorted links


1. Here is a piece by the same author, geared a little more for the general reader.

I'd say watch out for arguments that just talk about out of pocket for healthy people. Insurance in the modern age isn't about healthy people. It's about that sudden transition from healthy to tens, or even hundreds, of thousands in medical bills.

It's about the cancer scenario, not the broken arm.

Insurance is about protecting financial assets. Obamacare is geared towards those with little to no financial assets. It’s not a health insurance scheme, it’s a redistribution scheme.

As usual the ones who get screwed are those that have enough assets to lose and enough income to not get a handout.

I'm not sure if we are agreeing or not. Before Obamacare, when the government set no standard for "good coverage," people could buy "broken arm insurance" and think "I'm covered."

Perhaps hardcore free marketers still think this is the preferred scenario. If people want that level of insurance, they should be able to buy it.

But as "Sure" says below, that builds in a hidden liability. People will get cancer, and somebody will pay for it. If the hospital is sending out unanswered collections bills, they'll have to make it up somewhere else.

Does anyone need a policy that covers more than $100,000 if he does not have $100,000 in assets?

Think about that for a few minutes before you hit reply.

Boy, does that ignore everything "Sure" says below.

I mean, assuming you think people with less than $100,000 in assets should be allowed $101,000 in lifesaving medical care. And not just kicked to the curb.

All of this begs the question: Why is it mandatory? It should be a choice not a mandate. If you like your insurance you should be able to keep your insurance.

Are you saying everyone gets to keep their job providing health insurance if they like the insurance?

Mandatory because the uninsured know we will not let them die on the spot. Subsidized because some of us might like it that way.

Ironically you are more likely to die in a socialized health care country because they don't have enough doctors, staff and resources to see you for six months.

Everything that goes on in the US health-industrial complex is determined by federal government policy, everything. We already have socialized medicine in all but name.

This is kind of basic, but maybe it will help:

There is no universal healthcare. The U.S. government does not provide health benefits to citizens or visitors. Any time you get medical care, someone has to pay for it.

MITMedical, Healthcare in the United States

You didn’t take the time to reflect on why we call it insurance.

Then you switched from insurance to healthcare. Not the same thing.

Then you replied to yourself for some reason to make some point about healthcare, not insurance again.

People are not denied critical care due to lack of ability to pay. Insurance is to protect financial assets. Not to receive healthcare.

This is not how this works. It’s not how any of this works.

I know what you did there. You went from pretending you were a free marketer to relying on a huge market intervention and unfunded mandate:

The Emergency Medical Treatment and Labor Act (EMTALA) is a federal law that requires anyone coming to an emergency department to be stabilized and treated, regardless of their insurance status or ability to pay, but since its enactment in 1986 has remained an unfunded mandate.


He is being accurate and honest and taking the world as it is. Maybe you live in some fantasy land where the EMTALA might be repealed but your fantasy is irrelevant to the rest of us who care about the real world.

However, a lot is elided by the term "critical care"

We should also note that the EMTALA creates all kinds of perverse incentives. People avoid lower cost preventive care because it would be out of pocket. Some people avoid insurance and personal responsibility because they think the EMTALA will save them.

Now you're an expert on the healthcare industry. That's nice.

Name something that is wrong with that "perverse incentives" argument, ankle biter.

I'll help you:

The health plans have a perverse incentive to avoid fair contracting because they know emergency departments are beholden to EMTALA and will take care of any patient, regardless of their ability to pay. Knowing that patients will be cared for regardless, insurance companies have little incentive to offer fair reimbursement rates.

More here.

Nothing, but he's right about you playing pretend: nobody who knew actually knew what they were talking about would call EMTALA an "unfunded mandate." The Medicaid DSH program, for example, covers somewhere between some and all of these costs for hospitals every year (it varies a lot from state to state and by hospital type.), not to mention state level programs like Trauma funds, Charity Care programs, Uncompensated Care Cost Pools, etc.

"One estimate put the cost of uncompensated care for 2004 at $41 billion, of which $34.6 billion was funded through a patchwork of government programs. Over half of all government reimbursement for uncompensated care comes from the federal government; most of that is provided through Medicare and Medicaid. These federal funds are a primary source of support for health care providers that serve the uninsured."

Did you not follow the link?

That was the American College of Emergency Physicians who called it an "unfunded mandate."

I was quoting them.

You parroted them because you don't actually know what you're talking about, so you can't tell who's talking nonsense and who isn't. There are literally tens of billions of federal and state dollars budgeted and spent every year to cover the cost of care for the uninsured. It just doesn't usually cover 100% of the cost. If this means "unfunded," then I have a beach house in Iowa I can sell you.

lol, that was a good time to call it a day. Before you dug yourself deeper.

Yeah, good one. I only work for a state Medicaid agency. Clearly, you know more than me.

It’s 2019. I have access to the internet and respect free inquiry and truth.

I’m the expert.

I never said I was an expert, Jeff. I said "unfunded mandate."

You said: "nobody who knew actually knew what they were talking about would call EMTALA an 'unfunded mandate.'"

I said "That was the American College of Emergency Physicians"

You said "You're still wrong!!!!"

(and thanks other 'anonymous' but I think I've got it)

Bonus link, from the US National Library of Medicine National Institutes of Health:

EMTALA was passed in 1986 without any funding whatsoever, so there is no “insurance” component to the law that our congressmen refer to as “coverage.” EMTALA is considered by many to be an “unfunded mandate.”

Why the EMTALA Mandate for Emergency Care Does not Equal Healthcare “Coverage”

You said "You're still wrong!!!!"

And I was correct. Perhaps EMTALA was passed with no funding attached in 1986, but almost 35 years later, there are a bevy of programs at both the state and federal level aimed at offsetting the costs created by it. Anyone still repeating that canard in 2019 is just someone who wants more money or, in your case, an idiot repeating slogans he thinks will make him sound smart.

You might have led with that. But it's an incomplete argument in its own right.

The EMTALA is an unfunded mandate. There are "a bevy of programs" to navigate, but no guarantee that any particular patient will.

That's the difference, as the MITMedical page noted.

There is no universal healthcare. The U.S. government does not provide health benefits to citizens or visitors. Any time you get medical care, someone has to pay for it.

You might find a program, or costs might be passed to other patients, etc.

Bonus link, from the AMA Journal of Ethics:


The controversy surrounding EMTALA is easy to appreciate. It is an unfunded mandate, and complying with the act has placed a severe financial burden on hospitals.

Is EMTALA That Bad?

This part of the thread is now a one way pissing match about a mandate being 80% funded via third party and what the legal definition of federally unfunded mandate is.

Feel free to scroll past the lunatic.

Define "third party." Does it include other, richer or covered patients, covering the unfunded mandate?

No, and you either know that and are trolling or you are woefully underprepared for this discussion.

Scroll past the lunatic

And I quote:

Providers incur billions in the cost of uncompensated care for the uninsured, not all of which is offset by funding to defray these costs.

More here. Published: Jan 25, 2019

Now anonymous is arguing that 80% is not most.

Give it up dude.

Oh, sorry. Didn't see that I missed or mangled the link on that one.

EMTALA Fact Sheet

Defending the indefensible is a full time job.

Ideaology is stubbornly resistant to facts..

EdR: She seems to be one of the <20%, the illogical, irrational (brainwashed by 50 years of leftist control of "education") horde that thinks Obamacare was a net positive.

She deals in gross counterfactuals, non sequiturs and slogans, then demands that you disbelieve what you know or you have no heart!

Fun and games: Ask her what did the ruling class get right in the past 20 years.

When did I claim to be a “free marketer”? When did I claim any allegiance to any ideology whatsoever?

You’re shifting goalposts so fast I’m not sure you even have a point at all other than to play the part of a buffoon.

People are not denied healthcare based on inability to pay, they receive bills. Insurance is about protecting financial assets. Those with no assets have nothing to protect. There’s no point in buying a financial asset protection product if you have no assets!

Nothing I’ve said is even remotely controversial.

So you aren't a free marketer, just a little thief?

You have an almost unfathomable ability to be both wrong about anything you stick your nose into, and impervious to evidence.

Buddy, you just spent the morning saying people don't need insurance because they can just show up, and someone else (hospitals, the government, rich patients) will end up paying for it.

I spent the morning discussing what insurance is, you jumping from goalpost to goalpost notwithstanding.

Insurance is to protect financial assets. Instead of addressing this point at all you’ve engaged in ad hominem attacks and posting irrelevant links.

Me, in my first post:

"It's about that sudden transition from healthy to tens, or even hundreds, of thousands in medical bills."

So now you suddenly understand what that actually means.

Yes, it’s about protecting financial assets from large bills. That’s why we call it insurance. If you have no assets, there’s nothing to protect except your credit score.

I then made a broader point about insurance and you jumped around posting irrelevant crap for a few hours.

"Yes, it’s about protecting financial assets from large bills. That’s why we call it insurance. If you have no assets, there’s nothing to protect except your credit score."

What about your dignity? Your ethical obligation to pay your debts?

If your point is that people with few assets and little income should purchase individual health insurance out of a moral obligation to make health insurance cheaper for wealthy Americans....

Weird flex but okay. I disagree.

The poor and sick are not the only free riders. The middle class and so-far-healthy can be free riders as well.

Your definition of middle class is zero assets?

Try again

He's an expert.

You’re physically capable of reading but there is little to no comprehension going on.

If someone does not have insurance and incurs medical bills one of two things happens.

The person pays the bill using liquid assets or credit.

The person has insufficient assets and credit and his assets are seized in bankruptcy.

They’re not free riders. Their assets will be seized and they will enter bankruptcy.

You are arguing that I should go after your assets by being poor, sick, and uninsured?

If you have assets, like income, you need no protection provided by mandating I have insurance so you will not end up on the hook for my medical bills?

"We should also note that the EMTALA creates all kinds of perverse incentives."

EMTALA was signed into law by Reagan because conservatives reject creative destruction, aka, euthanasia.

Obamacare fixed the "perverse incentive" by mandating everyone be covered by insurance which pays all reasonable costs, with an emphasis on preventive care.

However, conservatives argued covering preventive care creates a perverse incentive to prevent injury or illness so patients need to pay out of pocket a large amount until they have delayed care until the cost ensures a really big bill which insurers pay a large part of.

Of course, the GOP has called for eliminating Obamacare, but never tried to repeal EMTALA signed by Reagan because that would mean the GOP promoting euthanasia of costly people no matter their age. Old? Euthanasia. Mentally Ill? Euthanasia. Disabled? Euthanasia. Poor? Euthanasia. Drug addict? Euthanasia. Abused child? Euthanasia.

On health care, conservatives are forced by Obamacare, based on GOP policy starting circa 1990, signed into law by GOP Gov Romney, to advocate free lunch health care policy.

Free lunch health care policy is arguing that never paying for medical care means health care is free and abundant, because free market health care is free. That's why it's called free market: the cost if free.

Until you say that the solution is euthanasia, not requiring everyone to pay medical bills for everyone, you are a free luncher. Only maybe 1% of health care is paid for by the patient, with the 99% paid for by redistribution, including across time and space. From infant to 25?, the patient never pays their medical bills. Half of all births and early infant care is paid for by government under Medicaid. In States without a history of union labor getting employer benefits, half of all child have their medical care paid for by Medicaid.

Most of those children then pay taxes on earnings to fund Medicaid, but a person in their 30s, 50s, is not an infant to teenager, so that's wealth redistribution across time, probably space as those paying the most for other people have moved to higher living cost areas.

Historically, health care costs were controlled by death. Yet conservatives opposed to paying health care costs do not demand death be used to limit costs.

Free lunch policies. Benefits without costs.

Easily my favorite Mulp post in a long time.

"It’s not a health insurance scheme, it’s a redistribution scheme."

If a sick person has no assets nor Obamacare, they are euthanized and that cost paid for by harvesting organs???

Going into debt and then declaring bankruptcy or dying is wealth redistribution under the US Constitution by Federal technocrat, aka Federal bankruptcy judge, or probate judge.

Thus wealth redistribution is written into the Constitution, giving the money of those who lent it to people with no assets permanently.

There is a relatively rarely mentioned opt-out path for the (healthy) middle class in "short-term" insurance. The trump administration has quietly made this a much more viable option by removing the individual mandate and relaxing enrollment terms and caps. I am curious why it's so under the radar given how supposedly burdensome obamacare premiums are for so many.

That's interesting. I didn't know that

You don't have to be poor to get an ACA subsidy, you only have to have very little taxable income. I did just discover that I will have to do a Roth conversion next year in order to keep our taxable income above 138% of the federal poverty level so that we're not forced into Medicaid. I only need two more years of this tax boondoggle until I'm 65 and eligible for Medicare. Early retirement has been great!

Yep. Obamacare is the wealthy early-retiree's best friend. Take just the right amount of 401K withdrawals annually to qualify for the max subsidy and then use post-tax savings to fund the rest of your lifestyle.

Interestingly, my financial projections are that my full ACA has a present value about equal to the value of the larger Roth conversions that I am giving up. But the ACA subsidy is real money now, while the value of the Roth conversion is highly dependent on a multitude of assumptions.

Law of Unintended Consequences. This is not the handout the proponents of Obamacare had in mind, but it is very widely used. Most government programs wind up taxing the middle class to support the rich and the poor, including this one.

What if Yoda were 6 feet tall and he smoked weed?

#3 My aunt - a senior nurse and nurse practitioner of 34 years - told me a horror story of how senior or elderly care, hospice, or special needs facilities are responsible for almost 1/4 of the illicit pharmaceutical grade drugs on the street in the USA today. There is a very good chance that your elderly or special needs family members - even at upscale facilities - are not receiving their medications. Now add fight clubs...holy crap.

#6 I really don't feel mainland China would have been all that different today under KMT rule with two exceptions, A) Capitalism 'with Chinese characteristics' would have been instituted earlier in the 50s or 60s (it would've taken than long for KMT to truly defeat the communists and the warlords), not the 80s and B) you would have people talking about Chinese 'capitalism with communist' characteristics instead of vice versa of Chinese 'communism with capitalistic' character. Oh and yes, the corruption would be very much the same.

I also don't feel that China would've, by default, remained in the US sphere of influence during the tensions of the cold war.

I don't think it would be much different either.

I also don't the American uneasiness about it would be much different either, even if it were capitalist and democratic and in the US sphere. Arguably, the uneasiness might have been even greater if capitalism made Chinese economic growth even higher. Think Japan in the '80s, but 10x bigger. Economic growth threatens US relative power and status, so equivalent growth or even greater growth from capitalism would result in a similar situation as we have today.

I am not so sure.

After all, the KMT is not going to back up the DPRK when it wants to unify Korea (i.e. no Korean War, or complete collapse and unification of Korea under the South/UN forces). That would have lifted millions out of poverty in North Korea and likely have given China more trading partners earlier in its development. Likewise, not throwing away so many lives and material would have been a boon to the Chinese economy.

Likewise, a large part of the Rise of China has been a sense that China should stand outside the norms for intellectual property and market access. With the KMT in power, even with nukes, they would not be seen as needing so much enticement to stay in the world economy. Quite likely, China would be much more akin to India in terms of IP theft and forced technology transfers. Maybe that makes China richer or maybe it makes China poorer, but it certainly would lessen a lot of the blowback.

Arguably the biggest effect of a KMT China would be on the US. Korea would never have happened or have been a resounding US success. Vietnam would likely again, have never happened, or been more akin to some smaller African intervention where the communist bloc could not as easily supply the north.

Oh and whatever atrocities the KMT thought up, it is likely that they would have had an order of magnitude fewer dead bodies than the Great Leap Forward and Cultural Revolution.


That last sentence is not trivial!

I see. The Chinese warlords were great, then.

On a scale of Gandhi to Hitler, they ranked something like an Idi Amin.

Chiang Kai'shek also had a lot of blood on his hands. Maybe double that of the warlords.

And if you add them together you still end up with a fraction of the dead from when the CCP decimated Chinese agricultural and caused the largest famine in human history.

North Korea and Vietnam were backed by the Soviets. A non communist China would mean that the Soviets would feel greater pressure to intervene more directly in the Korean and Vietnamese conflicts.

A capitalist KMT China would have greater economic growth, and that is precisely my point. Its economic growth alone would arouse US wariness and antipathy, much as Japan did in the '80s. Japan is about a third the population of the US.

Oh absolutely it would arouse that to some degree, though it would also be seen as an ally in the Cold War (much as Japan was), democratic or not.

I think it's for clever cynics to think that the US unease with rising China is purely attributable to China's rise to challenge the US as the world's superpower, and not to its authoritarian and repressive politics and its one party Marxist state.

A China that rose to Western European income standards and moved to representative democracy, and similar rights, would most likely have been accepted by the US, just as Great Britain accepted the rise of the United States, though with slightly different dynamics, with the US remaining probably still at the leading edge of technology.

Systems and ideology do matter, and the rise of Nazi Germany, within Europe, for example was not treated the same thing as the rise of postwar Germany, nor should it have been.

Though I imagine the US in such a parallel world probably would work to coordinate with Europe and Latin America to a greater degree than in OTL.

Postwar Germany has US military bases on it. It does not have much of a military and foreign policy independent of the US.

China could have all the Pride parades, transgender rights, feminism in the world, but as long as it had an independent military and foreign policy, with the economic growth to back it up, it would arouse hostility and wariness from the US.

India would be the obvious counter example. India was closer to the Soviets than the US, but post cold war there's minimal friction.

The American troop force in Germany today is, were it so deployed, just about large enough to securely occupy a recalcitrant territory with the area and population of the Saarland.

Not sure what the odd references are to gender+sexuality politics, but no way. Systems do matter. The US could have not one inch of soil for bases in Europe, not even have the EU in NATO* and if they are mostly liberal democracies, you're not gonna see a Cold War. Again the rise of the US for Britain, is instructive.

Conflict, at least involving liberal democracies, is ideological-systemic conflict, not driven by ideology free inter-state power politics. There are imaginable scenarios I can see when liberal democracies could be locked into struggles with each other, but those would be pretty dark, resource scarce, Malthusian regimes.

Think of how pro-global growth the US elite class is, and how enthusiastically they've received China's growth *despite* being married to Marxist one party authoritarian rule. How much more so in a world where it was not.

*of course, they would do in any sane world, but let us just imagine for a second they were not.

The US is a large continental state and regional hegemon. If there was potentially anything comparable in Europe, like there was with Germany in the last century, there would be tension and conflict, even if the European power were a liberal democracy.

The example of the US and UK aren't instructive, since the UK was faced with the nearer enemy of a rising Germany.

The US elite class is facing declining relative power and status, which is something Trump articulated during his campaign and during his administration, and this drives the change in stance towards China.

Yes and such direct intervention might well look like their direct intervention in Greece. It is vastly more difficult to intervene in such conflicts when you have to airlift everything in. At the end of the day the US controlled the seas and the Soviets were unwilling to pay any price for their client states.

Further, the Soviets intervening more directly might even more quickly have bankrupted the Soviets. Airlifting supplies is expensive and trying to prop up North Korea or Vietnam was going really hammer the industrial investment the USSR was making at the time.

Absent some really uncharacteristic willingness to use nukes for North Korea, but not Greek Communists, the USSR is going to have a much harder time making the Asian conflicts costly to the US.

To your point, one thing that really stands out through Chinese history is their lack of ability to form alliances, at least for very long and in any other way other than unsentimental pragmatism.

There's a myopia that goes along with China or Chinese having any kind of national pride. They've either got to be number one, independent, self-sufficient (and taking tribute from their neighbors...), or fighting with their neighbors and each other.

Chinese dynastic history is replete with these examples, and several have made arguments that the CCP is just another of these dynasties (which fyi tend to last between 200-300 years long before the pyramid inverts....and very catastrophically at that).

So yeah, I think any cooperation between the USA and a KMT mainland china would have followed the same unsentimental pragmatic, quid pro quo formula until one day KMT China would've decided it just wasn't working anymore.

I don't see why that wouldn't describe the US and most other large states as well.

My point was that there's nothing China, whether communist, capitalist, or whatever, could do to appease US wariness.
Significant economic growth threatens US relative power and status.

I think that the long-standing (as long as the US exists) alliance between France and the US goes beyond "unsentimental pragmatism", to use EverExtruder's words. After the conflicts of the independence war and the Napoleonic wars, you can add UK to this long-standing alliance with the US, and after WWII, all Western Europe. So I don't know if EverExtruder's description applies to China, but I would agree with him that he does not apply to America.

As to how America would react if it was caught economically by a capitalist democratic country instead of a dictatorial, nominally-communist one, we lack direct evidence, but we can offer an analogy.
The UK, dominant power of the world in the 19th century, were later caught up and surpassed many times by the US. How did they react?
they were not happy, for sure, but finally not that unhappy, and there were never any serious thought of war between those two countries at the time they were rivaling for being number one. It surely helped that they have similar values.

It's the same old saw from these folks. They want to persuade their audience that the US is just threatened by losing its status, with legitimate concerns about the Chinese system dismissed as jealousy* and that there's nothing that China could do or be to possibly mollify this, and that anyone with concerns are just persecuting the Chinese for getting richer and that such persons should be shushed before they make business more difficult.

*To the point of self-parodic claims that "They're basically libertarian and less Communist than the USA! See their low taxes!". Which low taxes don't exist anyway...

You're confused. The foreign policy realists who reduce the conflict to relative power and status tend to be hawks who don't prioritize international commerce.

Nope. Some are, but many are pro-business political cynics who claim to be apolitical.

Or Marxist cynics in the sane vein. In either case the charge is "It's not really about their system; that's an excuse; it's about money, power and relative status".

I disagree regarding France and the UK.

The US, as an extra Continental power, inherited the UK's basic strategy of opposing any potential regional hegemon on the Continent. From the Franco-Prussian War in 1870 until 1945, that potential hegemon and thus common enemy was Germany.

Especially since the turning point where the US surpassed the UK was World War I, in which the US was needed for the UK to secure victory.

Nothing aside from decentralization. A more EU-style China, or a formally broken-up one, is much less threatening even if its aggregate economic size is larger than that of the US. And personally I don't think it's a guarantee that the KMT would have been able to manage the whole of China as centrally as the CCP has, so that decentralization is a real possibility under the KMT hypothetical case.

Well, Zhōng guó is the middle kingdom after all. The people are mostly Han, so maybe everyone else is a foreign devil.

1. So the ACA continues to falter and probably nothing will be done about it.
6. The KMT vs. CCP argument really is ridiculous. Maybe try comparing Taiwan to the mainland. Or even Hong Kong and Macau to some of the coastal cities.

Correct. I wonder what the author receives as a reward for such a blatant propaganda paper?

"Maybe try comparing Taiwan to the mainland. "

That wouldn't have yielded the correct answer. It was an ideological paper that will be referenced for years. When you build up enough such papers they take on their own life. It becomes a shell game of a further derivative papers that aren't nearly as outlandish but use this paper as a source. And it takes more work to refute such items.

When I clicked on 3, about the filmed, fighting dementia patients, I was half expecting a link to a recent televised DNC debate on CNN.

1. "On the Republican side, so far there has been no plan."

1. Of course it works out this way. Obamacare was predicated upon a silly notion that somehow there was a a large pile of money sitting around in the healthcare economy that was there to be tapped to bend down the cost curve.

Somehow this mythic pile of money managed to elude all 50 state governments. It also managed to elude all the Fortune 500 companies that could self insure. It even managed to elude the large health networks for their own in-house medical plans.

So all those cost projections are gone. We do, however, have a bunch more poor people who are getting essentially free healthcare. Money has to come from somewhere.

You can try to take it from the hospitals ... but that means pissing off doctors and nurses which is a politically toxic option for most congressional districts (maybe there is a district where the local rep is more popular than the nurses who treated grandma or the surgeon who saved gramps ... but I doubt it).

You can try take it from the insurance companies ... of course they have small armies of lawyers and accountants. Somehow I think they outgun the regulators by an order of magnitude. Worse, it appears that the Dems made a political decision to simply buy them off to avoid the blowback.

Your could take it from the wealthy with good health insurance ... if you wanted to commit political suicide. Warren cannot even straight forwardly say that she is going to increase middle class taxes by some amount roughly inline with premiums, deductibles, and co-pays. The number of democratic constituencies who dislike this option was extensive and killed the Cadillac tax.

Or you could take it from the not-quite-poor with some contribution from the federal debt.

At the end of the day, people consume healthcare and not insurance. Unless you dump in more money, somebody is always left holding the bag.

Belief that significant savings exist merely in how to pay for healthcare is a fantastical notion that belies every real world experience out there. At best the gains are small and a fraction of the cost of expanded healthcare consumption. Pay more or stiff someone. Those are the choices.

Have you repealed and replaced Obamacare already?

Stated Republican beliefs have also been fairly silly regarding healthcare. Again if there were magic to be had from health savings accounts (something I favor as having the most sensible outcomes) or whatever it would have been done by one of the 50 states. Or one of the Fortune 500. Or Kaiser. Or Cleveland Clinic. Or MD Anderson.

Health care is expensive because we do very difficult things. Nobody in politics is willing to say they expect to pay more money in both real and relative terms as far as the eye can see. Yet that is what every policy experience the world over has shown. There are no long term sustainable cost controls, even when you let the NICE decide to let people die so they can not spend money of proven effective treatments. Every policy, everywhere has seen a reversion to mean with medical cost increases growing in the long haul.

The fact that Republicans are also unwilling to be candid about these data changes nothing about the fantasies upon which Obamacare was sold.

Any healthcare reform is going to achieve virtually no decrease in resource consumption. Any healthcare reform is going to do little to keep the healthcare cost curve down. Any healthcare reform that "expands access" or any other boilerplate that means "more people consume more healthcare" is going to have a real cost that somebody pays.

My prediction, which is standing up pretty well, is that the payers will be those who are least politically powerful: future generations who will pay more debt service and the not-poor-enough-to-be-photogenic are the current losers. Who do propose instead?

Well, the fantasy was that the mandate would work, and provide the buckets of money. I might classify that as naive rather than cruel.

It turns out that neither party, Republican or Democrat, went down and 100% signed up for medical insurance. Free riders remained.

There is a group of Americans who want younger and less wealthy Americans with little to assets to pay the medical bills of the older and wealthier group.

Shockingly, some balked.

I have yet to find the young conservative who objects to paying medical bills for old people actually killing themselves at age 30.

Every 30 year old will pay the medical bills of a 50 year old in 20 years, a 60 year old in 30 years, unless the 30 year old immediately commits suicide.

Every old person was a young person, so the young always pay the costs of living to be old.

I think it is time for fullscale nationalization and put the full power of the American government behind the little guy. We can send a man to the Moon and we certainly can make sure no one is bankrupted by greedy medical businesses.

All you need to do is halve the salaries in the Medical care system & halve the spending on R&D. Make the salaries comparable to what Canadian health care workers are paid. Problem solved.


Easy peasy, right?

Tautologically, the only way to spend less overall money on provision of healthcare is for someone to make less income: doctors, insurers, drug makers, hospitals, nurses...someone makes less. Who's it gonna be?

Technically, you could do it through boosting Medical provider productivity (ie halve the staff). So no, it's not tautological.

Halve the staff = someone makes less (the fired staff)

You can change the standard of care.

Euthanasia is creative destruction, the free marketers favor method of cost cutting.

Of course, euthanasia is post birth abortion, which is politically opposed by conservatives objecting loudest to Obamacare.

It's ironic that Red America opposes government health care and abortion, which means increasing the spending on government health care, because it's not the wealthy who never rely in government health care seeking abortions in large numbers.

Half of all births and early natal and child health care is government paid.

Fewer abortions and less birth control means more government health care spending.

So $3.5 trillion in additional taxes a year.

You really think the average household has $10,000 in additional income a year to pay the IRS? Instead of a few thousand going bankrupt from medical bills, half the middle class will lose their homes due to tax liens.

We can slash corporate welfare and close tax loopholes. We can use the government's size to get better deals. We can nationalize patents if Bug Pharma doesn't play ball. We are suffering from learned helplessness. There is a plenty of good options. Most democracies have nationalized healthcare with little to no side effects. Nationalized healthcare is little didferent from public utilities. We need the political will to act.

The number of western countries with nationalized healthcare is one.

I’ll let you guess which one.

The number of wealthy democracies without universal healthcare is one. I will let you guess which one.

It is a time for action.

The whiplash!

You went from nationalizing 1/5 of the economy to universal healthcare. Okay, doctors already have to treat you if you show up at the hospital.

Case closed then?

I am talking about universal healthcare.

“I think it is time for fullscale nationalization”

You’re either an idiot or Thiago is being slightly more clever in his trolling.

I believe in universal healthcare by all means necessary. If Big Pharma doesn't play ball, nationalize. If necessary, impose price controls on drugs, procedures and insurance. We need to be ready to treat giving Americans access to healthcare as the moral equivalent of war and bring to that mission the same sheer determination that put a man on the Moon and thousands of them on Omaha Beach.

Oh please.

If only it were as easy as putting a man on the moon or Omaha Beach. I routinely work with technology that was more expensive to develop than the Saturn V (which is not surprising given that my stuff has had decades more of steady investment). The man-hours that went into you surviving a STEMI are greater than ANYTHING it took to put a man on the moon. I mean seriously a single clinical trial represents a few weeks of 1960s NASA manpower budget; I burn through things that had at least 50 of those and that is before we get you to the cath lab.

The entire Apollo program was only 288 billion in 2018 dollars.

We have already burnt through that much on just Medicaid this year and will do it again by the end of the year.

Omaha Beach put 50,000 men ashore with a substantial amount of armaments. Yet even if we dectuple the manpower and say it took a full year to get things ready ... that is the same man-hours that nurses put in around 3 months.

The first rule of health care is that it always is more expensive than you can imagine it should be.

But maybe you are willing to pay an order of magnitude more than you just suggested. Okay, what does nationalization have to do with it? If there was a cheap option for providing first class healthcare somebody would have long ago set the whole shebang up in the Bahamas (or any other Caribbean statelet).

Again, if this were feasible somebody would have set up a racket to make bank.

In the richest country in the history of Mankind, we must fill the pockets of greedy explorers, bankrupt the Middle Class and turn down poor people in need of mental trearment because no Caribbean statelet has a system you like. Meanwhile, every single moderately prosperous democracy has universal healthcare. Have you no sense of decency left?

I am not sure what your goals are. Everyone gets critical care in this country. Everyone can have healthcare after they spend down their assets. If you are poor enough, I can treat you first and have my social worker sign you up for Medicaid. Sometimes we might even get paid through those channels.

If you are not poor enough, then yes you may need to liquidate retirement accounts, sell property, or similar things.

If the goal is substantially expand healthcare, then it will be expensive and you will have to pay. You could enslave all the doctors and that buys you a couple of years. You could cut nursing pay in half and maybe get a decade ... but good luck filling the slots.

If these sorts of cuts were feasible, somebody would import medical personnel to some Caribbean statelet, set up a massive hospital, and siphon off huge numbers of basic procedures (e.g. joint replacements). They haven't, so I am guessing it has something to do with the reason that places like Montana have to pay almost $100K per year more to get a doctor to work there.

Speaking as someone who has worked with docs from most of the prosperous democracy, count me out. There is not a single pathology that I have ever encountered where I would prefer to be treated in another country. Their mortality rates for the most medically intensive conditions are terrible. Were not for the mother of all Simpson's Paradoxes (i.e. Americans are terribly unhealthy regardless of healthcare) this would be trivial to show.

Thomas is playing you, doc.

Medical tourism for basics like joint replacement, dentistry, etc. is very definitely a thing and growing substantially. Insurers will fly you to Mexico/Thailand/somewhere similar and pay for your entire trip and still save a ton of money.

Look for this to be a bigger part of the process going forward.

That's a view held by 13% of the American public. So close to a fringe position.

Serious question, why do we have bankruptcy if not to protect people after having unfortunate luck like medical diagnoses?

I mean I get cancer isn't something you choose, but the vast majority of medical conditions that generate large bills have a significant "lifestyle" component. Is it really fair to demand that a guy who smoked, drank a 12 pack of beer a night, and never exercised should have his finances protected against the "bad luck" of his STEMI while a truck driver can lose his whole livelihood to an ice storm? Or a tree farmer losing his entire retirement to a lightening strike during a drought? Or a fisherman whose bought is caught in a hurricane?

There are a lot of ways that you can be bankrupted that are under far less of your personal control than health. What makes health special?

And I deal every day with people who are the unlucky ones, yet I have never seen anyone who went bankrupt from healthcare who was not already tapped out on credit and other fallback mechanisms. Likewise, when I have read through Chapter 11 paperwork, sure the $5,000 ED made you go bust ... but the car payments, credit card debt, and expensive electronics and all the rest put you precariously close.

Virtually no one goes bankrupt from $100K in new bills. Our average chapter 11 patient had something like under $5K.

So again, why is medical debt so unique? Why not have the government insure our cars, homes, and businesses?

". Again if there were magic to be had from health savings accounts "

They aren't magic and they would have to be broadly deployed for a couple of decades to work. But they would work. It's just a way to make people price conscious with respect to the costs of medical care.

I suspect they would work better if we were to enact clear pricing laws, which required health care providers to provide full pricing up front in easily read number.

Medical care is insanely expensive because we've shielded the consumer from the true cost since WW2. Without a clear price signal, the prices have gone up faster than inflation. Re-introduce a price signal.

In my case, my company opted for an HSA. Since I was male and my wife was on her companies plan (a state worker), it made little difference. I spent hardly anything just because I was young and male and my wife had much higher expenses, but paid hardly anything out of pocket.
We had kids, she left the work force and we now have a family plan. It was a drastic shock for her, when she went in for something fairly trivial and instead of paying a $20 co-pay, they billed us for $300+.

She quickly decided to prioritize. When our twins were first born she went back to work for a few years, still on her own company plan. For that period when the twins were sick, the pediatrician saw both of them. It was still one trivial co-pay to us. However, when we went the family HSA, my wife had the pediatrician examine the sickest baby (not both). (Amusingly enough both were always in the room, and it still took about the same amount of Doctor time 10-5 minutes). It was half the cost. Say, $150 instead of $300.

You make many good points. BTW, many people do not qualify for HSAs for various reasons. I wonder if it is politically feasible to instead just make individual's healthcare expenditures tax deductible, or something like 80% tax deductible? One could make such an arrangement revenue neutral (i.e., to the Federal Gov't) by also reducing the current deduction from employer sponsored plans from the current 100% to about 80%, or whatever the break-even point is. Just food for thought....not sure that this would fly politically

> Obamacare was predicated upon a silly notion that somehow there was a a large pile of money sitting around

This is an absurd caricature. I don't like Obamacare but I sure don't believe this nonsense.

If we change it to “was gamed to sell to the CBO and the public” does that fix it for you

+1, yes that was clearly true, the delay implementation which pushed substantial costs past the 10 year mark was clearly intentional.

However, to be fair, Obamacare specifically added substantial taxes and mostly covered it's own costs (as long as the mandate was enforced).

Obamacare's biggest faults were the deliberate lies told to sell it to the public & the reliance on a strictly enforced but unpopular mandate. It was inevitable that the mandate would be relaxed, and that was always going to lead to a downward spiral. So far, it hasn't been a spiral of death, but then again, it might become one, unless the mandate is re-introduced.

"I will sign a universal health care bill into law by the end of my first term as president that will cover every American and cut the cost of a typical family's premium by up to $2,500 a year."

"I have a healthcare plan that would save the average American family $2500 on their premiums."

There are 120 million households in the US. Let's be generous and say that there are half as many "families". Okay, so somehow there was $150 billion dollars that could easily be extracted from healthcare.

Great, which state managed to make a pilot demonstration work. How about New York? They did community rating and watched premiums skyrocket. Nor did we see any significant reduction in premiums with Romneycare. But somehow getting the feds involved, that was going to somehow move money out of the providers and back into the community.

I am shocked, shocked that Obamacare never managed a single year of premium reductions. I am shocked, utterly shocked that in years with or without mandates, the whole complex is still a giant money sink.

Whenever anyone says they can reduce the price of healthcare, they are saying that they can find money in a system where counting costs is its own multi-billion dollar industry that have been overlooked before.

Maybe, just maybe you might get really lucky and get a one-off bonus. Maybe you will get crazy lucky and bring down the curve by sometime fraction of a percent for many years running. But the world over, nobody's healthcare costs goes down by any significant amount. It is all just rejiggering who gets left holding the bag.

#4. The Club for Growth thought Trump would be bad for growth, and now they realize they were wrong. Bloomberg hates Trump, so this post is not surprising.

#1: manipulating a large and complicated market to achieve a desired outcome, in this case where there are stable, deep, health insurance risk pools with broad coverage, low monthly premiums AND low deductibles, and oh yeah, low insurance industry profits, too, was a Sisyphean task from the start. Good summary, though. I read that guy's blog fairly regularly back when Obamacare was still being debated, but I'd long ago forgotten it existed. Glad to know he's still at it.

The situation is not clear yet. The coming hours and days will be decisive.

Saez and Zucman should be ashamed of themselves. But no, they are feted in all the tony salons and their income will grow from their mendacity. What a world we live in that scholarly failure by professors like them and Nancy McLean allow fraud to prosper. Cantankerous and simple minded though economists were, I thought they were immune to this kind of nonsense. Perhaps they once were, but not today.

With all due respect to Mr. Laszweski, I think he omits some important points regarding this situation:

1. Medicaid expansion was always a key element of the ACA. I recall that when I first saw a draft of the ACA legislation, my thinking is that the most durable and substantial element of the ACA was the Medicaid expansion, and that the other elements were less durable. This is notwithstanding that the initial political coverage of the ACA focused more on the individual market (e.g., the individual mandate, ect.). The durability of the individual market of the ACA was always a key question, as is the case for any insurance market. Many insurance markets are not inherently “stable.”

2. I couldn’t find where Mr. Laszweski adjusted his individual market enrollment numbers for those persons who have migrated from the individual market to Medicaid rolls. This could explain a significant portion of the drop in individual market enrollment. But without the data, I can’t tell how much.

3. I think it is worth emphasizing the difference between economic/fiscal stability and political stability because these 2 are often in tension. For example, the individual market might be more popular among beneficiaries if their subsidies were increased, but this would make the program more fiscally expensive. This is the tension with most entitlement programs because it is usually popular to increase the “free” stuff flowing to the beneficiaries. Of course, these benefits are not actually “free, but simply obscured.

4. Also as a result of the realities of ACA enrollment, it was inevitable that concepts such as “Medicare For All” would emerge in this political landscape. As most readers know, the Medicare provides superior benefits to Medicaid for most potential beneficiaries (the exception being long-term care for some Medicaid beneficiaries who are eligible for it.) Because of this, concepts such as Medicare for All, or an expansion of Medicare at the expense of Medicaid, may become politically popular, once the details are explained to voters and provided that Medicare is not forced upon potential beneficiaries. As things stand now, Medicare is often combined with supplemental private insurance, so devising a “Medicare for All” plan where beneficiaries could retain their existing coverages and doctors would probably not be too difficult to structure.

5. I don’t understand Mr. Laszweski’s claim in one of his bullet points that “[the ACA] has made things much worse for the middle-class.” If he means worse in relative terms (i.e., relative to those who are now Medicaid eligible), well that is true. But again to focus on the inherent risks of entitlement programs, there is always someone who, due to the structure of a program, is being made better off. Thus, there is always a temptation to improve the standing of particular folks in an entitlement program to “level the playing field” but this is fiscally expensive in the long run. If by “worse” he means that enrollment is dropping, see points 1 and 2 above.

6. I also don’t understand why Mr. Laszweski’s statement in the last sentence that the ACA is very profitable for the insurance industry. Health entitlement programs (e.g., Medicare, Medicaid, etc.) have always been a key segment of the insurance industry. The health insurance industry is the sector that administers the vast majority of these programs. It is not the Federal and state governmental agencies (e.g., HCFA). I’m not saying that these insurer profits are desirable. But I am saying that they are, to a certain extent, somewhat inevitable. Voicing surprise that the health insurance industry is profiting from the ACA is analogous to being surprised that defense companies are booking higher profits during a war or military buildup.

7. Mr. Laszweski says “On the Republican side, so far there has been no plan.” Well no kidding. As described above, devising a plan that is both politically popular and fiscally neutral is extremely difficult. I challenge Mr. Laszweski to outline the basic terms of a plan that would be fiscally neutral. And also note that by fiscally neutral, I mean in the real long-term sense. As readers of this blog probably know, a fiscal scoring procedure used by a governmental entity, such as the CBO, must read the text of the program literally, and not take into account likely future changes in the program. Thus, one can “game” the fiscal neutrality criteria. Anyway, one can often “ballpark” the fiscal impacts of a plan without excessive brain damage, and provided that the plan terms are clear.

Ech, the system ate my post.

Looking at the numbers:
ACA added 18 million insured. 16 million of that was from Medicaid expansion.

Obamacare was almost entirely an expansion of Medicaid.

Wow!....I did not realize the enrollment mix was that lopsided towards Medicaid. Now I suspect even more that the drop in the individual market was fueled by migration into Medicaid. BTW, I know the feeling on the system eating your post. When I'm feeling particularly verbose (like today), I write my comment first in Word, then post it into blog comments when ready to send

Branko Milanovic has strong priors. He is thus mostly not worth reading, it is simpler to just read his priors and be done with it.

1. Update on the stability of Obamacare.
Obamacare is as strong as our willingness to pay interest charges in DC.

The true fact is that I have checked all the tribes. None of them plan on paying any Obamacare taxes and still want the ones they have reduced. So the debate is meaningless, we will get as much government services as we are willing to pay government interest charges. For millennials those federal interest charges are about 5% of income, as boomers retire. If millennials are willing to pay it, then fine, you can Obamacare all you want.

#4...In 2008, the Club for Growth proposed policies which would have led to a nightmare. As it was, they contributed to our not getting the needed spending via borrowing at the time, leading to a number of unfortunate events, like the Trump Presidency. Trump should give them a medal.


1. Follow the $: Massive transfer of $$$ from productive class to insurance companies.
2. It would have been cheaper (for productive class) to subsidize medical costs of the uninsured poor - which is what they did BEFORE ObamaCare was enacted.
3. ObamaCare removed disincentive to seek unnecessary care and resulted in increased US spending on medical care, i.e. transfer of $$$ to medical care providers.

Does anyone need a policy that covers more than $100,000 if he does not have $100,000 in assets?

Think about that for a few minutes before you hit reply.

Well, if you don't want to end up in medical bankruptcy and wreck your credit rating then yes.

Let's say I have a car worth $30K. Do I want to have to sell my car in order to pay my medical bills?

I'd argue it the other way. The people who shouldn't bother to buy insurance are the people who cann afford to pay their own medical bills out of pocket. The ultra-wealthy don't need medical insurance to protect their assets, because they can pay their own medical bills. The richer you are, the higher you can afford to set your deductible.

It's the relatively poor, who are going to burn through their entire net worth, who have more to lose if they have a major illness.
unless you assume that they can walk away from their unpaid medical bills without consequence.

Outstanding, +5 internet points

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