Category: Medicine

The idea is to create long-term care insurance that would be available
to anyone, including those who are already disabled. People would be
automatically enrolled, unless they chose to opt out, and would pay a
premium in exchange for the opportunity to receive cash benefits to
cover the cost of home care, adult day programs, assisted living or
nursing homes after they had been enrolled for at least five years.
Premiums and benefit levels would be set by federal health officials,
but advocates predict that the program would provide beneficiaries with
a minimal sum, around $75 a day.

The proposal has gained momentum in recent days as Democrats in both
the House and Senate cast about for cash to help finance a final health
package. Because the program would begin taking in premiums immediately
but would not start paying benefits until 2016, congressional budget
analysts have forecast that it would generate a nearly $60 billion
surplus over the next 10 years, cash that would help the larger
measure's balance on paper.

Here is the full story.  Now reread that last sentence and ask yourself how many different ways there are to do this and whether all of them will fail to pass.

Have I seen twenty MSM articles on this theme in the last five days?  Yet the betting odds are only slightly above their minimum point.  Right now the contract is running at about twenty rather than eighteen or so a few days ago. 

I don't follow the ins and outs of the trenches (try Ezra Klein), but as an outsider I don't understand why in strategic terms the Democrats are resurrecting this idea.  It's their most likely path to failure, namely that they can't pass a public plan and can't easily go back to a bill without a public plan either.  Any bill that is passed will be revised repeatedly in any case, so there's plenty of time to try to get a public plan in the future anyway.

Here is my NYT column this week and not surprisingly it covers health insurance.  Excerpt:

At this point, it seems more plausible that the cost of health
insurance will keep rising, just as the costs of health care services
have continued to climb. The upshot is that the burdens of mandatory
purchase, the subsidy costs and the associated implicit marginal tax
rates will all increase, eventually to the point of unsustainability.

A further problem is “mandate creep,” which we’ve seen at the state
level, as groups lobby for various types of coverage – whether for acupuncture, alcoholism and fertility treatments, for example, or for chiropractor services or marriage counseling.

There are now about 1,500 insurance mandates among the various states,
and hundreds of others are under consideration. The dynamic at work
here is that the affected groups have a big incentive to push for
mandates, while most other people are unaware of the specific issues
and don’t become involved.

Because mandates don’t stay modest
for long, health insurance would become all the more expensive. The
Obama administration’s cost estimates haven’t considered these
longer-run “political economy” issues.

There is more to the argument and I urge you to read the whole thing.  Do not forget my penultimate paragraph:

We’re often told that America should copy the health care institutions
of Western Europe. Yet we’re failing to copy the single most important
lesson from those systems – namely, to put cost control first. Instead,
we’re putting our foot on the gas pedal and ratcheting up the fiscal
pressures on the system, in the hope that someday, somehow, it will all
work out.

Of course much of this piece also can be taken as a plea for more government-supplied insurance; that debate didn't fit in the 900-word limit.  The more important lesson, for the time being, is that we're on the verging of passing a policy that simply cannot and will not work.

Ezra Klein reports:

For people, like, well, me, who think that the health insurance
exchanges have a real shot at lowering health-care costs throughout the
system, the graph
above is difficult. For conservatives who believe that the key to
constraining health-care costs is to encourage competition between
insurers and give individuals the opportunity to choose, the graph
above is difficult. Because what the graph above shows is that neither
of those strategies has worked terribly well, at least as of yet.

The bottom line is that premiums seem to go up no matter what the institutional structure or its degree of competition.

By the excellent Jonathan Rauch, this unexcerptable piece is very funny (and sad).  

I wonder what it would be like to extend this series: if Whole Foods worked like health care, if the internet worked like health care, if higher education worked like health care…wait…higher education does work a bit like health care.

With most infectious diseases, reducing everyone’s risk by a third would make
quite a difference across a whole population. But the problem with HIV is
that it is both an infectious disease and a behavioural one. I can get it by
sharing needles with other drug injectors, I can avoid it by using condoms
every time I have sex. If I know I have been vaccinated, will that make me
more likely to share needles, or less likely to use condoms? And if it does,
will that change outweigh the 30 per cent reduction in risk that comes with
the vaccine?

That is Elizabeth Pisani, here is more.

This is from Bill:

I am worried that the insurance companies will dump bad risks in the
public pool. They can do this by designing plans that have no value to
sick people, the way the do for Medicare Advantage programs. Here's how
you do it: have a high sticker price, but offer discounts for the use
of a gym or health club. (Non-ambulatory need not apply). Or, offer
special benefits to new mothers and well baby programs (over 50 persons
need not apply–unless you're pregnant)

I've been worrying about that for a while and of course there are many more dimensions of quality competition beyond what Bill mentions.  It's possible I don't understand the plan well enough and this isn't a real risk.  If so, I'd like someone to explain it all to me.  (Here is a related post by Matt.)  But as it stands I've soaked up all the lessons about how private insurers want to dump the high-risk individuals.  Under the reform, if you can't ever cut them off or "resciss" them (is that the verb?), won't you try much harder to avoid them in the first place?  Is there some provision in the bill which actually prevents this by regulating quality competition in just the right way?  Given that heterogeneous consumers, and employers, choose across plans on the basis of what they want, is such regulation even possible?  Right now I'm still worried.  Oddly, this is perhaps less of a problem in the states with more concentrated insurance markets.

Of course if there is no public plan these people end up somewhere in the private sector, they just are treated very badly in terms of quality of service.  Which makes the mandate an even less good deal for many of them.

South African saliva:

South Africans in an impoverished township are profiting from an illegal trade in a precious new currency †‘ saliva.

Tuberculosis
sufferers in Khayelitsha, Cape Town, were found to be selling samples
of their sputum to healthy people to pass off as their own in a scam to
gain medical grants.

An investigation by the West Cape News
identified people with TB charging R50-100 (£4.10-£8.20) for saliva
samples contained in bottles stolen from health clinics.

The
paper said that buyers of the samples were then able to get a card from
a clinic indicating they have TB and use this to fraudulently obtain a
temporary disability grant of R1,010 per month from the department of
social development.

It seems to be a competitive market:

A 54-year-old man told a reporter that he makes an average of R500 per
month from selling his saliva to people seeking to trick their way on
to the benefits system. But he said business was "not good" because so
many people were infected with TB in the township that he had a lot of
competition.

I thank Jonathan Thomas for the pointer.