SEBELIUS TO INSURERS: FORGET THE LAW, I MAKE THE RULES NOW

If you’re still confused about who now runs the U.S. health care system, this should clarify things. Health insurers have been reading the recently-passed Obamacare legislation in an attempt to divine what it actually requires them to do.

And it turns out that the Obamacare bill doesn’t actually require them to sell insurance to children with pre-exiting conditions.  But the Secretary of HHS has informed them that the law says what she says it says:

I am preparing to issue regulations in the weeks ahead ensuring that the term ‘pre-existing exclusion’ applies to both a child’s access to a plan and to his or her benefits once he or she is in the plan.

In other words, it doesn’t matter what’s actually in the legislation passed by Congress and signed by Obama. Sebelius is serving notice that the law of the land is determined not by Congress and the President, but by the appatchiks of HHS.

Comments 15

  1. Marc Brown wrote:

    You’ll note that the insurers have quickly replied saying that they will comply so you should add an update:

    http://abcnews.go.com/images/Politics/Letter_AHIP_Ignagni_to_Sebelius_100330.pdf

    But let me say that your fears about little kids getting healthcare are surely unfounded. Surely there’s room in your heart for them ahead of profit, David? Did you honestly think that denying kids insurance would play well with the voters in the mid-terms? Overall, the healthcare reforms are pretty much what the GOP had been putting forward anyway for years, so really this is a lot of silly fuss about not a lot.

    And let me congratulate America – this a step forward and there’s about as much chance of repealing this as taking Medicare away from Grandma.

    Posted 30 Mar 2010 at 2:49 pm
  2. Catron wrote:

    Marc, your genius for missing the point is shining through once again. It’s not about who or what is covered. It’s about who gets to decide.

    In this case, Congress wrestled with “reform” for a year, and Secretary Sebelius essentially says “It doesn’t matter what’s in the bill, this is what you’re going to do.”

    It is just that sort of bureaucratic caprice that has reduced your once-great country to the moribund husk it is today.

    Posted 30 Mar 2010 at 3:21 pm
  3. Matt Horn CBC wrote:

    Actually, this was a step that certain insurers were going to take anyway, so there was really no need to fight it. I believe that this was a piece of the bill supported by AHIP.

    Posted 30 Mar 2010 at 4:03 pm
  4. Marc Brown wrote:

    ‘It’s not about who or what is covered. It’s about who gets to decide.’

    Come on David – since this bill has passed all you’re doing is nit-picking instead of moving forward positively. Do you honestly believe that the bill intended to leave out kids with pre-existing conditions? Even your beloved insurance companies knew better. And as I’ve said, and as you know full well, opposition to the bill is much more to do with a right-wing movement against Obama and the Dems, and not on any one specific issue.

    Posted 31 Mar 2010 at 3:40 am
  5. Rich wrote:

    Marc –
    It’s not nit-picking. We are a nation of laws, not men. If the Secretary can change the effect of a law, without an act of Congress, even if some think it is a good idea, then she can change the effect of a law, without an act of Congress, even in most (or all) think it is a bad idea.

    It is fair for the Secretary to suggest to the insurers that they do this now. But to give it the force of law is a precedent that is intolerable.

    Posted 31 Mar 2010 at 9:15 am
  6. z9z99 wrote:

    Here’s something I posted on my blog in December, 2009:

    Of all of the promises forwarded in support health care reform, the most risible is that it will reduce fraud and abuse. Think for a moment how much legislative energy is devoted to “closing loopholes” in one set of statutes or another. Look at how many bills seek to amend current laws because of unanticipated exploitation that degrades the law’s effectiveness. the simple fact is that in most cases, people who make their living exploiting laws are much, much…much smarter than the politicians who make those laws.

    When a ship is commissioned, it is customary to subject it to a “shakedown cruise” to work out glitches in the ship’s systems, uncover defects in design or construction and generally verify that the vessel is suitable to the purposes for which it is intended. Obviously, every eventuality cannot be foreseen, and problems only become apparent when subjected to real-world use. Now consider that our Congress seeks to impose a novel scheme, creating over a hundred new entities that are to interact somehow, onto an industry that involves sixteen percent of the American economy. Does anyone seriously think that the system will not contain a miasma of faults, opportunities for fraud, insufficient oversight and inefficiencies born of too much wishful thinking and not enough experience?

    Some people will become fabulously wealthy exploiting the half-baked policies, venal pandering and sheer stupidity that Congress will apply to healthcare. Anyone who can’t see this coming miles away simply isn’t paying attention.

    Posted 31 Mar 2010 at 11:56 am
  7. z9z99 wrote:

    And here’s something I posted in November, 2009. You can’t say progressives aren’t predictable:

    The ability of progressives to advocate seemingly detrimental policies need not be thought of as evidence of some exotic psychological quirk. A moment’s reflection reveals that progressives are paradoxically opposed to progress, and simply misappropriate the title for another philosophy. What the modern progressive believes in more than anything is exceptionism. This is to be distinguished from the more familiar exceptionalism in that the latter at least contains a hint of merit and achievement.

    What the modern progressive believes is that rules are for other people. It is only the ideologically pure that may obtain exemption from the misery that they prescribe for others under the guise of “fairness.” Thus, Al Gore can deplete an entire oil field to lecture us on the evils of fossil fuels; President Obama can crank the heat in the oval office while he practices his sonorous admonition to the hoi polloi that they must “sacrifice.” Timothy Geithner can claim carelessness and self-interest as exemptions on his own tax returns while venerating the letter of the law for others. Chris Dodd, Barney Frank, and Nancy Pelosi can be very solemn-faced about the rules when prescribing them for others, but view their own conduct contrary to those rules as the tribute that audacity pays to ideology.

    Progressives seem oblivious to hypocrisy because they think themselves incapable of it. Their view of fairness means that exceptions will always be made for hard cases, and any divergence between their words and conduct is merely an exception that they are entitled to by virtue of their own wonderfulness. This explains why the left are so enthralled with anecdotes and victimhood. Of course they are not worried that the government will deny their cancer therapy or their hip replacement when the time comes. They assume that an exception will be made in their case, because the denials are for others, the people clinging to their guns and bibles and so forth.

    Progressives know that the cute immigrant child that brings Oprah’s audience to tears will get her bone marrow transplant, because an exception will be made in her case. They see all difficult policy issues as simply vignettes of special pleading. They don’t worry that costs will rise, that access will shrink, that quality will suffer, because the way they look at the world, it doesn’t matter. An exception will be made in their case.

    Posted 31 Mar 2010 at 12:02 pm
  8. Marc Brown wrote:

    Rich,

    ‘It is fair for the Secretary to suggest to the insurers that they do this now. But to give it the force of law is a precedent that is intolerable.’

    I think this is a non-issue – which is why I say nit-picking. There is no big deal about this.

    Meanwhile, back to my question to you, which you ducked before. Your neighbour has no insurance to cover her cancer surgery. Your answer – she’ll have to wait under Obama’s reform. Fair enough, although other reforms such as for children are coming through now, and just imagine the opposition if he’d tried to move more quickly. So – look her in the eye. You’ve impeached Obama for being a commie birther. How would _you_ have got her the surgery she needs?

    I’ll pose the same question to ‘z9z99′, who says: ‘This explains why the left are so enthralled with anecdotes and victimhood. Of course they are not worried that the government will deny their cancer therapy or their hip replacement when the time comes.’

    What would you do about the ‘anecdotes and victimhood’ such as the many with no access to care right now (or before the bill…)?

    Posted 31 Mar 2010 at 4:31 pm
  9. Rich wrote:

    Marc,

    1. I have never characterized Obama as either a “commie” nor a “birther”,
    2. I have never advocated, mentioned, or supported impeachment (literal or figurative).

    Now on to substance.

    I did not duck your question, which was:
    “Look them in the eye and tell them why the Dem’s reform is not in their interest. And then tell them what is.”

    To which I provided a detailed response (http://www.healthcarebs.com/2010/03/03/president-orwell-gives-another-reform-speech/#comment-458571)

    Had you asked me then what you have asked today: “How would _you_ have got her the surgery she needs?” I would have responded: I would enroll her in one of the two local hospital’s charity care programs, in which the hospital’s services are free (or deeply discounted based on financial circumstances) and the physician time and services are donated by local physicians. She would be treated by a team of medical, surgical, and radiation oncologists as needed. I provide care to several such patients. And these are community hospitals. Tertiary hospitals provide an even greater degree of charity care (I trained in the Bronx, and treated plenty of uninsured, documented and undocumented immigrants, Medicaid, and the well insured. All received excellent care without regard to their coverage).

    I am always amazed (but never shocked) about the persistent conflation of “coverage” with “access.” They are not synonymous; many with access to charity programs choose not to use them. Many with coverage have poor access (See Medicaid). Increasing “coverage” by expanding programs that provide poor “access” will not improve access. Eliminating programs that improve access (Medicare Advantage in rural areas) will not improve access. Both defy logic, but that is precisely what is being done in large part by the reform package.

    Posted 31 Mar 2010 at 7:14 pm
  10. z9z99 wrote:

    Marc,

    What would I do about people with no access to care? Well, everyone has access to care. EMTALA ensures that anyone can receive “stabilizing treatment” in emergency rooms. Even without that government mandate, lack of insurance does not equate to lack of access. Notice how many hospitals have “Saint” or “Holy” or “Presbyterian” in their names? Why do you think that is? Hospital medical staff rules do not allow physicians covering the emergency rooms to refuse to provide care on the basis of ability to pay. Most hospitals have payer mixes that include 15-25% uninsured patients. If those patients were not getting care, the percentage would, of course, be zero. “Safety net” hospitals are just that. Ever hear the term “emergency medicaid?” Ask a hospital case manager what that is, and see how that fits in with the notion that uninsured patients have no access. Medical schools, residency training programs, churches, charitable trusts set up by for-profit hospitals, and municipal governments all run indigent clinics. Many indigent patients receive care at these clinics even though they would qualify for VA benefits. Canadian patients who come here to avoid queues and pay out of pocket; they have access. Have you ever heard a 911 operator ask what kind of insurance a person has before dispatching an ambulance? Do paramedics call the number on the back of your insurance card before performing CPR?

    The myth that people in the United States have no access to healthcare represents an ignorant, and near-slanderous misunderstanding of how decent, compassionate and generous Americans are. So I don’t buy your premise. But for the sake of being sporty, let’s assume you are right. Close your eyes and pretend that Emergency room triage nurses euthanize 24 year old pizza delivery men who get injured skateboarding.

    The reality is this: even if the U.S. had a single payer system, it would have to (like Medicare and medicaid) purchase services from the private healthcare system. To the extent that it tried to control the costs of those services, they would become less available, just like they have in Canada. Having insurance will not get you “access” if there is no one willing to provide the services you need for what the single payer is willing to pay. Single payer would mean plentiful access to things like pap smears, appendectomies and uncomplicated fracture repair. Cancer surgery?, well if you have a complicated head and neck tumor and need the services of a fellowship trained surgeon, you may be out of luck; “just take the pain pills” as was once recommended. Kidneys crap out on you? “Well, you see, the thing is…outpatient dialysis slots are determined by government actuaries, since it pays for all dialysis, and well, nobody’s perfect. We guessed a few thousand short.” Access is more an issue of the optimizing dynamics of competition than it is insurance availability. “Insurance” is a method of insulating personal financial and healthcare concerns from each other; it doesn’t insure there will be somebody willing and qualified to care for you, or in fact to provide any of the other highly desirable benefits of American medicine that far too many people take for granted.

    Did you know that most private medical practices could not survive on Medicare re-imbursement alone? What that means is that in order to see Medicare pateints, most doctors have to cover their overhead expenses out of private re-imbursement. This means that Medicare is in fact subsidized by the private medical system. (Now to be fair, Medicare also subsidizes medical education, and nearly all VA hospitals are teaching hospitals, so Medicare is not a total mooch) If you remove the support provided by private payers such as insurance companies, you remove providers. Access suffers. And by the way, the higher payments of private insurers is not “inefficiency” or “greed.” It actually purchases something, such as the ready availability of CT scanners, the convenience of specialty surgical hospitals and air ambulances, research on drugs that are more efficacious and have less side effects than earlier generations of similar medicines, less invasive surgical technologies and quantum leaps in diagnostic technology. I’ll repost an earlier discussion of why healthcare is so expensive for you, and you can determine if you think there are any good trades there for access.

    Posted 31 Mar 2010 at 9:54 pm
  11. z9z99 wrote:

    Marc,

    With the webhost’s indulgence, here’s my earlier post on why healthcare is so expensive:

    Why is healthcare so expensive? If you are a politician you instictively assume that it because of “greed, fraud, waste” of industry fatcats. If you are an industry fatcat, you assume that it is because of the irresponsibility of spoiled patients, churlish doctors and meddling bureaucrats. And then throw in tort lawyers, pharmaceutical companies, unions, demagogues, and various undefined predators. I submit that this is a pretty typical schematic of the assumptions underlying current healthcare reform legislation. What each of these assumptions has in common is some questionable motive on the part of someone. I submit that the cost of American healthcare is really more a result of more benign factors and expectations. In my opinion healthcare is expensive because of :

    1.) Performance. As I have said befire, there is a reason why a Ferrari costs twenty times more than a Dodge Omni, and it is not because the Ferrari goes twenty times faster or farther. Marginal increments in high performance systems cost considerably more than proportional improvements in less ambitious systems. Excellence costs disproportionally more than adequacy, and Americans want and have been willing to pay for excellence.

    2.) Access. If you need your knee replaced in a fair sized American city, you can go to the local medical center. Or you can go to a specialty hospital or to a surgical center. These options allow you to schedule your procedure within a reasonable time, and not subject to operative room availability that is subject to ruptured appendices, multi-trauma car accidents, dissecting aortas, or perforated bowels. This ready access requires a certain amount of redundancy and redundancy costs money.

    3.) Uncertainty. Lets say you have chest pain. A skilled practitioner can take a low tech history and physical and tell you wiht ~85% certainty that you are not having a heart attack, and that he thinks the cause is esophageal spasm, or anxiety. The 15% uncertainty is unnerving, so you are willing to pay for cardiac enzymes that can tell with 95% certainty that you are not having a heart attack. But it’s your heart we are talking about so you get parked in an observation unit, with telemetry monitoring, and because something caused the pain, you get a nuclear medicie study the next day. (The readiy availability of the nuclear medicine study also costs money as mentioned above.) But you still don’t know what caused you to go the ER and you want to find out. You don’t like uncertainty where your health is concerned. You get a specialized CT scan and if this doesn’t answer the question you are scheduled for a swallowing study. If you are having headaches, how much are you willing to spend to be assured that they are due to tension and not a tumor or an aneurysm?

    4.) Choice. Heaven forbid you are given a diagnosis of cancer. There are several treatment options, the cheapest of which is disfiguring, or disabling surgery. Or you can opt for one the newer radiation techniques, chemotherapy protocols, high tech reconstruction, or some high tech monoclonal antibody therapy. Maintining these options and the expertise to use them costs money, money that we americans have been willing to spend in the private insurance market, until our politicians told us that we aren’t.

    5.) Autonomy. There is no one other than the patient who can tell us how important the last month of his life is to him. There is no reliable way of telling that the three months he spends at home with his daughter is less meaningful than the three months that a motorcycle crash victim spends in inpatient and outpatient rehabilitiation. The lifestyle and healthcare choices of individual people are matters of liberty and individual dignity, not actuarial variables to be guessed at by remote bureaucrats. It is much cheaper for treatment decisions to be made by venal accountants, it is much more meaningful for these same decisions to be made by unique and irreplaceable people.

    6.) Fantasy. We all engage in illusions that are comforting, or that provide emotional reassurance, even if we know these illusions are contrary to reality. We assume that the natural condition of mankind is to die at home in his bed surrounded by loved ones, of old age. We want to think that our doctors will succeed in whatever therapeutic interventions they try, regardless of reason, and if the outcome is less than expected, a jury will be asked to right the wrong. We want to pretend that the 87 year old who just had a massive stroke will get back on her feet “because she’s always been active” as soon as she is able to eat, and as a consequence we are willing to spend significant money for what may be a one-in-a-hundred shot. We do this, not because we are greedy or stupid, but because we look at our loved ones a certain way. It may be, in the case of healthcare, that these are futile expenditures, but the underlying presumption, that human life is never an ordinary thing permeates all that we do and all that we value as a society. The money we spend on fantastic healthcare ambitions is simply a consequence of our values.

    7.) Responsiveness. Ambulances and emergency rooms respond to everyone who has a medical emergency based only on the fact that the patient is a human being. It requires infrastructure to ensure 24-hour coverage, aerial transport if necessary, and tertiary care centers when needed. Again, we American have been willing to pay for this until our enlightened politicians tell us that we aren’t. The simple fact is that government provided healthcare cannot keep up with the private healthcare system in providing Americans with the attributes described above. So they tell us the government must take over and by fiat and diktat deprive us of many of the qualities of our healthcare system that we have already indicated are important to us. The reason, after all that Obama says we need to reform healthcare is not because it costs too much (it doesn’t “Consume” 17% of GDP, it produces it) it is because the government is not very good at providing it.

    Posted 01 Apr 2010 at 9:18 am
  12. Marc Brown wrote:

    So Rich:

    ‘I would enroll her in one of the two local hospital’s charity care programs, in which the hospital’s services are free (or deeply discounted based on financial circumstances) and the physician time and services are donated by local physicians.’

    Leaving aside the fact that it is often impossible for people to qualify for these programs, and also involve delay – the thousands of stories from uninsured and underinsured people show this and the outcomes for the under/uninsured are also worse – do you really want to live in a so-called advanced economy where people have to beg people like you for charity?

    z9z99: ‘Cancer surgery?, well if you have a complicated head and neck tumor and need the services of a fellowship trained surgeon, you may be out of luck’

    As many are now.

    ‘Did you know that most private medical practices could not survive on Medicare re-imbursement alone?’

    You are spending far more per head than all other modern economies. Where is the money going – do you actually want to spend more?

    ‘Maintining these options and the expertise to use them costs money, money that we americans have been willing to spend in the private insurance market, until our politicians told us that we aren’t.’

    No one will or wants to stop wealthy people buying often needless and ineffective procedures. We are talking about the dignity and benefit to the economy of all people having timely access to a cost-effective, mostly latest, standard of care that is available to all Europeans.

    Most of your points are frankly not relevant.

    Posted 07 Apr 2010 at 9:49 am
  13. z9z99 wrote:

    Marc,

    With all due respect, my points may not seem relevant to you because, quite frankly, your presumptions are wrong. Your response to the point about Medicare not covering physician expenses is a complete non-sequitur; “where is the money going”? Did you not understand the point? Private insurance makes it possible for doctors to see Medicare patients. The money goes for access, malpractice insurance, qualified support staff, rapid x-ray and laboratory turn-around times, 64 detector CT scanners, radiologists who have specialized training and expertise in neuroradiology or invasive procedures. It goes to continuing education and acquiring new skills that benefit patients, even more than does the “mostly latest” care that left off God-knows-when.

    And yes, I noticed how you tried to slip in the word “mostly.” Look up the name Belinda Stronach, the Canadian member of Parliament who decided that her health was too important to leave to the “mostly” up to date Canadian health system. Oddly, she did not go to Europe for her care. And those people who sit in ambulances outside of British emergency rooms because there is limited access? I guess dignity is in the eye of the beholder.

    As to your unsubstantiated comment about cancer patients’ access to specialized surgeons, again you are parroting talking points that are simply wrong. And you also seemed to have missed the point. People are not deprived of life saving care because they cannot afford it. Call up your nearest teaching hospital and ask them how much charity care they provide. Patients may have to do some looking to find it, but it is there. But it won’t be if there are not enough trained physicians there to provide it.

    I find it curious that I post seven reasons why healthcare is so expensive in America, and you ask “where is the money going” followed by “most of your points are frankly not relevant.” Let me suggest to you that they indeed are not relevant to faulty presumptions, uninformed conjecture and blinkered ideology. If you just want to take some talking points out for a spin, I am happy to accommodate you; it doesn’t cost me anything to reply. But seriously, do you really think that “your points aren’t relevant” persuades anyone of anything? Has anyone ever adopted the position you were advocating in response to this assertion?

    Posted 07 Apr 2010 at 12:47 pm
  14. Marc Brown wrote:

    z9z99:

    You have failed to address the key points with your blind faith in some magical market. The big one is of course cost – if you increase Medicare payments with no thought about the effectiveness of what you are buying your country will go bankrupt even faster.

    You have a touching faith in medical technology. Nearly all new cancer drugs are buying only very small gains, while equipment such as complex radiation machines require skilled, integrated and long term staffing and planning that is anathema to profit and is resulting in many serious overdosing errors in the US. And you may not be aware that Europe is the leader in many medical fields, not least because it has much higher patient registration in clinical trials.

    And in short, in Europe you will find healthcare systems that are as responsive, if not better, than the US in ER, far better and planned primary care, certainly far better doctor-patient interaction, very similar and better mortality rates for cancer and other diseases, and nothing like the one-off anecdotes you like to parrot from Fox News.

    Posted 12 Apr 2010 at 3:18 pm
  15. z9z99 wrote:

    Marc,

    I can see you are trying to be a decent guy; your inability to assert the misleading claim about the latest treatment being available in Europe without your conscience prompting you to add the hedging “mostly” is evidence of this. And you actually understand some things better than you think you do, while groping about others and missing wildly. I hope you are up for a long post.

    Let us begin with what should be an area of agreement. European medicine does some things very well. So does Cuban medicine, and Honduran medicine, Chinese medicine, etc. Kaiser does some things very well, as does the VA. But none of these systems do everything well, and all of thses systems, including the European ones benefit from America’s willingness to take the risks necessary to advance medical science for the benefit of all. Are we O.K. so far?

    If you look at the medical system of the Europeans, and Cubans, etc. you will notice that they do a good job of providing a particular type of medical services. So does Kaiser and the V.A., and if you were an astute reformer, you would immediately perceive both a rational approach to reform, and immediately spot the problems with the healthcare reform legislation recently passed.

    All reform begins with a simple task-classifying aspects of the thing to be reformed into groups according to their beneficial and non-beneficial attributes. Now we can do this with healthcare in any number of ways; trauma and non-trauma, catastrophic and non-catastrophic, preventive and acute, experimental and non-experimental, pre-existing and not, publicly financed and private pay, etc. Whether or not reform is successful depends crucially on which distinctions are selected as the bases of reform. When it comes to talking about cost savings, the classifications degenerate into rationing on the basis of condition (like the Oregon medicaid system) on the basis of who the patient is (e.g. Obama’s reference to patients who are better off taking pain pills), or on some homogenized metric of efficacy (comparative research panels.) Each of these approaches requires a trade-off at the expense of liberty and values of individuals, and this is the reason why “Obamacare” is unpopular, and actually antithetical to the purpose of healthcare. (Perhaps you would like to take a shot at answering that seminal question: what is the purpose of healthcare?)

    A more reasonalble approach is to realize that there is a natural discriminant in healthcare services: typical and atypical care. Typical care is that which you receive for uncomplicated pnuemonia, coronary artery disease, diabetes, etc. It includes preventive care and management of chronic diseases. Atypical care is everyting else: ICU stays for complicated pnuemonia, costs for defensive medicine, experimental care, elective surgery, the more exotic imaging techniques, care for extreme premature babies, etc.

    Europe and China and Cuba (and Kaiser and the VA) do very well with typical care for a very straightforward reason: typical care is relatively inexpensive. If so inclined a national formulary could consist only of drugs that Target provides for $4 a month. Furthermore, the vast majority of people could get by with only typical care. It would suck for some people if we didn’t provide for end of life ICU care, or organ transplants or reconstructive surgery, but these would affect a comparatively small portion of the population. If you reformed healthcare to only provide for typical care, the cost effectiveness would sky-rocket, at the expense of course of those for whom typical care is not good enough.

    Over time, things that start out as atypical become accepted and routine (and cheaper) and naturally become typical type of care. Laparoscopic surgery, statin drugs, PET scans, Herceptin, and so forth. Subsidizing atypical care eventually benefits everyone because it advances the state of the art. Admittedly, there is a huge amount of waste in the atypical category, including defensive medicine, futile care and needlessly expensive interventions where cheaper ones would suffice. We Americans put up with this for a number of reasons: 1.) because as mentioned, it advances the state of the art for everyone, 2.) because we have adopted a societal ethic that we will not discriminate on the basis of health, and 3.) that we will not intrude on the patient’s determination of what an acceptable quality of life or benefit of therapy is. Note that ineffective or inefficient therapies would not be accepted as “typical,” or if that is already the case, be replaced by better therapies that start out as atypical.

    An astute reformer would begin by assuring access to “typical care.” This is in fact the only thing that the European model has done, with very little downside, because those nutty Americans are traditionally disposed to uderwriting the benefits of care that others regard as atypical. If you were so inclined you could reform American healthcare to cover “typical” care and let people contract individually for “atypical care” and get the best of both worlds.

    Of course what Congress has done is to do the opposite. An insurance mandate is an artifice by which atypical care is treated as typical. It imports the inefficiencies of providing extraordinary and costly care into a market designed for cost effective and predictable care. It imposes the inflationalry pressures of private third party payers on a portion of the system that should be actuarily sound, and necessitates the replacement of discarded efficiencies with explicit rationing. Worse, it shoehorns providers into a system where the mandated inefficiencies will be addressed by preferentially treating those who are less ill, (which not surprisingly is more cost effective than treating very ill people) thus discriminating against those who receive adequate care now, and would receive such care in Cuba, China etc.

    You are correct when you note “if you increase Medicare payments with no thought about the effectiveness of what you are buying your country will go bankrupt even faster.” This is exactly what “Obamacare” does. It divorces payment for medical services from a rational allocation based on the expected risks, benefits and costs. It stifles innovation because it falsely treats newer and promising therapies as typical care before experience and ingenuity have enhanced their effectiveness, and efficiency.

    In short, no one, including Europe, could afford it if everyone’s healthcare system were like Europe’s. And our tradition of liberty and personal autonomy wouldn’t take well to it either.

    Posted 12 Apr 2010 at 9:34 pm

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