"This System Is Bankrupting Our State"

November 7, 2010 11:53 AM

Texas conservative lawmakers, now in the majority, are considering eliminating the entire Medicaid program lin their state, ostensibly to save money.
posted by Leta (191 comments total)

Good riddance. More for the rest of us.
posted by nevercalm at 11:53 AM on November 7, 2010

Good riddance. More for the rest of us.

More sick people, you mean. The goal here is to get all the poor, sick people to leave the state. Or, you know, die.

Either way, *ka-ching*
posted by delmoi at 11:56 AM on November 7, 2010 [14 favorites]

Unless the rest of us are the impoverished in Texas, of course.

But it isn't going to happen. It'd be political suicide, even in Texas. They'll no more do this than make good on their threats to secede.
posted by Marty Marx at 11:57 AM on November 7, 2010 [14 favorites]

This shouldn't come as any surprise really. Texas is always trying to be the best at everything. Just in this case, it's at f-ing over their own citizens. It is a match to the eagerness for the death penalty.
posted by petrilli at 11:58 AM on November 7, 2010 [3 favorites]

The ultimate death panel. Can't afford treatment, that means you die!

See, the Rally to Restore Sanity kind of missed the point that the lack of empathy on the right clearly indicates they are all extremely deranged sociopaths and we can't pretend that away and be polite about it, fuck them.
posted by furiousxgeorge at 11:58 AM on November 7, 2010 [35 favorites]

State Sen. Jane Nelson, R-Flower Mound, who chairs the Senate Public Health Committee, said dropping out of Medicaid is worth considering — but only if it makes fiscal sense without jeopardizing care.

How would that even be possible

--They will lose a huge amount of funding from the federal government
--They already administer it, so what savings would they expect by creating an entirely new framework?
--If they don't run an equivalent state program they will absolutely jeopardize care


This makes no sense to anyone who can read

(Thank god for Texas public schools, or folks like this would never get elected)
posted by the young rope-rider at 12:00 PM on November 7, 2010 [13 favorites]

See, the Rally to Restore Sanity kind of missed the point that the lack of empathy

You're not thinking about it correctly. Republicans hard-core conservatives think Empathy is A mental disorder.
posted by delmoi at 12:02 PM on November 7, 2010 [13 favorites]

It's stupid and they're stupid and their stupid idea is stupid and their stupid, stupid idea will never get past the stage of them talking stupid things about it but making stupid people who vote for them happy because stupid people love to hear stupid things from people who are also stupid.

And there is literally no reason to raise any level of discussion on it above that level.
posted by XQUZYPHYR at 12:06 PM on November 7, 2010 [82 favorites]

Texas is always trying to be the best at everything.

Hmm, I think maybe that memo never got to Rick Perry. Not to mention all the Texans who voted for him to have a third term last week.
posted by blucevalo at 12:06 PM on November 7, 2010 [1 favorite]

It'd be political suicide, even in Texas.

Yes, but that doesn't mean the Tea Party people won't do it. They are hardly characterized by their astute political sense and party discipline.

The Republican party is about to learn why it is dangerous to say crazy things to get elected. Sooner or later, the people to whom you've told these things will start electing people who actually believe them.
posted by enn at 12:09 PM on November 7, 2010 [13 favorites]

i'm sure that will go well for them.
posted by empath at 12:10 PM on November 7, 2010

This'll be a bonanza for the Democrats. All they'll have to do is show everyone what a disaster it is -- with a simple, forceful message that their people will drive home with one voice, day after day, week after week, on Sunday talk shows and in their home districts. They'll take the offensive, then stay on the attack until...until...*sigh* who am I kidding?
posted by PlusDistance at 12:10 PM on November 7, 2010 [52 favorites]

Are they going to eliminate their own state supplied coverage as well?
posted by lee at 12:12 PM on November 7, 2010

I think it's going to be interesting to see what happens when some truly hard-core conservative policies finally get put into place. Do people really want privatized government, no safety regulations, and no public social services? They apparently think they do, but we'll see.

I heard an interesting theory recently along those lines. The idea isn't that conservatives want people to starve, be forced to live on the streets, or whatever. Rather, they want to make sure you have no choice but to get help from religious organizations who can do things like make you attend mass before getting your bowl of soup. That thought hadn't occurred to me before, but it makes a certain amount of sense.
posted by LastOfHisKind at 12:13 PM on November 7, 2010 [15 favorites]

And there is literally no reason to raise any level of discussion on it above that level.

Well, just one thing, the Democrats need to DARE THEM TO ACTUALLY DO IT. Make the Republicans, for once, have to be the ones to explain to their idiotic sheeplike selfish base why we need programs like Medicaid.

I am so incredibly sick of Republicans being allowed to support these programs out of one side of their mouth and hate on them out of the other.
posted by furiousxgeorge at 12:13 PM on November 7, 2010 [19 favorites]

They'll no more do this than make good on their threats to secede.

I'm still heartbroken about that whole not seceding thing. Liars. Got me all worked up for nothing. I was waiting for the day when we could treat Texans like they treat Mexicans.
posted by eyeballkid at 12:15 PM on November 7, 2010 [16 favorites]

This article doesn't explain much. Let me see if I can find some other coverage...
posted by mrgrimm at 12:16 PM on November 7, 2010

I double dog dare them.
posted by The Whelk at 12:17 PM on November 7, 2010 [1 favorite]

I kinda wonder if cities and states will start to compete like this to make themselves unattractive to the poor. It doesn't make much sense if you expect the region's poor economic performance to be temporary, since it would take awhile for individuals and families to migrate away, but if governments start to expect mediocre economic growth indefinitely, policies like this might start to become more rational, assuming that your only goal is to minimize your government's budget deficit.
posted by gsteff at 12:20 PM on November 7, 2010

And now the conservative strategy begins to bear fruit - the Republicans have been spending like crazy and running up debt. Now, they are in a position to claim that America can't afford social services. They will try to kill off the programs in the name of fiscal conservatism, when it was their own disastrous policies that got us into the mess in the first place. This is where they attempt to drown government in the bathtub; it's been a long 30 years, but finally their end goal is in sight.
posted by Philosopher Dirtbike at 12:24 PM on November 7, 2010 [12 favorites]

they want to make sure you have no choice but to get help from religious organizations who can do things like make you attend mass before getting your bowl of soup.

Conservatives and Libertarians I have talked to literally believe private charity organizations would pick up the slack for the loss of the social safety net. I don't get the sense they believe this because they want to force religion, it's just an extension of their free market worship. Private organizations are ALWAYS better than government. (Aside from the military)

Never mind the fact that you can look anywhere at any time in human history and see private charity can't cover as many people as government action, never mind that this whole idea runs against the rational self interest inherent in free market faith, facts don't matter.

However, they have argued on the basis of the self sufficiency of the Amish community when it comes to healthcare even without insurance and that is a very interesting topic. It makes a good case. In the end, however, it is just socialized medicine on a small scale. The Amish community supports each other out of mutual consent, socialized medicine on the democratic nation state scale is just a larger version.

Interestingly, when I was looking for something to link there I ran into right wing poutrage that the Amish were exempted from the healthcare mandate on religious grounds. In an alternative universe, there is right wing poutrage that they had their religious rights violated by being forced to buy insurance, which they do not believe in.
posted by furiousxgeorge at 12:26 PM on November 7, 2010 [8 favorites]

I'm a New Yorker who's lived in Texas for the past eight years. (My partner is a native Texan himself, and has a steady job at the newspaper here; his career as a journalist restricts our ability to move elsewhere, but I guess that's our fault for wanting to work in a dying industry.) Our housemate moved here from Seattle two years ago. When I voted last week, and tried to get her to vote as well, she said she had no intention of voting in this election and nothing I could say would sway her. When this news came out, she finally told me, "Now I understand why you were so mad at me for not voting." Cold fucking comfort.

They want to stop providing Medicaid and CHIP. I find it amazing that anyone can actually be in favour of getting rid of CHIP - I can see people wanting to get rid of Medicaid; I completely disagree with them and I think that position boils down to "poor people deserve what they get," but I can see how "poor people deserve what they get" is on the surface a compelling argument to a bunch of crazy rednecks who focus themselves on some insane dream of being rich themselves one day. But cutting CHIP? Actually coming out and saying "fuck kids, kids don't need health care, babies don't deserve it"? KIDS AND BABIES, the group that's always protected by public sentiment? Really?

We've been going round the bend for a while now. We're still not completely around it but it seriously looks like it's a downhill slope from here. Like a nice cloverleaf exit ramp onto the frontage road of stupid. I was angry as hell when I read this shit this morning, and I'm still angry as hell, but not knowing what to do with my anger is exhausting me.
posted by titus n. owl at 12:29 PM on November 7, 2010 [24 favorites]

Can anyone speak to what the fuck the Republican end-goal with respect to government is? I honestly can't understand it - agrarian/hunter-gatherers? With fighter jets?
posted by odinsdream at 12:30 PM on November 7, 2010 [63 favorites]

Y'all are missin' the point. This is the new-fangled, Rick Perry/Texas legislature job creatin' program. You see, here's how this good ol' boy is gonna hunt.

First, we'll spur local entrepreneurship by stimulatin' the growth of new business. In this case, companies whose speciality is to clean up them dead folks. Ya know, the one's who are too lazy to leave the state to get medical care (good for nuthin's). With thousands of new rotting corpses at home each year, that's sure to make a stank. These new small businesses will grow. Grow, I say, grow.

Second, we'll help neighborin' states with their industry. Fer example, Illinois. They have that there Caterpillar company -- the one that makes that heavy diggin' machines. Well, with all of the new paupers graves that we're gonna need, we'll be needin' machines to do the diggin'. We reckin that there will be to dang many graves to dig for even Sheriff Arpaio's convicts (who we can borrow for cheap).

You see? Job creatin'. The Tex-ass way.
posted by scblackman at 12:31 PM on November 7, 2010 [4 favorites]

Enn: "The Republican party is about to learn why it is dangerous to say crazy things to get elected. Sooner or later, the people to whom you've told these things will start electing people who actually believe them."

Amen to that. I heard an NPR story about an anti-tax republican in Colorado who has actually been actively campaigning against three different anti-tax initiatives in the state because, well, he did the math, and realized the state would have to stop funding schools or prisons if they passed. My reaction was exactly Enn's. We've been telling those crazy idiots this sort of outcome was likely for years, and they refused to change their position, and now they've produced a new political generation of crazies who don't realized earlier Repubs were mostly posturing.
posted by hank_14 at 12:34 PM on November 7, 2010 [6 favorites]

“There are still a number of unresolved issues at the federal level,” she said. “Some people are even trying to repeal it. There just hasn’t been a lot of information out on what it would mean to us.”

{paging Parson Malthus, Doctor Jack, Doctor Malthus}

the guy who puts- you-to- sleep- before- surgery charged me twice. Post-Op care added 30 frikkin minutes to my bill.

because i was paying Cash?
even on Morphine im a fool and a dope but not stupid, my total bill was 1500$ less before i left...thanks mom:)
that is all


posted by clavdivs at 12:37 PM on November 7, 2010 [3 favorites]

Texas doesn't have a personal state income tax (which could surely help a little to dig them out of their hole).

So I guess they weighed the concept of paying for taxes, and they weighed providing basic medical services to the poor and to children and babies, and ... well, in the modern American conservative mindset there's not really even any ethical or moral quandary there, is there?
posted by barnacles at 12:40 PM on November 7, 2010 [5 favorites]

It's time for the Democrats to step up and agree with the Republicans. Starting with removal of free health care for active duty military, reservists, retired military and veterans.
posted by Xoebe at 12:46 PM on November 7, 2010 [4 favorites]

Notice they want to end Medicaid, but don't mention Medicare. Why is one socialism and the other not? Could it be because old people vote and poor people don't? Why go only part of the way towards a free market? Eliminate both or niether and remove other artificial government imposed, restrictions on the free market as well. Allow anyone who wants to practice medicine. Let people buy any drug they desire without a prescription. Maybe throw in a few consumer protection laws that require hospitals to give the same price to the uninsured they give to insurance companies. Require all medical providers to list the cost of their services on the Internet and in their front offices.
posted by Tashtego at 12:47 PM on November 7, 2010 [5 favorites]

This is merely an opening gambit, in the "make a ridiculous offer up-front and then settle for what your really intended to pay" manner.
I do believe they intend to severely restrict Medicaid, but not eliminate it, though. Expect tales of "illegals getting free healthcare" and "welfare boob jobs" and whatnot, to get the public riled-up.
posted by Thorzdad at 12:52 PM on November 7, 2010 [3 favorites]

Flower Mound?
posted by Ratio at 12:56 PM on November 7, 2010 [1 favorite]

PlusDistance: "This'll be a bonanza for the Democrats."

Surely this?
posted by Rat Spatula at 1:00 PM on November 7, 2010 [2 favorites]

The US is slowly but surely becoming the biggest trainwreck in the history of trainwrecks.

*goes to stock up on popcorn supplies for the next two years*
posted by sour cream at 1:00 PM on November 7, 2010 [2 favorites]

Medicaid and CHIP go primarily to the low income types, most irritatingly those that tend to vote the wrong way in elections. There is little perceived downside for Texas GOP with this kind of posturing. And it is just that ... posturing. Big talk, swagger and bluster with no follow-through are a cherished Texas tradition.
posted by jim in austin at 1:03 PM on November 7, 2010

Why is one socialism and the other not? Could it be because old people vote and poor people don't?

Because old people, in theory, paid the taxes that support Medicare their entire lives, and are getting back now what they gave up earlier.

The poor, on the other hand, are a bunch of leeches, contributing nothing and taking everything, sucking directly from the lifeblood of the hard-working Texans who built the greatest state in the union.

I say "go for it, Texas." Show everyone just how cluelessly mean-spirited you can be. Just as Massachusetts seems to be showing everyone how to social services and contemporary civil rights in a way that's both humane and cost-effective, we need an example of how to be completely wrong.
posted by fatbird at 1:06 PM on November 7, 2010 [4 favorites]

Yes, but that doesn't mean the Tea Party people won't do it. They are hardly characterized by their astute political sense and party discipline.

Except the Tea Party people are still a vast minority in the Republican Party. A vocal, easy-to-convince-to-donate minority, but a minority nonetheless.

And frankly they're useless to Republicans. Republicans don't want to do a single thing the teabaggers want (end earmarks? Cut the deficit? Close the borders? Please.) They sucked up to them in 2010, are going to do everything they can to ignore them for the next two years, and then suck up to them again in 2012 and probably get enough votes because the President is still black.

Teabaggers are useful because it gets the GOP votes and money. Case in point, Alaska. They're sending out fundraising letters to "support Joe Miller" in the vote count. Do you really, REALLY thing the GOP or NRSC will waste dollar one once they call the election for Murkowski? It's all a stupid lie.

It's yet another stupid, empty threat that the bulk of Republicans sill realize is so wildly fucking insane that it's almost laughable to even pretend they might try to do it. But it makes a great fundraising e-mail. I've made the analogy before and I plan to keep making it: Democrats have donkeys; Republicans have elephants. The official mascot of the Tea Party should be the Sneetch.
posted by XQUZYPHYR at 1:11 PM on November 7, 2010 [5 favorites]

Fortunately, the same insurance industry lobbyists that help prevent the public option from ever actually being a real option at the federal level will be able to remind the law makers of the great state of Texas that the insurance industry likes the money they get from Medicaid just fine, thank you very much.
posted by MCMikeNamara at 1:14 PM on November 7, 2010 [4 favorites]

“There are still a number of unresolved issues at the federal level,” she said. “Some people are even trying to repeal it. There just hasn’t been a lot of information out on what it would mean to us.”

The comments on that piece. I'm struck a bit speechless. I used to think that remarks like fatbird's ("The poor, on the other hand, are a bunch of leeches, contributing nothing and taking everything, sucking directly from the lifeblood of the hard-working Texans who built the greatest state in the union") were hyperbole or exaggerated for the sake of making a point.... but they are direct quotations, in spirit if not in exact wording. Astonishing.
posted by jokeefe at 1:26 PM on November 7, 2010 [1 favorite]

I wasn't too excited to see that this came from a State Rep. from Pampa (a small town in the Panhandle) and a State Sen. from Flower Mound (a well-off suburb of Dallas). But Perry! This might be the thing that finally drives him out! Take a look at the comments readers left in Houston Chronicle. The hate for Perry is palpable. We're calling him Gov. Goodhair again, just like Molly Ivins taught us.

I think this is Perry gearing up for a Presidential bid, though.
posted by Houstonian at 1:30 PM on November 7, 2010

I kinda hope they do it, get rid of Medicaid in Texas. It would be an interesting experiment.
posted by nomadicink at 1:34 PM on November 7, 2010

As long as you don't have to be one of those experimented on, hoarding your asthma medication or insulin because you have to choose between buying that and buying food....
posted by jokeefe at 1:37 PM on November 7, 2010 [3 favorites]

This is Medicaid not Medicare. I doubt taking away health care from some destitute poor people will make a big difference for their electoral prospects. The tea party got all the coverage in this election, and the tent cities got ignored.
posted by humanfont at 1:39 PM on November 7, 2010

Medicaid and CHIP go primarily to the low income types, most irritatingly those that tend to vote the wrong way in elections.

That's how I see this. "You voted for the wrong people, and we will punish you for your disloyalty." Plus it shores up the selfish I-got-mine base. Then they'll 'graciously' take that off the table and spin it as though they had a change of heart and it was the evil Democrats who forced them to suggest it.

Just another day of gambling with peoples' lives to improve the party image. Nothing to see here. Move along.
posted by cmyk at 1:42 PM on November 7, 2010 [1 favorite]

didn't Colorado have some sort of referendum (that failed) this past cycle to do away with taxation or some sort? I say put that on the ballot of every fucking state, lets see who is willing to put their money where their mouth is.

The crazy is just getting started, how far will Americans allow it to continue.
posted by edgeways at 1:44 PM on November 7, 2010

--They will lose a huge amount of funding from the federal government
--They already administer it, so what savings would they expect by creating an entirely new framework?

According to my Democratic congressman, Medicare rarely actually covers the cost of care (at least in my state).
We also already have a state-run insurance program.

So in our case, dropping out of medicare (and, crucially, being able to keep the money we send off to pay for it) would be a win.

I don't know how Texas does things, but it's possible this could just be a play for a more equitable distribution of funds.
posted by madajb at 1:48 PM on November 7, 2010 [1 favorite]

Hmm, medicare, medicaid.

Well, our insurance program targets mostly low-income folks, so maybe the numbers would still work out.
posted by madajb at 1:50 PM on November 7, 2010

Welcome to The Third World Texas. Hope y'all enjoy the Hell out of worse health care than Moldova! Yaaaay!
Next your daughters will be trafficked to marry rich old men to get health care. I sure hope Rick Perry has daughters.
posted by Katjusa Roquette at 1:52 PM on November 7, 2010 [2 favorites]

The US is slowly but surely becoming the biggest trainwreck in the history of trainwrecks.

The Republicans will solve this problem by defunding Amtrak.
posted by one more dead town's last parade at 1:54 PM on November 7, 2010 [29 favorites]

It's possible they're going to propose a replacement for Medicaid, you know. Something home grown. One of the biggest problems with Medicaid from a state budgetary perspective is that it's all or nothing: you provide all of the benefits mandated by Congress, or you get no federal money. And the fact that federal money isn't actually enough to pay for the program? Too damn bad.

Texas isn't the only state talking about it either. Indiana, which currently bears 35% of its Medicaid burden, is also talking about dropping out. And the new heath care law is sending Medicaid costs up, not down. To the tune of about $360 million a year. Considering that Indiana's annual budget is only $24 billion, that ain't chump change. Indiana made $300 million in cuts to its education budget this year, which is causing a lot of pain.

So talk of opting out of Medicaid completely isn't necessarily as bad as it sounds. The link in the FPP itself contains a discussion of maintaining some services, particularly long-term care, i.e. the kind of care that is most likely to be a problem for the poor, emergency medical care already being mandatory whether or not you can pay for it.

And here's where things get real: what would you rather do, cut funding for primary and secondary education, or funding for Medicaid? Because that's the position most of the states are in right now. Not cutting anything isn't an option, because most states are constitutionally prohibited from passing an unbalanced budget. Which is the only reason more of them aren't massively in the red the way the federal government is. You don't get to maximally fund all the programs you'd like. Every dollar you spend on Medicaid is a dollar you don't spend elsewhere. Dropping out of Medicaid in favor of a homegrown, stripped down version might be something more and more states are forced to do if they don't want to completely but their educational programs.
posted by valkyryn at 2:05 PM on November 7, 2010 [8 favorites]

I’m not from Texas, nor have I ever lived in Texas. I am from Washington State. We just overturned sales taxes on bottled water and candy, and voted down an income tax on people making more than 200K a year. Our (democrat) Governor is considering eliminating state Medicaid programs that support prescriptions, dental work, and hospice because our state does not have enough revenue to pay for required services such as public safety and education. So really, we’re not too far off of what’s happening in Texas – even though we still have democrats in charge of our state legislature.

Here is my completely personal and anecdotal perspective on what’s happening almost everywhere in our country. My parents are republicans. They vote against every tax – especially a state income tax. We have an almost 10% sales tax in Washington, which is mostly not deductible on federal taxes – but apparently there is some sort of principle attached to being opposed to an income tax. Whatever. They considered buying a second home in Arizona, and one of the big selling points was that there weren’t any school taxes/levies – hey, their kids are out of school! They really consider property taxes that go to schools as tuition for their own kids. And heck! They paid taxes when my brother and I went to school! Why should they pay for other peoples’ kids? They enjoy very generous federal retirement benefits because my dad worked for the navy. But screw those bus drivers and their demands to keep their benefits…which were negotiated and agreed upon. But whatever. Oh! And churches and charities and families should be the social support nets – not the government! But when my aunt needed $8k to re-vest in her state retirement plan, my mom dug in her heels and refused to help. She should have moved to a smaller place to save money! She should have kicked out her good-for-nothing adult son! She told me that it’s really not a big deal – it just meant $300 less per month for my aunt. Of course, it was the difference between $400 and $700. And my mom was an accountant. Apparently she couldn’t recognize that $300 was a HUGE deal in this situation.

So, basically, I’ve come to realize that my parents (and most other republicans) are really just selfish, scared children. Unless they directly benefit from something, they don’t want to contribute to it. They’re never going to need Medicaid! But they are sure happy to have Medicare! Apparently, they don’t see that they are both government-supported safety nets since they benefit from one, and (gasp) possibly help pay for the other. I think that the elimination of Medicaid, and the economic strangling of “Obamacare” is really going to happen.

Really, all of this awful, misogynistic crap just makes me want to move to somewhere sane.
posted by shrabster at 2:07 PM on November 7, 2010 [56 favorites]

Flower Mound?
posted by Ratio at 3:56 PM on November 7 [1 favorite +] [!] No other comments.

Home of, IIRC, Julie Colley, a pretty good wing for the Vanderbilt Lady 'Dores, back in the good old days of Jim Foster and Ashley McIlhiney. Saw them in the Sweet 16 in Denver the year Notre Dame won it all and Diana Taurasi went 1 for 25 in that brutal semifinal against the Irish. Remember how dominant Ruth Riley looked in that game?

Vanderbilt warmed up sloppy against Iowa State (Angie Welle, Erika Junod) but went on to mop up. Good bunch of games.

/derail
posted by toodleydoodley at 2:17 PM on November 7, 2010

All hat, no cattle. They won't drop out - the matching funds from the Fed is too much for them to cover by themselves. This is mostly hot air designed to show support for the monyed folks who *really* hate people less well-off them themselves.
posted by Old'n'Busted at 2:17 PM on November 7, 2010

> And it is just that ... posturing. Big talk, swagger and bluster with no follow-through are a cherished Texas tradition.

But they did manage to troll how many different mefi users so far? Lemme count...
posted by jfuller at 2:17 PM on November 7, 2010 [1 favorite]

what would you rather do, cut funding for primary and secondary education, or funding for Medicaid?

Neither. Cut funding and tax breaks for shit like a football stadium, shopping mall, and gambling casino.
And didn't Washington State just fail to pass an income tax bill that saved folks like Steve Ballmer a few billion in gains taxes?
posted by Old'n'Busted at 2:20 PM on November 7, 2010 [10 favorites]

Emergency medical care already being mandatory whether or not you can pay for it.

Yeah, but somebody still has to pay for it, after all, and if people lose Medicaid coverage, many of them will just go to the Emergency Room instead, given the EMTALA mandate to treat them there. For that matter, if former Medicaid beneficiaries lose support for managing conditions like diabetes or asthma through a primary care doctor, they're going to be having a lot more medical emergencies. Hospitals can't just absorb the cost of this, their margins are mostly thin or non-existent as it is. Unless the state acute care system as a whole is to collapse, the money will still have to come from somewhere - and where exactly will that be if not from Medicaid?

There's simply no way to make the numbers add up on dropping state Medicaid programs unless the federal Republicans can somehow get EMTALA repealed and just leave the uninsured to die on the street.

Notice they want to end Medicaid, but don't mention Medicare. Why is one socialism and the other not? Could it be because old people vote and poor people don't?

Well, it may have something to do with the fact that state government has no role in administering Medicare, and so they have no authority to touch it even if they want to.
posted by strangely stunted trees at 2:28 PM on November 7, 2010 [4 favorites]

Something about decreasing the surplus population.
posted by kafziel at 2:32 PM on November 7, 2010 [4 favorites]

Texas isn't the only state talking about it either. Indiana, which currently bears 35% of its Medicaid burden, is also talking about dropping out. And the new heath care law is sending Medicaid costs up, not down. To the tune of about $360 million a year. Considering that Indiana's annual budget is only $24 billion, that ain't chump change. Indiana made $300 million in cuts to its education budget this year, which is causing a lot of pain.

The Kaiser foundation has looked at the impact across many states. Some places will go down, some wil go up. The increase you cite ios between now and 2014 and should be able to be covered by modest increases in revenue from growing your economy.
posted by humanfont at 2:32 PM on November 7, 2010 [1 favorite]

sour cream: "The US is slowly but surely becoming the biggest trainwreck in the history of trainwrecks."

One wonders if this sort of knee-jerk anti-tax, anti-social democracy measures is going to start being referenced by progressive politicians in other countries. "Look, if we cut taxes like my opponent is saying, we're going to have to cut things. Have you heard the news out of the US? Do you want our country to be like the USA? If you do, by all means, vote for him. But you know the stories coming out of there. Would you want to live there ... really?"

Or maybe politicians in other countries are already saying this. I don't know. But maybe, in the long run, the final story of the US will be to serve as an example to which progressive politicians elsewhere can point when they want to scare their populace into not voting for conservative politicians.
posted by barnacles at 2:36 PM on November 7, 2010 [1 favorite]

Meanwhile, Mexico says "Phew!".
posted by srboisvert at 2:38 PM on November 7, 2010 [1 favorite]

Is there any electoral importance in Texas to the 550,000 Medicaid/Medicare dual eligibles?
posted by palindromic at 2:44 PM on November 7, 2010

And the new heath care law is sending Medicaid costs up, not down. To the tune of about $360 million a year. Considering that Indiana's annual budget is only $24 billion, that ain't chump change.

Am I doing my math wrong, or is 360,000,000 only 1.5% of 24,000,000,000? I mean, that's really not a lot overall, and as humanfont, could be made up through economic growth. If such a thing actually happens again in this country. /derail
posted by hippybear at 2:49 PM on November 7, 2010 [1 favorite]

Texas has 24,782,302 people. 550 000 / 24 782 302 = 0.0221932571. So, it's a pretty small group that has dual eligibility.
posted by Houstonian at 2:51 PM on November 7, 2010

the guy who puts- you-to- sleep- before- surgery charged me twice.

Well he did also wake you up at the end. But yeah, if you pay cash for healthcare you get screwed.

I have to say I am about ready to let the conservatives run health care for a while. It will take time, but they will eventually kill off a large part of their base.
posted by TedW at 2:52 PM on November 7, 2010 [3 favorites]

Not to interrupt all the Republican bashing, but the last graph of the story:

“I want to know whether our current Medicaid enrollees, and there certainly could be millions more by 2014, could be served more cost efficiently and see better outcomes in a state-run program,” Nelson said.

Nelson, at least, doesn't seem to want to throw all the medicaid recipients into the garbage, he wants to take care of them more inexpensively.

Did you all read the story, people?
posted by Huck500 at 3:02 PM on November 7, 2010 [2 favorites]

I have to say I am about ready to let the conservatives run health care for a while. It will take time, but they will eventually kill off a large part of their base.

That's one way to put it.
posted by Monochrome at 3:06 PM on November 7, 2010 [1 favorite]

Well, it may have something to do with the fact that state government has no role in administering Medicare, and so they have no authority to touch it even if they want to.

How interesting. It's almost as if one were set up to fail and the other was not.

Because old people, in theory, paid the taxes that support Medicare their entire lives, and are getting back now what they gave up earlier.

That's the theory but I think the reality is that defunding Medicare would be political suicide while defunding Medicaid is doable if none of your constituency is benefiting from it. Poor people pay a lot of taxes in this country even if they pay no income tax. A large part of that is FICA to support medical care for people who disproportionately vote to deny them medical care. Until healthcare is recognized as a fundamental right and the majority sees that the social safety net as something that benefits them and their families it will be easy for reactionaries to dismantle it. After all it is something we pay for that benefits those people. Most of us though spend out whole lives just a couple of paychecks away from becoming one of those people.
posted by Tashtego at 3:07 PM on November 7, 2010 [4 favorites]

Education or health care? While that is certainly a Sophie's choice, I gotta go health care.

I am far more confident in the average person's ability to homeschool than I am confident in their ability to set a bone, manage asthma or diabetes, or do heart surgery. Yeah, I know that puts the screws to college students and everybody with parents who can't homeschool, but I guess I'd rather have people illiterate than dead. If I have to decide, that is.

Still, I don't think this is a funding problem. I think it's a priorities problem. Cut military spending by the amount that Robert Gates wants to cut it, eliminate the drug war, end earmarks, hell, stop spending money on the interstate highway system, and then I'll choose, for real, between health care and education.

I know everybody's broke and the federal government is deep in debt. But letting people die doesn't solve much.
posted by Leta at 3:16 PM on November 7, 2010 [3 favorites]

Huck500: I think there's skepticism about whether they will actually receive adequate care under a plan run by the state of Texas. Texas is big, but it doesn't have the number of enrollees that the entire medicare system does, and that larger pooling of risk and the related economies of scale should mean lower prices (I say should because I don't know what sort of restrictions are placed on medicaid bargaining and risk pooling). Add to that federal matching funds, and I don't see how they would be able to provide the same level of care without incurring even more expenses than they do now. So they aren't going to remove healthcare entirely, but they'd have to dramatically reduce the scope of coverage.
posted by Marty Marx at 3:20 PM on November 7, 2010

If you voted for these motherfuckers, as many poor Texans did, you deserve what you get, including an earlier death.

Sorry, I just hardly care about people willing to vote against their own interests. As ye reap, so shall ye sow.

Anyway, Jesus will take care of everyone who is white. Mexicans are on your own.
posted by fourcheesemac at 3:21 PM on November 7, 2010 [1 favorite]

"I know everybody's broke and the federal government is deep in debt. But letting people die doesn't solve much."

Sure it does. That's the damn plan.
posted by fourcheesemac at 3:23 PM on November 7, 2010

Education or health care? While that is certainly a Sophie's choice, I gotta go health care raise taxes on the rich and on corporations.
posted by Saxon Kane at 3:26 PM on November 7, 2010 [13 favorites]

I'd like to think this is all hat and no cattle, but with the majorities that Republicans will be holding in both houses of the Texas legislature next session, it's not impossible. On the other hand, it's likely that the state will be too busy dealing with the actual fiscal crisis going on in the state to have time to really screw things over worse during the regular sessions. The idea that Rick Perry might call a special session to dismantle Medicaid as part of the presidential bid I'm sure he's gearing up for in 2012 scares the hell out of me though.

(FTNITK, the Texas legislature meets for 180 days in the biennium and otherwise only meets if the governor calls them into a special session for a specific reason. And don't look at me, I voted straight ticket D except where I voted Green.)
posted by immlass at 3:32 PM on November 7, 2010 [1 favorite]

fourcheesemac: "If you voted for these motherfuckers, as many poor Texans did, you deserve what you get, including an earlier death."

I tried. Boy howdy, did I try. I worked for Bill White's phone bank, voted for Tracey Smith, campaigned for Linda Chavez-Thompson, and had signs for Barbara Ann Radnofsky. However, none of that would make a difference. Why? Because I live in northeast Tarrant County (county seat: Fort Worth), arguably the 2nd-most Tea Party-concentrated area in all of north Texas. There's no Democrat or Green party representative on either the state House or Senate races, nor virtually any of the elected judges. See for yourself on a ballot from near me. The Democrats stuck to mostly state- or county-wide races and completely bailed on my section of the woods.

Know what's funny? I would love to live elsewhere, preferably in somewhere more liberal, maybe even in a state that's more liberal. The cost of living elsewhere, or even just getting housing--probably because those other areas are more popular--is so much higher, I can't afford it for my family. Even moving to a less Tea Party-infested area in north Texas would cause my rent to be much higher than it is, and that just doesn't fly. So, instead, I vote every time I can, lobby my friends and neighbors, and contribute money or time where possible.
posted by fireoyster at 3:37 PM on November 7, 2010 [11 favorites]

what would you rather do, cut funding for primary and secondary education, or funding for Medicaid?

I would rather raise taxes.

This is where they attempt to drown government in the bathtub; it's been a long 30 years, but finally their end goal is in sight.

The more I think about it the more I'm convinced that the Republican "endgame", that is, their ultimate goal for America, is some kind of steampunk .C.S.A that won the Civil War and went on to dominate the world. They basically want to take our social mores back to the 1850's (check), they find most new technology to be dangerous or suspicious (so there won't be any internet, or if there is it'll be highly limited -- maybe no pictures? No solar panels either. Too green.), unfettered capitalism and prison farms instead of slave plantations (still staffed primarily by blacks, though).

So if you want to imagine Tea Party America circa 2030, imagine the Confederacy, but with jet fighters, nukes and the Old Tyme Gospel Hour on TV. Maybe coal-fired zepplins patrolling our cities too.
posted by Avenger at 3:37 PM on November 7, 2010 [17 favorites]

I hate articles written like this. The numbers are really confusing, even after I break them down.

The state has a $25billion budget shortfall. Is that an annual number? The Heritage Foundation (gah!) says that TX could save $60billion between 2013 and 2019 if they drop out of the program. So, no immediate effects, and that's under $10billion a year in savings. The program costs $40billion per biennium, so $20billion a year, but the Federal government covers 60% of that, so TX is on the hook for $8billion a year for their program.

And they somehow think they're going to do a decent job on less than $8billion a year caring for 3.6 million children and adults they currently have on the roles. (It has to be less than $8billion if they're going to SAVE money by doing this.) Oh, no, wait. They'll do it by "dropping coverage for acute care but continuing to fund long-term care services." So, they'll offer fewer services for less money. Well, hell. Anyone can do that.

When the Affordable Care Act was being debated, I saw more than one report that said it was only addressing half the problem. The insurance side is covered (sort of) -- when do we do something about actually bringing down the COSTS of health care?
posted by hippybear at 3:40 PM on November 7, 2010 [1 favorite]

And they somehow think they're going to do a decent job on less than $8billion a year caring for 3.6 million children and adults they currently have on the roles.

And doing a bit more math... that's just over $2200 per person, per year.

Somehow, I don't think they have any clue what they're saying when they think they can do this for less money.
posted by hippybear at 3:45 PM on November 7, 2010 [3 favorites]

And here's where things get real: what would you rather do, cut funding for primary and secondary education, or funding for Medicaid?

You can't seriously believe that this is the question. It's nowhere near that principled - the same asshats that want to drop Medicaid want to kill the federal education system, too. Not instead of. Listen to any of these leaders - this is not about cutting spending, it's about shutting down things they don't like.

The drown-the-government-in-the-bathtub bombthrowers are dangerously, deliriously, insanely wrongheaded and dangerous right now. This is not some principled intellectual disagreement over the role of government. It's a full-on assault of New Deal America; a fight the right has been itching to have for 70 years.
posted by Benny Andajetz at 3:45 PM on November 7, 2010 [17 favorites]

hippybear: "The state has a $25billion budget shortfall. Is that an annual number?"

That's a biannual number, so $12.5 billion/year. The Texas legislature meets every two years, and the only constitutionally-required step during that time is to adopt the state budget for the two years following when the legislature concludes. Restated: The budget year concludes on August 31 of each odd-numbered year, so the legislature adopts the budget for September 1 onward until August 31 of the next odd-numbered year.

Clear as mud? :)
posted by fireoyster at 3:46 PM on November 7, 2010

No, thank you fireoyster. That answered one of my questions quite clearly.
posted by hippybear at 3:48 PM on November 7, 2010

Sorry, I just hardly care about people willing to vote against their own interests. As ye reap, so shall ye sow.

You sound like you're three-quarters of the way to being a Republican yourself.
posted by strangely stunted trees at 3:51 PM on November 7, 2010

And hoping that other States enact (and the Fed's support) a 1 year residency law so poor/disabled/children from Texas do not move to States with Medicaid--It is an interesting , if not severely morally compromised experiment, if Texas is forced to deal with the problems it creates.
posted by rmhsinc at 4:15 PM on November 7, 2010

Sorry, I just hardly care about people willing to vote against their own interests. As ye reap, so shall ye sow.

This is, I think, a major impediment to social change. When confronted with apparent injustice, there is a tendency to come up with a narrative for why it is, in fact, just. The same thing happens with wrongful convictions ("He must have done something"), deaths from illegal abortions ("She wouldn't have been at risk if she hadn't been a slut/broke the law"), racial discrimination ("If they'd pull their pants up people wouldn't confuse them with drug dealers!"), the so-called undeserving poor, ("They don't have health insurance because they're too lazy to work!") and so on. I suppose this makes it easier to go on from day to day, but it also hides injustice, which makes it harder to mobilize public opinion in favor of remedying it.

The fiction here is that the folks who die or receive substandard care deserve to die or receive substandard care because they voted for these jerks. That's not the case, since not all people receiving medicaid benefits voted for people who support scrapping medicaid.

It is worth pointing out that many of the poor are formally disenfranchised through felon voting laws, or practically disenfranchised through the variety of voter suppression efforts (voter ID, caging lists, inadequate polling infrastructure, etc.). Further, certain non-citizens are eligible for medicaid in Texas, but not eligible to vote, and many citizens under 18 are also beneficiaries of CHIP.

Sometimes an injustice is just what it seems: injustice. Coming up with explanations for not caring is part of the problem of injustice, not part of the solution.
posted by Marty Marx at 4:18 PM on November 7, 2010 [29 favorites]

Flower Mound?

Fucking hell on earth. Rich suburb of Dallas. Just absolute hell. Also, Warren Chisolm is like our lown little miniature Jesse Helms. A very angry, ignorant little man who has not denied being a pig-fucker, form what I hear.

This has got to be political theater, designed as red meat for the Teabaggers, but also doomed to fail by design. It'd be financial suicide for the state, as well.

“I want to know whether our current Medicaid enrollees, and there certainly could be millions more by 2014, could be served more cost efficiently and see better outcomes in a state-run program,”

The bolded bit there reads like a "Bad, bad brown people from sath uh th' border" dog whistle to me. The only thing that gives me hope, long-term is that the Texas Republicans are throwing the fastest-growing demographic under the bus for short-term Teabagger street cred, and that by the time my kids are grown up enough to care about politics, this will have utterly backfired on their miserable, selfish know-nothing asses.

Short-term, I am utterly bereft of all hope. I think I have to stop even paying attention now, for the sake of my sanity. I really don't want to hurt somebody, because that would involve jail time, and this shit gives me violent urges.

I will forthwith absent myself from threads with the word Texas in the title for a goodly spell, I think. Please be nice to my mefi Texan friends, willya?
posted by Devils Rancher at 4:31 PM on November 7, 2010 [2 favorites]

Like fireoyster said, my family and I would love to move if we could afford it. I mean, I'm gay, liberal, atheist, and mentally ill -- you REALLY think I would live here in Texas if I had any choice? I've got a lifetime's worth of reasons to hate this fucking state already; me and my sick Medicaid-dependent mother weren't really in the market for any new ones, thanks.
posted by Noah at 4:39 PM on November 7, 2010 [10 favorites]

Has anyone mentioned Rick Perry's hair? It is gigantic.
posted by gordie at 4:43 PM on November 7, 2010

when do we do something about actually bringing down the COSTS of health care?

We don't. The only way of spending less on health care is consuming less health care.

That's what Europe's doing, by the way. Sure, they've got better access to primary care, but primary care is cheap. Their cancer survival rates are way worse than ours--which are the best in the world. This is significant, because treating cancer is really, really expensive. End of life issues are, generally, and something like 60-70% of the Medicare budget goes to the last six months of life. I'd imagine that private insurers' cost structures are similar.

The ironic thing is that we could spend trillions on fighting cancer and 95% of the people that were going to die from cancer would still do so anyway. In exchange for our billions, retirees get an extra couple of infirm months. You could send two kids to college for what it costs to give one senior citizen the full course of cancer treatments. Heck, slash spending on end-of-life care--replace attempts at treatment with hospice and palliative care, particularly home nursing--and you could easily save a couple of hundred billion annually.

But telling old people--and cancer is still mostly a disease of the old--that they can't have heroic attempts to treat their cancer isn't really much of a viable option, politically. Regardless, that's why the US spends so much on health care and yet so many people don't have full access to the system. We're spending far, far more than is optimal on the old.
posted by valkyryn at 4:46 PM on November 7, 2010 [13 favorites]

By returning tax rates for those making 250k/year and above to the levels enjoyed under Saint Ronald Reagan we would have enough to fund all of this.
posted by humanfont at 5:10 PM on November 7, 2010

valkryn:

God knows you fight the conservative battle here, and more power to you. But not every issue comes down to money. Values have to come first; if an issue is important enough in our value system, then the money can be prioritized.

Doing it the other way, IMO, is ass-backwards. And the National Center for Policy Analysis you reference above are firmly entrenched in the ass-backwards camp.

From their web site:

Our experts have extensive knowledge in free-market health reform and consumer-driven health care. (This is right next to raving NCPA testimonials from Newt Gingrich and John Stossel).

Simply put, if you have to put "free-market" in front of "health care", then "health care" is not your main concern.
posted by Benny Andajetz at 5:11 PM on November 7, 2010 [7 favorites]

"Teabaggers are useful because it gets the GOP votes and money idiots."

FTFY.
posted by vhsiv at 5:28 PM on November 7, 2010 [1 favorite]

Why does government exist if not to care for its people?
posted by giraffe at 5:41 PM on November 7, 2010 [2 favorites]

On one hand, it feels good to hope Texas pulls the trigger, and that the federal gov't in turn pulls all the other subsidies it gives the parasites who run that state deeper into the ground. Let Texas feel some consequences for its belligerence, for once.

On the other hand, there are real human beings who keep getting the shaft time and time again who are unlucky enough to live in a place like Texas, who don't deserve to have their medical care taken from them just because the state is dominated by assholes. So, I hope common sense and basic humanity prevails.
posted by Blazecock Pileon at 5:58 PM on November 7, 2010 [1 favorite]

By returning tax rates for those making 250k/year and above to the levels enjoyed under Saint Ronald Reagan we would have enough to fund all of this.

True, but I wish people would stop using the this language, which has served the right well. It's income over $250K/year on which we want to let taxes go back to the pre-Bush rate. Saying "those making 250k/year" makes it sound like those people would no longer be getting a tax cut, which of course they still will.
posted by nicwolff at 6:18 PM on November 7, 2010 [1 favorite]

These are the same pernicious bastards that want to make it a federal offense for clergy to perform gay weddings in Texas. I swear on all that is holy, if they pass that into effect I am going to gay-marry people all over their big stupid state. I will become a gay-marrying ninja and make it rain gay weddings until they are in the midst of some fabulous tulle monsoon. They can stick me in prison and I will gay-marry the prisoners. Mark my words.

shrabster: Really, all of this awful, misogynistic crap just makes me want to move to somewhere sane.

I was seventeen years old when W was elected. I was spittin' mad. I told my dad that as soon as was able I was moving off to Canada and that was it. (I grew up in rural Michigan so it wasn't a crazy stretch.) And you know what he said? He laughed at me and called me a coward. My dad (and his dad and my mom's dad and all the freaking dads in my family) was military. And he said that he had to fight with a gun so I could fight with words. He said if I ran off to Canada I would be taking all my talents and abilities with me and I would be abandoning all the Americans who couldn't just run off to Canada. All of the Americans who needed me to stay and fight for a country worth living in.

Dad passed away before I could really push the issue. But Norway looks awesome. Speaking as a native Michigander, Norway looks absolutely spectacular. And the crazier things get, the closer I get to saying, "You know what? I could do it, I have marketable skills, I don't have children yet, I could actually swing this thing." But my dad's lecture still sticks in my throat and when I see these evil bastards carrying out their evil bastard plans, I still shake my fist at them and vow to fight them till my dying breath. Because I still believe that America can be awesome. But we're stumbling backwards right now.
posted by Baby_Balrog at 6:22 PM on November 7, 2010 [49 favorites]

I swear on all that is holy, if they pass that into effect I am going to gay-marry people all over their big stupid state. I will become a gay-marrying ninja and make it rain gay weddings until they are in the midst of some fabulous tulle monsoon. They can stick me in prison and I will gay-marry the prisoners. Mark my words.

That is fantastic. No. Fabulous.
posted by Marty Marx at 6:57 PM on November 7, 2010 [5 favorites]

Can anyone speak to what the fuck the Republican end-goal with respect to government is? I honestly can't understand it - agrarian/hunter-gatherers? With fighter jets?

A company town with tax subsidized fighter jets.
posted by bionic.junkie at 6:58 PM on November 7, 2010 [2 favorites]

We don't. The only way of spending less on health care is consuming less health care.

That's not obviously true at all.

Another way of spending less on health care is by paying medical providers less. I mean, it's not written in 100-foot letters of fire straight from God that physicians have to get paid $150K+. An easy way to do this would just be to directly reduce payments, but you could also go a long way towards this by simply ramping up medical admissions and increasing the supply of physicians.

Another way of spending less on health care is by paying pharmaceutical manufacturers less. In real life, this is also something that the rest of the world does. Obviously going along with this you'd have to have the government directly funding more pharmaceutical research.

More generally, there are probably lots of rents in the medical sector that could be eliminated.
posted by ROU_Xenophobe at 7:11 PM on November 7, 2010 [4 favorites]

The only way of spending less on health care is consuming less health care.

The only way of spending less on apples is consuming fewer apples. Or--WAIT--what if we made apples cheaper?

The ironic thing is that we could spend trillions on fighting cancer and 95% of the people that were going to die from cancer would still do so anyway. ... But telling old people--and cancer is still mostly a disease of the old--that they can't have heroic attempts to treat their cancer isn't really much of a viable option, politically.

Sure it is. We just have to be honest about why those heroic attempts are so expensive. What is it about something like docetaxel that makes it cost over a thousand bucks a dose? Who footed the bill for the research into its effectiveness? If taxpayers helped out through NIH grants, or through research done at publically-funded universities, shouldn't they get the drug at a discounted rate? If Grandpa gets talked into having a proton beam aimed at his prostate, maybe he'd like to know that the treatment will cost something like 40,000 dollars, and that the treatment center costs somewhere over 100 million. Maybe he'd like to know why it's so expensive.

I tend to agree that tacking on a few miserable side-effect-ridden months at the end of life isn't much of a goal, and it's a fine debate to have--but the cost of adding those months is, well, fake. It's a scam.

Regardless, that's why the US spends so much on health care and yet so many people don't have full access to the system. We're spending far, far more than is optimal on the old.

We spend far, far more than is optimal on pretty much every area of care. It's a redistribution racket. It's an inefficient one, of course; I'm sure that Texas could find simpler ways of moving the money upwards by cutting out the middleman (or, in CHIP's case, middleinfant).
posted by mittens at 7:12 PM on November 7, 2010 [4 favorites]

Why does government exist if not to care for its people?

Government exists to make itself a profit. I should know, I am a government worker and I am insanely wealthy. Just yesterday, I walked over to the store and bought a Totino's Party Pizza. Now, I could never do that without Medicaid making bank. Fuck you, Texas.

I hope Texas does make this happen. I don't know anybody from Texas, so I won't be affected by this social experiment. Poor people could stop being poor if they just got motivated. Maybe dying is just the sort of motivation they need.
posted by Foam Pants at 7:15 PM on November 7, 2010

I think this is potentially a very strategic move to (further) demonize "Obamacare" and make it's "failure" the rallying point of the next election. Of course it will all be lies and spin, but when 2012 comes around, all they'll have to say is "How do you like Obamacare now that the State of Texas can't afford to help your grandmother continue buying the medications that keep her alive?"

And it will work, flawlessly. The democrats won't know what hit them (as usual). Death panels, indeed.
posted by treepour at 7:22 PM on November 7, 2010 [1 favorite]

Obviously going along with this you'd have to have the government directly funding more pharmaceutical research.

I think this would be a great idea (although drug companies would then spend an even greater amount on marketing in proportion to their research costs...I think marketing currently consumes about twice as much as the research does), if we could be sure we weren't just throwing a fat subsidy towards the manufacturers. Research funded by the government is great, but us actually getting something for that money would be socialism.
posted by mittens at 7:27 PM on November 7, 2010

...drug companies would then spend an even greater amount on marketing in proportion to their research costs...I think marketing currently consumes about twice as much as the research does

You could just stop them spending all of that money on advertising. Though I imagine that would be unconstitutional. Darn First Amendment.
posted by greymullet at 7:46 PM on November 7, 2010 [3 favorites]

Political suicide. Why? Long-term care.

We can go on and on about how Medicaid doesn't affect the typical Republican base. But Medicare doesn't pay for assisted living or nursing homes. That's Medicaid. A surprising amount of middle class folks end up needing this assistance. And it's not just the patients that are affected by this. It's their families as well. This proposal (which is just a talking point, they'll never go anywhere with it because they know it's a bad idea) would result in tens of thousands of people suddenly without the living help they need. That in itself would make for sone headlines. (Many nursing homes and assisted living facilities would have to close down if this ever happened.) Then picture tens of thousands of middle class families, many struggling to make ends meet, what comes next. Either you come up with $2000 a month, or mom has to move in with you. Oh, and you have to be a caregiver (a full time job and then some) as well as figure out how to fit this in your work schedule.

It's just smoke and mirrors to keep the base happy. They can't start a state run program. Good luck making a go of that without the big helping of federal Medicaid funds. And good luck dealing with more increases in the cost of health care when hundreds of thousands of Texans are forced to use the ER for primary care, without any way to pay.

Just remember - don't mess with Texas, because that place is already messed up enough.
posted by azpenguin at 9:34 PM on November 7, 2010

In climate politics, Texas aims to be the anti-California: The state has filed seven lawsuits against the EPA, and its members of Congress want to check the EPA's efforts to curb greenhouse gases. 'At times they're their own country,' one observer says.
posted by homunculus at 9:55 PM on November 7, 2010

I've never understood the complaint about drug companies spending money on advertising. Without advertising, fewer people would buy their product, and they would make less money, so from a Net income perspective advertising has a negative cost. They don't just buy those ads for fun.
posted by delmoi at 12:26 AM on November 8, 2010

And he said that he had to fight with a gun so I could fight with words.

The thing about this is most of our wars have hardly been about protecting American liberty, with a couple obvious exceptions. And while at times military force is rquired to protect or gain liberty, liberty itself does not flow eternal from the sword. This may be crazy enough to get you to move to Norway (which does look nice) I wouldn't flee as if there is no hope quite yet.
posted by IvoShandor at 12:41 AM on November 8, 2010

I've never understood the complaint about drug companies spending money on advertising. Without advertising, fewer people would buy their product, and they would make less money, so from a Net income perspective advertising has a negative cost.

You realize that the money doesn't come from nowhere, right? And that most people aren't educated enough to make informed decisions about drugs, and that fact is exactly what the drug companies bet on, right?
posted by Philosopher Dirtbike at 1:20 AM on November 8, 2010

But Norway looks awesome. Speaking as a native Michigander, Norway looks absolutely spectacular. And the crazier things get, the closer I get to saying, "You know what? I could do it, I have marketable skills, I don't have children yet, I could actually swing this thing."

I did this. Not Norway, but still, I had the same sentiment. I could go on and on about all the reasons, politics, quality of life, health care, social security, the economy, cost of living, the wars, the social conservatives ... but I'm sure you know already; if Norway looks spectacular to you then you already know.

Instead of going on about the big issue things, I'll just note that I take public transit to work when its too cold or wet to bike, and come home to a rent controlled apartment that's affordable. I am allowed sit on the banks of the canal and enjoy a beer. I can see my doctor same-day if I need to and it costs 10€ once every 3 months. The little things are what make the difference.

I make about half what I used to after taxes. Now if you offered most people, especially the young and skilled, if they would take a 50% pay cut in exchange for public transit and health care, they wouldn't take it. I don't think they value the intangibles as much as the income. If you want to get rich, then America is the place to be. This is the crux, and cutting medicaid is just the logical next step in the American philosophy: work hard, and everyone for themselves.

I feel like you either buy into this or you don't. Cutting medicaid is just political noise, questioning how far exactly to take the philosophy. I guess I didn't buy into the American Dream, which is why I don't regret leaving the states one bit.
posted by cotterpin at 1:40 AM on November 8, 2010 [8 favorites]

All of the Americans who needed me to stay and fight for a country worth living in.

I don't really get this. America was a brilliant experiment; version 1.0 of what a somewhat modern representational republic might look like. But it's quite clear that it was too early to market, and in the intervening years, bugs have cropped up, patches have been released, and now it's a slow, buggy, broken mess. Adherents cling to the strange belief that because it's version 1.0, it must be best. They believe that their quaint little documents, written by slaveholders who read by candlelight and had no idea what germ theory is, can never be improved upon. Since America released 1.0, with it's 27 service packs and 200+ years of established patches, many other vendors, particularly in Europe, have taken the good ideas from America and incorporated it into their own products. Products which include most of America's features with fewer bugs, as well as much nicer UIs and more efficient uses of system resources.

The United States of America, as a large organization, is resistant to upgrading to a better system (indeed, they seem devoted to moving back to a beta version, for some reason), and I can understand that - license management is a nightmare and who knows what weird shims are floating around in unknown systems locked in closets. But individuals don't have these restrictions, so if they happen to have the opportunity to upgrade, why not take it?
posted by cmonkey at 3:27 AM on November 8, 2010 [22 favorites]

cotterpin: It's not even a 50% pay cut, though - it's not as if there's zero tax in the US and 50% tax in Norway, even if you took into account sales tax, etc.
posted by adrianhon at 3:45 AM on November 8, 2010

Sorry, I misread your post - my bad!
posted by adrianhon at 3:49 AM on November 8, 2010

How do you like Obamacare now that the State of Texas can't afford to help your grandmother continue buying the medications that keep her alive?

No, that's not it. Medicaid is not the same thing as Medicare. The former has significant state-run components and is used to pay for medical care for the poor. The latter is entirely federal and is used to pay for medical care for the elderly and disabled persons. States can't actually do anything about the latter, but it doesn't cost them much. So for good or ill, opting out of Medicaid will do nothing to stir up the senior vote.
posted by valkyryn at 4:27 AM on November 8, 2010

I've never understood the complaint about drug companies spending money on advertising. Without advertising, fewer people would buy their product, and they would make less money, so from a Net income perspective advertising has a negative cost. They don't just buy those ads for fun.

I'd add a couple of things to Philosopher Dirtbike's comment. This isn't iPads we're talking about, where an advertisement might convince you that you wanted something enough to buy it, even if you didn't need it. Medicine should be about real needs being met, not artificial needs being created in the mind of a consumer, nor artificial solutions being created in the minds of doctors. If you go to the doctor saying you've just seen this great new advertisement for a drug that fights PAD, your doctor should say, that's irrelevant, you don't have PAD, and besides, we'd base that decision on research and your history, not how shiny the ad made the drug seem.

They don't buy those ads for fun. They buy them because the drug companies have been forced into searching out higher and higher profits for lesser and lesser drugs, so that the decision to use a particular drug can be driven by how great the ad is (either the ad the patient is presented with, or the ad the doctor is), without needing to acknowledge efficacy, side-effects, or cost.
posted by mittens at 4:32 AM on November 8, 2010

Another way of spending less on health care is by paying medical providers less.

There's a problem: medical school is expensive. My girlfriend is currently a resident and will be sitting on about $250k in student debt when she finishes. That's in the ballpark of $2000-2500 a month. At $150k, that'd be 20% of her gross income.

Remember that we're talking about perhaps the single most highly trained and highly specialized professionals in the country. There are only about 120 accredited medical schools in the country, which produce somewhere in the ballpark of 20,000 new physicians a year.

Also remember that unless you essentially require every single physician to become a government employee--a move which might not even be constitutional--if you cut reimbursements enough, physicians can and will simply stop accepting government insurance. It's already happening. There's generally only one, maybe two hospitals in any given city which will even accept Medicaid, the reimbursement rates are so bad. Most hospitals currently limit the number of Medicare patients they treat too, as treating too many of them is a surefire route to bankruptcy.

Heck, there are even physicians who are refusing to accept insurance at all. You pay cash at the time of service or you go somewhere else. The thing is, they can afford to bill just a fraction of what other providers bill, because the other providers are only going to get cents on the dollar. It's still expensive, as the entire bill comes out of the patient's pocket, but physicians that have done this see their patient volume plummet and their revenue and profits skyrocket. So unless you want to completely eliminate the market for physicians, making health care a public utility administered by the government, there really is a floor to what physicians will accept.

So there are two alternatives, really. The first is to have more and more patient care provided by non-physicians. We're already doing that: physicians' assistants and nurse practitioners are in increased and increasing demand. But the American public likes being treated by highly trained physicians, so unless you find some way of making them pay for that--or being willing to be treated by someone else--that's going to be a tough sell.

The second is to nationalize health care. In addition to the constitutional and economic problems, that really isn't a realistic move right now. You're just never going to get that passed.

Myself, I'm perfectly willing to accept a solution which involves everyone just using less health care. The number of people who go to the emergency department for completely trivial ailments, hell, the number of people who go to the ED for completely non-medical things, is pretty stunning. The number of people with an actual emergency in the ED at any given time is usually way less than half. And we money we spend on prescription drugs is just mind-boggling. These new-fangled designer drugs are, in general, only marginally better--if at all--than the generic versions that have been on the market for decades, but sick people want to know that they're getting the absolute latest and best in medical care, even if that extra 5% benefit comes at a 500%, even 1000% cost increase.

Here's my proposal. Expand Medicare coverage to the entire population, but modify it, and link it to income. So every American would be on the hook for 5% of their annual income* in health expenses. Then the government will pay 90% of all your health care bills until you've spent 10% of your income.* After that, the government will pay 100% of your health care bills up to a maximum amount per year, which would be the same for everyone. Say $250,000. After that, everything is on you.

This would be paid for with a payroll tax increase of sufficient size to account for projected costs, but which would not be felt quite so keenly, as most people wouldn't need or want to buy private insurance. Those that wanted to could buy insurance to cover their deductible and co-pay, plus anything over $250k (or whatever) but most Americans probably wouldn't need that, and in any case, that coverage would be drastically cheaper than health coverage now.

It's not a perfect solution, but I like it for two reasons. First, it imposes a deductible on everyone. That deductible would be something that you can afford--and the very poor would be subsidized--but it requires you to keep an eye on your costs, both as they occur and over time. $250k is going to treat the vast majority of conditions, but it's those few, rare conditions that cost millions which really put a dent in things. Essentially, yeah, we'd just stop paying for those. This would lead to some tragedies, but that's just kind of how life is. I'd rather spend money on schools, roads, and the energy grid than on people who have only got six months to live whether or not we drop $100k on them.

Second, I think it's a lot more equitable than our current system. Now, health care is pretty much unavoidably linked to employment, because that's the cheapest way to pay for it. This essentially puts an unfair burden on the self-employed and unemployed which really doesn't need to be there. It also requires everyone to pay the same relative amount of their income. The administrative costs of figuring that part out aren't zero, but that's something I'm willing to spend money on.

Again, far from perfect. But it gives people choices, and makes them take an active role in keeping costs down. The complete lack of transparency in health care cost structuring is a big reason why costs are so high. Maybe one we actually force people to look at the cost of their care, they'll get serious about cutting back. I can't see that happening otherwise.

*Based on last year's tax return but with provision for an adjustment if your income has changed drastically.

**The very poor could be eligible for a tax credit here, subsidizing their deductible and co-pay for people below certain income thresholds.
posted by valkyryn at 4:55 AM on November 8, 2010 [3 favorites]

Valkryryn what I forgot and I think you did as well is that almost everyone ends up in Medicaid during the last few months of their life. Full time nursing homes are super expensive and at some point the state takes over the costs. A big fight in states is at what point should Medicaid step in so that there is money left for the surviving spouse or various heirs. E.g. you don't want the family farm to be lost because the nursing home bills. Estate planners make lots of money figuring out how to transfer assets so that your estate can be passed to the next generation or your spouse without being sucked into the nursing home costs. See

http://www.seniormag.com/legal/medicaid_nursing_home_planning.htm

http://www.ultratrust.com/medicaid-estate-planning.html
posted by humanfont at 4:56 AM on November 8, 2010 [3 favorites]

So for good or ill, opting out of Medicaid will do nothing to stir up the senior vote.

You vastly underestimate the Republican ability to misconstrue and confuse people about anything. Medicaid, medicare - you think any of their voters will know the difference? They still think he's Muslim FFS.
posted by fungible at 5:01 AM on November 8, 2010

Myself, I'm perfectly willing to accept a solution which involves everyone just using less health care. The number of people who go to the emergency department for completely trivial ailments, hell, the number of people who go to the ED for completely non-medical things, is pretty stunning. The number of people with an actual emergency in the ED at any given time is usually way less than half. And we money we spend on prescription drugs is just mind-boggling. These new-fangled designer drugs are, in general, only marginally better--if at all--than the generic versions that have been on the market for decades, but sick people want to know that they're getting the absolute latest and best in medical care, even if that extra 5% benefit comes at a 500%, even 1000% cost increase.

This is the best solution. There is evidence that a decent chunk of medical spending has zero or very little effect on health outcomes. This spending can easily be cut without any negative effects. The problem is this is unpopular with voters and when people are spending their own money they still spend it on useless medicine. Robin Hanson frequently makes the case that medicine is more about showing you care than making people better. The problem is people think your an asshole if you won't purchase the most expensive health care for your loved ones [that you can afford] or support the government buying expensive treatments even if there is no evidence that it is better or even as good as a cheaper alternative. I think the reactions in this thread and also the conservative attack on 'death panels' are good examples of the problem of cost control.
posted by drscroogemcduck at 5:25 AM on November 8, 2010 [1 favorite]

So for good or ill, opting out of Medicaid will do nothing to stir up the senior vote.

Opting out of Medicaid would mean that lots of people from their 50s up through their early 70s see their very elderly parents kicked out of nursing homes and are forced to take them in or impoverish themselves.

OTOH, Medicaid coverage of long-term care is virtually certain to implode in a few decades anyway as the boomers start needing it in large numbers.
posted by ROU_Xenophobe at 5:43 AM on November 8, 2010

if you cut reimbursements enough, physicians can and will simply stop accepting government insurance.

That's certainly their choice, if they want to see only patients without insurance or who are wealthy enough to have private insurance. They will, of course, see a drastic drop in income if they stop seeing Medicare patients, because they'd be competing for a much smaller pool of patients.

Why not make medical school less expensive?
posted by mittens at 5:54 AM on November 8, 2010 [1 favorite]

Valkryryn what I forgot and I think you did as well is that almost everyone ends up in Medicaid during the last few months of their life

Opting out of Medicaid would mean that lots of people from their 50s up through their early 70s see their very elderly parents kicked out of nursing homes and are forced to take them in or impoverish themselves.

Even the Texas proposal includes maintaining coverage for long-term care. Which the state might be able to do if it eliminates coverage for acute care. Kind of a bastardly thing to do, but it would prevent the senior vote from biting you in the ass. Which is probably why the proposal is in there.
posted by valkyryn at 5:57 AM on November 8, 2010

Paying for LTC without any federal contribution seems well into the realm of "Wait, you were serious? Let me laugh even harder." (not at you, at TX legislators)
posted by ROU_Xenophobe at 6:02 AM on November 8, 2010

valkryn:

There's a lot of sensible ideas in that plan. Hell, not a few of us lefties have been proposing a Medicare-for-all-kind-of-back-door-public-option system for a long time.

A not so obvious result of a plan like that would be increased bargaining power of the government in negotiating rates, drug costs, etc. This is what scares the health-care-as-profitable-business people.

Realize, though, that you are proposing more government involvement and more taxes. In exchange, however, you are getting better and more equitable coverage and more cost oversight.
posted by Benny Andajetz at 6:02 AM on November 8, 2010

They will, of course, see a drastic drop in income if they stop seeing Medicare patients, because they'd be competing for a much smaller pool of patients.

No, they probably won't. If you're losing money on every Medicare patient you see--which is true in a lot of specialties--eliminating them can only have a positive effect on your revenue.

The numbers I've seen indicate that a lot of hospitals have about 80% of their revenue coming from Medicare patients but 100% of their profits coming from private insurance. In essence, the people with private insurance are completely subsidizing the people on Medicare.

Why not make medical school less expensive?

And you'd cut... what exactly? Skyrocketing education costs aren't limited to medical school, and no one's figured out how to cut those costs either. Medical schools in particular are a tricky problem, as they require tons of highly-trained staff and lots of expensive equipment. Cost-per-student is way higher at medical schools than it is at other schools, where all you really need is classroom space and a part-time adjunct.

Saying that medical school ought to be cheaper doesn't make it that way.
posted by valkyryn at 6:06 AM on November 8, 2010 [1 favorite]

"Texas could save $60 billion between 2013 and 2019 by opting out of Medicaid and the Children’s Health Insurance Program, dropping coverage for acute care but continuing to fund long-term care services."

From the article in the OP. Italics mine.

Even Texas Republicans seem to understand that dumping a bunch of Alzheimer's patients on the street to become the next wave of homeless is an unworkable idea.

Old people vote Republican. But children don't vote at all.
posted by Leta at 6:08 AM on November 8, 2010

On preview, valkyryn beat me to it. Sorry.
posted by Leta at 6:10 AM on November 8, 2010

If you're losing money on every Medicare patient you see...

Explain this to me, because I've heard it before, but no one has ever told me what it means. I can see that if you're in the hospital, and your x-ray costs 5 bucks but Medicare pays 4, there would be a loss. But if you're in private practice and the Medicare patient is in the office, what is the actual cost of going into the room to see the patient?
posted by mittens at 6:17 AM on November 8, 2010 [1 favorite]

Realize, though, that you are proposing more government involvement and more taxes. In exchange, however, you are getting better and more equitable coverage and more cost oversight.

Well, yes and no. It isn't actually single-payer, because people would have to spend their own money and health insurance would still be something you could buy. I'd also want to pretty much eliminate the government apparatus for setting rates and costs, something I should have included in my above proposal. I do want the market to work out what given procedures actually do cost rather than having some bean-counter determine that by pulling a number out of his ass, which is basically what happens now.

I'd also want to completely eliminate the idea that "We'll pay for that procedure, but not that one."** Let patients direct their own care. Maybe they don't want to spend two weeks in the hospital, but right now they may have to because the home care they want isn't covered, despite it being a drastically cheaper--and more humane--solution.

Here's the thing: if you make $10k a year, you'd have to spend $500 before you got any help, but your next $500 would get you $5000 in care. A person making $100k a year would have to spend $5000 before they got any government assistance, and their next $5000 would get them $50,000 in care.* The vast majority of people don't need even $5000 in care on an annual basis. So by making people feel the pain a bit for the first dollar of their care, you incentivize people to consume less care throughout. I think it's at least plausible that you could replace the completely irrational way prices are set now with a system like this one--I could get an MRI, but the doc thinks I'm okay and it'd cost me $250, so maybe we'll skip it--could do a lot towards rationalizing the cost structure.

Which I think has got to be part of any serious solution. One of the reasons we consume so much health care is that people don't have any real sense of how much things cost, compounded by the fact that those costs are not determined by market forces. Radiological imaging is reimbursed at a higher rate than echocardiography or electrocardiography despite the fact that the latter are far, far more diagnostically useful all things considered. Why? Because the radiology lobby is more effective than the cardiology lobby at getting CMMS. There's something we need to eliminate.

But it is totally a higher tax solution. I've got no problem with that. Though. I may think the Tea Partiers are responding to real concerns about government expansion and deficit spending, but that doesn't mean I think they aren't crazy. The only way out of the current fiscal hole is a combination of spending cuts--which absolutely must include entitlement cuts--and tax increases. Just no two ways about it.

*Again, total government benefits would be capped at the same place for everyone, it's just that the government would bear a lower portion of that burden the more money you make.

**I think we'd probably have to put some limits here, but only at the level out outright quackery. Granted, that's a tough line to draw, but I think it'd be easier than the bizarre system of loopholes, exceptions, and contradictions that we've got now.
posted by valkyryn at 6:21 AM on November 8, 2010 [4 favorites]

"The numbers I've seen indicate that a lot of hospitals have about 80% of their revenue coming from Medicare patients but 100% of their profits coming from private insurance. In essence, the people with private insurance are completely subsidizing the people on Medicare."


That revenue goes a long way towards making possible anything that is more efficient in bulk, or that takes a wider patient base to justify.

Cut 80% of a hospital's revenues and see what's left.
posted by the young rope-rider at 6:22 AM on November 8, 2010

if you're in private practice and the Medicare patient is in the office, what is the actual cost of going into the room to see the patient?

Well, for starters, Medicare only pays about 30 cents for every dollar you bill. Medicaid reimbursements are even worse--in the teens in some states, I think. So it's a really huge discount, not a little off the top.

But the other thing is that running a medical practice isn't free. Take a radiology lab, for example. An MRI suite can easily cost $3 million to install. That's probably going to be some combination of leased equipment and mortgaged real estate and improvements. Then you've got to pay your tech to take the pictures, your receptionist to deal with the patients, your nurse to help you out. Those are fixed costs. You can realistically only do so many images a day, and you know what your daily expenses are, so you can come up with a cost-per-image figure pretty easily, even if actually going in an operating the machine doesn't require you to spend money every time. So if Medicare and Medicaid are paying less than your fixed costs, you're losing money.

All of that's before paying yourself a salary, by the way.
posted by valkyryn at 6:26 AM on November 8, 2010 [1 favorite]

Cut 80% of a hospital's revenues and see what's left.

A much smaller but economically sustainable hospital. Any efficiencies of scale benefits are easily eaten up by the administrative overhead of actually dealing with Medicare. Most hospitals employ a full-time staff just to deal with the billing. Stop accepting Medicare and that's easily a couple of dozen positions you can eliminate completely.
posted by valkyryn at 6:29 AM on November 8, 2010 [1 favorite]

If I'm reading it right, this is ridiculous:

"Here's the thing: if you make $10k a year, you'd have to spend $500 before you got any help, but your next $500 would get you $5000 in care. A person making $100k a year would have to spend $5000 before they got any government assistance, and their next $5000 would get them $50,000 in care.*"


Do you know how much 10k a year actually is for the people who make it? Where will they get those $500 to go get a physical? And if I'm reading you right, they need to pay $1,000 in order to get $5,000 worth of medical care. Where will they get that $1,000, while they are sick and possibly unable to work?

And then their money only gets them $5,000 in care, even though they're paying the same proportion of their income as the person who makes more--why, is the cost of health care less for the person with less income? Or do they simply get less of it?

Or maybe people with low incomes never need $50,000 worth of health care?
posted by the young rope-rider at 6:29 AM on November 8, 2010 [2 favorites]

But if you're in private practice and the Medicare patient is in the office, what is the actual cost of going into the room to see the patient?

Running a practice costs money. You have nurses and staff to pay, as well as the rent, utilities, malpractice coverage, etc. Although these costs are usually thought of as being charged on a monthly basis, they can be broken down into "dollars per hour the clinic is open." If it costs more per hour to run the clinic than Medicare will pay you for an hour's worth of office visits, you're losing money.

What Medicare does pay a sufficient amount for are drugs and procedures (e.g., surgeries, diagnostic procedures, etc). Doctors generally don't make money directly from drugs (oncology and anesthesiology being exceptions, as I understand it), so everybody becomes a specialist that does operations or procedures. End result: something like 2% of medical students go into general practice.

The remotely-politically-feasible solution is to pull money out of drugs by allowing Medicare to negotiate rates, pull some money out of procedures, and make the Medicare tax progressive to create more funding. Take all that money and make office visits profitable again (it'll take more than break-even to bring doctors back into general practice).

The real solution is universal healthcare that takes profit out of the equation, negotiates prices on drugs and devices, and brings physician and staff salaries down closer to those in other developed countries. While we're dreaming, we'll move to a fast, efficient, painless no-fault compensation scheme for physician negligence.
posted by jedicus at 6:39 AM on November 8, 2010 [3 favorites]

If you're losing money on every Medicare patient you see--which is true in a lot of specialties--eliminating them can only have a positive effect on your revenue.

No. It might have a positive impact on profit, but unless you posit that every former Medicare patient will find other insurance and still visit, eliminating Medicare will result in a drop in revenue, as those patients don't appear at all, and you don't even get the Medicare payment.

Of course, while it might have a positive effect on profit, your revenue may drop to the point where you can't stay in practice.

Any efficiencies of scale benefits are easily eaten up by the administrative overhead of actually dealing with Medicare.

It's not just medicare. It's Medicares, because there are a lot of them (typically, but not always, one per state) and the Medicaids (collectively, we call them The Blues.) But there are vastly more private payers to deal with than government payers, and unlike Medicaid, and to some extent, Medicare, the private payers all have very different systems that you have to submit to, and while we have a "standard" for claims now (ANSI X12 Version 4010 is current, 5010 is coming) but there's so much slop in the standard that you have to make edits for every different payer.

One of the fundamental problems of our health care system is that you can easily find yourself talking to over 500 different payers.
posted by eriko at 6:41 AM on November 8, 2010 [1 favorite]

So, valkyryn, it would be nice if you'd cite something because you're throwing around a lot of figures.

Having been in hospitals that take medicaid, medicare, and private insurance, I've seen billing departments that are much smaller than "dozens" of people.

Perhaps they were all hiding from me. I certainly can't find information about it on google, so I'm wondering where you're getting it from.
posted by the young rope-rider at 6:42 AM on November 8, 2010

Or maybe people with low incomes never need $50,000 worth of health care?

You missed the part of my proposal where after you've paid your bit the government picks up the rest up to an annual maximum.
posted by valkyryn at 6:52 AM on November 8, 2010

I'm wondering where you're getting it from.

Medicare billing is so complicated that there are entire businesses devoted to handling it.
posted by valkyryn at 6:56 AM on November 8, 2010

"Texas doesn't have a personal state income tax (which could surely help a little to dig them out of their hole). "

Let me introduce you to our property taxes...
posted by kaseijin at 7:02 AM on November 8, 2010

your revenue may drop to the point where you can't stay in practice.

That is an issue. I'm personally of the opinion that we're in a health care bubble, arguably caused by the entrance of the government as a major payer.

Health care spending per capita went from $352 a person in 1970 to $5711 a person in 2003, and was $7722 a person in 2008. Adjusted for inflation, that's still $1402 in 1970 dollars, an almost 300% increase. Factor out government spending on health care--$880 billion in 2008--and you're down to just under $1000 a person in 1970 dollars, still a 185% increase, but not nearly as bad.

In other words, just under 50% of the increase in health care expenditures can be accounted for with government spending.

I'm not saying that things would be more or less expensive if the government wasn't spending that money, I'm just saying that if the government wasn't spending money on health care, the rate at which health care would have grown as a sector of the economy would be different.

My conclusion from this is that all that extra money has led to the currently justified but fundamentally unsound belief--which doctors still hold--that going to medical school is a sure-fire ticket to an upper-middle class lifestyle because demand is such that you can basically write your own ticket, i.e. there is always enough money to pay for more doctors.

I have a ton of respect for doctors--I'm dating one, the son of one, and count a number of others as close family friends--but in my experience, their business sense is pretty uniformly terrible. So the fact that there's all this money floating around has effectively hidden from them the fact that a ton of it is actually from the government rather than any kind of organic demand curve. Which means that if the government decides it's going to change how it spends money, the medical community is fucked. Medicare may not be a profitable business plan, but it has enabled the expansion of the medical establishment to levels that I do not believe are justified. If we're going to consume less health care--which is what I'm suggesting--that means that we need fewer people providing health care. This would be a major shock to an industry which has assumed that is and always will be a growth industry without any actual reason to believe that's true.

This may need to happen. It may be that while doctors are just expensive to have around, they may actually have to--shock!--start competing on price. Which they totally aren't doing now. I think getting market forces back into pricing of health care would have that effect as well. As soon as doctors realize that patients are no longer willing to spend other people's money in unlimited quantities, they're going to have to start being more economical in their prescriptions and procedures, something they're totally not effective at right now.
posted by valkyryn at 7:12 AM on November 8, 2010 [2 favorites]

Well, yes and no. It isn't actually single-payer, because people would have to spend their own money and health insurance would still be something you could buy. I'd also want to pretty much eliminate the government apparatus for setting rates and costs, something I should have included in my above proposal. I do want the market to work out what given procedures actually do cost rather than having some bean-counter determine that by pulling a number out of his ass, which is basically what happens now.


Well,see, here's the thing - the government negotiating lower prices is free-market.

In the real "free-market" world, larger customers demand larger discounts. That's the way the market works.
posted by Benny Andajetz at 7:13 AM on November 8, 2010 [2 favorites]

Having been in hospitals that take medicaid, medicare, and private insurance, I've seen billing departments that are much smaller than "dozens" of people.

Try visiting again. In an effort to save money, the departments are being slashed to skeleton crews. It's a lot easier to fire a clerk (who of course then will not have insurance and can't afford healthcare) than it is to say, "Maybe buying this new PET scanner as a marketing gimmick wasn't the best use of our money."
posted by mittens at 7:31 AM on November 8, 2010

"Medicare billing is so complicated that there are entire businesses devoted to handling it."

valkyryn, I am aware of these businesses.

I was asking about your assertion that hospitals could cut a substantial amount of their costs by eliminating medicaid (although somehow we switched to eliminating medicare, too).

Can you cite any kind of figure for that? Proportion of medicare and medicare billing? Cost of billing those specifically, vs. private insurance?
posted by the young rope-rider at 7:32 AM on November 8, 2010

the government negotiating lower prices is free-market

No, it isn't, because the government doesn't actually negotiate. Even under the current system, the government dictates what it is going to pay, and then it pays that. Providers can either take that or not take Medicare/Medicaid patients. And we're talking about a hypothetical system where the government isn't just a "larger" customer, it's the only customer. Monopoly power works both ways, you know. Monopoly buyers aren't any better for the market than monopoly sellers.
posted by valkyryn at 7:55 AM on November 8, 2010

The medical system is dangerously unbalanced currently and while it's limping along a greying population is going to put more and more pressure on it as the baby boomers quit paying into the system and begin taking money out of the system.

Fortunately there are a ton of inefficiencies in the system that if reduced would achieve significant cost savings. Unfortunately a lot of the good solutions aren't politically practical.

Ones that I think could be implemented fairly rapidly and with minimal political costs are the following:

Eliminate Paper Charting/ Institute universal electronic medical records- I'm still shocked that so many doctor's offices still go with manual charting. My daughter's pediatrician's office has like 12 doctors in the group and still goes with manual charting. It's bulky, it's expensive, it's not particularly good, and it forces you to keep a large staff. Further it doesn't transport well at all so if you are seeing multiple specialists they don't really know what the hell the other doctor's are doing.

Eliminate differential payments- Right now doctor's maintain large billing departments in order to handle the complexities of billing medicare/medicaid/private insurance for umpteen billion procedures. They don't charge any of those providers the same amounts. Basically they transfer offset costs to the plans most willing to pay and try to avoid taking patients from plans that pay less. I think most Americans agree that people should pay the same price for the same services, as such I think there might be enough political will to force providers to provide upfront pricing on procedures.

Pay for outcomes not per procedure- Right now most payers pay per procedure done instead of outcomes. As such doctors are incentivized to subject patients to extensive and expensive screenings, and numerous procedures even if the medical evidence supporting those procedures isn't particularly compelling. Invariably when you go to doctor's office these days you will get a barrage of tests (often done in office in order to maximize revenues) even though in many cases they aren't going to be that useful as a diagnostic aid. This also encourages doctors to spend less time with patients as spending more than 5-10 minutes per patient reduces revenue per hour.

Honestly though most doctors are going to have to realize that pretty soon under the current system medical school will no longer an automatic ticket to upper middle class status. Medical School costs are skyrocketing as are the costs of running a doctor's office. Private payer only or concierge medicine might shore up their bottom line for a while but does anyone really think that there is that large of a payment pool for those types of doctor's services?

Doctors are going to have to decide do they want to perpetuate a system where their compensation is being squeezed by high start-up costs (medical school, cost of opening a doctor's office) and declining rates of compensation as well as rapidly increasing insurance rates. A comprehensive reform of the medical system in which doctors and insurers make less but still reasonable amounts seems like the only long term solution to me.

This Texas plan would be retarded. Basically you'd be getting rid of all the relatively cheap prevention based care and transferring those costs to emergency rooms which can't deny treatment. If your kid is sick you seek treatment, I think it's better (for society) to see them in a doctor's office instead of an emergency room (which from recent experience can be a hellish experience). Eliminating medicaid and CHIP would have a significant impact on hospitals that still maintain emergency services.

Of course if I try to explain this to some of my fellow Texans, they immediately transform into the typical "screw them, I got mine debating stance" even though this means that their outcomes are reduced by emergency services being overcrowded should they ever need the services of an emergency room.
posted by vuron at 8:02 AM on November 8, 2010 [1 favorite]

"No, it isn't, because the government doesn't actually negotiate. Even under the current system, the government dictates what it is going to pay, and then it pays that. Providers can either take that or not take Medicare/Medicaid patients. "

This is, essentially, negotiating.
posted by the young rope-rider at 8:06 AM on November 8, 2010 [3 favorites]

Yeah, see that's exactly how my health insurance got negotiated.
posted by Rat Spatula at 8:13 AM on November 8, 2010 [2 favorites]

Why I am not comforted by everyone saying "Ah, they're bluffing!"

Texas: the only state that looked at the fact that they were doing better than Mississippi and said "Why are we trying so hard?"
posted by emjaybee at 8:26 AM on November 8, 2010

Why can't the government just straight out offer a $35 co-pay to any GP patient with a SSN?

Pick your doctor. Feds give the doctor $35. You pick up the rest. If you're on welfare double the co-pay if the doctor will accept that as the entire bill.

No hassle, no bullshit, no arguing. Rate is set, co-pay is paid on furnishing of a form saying this citizen received this care, call patients randomly to check for fraud.

Paying for it? Raise Medicare from 1.45% on the employer's side to 1.85%. Should bring in an extra 20 billion dollars to pay for the doctor's visits offset by a theoretical reduction in insurance premiums. Run an educational campaign for employers to let them know that insurance premiums should be reduced now that the fed is on the hook for primary care physicians. If you're not an employer providing benefits then go fuck yourself. You should be providing benefits and you can pay the damn extra 0.4% in tax.

Baddabing baddaboom. You now have government subsidized primary care and little Suzie gets to go to the doctor when she's sick.

Then you start going after acute care, then chronic care, then long term care.

Acute care? Start up government run teaching hospitals. Start wiping out student debt for students that do their internships, residencies and a certain amount of time as attendings in government teaching hospitals. Pay them a liveable wage. Don't need insurance. Rock up with a SSN and receive care. Have an all-night PCP office next door that residents rotate into (a'la clinics at private hospitals) and point people who come into the ER with the sniffles over to them.

Don't get the states involved. Too many of them have insane strangleholds over revenue provisions and just plain can't afford it. Your average state takes in much, much less than a state in a sane country. Start dismantling Medicaid in states that have sufficient government hospital coverage to balance out revenue requirements while simultaneously increasing taxes on Medicare and telling businesses to demand savings from their insurers now that Uncle Sam is picking up the tab for a lot of the stuff they used to do.

The only people that stand to lose here are insurers and businesses that don't provide health care benefits already. I don't know why big business wouldn't jump at the chance to not have to pay health care benefits as part of their pension plans.
posted by Talez at 9:01 AM on November 8, 2010 [1 favorite]

Paying for it? Raise Medicare from 1.45% on the employer's side to 1.85%. Should bring in an extra 20 billion dollars to pay for the doctor's visits offset by a theoretical reduction in insurance premiums.

That isn't even on the right order of magnitude. The US spent about $2.75 trillion on medical care last year, of which the government spent almost $900 billion. An extra $20 billion is almost rounding error, less than 2% of what's currently being spent, and you're actually talking about adding a couple of hundred billion dollars in government spending.

I thought Prop 19 failed?
posted by valkyryn at 9:17 AM on November 8, 2010

That isn't even on the right order of magnitude. The US spent about $2.75 trillion on medical care last year, of which the government spent almost $900 billion. An extra $20 billion is almost rounding error, less than 2% of what's currently being spent, and you're actually talking about adding a couple of hundred billion dollars in government spending.

Not even on the right order of magnitude?

Subsidizing visits to a doctor would be a very narrow part of government spending. According to the CDC there were 902 million physician visits last year. 49% of those to PCP. So 442 million PCP visits. 442 million visits at $35 a pop is a touch over $15 billion. Plus you need to account for an increase in visits to PCPs now that they're affordable.

It's deliberately very narrow in scope so that it would be a rounding error. Just getting people to a doctor instead of an ER would be a start. Hell, being able to afford a doctor thanks to the feds would make people more trusting towards further health reform.
posted by Talez at 9:29 AM on November 8, 2010

Rand Paul was on This Week with Christiane Amanpour. Read the transcript excerpt below. The rhetoric of their campaigns are about to his hard reality. Magic solutions like we'll just do an across the board spending cut of 10% don't work. Are you going to cut food stamps by 10%? Cut social security payments by 10%? They have yet to identify a single thing they can cut. Not one single thing. They fall back on magical solutions like eliminate waste, pork and corruption. Or when pressed say we'll cut by 10% accross the board, except defense (50% of the budget) and Entitlements (most of the rest), or Transportation, or what?

How do you cut 10% out of the new roadway project that is half built? Do you just cancel it? The same thing with staff salaries. The government contracts almost all the unskilled semi-skilled labor like janators, secretaries, etc can't cut those salaries and those arn't even part of his 120K/year number. The employees left are contract administrators, managers and senior professionals. Also many of them have a contract. Also they have unions and contracts which means you can't just cut their salaries by 10%. He took the military off the table, what about the FBI? What about Homeland security. They havn't a clue about what they are doing, but that doesn't mean they can't try to pass it.


AMANPOUR: Right, but without making strong entitlement and other cuts -- and even if one does, most of the economists say the math simply doesn't add up to keep -- to keep tax cuts on and on and on. Will you agree to some?
PAUL: My -- my hope now -- my hope is to be on the Budget Committee and to go through all of these numbers and, by January, to have a balanced budget that I will introduce. I want there to be a Republican alternative -- whether it wins or not, I want the Republican message to be one of balanced budgets. If they won't do it in a year, we'll say, how about two years? If they won't do it in two years, how about three years? But someone has to believe it.
AMANPOUR: Give me one specific cut, Senator-elect.
PAUL: All across the board.
AMANPOUR: One significant one. No, but you can't just keep saying all across the board.
PAUL: Well, no, I can, because I'm going to look at every program, every program. But I would freeze federal hiring. I would maybe reduce federal employees by 10 percent. I'd probably reduce their wages by 10 percent. The average federal employee makes $120,000 a year. The average private employee makes $60,000 a year. Let's get them more in line, and let's find savings. Let's hire no new federal workers.
AMANPOUR: Pay for soldiers? Would you cut that?
PAUL: I think that's something that you can't do. I don't think...
AMANPOUR: You cannot do?
PAUL: Right. I think that soldiers have to be paid. Now, can we say that gradually we don't need as large of an Army if we're not in two wars? Yes, I think you can say that. You can save money there. You can bring some troops home or have Europe pay more for their defense and Japan pay more and Korea pay more for their defense or bring those troops home and have savings there.

posted by humanfont at 9:32 AM on November 8, 2010

I thought Prop 19 failed?

Don't do this.
posted by hippybear at 10:01 AM on November 8, 2010 [1 favorite]

It's ok, hippybear. I find it quite amusing that giving strategic advice similar to what most first world countries have done gets me called a pot smoking hippie.

Ironic still because I've just arrived in California from Western Australia and the state is just so damn backward in a LOT of ways compared to home.
posted by Talez at 10:20 AM on November 8, 2010

You know, what Ayn Paul has to say about government versus private employees is true. My husband is a government employee, and it is the reason I get to stay at home with my kids. My husband could make $50K-$60K a year as a restaurant chef, even in the midwest. But he would have barebones benefits, if any at all, and he'd have to work 80-100 hours per week, even if sick or injured or if his wife was in labor (ask me how I know).

As a government employee, he makes $31K, plus 15% on top of wages to his retirement, and world class health care benefits that cost $40/pay period (every other week, so less than $100/mo) for a family of five, not to mention a straight 40 week that pays overtime, and free tuition at state university for his dependents. He's part of a union, a huge union, he doesn't suffer under some despotic "at will" employer, so he has job security, he gets sick leave and personal days, and 15 days of paid vacation every year (which will only go up), as well as weekends and holidays off.

This adds up to a helluva lot more than $50K per year, especially when you think that we'd be paying $12K or more every year for lesser insurance, probably have to self fund a retirement plan that we chose on our own, and be sacking money into a college savings account.

Why has private employment become so godawful? Because we've gutted the middle class. The chamber of commerce supports Republicans in every town, so they pay their employees less and treat them worse. In the name of free trade, we've replaced jobs with automakers, jobs that came with stock options and tuition reimbursement, with jobs with retailers, jobs that come with advice on how to apply for food stamps and Medicaid.

People feel grateful to eat, so they get food stamps and don't complain. Pondering retirement is too scary, so people just cross their fingers and hope Social Security is still around when they are old. But health care? That's something that stings as soon as you don't have it anymore. You know that you are living on the edge of catastrophe every single day.

I think that health care reform is going to have a huge impact on the middle class- that is, if it swells back up, or if it just ceases to exist in America. Health care is the thing that people permit themselves to feel entitled to.

I remember in 1993, I was a sophomore in high school. During that health care dustup, a close friend of mine said, "I think Bill Clinton needs to just not do anything. Leave the health care system just as it is." I looked at him sideways, and said, "I don't have health insurance." (This was before SCHIP.) He looked shocked. I continued, "Your dad is a state cop. Mine is self employed. Is that why you deserve health insurance and I don't?"

As an adult, I'm on the other side of that, now, thank God. Why don't other kids deserve the same health insurance that my kids get? Because their dad got lucky and applied at a state school at the right time? Really? That's why?

I'm so sick of the notion that people who work the hardest get the best jobs. Bullshit. The hubs worked twice as hard cheffing as he does now.

Everything in this economy, it all comes back to health care. You want to lower the cost of education? Relieve schools of the burden of having to pay the health insurance costs of their employees. Now, you may be able to privatize janitors and bus drivers, but good luck hiring teachers that way. In my state, teachers get Aetna, which is even better than our insurance. I don't have figures in front of me, but I know that doesn't come cheap. You want to cut military spending? Let's eliminate Tricare. Costs of government would be lowered if health insurance wasn't part of state/federal employee compensation.

I can hear it now: but you're just moving costs around. No. Creating a single payer system would render spending in many, many categories streamlined and transparent. It would make it easier to see where real cuts could be best applied in education, bureaucracy, defense. Universal health care would be a universal bailout.

There are tons of problems with American health care as things stand. I'm sympathetic to the arguments that billing is opaque and tests are overused. There are lots of ways to cut costs, but they are bailing out the ocean with a teaspoon. We need a fundamental overhaul.

Yes, the government will have to dictate prices to pharma companies. Yes, doctors may make less. (I would not be opposed to paying a special tax to unburden doctors of educational debt in order to make that an easier pill to swallow.) But we have to do it. We just have to.
posted by Leta at 10:37 AM on November 8, 2010 [15 favorites]

I heard an NPR story about an anti-tax republican in Colorado...

This American Life, This Party Sucks.
posted by We had a deal, Kyle at 10:45 AM on November 8, 2010

Subsidizing visits to a doctor would be a very narrow part of government spending.

Which is why your little plan wouldn't actually make a difference. For starters, paying PCPs $35 a visit won't cover their costs. They've got nurses, other staff, and medical office space to see in there. Even doing three of them an hour--that's only twenty minutes a patient with no time for transition--that's only $105 an hour to pay at least four people's salaries plus rent, utilities, and taxes. Your physician might wind up making twice minimum wage, if he's really lucky and can always see 120 patients a week. A more realistic figure is closer to $100 a visit, which puts your little program about $20 billion in the hole.

But that doesn't really matter one way or the other. Our country isn't spending two and a half trillion dollars a year because little Suzie has the sniffles. I'm completely on board with the idea that we can and probably should make sure that Suzie has better access to care, but she isn't the cause of the exploding entitlements budget. We're spending two and half trillion dollars a year because mom has diabetes, dad has hypertension, grandpa needs a bypass, and grandma's in a nursing home with COPD.
posted by valkyryn at 11:49 AM on November 8, 2010

In an effort to save money, the departments are being slashed to skeleton crews.

No, they're being outsourced.

Stop thinking of this as a Medicare problem. Getting a claim paid is a PITA, never mind if it's a blue or a private or union plan. Just because you've got your claim in the correct format for one payer -- even one Medicare -- doesn't mean it'll go through anyone else's system without dropping to paper -- read, literally being printed on a form and mailed. Drop to paper means you don't get paid for weeks.

So, everyone submits to clearinghouses. Basic clearinghouses just bundle-and-send, the better ones will clean up claims as needed, correct obvious errors and link to previous work to make sure "Do X, then we'll cover Y" claims get paid quickly.

So: What the US pays for, in part, is 500 sets of claim processors to pay claims, and several clearinghouses to sort and clean up claims, because nobody short of a large hospital can afford the admin staff needed to go direct to every payer they're likely to encounter.

With single payer, most of this goes away, and it would be trivial to write Practice Management Systems to submit claims to it correctly. Now? The various PMS vendors have to work with the various clearinghouses to make sure that the clearinghouse gets the claims, and if you find that your current clearinghouse isn't a vendor with your PMS system vendor, you either change vendors, change PMS, or drop to paper.

That's modern health care. It may look like the admin staff is shrinking, but in reality, they're growing leaps and bounds. They just don't work for providers and hospitals, they work for the middle tier vendors.
posted by eriko at 12:15 PM on November 8, 2010 [5 favorites]

This makes great fodder for the blue.
posted by Senator at 12:27 PM on November 8, 2010

Which is why your little plan wouldn't actually make a difference. For starters, paying PCPs $35 a visit won't cover their costs. They've got nurses, other staff, and medical office space to see in there. Even doing three of them an hour--that's only twenty minutes a patient with no time for transition--that's only $105 an hour to pay at least four people's salaries plus rent, utilities, and taxes. Your physician might wind up making twice minimum wage, if he's really lucky and can always see 120 patients a week. A more realistic figure is closer to $100 a visit, which puts your little program about $20 billion in the hole.

It's not supposed to cover costs completely. It's supposed to subsidise while allowing the free market to still compete on cost.
posted by Talez at 12:34 PM on November 8, 2010

It's supposed to subsidise while allowing the free market to still compete on cost.

Have you ever tried to shop for medical care based on cost, as a responsible consumer of services would do? It's nearly impossible.

I'm uninsured, and certainly don't get all the medical care I would like and probably should have. But once in a while, real things happen and I end up having to pay out-of-pocket for care. A couple of years ago, I had horrible pain in my abdomen and eventually had a barium x-ray ordered.

I spent TWO DAYS playing the phone call game with the health cooperative trying to get a real answer about how much that procedure would cost. It seems that nobody actually knew what the final bill would be. I'd get an answer from one department, ask if that was truly the total cost, they'd say they weren't sure, and give me another number to call. I'd finally get in touch with someone at that number, tell them what I had been told in the previous call, be told that couldn't be right, spend time on hold, someone would come back with a different number, I'd ask if that was the final cost, be told they weren't sure, be given another number... Rinse, repeat.

I think this lack of transparency is one of the biggest hurdles to truly driving down the cost of medical care. Consumers are completely detached from the billing process, especially if they have insurance. There should be a clear and easy way for those who want to find out actual billing costs to do so. Until this happens, people will continue to simply show up for various procedures and tests without applying any of the free market pressures which serve to keep costs low and quality high.

This is my complaint with Health Savings Account medical plans, too. They tell you that you get X dollars in an account which you can use for medical care, but then make it impossible to be an informed consumer when it comes to spending that money.

Between hidden costs, unclear billing totals, and doctor referrals to specific clinics and labs rather than allowing the consumer to shop based on price and quality of service, we've completely removed our medical care industry from any free market pressures at all.
posted by hippybear at 1:01 PM on November 8, 2010 [4 favorites]

Have you ever tried to shop for medical care based on cost, as a responsible consumer of services would do? It's nearly impossible.

For strictly a primary care provider? Call up, "how much for a consultation? I like that price so when's the next appointment?"

People try to extrapolate baby steps over a whole system and it doesn't work because it's NOT SUPPOSED TO.

Get people to a doctor instead of an ER.
Then get acute care covered.
Then look at chronic care.

You can't just wholesale implement a nationalized healthcare system in the US in the current political climate.
posted by Talez at 1:07 PM on November 8, 2010

For strictly a primary care provider? Call up, "how much for a consultation? I like that price so when's the next appointment?"

Well, in my experience, not even that is entirely possible. How much for a consultation? That means simply walking in the door and talking to the doctor. Does he use any supplies in his office as part of the visit? The price goes up, in odd and random ways which don't seem related to the actual price of what is being used. I was once charged $5 for a tongue depressor and those protective sleeves that get put over the lighted scopes they use to look into your ears and nose. Seriously? Those cost $5? I doubt that.
posted by hippybear at 1:33 PM on November 8, 2010

Those cost $5?

3.15 for a box of 100 on Amazon...stock up for your next doctor's appointment!
posted by mittens at 1:52 PM on November 8, 2010

You can't just wholesale implement a nationalized healthcare system in the US in the current political climate.

You may not be able to implement a nationalized healthcare system without a constitutional amendment, when it comes right down to it. Medicare, sure, the Court has been willing to go that far, but NHS? That's another thing entirely.

Not saying how it would turn out, just raising the issue. It's far from clear cut.
posted by valkyryn at 2:14 PM on November 8, 2010

There should be a clear and easy way for those who want to find out actual billing costs to do so.

Amen to that a million times over. Like you said, sometimes even providers don't know what they're actually charging. Which is compounded because they also don't know what they'll actually get paid. No one person does either. You couldn't design a less transparent system if you tried.
posted by valkyryn at 3:00 PM on November 8, 2010

You may not be able to implement a nationalized healthcare system without a constitutional amendment, when it comes right down to it.

On what grounds would such be unconstitutional?
posted by eriko at 4:01 PM on November 8, 2010

Now that there will be insurance co-ops and regulation of how much can be spent on administrative costs and how much profit can be taken out, it is really only a matter of time before we have something that looks a lot like single payer. Watch in 5 years it will be nothing but co-ops for your basic employer coverage, then the insurance companies will move up to premiums like private room and some employers will use that as a carrot, those extra benefits will be taxed under the cadallac provisions to keep costs down because you'll know how much you are getting out of it. And now you know why republicans want to repeal this.
posted by humanfont at 5:24 PM on November 8, 2010

Between hidden costs, unclear billing totals, and doctor referrals to specific clinics and labs rather than allowing the consumer to shop based on price and quality of service, we've completely removed our medical care industry from any free market pressures at all.

This. So totally this. What we have doesn't even vaguely resemble a competitive system.

Most people don't know how much their insurance costs. Oh, sure ask them and they'll say it costs maybe $35 bucks a pay period, but ask them the total cost including employer contribution, and they're clueless.

We don't know how much what we have costs, we don't know how much the competition would cost, and most of us can't switch insurers if we wanted to.

When it comes to procedures and billing, the opacity only gets worse.

Health care costs are going up, because nobody can count the beans any more. Shell game anyone?


On an unrelated note: Anyone know why my greasemonkey metafilter quote script won't work anymore?
posted by Sportbilly at 5:57 PM on November 8, 2010 [1 favorite]

You may not be able to implement a nationalized healthcare system without a constitutional amendment, when it comes right down to it.

Based on what?
posted by one more dead town's last parade at 5:57 PM on November 8, 2010

should've previewed
posted by one more dead town's last parade at 5:58 PM on November 8, 2010

Never mind, I got it, dog ate my homework etc etc. Sorry for derail.
posted by Sportbilly at 6:08 PM on November 8, 2010

What we have doesn't even vaguely resemble a competitive system.

Why do we want it to?
posted by mittens at 6:15 PM on November 8, 2010

Mittens, you forgot the HAMBURGER tag
posted by Sportbilly at 6:26 PM on November 8, 2010

On what grounds would such be unconstitutional?

It isn't an enumerated power of Congress in Art. 8, and whether or not the Court would permit Congress to use the commerce power to nationalize the health care sector is an open question. It very well might not.
posted by valkyryn at 4:46 AM on November 9, 2010

I suppose if being healthy and having that health cared for were considered a right and not a privilege, it's possible that it would be held up under the equal protection clause, too.

It depends on whether Scalia is still on the court by the time it gets that far or not, I'm sure.
posted by hippybear at 6:47 AM on November 9, 2010

I suppose if being healthy and having that health cared for were considered a right and not a privilege, it's possible that it would be held up under the equal protection clause, too.

Except there's really no text in the Constitution which would support such a right. There just isn't. The most liberal legal scholars with whom I'm familiar are pretty adamant that there's a moral right to health care, but none of them spend much time arguing that the Constitution actually requires it.
posted by valkyryn at 9:38 AM on November 9, 2010

Except there's really no text in the Constitution which would support such a right. There just isn't.

We the People of the United States, in Order to form a more perfect Union, establish Justice, insure domestic Tranquility, provide for the common defence, promote the general Welfare, and secure the Blessings of Liberty to ourselves and our Posterity, do ordain and establish this Constitution for the United States of America.

That certainly could be a place to start.

I'm not a constitutional scholar, and certainly don't want to try to get into a deep discussion about specific verbiage in that document right here. I'll dig around online and see if I can find the two or three articles I read in the past which did create a seemingly valid argument for the concept of health care as a right of the citizenry with constitutional support.
posted by hippybear at 10:01 AM on November 9, 2010

That certainly could be a place to start.

That's the Preamble. It's nice language, but not a grant of authority. The Court has never and as far as anyone can tell will never permit Congress to use the Preamble as an exclusive justification for an particular Act. They've got to be able to find some specific grant of authority in one of the Articles, usually Art. I.

That's why there's an income tax amendment. It's easy to argue that an income tax promotes the general welfare, and Congress even has the explicit authority to tax and spend. But a tax on incomes is not one of the things that Art. I says they can tax, so it required a constitutional amendment.

If Congress couldn't eve pass an income tax without a constitutional amendment, it's not that hard to argue that they can't create a nationalized health system either.
posted by valkyryn at 12:54 PM on November 9, 2010 [2 favorites]

After that, the government will pay 100% of your health care bills up to a maximum amount per year, which would be the same for everyone. Say $250,000. After that, everything is on you.


So, fuck off if you get cancer and need treatment? Or a myriad of other diseases that are expensive to treat.

I had cancer two years ago, I am cancer free now my treatment cost my insurance company a lot of money. Between cancer and several hospital stays for related issues, it was over your limit.

My life expectancy is long, close to the life expectancy of any of you all, should I have died because I don't fit what you think is the right amount to spend on 40 years of life?
posted by SuzySmith at 3:31 PM on November 10, 2010

So, fuck off if you get cancer and need treatment? Or a myriad of other diseases that are expensive to treat.

The response is actually a question: Do you really think that you have the right (or the body politic has the obligation, if you prefer) to spend an unlimited amount of money on you just because you got sick? $250,000 is a lot of money. With that you can send a kid to four years of college at one of the most exclusive colleges in the country, or five kids to college somewhere cheaper. You can pay the salaries and benefits of three public school teachers for a year. You could pay twenty-five people's maximum annual unemployment benefits (in Indiana anyway). You can repair a bridge. You can signalize an intersection. So you want to claim that the fact that you had cancer means that you have a better claim to those funds than any of these other uses?

At $250,000, you can cover a whole ton of medical expenses. Can you cover all of them that it is possible to imagine? No, of course not. But again, we could spend the entire GDP on health care and every single one of us would still die at some point. I, for one, think we should shift money away from health care--even if that means that people who could survive if we threw half a million at them wind up dying--so we can spend that money on other necessary and beneficial things.

And answer me this: in just about every other area of life, there comes a point when you have to say "No, I can't afford that." Why shouldn't that apply to medical expenses?
posted by valkyryn at 11:59 AM on November 11, 2010 [1 favorite]

I think part of the problem, again, is outrageous medical fees. I'm poking around online looking at people's complaints about exactly how much they're being billed for mundane things. My example earlier in this thread of being charged $5 for a tongue depressor and plastic scope protectors is not even a very egregious example, apparently. $127 for a box of kleenex? $9 per pill of ibuprofen? $12 for a single-use tube of lanolin? $750 for a person to walk into a room for under 60 seconds and ask how one's post-surgery pain is going? Or being charged for things like towels and sheets which should be included in the room fee.

And this doesn't even cover basic billing errors. Like child delivery charges which include an epidural when one was never administered. Or billing for circumcision when that procedure was never done. There seems to be a lot of this "well, everyone does it that way, so we just put that on everyone's bill" kind of thing going on. The situation has gotten bad enough that even Consumer Reports suggests that you keep a diary of all treatment you receive, request your medical records and a fully itemized bill, and make sure that you're not being tagged for anything you didn't actually get, or double-charged for a procedure you only received once.

Again, the problem here is that the consumer is completely detached from the actual payment process for the care delivered. Insurance companies act as a screen that hides everything but the co-pay. At times, it smacks of collusion, with the insurance industry and the medical care providers working together to squeeze money out of patients and deliver it into the pockets of corporations, all using the slight-of-hand of multiple layers of middlemen to provide confusion and opacity, all the while paying hospitals ridiculous fees for low-cost supplies and skimming a bit for themselves off at every step of the way.

That $250,000 fee for cancer treatment? Why should any consumer truly believe that is what it costs for that treatment? I know that some medical procedures are truly expensive, for any number of reasons ranging from specialized medical training to high-priced equipment to drugs which cost a lot to develop and produce. But after a while, it's kind of hard not to believe that the entire thing isn't just a hyper-inflated scam bilking those in their hour of need for every dime possible.
posted by hippybear at 2:29 PM on November 11, 2010 [4 favorites]

And answer me this: in just about every other area of life, there comes a point when you have to say "No, I can't afford that." Why shouldn't that apply to medical expenses?

Most things you can't afford will not directly end someone's life. You can't afford a brand new car? Pity, buy a used one. You can't afford that expensive piece of electronics? Damn, that's not gonna kill you either.

You can't afford to have the treatment to cure your cancer? I'm sorry, that you're only 33, but, you're going to die. You can't afford to treat your diabetes? I'm sorry that you're five and your pancreas doesn't work, you're going to die. You can't afford to have that surgery? Sorry, you die.

Do you want to be the person to say that a 33 year old's life is worth only 1/4 of a million dollars? When the defense budget is "between $880 billion and $1.03 trillion in fiscal year 2010. why the hell should we be willing to let people die of curable, or treatable, disease?

I call bullshit. Let's not spend so much money on useless bullshit, not just including useless wars, but a myriad of things and keep our damn citizens healthy and alive.

Our priorities are fucked up.

That $250,000 fee for cancer treatment? Why should any consumer truly believe that is what it costs for that treatment? I know that some medical procedures are truly expensive, for any number of reasons ranging from specialized medical training to high-priced equipment to drugs which cost a lot to develop and produce. But after a while, it's kind of hard not to believe that the entire thing isn't just a hyper-inflated scam bilking those in their hour of need for every dime possible.

As I stated earlier, the money was for my cancer treatment and several other hospital stays. I am sure that it didn't cost the amount that was charged. Unfortunately, one person can't change the system. I go through my hospital bills to the best of my ability. I have caught numerous errors and had them corrected. Following my surgery I obviously don't remember everything done, due to anesthesia and then very strong pain medications, but everything I was alert for was kept track of.
posted by SuzySmith at 9:52 PM on November 11, 2010 [1 favorite]

Do you want to be the person to say that a 33 year old's life is worth only 1/4 of a million dollars? When the defense budget is "between $880 billion and $1.03 trillion in fiscal year 2010. why the hell should we be willing to let people die of curable, or treatable, disease?

First of all, that wasn't the defense budget. That's the combined federal and state spending on health care. The defense budget is "only" $600 billion. That's admittedly a lot of money, but it is less than we're spending on health care.

Second, you aren't thinking about this like a policymaker, you're thinking about it like a patient. Since you were a patient, I understand why you might do that, but you're overlooking some pretty basic problems of scale. One person's cancer treatment won't break the budget. But a million people? At $250,000 a head? That's $250 billion, between 1/4 and 1/3 of our total health care spending. That ain't chump change. Even half that many is a significant chunk of the budget.

Now here's the thing: if we want this system to be fair, and I think that we do, we need to either make sure that everyone has the same access or find rational criteria for treating some people but not others. Is age the criteria, i.e. do you get treatment below a certain age but not above it? On what basis do we make that cut? Why should you get treatment but a 60 year old not? A 70 year old? 80? Maybe you want a different criteria? Treatment for some diseases but not others? Whoever you're trying to exclude happens to be a person with just as much moral deserving of free health care as anyone else.* They also happen to be a voter, so good luck with that.

Frankly, I'd be more or less okay with saying "Look, we'll pay your health care until you're 80, but after that, you've had a good run and it's time to either make it on your own or check out." We'd save a ton of money doing that, as old people are the most likely to need expensive medical treatments. But that's a pretty damn unpleasant thing to say and probably politically impossible.

And the thing is, you can't make these decisions on a case-by-case basis. The potential for corruption and discrimination is just immense, and any such decision is likely to run afoul of Equal Protection or Due Process claims, which would create a whole bundle of messy civil rights litigation overnight. The government would find it really hard to win most of those cases, as juries like giving money to sympathetic plaintiffs, so any case-by-case process would ultimately wind up being more costly than just giving money to everyone because most people would still get their money, only now we have to litigate the process too.

But if you do want equal access, then you need to find some way of curtailing that access for everyone. I think that $250,000 is a reasonable allowance for health care, as it's going to cover the vast, vast majority of the population. Even for those people that do come down with an expensive condition, there are always choices between more expensive and less expensive treatment options. As the more expensive ones are rarely that much more effective than the less expensive ones, I think it should be incumbent upon the patients to choose the less expensive ones wherever possible, and I'm okay incentivizing that by capping annual benefits.

This does mean that some people are going to be sick and die despite the fact that if we had unlimited money we could have saved them. That's the world we live in. Pretending otherwise won't magically increase the amount we can responsibly spend on health care.

*Exactly how much that deserving is is left as an exercise for the reader, but whether it's "a whole lot" or "not at all," the latter being my personal belief, neither gives you any way of distinguishing between persons.
posted by valkyryn at 6:34 AM on November 14, 2010 [1 favorite]

It's hard to take you seriously considering that you think no one has a right to health care. How massively Christian of you.
posted by the young rope-rider at 8:37 AM on November 14, 2010

You also seem to think that $250k is an actual price, that this is simply how much money is necessary for cancer treatment. Do you think it at all possible that maybe, just maybe, the prices are artificially inflated? As mentioned repeatedly above and ignored just as repeatedly, does docetaxel actually have to cost $1000 per dose, or could it perhaps be that the number is arbitrary and can drop dramatically when the only buyer wants to pay less than that?
posted by kafziel at 9:07 AM on November 14, 2010 [2 favorites]

Frankly, I'd be more or less okay with saying "Look, we'll pay your health care until you're 80, but after that, you've had a good run and it's time to either make it on your own or check out." We'd save a ton of money doing that, as old people are the most likely to need expensive medical treatments.

And here I thought death panels were a conservative invention to slander Obama's health care plan...
posted by jokeefe at 12:31 PM on November 14, 2010

Also, I now have Kill the Poor stuck in my head.
posted by jokeefe at 12:39 PM on November 14, 2010 [1 favorite]

How massively Christian of you.

"Rights" aren't actually a Christian idea.
posted by valkyryn at 2:35 AM on November 15, 2010

Do you think it at all possible that maybe, just maybe, the prices are artificially inflated?

Maybe a little--I wrote about the health care bubble above--but not significantly. Providing health care is a labor-intensive activity, and it isn't cheap labor either: just about everyone involved has at least a college degree and a good number of them are going to have masters or doctorates. I talked about the cost structure of providing health care in an earlier comment: moving to single-payer won't change any of that.

As far as your specific pharmaceutical example, no, I don't think that price is going anywhere all that soon. There isn't that much demand for said drug, unlike say ibuprofen or acetaminophen , so economies of scale don't apply nearly so well. But there are cheaper drugs out there that probably do close to 100% of the same thing--especially in combination with other drugs--so maybe patients will just have to choose the two generic drugs that have been getting good results for twenty years rather than the new designer drug that does the job of both at ten times the price. But that isn't cost inflation, that's just choosing to do things the expensive way rather than the cheap way.

So I ignored that suggestion because I don't think it's actually true, and there aren't any numbers at all to suggest that it might be.
posted by valkyryn at 2:42 AM on November 15, 2010

If Congress couldn't eve pass an income tax without a constitutional amendment, it's not that hard to argue that they can't create a nationalized health system either.

That's absurd. There's nothing to stop the federal government from saying the following to each of the states: "We will pay for a universal health insurance program run by your state that looks like such-and-such. If you choose not to run such a program, federal funds will still go to other states, and the people of your state will not owe any less income tax." This is basically how the system in Canada works, and how federal highway funding works.

It looks highly unlikely to me that we'll get any sort of public option soon, but Congress would face few constitutional hurdles if it wanted to create one.
posted by one more dead town's last parade at 9:38 PM on November 17, 2010

That's absurd. There's nothing to stop the federal government from saying the following to each of the states: etc.

What you propose is not, in fact, a nationalized health system. Universal insurance is not the same thing as an NHS. An NHS would involve hospitals becoming federally-operated agencies and their employees becoming federal employees. That's, by definition, what a nationalized health system is.

It is not at all clear that Congress has the power to do that. There are Art. I, Fifth, and Tenth Amendment reasons for believing that it might not.
posted by valkyryn at 10:28 AM on November 22, 2010

If Congress couldn't eve pass an income tax without a constitutional amendment, it's not that hard to argue that they can't create a nationalized health system either.

Not true congress could and did pass a national income tax prior to the constitutional amendment. The only difference was that prior to the constitutional amendment incomes from business and investments were deemed to be earnings from property and thus subject to the apportionment clause of the constitution which required that the burden be spread equally across the states.

By your argument national pensions under social security would also be unconstitutional since you are required to purchase into a national pension plan and forced to pay a part of your wages.
posted by humanfont at 11:00 AM on November 22, 2010

What you propose is not, in fact, a nationalized health system.

No; it's a nationalized health-insurance system, but depending on how much the individual states' plans vary from the minimum requirements, it's indistinguishable to the end user. Someone living in State A has exactly one choice of insurance plan, as do State B and State C. The individual states are allowed to provide more with their insurance plans, but may not provide any less than the federal mandate. The government can aggressively negotiate prices (because it's the only insurance game in town), but doctors are not government employees by any means.

I've seen no plausible suggestion that this arrangement would be unconstitutional.
posted by one more dead town's last parade at 2:45 PM on November 22, 2010