August 21, 2009

The Real Issue in the "Nationalizing Our Health Care" Rhetoric, or The "Government Takeover"

Millions of Americans fear health care reform would lead to "nationalization" (or "Government takeover" or "socialized care") of health care in America.

I've read or heard "nationalize" used this way dozens of times now in the last month -- enough to know that it is a widespread idea. Just lately, this same idea is being expressed often with additional phrases that have the same meaning.

A significant part of the opposition to health care reform -- the major part -- springs from fear of a Government takeover of health care, which would seemingly lead to rationing of health care and all the other familiar ills of a big, impersonal Governmental bureaucracy.

Arbitrary power. The idea of "pulling the plug" on Grandma is only a representation of this more general fear of impersonal, arbitrary power.


"Nationalize" has a meaning which is clear to most people -- a government takeover -- government owns and thus fully controls the business or industry, such as a nationalized railroad or even an entire nationalized sector of the economy.

So a nationalized Health Care System in the true, genuine meaning of the word would be when most hospitals were taken over and owned by the government, along with most clinics, so that many or most doctors would work for the government directly or through a thinly separated veil. Most health care workers would be government employees -- their paychecks would be directly from the government.

This would be nationalization, in the true sense of the word.


Now, in contrast, the proposed House bill HR 3200 leaves private, free-market hospitals private and free-market.

Private or self-employed doctors remain privately- or self-employed under HR 3200.

Instead of nationalization, the private health insurers and a public health insurer would compete to gain policy-holders and would pay doctors and hospitals according to negotiated pay scales, just as now. Some low-income individuals and families would receive help paying their premiums, regardless of whether they choose a private or public insurer.

Did you get that last part? Those choosing private insurers would get the same subsidy those choosing the public insurer get.

Level playing field. From the beginning.

The conservative Heritage Foundation points out "Individuals will not be permitted to use their subsidies to purchase coverage that does not meet the definition of 'essential health benefits.'"

But...who would want to purchase insurance without essential benefits??

People purchase such policies only because they are fooled by the insurers.

There is indeed private insurance available right now without essential benefits -- that is why medical bills piling up on people who actually had/have insurance is the leading cause of bankruptcy!

Those bankrupt families and individuals had insurance without essential benefits.


So those on the other side of the debate, who do not worry about "nationalization" can reasonably ask:

Where's the Beef?

Where is the nationalization??


It is then tempting to conclude that this fear is simply the result of intentional fear-mongering.

Calculated lies.

I concluded this myself after hearing of Palin's "Death Panel" idea.

That was indeed a lie.

There never was anything remotely similar to death panels, or panels to choose who gets what care, in the legislation. There is a public panel to help form the standards of minimum acceptable benefits insurers can offer -- the opposite of a death panel. This is more a life panel, which helps prevent insurers from tricking policy holders with loopholes. Of course this isn't the panel Palin meant.

There is a panel to oversee comparative effectiveness research -- research to find out what treatments work the best. Again, more of a life panel, since finding out what works best will improve all of our odds of getting the best possible treatment. Of course, this isn't the panel Palin meant. I'm not sure if I can find the panel Palin meant.

Instead, the last panel of note is the patient-friendly panel the administration has proposed, IMAC, a panel of experts (including doctors) given the task to think up ways to improve among other things Medicare quality, access to care, and reimbursement rates and to consider broader reform ideas such as increasing effectiveness. IMAC is to make proposals, which the President and Congress can reject or accept each year.

IMAC should help to improve Medicare effectiveness. Effectiveness, for instance, would mean at times paying $200 to repair something now so that it won't break down in a year or so and cost $2000 instead.

"Effectiveness" does not mean refusing to pay $2000 when necessary.

It means smart choices such as planning ahead and choosing better treatments, often reducing costs while maintaining or increasing quality.

The effect would be to improve health by encouraging more effective treatments (such as by higher payments). Savings result since more effective treatments save time and expense, and reduce patients' suffering.

That would be like quality auto-repair.

In other words...just ordinary common sense.

There're the panels.

Where's the beef?


So the "Where's the nationalization?" question is quite reasonable.


But...there is an indirect way in which one can fear that there would be a sort-of "nationalization" of health care, in a sense, in a way that is somewhat related to the word nationalization.

The entire issue boils down to this single question -- and only this one single question -- whether the government would take over all health care reimbursement over time and then decide what is paid for in a top-down way, so that most doctors and hospitals would then only be able to do what government would decide to pay them to do.

In a word, control.

Notice the crucial distinction here. This isn't even about whether there will be a Single Payer system. No, it's more exact.

It's about whether the decisions will end up, in the long run, being made in a top-down way.

Single Payer, or the very different Public Option (which is a competing public health insurer), either one, could be top-down, or not, depending on how it is set-up.

A strong, popular public insurance provider itself could try to operate in a top-down manner, but if it did...many people would choose to go elsewhere for their insurance!

Indeed, there is a severe problem right now with private insurers making top-down decisions!

That's why people are so sensitive about it!


So there is only one real issue here in relation to a Public Option or HR 3200.

Will doctors and patients have most of the control in deciding what care/treatments to have?

That's it, nothing else.

That's the fear that dwarfs the others, in real opposition and fear of heath care reform.

Cost is also a central issue -- one this blog has focused on in multiple posts (see Reader Favorites in the right-hand column) -- but the fear and larger anger is about losing control and such possible imagined outcomes as severe rationing.


That issue of choice (control) is one this blog has addressed and 100% satisfied in a major post on how to structure reimbursement for health care.

Here's how to correctly set up reimbursement to doctors and hospitals (click here).


Let me suggest to President Obama that he needs to be still more plain-spoken. For now, he needs to leave behind lengthy, technical paragraphs.

In a short, brief statement, Obama needs to communicate on this real issue.

Without any other competing issue or information or topics during the statement.

This one question by itself.

I recommend 150 words or less.

Here's a suggestion:

Some political figures and commentators have made-up some distortions and outright fabrications in the last couple of months to try to torpedo our much needed health care reform. One of these fabrications is using the word "nationalization" to refer to health care reform when in fact hospitals and doctors would remain completely in the private free market just as they are right now.

I am proposing to Congress today that we clarify our reform legislation to explicitly leave all the choice and control of health care in the hands of doctors and patients, and that we do this by changing payment to be primarily for the outcomes of treatments. We will begin to
pay for outcomes over time, instead of just for the sheer number of tests and procedures regardless of effect. It won't be the number of tests you order, it will be the number of patients you help that determines your pay. In this way the actual choice of what treatment is used by a doctor or hospital will be entirely up to that doctor or hospital and the patient, and never up to any government bureaucrat. Paying for care in this way will increase innovation and unleash the real power of the free market to improve our health care.


  1. “The conservative Heritage Foundation points out "Individuals will not be permitted to use their subsidies to purchase coverage that does not meet the definition of 'essential health benefits.'"

    “But...who would want to purchase insurance without essential benefits??”

    Me! I would like to purchase a basic high deductible low cost insurance plan for my wife and myself. I don't need it to cover prenatal care, we are not having children. I don't want it to cover the drugs I take to lower my cholesterol they are daily maintenance and should not be covered.

    Change the law so that I can purchase health insurance from any provider in any state or country I choose and watch the cost drop. That would be real reform.

    “Essential benefits” are neither essential nor benefits. They are “benefits” to special interests. Chiropractic care givers have a strong lobby so coverage is essential. Acupressure lacks political power so it is not “Essential”. Let consumers decide if they want to purchase insurance that covers Chiropractic care or not!

    Free the market and force insurers to compete with each other in the US and around the world and we would not need fake competition from the shortly to be “nationalized” insurance market.


  2. I think there is more than one defined level of coverage being proposed, and if so, then you could choose the most basic level under the proposed criteria.

    The word "essential" though speaks to something more dramatic than whether you could choose to have drug benefits or not.

    It's about something more like whether the policy actually does in fact cover what you *think* it covers!

    If you if you are hospitalized....

    Even if you think your policy does cover hospitalization completely -- it appears to -- in fact for many people it turns out that many policies in the individual market are tricky, and do *not* cover what the policy holder thought they did. So they end up facing enormous bills they thought could not happen. This is the issue.

    "Essential" includes things you yourself would consider very essential, see?

    My own proposal, on this blog, in detail, is simply to require a very clear, unambiguous disclosure from insurers precisely what a policy covers and doesn't cover in simple, brief, clear language that isn't technical or confusing.

    So actually you probably would agree with me fully, it appears. I indeed would like to be able to choose a basic policy that fully covers hospitalization, with no tricky loopholes that I can't figure out ahead of time.

  3. Hmm. I understand that HR 3200 aims to reduce "unnecessary" care, to eliminate widespread inefficiency and overuse that are the "real" source of our healthcare crisis.

    Um, who will be determining "necessity"?

  4. The way health care is paid for typically simply pays more for more procedures *regardless* of effect, so that a more effective provider of health care who actually accomplishes more with less treatment gets...less money.

    If a hospital or doctor today cures a patient sooner and more cheaply, they will receive *less* money in return for their services than a hospital or doctor that does *not* cure the patient, and then tries a 2nd, 3rd, etc. treatment.

    That's the so-called "fee-for-service" problem, and you can read on this blog a better way to pay for health care -- outcomes-over-time, as a suggestion to private or public insurers on how to better reimburse. Such a payment system would reward more effective top providers like the Mayo Clinic for instance for their efficiency. This would be similar to a normal free-market situation in other industries.

    Does that clarify? If not, you may find it better to read extensively on this from many sources.

  5. So you honestly believe that your personal doctor sends you for tests and procedures that you don't need, just so that he can prolong your illness and get paid for more visits and procedures? Or he sends you to specialists who prolong your illness, and he, like you, is simply falling for the scam? Do you think your personal doctor is receiving kickbacks from the specialists, too? You're not a "birther," are you?

    And you believe that your insurance company, which supposedly would drop you in a fibrillated heartbeat for a pre-existing condition, happily authorizes all these unnecessary procedures at its expense, even though it has its own team of doctors whom it pays to tell it which procedures are unwarranted??? Or are you saying the insurance companies' doctors are in on the scam, too???

    No, your explanation does not account for the incentives of insurance companies to deny these unnecessary procedures. They're approving them for some medically significant reason that they cannot escape -- otherwise they would simply -- eagerly -- deny this "wasted" care.

  6. "Of course, this isn't the panel Palin meant."

    Actually, yes, it is, if what you need is something that panel declares "ineffective" or "unnecessary."

    Same exact panel. The only difference is whether you're the one dying.

  7. whois -- I haven't needed many personal doctor visits. Only one in perhaps the last 15 years. But to answer the question of would some medical providers potentially end up prolonging an illness, I think some doctors and hospitals would, from what I've read, unless I did extensive research on my own to checkup on the therapies and find better ones. The problem is they don't get paid *more* for better quality. To generally answer most of the issues in your questions in the 11:42am comment, just read more in this blog and/or read from Google searches more diversely about health care in America now regarding waste and inefficiency and "fee for service". I recommend not to rely on one or two sources. I prefer at least 5 sources, and that they be independent from one another, and that they have diverse ideas. In practice most of the link on this blogs are among the best I found out of dozens of similar articles.

    I think the reason we have so much inefficiency is because we do not have a "market like" situation, which would have a strong connection or correlation between cost and what is bought (on average). Contrast for example the real-life instance of Mayo Clinic which is rated among the best handful of hospitals in the nation in most measures, yet has lower costs than numerous competitors that offer less quality. How can that happen? Because more often the cost is not connected to the outcome or the quality of care. You can read on this blog and elsewhere more about "fee for service", etc.

    In the scientific method, you have to compare ideas/hypotheses to actual detailed concrete instances in the real world, and more than a few. For instance a woman who testified in Congress from Texas was dropped by her insurer during breast cancer because she did not include the fact she had some acne on her application. This is not an isolated instance though. So yes, I specifically think my own insurer will, if possible, follow the industry practice in "individual" insurance, and should I have an expensive illness, carefully search for any pretext to drop me. That is something that would in most nations be naturally illegal -- a type of breach of contract. Somehow it's not illegal here though! Most forms of theft through breach of contract are illegal, and this one should be also.

    Regarding Palin's panel, if you would like to cite specific passages somewhere in a current proposed bill and explain how it is similar or equivalent to a death panel in some fashion, I'd be glad to learn about that.

  8. Look, we only have to get one point straight to communicate here. Now I wager that probably on this blog -- but certainly on other sites that you no doubt visit -- there is talk about evil insurance companies. How they refuse to insure because of pre-existing conditions. How they cancel policies on people who get sick. How they leave no stone unturned in the search for excuses to deny claims.

    Now, you've implied here that these same miserly insurance companies who would rather let us die than pay for our necessary treatment -- no doubt so their CEOs can take bigger bonuses for themselves -- you've implied that those companies are "wasting" money to pay doctors to give unnecessary care.

    So I want you to explain why they approve that care for payment. I want you to explain how insurance companies, with doctors on staff to tell them which treatments to authorize, and with their obvious readiness to cut corners wherever they can -- I want you to explain how come they're supposedly hemmorhaging all this cash for treatment. I want you to explain why they can't just start denying that care so their CEOs can have a bigger bonus.

    I need you to reconcile your assertion that all this money is somehow being spent on unnecessary care against the obvious greed that should be motivating them to deny it.

    Now, if you can give me an honest, rational answer that accounts for everything your side claims about healthcare -- then we can proceed.

    I'm going to tell you in advance that I believe insurance companies approve all this care you calll "unnecessary" because they realize they could be sued for breach of contract -- for withholding care -- if they didn't approve it.

  9. whois -- let me warn you I won't respond to misrepresentations of my positions, which are laid out clearly on this blog already, but in more than one single post.

    Anyone can make the modest effort to simply read a few (more than two) detailed posts, some of them brief, none more than a few minutes of reading.

    The ones on the right under the Favorites links are an good starting point.

  10. Here is a good starting point with just the simple basics of the challenge of creating private health insurance for individuals (as distinct from large groups not overly self-selected):
    "Most health costs are incurred by a small proportion of the population whose expenses greatly exceed plausible limits on out-of-pocket spending." In other words, if people had to pay for medical care the way they pay for groceries, they would have to forego most of what modern medicine has to offer, because they would quickly run out of funds in the face of medical emergencies.

    So the only way modern medical care can be made available to anyone other than the very rich is through health insurance. Yet it's very difficult for the private sector to provide such insurance, because health insurance suffers from a particularly acute case of a well-known economic problem known as adverse selection. Here's how it works: imagine an insurer who offered policies to anyone, with the annual premium set to cover the average person's health care expenses, plus the administrative costs of running the insurance company. Who would sign up? The answer, unfortunately, is that the insurer's customers wouldn't be a representative sample of the population. Healthy people, with little reason to expect high medical bills, would probably shun policies priced to reflect the average person's health costs. On the other hand, unhealthy people would find the policies very attractive.

    You can see where this is going. The insurance company would quickly find that because its clientele was tilted toward those with high medical costs, its actual costs per customer were much higher than those of the average member of the population. So it would have to raise premiums to cover those higher costs. However, this would disproportionately drive off its healthier customers, leaving it with an even less healthy customer base, requiring a further rise in premiums, and so on.

    Insurance companies deal with these problems, to some extent, by carefully screening applicants to identify those with a high risk of needing expensive treatment, and either rejecting such applicants or charging them higher premiums. But such screening is itself expensive. Furthermore, it tends to screen out exactly those who most need insurance."

    So, given those simple basics, the question might private or public health insurance be devised so that it can work well in the individual market (described just above)? Generally, the proposals in Congress attempt to answer that question, and then in turn I try to offer better or in certain ways more effective proposals here on this blog.

    So for example, on this blog you'll never find me doing a political gamesmanship of using labeling against any party anywhere with characterizations of any kind such as "greedy" or "socialist" any other such simplistic mischaracterizations. In fact, I think any characterizations are problematic and usually contain signficant error.

    Instead, the purpose here in relation to the issue of health care and insurance is sharply different: I try to devise, from the ground up, better alternatives for good health insurance reform or structure.

    The topic is complex and quite interesting. I've been lucky enough to attract the attention of a couple of physicians who have offered helpful counterpoints and questions.

    This is not solely a health care blog, but it is one of the most fascinating and important issues around and at the top of the list right now.

  11. Try to be consistent. When I asked about "unnecessary" care, you clearly blamed "fee for service," saying that doctors profit from all sorts of procedures instead of actually curing patients.

    Quite frankly, you made it sound like doctors would actually rather keep people sick. Or like pediatricians remove tonsils because it's more profitable than treating infections. Or like amputating feet is better than treating diabetes.

    Again, I want you to explain how these procedures -- which are all characterized as more profitable for doctors than real, effective treatment -- I want you to explain why insurance companies, with their own experts on staff, authorize and pay for these overpriced incorrect treatments instead of simply demanding the correct, simpler treatment to cure the patient and protect their CEO's bonus.

    It's not that hard. Well, it shouldn't be, if your position aligns with reality. The truth is that I expect it to be very hard to explain, just as I expect you to try changing the subject to concepts like adverse selection.

  12. I think Obama if and when he references "unnecessary" treatments is referring to situations where objectively one hospital subjects patients to far more procedures for the same condition than another one that does fewer procedures but has good medical outcomes. This is no abstraction. Read Dr. Atul Gawande on this. let's

    Read that, and you'll learn something crucial, along with my answer to your question.

  13. On this blog I won't tolerate personal attacks on anyone, including 3rd parties, nor any intentional mischaracterizations. I will try to find a place to post this comment standard. If you wish to be able to comment here, you will have to refrain from the typical personal attack style used by "trolls".

    If you cannot decipher from Gawande's excellent article what might be meant by "unnecessary" in a medical context then perhaps you should hesitate to use disparaging adjectives.

  14. I think the question, if "whois" could have asked it without direct insults towards anyone, amounted to: who decides what is "necessary."

    This is a good, obvious, basic question, but...this blog post itself was exactly about this question. Simply reading the post in full would have answered the "who decides" question according to my own answer.

    But further, regarding Obama's position, I haven't found any indication that Obama supports taking that decision-making out of the hands of doctors and patients!

    Implying he does seems misleading, unless one can produce a full quote with *full* context, in the last few months (not 2 or 5 or 10 years back) to that effect.

    There is a lot of ideology behind the opposition to reform. That's fine *if* opponents can actually point to concrete, specific language in a proposed leading current Congressional bill in full context, without distortion. Otherwise, they appear to be tilting-at-windmills.

    Tilting at windmills is commonplace. Therefore to oppose reform in any meaningful way requires not just an *idea* or two, but also needs very specific, concrete detail that is actually in one of the 5 bills at issue.

  15. I'm well aware that Obama wants us all to believe that these "unnecessary" procedures are truly unnecessary -- doctors keeping people sick for money, redundant tests, etc.

    The FACT is that these procedures are currently approved by some of the most stingy, cutthroat tightwads out there -- insurance companies. If they didn't have to authorize them -- if the procedures had no medical merit -- then they wouldn't. In other words, the procedures have some medical value, and they only authorize them because it's cheaper than getting sued.

    If you choose to drink the Kool-Aid -- that these procedures are actually unnecessary -- then you are kidding yourself.

    The fact that Obama's investment is in bioethicists -- people who specialize not in effectiveness but in rationing; in finding ways to make "tough choices" -- should tell you all you need to know about the "waste" he intends to eliminate.

    You are rationalizing, Hal. There's no such thing as a free lunch, and the insurance companies have already cut back as far as is legal. Obama intends to cut back further, and the job of bioethicists is to decide who feels those cuts.

    Wake up and smell the coffee.

  16. If Obama has a hidden plan to ration care, I don't know how to find that out. If he asks for opinions and insight from a lot of different experts, and I know it is reported that is exactly what he does, then such gathering of diverse ideas is prudent and a sign of seeking the best ideas to compare them to one another.

    If the administration mistakenly finally settled on top-down rationing though (I say "top-down" since *all* good and services are rationed, all the time, by the market, always...), then such top-down rationing would be a mistake as I've pointed out on this blog here:

    But I frankly doubt such a mistake from the administration.

    Instead, if I myself were President, I would exactly gather all types of experts, over a period of weeks, for discussions, just to make sure I really am on top of such a crucial issue. Thus having some expert around that has considered rationing top-down does not demonstrate an intention to ration top-down. It demonstrates this is a possibility, but not a probability.

    About the real central question: ineffective treatments administered more due to incentives. There is research on this. You can read it and evaluated for yourself.

    If you have some links or references to support the idea that insurers have been (past tense, recent years) competent in selecting what procedures to allow, other than in an HMO, that would be of interest. I understand currently that much medical care is delivered via PPO plans, and am not aware how insurers restrict treatments except in the most loose way. Of course, in an entirely different fashion they can restrict treatments by simply dropping policy holders, etc. If I presume by "medical merit" you mean evidence-based care, I don't think that is the most common type of care. Are there any insurers that uses evidence-based care requirements? -- Of course there are. I bet Kaiser Permanente does in some fashion somewhere, as part of an integrated system. But do most PPO insurers do so in most situations? I suggest you find out.

  17. To clarify, I don't think most PPO insurance requires certain procedures or tests in a specified sequence according to likelihood of success, for example, as "evidence-based care" could lead to. What sign of "medical merit" are you referring to?

    What of a situation where a doctor, instead of prescribing a very-likely effective (and inexpensive) statin first for a certain condition, instead tries a more expensive drug or procedure first, even though research evidence suggests a statin should be tried first due to efficacy? Will the insurer deny the claim? I don't belive so.

  18. To clarify even further, in case you simply refuse to read the linked posts on this blog I suggested: I myself prefer exactly that the doctor has the freedom to choose what treatment to try first!

    And...that the reimbursement be according to outcome-over-time, as my blog post lays out in detail. See the Quality Health Care (and Choice) under Favorites in the right-hand column.

  19. "Vague promises of savings from cutting waste, enhancing prevention and wellness, installing electronic medical records and improving quality of care are merely 'lipstick' cost control, more for show and public relations than for true change."

    -- Ezekiel Emanuel, JAMA 2/27/08

  20. From that quote, sounds like it's a good thing Obama relies on many and diverse sources of ideas.


    For your entertainment:

    The Internet--Where Rumors Never Die:

    “Page 29: Admission: Your health care will be rationed!”

    “Page 50: All non-US citizens, illegal or not, will be provided with free healthcare services.”

    “Page 429: Advance Care Planning Consult will be used to dictate treatment as patient’s health deteriorates. This can include an ORDER for end-of-life plans.”

    All fabricated, but the above email circulates, relying on ignorance and laziness in some readers.

  21. Well, judging from this next quote:

    "At least we can let doctors know — and your mom know — that you know what, maybe this isn’t going to help. Maybe you’re better off, uhh, not having the surgery, but, uhh, taking the painkiller.” -- Barack Obama

    ...and the fact that he appointed the bioethicist as a counselor in the OMB, says that Obama embraces these rationing ideas.

    By now it's quite clear what's going on. If you don't see the rationing in this plan -- the same sort of rationing that every other such plan in the world has had to incorporate -- then it's only because you choose not to see it.

    Or perhaps you do see it, but you're just part of the distraction?

  22. hmmm....judging exactly from the Obama quote your offer, and what is actually on the table in bills and administration proposals to appears you are implying (inadvertently?) that if Comparative-Effectiveness research of medical researchers finds that a certain therapy in a certain near-end-of-life situation does little to extend life, and simply robs dying patients of some peace and time with friends/family, that...should *not* publish such *information* -- the findings of the research?

    This is what Obama has actually proposed -- to publish the results of comparative-effectiveness research, and specifically to make such information directly available to patients.

    Regarding the string of logic that concludes a bio-ethicist indicates an intention to ultimately euthanize...let me point out:

    If someone *thinks* and *writes* about whether abortion is a good or a bad thing, it is paranoid to jump to the conclusion that this person who thinks and writes about the complexities of abortion wants to "kill babies" or "force young women into dying in back-alley coat-hanger abortions", etc., *unless* they specifically say exactly some such insane idea -- to require abortions against patient's will according to some set of rules, or to prohibit abortions against patient's will, according to some set of rules. But even a "wingnut" bio-ethicist for instance should not color-by-association.

    In other words, if one of my circle of friends has some foolish ideas, it cannot be reliably concluded (by any high quality of thought) that therefore I must also think the same thing.

    If you yourself advocate capitalism, I won't jump to a conclusion that this means you want to "exploit poor working people" or other such nonsense.

    Paranoia is a normal human tendency, and we only avoid it through awareness and fact-checking.

    Fact-check is *not* trying to find bits and pieces to support an idea.

    Fact-checking is trying to find anything that rules out the idea in question!

    You must try to kill the idea and see if it can survive!

    Not many people seem to be aware that being objective is *not* marshaling facts to support one's current position/idea.

    Being objective is thoroughly searching for real data or facts that can *shoot down* and *destroy* a weak idea which you currently hold.

    It's working *against* one of your ideas, so that...each idea left standing after this critical review is a strong one, and worthy of communicating to others.

  23. Burden of Proof.

    If you walk up to to me and assert that my friend or associate John is a fascist, then you have to prove that he is.

    I don't have to prove that he isn't, of course.

    The burden of proof is on the person making the assertion, as I expect you realize.

    Further, if you believe he is likely a fascist, based on a certain bit of evidence, it is a good quality-of-thought process for you to painstakingly spend time and energy trying to shoot down and demolish your hypothesis.

    You might find something like John once had some ideas that were fascist -- for example perhaps John once wrote or co-wrote a booklet of tactics where it was recommended that those of another viewpoint at public meetings should be beaten with clubs or shouted down and lied about. (Actual, historical fascist tactics, etc.)

    Perhaps John co-wrote that groups should organize, attend public meetings, and intentionally disrupt their political opponents, shouting them down, speaking out of turn, etc., in order to prevent opposing viewpoints from being heard.

    Actual, historical fascist tactics (anyone can look it up).

    In other words, you need this kind of red-handed, actual fascist tactic as evidence of fascism, first. have to fact check...

    On further checking, you might find that in fact the John who wrote up those fascist tactics is a *different* John P. than the John P. who is my friend!

    Or, maybe not. If he's the same person, further fact checking might discover some other new information, like John was one of several authors of the tactics-book, and didn't realize that some fascist tactics were going to be in it, until too late, and later denounced the tactics.

    Etc., checking the hypothesis critically.

    So, only if in fact John advocated the fascist tactic, and later still advocated it, could you reasonably finally say "John advocated fascist tactics", etc.

    Now, it could still turn out to be mistaken to assert that John is a fascist in reality, but at least you've really tried to verify the hypothesis by trying to shoot it down.

  24. "If you walk up to to me and assert that my friend or associate John is a fascist, then you have to prove that he is."

    Actually, if you nominate John to a political position, then you carry the burden of proof. It's called "vetting." So when I say, "Your friend appears to be a fascist," your careful planning allows you to produce the proof that he is not.

    I say, "This is rationing." Where is Obama's proof that it is not? Judging from Obama's quote above, it appears that I am correct. In fact, we are going to ration care which in your opinion, "does little to extend life."

    Which is all fine and dandy until it's your life, and perhaps you want it extended as much as possible.

    I think we are on the verge of an honest breakthrough here. As long as you can admit that you support these forms of rationing, of course.

  25. Has the Obama administration proposed a top-down rationing scheme to Congress?

    Not that I am aware of. Do you have an instance of such a Congressional proposal?

    Regarding the broader question of "rationing", my opinion was expressed in my blog post on "Rationing", as linked above.

    You also speak as if the current practice of those on Medicare, for instance, of buying private supplemental insurance would not...exist.

    Do you have an explicit reason to believe that the private, individual purchase of private supplemental insurance would be prohibited?

    Obama has indeed proposed precisely that for only the specific treatments that Medicare does in fact cover, that a private "Medicare advantage plan" would no longer have an extra subsidy to the private insurer itself for the specific Medicare benefits it effectively only passes through.

    But that isn't supplemental insurance. The Medicare benefits are Medicare benefits. The supplemental insurance policies are designed to offer additional benefits above the Medicare level.

    Perhaps you should clarify what you mean exactly.

  26. What I mean, exactly, is that a formulary will be developed, specifying which treatments will be reimbursed for various conditions.

    This formulary will exclude, as "unnecessary," various heroic measures which are currently administered, but which rarely save lives, or which only extend them briefly.

    Many people who might benefit (or benefit only slightly or briefly) from those procedures under their current plan will no longer receive them. They will not even be tried.

    The bulk of the savings from this new rationing will go to subsidizing care for the uninsured and the underinsured.

    And for some reason the advocates of this system find it necessary to invent savings in other areas that are very unlikely to materialize, while essentially denying this actual centerpiece of the cost-cutting that will ultimately take place.

    Why do you supppose that is, I wonder?

  27. You've described how rationing could be structured, but haven't cited where it is being proposed.

    In what bill before Congress, on what page?

    I will be out for a few hours, attending a town-hall meeting. :-)

  28. Yes, we've been over this before. Here's what it looked like:

    "You'll have to show me a specific proposal in an actual bill in question."

    And I said:

    Regulation doesn't work that way. You create a provision to establish a regulatory body, and then you populate that panel with people who hold whatever philosophy you want. Philosophies like "The Complete Lives System."

  29. Ok. So the only proposal I know of (I've not read the whole of HR3200) that could be like that somewhat is the IMAC panel, which is tasked with proposing reforms to Medicare.

    But the periodic proposals from IMAC of reforms can be voted down by Congress.

    Therefore, Congress is responsible to accept or reject each set of proposed reforms.

    So to get top-down rationing, you'd need first that IMAC proposes such in some fashion, and then that Congress and the President both accept those particular proposed reforms.

    This is not a panel that has some power to make rules independent of Congress.

  30. "This is not a panel that has some power to make rules independent of Congress."

    What difference does that make?

    I honestly don't know if it will be IMAC. Perhaps it will, since Medicare by far consumes the most care. Somebody has to define the benefits of the various programs -- what gets reimbursed, what does not. Look there. A lot of the procedures they've been approving are going to be declared "unnecessary." We'll be ringing in a new era of "efficiency."

    It is the ONLY way they are going to reduce consumption on the scale they're attempting. You are fooling yourself if you think otherwise -- you are falling hook line and sinker for the bait and switch.

  31. hmmm...the stated goal is to slow down the rate of increase. The stated intention is to find out what is the most effective treatment in many narrow conditions. Presuming you know the future outcome of research, then you could assert those results will be A or B. But...I don't actually have a crystal ball. I do know that typically over time there is progress in techniques/treatments, so the idea that more effective therapies could be actually more efficient (less wasted treatments that didn't work) is plausible.

    Frankly you are falling for a certain view of the future..."hook, line and sinker."

  32. Time for some humor: I've found a future scenario to post...

  33. "Frankly you are falling for a certain view of the future"

    No. It's a view of NOW, as the policies you advocate apply around the world, today, in many countries who have already adopted them.

    The only futuristic notion is that we can be the lone exception to somehow escape the exact same outcome as everyone else who has already done it. And that is a fantasy.

    Frankly, I think your side would be faring better if it would argue honestly for its goals. But that would involve "tough choices," wouldn't it?

  34. "the policies you advocate apply around the world, today"

    ! I wish that were true!

    " I think your side would be faring better if it would argue honestly for its goals"

    Well, if I have a "side", then its the market/pay-for-outcomes-over-time side. I'm not aware that is so common! Are there millions on my side?

    Argue honestly? By all means! I could not agree more.

    My main argument, in full, from June-July, which many visitors have loaded the page on. I think it may intimidate some readers with length, but it is simple enough finally, and most people could understand this with only a half hour or less of reading and thinking:

    Now that you've discussed the national rhetorical spin and appearances with me some in this thread, did you actually read what I advocate?

  35. I'm not concerned with your option. Your option is not on the table. Furthermore, if your option is so good, then why do you keep defending the very bad one that is before us?

    Getting a better option begins with rejecting the option that's currently being considered. But according to you, the worst aspects of that bill are only imaginary.

  36. It's 100% true that death-panels and all somewhat similar notions and fabrications like top-down rationing are nowhere in sight in the legislation, nor is there any mechanism in the legislation that would permit such. So those "worst aspects" widely believe are quite imaginary, yes.

    And spreading imaginary rationales to oppose something discredits those using the rationales.

  37. "nowhere in sight in the legislation"

    When the President talks about "taking a pill," and one of his top advisors is a rationing specialist who has pointed out that the strategies you embrace are not really the meat and potatoes of the plan, then reasonable people know the rationing is in there somewhere even if it's not in plain sight.

    Wouldn't it be more honest for you to admit you support the model than to try and deny that it exists? You could argue that you think it's better than what we have now, or that you'd much rather we used your model, but you'll settle for this one. Saying that the things which logically are in there "are nowhere in sight" is just slope grease.

  38. Ok, that's a reasonable point to raise -- shouldn't I advocate *only* the best idea I know of, and nothing else.

    Well, I've mainly wanted to shoot down the distortions so that the *real* issues can be talked about.

    The *real* issue, as I see it, is the non-market-like setup, the current setup, for health insurance, and the cost-inflation outcome of our current setup.

    But, now I'm wondering how you reconcile your own proposal on your blog for a basic "merely good" level of universal insurance (a pragmatic idea) with your own focus against the [top-down] "rationing" you expect.

    It appears, and it really is up to you to make appearances clear, that you advocate a sort of rationed care, and then everyone is free to purchase more extensive private health insurance on top, right?

    How would that be any different from what you expect to come out of the current health reform!?

  39. "I'm wondering how you reconcile your own proposal on your blog for a basic "merely good" level of universal insurance (a pragmatic idea) with your own focus against the [top-down] "rationing" you expect."

    It starts with not pretending that government-rationed care is just as good. Rationing implies cuts. The current proposal is a scam, designed to spread inferior care over more people. Nobody who currently has care should want it.

  40. I can't see any difference between your own form of rationing -- "merely good" care -- and the likely "basic" insurance policy that will be mandated. And I've actually read more than opinion pieces.

    If you want, you can use the links I offered and even go so far as to discuss precise, specific proposals I make under those blog entries.

    In terms of just making characterizations, as you offer, mine is:

    The current proposal, H.R.3200, is typical Congressional compromise, not ideal, and far better than doing nothing -- doing nothing truly would be unsustainable, as any research and/or effort to read non-opinion pieces can reveal.

    The insurance-reform, for instance, which will likely pass Congress, and will prevent some fraudulent activities by insurers where patients are dropped on shaky pretexts when they have an expensive illness. Also, portability will allow more health security for individuals thinking about starting their own business.

    An individual can take the risk to start their own business -- enterprise and capitalism -- if they know their health insurance is reliable to actually pay as expected when needed. Some people say they haven't taken the plunge exactly because of preexisting conditions in their family which could not get covered if they became self-employed.

  41. "I can't see any difference between your own form of rationing -- "merely good" care -- and the likely "basic" insurance policy that will be mandated."

    Do both alternatives -- my "merely good" plan and the "basic" mandate -- do both admit that the quality of the care will not be as good as that which most people currently enjoy? My alternative says that. Does HR3200 say that???

    Which politicians have admitted, as my version stipulates, that the care in HR3200 won't be as good? (Besides the "lying" Republicans, of course.)

  42. "Do both alternatives -- my "merely good" plan and the "basic" mandate -- do both admit that the quality of the care will not be as good as that which most people currently enjoy? My alternative says that. Does HR3200 say that???"

    Good question. I haven't seen any specification of what the "basic" plan would be, and it's a huge question, and it could be only a matter of more co-pays, but I need to search this out.

    I think your explicit "merely good" idea is superior to any "basic" plan which is willing to pay for treatments with low success rates. Such should be purchased individually with private supplemental insurance I think. Or...a co-insurance requirement is another good way, in that if the treatment is expensive and uncertain, then the out-of-pocket cost is higher, but...I think the insurance reform will cap total out-of-pocket.

    So I think your idea would be a good option, or alternative plan, people should be able to purchase, by choice.

    Did some representatives stipulate something about HR3200 regarding the quality in the "basic" plan?

    btw, I edited my new post to be sure it is more exact -- only some Republicans have distorted HR3200 I expect. I do know some have. I've watched some do so in video clips with context. But the entire party should not be painted by its least informed.

  43. The idea that there is little genuine waste (or that waste is only relative -- in the eye of the beholder) doesn't survive real-world testing.

    Here is yet another typical example of clear waste in medical care:

    But what is even more fascinating: consider, if "30%" of medical care is ineffective compared to best-practice, and also about 1/4th of insurance costs being spent to pay for administration in insurers and providers to battle over reimbursements, then the math says...

    .75 * .7 = .53


    American medical care *isn't* naturally "twice as expensive" as other top-health-quality nations!

    Indeed, it is right in line.

    It only needs a more rational reimbursement system!