Montana Politics

A Path to Affordable Healthcare

I think you’d have to search pretty hard to find a person in this country totally pleased with the ACA. For every element of it, there are those who think it changes too much, and those who think it changes to little, that government does too much or too little, that there are too many requirements for insurance companies, or too few. This is pretty standard for any bill drafted in an elected legislature. But the question is, is the thing salvageable? Can it lead to true affordable care? Was the title of the bill premature, or straight up misleading? I think there is a path to real health care savings, and it is more accessible if we keep the ACA.

The key to making the ACA work, which has not been discussed nearly enough by opponents or supporters, is the limit it places on insurance company’s overhead costs. By enforcing a medical loss ration of 80/20, the law limits how much money insurance can spend on overhead and profits – causing them to return over a billion dollars this year alone. I only bothered looking into the law because my father was bragging about his rebate. This alone, however, is not going to solve our problems with high health care costs – the problem of states being granted waivers, for example, needs to be cleared up. It can, however, be the first step.

Insurance companies are fully capable of of running at over a 95% medical loss ratio. There’s no reason the 80% rule can’t be gradually raised to up to 90%, saving customers even more money. More importantly, the ACA sets a precedent for federal mandates regarding how insurance companies make and use their revenues. It may in the short term raise more money for insurers, with its individual mandate, but having been passed and found constitutional, the ACA unlocks a hefty toolbox for controlling their rates in ways that benefit customers as well – growing closer and closer to the Swiss model, allowing for a private but largely non-profit healthcare model that nonetheless leaves the health insurance industry able to provide supplementary services.

And that, my friends, would actually be a big $%&#ing deal.

If you appreciate an independent voice holding Montana politicians accountable and informing voters, and you can throw a few dollars a month our way, we would certainly appreciate it.


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    • I think “putting the cart in front of the horse,” at least in terms of this particular argument, is probably the best way to go. The article you site mentions that Medicare funds ~100,000 residencies each year; if you’re of the opinion that we need to ensure the cap is raised, and that more doctors are given residency each year, it seems you should be on board with redistributing roughly $700b in Medicare spending toward programs that could desperately use bolstering.

      Robust, quality healthcare and affordability aren’t mutually exclusive.

      • Mal, think “rationing” if we don’t have the medical professionals. To see what that means study up on what has happened on Indian reservations.

        • I understand what “rationing” means–particularly in the context of Indian reservations–perfectly well. We’re considering hypotheticals for the development and improvement of the ACA (as we know it) in this discussion, and my point is that by funding programs like medical residencies with Obama’s proposed $700b in redistributed Medicare spending, you would ultimately find the demand for primary care and physicians would be met with increasing efficiency. Less demand=less rationing.

    • Perhaps, Craig, but we have the cart, just sitting there. We can demolish it, go get a horse, and then try to make another cart. Limiting the overhead costs of insurance companies ought not to have any effect on keeping our doctors well paid – indeed, insurance companies actually have a bit of an incentive to pay doctors well to prop up that 80% requirement.

      • PW, remove the insurance co aspect from the discussion of ACA and what it does to healthcare delivery. ACA tends to rob Peter to pay Paul and NOT address the lasting effects. Rationing will be upon us if the bottleneck is not removed. We have a burgeoning elder population on our hands and no plan to ensure that there will be timely robust delivery of service.

        • I’m afraid I don’t really understand your first two sentences, because I don’t really know to which particular part of the ACA to which you are referring. But I will say this much – if we want more doctors, I’d like to hear your proposals on it. To me, two steps we need to take are preparing more kids for medical careers in high schools, making sure our kids that might want to enter the medical profession can get a good basis in science, and making medical school a great deal cheaper. (You know a country that has no shortage of doctors? Cuba.)

          • The bottleneck Craig refers to is what we’ve seen with med school graduates specifically. We have more MDs than residencies, i.e. more doctors than jobs. We don’t need to focus on preparing youngsters for careers in medicine so much as on creating a place for qualified physicians in the healthcare industry. I think the ACA has serious potential to do that, given the reforms siphon money to the right places.

            Craig: could you tell me who the ACA has “robbed” and who it’s paying?

          • PW, look here as to the scope of the problem: Don’t get hung up on the recommended fixes suggested. I am not a supporter of importing healthcare professionals to make up for our problems. We need to grow our own solutions.

            The GME (graduate medical education bottleneck should be removed from Medicare altogether so as not to exacerbate the problem that presently exists or the “gasoline added to fire” that Medicare reductions will have. GME needs it’s own spotlight and funding requirements analysis.

            Second we need to incentivise current aging medical professionals to stay in the game. Continually squeezing their finances with tighter fee limits is not the way to go.

  • Only a single-payer system can cover everyone at an economically sustainable cost. Private health insurers are parasites that drive up the cost of health care while doing absolutely nothing to improve it.

    • See, James, that’s not really true. Single payer is the cheapest way, but that’s not likely to happen. A plan like Switzerland has, wherein insurance companies provide insurance, but wat profit-controlled rates, is slightly more expensive but much more likely in the coming decades.

      • (1) “Single payer…[is]…not likely to happen. That’s true if that assumption, which I dispute, is allowed to become a self-fulfilling prophecy. Once the ACA become economically unsustainable, and it will, the only remaining choices will become no national health care or everyone covered for everything single-payer.

        (2) Switzerland essentially treats the private health insurance industry as a regulated public utility, an approach that some of the Democratic Party’s blue dogs favor. Swiss insurers are not permitted a profit on the required basic health care package, which residents are required to purchase. But the insurers can make profits on supplemental policies, so there is a tremendous economic incentive for the Swiss insurers to oppose a generous basic package.

        The Swiss system condemns individuals to choosing among various insurers, putting them at the mercy of profit makers. Switzerland would be better off with an everyone covered for everything single-payer system. And that’s true for all nations.

        (3) Private health insurers, non-for-profit and for profit, exist to collect premiums and deny benefits. They contribute nothing useful to our health care system. A medical equipment manufacturer, for example, produces products, wheelchairs for example, that help people. Those products may be overpriced, but they are yours once you pay for them, and the manufacturers do not try to keep people from using what they own. But the health insurance industry does. It’s parasitical and the moral equivalent of a mob protection racket. Its mere existence creates harm, not good, and no amount of regulation (which just adds to the costs of the scheme) can mitigate its societal evils.

        • “They contribute nothing useful to our health care system.”

          You’ve put me in the unfortunate position of defending the insurance companies, but someone has to point out that insurance companies, whether health, auto, or other property insurance, do perform a societal good, by covering the risk that individual consumers are unwilling to pay. It’s what they are selling. Just to break even on claims, insurance companies would have to charge the actuarially fair price–the price at which the average person would break even. But then they have to pay their employees, so even the most charitable insurance company must charge a premium above the “fair” price. What do consumers get for this extra charge? The peace of mind that the insurance company will have you covered when your house floods, or you have a serious medical procedure.

          Even if the theory doesn’t work perfectly in the real world (insurance companies take large profits and deny claims), millions of people willingly choose insurance for the peace of mind, even though its a money-losing proposition. It’s why I have faith in the ACA, since it addresses the two big malfunctions with insurance: large profits and denied claims.

          • You’re comparing apples and oranges, you know it — or you should damn well know it, and you should be ashamed of yourself for doing it. My comments were limited to private health insurers and cannot be extrapolated to insurance as a class.

              • The need for health care is a certainty, not a risk that can be avoided by not engaging in an activity (you probably don’t need a car if you live in a large city). The only question is how much it will cost. That’s why putting all of the nation’s residents into a single risk pool managed by the government (we the people) makes sense: it eliminates diversions of money to private profiteers who contribute absolutely nothing to health care. Private health insurance is in its own class of evil.

            • How is there any difference between health insurance and, say, car insurance? They serve the exact same function, and operate the same way. Just because one has been vilified more effectively than the others doesn’t mean the basic principle is the same.

              Now, there may be a big moral difference between different kinds of insurance, because you can make the case that everyone deserves health insurance, but not everyone deserves car or fire insurance. But that doesn’t change the economics of it – you lose some money on ‘expected value’, but in exchange you get peace of mind and a better chance of paying for your medical care.

              Now, that brings us to relatively low cost procedures – office visits, physicals, vaccines, etc. Insurance doesn’t make a whole lot of sense in this case – you are pretty sure that you’re going to pay for those things, and they aren’t going to break the bank. The percent of your premium that goes to these procedures is a waste, and no thinking person making a transparent decision about this would choose to have them on their insurance – unless you’re making a much higher than average number of trips to the doctor, the best case scenario is you lost 20% of your money to insurance company overhead.

              But, you’ll say, vaccines, check ups, and testing are the keystones of good preventive health care, and if they aren’t covered by insurance, people won’t get them. Because these services theoretically save money down the road, insurance companies may choose to subsidize them. But, based on Mark’s anecdotes, that’s not happening to a wide extent. As these are a key to bringing down health care costs, these would be a good target for government subsidies.

              I’m getting off topic here – economically, health insurance is functionally no different than any other kind of insurance.

          • Your argument fails, Tyler, in equating health care and casutalty insurance. It would be possible to segregate insurance for catastrophic health events for young people. Then comparison might be valid.

            But the need for basic health care is pretty much a certainty, so that the insurers need to move out of the way. In that area, they are mere brokers who impose huge overhead on everyone. To save money they deny basic care, impose co-pays and deductibles and out-of-pocket and even refuse to pay many claims. They do this knowing full well that once saddled with large insurance premiums people are reluctant to take on additional costs, and so avoid basic care. So health insurance becomes a roadblock to public health. Indeed, since ACA I’ve seen insurers back away from paying physician office visits in total, not even counting them towards deductibles or out-of-pocket limits.

            Also note that most health care costs are for the aged, and that we all travel that road, so that Medicare is not so much insurance as an intergenerational transfer. But also note that before we had Medicare health insurers, knowing the high certainty of claims, refused to cover most seniors. Again the insurance model fails.

            Casualty insurance and health care coverage are, in my view, two separate functions that are not comparable.

  • Wendell Potter, in his interview with Bill Moyers on PBS back before passage said that Wall Street watches MLR very closely, and if it exceeds 80% they clamp down. In other words, ACA, written by point person Liz Fowler of Wellpoint/Baucus and other insurance executives, froze health care companies in place. Tough old Obama nailed them telling them that what they were already doing is not part of the law. Zounds! I don’t know where you got your $1 billion figure. Would like to know.

    Now here is the crux of the matter: ACA passed at a time when your party effectively had sixty senates seats, the house and the presidency. Now you come back and tell us it will be fixed in the future … when you are not burdened by huge majorities?

    • “, and if it exceeds 80% they clamp down.”

      One of two things is happening here. Either by exceeds you mean falls below, or you do mean exceeds, and you are arguing for me. If you mean ‘falls below’ 80%, that would be something. But it’s not true, and doesn’t make sense. Insurance companies with little competition routinely operate at close to 60/40. If 80/20 were the norm, states like Maine wouldn’t have applied for waivers to allow them to operate at 65/35. Because why would Wall Street want to limit profits to under 20% of revenues? Especially since that 20% isn’t pure profit; you still have to take out overhead and salaries.

      If you mean what you’re saying, that Wall Street cracks down when companies exceed 80%, then again you’re wrong (as I noted, companies in highly competitive markets often operate at above 90%), but you’d be supporting my point – insurance company investors want a low Medical Loss Ratio, because that second, smaller number is where they can get their dividends. The law forces them to accept a higher MLR, which means lower profits.

      As to the ‘essentially’ sixty democrats in the Senate, we’ve been over this. If anything, there were essentially 46 Democrats and 13 moderate conservatives whose constituents didn’t support Obama or his healthcare initiative but couldn’t stomach whatever stupidity was coming out of the Republican party at the time. This was a huge shift, and it took a lot to get those conservative Dems on board. But it was also the most difficult shift. Now that we have the law on the books that gives Congress the power to regulate insurance industry profits, and it has been declared constitutional, it will be much easier for congress to tweak that number, the next time congress is functioning.

      Oh, and as to the source of the over a billion dollars number? There’s a link in-text to the Huffington Post, which in turn links to the Department of Health and Human Services. There’s more links from there if you want more details.

      • “WENDELL POTTER: Well, there’s a measure of profitability that investors look to, and it’s called a medical loss ratio. And it’s unique to the health insurance industry. And by medical loss ratio, I mean that it’s a measure that tells investors or anyone else how much of a premium dollar is used by the insurance company to actually pay medical claims. And that has been shrinking, over the years, since the industry’s been dominated by, or become dominated by for-profit insurance companies. Back in the early ’90s, or back during the time that the Clinton plan was being debated, 95 cents out of every dollar was sent, you know, on average was used by the insurance companies to pay claims. Last year, it was down to just slightly above 80 percent.

        So, investors want that to keep shrinking. And if they see that an insurance company has not done what they think meets their expectations with the medical loss ratio, they’ll punish them. Investors will start leaving in droves.

        I’ve seen a company stock price fall 20 percent in a single day, when it did not meet Wall Street’s expectations with this medical loss ratio.

        For example, if one company’s medical loss ratio was 77.9 percent, for example, in one quarter, and the next quarter, it was 78.2 percent. It seems like a small movement. But investors will think that’s ridiculous. And it’s horrible.” (Moyers interview, July 2009)

        Your examples qualify as anecdotal. And yes, I know about the fact that so many Democrats are more like Republicans – that does not address the fact that the very bad bill we got came at a time when your party crested in legislative power and held the presidency. If you can’t get things done then, what makes you think you can do it when you have even less power? 2008-10 was your window.

        • You are killing your own case, Mark. Look at what you’re saying, and then what your source is saying:

          Mark says, Obama isn’t really standing up to insurance or Wall Street – he’s ‘making’ them adhere to a ratio of 80/20 that they are already adhere to.

          Wendell Potter says, even a rise from 77.9 to 78.2 is enough to invoke the wrath of Wall Street.

          Huh, Mark, I wonder if Wall Street, which was upset at a .3 decrease in potential profits, was just thrilled to learn that the same hypothetical company will now see a 1.8 point decrease. Especially when, in one year, that means a one billion dollar loss in profits. That billion dollars, mind you, more than either candidate spent in 2008.

          As to ‘when will it be easier’? The answer is, whenever congress functions again. Which is harder, moving the minimum MLR up a few percentage points, or introducing the concept of it, passing it through committee and two chambers, and getting it approved by the Supreme Court? Limits on insurance overhead are going to be needed to get health care costs in this country down. We’ll get there a lot faster amending the current ACA than scrapping it and starting over.

          • You are splitting hairs while beating a strategic retreat.

            Some other thoughts: Insurance industry accountants can easily overcome any real pressure to adhere to an 80/85% margin. It’s a corrupt industry, and pressure works on people whose paycheck depends on management approval.

            You seem to think that bringing down costs is a driving force in this debate. That’s an illusory goal, one not even sought by the industry. Their goal is quite obvious: a captive client base and government subsidy. That’s what ACA gave them.

            You seem to think that congress acts based on public pressure even when the public is largely uninformed and unorganized. There is no stick holding that carrot.

            Your notion that we can fix it down the road indicates a belief that ACA was a partial fix. Quite to the contrary, ACA was the final nail in the reform coffin. We now have an individual mandate, no public option, serious fines for failure to submit, no cost controls, amazing subsidy that overshadow the illusary $1? billion you say has been saved so far. Industry power made all of that happen, but you are saying that diffracted public pressure expressed only by uninformed votes will bring change down the road.

            By the way, here’s n anecdote that sheds some light on a insurance company response to “reform:” when I got my physical earlier this year, which Anthem is required by law to pay for, they refused to pay for the office visit portion. Since that was the majority of the cost, it is safe to say they have skirted the requirement. Further, in looking for insurance for my daughter, I found that BCBS of Montana no longer covers office visits under any but their one most expensive policy. So it appears their coverage has retreated in the wake of so-called reform. Office visits are essential and experience shows that people burdened with high premiums avoid non-covered medical procedures.

            • “You are splitting hairs while beating a strategic retreat.”

              In other words, you are admitting that everything you said before is pointless or, indeed, proves my point? That the ACA is forcing companies to do what the stock markets would have battered them for doing on their own? And yet you continue to insist that this is just what they wanted.

              More likely, Mark, a compromise was reached – individual mandate in exchange for profit limiting. Insurance companies make more money because more people are insured, so revenues go up, making up for limited margins. Insurance companies still probably come out ahead, you’re right. But so do customers, because companies are required to achieve greater efficiency. And low-income customers gain the most, as they will qualify for Medicaid or tax credits to purchase insurance. The big losers are wealthy health care consumers who don’t have insurance because, as Tyler noted, its a bad investment on a cost-benefit analysis. They have to purchase, unassisted, a product that will likely lose them money, which is rough for them, very much like it’s rough for wealthy people to have to buy car insurance.

              As to avoiding payment – yes, insurance companies will and always have done that. And they will try and get around any regulations we throw at them – but they will not always succeed. And the MLR rule, if properly enforced, will make most other rule-dodging pointless – why go through so much trouble to avoid paying claims if you’ll just have to give back extra money over 20% to your customers anyway? Especially when lawyers, bureaucrats, and PR guys have to come from that precious 20%, while actually paying claims contributes to the 80%. And the higher we raise the bar, the more incentive there will be to pay on claims. Sure, every time we raise the MLR there will be insurance lobbying against it, but it’s a simple metric, easy for voters to understand and hard for insurance to spin.

              • Your faith in voters is dependent on a burrowing press, which we do not have.

                And again, they were at 80%, which is by itself absurd and are frozen at 80%. Yippee! You don’t seem to grasp that having yielded so much ground since the 1990’s, any victory we might have achieved is of the Democratic variety where we have to search hard and pretend. One more victory like that and we are cooked.

                And, there are no laws regarding underinsurance, which is where the new captive clientele will surely retreat when faced with unaffordable premiums.

                All in all, it’s not even a mixed bag. It’s an empty one. You sold us out.

                • “And again, they were at 80%, which is by itself absurd and are frozen at 80%.”

                  In fact, they were at about a billion dollars below 80%, excluding the states with the least competition. Remove those waivers, and you’ll see them go up further. And given that for twenty years we were losing ground, freezing it at slightly above the current amount seems like a good start, no?

                  Again, there may continue to be under-insurance, but the profits companies can reap from under-insurance will still be less than they would be otherwise. All you’re telling me here is that the individual mandate may be ineffective. I’m not disputing that, I think it’s by far the worse part of the ACA. What I’m saying is that the MLR is the first step on the path to actually bringing down health care costs. Phase out the waivers, raise the MLR, and you can at least bring down the costs by the ten percent that has been caused by insurance overhead going up in the last twenty years.

                • “the profits companies can reap from under-insurance will still be less than they would be otherwise.”

                  Your words remind me of Matt Singer when he realized that a bad bill was in the works – he retreated and said “we’re just trying to bend the cost curve.” It appears to me that you have once again pitched your tent in the non-testable hypothesis camp. Health insurance stocks are doing quite well – investors disagree. Since passage of ACA, CIGNA was gone from 10.87 to 44.68, Wellpoint from 33.35 to 58.57. You can say what you will about that, but don’t tell me that the prices would even be higher without ACA, as that would be that thing you do again.

                  The essence of your argument is that by some magical process the market is now going to close in on the health insurance companies because Obama told them that 80% was far enough. From there they are going to see less profit than they would have otherwise, and we have no way of testing that hypothesis. Investors are optimistic, running ups tock prices since passage of the bill.

                  And again, the $1? billion you say has been saved thus far pales in comparison to god knows how many million new clients forced by government to do business with them. You’re telling me they would not give up a little to get a whole lot back?

                  Please, now, PW, dont’ help us no more. OK?

                • Of course health care stocks are going up – I’m not arguing that this is bad for insurance companies. If they can increase their customer base by 15% while losing less than five percent in profits percentages, that’s a good trade for them. The thing is, it’s not a zero-sum game: if they make more money because they have more revenue, but their profit margins are legislatively limited, we will also be better off. We now have the ability to squeeze them further, if we can get the congress on board.

                  And you already proved my hypothesis with your quotations – Wall Street was exerting powerful pressure on the MLR, pushing it further and further down. Your hypothesis, that the MLR would somehow have stopped at 80 even though it had already fallen below that point, and the had fallen substantially from 1993, and was continually under pressure to be lowered, is laughable on its face.

                • Potter, CIGNA executive, asserted that Wall Street had already settled on 80%. Since the bill was written by Liz Fowler and other industry executives, I take it to mean that they are happy with 80/85. It’s always good politics to strongly fight for something hat is going to happen anyway.

                  You’re wading in the shallow end of the pool. Health insurance is a racket. Obama acted as point man to make sure that the racketeers rule. You’re doing the job all intellectuals do, walking behind the parade with a broom.

                  Question for you. Asked many times by many people: Why do intellectuals align with power?

                • Your own source stated that Wall Street punished companies for allowing their MLR to rise to 79%. Settled on 80% is clearly false, then.

                  I think it’s funny that I’m an intellectual in this conversation. I’m not aligning with anything – I’m stating the facts. The makeup of the Senate will not allow for single payer. Profits have been squeezed by a billion dollars. I’m not saying that’s a victory – I’m saying that’s a blueprint for much more substantial gains.

                • The points you imagine scoring, with much fanfare, are so insignificant! And I’ll stand on one thought which will be testable: Health care costs will not go down. One, they did nothing about effective monopoly, and two, they imposed no cost controls. It’s kind of a no-brainer, and your fictional 80% victory has no bearing.

                  And again, the “makeup of the Senate” has two factors to consider: one, that Democrats enable the filibuster, and two, that you and others complain that we don’t back your candidates even as they are the kind of candidates that make up the senate. You know, like Tester, right-wing Democrats who turn slightly liberal at election time.

                  I know, you’ll say that we’re better off with weak Democrats than strong Republicans, but that is the crux: we’re not. Neither are any good, and one, the false friend party, is a far bigger roadblock to progress because it prevents the rise of a second party. The circle completes, we start over again.

                  You do know that, right? That your party squeezes out fighters, marginalizing us, demanding that we settle, as do you, calling it progress.

                • And there we have it – Mark’s own source directly contradicts what he says, so he starts ignoring 1) what I’m saying – that the ACA can be used to bring down costs, not that it already has 2) the topic at hand and goes back on the same robotic rant against Democrats.

                  The other possibility, of course, is that Mark isn’t typing anymore, and his iPad is just auto-filling whole comments based on everything he’s written before.

                • (sigh) … I much prefer football to debating with you. A least in football a player must score a touchdown before he does the chicken dance.

                • And we have a complete Mark Cycle here. It goes about like this:

                  1. Mark Reads a Post (no real evidence that this actually happened, but we’ll assume).

                  2. Mark doesn’t feel like (capable of?) responding to the point of the post. In this case, the post posited a means to achieve more affordable healthcare using the framework of the ACA. Mark instead chose to respond to the unmade assertion that the ACA will reduce healthcare costs as it stands.

                  3. Mark cites an inappropriate source. In this case, his source supported both my actual argument (that MLR can be lowered) and the argument I didn’t make, but that Mark is arguing against (that even an 80% limit will reduce insurance company profit percentages).

                  4. Flustered at having failed to successfully argue against even the point he was pretending I made, he generalizes the debate to ‘Democrats (embodied by me, apparently) make it impossible for activists to get anything done and so their achievements through compromise are worse than just letting Republicans run the show.’

                  5. Someone (here, me) points out that Mark has dropped even the facade of addressing the post and has fallen back on his same talking points without giving even the hint of a workable alternative suggestion,

                  6. Personal insults (in this case, wittier than is typical) ensue.

                  Now, you can plug in me, or Rob, or Ken, or Don, the cycle is the same. The only variance is how much patience the non-Mark party has before we skip to the last steps.

      • Potter, I should add, is a former CIGNA PR executive who resigned in 2008 and authored the book “eDeadly Spin” about the health insurance business.

  • Thanks James Conner, that needed to be said.

    A single-payer system is possible, but only if it gets a fair hearing. That didn’t happen before Chairman Baucus, and it isn’t happening here. PW, you admit single-payer is “the cheapest way,” and then dismiss it out of hand. Yet, you will beat a truly dead horse — ACA — which is neither universal, nor affordable. Realpolitik is for fence-sitters and party hacks. If you want change, you will have to fight the media, insurance companies, and both parties. Sucking up to the status quo simply won’t get the job done.

    I suggest Switzerland is more like a bank than a country. Montana Power was a highly regulated monopoly once, and look how that turned out. Pick another country, one with several hundred million citizens and a large land mass, please. Now, if you don’t believe everyone in America deserves basic, affordable health care, why don’t you just say so.

    • Switzerland is roughly equal in area and population to Virginia. There are differences, of course. Switzerland probably has more banks that Mitt Romney would find worthy of accepting his deposits, while Virginia’s women (white women, to be sure) received the right to vote half a century before Switzerland’s women. See my remarks above for my thoughts on Swiss health care.

    • “Pick another country, one with several hundred million citizens and a large land mass, please. ”
      I do think one of the best uses of blogs is sharpening the arguments of fellow progressives, so I’m going to do you a favor – don’t try to use those requirements in an argument. Here’s why:

      That’s a pretty exclusive club – China, India, the US, Indonesia, Brazil, Nigeria, Mexico, Pakistan, Russia. Drop ‘large land mass’ and you can throw in Bangladesh and Japan. The US has better health care outcomes (life expectancy and infant mortality, easy and pretty representative metrics) than all of those countries except Japan, which as we discussed barely qualifies.

      Indeed, the ‘large country’ argument is one of the best arguments AGAINST single payer – it can be construed to work best in small to mid-sized countries – up to about a hundred million people, or a half million square kilometers. Bigger countries attempting similar systems don’t tend to have equivalent results. Now, that’s in actuality due that the fact that those large populations derive from a lack of human development in the first place, but it’s hard to argue against.

      Now, I think you’re right and that a single payer system would be great. But the population distribution in this country means that well after the majority of Americans come around to the idea, Senators are concentrated in more conservative states, so 20 or 30% of Americans will suffice to keep it from happening. On the other hand, it’s pretty straightforward to require insurers to spend more money on medical care or charge less in premiums. And once insurance is less profitable, perhaps it will be easier to supplement it with a robust public option.


        I think a nation’s approach to health care depends on economics and political culture, and is independent of area or population. That proposition could be tested using World Factbook and data.

        I think we are in general agreement that a single-payer system is the standard against which all other health care systems should be measured. I think we also agree that compared to a single-payer system, Obamacare falls short. And I suspect we also agree that compared to the health care system in place when Obama was elected, Obamacare is an improvement. I don’t know whether we agree that Obamacare is good enough, or that relying on better regulated private health insurance is a viable long term solution.

        We disagree on the likelihood that the US will adopt a single-payer system anytime soon. I think that once the unsustainable costs and fundamental cruelty of relying on private health insurance become too much to accept, the transition will occur pretty quickly.

        I agree that the health insurance companies got a sweet deal from Congress and Obama, too sweet for the private good. I’m all for hammering down their profit margin. But even if their cut is hammered down, they will still be economic parasites running the moral equivalent of a mob protection racket.

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