Tag: Medicare

Vermont Falls

I am Hal’s total lack of surprise:

Vermonters will not be part of a single-payer healthcare system.

Gov. Peter Shumlin had hoped to create the first state-based single-payer system in 2017, but skepticism from both state lawmakers and constituents has halted the idea.

“This is not the right time” for enacting single payer, Shumlin said in a statement.

Shumlin cited the big increases in taxes Vermonters would see that would be required to pay for the plan.

“These are simply not tax rates that I can responsibly support or urge the Legislature to pass,” the governor said. “In my judgment, the potential economic disruption and risks would be too great to small businesses, working families and the state’s economy.”

Federal funds available were also $150 million less than expected, Shumlin added.

Note that Jonathan Gruber was involved in this, just in case you might be wondering what his overall intentions for Obamacare were.

I’m sure this will be blamed on the “greed” of Vermont voters, wanting to keep more of their money. But Megan McArdle called this months ago. The plan was slated to cost $2 billion, requiring Vermont to raise taxes by 75% at least.

Especially when you consider that estimates for this plan’s cost are likely to err on the optimistic side, because, well, people drawing up proposed budgets for their pet ideas tend to be a little optimistic. Yes, yes, there may be fabulous cost savings from using the government’s monopoly buying power to bargain prices down with providers. But Vermont is already the beneficiary of significant monopoly buying power: One insurer has 74 percent of the state’s small-group business. It’s a Blue Cross/Blue Shield, so don’t count on fabulous savings from squeezing out profits. The large group market is even more concentrated, though on a for-profit insurer.

Nor can you get much administrative saving at the provider level, because they still have to deal with out-of-state insurers quite a bit. And the once-vaunted fabulous savings from preventative care have mostly turned out not to exist.

So this is going to be expensive. So expensive that I doubt Vermont is actually going to go forward with it.

Supporters of single-payer healthcare tell us constantly that such a system would be massively more efficient than what we have now. They base this partially on bogus claims that Medicare and Medicaid have low overhead costs. They base this partially, as McArdle points out, on comparisons to a healthcare system that is already, in many states, a monopsony, one that Democrats have fiercely resisted challenging by allowing insurance to be sold across state lines.

But, in the end, it’s mainly wishful thinking. We’re supposed to believe that socialized medicine magically keeps costs down. But the cost curve in the evil capitalist US system has basically matched that of socialized systems for the last twenty years. Most of the explosion of medical costs occurred in the 1970’s and 80’s and is baked into the system we have.

Vermont has now shown that switching to a single-payer system would be expensive and intrusive. Can’t we try anything else before we go there?

The Right to Die

Brittany Maynard has a few months to live. Or three weeks, if she ends her own life on November 1.

For those of you who can’t or don’t want to watch the video, she has been diagnosed with terminal brain cancer. There is basically no chance she will live for more than a few months. She has moved to Oregon, which has a law allowing terminally ill people to self-administer drugs to end their own lives. Doctors may participate if they choose. She is using the last months and week of her life to advocate for other states to enact similar laws so that people may make similar decisions if they choose.

I don’t know that I would personally make the same choice Brittany has but, then again, I’m not facing the same grueling brutal decline she is. I do think people should have the option to end their lives if they choose. It is, after all, her life. I’m a bit uncomfortable with laws that allow physicians to direct this (and I’m convinced that the infamous Jack Kervorkian was no hero). This is an issue I’m still pondering.

I may have mentioned this before, but we have developed a medical system that has an astonishing ability to bring people back from the brink of death. But it can also drag out the suffering of the dying. Enormous amounts of money are spent keeping terminally ill patients alive. The left favors a solution that involves bureaucrats making decisions about withholding care. I prefer a simpler and more empowering solution: anyone who is on Medicare has to fill out a living will.

There would be no regulation of what is in the living will. And Medicare patients could change it at any time. Many people will choose the most extreme life-saving measures and that’s fine. But I believe that a lot of patients would choose to forgo the extreme heroic measures that are the default in most hospitals. Doctors rarely choose extreme life-saving measures. My mother used to be a nurse and wealthy people who could keep themselves out of the hospital system almost always just wanted a quiet room and something for the pain. I’ve spoken to numerous seniors who don’t want extraordinary measures taken but have yet to fill out a living will. They rely on their families to remember this.

What people don’t realize that if you are dying in a hospital and don’t have a living will, they will almost always go the last full measure to keep you alive. Hospitals do it because they don’t want to get sued for letting great-grammy die. And families allow it because they can’t let go or deal with the guilt of letting a loved one die who might be saved.

If we are going to preserve a Medicare system, I don’t believe we can allow people the luxury of pretending they are never going to die. Make people express their wishes and then respect those wishes.

The $2000 Eye

One of the biggest problems with our healthcare system, as David Goldhill has relentlessly argued, is that the incentive system is completely messed up. Almost all the economic forces in healthcare push us toward more expense for less return. Insurance insulates people from cost, the government shells out money with little concern for its use and so the pressure to push costs back down — a pressure that exists in every other industry — is mostly absent. Most people don’t even know how much their healthcare costs, let alone what cheap alternatives might be available.


The two drugs have been declared equivalently miraculous. Tested side by side in six major trials, both prevent blindness in a common old-age affliction. Biologically, they are cousins. They’re even made by the same company.

But one holds a clear price advantage.

Avastin costs about $50 per injection.

Lucentis costs about $2,000 per injection.

Doctors choose the more expensive drug more than half a million times every year, a choice that costs the Medicare program, the largest single customer, an extra $1 billion or more annually.

The WaPo, being the WaPo, blames this on greedy drug companies and kickbacks paid to doctors. Certainly, that plays a role. But it’s part of a bigger problem with Medicare which is that they simply don’t give a damn about costs. No, that’s not quite correct. The have set up elaborate schemes to try to control costs by setting prices and either freezing or lowering those prices over the last thirty years. What they have no control over, however, is people who obey the rules but use them to game or defraud the system.

Here’s me, back in 2009, pointing out that Medicare’s much-vaunted “efficiency” is, in fact, a giant load of crap:

Second, Medicare saves money because they have, arguably, too little administration. Decisions about what to pay for are handed down from the bureaucrats. I know — I’ve worked for years to get a hearing with an Administrative Law Judge on whether or not Medicare was going to pay for something. But if the Medicare rulers have decreed that something will or will not be paid for, there is usually no argument. And Medicare often cuts checks with little regard to whether those checks are going to actual services that have actually been rendered. If you’re an honest doctor, you get screwed by low Medicare fees. If you’re a crooked doctor, you can do fine.

But don’t believe me. I wouldn’t. Believe the CBO (PDF), which noted that Medicare has very few cost controls. Believe Obama, who has claimed Medicare is subject to $60 billion a year in fraud (a number I find unbelievable, frankly). Believe recent testimony that Medicare needs to increase the money spent on claims review by a factor of 10-20 to cut fraud.

This isn’t fraud, but it’s in an adjacent boat. The Medicare administrators — who are actually private insurance companies — just cut checks. Whether the check is for $2000 or $50 doesn’t matter. They get the claim, they process the claim. I won’t say this sort of thing doesn’t happen with private insurance companies. But they are known to try to avoid it by encouraging the use of generics and cheaper drugs. The private insurance companies, when their own money is at stake, tend to be a bit more circumspect. When it’s Medicare’s money? Meh.

Keep this story in mind. This is unlikely to be an isolated incident. As more and more of us are swept into the glories of Medicare and Medicaid, the press may actually start doing their job and look into these bogus claims that our government-run insurance agencies are so very efficient. And once they open up that can of worms, it’s going to get very ugly very fast.

We Should Hope This Works

As the insurance exchange debacle drags on into its fourth week, the Democrats and the Obama Administration continue to dodge questions, obfuscate and try to find ways to blame Republicans. Yesterday’s hearing featured Democrat Frank Pallone calling the hearing a “monkey court” because Republicans have the temerity to wonder what the hell is going on with an overhaul of one-fifth of our economy. The Democrats’ media dog-washers are trying to silence liberal critics of the system using the “under no circumstances ever agree with conservatives, especially when they’re right” doctrine.

But they can’t keep up the facade. Conservatives, libertarians and honest liberals are detailing the many flaws this system has and the significant hurdles it faces getting online. Those critics are not passe about this; they are livid. And they should be.

One of the memes that is emerging among the Obamacare defenders is that Republicans and other opponents of Obamacare have no right to criticize the utter complete failure of the federal exchanges because we opposed it reform the first place. Since we opposed Obamacare, how can we complain about it? You’ll remember, of course, how that logic was applied to the Iraq War. Those who opposed the war never complained about how the war was executed or what happened in the aftermath of it.


But as an opponent of Obamacare myself, I am highly critical of the rollout because … I actually want the insurance exchanges to work. Everyone — conservative, liberal, libertarian or monarchist — should want the exchanges to work for three very important reasons.

First, the exchanges are one of the few good ideas that got into Obamacare. One of the things that drives up insurance costs is the lack of competition. The exchanges force open competition between the insurance companies, which is a good thing. They’re not perfect, of course or even particularly good. A better exchange system would have cheaper entry-level insurance, allow insurance to be sold across state lines and have fewer coverage mandates (it would also, you know, work). But compared to subsidies, coverage mandates, purchase mandates, Medicaid expansion and the IPAB, the exchanges are almost smart.

Second and more far more important is that if the insurance exchanges don’t work for a long time or if the purchase mandate is delayed, the result could be the complete destruction of the individual insurance market.

A lot of people don’t appreciate how much Obamacare is like a house of cards. Insurance companies can no longer deny coverage and have priced insurance on the exchanges based on the idea that people will be “taxed” for not buying insurance. This only works, however, if people are actually forced to buy insurance. Otherwise, they will wait until they are sick to insure themselves. If people can’t buy insurance or aren’t made to, the result is a death spiral where insurance gets more and more expensive and more and more people wait until they are sick to buy it.

This isn’t some theoretical possibility. It happened in New York:

New York state’s guaranteed issue and community rating rules—the two regulations that limit how insurers can charge based on health history and require them to sell policies to all comers—took effect in 1994. At the time, there were about 752,000 policyholders in the state’s individual market, or about 4.7 percent of the non-Medicare population. But by 2009, according to a Manhattan Institute report by Stephen Parente and Tarren Bragdon, the state’s individual market had practically disappeared, leaving just 34,000 participants, or about 0.2 percent of the non-elderly population. Individual insurance premiums, meanwhile, were among the highest in the nation—about $388 on average in 2007, compared with just $151 in California, another big Democratic-leaning state. In New York City, the annualized premium cost for individuals was more than $9,300 and more than $26,400 for a family.

The result, in other words, was a combination of sky-high premiums and far fewer insured individuals.

The individual markets only survived at all because insurance companies could make up the losses from less stupid states. But Obamacare is national; there is no other state to make money off of.

If people can’t buy insurance, the result will be the complete meltdown of the individual insurance market and millions of Americans becoming uninsured. In fact, many have already lost their insurance as companies cancel individual policies in anticipation of the Obamacare exchanges.

Now maybe you think that’s acceptable. Obamcare will implode, the Democrats will be blamed and Republicans will sweep back into power (assuming they don’t screw it up). But look beyond the politics. Millions of Americans will be cast into an insurance purgatory that they may never get out of. The individual insurance market works because of people being good citizens — buying insurance when they don’t need it so that the market can support those that do. If that culture is destroyed, if Americans get into the habit of waiting until they are sick to buy insurance, they may never get out of it. A good example of this is the Israeli Daycare Study where daycare centers imposed a fine on people for picking up their kids late. The result? More parents showed up late because they could now buy off their guilt. And when the fine was rescinded, the parents kept showing up late because the social norm of being on time had been effectively destroyed.

Once the individual market collapses, we may never be able to rebuild it. We may be in a situation where your insurance choices are either through your employer or through Medicaid. That is an extremely high price to pay for making Obama look bad and maybe winning an election.

(It has been suggested, here and on other blogs, that this sabotage is deliberate; that Obama is deliberately crippling the individual market to lead us toward single payer. I’m open to the possibility of a subconscious desire to wreck the private market. But I have a hard time believing in any conspiracy with this administration. It’s not that they wouldn’t try. It’s that these guys are so incompetent that if they actually tried to sabotage the exchanges, the result would be a perfectly functioning exchange system.)

Now my second point may cause many liberals — who see Obamacare as a stepping stone to single payer — to quietly rejoice. Already, many are blaming this on the private sector. Who will be the first to say this “proves” we should trash private insurance and go with single payer? Who will be the first to say we should just expand Medicaid to everyone who isn’t insured by an employer?

But this idea is mind-bogglingly stupid. If the Democrats destroy the individual insurance market and increase the number of uninsured, Americans will not thank them for it. We are not going to rise up in a mass and say, “Oh, you great ones who took away our insurance. Tell us what to do next!”

And frankly, if anyone thinks Medicaid is the future of health insurance (oh, wait, here’s Krugtron the Ever-Wrong making the case) they need to spend a few weeks working in a hospital that only takes Medicaid. Medicaid is only marginally preferable to no insurance at all, providing a consistently lousy quality of service. That’s how it keeps costs down. In fact, Krugman’s defense of Medicaid is made entirely in terms of costs. His only acknowledgement of the downside of consigning millions to the Medicaid gulag is this:

But the problems of access, such as they are, would largely go away if most of the health insurance system were run like Medicaid, since doctors wouldn’t have so many patients able and willing to pay more.

Yes. I’m sure those doctors will take massive pay cuts rather than leave the field. Let’s apply Krugman’s logic to academia, another industry afflicted with runaway costs. We could cut those costs by turning the entire shebang to the community college model. And the problem of finding good professors for those colleges would disappear if they no longer had universities like Princeton able and willing to pay more.

(My apologies to community colleges, who are far better at teaching than Medicaid is at insuring.)

Obamacare is a bad law. It ignores everything we’ve learned about healthcare reform over the last decade and applies a model that at least twenty years old. But the situation with Obamacare could get far, far worse and could do permanent damage to the healthcare system if the exchanges don’t start working. Everyone should hope that they do because this isn’t a political game: this is the healthcare of millions of people. We will never be able to truly reform the system if there’s nothing left to reform.

A Tale of Two Budgets

Earlier this week, Alex posted on the first Senate budget in four years. I have little to add to his criticism. The Democrats claim it continues the good work of the last two years — you know, the flat spending that they have continually claimed is going to ruin the economy and that their budget undoes. Remember that last point: our economy is supposed to be falling into ruin right now because of the payroll tax hike and the sequester. We have yet to see post-sequester numbers, but February saw solid gains in jobs and consumer spending. If the economy continues to move, it will be solid evidence that “austerity”, such as it is, is not necessarily ruinous.

But even liberals, if they are honest, have to be disappointed with this budget. In contrasting it against Ryan’s budget, which I’ll get to in a moment, Ezra Klein notes:

But even given that difference in objective, Murray’s budget is deeply, even excessively, respectful of existing institutions. If the problem of Ryan’s budget is that it wants to do far too much, the problem with Murray’s budget is that it is almost entirely devoted to saying what it won’t do, and it gets very vague when the topic turns to what it will.

If the budget is vague about what it would change, it is specific and effusive about what it will keep. A tremendous amount of the budget document is, in fact, an appreciation of what the federal government is already doing.

About all we really know of this budget is the top lines: It plans $975 billion in tax increases, though it doesn’t say precisely how it will get there, and it plans $975 billion in spending cuts, though it doesn’t say precisely where they will come from.

So Ryan’s budget is preferable, right? Well, not exactly. It keeps all of the Obamacare tax hikes. It proposes tax reform but, again, is not specific in how it is going to cut rates without getting rid of cherished deductions (probably because it can’t). It relies on the CBO’s very optimistic growth projections to keep revenue up.

Most importantly, it also punts on the most important issues. Medicare reform is put off for ten years. Social Security reform is not mentioned. Making the math work requires heavy reductions in discretionary spending which are not the cause of our budget woes.

It also relies on two things that are simply not going to happen under this President: a repeal of Obamacare and huge reduction in tax rates. Look, I can appreciate that the Republicans are trying to contrast their vision against the Presidents. But a plan that has no chance of passing — and only works if those undoable things are done — is not really a serious plan.

These are steps in the right direction. We seem to be returning to a budget process rather than a self-created series of bullshit crises. So I’m hoping a bargain can be struck. But a real bargain — a Simpson-Bowles style one — has to rely on something that is in neither plan: near term reform of both Social Security and Medicare. Until that’s on the tabls, we’re just chipping away at the problem and hoping an economic boom allows to paste over the deficiencies.

Update: Of course, when it comes to bullshit budget plans, no one does it better than the Congressional Regressive Caucus, whose plan was praised by Paul Krugman today. It calls for an immediate 6% spending hike which they claim will bring us back to full employment within a year.

Yeah, ‘cuz that worked so well last time.

This Week in Flip-Flopping


Mitt Romney said congressional Republicans were wrong to accept a deal last year that could ultimately result in across-the-board spending cuts, including massive cuts to the military.

“I thought it was a mistake on the part of the White House to propose it,” Romney said on NBC’s “Meet the Press.” “I think it was a mistake for Republicans to go along with it.”

I’m just reeling at that. The spending cuts were Obama’s idea? And the Congressional GOP went along? And now we need to undo those spending cuts? What on Earth is Mitt Romney talking about? Oh, wait … it gets better:

And while the Republican nominee has repeatedly vowed to work towards a repeal of President Barack Obama’s health care reform, Romney said in the interview he favors some measures found in the law.

“Well, I’m not getting rid of all of health care reform. Of course there are a number of things that I like in health care reform that I’m going to put in place,” he said.

Romney listed the provision that ensures those with pre-existing conditions can get coverage as one aspect he would include in his own health care plan, which he said would “replace Obamacare.” The former Massachusetts governor has taken heat for opposing the federal health care law despite the fact it was largely modeled after the 2006 law he signed in the Bay State.

It is just a week past Labor Day and Romney is already conceding bits of the agenda. To be fair, some commentators think he means going back to the pre-Obamacare law which said that you could transfer insurance and not be denied for pre-existing conditions. But if he does mean that people should be not be barred from insurance for pre-existing conditions in general, something Republicans have supported, that, uh … won’t work without a coverage mandate.

The “good news” is that Obama is matching Romney in the Flip-Flop Voter Flip-Off Sweepstakes. You remember the Ryan Plan and how evil it was to offer seniors the option of a private plan? Well, it looks like HHS is about to implement … the Ryan plan:

In his convention speech in Charlotte, President Obama vowed to block the Republican Medicare reform plan because “no American should ever have to spend their golden years at the mercy of insurance companies.”

But back in Washington, his Health and Human Services Department is launching a pilot program that would shift up to 2 million of the poorest and most-vulnerable seniors out of the federal Medicare program and into private health insurance plans overseen by the states.

The administration has accepted applications from 18 states to participate in the program, which would give states money to purchase managed-care plans for people who are either disabled or poor enough to qualify for both Medicare and Medicaid. HHS approved the first state plan, one for Massachusetts, last month.

Medicare only covers 80% of medical expenses. Seniors have to find the other 20% from other resources. And for poorer seniors, Medicaid is that other resource. What the states want to do is roll these dual-coverage citizens into private plans that will used managed care to cut expenses. California estimates this could save them half a billion a year.

It’s not a bad idea, actually. Medicare and Medicaid are notoriously wasteful, paying out just about any claim. If private companies get involved, there might be some actual resource review. Hell, there could even be — gasp! — fraud investigation! Bowles-Simpson recommended it. And the list of opponents is practically a whos-who of bad healthcare reform ideas.

No, the policy is not necessarily the problem; the hypocrisy is. Either moving patients to private system is an evil abandoning of our commitments or it isn’t.

So Romney is embracing Obama policies and Obama is embracing Romney policies. The closer we get to this election, the more it looks like no choice at all.

Running from the Cuts

It’s really pathetic that Team Obama is trying so hard to pretend they didn’t sorta maybe cut Medicare spending, unlike the evil evil Paul Ryan who … also … hasn’t … yet. You can read Avik Roy’s response here. The critical point is this:

Of [Obama’s] $716 billion in [Medicare] cuts, $415 billion come in the form of “updates to fee-for-service payment rates,” a euphemism for reducing Medicare’s payments to doctors and hospitals. But what happens when you reduce payments to doctors? Doctors stop being willing to see Medicare patients. And if you can’t actually get a doctor’s appointment, what does it really matter what your insurance plan covers on paper?

We already see this happening in the Medicaid program, where sick and injured children can’t get appointments to deal with urgent medical conditions, because Medicaid so severely underpays doctors relative to private insurers. By the end of this decade, under Obamacare, Medicare reimbursement rates are set to fall below those of Medicaid.

(Aside: The Obama people keep referring to their cuts as “savings”, a euphemism I find hilarious. Ryan also refers to his cuts as “savings” but because he has an R after his name and doesn’t want to socialize the whole smash, these become “savage, brutal, turing-grandma-into-fertilizer cuts”. But they are cuts. Don’t be ashamed of the word.)

Look, the reality is that Medicare is growing out of control and its “trust fund” will be exhausted in just a few years. Medicare spending is going to have be cut. As I said last week, that’s not even up for debate any more. The debate is over how. Ryan, to his credit, is trying to come up with a more sustainable system. Maybe it won’t work; maybe it’s a piece of shit. But it tackles the problem head on and admits to what it is doing.

By contrast, the Obama Administration is engaged in a great deal of deception. They are saying there are “no cuts in benefits” which is true as far as it goes. But the benefits are cut through the back door by cutting reimbursement rates (already near unsustainable levels) and hoping this, somehow, produces more efficiency in the system. IPAB is thrown in for good measure but we’ve already seen that Congress will happily override the IPAB any time a pet issue like breast cancer comes up.

The irony is that these cuts, such as they are, are unlikely to happen anyway. In fact, the AMA’s support for Obamacare was conditional on them not happening. Our politicians know what Roy does: that cuts of this magnitude would cause doctors to leave the system. They are barely able to keep up with the present reimbursement rates.

(In arguing this on another site, one liberal said this would lead to a decrease in “unnecessary procedures” and this was a good thing. Keep in mind: (a) that is rationing, by definition; (b) if providers leave the system, they’ll take a bunch of necessary procedures with them; and (c) every rate cut for the last 30 years has come with Medicare telling doctors to make it up with volume.)

I’m getting a little sick of this bullshit on Medicare. The Obama Administration already got called out by the CBO for claiming the $716 billion in “savings” for both deficit reduction and shoring up of the Medicare trust. Now they’re trying to pretend that this cuts are really going to happen but won’t result in decreased healthcare because … well, just because, that’s why!

I appreciate that the healthcare market is diseased. Over time, most industries see costs fall and quality go up. We have not seen this happen with healthcare (although, to be fair, it’s a lot more complicated than that). But the solution is not to cut prices and hope that some magic happens to improve healthcare quality. If Republicans suggested improving education by slashing teacher salaries in half, they’d be laughed off of the Capitol.

Medicare needs to be cut. Obama has to run away from that because seniors vote like hell. But if he’s going to do the necessary thing, he could do it in a sustainable way. He hasn’t and he won’t. And all the easy-on-the-eyes cliche-spouting senior advisors in the world aren’t going to change that.

The Ryan Factor

(I’m on vacation. I spent today in a pool throwing Sal 11000 Beta up in the air. So, this week, I will just have an occasional post when the family’s asleep and I haven’t had too much to drink yet.)

I’ll give Team Romney credit for this: his VP pick sure has the Left shitting their pants. Today, some protesters tried to rush the stage. And the Democratic leadership, with Ms. Verbal Diarrhea in the lead, has been … to put it mildly … lying their asses off about him:

It had the makings of a scandal: Paul Ryan traded banking stocks during the financial crisis the same day as a meeting with top Treasury Department officials, a Virginia blog wrote Monday. But the rumor, which spread rapidly across the Internet, doesn’t hold up to scrutiny.

The meeting in question took place on Sept. 18, 2008, between Federal Reserve Chairman Ben Bernanke, then-Treasury Secretary Hank Paulson and congressional leaders including Nancy Pelosi, John Boehner and Harry Reid. The Richmonder, a progressive Virginia blog, noted on Monday that Ryan’s financial disclosure form from 2008 showed that he sold stock in Citigroup and JP Morgan, who were in crisis, the same day and bought stock in Goldman Sachs, which proved to be stronger. The blog claimed that Ryan also attended the meeting. The implication, they stated, was that he was using information gleaned from the briefing for personal profit.

It was wrong. In fact, the meeting with Bernanke took place in the evening after trading hours, meaning Ryan wouldn’t have had time to execute the move if he wanted to.

The Romney campaign said Ryan had nothing to do with the trades in the first place. They were part of a Russell 1000 index fund that automatically traded stocks as part of a pre-set formula. Ryan’s disclosure forms include several similar trade patterns at various points throughout the year.

There have been other lies too. There has been what Politifact labelled as their Lie of 20011: that the Ryan Plan ends Medicare as we know it. The Democrats are leaving out the part where people over 55 will not be moved to vouchers and other can opt out. They also incorrectly claimed that the Federal Personhood bill he supported (which was bad enough) tried to outlaw abortion, which it did not. It simply called on the states to recognize that life begins at conception. And so on.

Look, Ryan has a lot of controversial views. We can discuss them. But we don’t need to resort to making shit up, do we? No? No? OK. I don’t like his views on a number of issues, including abortion. But, as I said on Twitter, it’s unlikely abortion is going to be outlawed in the near future. It is likely — very likely — that we will go bankrupt or have a major fiscal crisis. And Ryan is one of the few people who has proposed doing something about it.

I expect, that as time goes on, most attention will focus on Ryan’s budget plan. This is a good thing; we need to be discussing the budget. Ryan will take a lot of heat for his plan but … well, this is what he gets for actually having a plan (unlike Obama) and not trying to have every plan simultaneously (like Romney).

The big problem is Ryan’s plan hits Medicare. You want to criticize him for it? Fine. But first you have to put out a plan that balances the budget without cutting Medicare (no, raising taxes on the rich won’t get us there).

You can’t. It’s impossible. Because, without changes, Medicare is going to swell to gobble up an unrealistic section of our economy. No budget plan — no plan — works without reining in MedicareMedicare. As Ryan said in testimony to the House, Medicare as we know it is ending. That’s not up for debate. What we’re discussing is how it’s going to change. Both Simpson-Bowles and the President’s semi-plan incorporate cost controls to Medicare. Medicare changes are going to happen; the debate is over how we are going to fix the program.

So all the people screaming about the Ryan plan need to shut up. Because what they are advocating is no plan. What they are advocating is bankruptcy.

Wishful Thinking

So the consensus, even among liberals, is that Obamacare did not have a good week at the Supreme Court. It was so bad, in fact, that I heard people speculating that the Solictor General deliberately did a bad job to get it struck down.


The thinking is that if Obamacare is struck down, this will pave the way for … a single payer system. Seriously:

In the face of a total strike down, single payer probably becomes the best option. But it’s not an easy one. The hurdles to passing Obamacare were that Democrats needed to have a majority in the House, the presidency, and 60 senators. The good news to passing single payer is that they probably would only need 50 senators. (Single-payer could be done simply by expanding Medicare, a pure fiscal change that could be accomplished through a budget bill that can pass the Senate with a majority vote.)

I tweeted about the absurdity of the other night, but I thought I’d expand on that thought. The idea that striking Obamacare will pave the way for single payer is ludicrous. It is based on two bogus schools of thought that run through liberal thinking.

First, liberals are big believers in political determinism. They believe that their idea are so wonderful and fabulous that it is only a matter of time before everyone realizes it and we finally evolve into a liberal utopia. This line of thinking can be traced to Marxism, which posited that the forces of history were leading to the inevitable collapse of capitalism and the inevitable rise of communism. Just as the communists predicted that labor relations would get worse and worse until we had the inevitable worker revolution, liberals are now predicting (hoping) that our healthcare system will get worse and worse until we have the inevitable single payer revolution. All they had to do was stand back and let it happen.

But they are just as deluded as Trotsky was. First, it is not inevitable that our system will get worse without Obamacare. It is possible, if we allow competition across state lines and move people toward more consumer-controlled system, that we could turn the tide. And even it our system does continue to get worse, why would this lead to a surge in support for single payer? Why would people who have vehemently opposed single payer suddenly favor it in the wake of an Obamacare defeat? Liberals want single payer. Indeed, their biggest problem with Obamacare was that it was not single payer. But conservatives and libertarians opposed Obamacare because we saw it as leading to single payer.

The second problem with this line of thinking is that it completely misreads the political situation. To listen to the Left, Obamacare was passed over the fierce opposition of the health insurance companies, pharmaceutical companies and physicians. This is complete bullshit. The insurance industry favored Obamacare. Big Pharma was bought off with promises of no price controls. The doctors and hospitals were bought with promises of a permanent stay of the SGR cuts. All kinds of special interests favored Obamacare because they knew precisely what would happen: healthcare would become even more politicized. More money would flow to companies that were politically connected. Do you think Big Pharma is mad that HHS is mandating that their most expensive birth control pills be covered? Do you think the insurance companies hate it that people are being force to buy insurance? Give me a break.

Obamacare was a product of industry, a distillation of what they wanted out of healthcare reform. And they supported it heavily. They will not, however, have such a love affair with a single-payer system. Such a system will put private insurers out of business, set the stage for price fixing in all branches of healthcare and, given Medicare’s horrific finances, necessitate massive cuts in physician and hospital reimbursement. The special interests will unite against single payer just as they united for Obamacare.

At most, striking down Obamacare may set the stage for an Australian-type system where the government provides basic insurance and everything else is private. Or it may set the stage for the Ryan plan of breaking the federal monopsony that already controls half the healthcare system. But the idea that this sets the stage for single payer is pure Left Wing fantasy.

(And since we’re on this, it’s always worth pointing out that the contention that Medicare is more efficient than the private sector is bullshit.)

Dying With Your Stethoscope On

I’ve been mulling over this absolute must-read for some time:

It’s not a frequent topic of discussion, but doctors die, too. And they don’t die like the rest of us. What’s unusual about them is not how much treatment they get compared to most Americans, but how little. For all the time they spend fending off the deaths of others, they tend to be fairly serene when faced with death themselves. They know exactly what is going to happen, they know the choices, and they generally have access to any sort of medical care they could want. But they go gently.

Of course, doctors don’t want to die; they want to live. But they know enough about modern medicine to know its limits. And they know enough about death to know what all people fear most: dying in pain, and dying alone. They’ve talked about this with their families. They want to be sure, when the time comes, that no heroic measures will happen—that they will never experience, during their last moments on earth, someone breaking their ribs in an attempt to resuscitate them with CPR (that’s what happens if CPR is done right).

Growing up in a medical family, I can confirm that this is mostly true. I know several medical people who want the last full measure but many more want nothing more than some pain meds. It’s not just doctors either. Rich people die this way too. If they can afford their own in-home nurse, they will go home, make sure they have enough opioids and die peacefully (and cheaply). It’s the ultimate irony of our broken Medicare system that you have to be rich to die on the cheap.

It got lost in all the talk of “death panels”, but end-of-life nonsense is a huge and avoidable contributor to Medicare’s bloated budget. For many people, almost inhuman procedures drag out death for days and tally up hundreds of thousand in costs. You can read personal story in Goidhill’s article, which is still, 2.5 years later, the best thing written about healthcare in the United States.

The thing is, the system is set up this way. In the absence of specific orders, hard coding is the default. Part of it is defensive medicine — although the silly misinformed twats who do their studies of “defensive medicine” don’t include it when they assure us defensive medicine only costs 2% of the bill. Doctors can be sued and even prosecuted for “pulling the plug” if they don’t have legally binding instructions from the patient.

Another part is that if a patient is unable to make decisions, the responsibility falls to the family. And families often choose to go the last full measures since (a) they have trouble letting go; (b) they don’t want to take the responsibility for killing grandma; (c) they often have a poor understanding of precisely what’s involved; and (d) it’s the government’s dime anyway. Unless the patient had legally binding orderes written in advance, they will almost go out in misery.

The thing is, most people don’t want this. But they end up getting it because they don’t know it’s standard. They end up getting it because they left no legally-binding orders. They end up getting it because they didn’t want to deal with the fact that they were going to die one day.

Well, tough. When you’re on the taxpayers’ dime, I don’t think you get the luxury of pretending you’re not going to get sick and die. This is why I support a change to Medicare: to enroll in the system, you must write end-of-life orders. There’s no restriction on what you can do — if you want the last full measure, you can get the last full measure. Or you can hoose, if you want, to get a home nurse and some drugs. But you have to make a decision (albeit one you can revisit if you change your mind).

Over the long haul, this would save the taxpayers hundreds of billions and save millions of people from needless anguish. Just ask the doctors.

What’s stopping it? Mostly, there’d be too much of a political price to pay. The epic brouhaha over Terri Schiavo is too fresh in many minds. Even suggestions of end-of-life counseling brought out cries of “death panels”. And the Democrats are in a glass house, since you can bet the farm they would say the same or worse if a Republican proposed such a thing. And so we sit here, year after year, sending hundreds of thousands of our citizens shrieking into the afterlife while our national treasure burns up.