In Favor of the Insurance Mandate

I understand the practical necessity of the mandate in the ACA even while I am appalled Democratic leaders utterly failed to include a public option that would have and could have made the mandate palatable (i.e., if you don’t have insurance or have a waiver for purchasing insurance, you have to get it, but you can get it through this great Medicare For All Option that is affordable and easy to use because it’s got millions of members nation wide).  Failing to include a publc option was foolish and short sighted.  The Democratic base could be rallied to defend a public option, not so much a mandate.

That said, however, without the mandate, health care reform will bankrupt the insurance companies.  Universal health care only works if everyone is in the system.  Any insurance plan relies on healthy people to pay for the sick people.  That’s how it works.  The mandate is nothing more than a means of getting everyone into the system (I read somewhere that it will ultimately apply to about 9 million people nationwide, i.e. 3% of the population so it makes me wonder if the brouhaha over it is overblown).  Anyway, one of the main arguments deployed against it is that the government shouldn’t be able to force you to buy health insurance.  Since it’s already well established that the government can tax you for insurance and other benefits, the issue is that it’s forcing you to buy from private industry.  Essentially the case is “If the government can force me to buy insurance, why not broccoli or running shoes or health club membership?”

Ed at Dispatches From the Culture Wars has an interesting answer.  The key quotes:

The broccoli argument is like something they said when we were debating the income tax: If they can tax me, they can tax me at 100 percent! And yes, they can. But they won’t. Because you could vote them out of office. They have the power to do all sorts of ridiculous things that they won’t do because you’d vote them out of office. If they can prevent me from growing pot, can they prevent me from buying broccoli? Perhaps, but why would they if they want to be reelected? So if you ask me what the limits are, I’d say read McCulloch vs. Maryland. And reread it. And keep reading it till you understand it. The Constitution is a practical document,. it’s designed to work. And the powers are designed to be flexible in order to achieve the aims of the document.


The analogy of the power to tax is an excellent one. The fact that an exercise of government power could theoretically include some draconian policies does not mean that the government shouldn’t have that power at all. The Constitution gives Congress the power to regulate interstate commerce; one could come up with all kinds of crazy things they might do within the scope of that power, but that doesn’t mean they shouldn’t have the power in the first place.

IOW, just because they could do something doesn’t mean they will and if they go over the edge, we can vote them out of office.  Ed concludes that the mandate is constitutional because health care falls clearly into interstate commerce and since its enforced through the tax code, it’s also within Congress’ power.

The ACA, for all its faults, represents an improvement over what we had before.  It doesn’t go far enough, and it uses Rube Goldberg devices to accomplish its goals, but it represents a start on something we should have done years ago.

  1. #1 by Richard Warnick on March 30, 2012 - 1:09 pm

    Glenden, your premise is wrong. Yesterday none other than Howard Dean was on MSNBC’s “Morning Joe.” He said that Vermont’s health care system works just fine without a mandate. The only reason there’s an individual insurance mandate in the ACA, he explained, was as a payoff to the insurance companies in exchange for not trying as hard as they might have to kill the legislation.

    You may recall that in 2008 candidate Obama mocked the mandate proposed by Hillary Clinton, saying we might as well try to solve the problem of homelessness by mandating everyone to buy a house.

    Whether or not it’s unconstitutional, the mandate is a bad idea and nobody likes it except the insurance industry.

    Meanwhile, the health care crisis continues. Health insurance premiums are still skyrocketing at 30 percent a year, more and more employers are dropping health plans, and the number of uninsured is increasing (50 million plus). I recently fell and fractured my collar bone, had to go to the ER for the first time in my life (nothing else was open Sunday night). The bill was more than $15,000 for a minor injury!

  2. #2 by Glenden Brown on March 30, 2012 - 1:29 pm

    Richard – I may be mistaken but I believe that Vermont has or on the path to creating a single payer system, so they don’t need the mandate. All Vermonters are covered.

    That said, since Congress chose to pursue the Rube Goldberg approach to health care reform and insisted on using private industry to realize public policy, they put in place a host of regulations (i.e. no eliminating people based on pre-existing conditions, capping the percent insurance companies can spend on administrative costs), and did not offer a public option, the mandate becomes the only real viable means to getting people into the system.

    Don’t misunderstand, I’m not saying the mandate is my preferred policy, I’m saying there is a viable argument in favor of it.

  3. #3 by Richard Warnick on March 30, 2012 - 1:39 pm

    You have to admit that Dems are not smart for taking responsibility for a Republican policy proposal that everybody hates. And they were really not smart to forget to include a severability clause in the legislation, thus giving our right-wing Supreme Court majority the power to totally cancel the ACA, President Obama’s signature achievement in his first term.

    BTW you came close to saying what Howard Dean said, i.e. the mandate is the only reason the insurance companies went along with the other stuff in the law. Of course, unlike Washington politicians, average Americans are not on the side of insurance companies, and we don’t care what they want. Insurance companies do nothing for health care except make it more expensive.

  4. #4 by Glenden Brown on March 30, 2012 - 2:02 pm

    I think Dems were insane for adopting a Republican plan. The only less popular than typhoid are insurance companies. They should have fought tooth and nail for Medicare for all – I think it would have been popular. I can’t find it now, but I offered some strong criticisms of how the ACA became law pointing out that Democratic leadership screwed it up from the get go. It was mismanaged by Congress and the Administration from day one. The Administration in particular fumbled it in every possible way. Since it passed, they’ve basically ignored it, forgetting to tout the good things it’s already doing. In Congress, the leadership lost control of the process and the message from day one. They were caught flat footed by Republicans and that by itself was amazing How could they have not predicted the ‘Pubs would go freaking insane? It was a mess and it didn’t need to be.

  5. #5 by Glenden Brown on March 30, 2012 - 2:02 pm

    FWIW, here’s my analysis of what makes health care difficult.

  6. #6 by brewski on March 30, 2012 - 2:57 pm

    This is what government does. It pretends to solve problems by not taking care of the problem themselves, rather they tell someone else to solve the problem for them. So rather than providing healthcare to everyone, they just make an imperial edict telling employers to provide insurance and telling individuals that they must buy their own. So then Obama has a big signing ceremony celebrating when he hasn’t solved anything. Another example is immigration. The government hasn’t been willing to control immigration, but they demand that every employer be the immigration document police and be responsible for doing what the government didn’t.

    Glenden, I read your analysis from 2009. I think you greatly underestimate the impact of behavior. People overuse things which are cheap, and this includes water, gasoline, electricity, etc. When stuff gets more expensive then people use less of it. If third-party-payer insurance makes no difference in cost to the patient of procedure A vs procedure B, or drug A, or drug B, then people will tend to overuse all medical services. There are two ways to make people use less of something. You can either ration it or make it more expensive. Passing the cost on to someone else just makes that someone else increase their rates. Then there is the cartel factor. Doctors in the US make far more than their peers in other countries. Some hospitals look more like Taj Mahals. Drug companies buy congress to so the government is forbidden to negotiate on prices for drugs. In short, it is all a rigged system, just like OPEC and the South African diamond mine cartel. You end up with much higher costs. None of these issues are addressed at all in ACA and that is why all liberals should be cheering for this bill to be struck down in its entirety. At least then we will have a chance to replace it with something, anything.

    • #7 by Glenden Brown on March 30, 2012 - 4:32 pm

      I’m going to both agree and disagree with regard to the impact of behavior. I think, to borrow Dan Ariely’s phrase, behavior is predictably unpredictable. We can predict it will be unpredictable and in certain circumstnaces we can predict how people will act but not always. When I’m having a heart attack, I don’t care just get me to the nearest hospital. I won’t price shop and as long as I get to a quack, I don’t care where or how much is costs. That’s predictable it’s also not the model of a good, rational consumer. Some people rush to the doctor when they get the sniffles, other people will put off seeing the doctor until gangrene has set in. We’re hampered in making behavioral choices because we have a hard time determining actual costs of medical care i.e. for my last doctor’s visit, I had three separate bills, none of which I was responsible for because it was preventative, but each bill had a billed amount, allowed amount, discount and then patient responsiblity amount and it took five minutes to decode the bills. I still have no idea the actual cost of my visit. That makes it really difficult to figure out how to use my medical insurance wisely. We can’t treat medical care like other consumer products.

      I agree that if something is cheap, people will overuse it. Back in the day, you went to the doctor and your insurance paid 100%. Well that didn’t work, so we invented HMOs and you had copays. That didn’t work either. So now we have cdhp or hdhp (consumer driven and high deductible health plans) which supposedly make employees more aware of the cost of care. Except they don’t because if you are having a medical crisis you don’t care the cost. It’s also problematic because a very small number of patients create most of the cost of health care (I dont’ recall if it wsa 5% of patients account for 95% of health care costs or if it was 10% who account 90% of health care costs but you get the idea). We have a situation where costs are being driven by a small number of patients and treatments. To give one example, in the last twelve months I would have saved at least $1000 if I had not had health insurance but had used the health care system exactly as I did. By contrast, I know someone whose insurance premiums (their portion alone, not total paid by employer) were $2400 in the last 12 months but who incurred at least $30,000 in expenses.

  7. #8 by brewski on March 30, 2012 - 10:58 pm

    I am sorry, but your post doesn’t square with the empirical data:

    Evaluating this tradeoff requires addressing several questions. First, to what extent do higher patient co-insurance charges reduce use of medical care? Second, to what extent is that reduction harmful in terms of personal health? Third, how do these effects vary by patient characteristics such as income and health status? To obtain answers to these questions, researchers typically turn to the results of one of the most ambitious and important social experiments in U.S. history, the RAND Health Insurance Experiment (HIE). In the 1970s, the HIE randomly assigned several thousand families to insurance with varying levels of patient co-insurance, and then followed them over a five-year period to evaluate the effect on their medical utilization and health. The results of that study are still the gold standard for evaluating the answers to these questions.


    In summary, the lessons from the HIE are very clear: higher co-insurance rates, with an out-of-pocket limit, can significantly reduce health care use without sacrificing health outcomes for the typical person. The results are surprisingly robust and hold across many subsamples of the data: rich and poor, sick and healthy, adult and child.

    So the lesson is that when non-emergency doctor visits are too cheap (someone else is paying for them) then we tend to go to the doctor too many times. When we go to the doctor fewer times, then costs go down for the whole system AND there is no change in outcomes.

    This sounds to me like understanding the behavioral aspects of third party payers is an enormous part of the solution. No, we don’t want to discourage people from going to the doctor when they really need to, but as the data show, there was no decrease in outcomes when people went to the doctor less.

    • #9 by Glenden Brown on March 31, 2012 - 7:51 am


      Data shows that 10% of patients account for 2/3 of medical costs.

      Only 10 percent of the U.S. population accounted for nearly two-thirds of all health care costs in 2008, according to the latest News and Numbers from the Agency for Healthcare Research and Quality (AHRQ). The average annual cost for each of these individuals totaled almost $24,000, which includes costs covered by insurance and paid out of pocket. Approximately 45 percent of these individuals remained in this 10 percent of the population in 2009, based on their health expenses that year.

      Even more surprising:

      In 2008, 1 percent of the population accounted for 20.2 percent of total health care expenditures, and in 2009, the top 1 percent accounted for 21.8 percent of the total expenditures with an annual mean expenditure of $90,061. The lower 50 percent of the population ranked by their expenditures accounted for only 3.1 percent and 2.9 percent of the total for 2008 and 2009 respectively. Of those individuals ranked at the top 1 percent of the health care expenditure distribution in 2008, 20 percent maintained this ranking with respect to their 2009 health care expenditures (figure 1).

      I think we’re talking about different parts of the health care system. Last time I was at my doctor’s office, there was a woman there that the staff knew incredibly well – they didn’t realize I could overhear them and they were talking about whether or not she had a cold or hangnail that day. There are people who overuse medical care, who rush to the doctor for everything. But, in terms of costs incurred by the system, a small portion of the population incurs a vastly disproportionate amount of overall medical spending. To put it bluntly, one person with cancer will incur far more in medical costs in the next year than a person without cancer will in the next ten years.

      As I see it, there are two key issues. First is using the system in appropriate ways – i.e. making sure patients are getting their regular preventative treatments, but not rushing to the doctor every time they get a cold and making sure that we are living in healthy ways (i.e. regular exercise and healthy diet will do more most of us than will a prescript of cholesterol lowering drugs and save everyone money). Second is to find ways to manage costs for that 10% that is incurring 67% of cost – at least part of that is early diagnosis but it’s also end of life issues. When my grandmother was 92, she had a massive stroke. My aunt and uncle were ready to have the doctor perform brain surgery to extend grandma’s life. It’s not that I wanted her to die, but really? Brain surgery o a 92 year old to extend her life by six months? I have a friend whose father was in his 80s when he discovered he had cancer. He opted for death with dignity, used pain management and enjoyed his last six months of life. He died, surrounded by friends and family after having been himself, not some little dried apple person hooked up to machines.

      The mandate – frustrating policy though it is – aims to get everyone into the system so that they are getting their regular preventive care and early diagnosis. Those two things can help us manage costs.

  8. #10 by brewski on March 31, 2012 - 9:22 am

    Glenden, you are correct about the skewed nature of health expenditures as noted here:

    But this still does not address the question of the patient being insulted from the cost of health care decisions. Those high users of health care still don’t know or care how much it costs.

    A neighbor of mine died of cancer last year. She was very poor but had military spouse insurance (Tricare). So she was diagnosed with stage 4 cancer three years before. She received chemo and the best of care. Then about a year before she died she was diagnosed as terminal and that at this point all care was just to delay her death. So she received a lot of chemo as well as pain management drugs.

    She also got 2 titanium hip replacements after she had been diagnosed as being terminal. She didn’t pay a dime for this and Tricare paid for it all. I would be willing to bet that if she lived in Canada that their egalitarian single payer system would not be providing free titanium hip replacements on someone with terminal cancer. But we do. We do because it doesn’t cost the patient anything, the hospital gets paid more to perform the procedure than to not perform it, and the insurance company in this case is the taxpayer and the taxpayer is just told to pay more.

    • #11 by Glenden Brown on March 31, 2012 - 5:37 pm

      Single payer systems also insulate patients from the cost of care. That’s sort of the whole model. They keep down costs. As you just pointed out by not performing hip transplants on terminal patients.

      But there’s also the issue of American attitudes towards health care – ie the notion that we have to give every possible treatment even when it’s obviously pointless. We scream about rationing but accept it in the most brutal form – if you are poor you are screwed. If you are rich there’s no limit to what you can have done. If you have insurance we expect it to pay for everything and when it doesn’t we get mad. It’s not just insulating us from costs. It’s about our attitudes toward health care. I will have more to say later but I have to run now.

  9. #12 by cav on March 31, 2012 - 10:09 am

    It is a proven fact: The dead have no need of doctors.

  10. #13 by brewski on March 31, 2012 - 11:56 am

    That’s why countries like Canada and the UK cut people off who are too expensive to keep alive.

  11. #14 by Ronald D. Hunt on March 31, 2012 - 6:41 pm

    “That’s why countries like Canada and the UK cut people off who are too expensive to keep alive.”

    Nonsense, In both nations you can buy supplemental coverage up to whatever level you desire.

  12. #15 by brewski on March 31, 2012 - 10:40 pm

    So the wealthy can buy more if they want but the poor can die. Thanks for the clarification.

  13. #16 by brewski on March 31, 2012 - 10:43 pm

    They keep down costs. As you just pointed out by not performing hip transplants on terminal patients.

    Yes. And someone needs to be honest for once and admit that. You won’t get infinite care no matter what.

    But there’s also the issue of American attitudes towards health care – ie the notion that we have to give every possible treatment even when it’s obviously pointless.

    American “attitudes didn’t materialize out of the ether. They are the product of being told we will pay for everything and you don’t need to pay for anything for the last 60 years.

  14. #17 by Shane on March 31, 2012 - 11:04 pm

    Anyone here think there is the slightest chance brewski will notice that by conflating a non-neccisary hip replacement and non-existent death panel he has successfully refuted two seperate arguments, both made only by him?

    Yeah, me neither…

  15. #18 by Shane on March 31, 2012 - 11:10 pm

    ….and that is ignoring the “drug cartels” in reply #6 that have even more free reign to lobby under citizens united. Which I guess explains why brewski is so against that decision.

  16. #19 by brewski on March 31, 2012 - 11:31 pm

    I can always rely on you to provide living evidence that I am right. Thank you.

  17. #20 by Ronald D. Hunt on April 1, 2012 - 2:17 am

    “So the wealthy can buy more if they want but the poor can die.”

    The wealthy will always have better care, this is a flat fact that will NEVER change.

    The measure we should look at is whether or not the poor, and the middle class have access to health care at all.

    And in America their is well over 50 million Americans with no access what so ever, either from not being poor enough, or old enough, or rich enough, or work for an employer that provides the benefit.

    The family making 30-40k per year in either Canada or UK is in a much better position health care wise then the united states where they likely won’t have any access to care at all.

    And we can back and forth on outliers all day long in pretty much any system, Lets instead use the overall trend of health outcomes.

    Which system works better on a whole, Clearly our system is a disaster, Clearly both the Canadian system and British system, or a better comparison the French system are better.

  18. #21 by cav on April 1, 2012 - 10:04 am

    If you want anything, from better healthcare to high-speed-rail, even quality maintenance of our present almost antiquated infrastructure – and face it, the more costly and involved the project, the more jobs there will be created, it is going to have to involve higher taxation on corporations and the rich.

  19. #22 by cav on April 1, 2012 - 10:10 am

    March 32, 2012

    Wisconsin — On Wednesday, Republican presidential candidate Mitt Romney broke from script once again and blurted out to reporters during a teleconference call, “For fuck’s sake, when are you fucking zombies going to wake up and realize what a fucking elitist asshole I am?!”

    The 10 reporters taking part of the call were stunned into silence and the former Massachusetts Governor continued.

    “Seriously, this has been eating away at me. I just told you what I considered to be a humorous story about my Dad closing a plant in Michigan that cost 4300 workers their jobs and you took it without even a whimper. Seriously, this is really beginning to eat away at me, people. What the fuck do I have to do before you morons wake up and realize I’m an asshole? Stuff my mouth with suppositories and spew baby shit in your eyes? Drink barium from an enema?”

  20. #23 by Richard Warnick on April 1, 2012 - 11:30 am


    Since no one called you on this, I will. The ACA does not require employers to provide health insurance. We’ve been over this before.

    In fact, once the individual mandate kicks in I believe many companies will cancel their insurance plans, dumping their employees onto the so-called “exchanges.” This is why I don’t buy the argument that the mandate will only affect 3% of Americans.

    On the subject of patients as consumers, when a doctor tells me to go for an X-ray or ultrasound it could be because it’s really necessary for a diagnosis or because they need to pay for the machines. How am I supposed to make an informed decision on what’s a necessary expense? As Glenden points out, even after the fact it’s hard to figure out what the cost was and who paid.

    On the subject of unnecessary medical procedures, what about performing a heart transplant on a 71-year-old man when thousands of younger people are waiting for one?

  21. #24 by cav on April 1, 2012 - 1:32 pm

    Post-op Dick Cheney:

  22. #25 by brewski on April 1, 2012 - 2:09 pm

    The ACA does require that employers provide health insurance for their employees, or pay an additional payroll tax.

    And yes, per the CBO, the ACA will cause 22 million people to lose their employer provided health insurance.

    If Country A has X number of tests per 1,000 people, and Country B has X/2 number of tests per 1,000 people, and Country A’s health outcomes are no better than Country B’s, then Country A is wasting tons of money for no benefit. So you need to analyze why Country A has so many more. Is it because Country A’s doctors get paid more the more tests they order? Is it because Country A’s doctors go to free medical “seminars” in Hawaii paid for by the companies who make the test equipment? Is it because in Country A the patient can get as many tests and he or she wants and no one questions it while in Country B those tests are limited by a third party reviewer and approver? Or all of the above?

  23. #26 by Ronald D. Hunt on April 1, 2012 - 9:01 pm

    You know Japan has for times as many MRI scans then we do right?, and no not per capita, I mean by numerical quantity. And they have one quarter the population we do. Ohh and they spend one quarter what we do per capita.

    They also live much longer and have better health outcomes.

    Tests cost money yes, but they are cheaper then the alternative. That is the great fallacy you are having here.

    We don’t get more tests then other Nations we get fewer tests. Because our private insurance acts as a third party reviewer and approver!!!, only instead of their mandate being to provide for the health care of their customers their mandate is to maximize profit for their share holders and executive staff.

    The number one cost in health care is insurance profits and “administrative costs”,why don’t we start their?!

    “And yes, per the CBO, the ACA will cause 22 million people to lose their employer provided health insurance.”

    I don’t see a problem here. Their are insurance exchanges and subsides to purchase insurance on them, Poor insurance companies will lose their employer provided monopoly ohh woe and pity unto them.

  24. #27 by Richard Warnick on April 1, 2012 - 9:12 pm


    We have been over this before. There is no employer mandate in the ACA. As of 2014, the act’s “play-or-pay” provision will kick in (assuming the Supreme Court doesn’t throw out the law). It only applies to large companies with 50 or more full-time employees. Anyway, the $2,000 ACA play-or-pay penalty is less than the cost of providing health benefits.

  25. #28 by brewski on April 1, 2012 - 10:51 pm

    Being required to pay $2,000 or being required to provide health insurance coverage are both a requirement.

    An employer with 50 employees is not “large”.

    Japan is interesting. They go to the doctor far more times. They get far more MRIs. But they pay far less for it all. France has far far fewer MRIs. But they have the same outcomes.

    The government has well controlled cost over decades by using the nationally uniform fee schedule for reimbursement. The government is able to reduce fees when the economy stagnates.[4] In the 1980s, health care spending was rapidly increasing as was the case with many industrialized nations. While some countries like the US allowed costs to rise, Japan instead tightly regulated the health industry to rein in costs.[5] Fees for all health care services are set every two years by negotiations between the health ministry and physicians. The negotiations determine the fee for every medical procedure and medication, and fees are identical across the country. If physicians attempt to game the system by ordering more procedures to generate income, the government may lower at the next round of fee setting.[6] For example, the fee for MRI were lowered by 35% in 2002 by the government.[6] As of 2009, in the US an MRI of the neck region costs $US 1,500, but in Japan, it did $US 98.[7]


    I’d like to see Obama and Pelosi tell the AMA that the US will adopt the Japanese model.

    As for life expectancy. Japan has 3% obesity and the US has 33%. It makes a big difference if you eat fish vs fried chicken. Doesn’t matter how many MRIs you get. Shitty food will kill you.

  26. #29 by Ronald D. Hunt on April 2, 2012 - 2:48 am

    “Japan has 3% obesity and the US has 33%. It makes a big difference if you eat fish vs fried chicken. Doesn’t matter how many MRIs you get. Shitty food will kill you.”

    I thought you where complaining about the cost of testing?, Never mind the Nation that tests 16times as often as we go and pays a quarter of what we do. Not suggesting we pick up their model, but clearly this blows a few holes in your theory of the costs being in the tests.

    I like the French model, they actually do better then japan depending on the particular statistic. Rated #1 by WHO in 2007. My primary problem with copying their system is the unique and over the top corruption in US corporations. Really I think the only viable option in the US is single payer, perhaps with a voucher opt out but their absolutely must be a publicly ran insurance pool to keep the remaining insurance industry honest.

    Either way #1 biggest cost is insurance industry profits and administrative costs, This is the place to start for savings.

  27. #30 by brewski on April 2, 2012 - 9:28 am

    n October 2009, Jackson Healthcare conducted a national survey of physicians to qualify their attitudes regarding the practice of medicine in light of the healthcare reform environment. In their open-ended responses, defensive medicine was an issue consistently offered by physicians as the primary problem driving healthcare costs. Survey participants reported that medically unnecessary diagnostic and treatment services were being ordered in an effort to avoid lawsuits.

    Jackson Healthcare believed this issue merited further exploration and quantification. Our secondary research found no publicly reported research that quantified the extent and economic impact of defensive medical practices among U.S. physicians.

    In December 2009, Jackson Healthcare polled physicians again to quantify the scope and impact of defensive medicine practices. Jackson believed physicians were the most reliable source to quantify unnecessary medical activities, since physicians drive all healthcare expenses through their orders. Survey participants estimated that 34 percent of overall healthcare costs is attributable to defensive medicine. Nine out of 10 physicians reported practicing defensive medicine. In Texas, where tort reform legislation was passed in 2001, physicians reported defensive medicine practices no less than the overall participant average.

    Based upon these findings, and in an effort to validate the scope and impact of defensive medicine, Jackson Healthcare retained


    to conduct an independent national physician poll using their world-renowned methodology. Gallup’s findings, though more conservative than Jackson’s, found that physicians attribute 26 percent of overall healthcare costs to the practice of defensive medicine. Of the physicians surveyed, 73 percent agreed that they had practiced some form of defensive medicine in the past 12 months.

  28. #31 by Ronald D. Hunt on April 2, 2012 - 12:12 pm

    First link please.

    Using a poll on doctors is far from an accurate tool, one they are a group that carries political opinions on the matter polled. And two Medical liability insurance costs around 2% of total costs.

    And 3 that 26% number is utter nonsense, After you insurance administrative costs/profit, hospital care, and drugs their isn’t 26% left in the system to be distributed to “Defensive medicine”. And if we add doctor care and legitimate non defensive testing then it follows that the number 26% becomes even more patently absurd.

    Third, medical liability reform has in fact been tackled by several states(33 last i checked), And in fact the savings is nonexistent. Hell in some States liability reform has lead to lower quality in service, for example Texas leads the Nation in staph infection rates at their hospitals at a mere 3times higher then the national average and 6 times higher then Canada.

    Using polls to determine costs is idiotic.

  29. #32 by brewski on April 2, 2012 - 2:20 pm

    Yes, I agree that doing a poll to determine costs doesn’t make much sense from an estimating point of view. But what it does mean is that doctors themselves think that they do procedures, prescribe drugs and order tests that they themselves believe to be not medically necessary. But they do so only because of the fear of getting sued if they don’t.

    Speaking of idiotic, you math makes no sense when you try to make the argument that there is no room for 26% to be distributed. Of course there is. It is embedded inside the cost of care long before anyone makes a profit or adds administrative costs.

    Also, the 2% cost of liability insurance is not relevant at all to the total cost of medicine that it practiced for the purpose of not getting sued later. Apples and oranges.

  30. #33 by brewski on April 2, 2012 - 3:34 pm

    Obama is officially an idiot and an asshole:

    In a highly combative salvo on a case which could have a critical impact on his reelection chances, Obama warned that health care for millions of people was at stake, even as nine Supreme Court justices deliberate the arguments.
    “Ultimately, I am confident that the Supreme Court will not take what would be an unprecedented, extraordinary step of overturning a law that was passed by a strong majority of a democratically elected Congress,” Obama said.
    The US Supreme Court held compelling legal arguments on the health reform law, the centerpiece of Obama’s political legacy, last week, amid a flurry of commentary predicting the law will ruled unconstitutional.
    Obama noted that for years, conservatives had been arguing that the “unelected” Supreme Court should not adopt an activist approach by making rather than interpreting law, and held up the health legislation as an example.

    Time for impeachment.

  31. #34 by Ronald D. Hunt on April 2, 2012 - 3:53 pm

    “Speaking of idiotic, you math makes no sense when you try to make the argument that there is no room for 26% to be distributed. Of course there is. It is embedded inside the cost of care long before anyone makes a profit or adds administrative costs.”

    No, Doctor care is only 25.4% of total costs, if “defensive” medicine is 26% of total costs then doctors would be performing “defensive” medicine for well over 100% of their services. Which is nonsense.

    This also wouldn’t fit with the reality of outcomes in states with malpractice reforms vs those states without. States that have award caps, steapper proof requirements, third party doctor sign off rules, etc simply do not see a reduction in the testing rates. In fact as I pointed out those states have high costs in other area’s due to the freedom from liability.

    Your inability to parse outlandish partisan claims into understandable numbers isn’t helping your argument.

  32. #35 by cav on April 2, 2012 - 4:11 pm

    Yes, by all means, it is time to impeach Justices Scalia and Thomas.

  33. #36 by Richard Warnick on April 2, 2012 - 4:15 pm


    President Obama laid down a marker. Activist is as activist does. Because of its radical right-wing majority and their behavior, the Supreme Court is getting a reputation as a partisan institution.

  34. #37 by brewski on April 2, 2012 - 4:28 pm

    No. You and he are redefining activist to turn the English language on its head. That is not what the word means.

  35. #38 by cav on April 2, 2012 - 5:54 pm

    So you agree that it’s strictly a messaging problem.

  36. #39 by brewski on April 2, 2012 - 11:49 pm

    I agree that if SCOTUS throws out Obamacare that that will not be judicial activism.

  37. #40 by cav on April 3, 2012 - 8:57 am

    Aside from the U. S., advanced countries with single payer systems spend half the amount we spend on health care and have longer average life expectancies.

  38. #41 by cav on April 3, 2012 - 9:04 am

    And the zombie lies continue…

    A small hint of how this push to the right moves moderates away from moderation came in an effort last week to use an amendment on the House floor to force a vote on the deficit-reduction proposals offered by the commission headed by former Sen. Alan Simpson and Erskine Bowles, former chief of staff to Bill Clinton.

    There were NO committee recommendations: the recommendations, identified as such are the recommendations of the chairmen: not the committee.

  39. #42 by brewski on April 3, 2012 - 10:34 am

    Just like the Zombie lies given yesterday in the White House Rose Garden.

  40. #43 by Glenden Brown on April 3, 2012 - 1:09 pm

    Does shifting costs to consumers really lead to savings in health care?

    Igor Volsky’s take:

    As Yale professors Theodore Marmor and Jerry Mashaw pointed out in the Philadelphia Inquirer last year, “if free medical care led to more reckless overuse, countries like Canada and Germany, where patient costs are either zero or minimal, would suffer disproportionate inflation in expenditures or severe access pressures. They don’t.” Indeed, those nations spend less on health care than Romney’s Swiss model — which has higher out-of-pocket costs and the third highest health spending in the world! The theory doesn’t even hold up in the American health care system, where individuals with higher cost sharing in the employer based system with higher cost sharing don’t spend less than Medicare enrollees with smaller cost sharing.

    Here’s the article from the Philadelphia Inquirer and a good quote:

    However, the proposed increase in Medicare outpatient deductibles – from the current average of less than $200 a year to more than $500 – has almost nothing to recommend it besides ideological conviction. There is ample evidence that deductibles dissuade useful as well as useless care, increase administrative complexity and cost, fail to address expensive care for the very ill or injured, and act as a tax on sickness.

  41. #44 by cav on April 3, 2012 - 1:45 pm

    What happened in the rose garden Monday? Did Barack diss the ‘Supremes?

    If so, fair play, I’d say.

  42. #45 by brewski on April 3, 2012 - 2:56 pm

    Canada doesn’t keep costs down by allowing patients and doctors to make any kind of informed cost/benefit decisions on the course of care. Canada does so by simply denying care or delaying care or rationing care.

    CBC News Online | August 22, 2006

    One Supreme Court decision may have done more to change health care in Canada than three major reports and a first ministers conference that ended with a $41-billion infusion into the system.

    On June 9, 2005, the high court struck down a Quebec law that prohibited people from buying private health insurance to cover procedures already offered by the public system.

    “Access to a waiting list is not access to health care,” two of the justices wrote in their decision.

    The Quebec and federal governments asked the high court to suspend its ruling for 18 months. Less than two months after its initial ruling, the court agreed to suspend its decision for 12 months, retroactive to June 9, 2005.

    In the provincial government’s response in February 2006, Premier Jean Cherest said the private sector could play a role in health care in Quebec, but said he remained committed to public health care. He also said Quebec will introduce guaranteed wait times for procedures including some radiation treatments and cardiac surgery, as well as knee and hip replacements and cataract operations.

    The ruling has impact only on Quebec, but it could eventually lead to some of the biggest changes since former Saskatchewan premier Tommy Douglas was credited with fathering medicare. Most Canadians take government-funded health care for granted today, but when it was first introduced in Saskatchewan in 1962, most of the province’s doctors responded by going on strike to protest against “creeping socialism.”

    The strike lasted three weeks – public support for the doctors had collapsed, persuading the doctors to accept a deal with the government. Within five years, government-funded health care spread across the country.

    While most Canadians – 80 per cent according to Statistics Canada – are satisfied with their access to the health care system, many experience long waits to see a specialist, get diagnostic tests and undergo elective surgery. Others find themselves facing huge bills for prescription drugs they need to survive.

    A long wait for hip replacement surgery was what prompted the Quebec case that wound up before the Supreme Court.

    George Zeliotis argued his yearlong wait for surgery was unreasonable, endangered his life, and infringed on the charter’s guarantee of the right to life, liberty and security. The second plaintiff, Dr. Jacques Chaoulli, wanted the court to overturn a Quebec provision preventing doctors who don’t operate within the medicare plan from charging for services in public hospitals.

    • #46 by Glenden Brown on April 3, 2012 - 3:48 pm

      That’s an interesting news article, brewski, but entirely off topic.

      No one has ever claimed Canada’s system is perfect. Yet spending significantly less per capita, they produce better results than our system.

      Canada’s single payer system controls costs through many different means. Attempts to identify ways to control costs in the US have been inaccurately described by conservatives as death panels or as some sort of dictatorship. As for example, a board of doctors who would determine comparatcive effectiveness of specific treatments has been routinely attacked by people on the right for all kinds of things, most of them inaccurate.

      The relevant point of course is that single payer systems aren’t flooded with massive overuse. Single payer systems are significantly cheaper per capita than our system, cover everyone and aren’t continually forcing patients to pay more and more out of pocket. That doesn’t make them perfect, but when overall outcomes are far superior to what our system can produce, it certainly gives me pause.

  43. #47 by brewski on April 3, 2012 - 2:56 pm

    I am in moderation

  44. #48 by brewski on April 3, 2012 - 2:57 pm

    You can call it fair play. But he is still a zombie liar.

  45. #49 by cav on April 3, 2012 - 3:45 pm

    I’d like to see your moderated comment before I declare:

    That’s all you have?

  46. #50 by cav on April 3, 2012 - 4:17 pm

    Ok. That’s all you have?

  47. #51 by Richard Warnick on April 3, 2012 - 5:47 pm

    In 2009 the Harris poll discovered widespread satisfaction up north:

    An 82% majority of Canadians believed their country’s health care system was superior to the U.S. system. Only 8% thought the U.S. system was superior.

    The U.S. version of single-payer, also known as Medicare, gets rave reviews as well.

    More than two thirds (70 percent) of traditional Medicare enrollees say they “always” get access to needed care (appointments with specialists or other necessary tests and treatment), compared with… only 51 percent of those with private insurance.

  48. #52 by brewski on April 3, 2012 - 8:27 pm

    Not one word of that refutes my point.

  49. #53 by cav on April 3, 2012 - 10:21 pm


  50. #54 by Richard Warnick on April 4, 2012 - 8:08 am


    So in your imagination the existence of waiting lists for some medical procedures in Canada makes their system bad. But the U.S. status quo is OK with no health insurance for 50 million Americans, medical bankruptcies for even those who have insurance, and high costs all around?

  51. #55 by brewski on April 4, 2012 - 9:07 am


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