Posted by: elambend | November 13, 2009

Things the Health Care Bill does NOT do

I randomly found this post which has a pretty good rundown of the bill on a supply and demand basis:

The problem with US health care is cost. It costs too much relative to what it costs in other OECD countries and it costs too much relative to income. A cost problem is in essence a price problem. Prices serve as signals. Since HC is a marketplace- quite distorted, but a marketplace- the price is telling us that there is a supply-demand imbalance. There is either too much demand, too little supply, or both.

Like good market fundamentalists, let’s look at both sides:


(1) Doctors: the medical mafia has made it very difficult and expensive to become a doctor in the US, all in the name of patient safety, of course. I am not saying that it should be easy, BTW, but compared to other OECD countries, where doctors are more or less a middle class-level occupation, here, in most locations, doctors are not. Part of the supply constraint is the number of years of schooling required (upwards of 10 years post high school; often 15 with fellowships for certain specialties) and another part is the cost of education. When software engineers make too much in the US, somehow the H-1B quotas get adjusted and the supply of engineers in increased. Doctors, obviously, are luckier and smarter in restricting entry into their fields.

Does the Pelosi bill address doctor shortage? No. In part, they “promise” to cut reimbursements. Like that’s going to happen.

(2) Coverage availability: A huge problem now is the incredibly high cost of individual policies. There are a number of reasons for this, such as negative selection, state-level insurance market regulation, monopoly law exemptions, absolute lack of transparency in pricing and others. There really isn’t a functioning market for individual policies, as far as I can judge. We recently changed car insurance policies. It took minutes. While the parallel is far from perfect, there is something to learn there.

Does the Pelosi bill address the dysfunctions of the individual policy market? Only partially, and will create more problems than it solves. At least, they recognize that it is a problem and they are attempting to take steps towards a more transparent marketplace.

(3) Employer-link: I mentioned “unintended consequences” above. A big part of the problem is that most employed get coverage via employers, and this started as an unintended consequence back in the 1940’s when the government started limiting compensation to control war-time inflation. This is a very, very perverse aspect of the existing HC system. It forces employers to get in the business of buying healthcare, medicines, flexible spending accounts, dental, fitness programs and other what I would call “non-essential” business activities. In addition, employers pay for a part or all of the insurance, on top of payroll taxes. This makes American businesses waste resources on non-business activities, and makes hiring in the US expensive.

Does the Pelosi bill try to move away from employer mandates? No, it makes them worse by taxing businesses that do not offer it. I am going to make the prediction that within 3-5 years employers will be choosing to pay the 8% payroll tax penalty and not bother with the whole thing. If an employer can fire 60% of their benefits department, save on insurance costs and get away with an 8% payroll tax, I think the decision will be a no-brainer. Either that, or a wholesale move to hiring “contractors” in lieu of “employees”: why even bother with payroll taxes at all? Or some other “who could have known” side effect.

I should also point out that the worst side effect of the employer-linked coverage is that it makes it difficult for start-ups to attract people. We all lose in aggregate when this happens but too few people care about what “might” have been. If Sergey Brin needed kidney dialysis, do you think he could have dedicated all his time to starting Google?


(1) Users of free HC goods and services: “poor”, illegals, elderly
Most of our representatives are both innumerate and economically illiterate. Some even have troubles filing tax returns. They fail to understand that the demand for free goods is near unlimited.

As a result, here in the city hospitals, you have a huge population that pays nothing for their hospital stays, and as a result, they treat it like a full-service hotel: non-stop demands, frequent visits, you name it. Homeless people simulating sickness to stay in for a couple of days, eat and take a shower. Nursing homes refusing to pick up patients if they have another test in two days. Families collecting the social security check from grandma refusing to let her die. Caribbean tourists visiting family trying to get in for a kidney transplant. Illegal aliens giving birth to their “anchor” babies. Drug addicts faking illness to get morphine and a good night’s sleep. “Poor” trying to get themselves checked in so that they get 2 week supply of meds without a copay. These are all actual cases. ALL PAID FOR BY THE TAXPAYERS/FUTURE TAXPAYERS AT $5,000/DAY.

Does the Pelosi bill address these huge generators of losses for the system? Absolutely not. Even the simplest thing, such as mandatory minimum copays, are not in. Never mind some other solutions, like, gasp, rationing. The bill even bans illegals from buying insurance, even if they want to, thus guaranteeing that the taxpayers get the tab.

(2) Heavy users of HC goods and services: the obese, the smokers, the drug users, people with genetic conditions

Another way to reduce demand would be to discourage behaviors that are likely to result in increased health care demand. The way I would approach it, the government will not pay for anyone’s care if they are obese (based on BMI or body fat %), smokers or drug users. And, on top, the system should assume that one does not qualify, unless proven otherwise, with annual eligibility checks.

Does the Pelosi bill do anything to reduce future demand by discriminating against the obese, the smokers and the drug users? No.

One exception to this group are people born unlucky with genetic disorders. I would have no problem with a portion of my healthcare dollar going to those truly, genetically unlucky people. However, smoking, obesity and drug use are a matter of choice by and large (with the exception of metabolic disorders affecting obesity), and have to be actively discouraged, something the bill does not do at all.

(3) Federal programs matching state spending
Another large factor in the “demand” side of the equation is that for many of the state-level run programs, the Federal government provides matching funding. Obviously, this creates huge incentives for states to maximize spending on everything, and, as a result, costs skyrocket.

Does the Pelosi bill change these incentives to reduce demand? No.

Again, unlike most HC problems, the solution here is relatively simple. Move away from matching, and go to zero-based budgeting: every year the budget resets at 0, and every dollar has to be rejustified.

(4) Tort reform
Talk to any doctor, particularly anyone doing invasive procedures of any kind, and you are likely to hear horror stories about malpractice lawsuits. The lottery-ticket tort system (the cesspool home of slime like John Edwards, and a major donor to the DNC and the President) encourages frivolous lawsuits and outsized jury awards. Since most jury verdicts are unpredictable, doctors and their insurance companies often choose to settle, thus feeding the scum.
The current system has two perverse consequences, one is an increase in insurance costs (which can run tens of thousands of dollars or more per year). The second, and much more costly but difficult to quantify, is that doctors overorder medical tests for unlikely conditions both in in-patient and out-patient setting, and have patients overstay in hospitals while waiting for all of those to come through. This is a huge money drain in the entire system.

Does the Pelosi bill address tort reform as means to reduce demand? No.

The solution is relatively simple: limit the maximum award in any malpractice suit to $50-100k, and refer all alleged cases to the State medical boards for review. As a result, in a true malpractice case (which is something a jury in my view absolutely cannot decide as most Americans in my view lack basic science skills), the doctor would lose his license.

(5) Prescription drugs
There are a few problems here. On one side, drugs are incredibly expensive to develop, and the people who develop them must earn a proper risk-adjusted return on capital for doing so.
Then there is the other side. The US taxpayer and paying HC consumers have been paying for the development of drugs that the rest of the world gets at much lower prices. This is not a system that can last for too long as the free riders have to be cut off. Second, the US is the only OECD country, to my knowledge, that allows direct-to-consumer (DTC) drug ads. This generates demand for certain brands even when generics are available. “Ask your doctor if the purple pill is right for you” has a cost and it is coming out of your pocket.

Does the Pelosi bill address the problems with prescription drug costs? No.

There are a few things that can be done: ban consumer advertising, ensure flat or reasonable pricing across regions, and so on. Obviously, it would take too much thinking on Congress’s side.

(6) Demographics
There isn’t anything the bill can do per se, but it would have been the perfect occasion to start with future cost reductions via various mechanisms as it is clear that the problems we have now are only going to get worse in the future. To paraphrase a famous management thinker, demographics is the future that has already happened. And it is not pretty, in my view. Ideally, this would be a wider national discussion on aging, and how what was promised simply will not be there. There will be substantial reductions in benefits in the future, whether you like it or not, and these reductions will be in healthcare, pensions and social security, again whether you like it or not.

Does the Pelosi bill address the coming demographic upheavals in the healthcare system? No.

(7) Fraud
Finally, it is not a secret that there are substantial fraud operations going on with the various programs. Every major bust there is simply staggering in scope, but what is also staggering are the incentives for people not to work and to hide assets to qualify for the “free” programs, a small-time “beat the system” operators.

Does the Pelosi bill address fraud at the large and individual levels? No.

This is my market-based look on the bill. I am sure there are a lot more aspects of it, but I have given up thinking any more about it as there is no way I can change anything. I rate this bill at FAIL as it fails to address the underlying problems with the current system. It simply raises taxes while doing nothing for a “true” reform even though the bill is marketed to the clueless populace as “reform.” It is not.



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