ObamaCare and the General Welfare Clause

[IJ]

"Why should I comment on something that you present as fact when it isn't? Fercryinoutloud, Ian. Don't you ever fill out your forms every year which itemize the a-la-carte benefits you choose for your pre-tax compensation?"

So if an argument is presented that you don't agree with, you just ignore it? It would be really interesting if discussions usually ran that way. Here's what I know: lots of people believe that the fact that much of our income is concealed by virtue of it being an employer contribution to our healthcare. We then do not appreciate how much we are gettting paid and what huge fraction of our pay goes to that healthcare, because it's an employee, not an employer, who pays for everything. I didn't make this concern up. It's been presented in our Grand Rounds by a knowledgeable colleague who presented data on healthcare debates from the 60s on. It's been in the NEJM editorials. And it makes perfectly good sense, too. If someone who thinks they are making 40 k (and their employer is making some nebulous contribution to their insurance) found out they were making 50k and 10k a year was going to healthcare, I would expect they really would get excited about that really fast. Do YOU know exactly how much your employer contributed to the healthcare of you and your family last year? I sure don't and it sure as heck wasn't on my W2 or income tax forms.

We know that when people are confronted with the true costs of TV sets paid slowly and with huge interest, or pay day loans with huge interest, they make better decisions, even though a Bill Glasheen would be smart enough not to fall into those traps without needing the warning, because he could do math. People are not all Bill Glasheens out there. Maybe you're so smart you're missing this point? This isn't just about pre or post tax income; it's about hiding a huge chunk of our income as an employer paid benefit we fail to appreciate as income. Get it now?

My point is valid; it's at least valid enough that it deserves some kind of a reply rather than your assumption it's so obviously worthless you wouldn't say anything (not that that's rude or anything! )

"Why should I comment on a misrepresentation of my position?"

99.5% of the population would say, "To correct the misrepresentation, especially because Ian said himself that your point didn't seem clear," but ok...

"The difference between you and I is I don't do the BS warm and fuzzy dance."

You have me totally figured out Bill--I'm the guy who wants to slash social security benefits, raise the retirement age, and ration healthcare--just another typical fuzzy headed warm hearted liberal What are you talking about?? You are using too much LSD if you think I do not understand incentives in America; I've never given you reason to think otherwise. Meanwhile, my budget suggestions have been more specific about cutting entitlements and leaving people on their own than any I've heard here, or from politicians, except perhaps the libertarians.

"Can I be any more clear?"

YES!! You said, in your own words, "If you buy coverage, you get deluxe. If you don't, then you get deluxe at an ultra-deluxe (non-negotiated) price OR you get economy." THAT is unclear given the context of your prior comments, but you lay it out yourself: "if you don't [buy coverage] you get economy." Economy is not nothing; it is something. People who don't buy healthcare and then get sick currently get a prety good package of EMTALA required healthcare including for fabulously expensive conditions; I gave the examples of cancer and heart attack. You didn't say no care; you said economy. There is either subsidized, guaranteed healthcare for such conditions or there is no care for them; people cannot pay for them out of pocket (if any can, they're insured anyway). Are those not your words? How am I not to take them as your view that people should be getting economy class healthcare (which by virtue of cost will have to be subsidized by others) if they haven't gotten insurance? If you had meant "if you don't buy coverage, then you have to pay out of pocket or you simply don't get care," you could have said that, but you didn't; you said "economy [healthcare]." (*I* have laid out our options including the choice between mandatory insurance and letting people go without care if they fail to think ahead).

Unbiased observers? Would anyone else like to explain to me how "if you don't buy coverage, you get economy" healthcare means anything besides the suggestion that uninsured people get second tier of healthcare--less, but something perhaps adequate? Bueller? Bueller?

[IJ]

To further explore issue #1, I did some digging on the UCSD "at your service" website. They actually have a calculator to let people know how much total compensation they get, because as they put it,

"The value of your UC employment goes beyond your salary. As a UC employee, you enjoy a full range of benefits, services and programs. To calculate the approximate value of your total UC compensation, indicate your medical and dental plans and coverage levels and whether you are coordinated with Social Security. Enter your annual salary and select "Calculate.""

The site is there to help people appreciate how much they are paid but don't realize. But you have to look for it. It turns out that my benefits, "paid" but UCSD, are actually 25.6% of my total compensation. The # would be 10k more if I had family on my plans, but I don't (you get paid more if you have a nonworking spouse and some kids).

If everyone saw that money as THEIR money going to a healthcare sink, they would care a lot more about it than if they figured this was an "employer" contribution and thus "free money."

[Bill Glasheen]

If someone who thinks they are making 40 k (and their employer is making some nebulous contribution to their insurance) found out they were making 50k and 10k a year was going to healthcare, I would expect they really would get excited about that really fast. Do YOU know exactly how much your employer contributed to the healthcare of you and your family last year? I sure don't and it sure as heck wasn't on my W2 or income tax forms.

I couldn't tell you how much, Ian. I also couldn't tell you my GPA at any one point of any part of my academic life. However I knew whether or not I was doing well enough to get on to whatever next level I needed. That's plenty.

I'm all for educating people about their benefits, Ian. I've seen it done. However I'm not convinced it will help any more than putting health care kiosks at work will make people take better care of themselves I'm the science guy on all this, and I want to see proof that it helps. Otherwise you get the big shrug from me.

For what it's worth... I measure outcomes from such interventions for a living, and they let me hold back a control group for comparison. We're always throwing pasta up at the ceiling in our population to see if it sticks. Mostly when it does, it's marginal at best. We like the expression "herding cats." Behavior modification in health care inspires it.

Do you know what does work? High deductibles. The higher the deductible, the fewer the episodes of care that are initiated (by the patient). Furthermore, the effect has persistence through the rest of the year when the deductible runs out.

Medical Savings Accounts combined with super-high deductible health plans (as a fall back when the bottom drops out) is the most recent idea du jour.

We know that when people are confronted with the true costs of TV sets paid slowly and with huge interest, or pay day loans with huge interest, they make better decisions, even though a Bill Glasheen would be smart enough not to fall into those traps without needing the warning, because he could do math. People are not all Bill Glasheens out there. Maybe you're so smart you're missing this point? This isn't just about pre or post tax income; it's about hiding a huge chunk of our income as an employer paid benefit we fail to appreciate as income. Get it now?

I'm unconvinced.

I see it over and over and over again in data, Ian. Pareto's distribution holds. The reason why we have disparities in income and wealth has to do with basic laws of Nature that we can understand on an empirical level far before we ever get it at a first principles mathematical level. Pareto observed it centuries ago in Italy, and it still holds today.

The statistical distribution also occur in other parts of the data such as the number of hospital days per person per year, the amount spent per person per year, etc., etc.

Maybe if we taught kids about the time value of money in algebra class when logarithmic and exponential functions were discussed, then they'd get it. But I doubt it. Twenty percent of the class would get it at an intuitive level, and the other eighty percent will be more worried about getting laid or drunk (or both) that weekend.

Maybe if we taught kids about the dangers of drugs and alcohol and STDs and pregnancy, then they'd "Just say no." Some will... And others will become alcoholic, smoke, get pregnant, and suffer from cervical cancer years down the road.

It doesn't mean we don't try, Ian. But I'm always depressed when I see the magnitude of the effect of any intervention. We can beat on our chests at political conventions and talk about how our way is the better way. Maybe if we say it loud enough and long enough, we'll start to believe our own propaganda. But at the end of the day, it's just politics.

So then it just comes down to philosophy and execution. Everything else is just the numbers. I know how I want to live, and I find a way to make things work in my world.

I'm the guy who wants to slash social security benefits, raise the retirement age, and ration healthcare--just another typical fuzzy headed warm hearted liberal

If you wish...

We have no choice but to raise the retirement age, and we're already rationing health care. On the latter front, the "r" word is just semantics.

It ain't the what; it's the how. I want the money up front, and I want to ration my own health care. One thing I learned in my research is that people want what they want - even if they don't get the best outcome. This one very elaborate 3-year study comparing two benefits of the two largest employers in Virginia taught me this. At the end of the day, there was no "winner." Satisfaction with what you had was just as valid a measure of "quality" as health status or cost, and there was no product where all three metrics peaked. Who are you or The Guru to say what we can and cannot have? What mattered most to people was choice.

You like your Prius; I want to drive fast. We're happy with our individual choices. We'll go ballistic if someone chooses for us - particularly if it's "the wrong choice."

THAT is unclear...

What is "economy" in health care when someone doesn't want to get out of bed and play? What is economy in health care when Maria wants to swim the Rio Grande and have her baby in a San Diego hospital?

It has to do mainly with public health, or what will serve us all. Even altruism is a selfish trait, albeit a wonderful one. Deliver Maria's baby, and send them back south of the border. Buh bye!!! Diagnose and treat hepatitis and tuberculosis, and do what you can to contain it in the population. If it serves the individual but not so much the public good, then go home and work for it, baby. Buh bye!!!

Most people need to go hungry before they'll get out of bed and get a job. Tough love isn't just something your parents do for you. It's a part of teaching people about dignity and self worth. It generates pain and income disparity, but it also inspires the best among us to be the best. And at some point, the passion reaches critical mass. Achievement then become a contagious disease.

- Bill

[IJ]

Your view is that giving people more information about their benefits is maybe useful, but not proven. Swell. I like data as much as you do.

Here's what you might not be considering: it's not just data. Let's look at me as an example, and let's remember that you want your money up front and to ration your own healthcare.

Right now I am paid a total compensation, X. 75% I get in my paycheck; 25% I get as benefits (I now know). Currently, I have BC/BS insurance because it's nice and I get to see colleagues here if I need them, two blocks from the hospital.

UCSD is paying for most of that insurance. If I switch to Kaiser they save lots more than I do.

If I were simply paid X bucks up front, I probably wouldn't have BC/BS. I basically don't need healthcare, outside of emergencies; I'm healthy. So I would probably recognize the larger than needed payment to BC/BS and switch to Kaiser for a once yearly (or less) inconvenience of going to another site for healthcare, and maybe less ritzy something. I dunno. But healthcare expenditures drop; competition is increased. Plans change their behavior. Point is, if you compensate people transparently and give them more control of their outcomes (take home) they change behavior. This is Bill-ism 101, and I hypothesize you were cool to it initially because I said "meh kinda sorta" and my modification sounded like a diss to you (it wasn't intended to be).

If you want data, fine, cool, study it; it's still a good idea. As with your insurance exchanges in Germany, it's unproven. What works in Germany may not work here, for reasons we've discussed many a time in threads such as those about gun control. Different population. Different context. Needs as much study.

On high deductibles: people do use less healthcare when they have more skin in the game. They also do cram as much healthcare into years when their deductible is exceeded as they can (Tim is doing it this year with a new baby pushing the limit so he's getting his knee looked at again). But yes it'll save $. Problem is people are really poor at picking good value healthcare and they tend to get stuff they don't need as much as things they do need, and miss things they shouldn't. Therefore, the physician (or person promoting health, whomever) can't simply be satisfied with a reduction in cost.

People's health savings accounts were designed to reduce spending, but they may have the perverse effect of expiring and spurring "use it or lose it" thinking. This could be tinkered with.

The funny thing about Pareto's distribution is that it doesn't hold. There have been dramatic redistributions of wealth in this country in the last few decades. The poor, poorer, the rich, richer. It does not make sense to just say "80-20" and throw up your hands. It is also merely an observation and not a law; if the system is changed, that ratio may change, or there may be an increase in the middle class, something. Maybe if Pareto studied a slave holding society he might have observed that 30% of the population owns literally nothing. 200 years later had we not changed, that would still be true, but justifying nothing.

Personally, I could never make money on payday loans or predatory credit cards or TV scam deals because I cannot be involved in those things, morally. Now, we might say some people are dumb and can't be helped or we could decide that people be shown several alternatives and made to choose the best one for them. I strongly believe that informing people that they would pay 3 times what a TV is worth with that shady payment scheme will encourage them to save and buy it once. Not all; a worthwhile improvement. So if you want to be pessimistic, fine; as you say, it doesn't mean we don't try, and there is then no reason not to have this part of the discussion; we should just make such pricing, and medical costs, available to people so they have a better chance of making good choices.

On my liberal credentials: We do have a choice in raising the retirement age, taxes, and rationing; we can continue as we are, or change. Right now everyone is putting it on a credit cards. Dems are still spending and republicans still cutting taxes. No one is actually promoting hard choices right now. I am saying something important; I'm just not in charge.

As for satisfaction in healthcare, yeah, it's a nice goal. Again, as a physician, I'm morally obligated (and I believe everyone is) to serve the principles of beneficence and justice, not just autonomy. I can't just do the wrong thing to get a higher satisfaction score, and neither can our healthcare system. If you WERE able to accomplish this, putting satisfaction first, letting patients chose prius vs ferrari, you would have to do a moral-ectomy on the physicians and we would be even more doomed. Sorry, decisions are joint patient-physician but they literally do have limits put on that deal, "someone choosing for them," every day they see me as their doctor--and they don't go ballistic and they actually appreciate that have no conflicts of interest and always insist on what's best not what they were necessarily expecting or asking for. This is the reality up in the hospital rooms.

As for your tough love plans, problems arise immediately.

"If it serves the individual but not so much the public good, then go home and work for it, baby. Buh bye!!!"

I'd love to hear you explain that to a patient. You might as well shoot some of them. You're basically suggesting we let them die. Because people without insurance can't pay for their cancer care or acute MI, and THEY CAN'T WORK. It's like kicking a limbless bum on teh street and saying "get a job!" Get it? They die. If that's what you want, just say you'd deny required care to people and they'll suffer and or die. Hard to feel self righteous just then; it's too late.

As you put it,

"Tough love isn't just something your parents do for you. It's a part of teaching people about dignity and self worth. It generates pain and income disparity..."

Yeah, but parents don't let their kids die when they goof up. Tell me exactly how to explain to a patient with cancer that they won't get treated as part of their daily lesson in dignity and self worth. Tell me how dying with a treatable disease, unable to work or pay, or just dying in pain, teaches people dignity. Or selfworth. I never spare change bums because I know it just goes to ethanol; that's my tough love. Sick people though? These people I can't just let die on the street (provided they don't have anything contaigious). And America has a long history with trouble making cost saving decisions anyway; we found that needle exchange lowered cost and HIV, but couldn't put self interest ahead of judgement, and it was blocked. Drug treatment can similarly lower costs and risks of theft / violence, but we run into "free care" objections.

As for kicking the American citizen back to mexico, would you be re-writing the Constitution to deny her citizenship? Or would you let her reenter when he uncle in country is ready to take her? You're stuck either treating her like a citizen or dissing the Founders here.

Here's the thing. I like incentivizing people to do the right thing. I ethically can't kick dying people though. I can say DO THE RIGHT THING OR PAY A TAX. That's a fair stick. It's Obamacare. And the fact that the rest of western civilization provides medical care is a sign that "poor sick people need to learn a lesson" is not as obvious as you make it out to be.

I do admire your philosphical purity.

[Bill Glasheen]

Your view is that giving people more information about their benefits is maybe useful, but not proven. Swell. I like data as much as you do.

Not exactly. My view is that IF it helps - and we don't have proof - the effect will be marginal.

I like information. I like education. I think consumers should be informed. It's the responsible thing to do in a free market economy. We're all on the same page.

But I'm not expecting that to be a "cure". If people were generally teachable, then we wouldn't have payday loan centers and credit card companies making a fortune off of the stupid. A good deal of people will never handle their money well. Those same people will pretty much abuse all resources available to them. Don't believe me? Then why do automobile insurance companies use your credit score to adjust your auto insurance rates? The data do not lie.

For most people, having the "rationing" happen in the here and now is the best way to get their attention. For a system where choice is kept sacred, this means simple things like MSAs or deductibles. That's the best of both worlds. You get choice, but you see and feel the pain right away when you tap into the resources.

As for your liberal guilt trip above... I stand by what I say, Ian. If you don't pay, you don't play. If you're not a citizen, you don't have the rights of citizens.

I'm glad you have a heart, Ian. That's why you're a doctor and that's why I want you to stay a doctor. But good will can be abused. That's why we have people who make sure that the players play by the rules. Without rules, you have disaster - sort of like the California economy. Then sooner or later, EVERYBODY loses.

And no, I won't support a federal bailout of California when/if that economy collapses. It's that tough love thing you know... Without the fear of failure, many people will be doomed to fail.

- Bill

[IJ]

"Not exactly. My view is that IF it helps - and we don't have proof - the effect will be marginal."

Ok. I accept your contention completely. We should still do it. The effect of malpractice reform will be marginal. The effect of raising the retirement age a year is marginal. The effect of hydrochlorothiazide on cardiovascular outcomes is marginal. My entire job is marginal--frequently giving people a little bit more time or a litle bit better function or giving them a pill to reduce their risk of an event by <1%. That's medicine--and margins keep companies (and health care systems) operating.

I know there are predatory cards and payday schemes, but my point has always been that they will be LESS effective if there are limits placed on their rates, and transparent information required. I mean, this is no less logical than an airbag. They only increase your chances a little.

Re: liberal guilt trips:

1) It's not liberal. Nice try. Find me >1-2 politicians who are advising we leave heart attack patients untreated if they can't pay. If liberal means necessary lifesaving care, then I'm in the most liberal... 99% of society! Recommending "pay or die" is highly extreme rhetoric. I have never heard of anyone advising that we repeal the EMTALA rules.

2) that baby from the mexican mom is a citizen. As per the Constitution. Sorry. You have to rewrite the Constitution or recommend denying entry to a citizen.

3) You state: "But good will can be abused. That's why we have people who make sure that the players play by the rules. Without rules, you have disaster - sort of like the California economy."

Yes, everyone here knows that a) we need rules and b) we need to incentivize people to do well.

However, obviously it's not always a matter of responsibility and trying. Some people are born too sick to work and will need a safety net. We've decided to help them out. We've also decided that denying care for a heart attack is not something we will permit as a society. So whatever your views are on this, your plan to pay or play is completely, 100% going nowhere in this country. Remember that you tell people it's stupid to talk about slashing the use of fossil fuels because it's just going to be done by India and China if the USA and europe decide to cut back. I agreed with you. Agree with yourself: we are not kicking people to the street with a heart attack any sooner than we're voluntarily crashing our economy by ceasing using oil.

As far as rules and making sure people play by the rules, again again, this is Obamacare. Our society guarantees some healthcare via EMTALA. We need everyone to responsibly pursue insurance to keep the system healthy. Obamacare says since you ARE going to PLAY that you will have to PAY. "That's why we have Obama who makes sure the players play by the rules," you might say.

If you're against free care, support an insurance mandate or tax requirement. Because denial of crucial care is never going to happen outside of a disaster/triage scenario.

That's a "liberal" fact trip.

[Jason Rees]

2) that baby from the mexican mom is a citizen. As per the Constitution. Sorry. You have to rewrite the Constitution or recommend denying entry to a citizen.

So how do you feel about a new effort to eliminate anchor babies by amending the Constitution?

[Bill Glasheen]

2) that baby from the mexican mom is a citizen. As per the Constitution. Sorry. You have to rewrite the Constitution or recommend denying entry to a citizen.

So how do you feel about a new effort to eliminate anchor babies by amending the Constitution?

Ian

First... Good luck balancing that California budget.

Second... Does the Constitution say the mom gets to stay? If not, what's moral about sending her home without her baby?

And finally... Last I checked, women are allowed to vote. What's up with that? Oh yea... it's that AMENDMENT thingie.

I don't blame the woman who tries for the anchor baby feat. But that doesn't mean I endorse it. It's unfair to those who wish to immigrate via legal means.

- Bill

[IJ]

"First... Good luck balancing that California budget."

Um, ok, thanks. How is this related? I blame prop 13 more than anything, but Californians (the ones whose taxes I pay for them) will be loathe to give it up. Jreey Brown opposed it back in the day. I hope he comes up with something other than labor giveaways.

"Second... Does the Constitution say the mom gets to stay? If not, what's moral about sending her home without her baby?"

No, it wouldn't be moral to leave the baby on the ground and send mom home, but the kid is a citizen. Maybe permanently barring anchor moms might be a disincentive. The kid would go with mom due to necessity, but I can't see any courts telling a family with a citizen in country they can't have the baby because mom was bad.

"And finally... Last I checked, women are allowed to vote. What's up with that? Oh yea... it's that AMENDMENT thingie."

Gosh that is obvious--we've been talking about the 14th Amendment all this time afterall. Listen, I don't think it would be crazy to modify it to read:

"Section 1. All persons born to citizens or legal residents, or naturalized in the United States, and subject to the jurisdiction thereof, are citizens of the United States and of the State wherein they reside. No State shall make or enforce any law which shall abridge the privileges or immunities of citizens of the United States; nor shall any State deprive any person of life, liberty, or property, without due process of law; nor deny to any person within its jurisdiction the equal protection of the laws."

But a lot of people have issues with limiting the rights in the Constitution and/or partially deify the thing and don't want to do this.

I would need to see the number of anchor babies, thoughts on the continuation of this problem, ideas about how border control could solve it, and how the families are handled before modifying the Constitution, but I think it's an option. My main point is it's not as simple as "gosh, kick them out."

Overturning EMTALA remains functionally impossible; Americans are at least partially insured, and so I still think it's reasonable to expect them to contribute. No free lunch, eh? And mandating insurance allows those other features like permitting people to switch/obtain insurance more easily; you can't do that if people would only wait for need to think about insuring themselves.

The real issue here isn't coverage but costs, and how to bend the cost curve. Those pricing trends cannot continue, and we have to choose a crash v soft landing.