Obamacare...(new title): GOP DEATH PLAN: Don-Ryan's Express

[Tulane Skins Fan]

Read this again and tell me it passes the sniff test. It gives healthcare to 30 million people, and saves a trillion? If you believe that, I have a bridge to sell you. By the way, current estimates say prices will be higher because of the ACA.

WD,

Do you understand the ACA does not give public insurance to those 30 million people? Do you understand that the individual mandate that you probably said was the worst thing ever, is an attempt to cut health care costs? The idea is that people who can afford health insurance will chip in and pay for it. NOT THE GOVERNMENT.

[skinsmarydu]

WD,

Do you understand the ACA does not give public insurance to those 30 million people? Do you understand that the individual mandate that you probably said was the worst thing ever, is an attempt to cut health care costs? The idea is that people who can afford health insurance will chip in and pay for it. NOT THE GOVERNMENT.

Thank you. The ACA is NOT a government takeover of healthcare.

[JMS]

WD,

Do you understand the ACA does not give public insurance to those 30 million people? Do you understand that the individual mandate that you probably said was the worst thing ever, is an attempt to cut health care costs? The idea is that people who can afford health insurance will chip in and pay for it. NOT THE GOVERNMENT.

It is true that private insurance policies for young healthy people will offset costs for insurance companies to actually provide insurance which will be useful.. ( no pre-existing condidtions, hikes for use, dropping sick people ).. But Wrong Direction is also correct that there are a lot of government subsidies to those 30 million newly insured Americans. Medicare is being increased to cover some, and small businesses which can't afford to provide coverages usually also get subsidies.

[Tulane Skins Fan]

It is true that private insurance policies for young healthy people will offset costs for insurance companies to actually provide insurance which will be useful.. ( no pre-existing condidtions, hikes for use, dropping sick people ).. But Wrong Direction is also correct that there are a lot of government subsidies to those 30 million newly insured Americans. Medicare is being increased to cover some, and small businesses which can't afford to provide coverages usually also get subsidies.

WD's premise is that you can't increase coverage to people and save money. He's completely wrong that the government is increasing coverage to everyone that is now going to be covered.

There may be some analysis to be done to see whether ACA actually saves the government money or not. But his premise is entirely wrong.

[JMS]

Thank you. The ACA is NOT a government takeover of healthcare.

Sure it is. You can argue that it's not because there are still private insurance companies in the market... But come on, Healthcare in this country is one of the most heavily regulated and controled markets in all of human history and has been in this country for 70 years. The ACA doesn't change that one way or the other. My point is the notion of a "free market" healthcare system is a Red Herring our system has been tightly controled by legislation since at least 1948 when congress exempted Insurance companies from competing with each other and allowed them to colude on cost.

With the massive specialization in healthcare which occured beginning in the 1920's free market ceased to be a viable delivery method. Hense the need for collectivism, insurance. Collectives of people pooling their money to afford services. The healthy paying for the sick.. another name for that is socialism. Only our socialist healthcare system is not geared towards providing services to patients at a reasonable cost anylonger, rather it's geared towards generating profits.... Hense the need to reform it..

The ACA or Obamacare is a very modest reform. We frankly need a lot more. We have had major reform to heathcare every decade of my life... ( from the 1960's) in that time we have gone from consistantly the best healthcare system in the world, to one of the worst in the industrialized world ( 37th)... Every decade we have slipped in price per capita, services, and coverage to folks who began to reform their system in the 1960's and 70's. Today we are the only industrialized country in the world not to have universal coverage and our healthcare system costs nearly twice what other countries pay per capita too. These costs are so high it hurts our abilities to compete in many industries including manufacturing...

[PeterMP]

Three things:

1. Preventative healthcare is not believed to lower health care costs. At least not doing it the way we current practice healthcare.

2. The ACA is not predicted to lower health care costs really (they will be lower some further out, but not by much, and more expensive in the very near future).

http://voices.washingtonpost.com/ezra-klein/2010/09/does_health-care_reform_bend_t.html

So in terms of real savings, there aren't any or they are very minimal.

3. In terms of Madicaid in healthcare out comes, there is no study or real reason to believe that the health care people on Medicaid are getting is inferior to people w/o insurance. There are good reasons to believe that people on Madicaid are different than people not on Medicaid, including the fact that they've qualified for medicaid. There is no reason to believe that by extending Medicaid the people that are now covered on Medicaid are going to really see a decrease in their health out comes:

http://theincidentaleconomist.com/wordpress/on-gottliebs-favorite-medicaid-outcomes-studies/

"I read the four studies Gottlieb explicitly cited (listed above) and guess what? In every single case the authors are careful to assert that they are investigating associations. They point to ways in which their study does not completely control for all the differences between Medicaid enrollees and the uninsured or other groups. They very clearly state that health insurance status is being used as a proxy for broader socio-economic status.

Thus, one cannot conclude — and the study authors do not — that Medicaid is the cause of worse health. One can only say that there is something about Medicaid enrollees that is associated with worse health outcomes. Since changing only the Medicaid program without changing who is enrolled in it won’t address that something, it is unclear that these studies support any particular reform, though they all suggest that Medicaid patients could do with a bit more help. Just as one cannot conclude Medicaid harms health, one cannot conclude that Medicaid is perfect and not in need of some reform. I am not concluding that. For me, this is about methodology, not policy."

While it is true, that people on Medicaid have worse health out comes, if that becomes a fact to assert that something is really wrong with Medicaid, the person is stretching the facts.

Edited July 20, 2012 by PeterMP

[JMS]

WD's premise is that you can't increase coverage to people and save money.

Yes by cutting waste/overhead/profits, it is possible to cover more people for less money.

He's completely wrong that the government is increasing coverage to everyone that is now going to be covered.

Creating an absolute and then hiding behind it isn't intellectually profitable. The government is mandating 30 million new people will get insurane and is trying to ensure insurance companies don't go broak by heavily subsidizing those new policies in several ways. One way is the mandate on healthier people, another is direct subsidies to small businesses, another is by getting states to extend medicare with the Federal Gov picking up like 80-90% of the costs.

There may be some analysis to be done to see whether ACA actually saves the government money or not. But his premise is entirely wrong.

I think that analysis has been done. CBO says it will be revenue neutral over the short term, save money over intermediate term (10 years), and save more money over the long term.(10+ years ). Anybody in the GOP who wants to argue about the CBO's numbers is dishonest. The CBO's numbers may not always be right, although they have a good track record. They are and have been the non partisan gold standard of forcasting expense of bills. Objecting to their numbers on Obamacare is like a kid arguing with the umpire half way through the ball game.

---------- Post added July-20th-2012 at 12:23 PM ----------

So in terms of real savings, there aren't any or they are very minimal.

While I fundimentally agree with you given how much we spend on healthcare, the projected "savings" are very very modest

It is still a little shocking to dismiss a hundred billion, or a trillion+ as no real savings.

Your Washington Post article source is from 2010, The latest CBO report is from 2012.. So I am going with CBO numbers, because those are the best numbers available. I know we can poke holes in their costing, but we can also poke holes in their savings projections. Thus to cherry pick on one side is irrelivent. Those are the bipartisan projections which should frame any debate.

Edited July 20, 2012 by JMS

[Wrong Direction]

The terms of the expansion of Medicaid under the Affordable Care Act are quite favorable for the states...

You are right that the ACA picks up a larger portion than traditional Medicaid. My point is that the federal budget picture makes that match unsustainable in the eyes of many. It provides states with huge incentives to drive up costs and diminishes their incentive to lower costs. This is the historical problem with programs like Welfare and Food Stamps. It was the crux of welfare reform. It is unsustainable.

10% of your electorate is a pretty large chunk of people to condemn to live without health insurance just because of you want to political posture.

They're not condemned to live w/o insurance. They're condemned to the exchanges. Very different.

The employers dropping insurance plans is another GOP red herring.

Note this passage from the CBO estimate: The 2012 estimate didn't assume that more low-income people would be placed in the exchanges. As a result, costs will increase in the new CBO report. I have this on pretty good authority.

With those cross currents, the net effect of a larger reduction in employment-based insurance coverage on the budgetary impact of the ACA depends crucially on the share of the workers and their families losing such coverage who are eligible for Medicaid, CHIP, or exchange subsidies and on the tax rates those workers pay. If an additional firm with a large share of low-income workers chose not to offer insurance coverage, the net effect would tend to be an increase in the federal budgetary cost of the ACA’s coverage provisions; if an additional firm with a small share of low-income workers chose not to offer insurance coverage, the net effect would tend to be a decrease in the federal budgetary cost of the ACA’s coverage provisions.

healthcare is the biggest fiscal liability we face with regard to out of control spending which will bankrupt us... followed by out of control defense spending.

Healthcare is #1 by a wide margin, I agree. It continues that way regardless of the ACA.

You mean Bush used smoke and mirrors passing his healthcare bill in 2003 but having benifits kick in, in 2006? Aren't you outraged by that? No one is talking about repealing Part D; it’s simply become too popular with the GOP’s base of elderly white voters (not to mention Big Pharma).

No offense taken because I don't think you know what you are talking about either. Bush's "Medicare Prescription Drug, Improvement, and Modernization Act" passed in 2003 cost more than was projected. The cost estimate has increased twice since it was passed.

Bush absolutely did that. He absolutely should have paid for it. This has been something that conservatives have been crowing about since the day it happened.

As to costs, you refer to a couple of different estimates. The two original estimates for the full bill were for $400 billion (CBO) and $500+ billion (CMS Actuary). However, the actual yearly costs of Part D (e.g., 2006 actual versus 2006 predicted, 2007 actual versus 2007 predicted) came in below both estimates. The Medicare Advantage insurance costs were as expected and the DME savings were reduced because the program was delayed by Congress. Sure the 10 year costs are higher, but it clearly doesn't tell the whole story. That's because they account for a full 10 years of spending, versus 7 years originally, and savings from competitive bidding were slower to accumulate. Overall, Part D scored better than originally expected. It has now been altered by Democrats (donut hole), so any new cost estimates would have to take those additional costs into account.

YES ACCORDING TO THE CBO... The Cost of Obamacare Has Gone Down, Not Up

#1 - The CBO hasn't scored the bill after the SC ruling. The effect of the SC ruling was a major point in my original post.

#2 - The CBO scores the bill in a vacuum, and makes what I think are flawed assumptions as to the number of employers who will find it cheaper to drop coverage.

#3 - I have it on pretty sound authority that the SC decision will increase the costs seen in the next CBO report. Time will tell.

#4 - I'm not sure why this conversation has devolved from my original points.

I've said before on this site that I'm not 100% opposed to the ACA. I'd do it differently, but even the current structure has some benefits and provides some opportunities to future reformers.

---------- Post added July-20th-2012 at 12:32 PM ----------

WD,

Do you understand the ACA does not give public insurance to those 30 million people? Do you understand that the individual mandate that you probably said was the worst thing ever, is an attempt to cut health care costs? The idea is that people who can afford health insurance will chip in and pay for it. NOT THE GOVERNMENT.

As written, it expands the Medicaid roles by something like 20 million people. I don't have the exact estimates handy.

[PeterMP]

While I fundimentally agree with you given how much we spend on healthcare, the projected "savings" are very very modest

It is still a little shocking to dismiss a hundred billion, or a trillion+ as no real savings.

Your Washington Post article source is from 2010, The latest CBO report is from 2012.. So I am going with CBO numbers, because those are the best numbers available. I know we can poke holes in their costing, but we can also poke holes in their savings projections. Thus to cherry pick on one side is irrelivent. Those are the bipartisan projections which should frame any debate.

The CBO, as far as I know, isn't talking about real health care costs.

It is talking about government costs.

There is a difference.

Edited July 20, 2012 by PeterMP

[Wrong Direction]

Thank you. The ACA is NOT a government takeover of healthcare.

No. It just establishes a federal government bureaucracy to create mandates for all plans in the nation. Then state governments are required to design their own exchanges which meet federal government guidelines. If the federal government disagrees, there's a federal government-state government process to approve plan structures. Then insurers have to bid to state governments to make sure they meet the guidelines. This will be done for every individual state government. God forbid the federal government catches wind of something in a state government exchange that may not meet the federal government requirements. Depending on the individual, the state government and federal government will determine how much of subsidy that person/family can receive. This is all enforced by the federal government's IRS.

The law prohibits people from buying plans based on another state government's requirements unless that other state government and your state government have entered into an agreement approved by the state legislatures, and submitted to the federal government for further approval.

Really, government doesn't have much of a role in this at all.

---------- Post added July-20th-2012 at 12:55 PM ----------

WD's premise is that you can't increase coverage to people and save money. He's completely wrong that the government is increasing coverage to everyone that is now going to be covered.

No. My premise is that you can't increase insurance coverage to 30 million people while adding new mandates and without fundamental reforms to the marketplace and do it for free.

---------- Post added July-20th-2012 at 01:04 PM ----------

While it is true, that people on Medicaid have worse health out comes, if that becomes a fact to assert that something is really wrong with Medicaid, the person is stretching the facts.

I generally agree with the post, but on this point, there are clearly case-mix issues in comparing the Medicaid population (and various age/race demographics within it) to any other population. This certainly causes some of the outcome disparities. However, the association with worse outcomes is also made due to longer wait times, lower access and access at worse institutions through Medicaid. Given that context, I don't think it's fair to attribute the full difference in outcomes to the individual beneficiaries. I do admit that the proportion is difficult (and probably impossible) to quantify.

[JMS]

You are right that the ACA picks up a larger portion than traditional Medicaid. My point is that the federal budget picture makes that match unsustainable in the eyes of many. It provides states with huge incentives to drive up costs and diminishes their incentive to lower costs. This is the historical problem with programs like Welfare and Food Stamps. It was the crux of welfare reform. It is unsustainable.

And I'm sure if we get a republican majority in the senate, house and executive they may try to cut those subsidies along your rational. Problem is when start to provide services, these things become hard to cut. And as I said before, this package saves money, taken in it's entirety. Including all the money they are spending because they are cutting money elsewhere; Like Bush's gifts to pharma and Insurance companies.

They're not condemned to live w/o insurance. They're condemned to the exchanges. Very different.

The exchanges still cost money, they can't afford the exchanges. Medicare is the safty net which catches the working poor in the ACA. If you don't extend medicare because you are trying to expoite some short term political wedge issue; you are condemning a sizeable percentage of your folks to no insurance... And you will pay a price for that as working poor in neighboring states have their positions improved. It will hurt you with the poor, with moderates and indepednents... turning away billions because you don't want to spend millions.

Note this passage from the CBO estimate: The 2012 estimate didn't assume that more low-income people would be placed in the exchanges. As a result, costs will increase in the new CBO report. I have this on pretty good authority.

So if I'm interpreting what you are saying correctly... You are saying that so many republican governors are going to opt out of extending medicare, that it will increase the cost of healthcare for everybody to go up, which will in turn result in more employers to cut coverage; according to an as yet not released CBO report which you refference? And you want to hold the ACA responsible for that?

Healthcare is #1 by a wide margin, I agree. It continues that way regardless of the ACA.

Exactly the ACA is modest reform not radical reform. It is not the answer, it may be part of the answer. It is better than nothing because it actually makes insurance valuable again for many folks who today have worthless plans and only find out about it when they need it. It is fundimentally not the savings plan we needed althouth it does save money. It fundimentally is a reform to the existing system which allows healthcare costs to be the #1 reason sited in all US Bankrupcies even for people with insurance.

(Bush's 2003 Healthcare Bill)

This has been something that conservatives have been crowing about since the day it happened.

Yeah like two of them. Pat Buchannan and George Will. Everybody else was silent.. Rand Paul was one of the ringleaders of it. Not that the Dems didn't let it happen too. Only two dem senators voted for it, but they had the votes to filibuster and didn't. This is one of the reasons why I don't think the Republican party is conservative any more. Not fiscally conservative anyway. Because they only get "outraged" when the Democrats spend money, and even then they don't care if the idea saves money in the long run or not. It seems their objections are entirely based on politics not the good of the country. Drives me nutz.

#1 - The CBO hasn't scored the bill after the SC ruling. The effect of the SC ruling was a major point in my original post.

Then I apologize because I missed that point.

#2 - The CBO scores the bill in a vacuum, and makes what I think are flawed assumptions as to the number of employers who will find it cheaper to drop coverage.

Again the CBO numbers are what they are. You can poke holes in them here or there on revenue, cost, and savings. Thus you have to take them as they are until they change.

To do otherwise is to change the rules of the game half way through the contest. The CBO's number are the gold standard for cost forcasting and are geneerally fairly accurate..

#3 - I have it on pretty sound authority that the SC decision will increase the costs seen in the next CBO report. Time will tell.

The SC decision did take away a stick the federal government was trying to use to get the states to expand medicare. Namely denying the federal governments ability to withhold all medicare funding if the state opted out of the expantion plan. As you say, we shall see. I think there are other sticks the Federal government can use. Highway funds are still at risk.

I've said before on this site that I'm not 100% opposed to the ACA. I'd do it differently, but even the current structure has some benefits and provides some opportunities to future reformers.

I agree wth that, It's amazing to me this thing was so very devisive. It is modest reform.

---------- Post added July-20th-2012 at 01:08 PM ----------

The CBO, as far as I know, isn't talking about real health care costs.

It is talking about government costs.

There is a difference.

Ah, good one. I'll reread your post article..

Here is my retort. The federal government consumes 40% of Healthcare services. The ACA increases this number by expanding medicare, new subsidiies for uninsured, etc..

If the CBO is projecting 1.2 trillion in savings from 10-20 years out ( roughly )... That must come from lowering the growth of healthcare costs... ie savings.

Using the old ratio transformation I learned in Quant; that means consumers would save even more. About 1.5 trillion 10-20 years out. Again not huge savings given we will probable spend 60 trillion in healthcare over those years... But hey I'd pick up a trillion dollars if it was just laying on the side walk... Save a trillion here and a trillion there and eventually you are talking real money.

Edited July 20, 2012 by JMS

[Son of Gadsden]

As someone who makes a living explaining it, I've yet to meet a single homeowner who understood his/her homeowners insurance well enough to get the contractors paid right by themselves...or even communicate properly with them. So on the subject of health insurance, I've seen so many average Joe's trying to argue a health insurance POLICY whom have absolutely no idea how insurance even works, it's laughable and impossible to take seriously.

You know, my sister-in-law is a liberal. She argues Obamacare with me all the time, and I just sit there and listen to her theory on how health insurance works...which is quite honestly made up based on a good guess in her head...and makes sense in theory...but factually is absolutely incorrect. I usually just say, "You know, you're a psychiatrist...and as a insurance restoration contractor, I don't try to explain to you exactly why a schizophrenic patient has an imbalance and why they see things that aren't there." So let's just take a step back and see if we all have any idea what we're talking about...or if we are making educated guesses on a subject we aren't even qualified to argue. Because quite often, that's what I'm seeing.

But, hey, here's a thought that goes beyond the whole "You can't make people buy whatever the government wants them to buy in a free country."

What about those who's religion causes them not to believe in the healthcare system? Are they still fined because of their religion? If that's so they don't have freedom to practice their religion...they are fined for practicing their religion. If you say you're going to exempt them from the tax (as the Amish are from social security), then it's not fair that they aren't forced to buy it, but I am.

The health care system is screwed up. That's for certain. The welfare system is screwed up. That's also for certain. The social security system is screwed up. That's proven. And we keep piling more stuff on the government to fix, when everything they touch dies. The government has a hard time handling the things they are SUPPOSED to be handling, and we want them to handle more. It's time to tell the government to back off and take our country back ourselves, and pay for it and run it ourselves...while the government stands guard to make sure we are allowed to. After all, that is their ONLY designed purpose. Free market is the system that caters to human nature, socialized systems of ANYTHING have always proven to be flawed and have always failed. Even our police are a grand example, and I mean that to no offense of any officers that may be reading this. How often do we hear of "dirty cops". Dirty cops would be gone if police were privatized, because they company would be fired and a new one replace them. Government spawns corruption in everything it touches...and we continue to have faith in it.

[PeterMP]

Free market is the system that caters to human nature

For a free market to work, it requires several things. First and for most that people can make good decisions.

socialized systems of ANYTHING have always proven to be flawed and have always failed.

There are many countries that have a more socialized health care system than us that at least appear to be paying less than us- most notably by reducing over head costs.

Even our police are a grand example, and I mean that to no offense of any officers that may be reading this. How often do we hear of "dirty cops". Dirty cops would be gone if police were privatized, because they company would be fired and a new one replace them. Government spawns corruption in everything it touches...and we continue to have faith in it.

Do you really want to claim that "corruption" doesn't happen in private industry?

Let's say, that people don't embezzle money from their employer?

---------- Post added July-20th-2012 at 01:27 PM ----------

Using the old ratio transformation I learned in Quant; that means consumers would save even more. About 1.5 trillion 10-20 years out. Again not huge savings given we will probable spend 60 trillion in healthcare over those years... But hey I'd pick up a trillion dollars if it was just laying on the side walk... Save a trillion here and a trillion there and eventually you are talking real money.

But the government isn't really JUST saving money. The money is coming IN too (e.g. the "tax" from the mandate).

That is the "savings" are driven by more earnings (w/ respect to the federal government), but those earning realistically are healthcare costs to the person paying the penalty.

The net sum is no real savings in health care costs.

As a private person, I'm not going to start collecting more money from anybody after ACA to pay for my healthcare.

Edited July 20, 2012 by PeterMP

[Wrong Direction]

JMS,

You're an energetic discussion partner. I can't even quote your last passage. My site just hangs up. A few points in response (by paragraph).

1. The future cuts are very possible given our federal budget outlook. As I said in my original post, I'm hearing more and more that both parties see our deficits and debt (because of interest) to be reaching crisis levels. Cuts have to come from somewhere, and the state-federal match is one likely place.

2. You're using Medicare (generally for old/disabled) and Medicaid (generally for poor) interchangably. The Medicaid expansion was supposed to catch those working poor. The politics of the issue will be interesting, but less so in conservative states than I think you're assuming. Note again that my original post predicts that the flexibility granted to states may very wll allow them to tailor their Medicaid programs to the more needy. This is a non-trivial point.

3. No, that's not what I'm saying at all. It will cause the costs to the federal government to go up. Also, I've long held (and heard) that the CBO used Part D models for shifts from private to public subsidized insurance and I think those models (if my understanding is correct) under estimate the number of employers that will drop coverage because those models (and covered populations) are not comparable. I think the CBO report underplays this point by claiming additional tax revenue will offset that change. In any model, I think the cost of providing insurance is higher than the cost of additional tax revenue.

4. No comment.

5. Nah. I've been hearing it from all circles for many years. It's not just George Will, it's talk radio and more conservative Republicans who were elected after the bill was passed. For what it's worth, I don't think Part D is a bad program at all. To the contrary. I do think it could use some simple reforms and I do think it should have been offset with cuts. Bush could have never gotten it passed with offsets though.

6. Cool.

7. There are three very general complaints conservatives have about CBO estimates. One, conservatives claim the CBO systemically underestimate the costs of bills because their coverage estimates are lower than actual and based on rosy future economic scenarios. Second, CBO cannot do dynamic scoring. Third, the CBO can't anticipate the almost certain higher costs resulting from future legislation. The Medicare Modernization Act was a great example. Future laws delayed competitive bidding and expanded coverage to additional drugs and in the donut hole. None of that could possibly be accounted for in the original scores.

8. Another reason this law is bad. It grants the feds (Democrat now, but eventually Republican) big sticks over states to make them do what they don't think is in their state's interests. This is a huge fundamental problem with the bill.

[PeterMP]

There are three very general complaints conservatives have about CBO estimates. One, conservatives claim the CBO systemically underestimate the costs of bills

Is there any actual evidence this is true?

That the CBO DOES systemmatically underestimate the costs of bills?

[Wrong Direction]

Is there any actual evidence this is true?

That the CBO DOES systemmatically underestimate the costs of bills?

Here's one piece, though it's not the report I'm thinking of.

http://www.freedomworks.org/files/capitol_comment_CBO_scores_PDF_2.pdf

---------- Post added July-20th-2012 at 01:54 PM ----------

By the way, this is a little off topic, but I strongly encourage anyone who's interested in political books to read Tom Coburn's (R-OK) book the Debt Bomb. He's conservative, but willing to work with reasonable people as evidenced by the fact that taxes and defense are "on the table." This man understands the debt as well as anyone.

This book does a great job of articulating he debt problem in general, and also articulating conservative positions to deal with the issues that face us, with solutions on healthcare, taxes, defense, etc. laid out in the book. Some seem to think good conservative solutions don't exist, so I'd recommend checking this book out if you're at all open to that side of the discussion. It has been a pleasant surprise to me.

[Edit: I'm having a hard time finding the report I'm thinking of re: future economic scenarios. There is much out there about underestimating the costs of healthcare programs historically, and I think I recall the same about other Great Society/welfare programs, but that's what I'm not finding now.]

Edited July 20, 2012 by Wrong Direction

[PeterMP]

Here's one piece, though it's not the report I'm thinking of.

http://www.freedomworks.org/files/capitol_comment_CBO_scores_PDF_2.pdf.

Come on. You know enough that cherry picking a few things, especially programs that were changed after the original projection, doesn't amount for evidence of much of any thing.

Much less that something is systematically biased in one way.

**EDIT**

Other than maybe a systematic bias in the person that put together the cherry picked/miss leading list.

Edited July 20, 2012 by PeterMP

[Jumbo]

Your framing of JMS' nature as a debate partner is just another sign that you've gained some solid tailgate legs, WD.

Keep it up.

Independent of my agreeing or disagreeing to what degree about whatever, you regularly bring worthy considerations and well-presented views and do a great job of staying out of any muck.

Edited July 20, 2012 by Jumbo

[Wrong Direction]

Come on. You know enough that cherry picking a few things, especially programs that were changed after the original projection, doesn't amount for evidence of much of any thing.

Much less that something is systematically biased in one way.

See my edit. I'll add that (upon reflection) the first reason I cited re: CBO being wrong is likely due to the third thing I cited, which you mention above. This is the general conservative position about government never going away and always growing. For health reform, some good early examples of originally unanticipated costs would be coverage of birth control and a cost shift away from Medicaid. I gave other examples in this regard for how Part D costs have changed since the original bill. Politicians generally don't cut the waste. They simply identify the "weaknesses" and add funding for them.

So, my critique of the CBO is partially unfair, I agree.

A counter example to my generalizations above would be the catostrophic coverage bill in the 80's. That bill was repealed when CBO raised it's estimates. I happen to think (maybe naively hope) that the political atmosphere in Washington now will allow for VERY substantial cuts in 2013.

So, coming full circle to my first post on this topic, I think this could dramatically change Medicaid moving forward.

[Larry]

Three things:

1. Preventative healthcare is not believed to lower health care costs. At least not doing it the way we current practice healthcare.

That certainly seems counter-intuitive, to me.

Although I do recall readong about a study, several years ago, that looked at health outcomes for four common major medical procedures. (The one procedure I remember was coronary bypass surgery. I forget what the other three were.)

The study looked at:

1) People who had had coronary bypass surgery (and whatever the other three were), and

2) People who had had coronary bypass surgery recommended, but who declined the procedure.

And they looked at how many of each group were still alive, five years later.

And what they concluded was that all four of these procedures had no significant effect on the patient's odds of still being alive after five years. Both the croup who had the surgery, and the group who didn't, had roughly the same percentage of deaths over the next five years.

One of the things I remember from the article I read about the study was that the study didn't say that coronary bypass surgery didn't reduce the number of heart attacks. But that a lot of the people who had the various procedures would up dying from some other condition, within five years.

In particular, one thing the study noted was that, of the "had coronary bypass surgery, but died, anyway" group, more than half of them died from an infection that they picked up in the hospital.

[Wrong Direction]

That certainly seems counter-intuitive, to me.

Peter's right. It is counter-intuitive, but if you think about it then it does make sense.

Generally, a high percentage of our healthcare costs occur in the last couple of years of life. Even great prevention doesn't get rid of the last couple of years of life, it simply delays those costs for another day and adds the costs to care for someone in between that "prevention" and their ultimate terminal illness.

The relatively healthy period between prevention and terminal illness doesn't pay for itself, because it isn't truly healthy. For a young person to find prostate cancer early, for example, it could result in many healthy years of premium payments and thus some chance of cost savings. However, prevention isn't only for the relatively healthy. For many it would still result in very high end of life costs plus higher treatment costs in the interim.

One of the things I remember from the article I read about the study was that the study didn't say that coronary bypass surgery didn't reduce the number of heart attacks. But that a lot of the people who had the various procedures would up dying from some other condition, within five years.

Good analogy. This is more quality care than prevention, but my boss always talks about the high costs of saving lives from heart attacks. Whereas people used to die a lot more in the 70's, treatment paradigms are now saving a ton of lives. Unfortunately, those patients end up with chronic heart failure and they become an enormous financial drain on the system in the following years.

It's sad, but death is the cheapest option.

[JMS]

JMS,

You're an energetic discussion partner.

Thank you, It is fun and rare to speak to someone here who is both knowlegeable and willing to entertain alternative opinions. I hope I reflect that too.

The politics of the issue will be interesting, but less so in conservative states than I think you're assuming.

Yeah, I don't think so. The folks we we now equate with conservatism love a free lunch as much or more as the next guy. They just don't want to pay for it.

Even if their party leaders see political advantage for sabatoging a democrat's attempt at reform; the rank and file folks are still going to have to go hungry to enable that. That will be a hard sell to moderates and independents crucial to GOP power in any state except maybe Utah.

3. .... I think the CBO report underplays this point by claiming additional tax revenue will offset that change. In any model, I think the cost of providing insurance is higher than the cost of additional tax revenue.

But WD, not the CBO's model.. and again it's really not reasonable to blast the CBO's model in favor of a partisan one is it? And It really isn't revenue which offsets the projected savings going out in future years, cause their isn't much revenue in the ACA. They tax/ penalize folks who don't get insurance to offset any financial incentive for this behavior. That's not going to generate much. Millions a year? I'm sure they'll tag Sarge, and MassSkinsFan every year but that's only $10k.. We are talking hundreds of billions in savings over the first 10 years, and 1.2 trillion over the second ten.

That all comes from curbing the projected growth rate of healthcare costs.

( On Bush spending 600 billion on the Medicare Prescription Drug, Improvement act of 2003 and not paying for a dime of it )

5. Nah. I've been hearing it from all circles for many years. It's not just George Will, it's talk radio and more conservative Republicans who were elected after the bill was passed. For what it's worth, I don't think Part D is a bad program at all. To the contrary. I do think it could use some simple reforms and I do think it should have been offset with cuts. Bush could have never gotten it passed with offsets though.

Are you kidding me? Don't make me vomit on my keyboard.... Conservatives were silent. Talk radio was silent. The GOP had the majority of both houses, and they all sold out. I still remember George Will's comments. He was pretty tenative in even broaching the subject. Bush was riding high on his 911 popularity. If you were against him you were a communist.. George Will was the only "Republican" who said something like... "hey, that's a huge expansion of the entitlement".... Pat Buchannon who isn't a republican anymore, as I remember wasn't so hesitant.. I heard no other voce even broach an objection. Maybe now they will, but back then there weren't.

As for "more conservative" Paul Ryan Rep from Wisconson Mr. Soak the poor to balance the budget!!, he voted for it. He lobied for it.

Aye Ryan, Paul ®

Medicare Prescription Drug, Improvement VOTE, ... (On Passage of the Bill)

The House Vote

Yes 207 Republicans 9 Democrats = 216 votes

No 19 Republicans 195 Democrats 1 Independent = 215 votes.

http://www.govtrack.us/congress/votes/108-2003/h332

The Senate Vote

Nay 9 Republicans 35 Democrats

Yay 42 Republicans, 11 Democrats, 1 Independant

http://www.govtrack.us/congress/votes/108-2003/s459

If "conservatives" objected.. then only 8% of the GOP in the house are "conservatives" (19 / 226 x 100 = .08 )

And 17% of the Republican Senators are "conservative". ( 9 / 51 x 100 = .17 )

7. There are three very general complaints conservatives have about CBO estimates. One, conservatives claim the CBO systemically underestimate the costs of bills because their coverage estimates are lower than actual and based on rosy future economic scenarios. Second, CBO cannot do dynamic scoring. Third, the CBO can't anticipate the almost certain higher costs resulting from future legislation. The Medicare Modernization Act was a great example. Future laws delayed competitive bidding and expanded coverage to additional drugs and in the donut hole. None of that could possibly be accounted for in the original scores.

And I think partisan cherry picking on the CBO given these same guys supported the bush bill which was entirely unpaid for is crazy.

8. Another reason this law is bad. It grants the feds (Democrat now, but eventually Republican) big sticks over states to make them do what they don't think is in their state's interests. This is a huge fundamental problem with the bill.

It doesn't create sticks, but it may use sticks... Man both parties have been using highway funding to make the states submit since the Eisenhower administration first built the interstate hwy system, now that's the ACA's fault? Nooooow Republicans object to that, given they've done the same thing countless times when in power?

Edited July 20, 2012 by JMS

[PeterMP]

That certainly seems counter-intuitive, to me.

Although I do recall readong about a study, several years ago, that looked at health outcomes for four common major medical procedures. (The one procedure I remember was coronary bypass surgery. I forget what the other three were.)

The study looked at:

1) People who had had coronary bypass surgery (and whatever the other three were), and

2) People who had had coronary bypass surgery recommended, but who declined the procedure.

And they looked at how many of each group were still alive, five years later.

And what they concluded was that all four of these procedures had no significant effect on the patient's odds of still being alive after five years. Both the croup who had the surgery, and the group who didn't, had roughly the same percentage of deaths over the next five years.

One of the things I remember from the article I read about the study was that the study didn't say that coronary bypass surgery didn't reduce the number of heart attacks. But that a lot of the people who had the various procedures would up dying from some other condition, within five years.

In particular, one thing the study noted was that, of the "had coronary bypass surgery, but died, anyway" group, more than half of them died from an infection that they picked up in the hospital.

I have to go and have a PSA test done.

Let's assume that I have prostate cancer. They catch the cancer, treat it, and I don't die of prostate cancer.

Good, right?

No. I'm going to die of something some day and almost no matter what I die of there will be associated costs. There is no reason to believe that me dying from prostate cancer will be cheaper than me dying from whatever else I'll die from. And in fact if I live to get a disease or a point where I need long term care, it'll almost certainly end up costing more than if I had died younger of prostate cancer.

And that doesn't even get into all of the people that you do PSAs on that don't have prostate cancer (essentially wasted money) and false positive PSA tests.

In terms of costs, it is cheaper if you keel over at 50 of cancer or some heart disease than if you live until you are 80, have associated problems (hip replacement, etc) and tests done over the course of your life, and end up dying of dementia or some other disease normally related to the oldest population.

But don't take my word for it:

http://www.politifact.com/truth-o-meter/statements/2012/feb/10/barack-obama/barack-obama-says-preventive-care-saves-money/

Barack Obama says preventive care 'saves money'

rated false

Or if you like the CBO:

"In yet more disappointing news for Democrats pushing for health care reform, Douglas W. Elmendorf, director of the Congressional Budget Office, offered a skeptical view Friday of the cost savings that could result from preventive care — an area that President Obama and congressional Democrats repeatedly had emphasized as a way health care reform would be less expensive in the long term.

Obviously successful preventive care can make Americans healthier and save lives. But, Elmendorf wrote, it may not save money as Democrats had been arguing.

"Although different types of preventive care have different effects on spending, the evidence suggests that for most preventive services, expanded utilization leads to higher, not lower, medical spending overall," Elmendorf wrote. "That result may seem counterintuitive.""

http://abcnews.go.com/blogs/politics/2009/08/congressional-budget-expert-says-preventive-care-will-raise-not-cut-costs/

**EDIT**

Now, I think if you conducted very selective preventative care, you essentially didn't do broad tests like we do in many cases, you could probably make preventative care save you money.

I go get blood work done every year or 2 where they do a whole bunch of tests. But realistically most of them are a waste of money.

Doing them is "standard", but realistically most of them aren't affecting my health or the majority of people's health that are getting them.

Especially when you start taking into account costs.

Edited July 20, 2012 by PeterMP

[JMS]

Is there any actual evidence this is true?

That the CBO DOES systemmatically underestimate the costs of bills?

There is no such evidence. Nobody really knows what these things will cost the CBO consists of experts who try to act independent of party ideology in there predictions. They have a pretty good track record of being close...

They are about 1000x better than partisan predictions from either party. That's the whole reason they were created.

But seriously let's say they are wrong... they aren't going to be wrong by say 100%... The same folks objecting to Obamacare because they just know it's going to cost something ( over the objections of the best available evidence)... Those are the same folks who overwhelmingly voted for Bush's healthcare reform which was just about as expensive; and was ENTIRELY UNPAID FOR.. Bush just put the entire thing off budget and right onto the deficit.

Edited July 20, 2012 by JMS

[PeterMP]

double post

Edited July 20, 2012 by PeterMP