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Probably not. ^.^

No.

I'd focus on reforming it back toward a market based system. Since we haven't actually tried that yet.

Market-based system of healthcare is not a good idea. That's been tried and failed. That's the whole reason why this bill has even passed.

It hasn't actually been tried. That was my point. We had something that's mostly government controlled or mandated already.

The usual cause of a "market failure" is government.

? It was a pure market system. This bill is the first to even touch the system in decades.

I keep forgetting you have no idea what a market even looks like.

It does not look like a system where half of the money comes from the government (8% of GDP is medicare/medicaid and public spending on medical benefits while overall health care spending is around 17%) or the government declares the price it will pay (medicare/aid services).

You're also overlooking yet another bill passed in 2005.

Further problems with your theory
1) the government provides a tax exclusion for one type of purchase over another (employer benefits over individual). This heavily distorts the prices of insurance and makes it very difficult for individuals to purchase
2) the government mandates particular varieties of insurance as acceptable (ie, your insurance must cover xyz services) rather than allow consumers to decide which services they must cover themselves. This results in large barriers to entry because the cost of insurance is higher. Fewer competitors are protected against competition from smaller and more nimble or even market niche insurers. This operates very much like a classic regulatory capture rather than a market.
3) So medicare and medicaid (along with the VA) don't exist in your world? I thought it was funny when people complained with "keep your government out of my medicare", but this is also pretty rich.

Pretty sure no one in the U.S. wants a healthcare system like Singapore.

http://en.wikipedia.org/wiki/Healthcare_in_Singap…

This is pretty close to what a free market health care system might look like. I suspect it's about as close as human beings can get simply because of anti-market biases. I suppose we could do without the price controls, which would make it a little more expensive.

Pretty sure I can list off at least a dozen economists who would love to see a Singapore style system. Probably a lot more if you go ask them. Most of them have written extensively about a system like this. There's also a popular journalistic endeavour cataloging one man's attempt to come up with a functional health care system here: http://www.theatlantic.com/magazine/archive/2009/… which very liberally steals from a Singapore style system. The fact that YOU don't want a Singapore style system is not proof that nobody, and more importantly, nobody important who has thought carefully and long on the ideal structure of health care reforms wants such a system in place.

There was also a relatively popular (and bi-partisan) health care bill prior to this one that resembled some key features of the Singapore system called Wyden-Bennett.
It didn't get off the ground mainly because of entrenched interests who would stand to lose billions of dollars like big insurance companies or health care providers (doctors) and who lobbied against it (plus Obama threw it under the bus back at the beginning of this process. Admittedly, it's a radical way to reform the system, but it would actually fix the problems with the status quo and do so at a much cheaper rate). But it had around 60-70 co-sponsors in the House and Senate from both parties.

I'd also question why nobody would want a system which results in superior health care outcomes (people live longer and healthier in Singapore than in the US) for LESS money. WAY LESS money. The fact that people would not want such a system strikes me as absurd. Consumers constantly want more efficient products and transactions for themselves when they are allowed to express their preferences through market interaction rather than government processes of collective interaction.

The problem is not that people would not prefer such a system but it is more that people are more comfortable with the current system and biased toward the status quo. We thus saw a health care bill passed which more or less kept the current vital features in place without actually reforming anything important or reducing the structural costs. I will be amazed if we are not back in the drawing room trying to "fix" our system again in less than 10 years as a result. Rescission and access to health care insurance are trivial problems with the status quo, not reasons to pass major legislation. They are "story problems" as I call them and not empirical problems.

Or maybe because they have a crappy system set-up there. The United States has the best hospitals and treatment centers for a reason.

Do you even read? Go look up ratings of health care delivery in any country in the world. The US ranks somewhere in the top 40, which is good.

But it's behind Singapore. Nationalism will get you nowhere for this argument because it does not establish the actual facts. Only the facts as you would wish them to be.

Health care delivery right. That's why Sloan Kettering and all the best hospitals like Bellevue are right in NYC. You are the type of person who talks bad about America but yet you still live here.

I'm not talking "bad about America". There's a difference between "talking bad about America" and seeking out the realities under which it operates and then seeking to improve upon those realities. People are entitled not to believe blindly that their own country is the best in the world at everything under the sun, which I regard as an idiotic and dangerous belief. It is precisely that thinking which contributed to the start of the Iraq War for example; that we somehow were so great at democratic forms of governance that we could impose it somewhere else.

We cannot reform a health care system that people believe is the best in the world when it is not in fact very good at very many things which are vital to good health care delivery and outcomes.

By the way, neither of those two hospitals are listed as in the top 50 in the US. I just checked. In fact there's only one hospital in the NYC area that has been so listed in the last couple years.

Singapore was 6th on the WHO rankings in 2000. The US was 37th. There are certainly significant quibbles to be had with the methodology of those rankings, but it's impossible to come away from that with the idea that they have "a crappy system".

Even if it's somehow less adequate than America's, it still achieves a pretty good health care outcome for a quarter of the price of ours. One could assume that perhaps if they spent as much as we do it would be better.

Sun Tzu, It is no use talking with Jared because he drank all the Obamacare cool-aide and is so into this government total takeover of the American individual from birth to death that he cannot see the forest for the trees!

As for the original question – I pray every night and day that not only will it get repealed, but that they repeal Obama and his cohorts in the process!

Jared – The reason that we HAD the best hospitals and doctors (that will go away under this socialized Obamacare system) was because of the free enterprise market based healthcare/health insurance system that has been in place since we became a country!

Just my VERY not-so-humble opinion. B)

I'm late to the party and Sun Tzu said everything I wanted to already.

I guess it really doesn't matter because my view is the way the law sees it now.

Jared I've been trying to respond to this comment in ways that won't qualify as harassment. Let me just say that it is VERY worrisome to me that the federal law has become a means for some people to push their views on others, and even more so that people would defend their positions not with an articulated position but with the statement, "the law is on my side." as if the law exists as an absolute. This is perhaps the weaker bastard child cousin to the "strict constitutional" argument.

I'm trying to educate him on market economics. As well as the dangers and flaws of blind faith nationalism. I could care less whether he changes his mind on this point immediately. Eventually he'll figure out he was wrong.

And we did not have a free enterprise market based health care system, it was largely based on public supports through regulation, price controls and taxation. That's part of the problem. Telling him that it was a "free market" is a lie.

Sort of. I doubt the law sees it that the previous system was a haven of free markets.
Here's an enlightening passage from the NYT.
"….a visit by the Dutch health minister to the US:

His first official visit to the United States as health minister came in 2007, and he came with the usual European preconceptions that this country had a wide open and fiercely competitive health insurance market with a myriad choices.

“And what struck me,” he said, “is actually the lack of competition you have.”

Mr. Klink pointed out that nearly 40 percent of the nation’s population gets care from Medicare, Medicaid and Veterans Affairs, all of which have significant restrictions on the choices available to patients. “We don’t have these kind of public insurance groups in our country,” he said.

And even among those in the United States who get insurance from their work, he went on, “it’s the employer who is making the choices of the health plans from which you can choose.”

None of these traits would be aptly described as a fiercely competitive and open market society. And this was the way things already were. Much less what they will become because of this bill (which more or less sets in stone the parameters already in place rather than fixing any of them).

I'm pretty sure no sane person looks at what just became law and presumes that it is a self-sustaining reform that addressed the key portions of needed health care policy reforms. We'll be back at this in 5-10 years, in large measure because of the way they proposed to pay for this. Medicare cuts among other things, consolidating student loan programs into direct federal loans rather than having banks do it, but the medicare cuts are the key.

They're never going to happen because they are a transfer of wealth from poor to rich and the rich will fight the cuts (note: they're also a transfer from young to old and healthy to sick, both of which present some odd moral incentives as well). That's a huge problem. Medicare was already unsustainable before this. I doubt it has or will be substantially improved, but even assuming they do make the cuts, they didn't substantially improve the ability of the future US government to pay for the program anyway. So we'll be back at this doing the same thing in no less than 10 years.

Naturally this means that the "law is on my side" argument is stupid. The law will have to be changed, even in the limited sense because the law itself "promises" to make changes at some point.

Only fair. You beat me to it recently on this same topic.

? Sloan-Kettering is the best Cancer-treatment hospital in the world.

Doesn't even matter. My view is the view in the entire neighborhood.

Yea Obama! He deserves a day off.

Oh okay, I have a great webpage you can check out:

http://en.wikipedia.org/wiki/Patient_Protection_a…

I believe it was passed. Not that sure though.

How does that reply at all on topic to the post I just made here? All you're doing there is listing the provisions of the bill.

Which I have already said does not answer my criticisms of either the bill itself or the situation as it was prior to its passage.

Barack Hussein Obama, Harry Reid, Nancy Pelosi and the rest of that insane bunch need to be put into an insane asylum . . . They fit the 5150 criteria – they are a clear danger to themselves and others! (If you don't believe me, just look what they have done to poor innocent little Jared) o.0 :p

Oh lighten up Jared, it ain't personal . . . Its just that I cannot understand how someone with your obvious level of intelligence could fall for all that garbage!

papadawg, the future tells us that the younger generation, my generation, will not have a steady job. We will instead move from job to job with few-year intervals. This bill means that we don't have to worry about having to afford payments of $600 a month or so and having to worry that the insurance companies will try to f*ck us over. This is a good bill, and even the teachers at my college are preaching it.

Okay Jared. What college is that? We already know you're in NYC. And WHY are they for it? Are they perhaps liberal arts professors? Is their college massively subsidized by government funding or just indirectly so through massive government education grants (more of which were latched onto this bill.)

Better yet, watch this.
http://www.youtube.com/watch?v=Yfk7h2TrR_s

Seriously, I'm almost contemplating applying to get into mensa (and hoping it really is different there, because if it's not then I just might cry.)

Then perhaps our respective generations should make more of an effort to be trustworthy and keep jobs instead of being lazy, shiftless people who feel like we're entitled to what we'll never get, and then we could afford it. Just a thought.

Or at least not rely on the idiotic notion that your health insurance therefore your access to health care is somehow dependent on your job.

I'd settle for that if we cannot break the molding that says insurance is necessary to have health care at all.

Jared, if your generation would take a hard look at investing in a career – like all other successful people have done in the past – instead of trying to get to the top by the leapfrog method, then you would not have to worry about making insurance payments.

What the teachers at NYC college are not telling you is that when government gives you something not only does government have to take something away from someone else, but that YOU now become beholden to that government for the rest of your life. It really is not about healthcare at all, it IS about government control over the individual from cradle to grave. Those that founded this country believed (as I do) in the individual, and that each individual is responsible for ourselves, and that means feeding and providing for our own health and welfare.

Freedom and Liberty are the most wonderful things, however, if you do not believe in yourself – that you are the best provider for you – then you will be destined to be a slave to your governments (and its greedy politicians) for ever.

It is your choice. I choose to be free. What will you choose to be?

Indeed, indeed. That would be good, too.

What would you consider a "free market" in a health care system?

Doctors set their charges to each patient based on their own (the doctors) overhead. You know, office space, equipment rental, employee costs, malpractice insurance, etc.

The highest cost to individual doctors and hospitals are malpractice insurance and employee wages and insurance. Just like any other free business. Why would you not call that a free market?

Doctors do not set their charges. Medicare (the government) and the insurance company sets their charges. Individual people receive prices if they must outside of these two methods of payment (public or insurance) but it is very rare that individual consumers have any idea ahead of time what prices will be for medical services. Imagine going out to buy a car without any idea how much it would cost and then tell me if you would still call that a free market.

Malpractice insurance accounts for less than 2% of the cost of being a doctor, with some exceptions in fields like anesthesiology. You should talk to more doctors rather than listen to talking points. Those costs are the highest for doctors in socialized medical countries like the UK as well. This is hardly proof that they are existing in a free market and enterprise.

I would consider it still a free market that encourages doctors to insure themselves against calculable risks, such as medical errors, but not one that the government requires it of them. The net effect of not self-insuring such risks is that you, as a doctor, are an idiot and may stand to lose millions of dollars of personal assets, and presumably your ability to earn new income as a doctor by being discredited in a very public legal fight to defend yourself. It should not be that you are in violation of the law. As an example of how this works, pretty much all doctors should have some sort of umbrella policy on themselves taken out in the event they get into a car accident and someone else is injured. That someone else, upon learning they are a doctor, regardless of their actual wealth and income, will attempt to sue their pants off on the logic that they can get more money out of a doctor than some hapless auto worker. It is stupid for a doctor not to defend themselves against litigation for some non-work related incident. But it is not legally required of them to purchase this type of insurance. Instead of the government making such a requirement to purchase malpractice insurance, their employer should and in fact it usually is their employer that does make this requirement first. Without needing a nudge from government.

If you're referring to paying unemployment insurance or OASI or workman's compensation coverage, then yes, that's required by the government. I'm somewhat ambivalent about these since they represent direct taxes on labour inputs, essentially paid in lost wages, rather than require someone to purchase something. I think they are probably reasonably smart things for employers to purchase for their employees, but I'd probably prefer just paying people more while they are working.

Ideally a health care free market would have the following principles to it

1) Transparent and open prices. I suspect this would lead toward more people purchasing primary care through some sort of planned price arrangement (a monthly retainer fee for example) rather than through a per procedure payment, but that's not required for a free market to function. It's just more efficient for doctors and patients in the health care market itself. This was the one provision of the health care bill I was happy about: it requires health care providers and employers paying for health insurance to disclose the full amounts of prices. One reason they weren't before was because of medicare and insurance price fixing (ie, price controls, hardly the hallmark of free enterprise systems).
2) Transparent or non-existent barriers to entry on both consumers and providers of health care. This would mean: no, or at least fewer, medical licensing laws and consumers could go to any provider of their choosing rather than only those which their insurer (who they often do not select) tells them to go to, much less who the government tells them they may go to. One potential outcome of this is the prevalence of "doc-in-the-box clinics" being set up to care for minor health care needs using nurses or medical assistants at lower cost than charging people to see the doctor when they have a cold, for example. Again, this is not required for a market economy, but would be a socially desirable outcome of one (essentially offering quality lower cost or discount treatment in the same way that generic drugs operate).
3) Most costs are paid by first party choices rather than third party transactions. Americans only pay directly about 11% of the cost of their health care. The rest is paid by someone else (although technically, "someone else" charges them in the form of taxation or deferred wages paid to benefits). Switzerland, by contrast, pays about 37%. Singapore pays around 75%. Both countries have universal coverage. We don't. I'd still say both places have more market oriented processes in their health care than we do and tend to produce better health care outcomes on most diseases and conditions (cancer being the primary exception), and both do so for far less money.
4) Insurance is purchased through private and direct consumer choice rather than choices imposed by employers because of tax benefits favoring employer benefits (a government intrusion into the free market).
5) Insurance or health care is not delivered solely or at least primarily through having a job and could be purchased by any individual (or family) at any time, such as in retirement or in between jobs.
6) Incentives are oriented toward health care treatment and recovery, the actual product desired by consumers, rather than mere health care procedures, which may or may not produce this more desirable product. Informational asymmetry means this will be sometimes impossible, but good clearinghouses of information on the quality of care or actual cost-benefit of medical procedures would be helpful here. These are difficult when a) patients are not the true customers because someone else is paying for their care and thus has their own evaluations rather than quality of care and b) the actual cost is undisclosed and cost-benefit analysis as well as comparisons with competition is rendered impossible.
7) Fewer price controls on prescription drugs and fewer tariffs restricting the sale of international drug production. Some constraints are imposed here by intellectual property rights laws (patents). The current bill cemented this constraint into existence rather than examining its market necessity on innovation.

Also: government does not mandate what insurance, as a product, should cover.

Uh, Sun Tzu, all I asked was what would you consider a free market in the health care industry . . . . . . .

This answer is almost as long as the government health care takeover bill that the messiah just signed . . . Please have patience with me as I try to find a thousand lawyers to help decipher this answer

In all seriousness, I really didn't mean for you to write a book on the subject. But thanks for all the effort as it was very informative.

Up until the other day we could purchase a health care insurance plan from private insurers on a private individual basis. However, it was always rather expensive.

Most employers in the U.S. are small business owners and as such have to purchase their own health care insurance. This bill will now put most small business owners out of business as their cost for health care insurance will skyrocket. These socialization ideas that Obama and his cohorts are doing will render this once great nation down to a third world status.

You're welcome. But you're still wrong That is not the answer because it implies we had a free market before. We did not. We were not even close to one.

Small business owners, if they are smart, will simply pay the fine and pass the cost of providing the health insurance to the federal government. It's usually going to be way cheaper to pay the fine than to provide health insurance. In many cases they could even give all their employees a raise to cover their costs of health care by buying it through the public exchanges and still come out ahead.

I am not saying this is an ideal policy change. But it's entirely rational for small businesses (at least those that didn't receive tax advantages in the bill) to do exactly as I describe here. If the government is handing out free money, or even cheap money (as in the case of having to pay a fine), then they may as well take it.

Put it this way then. Simply because either Obama or the Republican party or Glenn Beck or whoever claims we had a free market policy before does not make it so. It has to actually fulfill at least at some level the factors involved in a free market's theoretical design (ie the things I listed above that you claim to have trouble understanding. Which is unsurprising, most Americans don't understand or even study basic economic theory. You're hardly alone here).

Health care in the US did not and has not for decades resembled any of these tenets. No serious economist would think so, either from the left or the right. You don't need to find an Austrian economics or Chicago school disciple to think this to be the case. No outside observers (ie Europeans looking to adopt more market based policy or those Asian Tiger economies trying to design their own health care policies) thinks so either once they actually look at it. These are not good promising signs that we had a system worth preserving in the first place. It is arguable that we have further damaged it with this "reform", I'm inclined to agree on that point in some ways (I think we mostly cemented things in place more than changed anything though). It is however not arguable that this was somehow a haven of capitalism on health care policies and that we were preserving such a paradise from some parasitic socialistic intrusion. It wasn't and it has not been for a very long time free from such intrusions.

I see that. Thanks for the correction.

You cannot call something a "free" market when (I believe it is) half of the expenditures are from the government. That is a system run by the government in nearly every sense of the word. Nor would I consider a system where the government tells doctors they have to have insurance, hence driving up their costs, free. Perhaps we should reevaluate what we call a "free market."

Back in the late 1800's my great grandfather was a doctor . . . of sorts. He had a clinic that catered to those who had TB and other breathing difficulties. He was never a member of the fledgling AMA as he believed in preventive medicine and not reactive medicine. He was never controlled by any governmental pricing controls or even by what we now call medical insurance companies. His patients paid their own bills out of their own pockets. I have no idea how much good he did if he did any good at all. However, I believe that back then, it was a "free market" in his medical field.

You are correct in that I do not have an economists view on what a free market would look like, however I do believe that that sort of thing is nothing but being nitpicky about how we would count the apples and oranges instead of just being satisfied that the apples and oranges were counted in the first place.

In the end, the average working stiff (like me) just wants to be able to afford and control his/her health care costs. But we must never forget that there are some people out there who do not want to spend the money on things like that until it is too late. Having a government that forces everyone else to pay for this is just wrong in my not so humble opinion . . . but I have stated that many times before.

The fact that we had a free market back in the 1800's really doesn't prove anything about recent history. Just saying.

The fact is though that the average worker doesn't control their own health costs. The insurance companies and the government do, and that was true before this bill as well.

I know, and all that started with the advent of the Progressive Movement around the beginning of the 20th Century. My Great Grand Father went into the breakfast cereal business in 1902 after he was censured by the AMA.

Not quite. Utah for example had universal health care back when the Mormons ran the place in their private theocracy. Several states had health related controls and mandates in place long before federal style controls or unionized doctors. But the big problem in US free market health care didn't hit until WW2, when wage freezes (price controls) were circumvented by businesses offering health care as a perk and then in the later 50s when the Congress passed a tax benefit to employers for offering health care rather than paying wages. FDR and some early 20th century progressives may have wanted more central authority over health care among other industries, but they never got much. The "rules and standards" problem didn't become a major problem until lots of people began using employer insurance to pay for first dollar health care, rather than their own money (technically it was their own money, but it was disguised on the paycheck rather than disclosed as wages lost). This didn't happen until shortly before Medicare was passed (roughly 1954 was when most Americans received insurance through their employers, a decade later LBJ gets Medicare passed).

The problem goes back decades as a result, but unfortunately it can't be blamed on the progressives from the Wilson era, or the Roosevelt dynasty. Maybe Truman deserves some blame, and certainly the Eisenhower Congress (and Ike for signing the thing), and definitely LBJ for passing Medicare, and the War and FDR for rationing. But it's hard to say that the actual problems of medical free markets go back to 1902 unless you want to focus on medical licensing laws as the sole factor and problem.

This is not the common approach taken, but if that's the path you want to use, that problem actually goes back to the COLONIAL era, to Dr Rush and others, not the progressive era. They had medical licensing laws in the 1790s, not merely in the 1890s, and almost all medical licensing occurred at the state level, particularly in the resurgence of such laws in the 1870-80s, long before any Federal involvement or the progressive era's heady days of TR and Wilson.

I think my point here on the economics would be that it's fine to count apples and oranges as apples and oranges. The problem is counting things that AREN'T apples as apples. Which is how the presumption that says we had a pretty good system based solely or even primarily on market forces operates.

It's precisely claims like these that allowed people like Obama to take a position that it was those markets had failed and that reforms such as he proposed were necessary, supposedly to fix the markets. The failure was elsewhere, but the supposed market advocates (Republicans/conservatives) in the minority party never bothered to explain this or establish a coherent narrative over the problems with this view. Instead they expended useless energy defending Medicare of all things (one of the prime villains in the market based story), energy which will make the one utility I find for conservative politics obsolete by making cost containment in the bill fruitless. If Medicare cuts are now protected against by BOTH political parties they will never happen. Regardless of whether they're used to fund this bill or to cut our long-term deficit obligations, they are absolutely necessary, as are social security and defense spending cuts. All of these are untouchable according to most Republicans and conservatives. As well as doing still less productive things like making up stories about death panels, scaring people about rationing (as though it doesn't already happen or that somehow health care spending should be limitless and not conform to any economic theory whatsoever), and conceding the debate over rescission, thus rendering their objections to the mandates as equally pointless even before they bothered to complain about them (which was too late in the game).

No. But I can envision amendments being made in the future, which I am all for…

Republicans complained that they didn't contribute to the bill. They were probably hoping it was going to be killed because of their obstructionist policy, but when it passed, reality set in, and now, in order to get their ideas put in, they are going to have to write up separate bills… if the idea is good enough, it will be added. the reform bill was a start to fixing a broken system, but by far a solution

How would an amendment for this get made? You require 2/3s of Congress or 3/4 of the states to pass amendments. ERA has been sitting around waiting on those requirements for decades and that's a far less ridiculous amendment than anything ascribing a positive liberty requirement on government to ensure or provide health care in a Constitution largely composed of negative rights denied to the government.

I'm from the UK and I know our health care system leaves much to be desired but at least it means if you need treatment it doesn't matter how much money you earn, you can still get it. If you live in relative poverty not only are you likely to be in more need of treatment but also you need to be healthy just to work and maintain a decent standard of living. I know it creates huge amount of market failure but somehow anything else just seems unfair.

sorry I should have said government failure not market failure