"Republicans are learning an unpleasant lesson this morning: The only thing worse than having no health-care reform plan is releasing a bad one, getting thrashed by CBO and making the House Democrats look good in comparison. Late last night, the Congressional Budget Office released its initial analysis of the health-care reform plan that Republican Minority Leader John Boehner offered as a substitute to the Democratic legislation. CBO begins with the baseline estimate that 17 percent of legal, non-elderly residents won't have health-care insurance in 2010. In 2019, after 10 years of the Republican plan, CBO estimates that ...17 percent of legal, non-elderly residents won't have health-care insurance. The Republican alternative will have helped 3 million people secure coverage, which is barely keeping up with population growth. Compare that to the Democratic bill, which covers 36 million more people and cuts the uninsured population to 4 percent." - Alejandro from Bookmarklet

CBO document here [http://www.cbo.gov/ftpdocs...] - MikeAmundsen

Ouch. What is the GOP saying about CBO's analysis? - Christopher Chung

I was never under the impression that the GOP cared about getting more people health insurance. - ronin

Imagine my surprise. - ProsePetals (aka Denise)

all that squawking from the GOP about how poorly designed HR3200 is and then they do _this_? sheesh! - MikeAmundsen

GOP are only concerned about filling their pockets and protecting the rich, been true for over a century. - Joe Silence is silent

i'll be curious to see if the news outlets pay any real attention to the CBO findings or just continue to play the "he-said, she-said" game w/ both side spewing sound-bites at the interviewer. oohhh, how i wish US media still had a backbone.... - MikeAmundsen

The GOP only cares about CBO analyses that make the other side look bad... - Andrew C

I suppose this is true of all sorts of partisans, but the Democrats have both conservatives and liberals in the same party... - Andrew C

It's not Constitutional to force health care on people, and then to FINE them if they refuse. - Spencer

This is health care _insurance_, and I will start buying this line of reasoning once you guys also fight mandatory drivers' insurance. - Andrew C

Drivers insurance is defensible since its done at a state level and is a precondition only if you drive on the state's highways so it has an opt out, don't own a car or drive. There isn't really an opt out for the Federal mandate, other than extreme poverty. On the other hand the mandate has to be there since they want to force insurers to take people with preconditions, so people could wait until they get sick then demand insurance so the mandate discourages that. - Ed Millard

Unfortunately the mandate is also to force the young and healthy who are least likely to get insurance, if they don't get it from an employer, to increase the size of the pool and cut costs for the insurance for older and less healthy. In that roll it is kind of a big new tax on the young and healthy, many of whom probably don't have the extra income to pay it, since its nearly a second rent, mortgage payment. - Ed Millard

"since its done at a state level" - I have never gotten why this makes a difference. - Andrew C

Division of power under the constitution, allows different states to handle things differently based on the preferences and needs of their citizens. - Ed Millard

Yes, but...? It's not like people don't get ill or injured in all states. - Andrew C

Yea but there are trade offs to be made in how to best handle it, and there are pronounced differences between states on how big the governments role should be. Badly done mandates where there isn't regulation of the insurer or healthy competition can quickly result in skyrocketing premiums and big profits for insurers. Massachusetts insurance premiums are soaring since they put in mandates with bad cost controls. Its costing the state a LOT more than paying for emergency care for the uninsured did. - Ed Millard

Emergency care for the uninsured is a crummy health care plan for them... - Andrew C

Eureka! Let's scrap every form of health insurance altogether, ERs for the win! - Rene Wirtz

The Mass. plan has been a huge success in covering the uninsured, no argument, part of the reason premiums are soaring is there has been a huge surge in people demanding and getting care since they now have insurance, and its caused shortages in services. But if controlling runaway costs was one of the goals, which it is for fed reform, skyrocketing premiums is a fail. - Ed Millard

The illusion of insurance is people thinks somehow they aren't paying for their health care. If you just banked the premiums and self insured you would pay less for the same or better care. Health insurance especially from employers is a recent invention. It started during World War II when wages were controlled and employers did it to attract scarce workers. After World War II Congress made it tax deductible so tax payers subsidize employer insurance and it exploded, costs have also exploded ever since. - Ed Millard

"If you just banked the premiums and self insured you would pay less for the same or better care." Yeah, until you run into a catastrophe. Then you will likely have $5K to $10K (say) and be staring at a bill that starts at $20K easily and could go into six or seven figures. - Andrew C

The other problem with insurance is once people have it they and their doctor's immediately stop discriminating between the services they need and don't need, so they get too many tests and unnecessary services and balloon costs for everyone. Self insuring, with catastrophic insurance only, would rein in all the waste you see in the current system and in socialized care. People need to realiz "insurance" doesn't mean unlimited "free" care. Insurance works for rare tragedies, not for constant services - Ed Millard

I've never bought that claim. I live in Canada, a single-payer nation, and no one I know goes in for all sorts of unlimited free care. You know why? Because (1) it's a hassle and (2) it's not that fun to visit the doctor's. - Andrew C

Hell, how many insured Americans are pushing up the cost of health care in this way? - Andrew C

And the way it currently works is that doctors, edged on by insurance companies, are prescribing all sorts of unnecessary and expensive things like CT and MRI scans for health care issues that can be solved by drinking hot tea and staying in bed. - Rene Wirtz

Ed Thats a story as in that not true after 40 years dealing with Docs and Hospitals they have little time to play around with fee pumping and frankly most are honest people who don't game the system. The automaticv assumption that greedy folks are gaming the system comes from an interesting perspective - WarLord

I've seen the syndrome in most of my relatives who are on Medicare. One set of grandparents would go to the emergency room every month or two for not very serious issues. Step grandmother would request and get every possible test for every possible phantom condition imaginable. - Ed Millard

@Ed - do your relatives live in McAllen? (ref http://www.newyorker.com/reporti... ) - Andrew C

I don't mean to imply most health care workers are gaming the system, a few are but most are honest. But many are playing defensive medicine to avoid malpractice for failing to catch something, many doctors wont say no when patients press for services. Another pressure is hospitals need all the most expensive equipment to compete these days and then they have to pay for it, and the way to do that is to use it as much as possible. - Ed Millard

And why do doctors not refuse unnecessary treatments? Because it's better for them and the insurance companies. If the government can regulate spending, doctors will be a lot less easy-going on frivolous patient requests. - Rene Wirtz

The government does regulate doctors on Medicare services, they squeeze them hard and it results in many doctors refusing to take Medicare patients around here. One reason emergency rooms are so busy is they can't refuse anyone service so people go to them when they can't get in to a doctor's office. - Ed Millard

How much does EMTALA drive costs up, I wonder? I think that our current system with an unfunded mandate is simply unsustainable. Philosophically speaking, there are only two ways to go: abolish EMTALA and emulate the health care systems of developing countries where ambulance drivers have to make sure you can pay before they transport you to the ER, or actually provide a mechanism where hospitals will get paid for providing this level of care. The only way to do this is to make health insurance mandatory. - Victor Ganata

Again, if the government regulates that each doctor must accept Medicare patients that problem is solved, too, unless all doctors move to Hollywood or Miami Beach. - Rene Wirtz

You can't force a doctor to take more patients than they can see, in rural areas they are often over committed so they just stop taking all patients and at that point they start cherry picking. Even if you mandate insurance doesn't even mean people can get it since in rural and poor areas there already aren't enough doctors, they all flock to affluent suburban areas and specialties that are more lucrative than general practice. I'm pretty sure Mass. is pretty big in to shortages of doctors and services. - Ed Millard

People who support government health care don't see much beyond "free". They don't understand the impact on the majority of the country who have good health care. As usual, the government would rather screw everyone just to give more "free stuff" to their base. - Spencer

Rene, actually, I think a lot of doctor's accede to unnecessary treatments because, rightly or wrongly, they're afraid of getting sued. - Victor Ganata

@Victor: and there's that too. *sigh* Friviolous litigation is the bane of US society, I'm afraid. - Rene Wirtz

Not sure I really want to argue this one, its an impossible issue to solve. Everyone wants everything for nothing. As broken as our Congress is I'm doubting they will make anything better. Spencer the one catch here is the government is already subsidizing health care for employer insurance since its not taxed, so the people getting employer insurance are benefiting at the expense of people with no employer insurance which isn't fair either. - Ed Millard

The invisible hand forces doctors to see possibly more patients than they can handle well, though. With the drop in reimbursement rate (both from private insurance and from the government) and with the way the reimbursement rates are structured, the only way to survive is volume, volume, volume. Since procedures are so much better reimbursed than office visits and preventative care, is it any wonder we're spending so much money on possibly unnecessary CT scans, MRIs, angiograms, and prostate resections? - Victor Ganata

I used to have government insurance and I realized full well it wasn't free. I never opted or requested or urged my doctors to give me something if it wasn't absolutely necessary. This was an expectation that I understood growing up as a kid. Maybe I'm too practical. I have an aunt who wanted a hysterectomy and she shopped around until she found a doctor who'd do it, even though it wasn't medically necessary. But in my family she was the only one who was frivolous and I think these kinds of excess are only a very small percentage of people. Just means that doctors need to man up, and that insurance companies should not pressure their affiliated doctors to do medically irrelevant procedures. - Rene Wirtz

It would probably be easier for physicians to man up if there weren't malpractice lawyers lying in wait :D If anything, the insurance companies weed out a lot of the excess by denying unnecessary procedures. Unfortunately, what drives costs up are paranoid patients who insist that they get the testing and treatment they demand, damn the science, and doctors who are only more than willing to cater to such clientele because they know they'll get reimbursed well for all the procedures they do. - Victor Ganata

Here is a REALLY great, though long, article that gives a lot of fresh perspective on how broken health insurance is and how much it actually costs you over your lifetime. Not sure I quite agree on his proposed solution but he changes the whole basis for the debate, versus the tired rhetoric which is all you hear, http://www.theatlantic.com/doc.... - Ed Millard

It may need a few generations to actually make a change in how health care is perceived. - Rene Wirtz

Here's a good article that I thought was a good complementary piece to the Atlantic article, which starts from the same premise, but comes to a different conclusion http://www.newyorker.com/reporti... - Victor Ganata

Victor, its also patients are demanding lots of drugs and test that are being aggressively marketed to them by health care companies out for a profit. Its no accident nightly news on TV which seniors still watch, is saturated with ads telling seniors to demand drugs and tests. There are also a lot of kickback schemes where drug and medical companies are giving doctors incentives to push their products. - Ed Millard

Ed: agreed. I think health care in the US is not health care, it revolves almost exclusively around sales. And this has been going on for decades and to change this, you need to change the mentality of the people: health care isn't something you just buy. - Rene Wirtz

@Ed - that Atlantic article has been discussed several times on FF already. I'm not trying to shut you down here, just saying I for one have already read it and said my piece about it. ( http://friendfeed.com/paul... , http://friendfeed.com/silas21... ) - Andrew C

I agree, Rene. If we're serious about reining in costs, the only way to do that is to change our cultural approach to health care. If patients want more autonomy in making testing and treatment decisions, they need to be better educated, and understand the science behind the indications. This means physicians need to spend more time talking to their patients. The only way to make this economically viable is for time spent counseling patients needs to be seen to be just as valuable as procedures. - Victor Ganata

Andrew it was just for anyone who hasn't read it. You just can't get people to stop thinking health insurance for all is the solution for everything and that article is the one I've read that made the best case against that. People should pay for office visits and non life threatening care out of their own pockets so they value it, don't abuse it, and demand price competition. The problem with politician, on both sides, is they always take from some and give to others. - Ed Millard

The best doctor visit isn't just the cheapest, but the one that gets me out of there in the best health. That's not easy for most patients to discern very easily... At least, not over the short to medium term. - Andrew C

@Ed: i whole-heartedly support this: "...so they value it, don't abuse it." i have seen no clear evidence that "paying for ... out of their own pocket" is the best way or even an effective way, to achieve those ends. and i'm not at all ready to accept that "price competition" is a goal to be encouraged - esp. in when it comes to health. - MikeAmundsen

The problem is that there are a lot of people who think they have a good doctor because their doctor always gives them Demerol when they ask for it, and get pissed off when they pay good money and don't get their Demerol. - Victor Ganata

It is a cultural problem, like you said Victor, people are used to pay for the service they want. Now it needs to go back to people getting used to receiving the service they need. - Rene Wirtz

Costs simply won't go down unless there's an incentive to withhold unnecessary testing and treatment, and I don't think the average uninformed health care consumer can wield enough clout to do it. As much as I'm not a fan of insurance companies, and as much as I'm wary of expanding the government, that's one thing they can actually do. - Victor Ganata

Mike, you either have price competition, price regulation, rationing, or spiraling costs. None of them is ideal. In a perfect world you can just spend unlimited sums on health care, we practically already are, but at the rate health technology is finding ever more, ever more expensive treatments, you are going to have to ration one way or another. The current system rations whether anyone admits it or not. It rations it to people who can afford it or who get it for free thanks to the tax payers. - Ed Millard

Victor: in the US there are multiple profit-centers are at the heart of rising costs: drug industry, hospital care/supplies, insurance companies, legal services, doctors (smallest one). until _all_ are properly constrained, things will be bad - including the quality of care, not just quantity or availability. - MikeAmundsen

@Ed: the list you provide is non-exclusive - we have all that right now; and it's a mess. tech is not the problem. Moore's law applies to all forms of tech. profit-taking is the problem. lucky for those interested in profits, the health environment in the US has done a great job of perverting common market constraints (pricing, innovation, cost-control, etc.) and well-funded lobbying groups have done a top-notch job of preventing broadly effective non-market controls (regulations, fraud/abuse monitoring, legislated safety/innovation improvements, consumer protections, etc.). there is no "invisible hand" in this space and, because of the peculiarities of the environment ("price is no object, save my son" and "we don't talk about price to our patients, it's crass", etc.) there is not likely to be any market-driven guidance that works. rationing is not the issue, health is the issue on which to focus. i am not convinced that there is much profit to be made in that space. thus, i am not convinced that work done to improve market conditions will have any lasting affect on the problem. - MikeAmundsen

Tech is A problem, not THE problem. Mass. has the most expensive health care on the planet partially because it has the best, most expensive, best equipped medical centers on the planet. There are also new drugs, chemo in particular, that are staggeringly expensive, like $50-100K per treatment. A million people need $100K each, that is $100 billion. Who pays? Until and unless tech breakthroughs make care cheaper, not just better costs spiral, eventually rationing will kick in, our we go broke. - Ed Millard

@Ed: I understand about Mass. tech is not the cause in increased costs there, tho. Yes, there's lots of tech there, but that was there long before Mass started their insurance experiment. the tech didn't just "show up" recently.tech has already made care cheaper. however, the price has not gone down. and care has not improved. not because tech failed. care is quite good in most other countries and they have tech, too. costs are up in the US due to profit-taking, not technology. plummeting personal health is also creating spiraling costs and that's not tech-related, either. - MikeAmundsen

The price of tech is high because most of these things are large expensive objects which hospitals and health centers don't need a lot of. The demand just won't justify a price drop. An MRI scanner still costs a couple of million dollars. And Moore's law may actually be counterproductive in this scenario. I'm sure if hospitals still bought new 1.5 tesla MRI scanners, they'd be cheaper, but it's moot because everyone wants 3.0 tesla MRI scanners now. - Victor Ganata

Mike, Mass. health care was the most expensive in the world before their health care reform. The hospitals around Boston offer the best, most expensive treatments, care and equipment there is. Their health care reform just didn't stop their escalating premiums like some claimed it would, it seems to have accelerated it. Since more people now have to pay for insurance there are more people demanding more care because its basically free if you have to pay the premiums or Mass. pays them. - Ed Millard

One of the underlying principles of health care IS rationing. No matter how much money you spend, resources are still finite, especially time. So you invoke the principle of triage: the sickest who have the greatest change of being saved get most of the attention. Just go to any ER in the nation and you'll see this in action. HMOs and IPAs perform triage on a greater time scale: the more urgent cases where intervention can actually change the outcome get their appointments and referrals quicker. - Victor Ganata

Victor: yep - you got it. it's not the scanner, it's who has them and how the are (ab)used. and the cost of these services is not high, but the _price_ sure is. MRI and other similar items are a great example of how typical market forces just don't work in the health space. where i live i can't throw a rock without hitting a couple stand-alone private MRI services. more than one! just near me and i live in a suburban area. i've talked w/ folks at one of them. it's quite a profitable biz, they tell me. - MikeAmundsen

The group causing some of the biggest rises in costs currently are all the people who get "free" insurance through their employer. They completely don't get it that government is already subsidizing a third of their health care by not taxing their health benefits. Their employer subsidizes most of the rest but its still part of your benefit package so the money going to your insurance is money that otherwise would go to your salary. Nothing is free in health care but most people think it is. - Ed Millard

Gee, maybe those employer health insurance plans should start denying unnecessary treatment. - Andrew C

@Ed: srlsy? where are you finding this information. recent studies show the opposite is true ([http://www.time.com/time...] for a recent high-level view; [http://www.watsonwyatt.com/news...] for a more detailed version). employers are certainly paying more - even passing more to employees, but the amount of items covered continues to fall. payments to insurance companies is certainly up, but not because employees are mis-using the benefits. in fact, employees are paying more than even and getting less. - MikeAmundsen

Employer insurance is certainly shrinking recently but it was a prime mover in getting us to where we are today. I had it for most of my life, until I switched to self employed, and it looked for all practical purposes to be free. One of the reasons most of the plans in Congress now want to tax high end employer provided insurance is because it has been government subsidized for so long. Goldman Sachs gives their employees lush insurance coverage partially because its tax free. - Ed Millard

Tax free is a huge perk for people who do get it through employers versus people who pay taxes on their income and then have to buy insurance out of their own pocket and they pay more without the cost savings big companies get in group plans. - Ed Millard

@Ed: no question employer-based health insurance was a mistake - all the other industrialized countries rejected that idea, too. taxing benefits is just a feeble attempt to give cover the massive spending needed to try to make up for 60 yrs of lunacy - gonna be ugly. and Sachs is one of the outliers; hardly worth discussion here. our mess has nothing to do w/ their benie pkg (they get my wrath for other matters not pertinent here).. - MikeAmundsen

There is just irony that tax payers subsidize insurance for people making that much, and they are just worst case scenario, a lot of other big companies provide "free" health care to their very well paid employees with government subsidy. Its an extremely regressive tax to subsidize health care for moslty affluent workers while lower and middle income workers don't get insurance through their employer and get no subsidy. And I bet Goldman Sachs employees are complaining loudest about reform. - Ed Millard