Is it just me? health insurance related

[Mulletsoldier]

As am I. However if those behaviors are not criminalized in the safety net, or at least otherwise dealt with, it serves no purpose because it is just allowing the negligent to pass their costs on to society. If you are going to ask society to provide for your health, then society gets to say under what terms they will do so. If you remit freedoms when entering into a voluntary contract in the private sector, you surely must remit along the same lines when using the government to force others to cover you via public contract. Otherwise you are saying a private organization has the right to deny my coverage or charge more per risky behavior that I may have, but the publically funded system can't do the same thing.

I see your point, but the issue here becomes: if coverage is stringently regulated in the safety net - presumably a safety net for catastrophic events, massive accidents, things entirely beyond the control of the citizen - then having it serves no purpose. In reality, it would be muddled with philosophical and practical issues.

Philosophically, "criminalizing" inherently personal behavior at the federal level is a de jure if not de facto claim by the government to restrict your personal freedoms how it so chooses. Arbitrarily allowing a government to decide what constitutes "risky behavior" also means that any Tom, **** and Harry special interest group with a moral opposition to this or that behavior can lobby the government into changing the safety net how it sees fit.

Practically, having the exact same or similar restrictions in the Government-mandated safety net as the private sector has one logical conclusion for a giant segment of the population: it would not only disincentivize the use of the single-payer safety net, but of health care as a whole. If I am some low-income Plumber Joe deemed to partake in "risky behavior" by both the Government and the private-sector, why would I pay to be denied? I would either: a) take my chances with the safety net, hoping to not be denied, or; b) I would remit healthcare as a whole. Sure, for certain segments of the population an option c) is always attain a better coverage, for a higher premium, but this again defeats the purpose of the safety net as a whole. Again, sectoralizing behavior with generally accurate but specifically inaccurate predictive systems means nothing more or less than institutionalized oppression and cluster-****, not unlike what we have now.

In order for a safety system to be of any real logical or practical consequence, it would have to be Universal. Without being universal, the tyrannical regulation of personal freedoms vis-a-vis special interest groups would be rampant; as many or more people would be left without coverage as the current system; and we would give the government the right to say, "You can do this but not this and that". Considering Canada spends 10%/GDP on a universal system and American pays 15%/GDP on Medicaid/Medicare now, a safety net that would provide the following basics is feasible:

• restricted physician visits
• restricted hospital stays
• restricted transport - i.e., ambulance travel only when necessary
• only life-saving or major surgery - i.e., only life/death situations

This means the free-market is free to disseminate health care however it so chooses via voluntary contract, and provide better service; however, it also means that discrimination is not systemized.

Where do you think all the risky people will go and 'demand' their 'right' to health care? That's another apsect of US context you may be missing, the welfare rights movement that happened in the sixties and seventies. You see, 'assistance' was usually there in some form or another, but frowned upon. Women on 'assistance' used to have to agree to things like having no make callers. Welfare offices used to make an effort to contact relatives and get them to contribute to a claimant rather than stick them on the public dole. Then the welfare rights movement began and encouraged people not to look on public assistance as shameful, but a right one should be glad to claim. They taught people how to overwelm welfare offices so as to avoid scrutiny and get their case through easily. They changed the very fabric of the US culture to where we now have a permanent underclass who not only received near permanent assistance from the government, but thinks it's their right to receive that assistance and that it's a good thing.

I don't know if you've had a similar movement in Canada, but this one swept the US a while back and changed a lot of perceptions vis a vi public assistance.

No, I am aware of the context of public assistance in a contemporary debate. As I said, I have no qualms with my Canadian system, but: if the citizens of my country voted for an a la carte system, I would have no philosophical qualms with that either; provided the business practices of the insurance providers were utterly transparent.

 

[CDB]

IPhilosophically, "criminalizing" inherently personal behavior at the federal level is a de jure if not de facto claim by the government to restrict your personal freedoms how it so chooses.

Not necessarily. If the criminalization is dependent on taking public funds then there is no prior restraint and it is a matter of choice, as with any other policy which may impose restrictions.

Arbitrarily allowing a government to decide what constitutes "risky behavior" also means that any Tom, **** and Harry special interest group with a moral opposition to this or that behavior can lobby the government into changing the safety net how it sees fit.

True, which is one of the reasons for the eventual failure of such systems.

Practically, having the exact same or similar restrictions in the Government-mandated safety net as the private sector has one logical conclusion for a giant segment of the population: it would not only disincentivize the use of the single-payer safety net, but of health care as a whole. If I am some low-income Plumber Joe deemed to partake in "risky behavior" by both the Government and the private-sector, why would I pay to be denied? I would either: a) take my chances with the safety net, hoping to not be denied, or; b) I would remit healthcare as a whole

Or, stop the behavior. It seems to me what you're getting at is that some people will fall through the cracks, choose not to have coverage, etc. Yes, that will happen. So what? Universal coverage is impossible, even in a system with universal coverage. Someone always falls through the cracks.

Sure, for certain segments of the population an option c) is always attain a better coverage, for a higher premium, but this again defeats the purpose of the safety net as a whole.

No it doesn't. The purpose of the safety net is to provide a last ditch option for the truly desperate and down and out, not to ensure universal coverage. As such a disincentive to use it must be built in. If it's not, people will default to it more and more until it is all that remains.

Considering Canada spends 10%/GDP on a universal system and American pays 15%/GDP on Medicaid/Medicare now, a safety net that would provide the following basics is feasible:

That ignores one of the reasons for the spending difference: more abundant supply here.

No, I am aware of the context of public assistance in a contemporary debate. As I said, I have no qualms with my Canadian system, but: if the citizens of my country voted for an a la carte system, I would have no philosophical qualms with that either; provided the business practices of the insurance providers were utterly transparent.

Good luck with that one, should it ever happen.

 

[Mulletsoldier]

Not necessarily. If the criminalization is dependent on taking public funds then there is no prior restraint and it is a matter of choice, as with any other policy which may impose restrictions.

I see your point here, but you also need to take into consideration the nature of choice itself. The choices involved in a system like this, both from the end-user and policy level, are much more complicated than choosing where you want to eat cheeseburgers.

Or, stop the behavior. It seems to me what you're getting at is that some people will fall through the cracks, choose not to have coverage, etc. Yes, that will happen. So what? Universal coverage is impossible, even in a system with universal coverage. Someone always falls through the cracks.

Exactly. So if this is the case, than the proposed safety net would eat capital like a Cookie Monster, with no practical consequence. It either has to be Universal, or not at all. As I say below, I mean "universal" in application, not coverage.

No it doesn't. The purpose of the safety net is to provide a last ditch option for the truly desperate and down and out, not to ensure universal coverage. As such a disincentive to use it must be built in. If it's not, people will default to it more and more until it is all that remains.

I understand the thrust of the argument, but do you take into consideration how dangerously arbitrary this becomes. Who gets to decide who is "down and out"? You, me, the government? It is riddled with possibilities for tyranny and systematic oppression of whatever group the group in power so happens to disagrees with, which is why I am surprised you would support it. I agree it has to be last ditch, but a last ditch to be accessed by anybody. The point of the restrictions means that, whatever the person intends to do, they are only allotted so much from the safety net. You used up all your doctor visits? Too bad; buy coverage then.

That ignores one of the reasons for the spending difference: more abundant supply here.

That is certainly one of the arguments.

In reality, I really don't disagree with too much of what you are saying.

 

[EasyEJL]

The fact that the politicians can blithely throw around numbers like 1.6 trillion over a decade to only cover 25% of the people they say so desparately need coverage to me proves 2 things a) our politicians are idiots b) we need to work on the other elements of the healthcare system to where costs are more realistic. I still have no comprehension though as to why the government plan's cost is roughly 3x what I pay for healthcare including what my employer pays.

 

[Mulletsoldier]

a) our politicians are idiots b) we need to work on the other elements of the healthcare system to where costs are more realistic. I still have no comprehension though as to why the government plan's cost is roughly 3x what I pay for healthcare including what my employer pays.

:head:

 

[CDB]

I see your point here, but you also need to take into consideration the nature of choice itself. The choices involved in a system like this, both from the end-user and policy level, are much more complicated than choosing where you want to eat cheeseburgers.

Not necessarily. In both instances it's a matter of which option serves your desired ends best.

I understand the thrust of the argument, but do you take into consideration how dangerously arbitrary this becomes. Who gets to decide who is "down and out"? You, me, the government? It is riddled with possibilities for tyranny and systematic oppression of whatever group the group in power so happens to disagrees with, which is why I am surprised you would support it.

I wouldn't if there was another way, but there isn't. In the end someone has to make a decision somehow, and what you're saying at root is you want to have a political solution but have it be apolitical in nature. Not going to happen. There are, as always, checks and balances and what not, means for assuring some kind of fairness in application. But the bottom line is you can't expect a lack of politics from a political system. Yes it has the weaknesses you describe, but that weakness is inherent to the system itself and can't be eliminated, which is why people must be disincentivized from using it as much as possible.

I agree it has to be last ditch, but a last ditch to be accessed by anybody. The point of the restrictions means that, whatever the person intends to do, they are only allotted so much from the safety net. You used up all your doctor visits? Too bad; buy coverage then.

Which is one of the reasons why I say a means test and payment post service is necessary. If instead of paying into a general fund and budgeting people had to pick up the tab yearly at the state level say, they'd be much more inclined to pick at every case and only let in people who really need the service. What's more, they're also far more likely to try and reclaim payment from those who used the system but really didn't need to. Say Joe Shmoe gets an operation and it turns out he slipped through, was perfectly able to afford his own coverage and just didn't have any. Well, Joe is having his wages garnished until he pays his bill.

My way of approaching such programs is to first know why they fail and to try and limit that. Why these programs fail is overuse and lack of economic accountability (profit/loss test), plain and simple. As such what needs to be avoided is an ever expanding budget and lack of regard for costs. The nature of the system is irrelevant at that point. The key parts of the policy must be aimed at transparency of actual cost to tax payers, which means no general fund or budget of any kind, disincentives to use the system in general which means whatever standards are maintained in the private sector, the public option must be less accountable for quality, and the margin people 'earn' from using the system, such as what a doctor gets paid for doing a procedure on the public dole, must be less than what he earns in the private sector.

That's the crux that few people get. To make such a system work in a place like the US where, unlike in Canada, it will or would otherwise be subject to massive demand, is to design it so people really don't want to use it, even those on the margins. Key to that is not forcing the population at large to pay for it beforehand, and freeing up the private sector and defining the public option in relation to that sector as always the worse of the two choices. If your health is a nail to be driven and the private sector offers a hammer, the government can only offer an awkward rock to use, and charge for it only after it's used.

 

[Mulletsoldier]

Not necessarily. In both instances it's a matter of which option serves your desired ends best.

Definitely, but boiling down choice as a pick-'em scenario between two extreme options shallows the nature of choice as a whole. Choice is either absolute, or to the extent where it is relevant, it doesn't exist; and so, the government's de jure claim to regulate personal freedom enters.

I wouldn't if there was another way, but there isn't. In the end someone has to make a decision somehow, and what you're saying at root is you want to have a political solution but have it be apolitical in nature. Not going to happen.

I can see how you would take this as the gist of my argument, but it's not what I am saying at all. Wherever politicizing activity has the opportunity to occur, it will occur; therefore, your only option is to reduce opportunity for politicization wherever you can, cognizant of the fact it is still bound to occur. There are only two options that will even marginally remove opportunity from a political system, then: a) level the criteria of the thing you are applying, or; b) do not apply at all. Any other type of system will lead us directly back here.

Which is one of the reasons why I say a means test and payment post service is necessary. If instead of paying into a general fund and budgeting people had to pick up the tab yearly at the state level say, they'd be much more inclined to pick at every case and only let in people who really need the service. What's more, they're also far more likely to try and reclaim payment from those who used the system but really didn't need to. Say Joe Shmoe gets an operation and it turns out he slipped through, was perfectly able to afford his own coverage and just didn't have any. Well, Joe is having his wages garnished until he pays his bill.

And I see your reasoning here, and agree with it, but it fails to address something major: a la carte does not mean on-demand, and therefore these doctors, EMTs, emergency staff, secretaries, janitors and so forth are still being payed, even if they are not working. Assume that this system and everybody using it are de novo: no yearly-collection has occurred, so who pays the attendant staff? In this scenario, tax consumption is still occurring by staffing these non-for profit institutions, but the opportunity for political abuse is still rampant.

I like your ideas of wage garnishment and the other disincentivizing options, but simply disagree in its application. I think averaging the amount of common health-related circumstances - GP visits, ambulance rides, days in hospital, and so on - and then offering restrictions slightly below that number disincentivizes the use of the safety net; as well, it provides even less opportunity for abuses of the system. The best option to ensure at least a marginally fair application, and reduce opportunities for abuse, both from a policy and end-user standpoint, is to level the criteria and provide a less attractive service than the private-sector will offer. In this respect, we are not submerging the drowning any further; you are not allowing people to drown whomever they disagree with; but you are also not giving them a tax-consuming lifeline in every situation.

That's the crux that few people get. To make such a system work in a place like the US where, unlike in Canada, it will or would otherwise be subject to massive demand, is to design it so people really don't want to use it, even those on the margins. Key to that is not forcing the population at large to pay for it beforehand, and freeing up the private sector and defining the public option in relation to that sector as always the worse of the two choices. If your health is a nail to be driven and the private sector offers a hammer, the government can only offer an awkward rock to use, and charge for it only after it's used.

Agreed, we only disagree in its application.

 

[CDB]

I can see how you would take this as the gist of my argument, but it's not what I am saying at all. Wherever politicizing activity has the opportunity to occur, it will occur; therefore, your only option is to reduce opportunity for politicization wherever you can, cognizant of the fact it is still bound to occur. There are only two options that will even marginally remove opportunity from a political system, then: a) level the criteria of the thing you are applying, or; b) do not apply at all. Any other type of system will lead us directly back here.

I disagree. Option A is not really an option. 'Leveling' is just your political opinion as to what's reasonable. The nature of the system is political and politicization of the issue is unavoidable, period. If the government is involved, the issue is by default politicized. There's no way to avoid that.

so who pays the attendant staff?

No staff is maintained. Handle the procedures as a jury pool. Joe needs an operation and the state agrees to cover because he really is in need and deserving etc., you get picked, your institution handles it, submit a bill for services rendered and the state pays. No need to maintain staff, no need to keep a budget. Case decisions made the same way. Send them to doctors who are picked at random from a pool. Service is compulsary. Not ideal, but it's the only way to avoid budgeting.

I like your ideas of wage garnishment and the other disincentivizing options, but simply disagree in its application. I think averaging the amount of common health-related circumstances - GP visits, ambulance rides, days in hospital, and so on - and then offering restrictions slightly below that number disincentivizes the use of the safety net; as well, it provides even less opportunity for abuses of the system.

That's the point of it, to disincentivize use.

The best option to ensure at least a marginally fair application, and reduce opportunities for abuse, both from a policy and end-user standpoint, is to level the criteria and provide a less attractive service than the private-sector will offer. In this respect, we are not submerging the drowning any further; you are not allowing people to drown whomever they disagree with; but you are also not giving them a tax-consuming lifeline in every situation.

The application will be unfair by nature, no way to avoid that. When you say leveling the criteria I get what you mean, but here's the issue: no matter how leveled the system is, some putz will come out of the woodwork, or some snot nosed theoretician, is going to come up with some possible hard luck case that your system would let fall through the cracks. It's called irrational exclusion and inclusion. Put simply, name the welfare program, and we'd all be able to point to people who abuse the system and don't really need it, and people who we could get almost universal agreement were in genuine need but didn't qualify for some reason or another. This is why the tendency is to widen the net to catch more and more people, when eventually it catches everyone.

By nature the system will be imperfect, any and every system will have irrational exclusions and inclusions. In order to keep the growth of the system in check one must accept this and thus the fact that some people will get screwed. The only other alternative is to progressively widen the net until there are no exclusions at all. And even then people will fall through the cracks or not get help they need and deserve, such as because of shortages and what not.

To sum up, you can't avoid politicization of the issue or the criteria, nor can you truly level the way it's applied to make sure all who need help, get help. Attempts to do so merely widen the net when the necessary pressure to apply is really the other way, to narrow it. Meanwhile the politicized nature of the system itself serves as a deterent to use, forcing more people to accept their responsibility to insure themselves at their own cost.

 

[Mulletsoldier]

I disagree. Option A is not really an option. 'Leveling' is just your political opinion as to what's reasonable. The nature of the system is political and politicization of the issue is unavoidable, period. If the government is involved, the issue is by default politicized. There's no way to avoid that.

I agree, and as I said, "therefore, your only option is to reduce opportunity for politicization wherever you can, cognizant of the fact it is still bound to occur." This is a far more maintainable and viable option than giving politicians the opportunity to restrict and exclude whoever they desire. Opinion and subjectivity always exist, and you can only minimize them. Which is why 'Option A' and 'Option B' are the only viable ones: they either give limited access to all or access to none, which are as binary as logically possible when dealing with humans.

No staff is maintained. Handle the procedures as a jury pool. Joe needs an operation and the state agrees to cover because he really is in need and deserving etc., you get picked, your institution handles it, submit a bill for services rendered and the state pays. No need to maintain staff, no need to keep a budget. Case decisions made the same way. Send them to doctors who are picked at random from a pool. Service is compulsary. Not ideal, but it's the only way to avoid budgeting.

As I see it, convening attendant staff on an ad hoc basis would be nothing more than bureaucracy followed to its painful and absolute conclusion; and the costs of convening these committees and pooling doctors would be excessive. Where would the doctors, staff, transport, institutions, etc., stem from? If none of these necessities are permanently state-run, we only have one logical source: the private sector; and, as you know, the private sector is not going to give up any of its provisions to the state. The logical conclusion is unnecessary cost in convening these individuals ad hoc, coupled with the extremely high costs of "borrowing" them from the private sector [the only solution they would allow]. Not only does compulsary service trample the rights of the citizens paying for the services of these doctors, the bureaucracy involved would most likely equal the cost of permanently staffing these individuals. Leading us to see that no safety net, from a consumption perspective, is most likely preferable to an ad hoc one.

To sum up, you can't avoid politicization of the issue or the criteria, nor can you truly level the way it's applied to make sure all who need help, get help. Attempts to do so merely widen the net when the necessary pressure to apply is really the other way, to narrow it.

Precisely, but: this would unfortunately allows the state to politicize and pander ad nauseam. There are no perfect systems, only those that are effective at reducing bias, and those that are ineffective at reducing bias. Allowing politicians to decide what constitutes "risky behavior" means nothing more or less than oppression, and you know this to be true. The fact is, removing access-criteria removes as many opportunities as possible for the "net" to by systemized for bias, and removes the opportunity for this or that special interest group to change the criteria at will.

That's the point of it, to disincentivize use.

Yes, I was agreeing with you there brother, which is something you may be missing. The safety net has two purposes: a) to disincentivize the citizen from its use, and b) to provide effective care for those that actually need it. Building access-criteria into the program ensures that biased politicians and special interests groups will never allow b) to truly happen; and having an ad hoc system means that a) will never happen, considering North Americans have not always been the most responsible when it comes to, "Have now; pay later". (see: recent destruction of the financial market.) Allotting, say, five hospital nights, five GP visits, five ambulance trips [whatever these numbers are predictive to be in the mean] and absolutely no more is certainly an effective disincentive as any [if people know they have five visits bar none, they will most likely put them to good use]. Further, not putting restrictions on whom exactly can access these services minimizes special interest group ****ery. Are things bound to occur, where people fall through the cracks; special interest groups crack through; abuse occur, etc? Yes, of course. However, they pose to be substantially less in this type of system.

 

[CDB]

I agree, and as I said, "therefore, your only option is to reduce opportunity for politicization wherever you can, cognizant of the fact it is still bound to occur." This is a far more maintainable and viable option than giving politicians the opportunity to restrict and exclude whoever they desire. Opinion and subjectivity always exist, and you can only minimize them.

That's the thing, you can't. Think about it: what objective measure is there of who should and will get someone else's money? The only objective measure is voluntary trade and the price system which inevitably gets built. What you consider unpoliticized is to the next person totally politicized, and to the person next to him perhaps moderately politicized. Or in other words and whether by design or not, totally politicized. There is no objective criteria to be had when you're trying to bypass the pricing system, which is the only way to turn subjective values into socially relevant and objectively comparable cardinal numbers. Beyond that measure, which tells you if something is 'worth it' or not, there is only ethics and morals.

As I see it, convening attendant staff on an ad hoc basis would be nothing more than bureaucracy followed to its painful and absolute conclusion; and the costs of convening these committees and pooling doctors would be excessive. Where would the doctors, staff, transport, institutions, etc., stem from?

The private sector. For example, you're a doctor working in hospital X. A requirement of doing so in society, just as all citizens must do, is registering for the public call. Society decides Joey need his knee replacent, you're the randomly selected doc, which means you're it for now.

the private sector is not going to give up any of its provisions to the state. The logical conclusion is unnecessary cost in convening these individuals ad hoc, coupled with the extremely high costs of "borrowing" them from the private sector [the only solution they would allow].

Agreed, it is a form of slavery or at the very least involuntary indenturement. So what? So is jury duty. Seems to function okay and not crowd out the market for private arbiters. Once more I think you're missing the real danger, which is a permanent and maintained public option. Like a standing army, the end result of a standing medical complex will be an ever expanding tendency to use it, ever expanding budgets, ever expanding safety nets, etc. In order to function with minimal risk to the private sector the public option can't get a foothold. It must be convened when necessary and essentially destroyed after every action and rebuilt when needed.

Not only does compulsary service trample the rights of the citizens paying for the services of these doctors, the bureaucracy involved would most likely equal the cost of permanently staffing these individuals. Leading us to see that no safety net, from a consumption perspective, is most likely preferable to an ad hoc one.

The same argument would then have to apply to jurors, and we should therefore maintain a permanent pool of professional jurors.

Precisely, but: this would unfortunately allows the state to politicize and pander ad nauseam. There are no perfect systems, only those that are effective at reducing bias, and those that are ineffective at reducing bias. Allowing politicians to decide what constitutes "risky behavior" means nothing more or less than oppression, and you know this to be true. The fact is, removing access-criteria removes as many opportunities as possible for the "net" to by systemized for bias, and removes the opportunity for this or that special interest group to change the criteria at will.

(see: recent destruction of the financial market.)

Here is where you're going wrong though, let me explain my reasoning. It is the existence of a permanent over supply of cash and credit that caused/fueled the problem in the first place. Without the existence of The Fed and FDIC we couldn't have had this recent financial calamity. However, maintaining a permanent official Second Guessing The Market complex, otherwise known as The Fed, lead naturally to its use and eventually its abuse.

Same with public education. The existence of a permanently funded complex lead to its eventual growth and crowding out of private alternatives. In a very real way you're trying to have your cake and eat it too. By establishing a permanent public option, budgeted and funded, you've already crossed the control lines necessary to stop its eventual burgeoning growth and collapse.

The reasons for this are many. One, having a resource available without cost restrictions, of which there are none in government programs of this type, means the resource will always be overused. Attempts to budget will therefore always come up short from what people want from the system and thus will always grow. Two, permanent complex means empire building. The incentive is to bring in more people and money to show your competence to govern and move up the political ladder. Three, despite over use, economic inefficiencies means you will have within the system strange surpluses. The incentive will not to cut those, but to use them. Four, you've forced a default first purchase. The most basic axiom of economics is the law of demand. For any homogenous good value declines with each additional unit added to supply. A permanent complex means a permanent budget, which means a tax burden. What you are doing is forcing a 'first purchase' of health care on the part of the whole tax paying population regardless of the want in doing so and any utility they get out of it. This means you are automatically providing a disincentive to use the private sector.

This last point needs to be illustrated, the best analogy I know of is cars. Say the government decides everyone needs the ability to commute. Most of us can afford it on our own, but there are forty million perpetually carless people out there who for whatever reason aren't caught by the existing mass transit system and so supposedly can't commute. A car tax is thus instituted and a permanent agency is established to get cars to the needy. A portion of the tax payer's money goes to run this agency, and they know it. Within that population are car buyers but more importantly marginal car buyers. Those are people who are sort of on the fence to one degree or another. Could buy a car, not sure of it though. Or bought a car, but hey not really a necessity. The existence of this group of people, and it is a perpetual group, means demand on the agency's services will only go up over time. And the fact that these people are paying into this service's existence and have a proportionately lower income because of it means they are much more likely than otherwise to use the system to get a car. It is this group of perpetually existing marginal users and the incentive to use the system created by charging them for it regardless of use that leads to the ever increasing demand on government services.

It is because for any given set of market conditions there is always a group of people on the margin of buying service X who will forego the private option a take the public route because: 1, they're already paying; 2, because of 1 they have less income. What's more, their first purchase is always lower than market because the population at large bears the cost. Under normal circumstances in order to be incented to buy two cars for example, you'd buy one and, for the exact same year and model as a second purchase, would be willing to buy only if the price were much, much lower or your need was truly great enough to justify the second purchase and you could afford it. Most people don't need two cars, it's the kind of purchase where you tend to buy one and be done with it. As such when the public system offers you a purchase at X and the private system offers a purchase at much more than X, you've automatically biased a significant portion of the population from going for that second purchase. If the government offers you a new Civic at $2000 bucks because the population at large is covering the price difference, there are going to be a hell of a lot fewer people willing to pay the private dealer 13K for a base model.

This affect snowballs and you get a situation where the majority of the population is for all practical purposes dependent on the public option, and the private market has shrunk in a distorted fashion such that the only people willing to use it are those who are willing to make that 'second purchase', who are willing to pay far more, and who have the dollars to back it up. Or in other words The Rich. And the second you turn a public service into a permanent fixture, that's the unavoidable tendency. Look at public education, a perfect example. It followed this pattern mercilessly to our current situation, even though no official nationalization of education took place. Look at public transit in places where demand actually manifests: cities. Who are the only people who can really afford to drive and park their own cars in cities? The rich. The rest of us walk, take subways or cabs. For the poor to lower class there publically subsidized options are the only real ones, the subways and bus routes. The permanent establishment of a public health care system will lead to the same inevitable result unless serious and massive disincentives to use it, or more correctly to use it and to provide it, are in place. That latter is key, because it is the increased incentive to rely on the public option coupled with the diffuse costs that allow its expansion beyond reasonable limits that lead to this eventualy result. As such there need to be disincentives to use and to provide, the latter being totally destroyed by the establishment of a permanent, budgeted system.

 

[Mulletsoldier]

That's the thing, you can't. Think about it: what objective measure is there of who should and will get someone else's money? The only objective measure is voluntary trade and the price system which inevitably gets built. What you consider unpoliticized is to the next person totally politicized, and to the person next to him perhaps moderately politicized. Or in other words and whether by design or not, totally politicized. There is no objective criteria to be had when you're trying to bypass the pricing system, which is the only way to turn subjective values into socially relevant and objectively comparable cardinal numbers. Beyond that measure, which tells you if something is 'worth it' or not, there is only ethics and morals.

Yes, but allowing politicians to ascribe the label "risky behavior" to this or that group does two things you may be missing: a) destroys the price system [still a public option] just the same, by allowing non-experts to determine insurability and; b) provides even more opportunity for systemized discrimination. As I say, the system is political by nature, but as I see it, your option is inherently predisposed for abuse.

In the private sector, the insurance premiums would ostensibly be a calculation of risk: the higher propensity 'population x' displays for 'behavior y', the higher their premiums will be. While certain cultural, religious and ethnic factors are bound to be ignored in private risk-tiering, discrimination is bound to be pushed to the margins in the pursuit of profit. However, determining risk on the political level means nothing more or less than the destruction of the price system as well as systemized bias; both defeating the purpose of the safety net. The only solution is to eliminate risk-tiering for the public option.

The private sector. For example, you're a doctor working in hospital X. A requirement of doing so in society, just as all citizens must do, is registering for the public call. Society decides Joey need his knee replacent, you're the randomly selected doc, which means you're it for now

The question was rhetorical. "If none of these necessities are permanently state-run, we only have one logical source: the private sector."

Agreed, it is a form of slavery or at the very least involuntary indenturement. So what? So is jury duty. Seems to function okay and not crowd out the market for private arbiters. Once more I think you're missing the real danger, which is a permanent and maintained public option. Like a standing army, the end result of a standing medical complex will be an ever expanding tendency to use it, ever expanding budgets, ever expanding safety nets, etc. In order to function with minimal risk to the private sector the public option can't get a foothold. It must be convened when necessary and essentially destroyed after every action and rebuilt when needed.

While I agree your logic is relatively sound here, the possibility for the practical application of a constantly dissolved public option is non-existent. One of the things you seem to be missing is the frequency and banality of most healthcare uses makes an ad hoc system both impractical and expensive. Your logic most certainly applies for open heart and brain surgery, for example, but what would the protocol be for general physician visits? It is neither feasible nor affordable to convene a general physician each time Joe Plumber has a cough. If you wanted to convene and dissolve the public option, the only viable route would be to make the compulsary service durational: have 'Doctor A' serve 8-12 weeks, at which point he returns to the private sector.

The logistics and bureaucracy involved in this ad hoc system would be astronomical, and the only way to display this is to run through it logically. The selection for other compulsary services - the military in wartime and jury duty - are done at complete random. For wartime military, a draft of eligible soldiers is made and each individual is conscripted based on nothing more than eligibility; likewise [depending on specific state/municipal law] juries are selected relatively at random and then screened for bias. In each case, this haphazard selection of fleeting membership is necessary for different reasons. In the case of the military, it is quite frankly necessary due to the number of soldiers necessary for a large scale war. In the case of jury duty, probability selection is necessary to arrive at a diverse and relatively unbiased collection of individuals, for the sake of a fair trial. In both situations, these random-public options to provide non-experts in the respective fields are feasible for four reasons:

a) There is no [large-scale] market for either soldiers or jurors in the private sector. As neither professional juror or soldier pools are maintained, the selection of each does not infringe of the contract rights of a paying customer in that specific market - i.e., aside from the obvious [transient] loss of labor power - which is obviously more substantial in the wartime scenario - the market effects do not reverberate. As well, the random selection from non-associated labor markets means that business owners are not weary of their specialized labors being conscripted to complete the same task for free elsewhere.

b) The infrequency of both criminal trials necessitating a panel-jury and wars large enough to require conscription. This is the key point where your system runs into the most logistical nightmares. It is only the very infrequent nature of war and jury duty themselves that make compulsary service the viable option. In every other situation aside from major criminal trials, where a panel of objective observers is necessary to disseminate evidence amongst themselves, the public selects experts in their respective fields of law to try cases. This is done in both the pursuit of objective justice - having a jury of 12 random individuals observe anti-trust laws is anything but objective; the complexity of the law necessitates experts - as well as for feasibility.

c) Expertise is not necessary for either position. Because neither a soldier or a juror is expected to be versed in the art of war or art of law respectively, random selection is an entirely acceptable option. However, as I said, the vast majority of legal situations require an arbiter [a judge] who is innately familiar with the law.

d) A combination of the previous three: there is no price system for determining the value of a juror or officer. The interplay between the supply and demand of any good and the labor consumed in its making determine its nominal value. In the case of jurors and officers, neither are present. On the one hand, no labor is consumed in the specific makings of a juror or officer, as [usually] you do not deliberately train for either. On the other, supply and demand are irrelevant when the obligation of your service is de facto. As a result, the government can arbitrarily determine the value for services rendered as an officer or juror.

Now, I have outlined these scenarios to display that selecting physicians, surgeons, cardiologists, etc., etc., in this manner is both unfeasible and dangerous. The expertise required to practice medicine in each specific field necessarily means that random selection is impossible. In order for this safety net to be of any practical consequence, deliberate selection committees would have to be convened; but again, we run into issues there. Who would comprise these selection committees? Surely we would not allow politicians with absolutely no knowledge of medicine whatsoever to determine which doctors have the requisite expertise for each situation - that is preposterous. So who, then? If more doctors from the private sector are to be conscripted for selection committees, than even more private-sector man hours are lost to this complicated system; if politicians do it, the probability for death, serious injury and so forth could not be understated. I agree its use needs to be discentivized, but this is not the way.

On an economic note, the market effects would be both broad and deep. In the most basic sense, compulsary doctor-service provides a disincentive for both business owners and doctor-laborers. Prospective investors would be detracted from starting operations in the private healthcare sector knowing their human capital can be appropriated at anytime; and likewise, students are disincentivized from becoming doctors knowing that they may be conscripted for service in this specific field. Obviously, given the excessive demand for healthcare services in the United States, this type of convening would happen ad infinitum. Again, your opinions here surprise me. This type of conscription is nothing more or less than a de jure claim by the government to appropriate healthcare contracts at will: the free market ostensibly continues unabated, but only as a guise when the government can eliminate any contract in fascist-esque manners. Obviously, this type of system completely delegitimizes the valuation of a doctor in the private sector. Unlike a juror or officer, whose values are arbitrarily determined by the government, a doctor's value is determined in the market itself. Undermining this valuation on a consistent basis would disintegrate the free market's valuation of doctor-goods as a whole.

A far more logical option is to simply maintain a scaled-down, permanent public option that does not appropriate provisions and laborers from the private sector. Now, I realize you feel "scaled-down" and "public option" are mutually exclusive, but I digress.

These are simply inherent and unavoidable problems of conscripting professionals from already existent, high-demand private markets. Not only do the logistics bare this situation impossible, but the sheer destruction of rights across the board make it entirely undesirable.

The same argument would then have to apply to jurors, and we should therefore maintain a permanent pool of professional jurors.

I disagree. Again, I think you are overlooking the issue of frequency and type of service rendered here.

Here is where you're going wrong though, let me explain my reasoning. It is the existence of a permanent over supply of cash and credit that caused/fueled the problem in the first place. Without the existence of The Fed and FDIC we couldn't have had this recent financial calamity. However, maintaining a permanent official Second Guessing The Market complex, otherwise known as The Fed, lead naturally to its use and eventually its abuse.

Yes, I agree. However, the the Fed artificially introducing liquidity - and subsequently market uncertainty - would be the exact same as the ad hoc public option artificially modulating supply/demand by removing laborers from the market at will. The nominal price for any service at any one time would be massively skewed if the supply is in constant artificial fluctuation.

One, having a resource available without cost restrictions, of which there are none in government programs of this type, means the resource will always be overused. Attempts to budget will therefore always come up short from what people want from the system and thus will always grow.

I definitely agree with your reasoning here, which is why use of the program is restricted. By offering 'X' amount of each service in a specific quantity, expectations are irrelevant; only what is being offered is relevant. Will public pressure come to expand the program? Yes, of course. However, it would be no different in the scenario you are proposing - such is the nature of the entitled citizen.

Four, you've forced a default first purchase. The most basic axiom of economics is the law of demand. For any homogenous good value declines with each additional unit added to supply.

Yes, exactly. And this is precisely why an ad hoc system would have disastrous consequences on the market. The value of any particular doctor is measured by the labor consumed in his production [school], the complexity of his work, and the demand for his type of labor. This is why a heart surgeon makes more than a general physician, for example. Removing doctors from given positions ad infinitum means constant artificial fluctuations in supply and demand. The price system would be skewed further if you had pathologists performing the duties of a physician, and so on, which would be bound to happen. Natural valuation of the doctor-service would give way to a de facto valuation instituted while the government is plucking doctors from here or there.

What you are doing is forcing a 'first purchase' of health care on the part of the whole tax paying population regardless of the want in doing so and any utility they get out of it. This means you are automatically providing a disincentive to use the private sector.

I completely agree. However, the exact same concept applies when 'customer A' pays for 'service Y' from a certain doctor, but that doctor is conscripted to perform the same service on a consumer of the safety net. The money 'customer A' invested in 'service Y' is lost and non-recuperable, and payed for 'service Y' to be performed on the safety net consumer via proxy. What motivation does 'customer A' have to use the private sector when the government can complete negate the contract 'customer A' has with his doctor at any time? If your doctor can be conscripted to work on the public dole at any time with no foreknowledge, the obvious choice is to simply get on the public dole yourself.

As I say, the far more viable disincentive is to provide extremely limited access to the public option: five GP visits, five ambulance rides, etc., etc., Knowing that you may not be able to get to the hospital during a heart-attack b/c you consumed your allotted visits is a far better deterrent than having your wages garnished. And, even if by your logic the public option is more attractive, the restricted use means the vast majority of users will have to seek private means anyway.

 

[EasyEJL]

the only viable route would be to make the compulsary service durational: have 'Doctor A' serve 8-12 weeks, at which point he returns to the private sector.

Thats kind of interesting, a "National Guard" of medicine program (if you are familiar with the US Army National Guard program)

 

[Mulletsoldier]

Thats kind of interesting, a "National Guard" of medicine program (if you are familiar with the US Army National Guard program)

Yes, that is actually what I was thinking of. IMO, that is the only feasible way for a system that conscripts and then dissolves its members to operate. It would mean that conscription is predictable, durational, and in a certain respect, less detrimental to the private sector. If, say, a healthcare-institution owners knows that his top physician can be commandeered for only 8 weeks at a time, once a year, he will not be so weary of the investment in the doctor. If you felt that at any time your assets can be appropriated by the government, what incentive do you have to attain assets? In this case, assets being doctors.

 

[EasyEJL]

Yeah, thats not a bad idea, could be possibly less time, even same structure as national guard - 2 days a month plus 2 weeks 1 month out of the year. And thats the price you pay to be able to practice private medicine the rest of the year.

 

[Mulletsoldier]

Yeah, exactly. This durational type of system addresses the constant need for doctors while avoiding the logistics of an ad hoc system. It would be a system I could technically agree with.

It would also ensure more accuracy in conscription, insofar as the proper doctor going to the proper institution, for the proper position. Each doctor is in a specific 'class', and the durations for each 'class' are determined based on the necessity and frequency of their work. A general physician, given the frequency of his work, would serve more time, whereas a open heart surgeon would serve less compulsary time. More people have colds more frequently than Angina, so it makes sense.

 

[CDB]

Yes, but allowing politicians to ascribe the label "risky behavior" to this or that group does two things you may be missing: a) destroys the price system [still a public option] just the same, by allowing non-experts to determine insurability and; b) provides even more opportunity for systemized discrimination. As I say, the system is political by nature, but as I see it, your option is inherently predisposed for abuse.

There is no such thing as nonabuse though. What you're saying is your opinion of what qualifies is more 'objective' and 'acceptable' than someone else's. Well that's your opinion. Since it's a political system by nature, and just as much their money funding this thing as yours, they have a vote and can use it too. The flip side of what you're saying is 'some' people can't have a say in how their tax dollars are spent. If one guy because of his opinions doesn't want "them faggots" to get help I understand your objection. But his vote is no less valid than yours, his dollars worth no less than any other tax payer's, and his ability to influence the system no more rightfully restricted than anyone else's, annoying and idiotic as he may be.

In the private sector, the insurance premiums would ostensibly be a calculation of risk: the higher propensity 'population x' displays for 'behavior y', the higher their premiums will be. While certain cultural, religious and ethnic factors are bound to be ignored in private risk-tiering, discrimination is bound to be pushed to the margins in the pursuit of profit. However, determining risk on the political level means nothing more or less than the destruction of the price system as well as systemized bias; both defeating the purpose of the safety net. The only solution is to eliminate risk-tiering for the public option.

Quite the contrary, discrimination is the name of the game here. If insurance companies find that a preference for pogo sticks is correlated with high cancer risk, you can bet your ass there will be a pogo stick premium to pay. Same for anything associated with race, sex, religion, etc. Certain Jews are healthier and longer lived than caucasions, they'll be paying less than me because of their ethnicity. That's life. You're going beyond eliminating risk tiering though. In a private setting that means take it or leave it, do business with someone else. By limiting input into the public system you are implicitly modifying the voting franchise and restricting the access rights of some people to the political system because you are not giving them a say in how their money is spent.

While I agree your logic is relatively sound here, the possibility for the practical application of a constantly dissolved public option is non-existent. One of the things you seem to be missing is the frequency and banality of most healthcare uses makes an ad hoc system both impractical and expensive. Your logic most certainly applies for open heart and brain surgery, for example, but what would the protocol be for general physician visits?

Exactly the same with perhaps a logistic aspect. Doctor X gets pulled for duty, he has to devote a certain block of time over the next week or two to satisfy his obligation to the system. Any case he gets during that time that needs follow up falls under that obligation.

It is neither feasible nor affordable to convene a general physician each time Joe Plumber has a cough. If you wanted to convene and dissolve the public option, the only viable route would be to make the compulsary service durational: have 'Doctor A' serve 8-12 weeks, at which point he returns to the private sector.

That's the idea, but it needs to be case based. IE, Joe Plumber has a cough, doctor X serves on his case until said cough is gone or until he gets handed off to other practitioner because it's more serious. If Joe has lung cancer, doctor X serves until Joe gets handed off to his public oncologist.

The logistics and bureaucracy involved in this ad hoc system would be astronomical,

Whereas the logistics and bureacracy of a permanent institutional type system would be simple and straight to the point, with a minimum of paperwork and a maximum of possible output...

To a certain extent Medicare/Medicaid already work along the lines I'm laying out, doctor's serve at the patient's time of need and bill the system. However instead of doctors submitting their bills the systems would get to essentially requisition space and service time too. The key issue is there can be no permanent budget or facilities. Once that's in place, there's no stopping the growth.

a) There is no [large-scale] market for either soldiers or jurors in the private sector.

Unknown actually. There has been a monopoly on these services for a long time. However a read through The Myth of National Defense would go a good way toward showing that there has always been and likely always will be a healthy market for Mercs. Jurors would be, my guess, no different, if the need were left unsatisfied by the state.

b) The infrequency of both criminal trials necessitating a panel-jury and wars large enough to require conscription. This is the key point where your system runs into the most logistical nightmares. It is only the very infrequent nature of war and jury duty themselves that make compulsary service the viable option. In every other situation aside from major criminal trials, where a panel of objective observers is necessary to disseminate evidence amongst themselves, the public selects experts in their respective fields of law to try cases. This is done in both the pursuit of objective justice - having a jury of 12 random individuals observe anti-trust laws is anything but objective; the complexity of the law necessitates experts - as well as for feasibility.

The problem here is even if you are right, the initiation of a permanent public institution does nothing to increase the supply of doctors and/or health care in general either. So the same problem still exists under any proposed system. However under my system there is minimal interference with the private market and thus minimal institutional resistance to increasing supply over time.

d) A combination of the previous three: there is no price system for determining the value of a juror or officer.

None has ever been allowed to develop. That doesn't mean there isn't a price for it, it just hasn't been discovered.

The interplay between the supply and demand of any good and the labor consumed in its making determine its nominal value.

Not correct. The value assigned to labor and capital flow backward from what the price of a good is, nothing has inherent value. The interaction of supply and demand on the market is what leads to market prices if that's what you're saying. But if there is no demand for something it doesn't matter what the cost of production of it was, it's worth zilch.

In the case of jurors and officers, neither are present. On the one hand, no labor is consumed in the specific makings of a juror or officer, as [usually] you do not deliberately train for either. On the other, supply and demand are irrelevant when the obligation of your service is de facto. As a result, the government can arbitrarily determine the value for services rendered as an officer or juror.

No, it can't actually. What it can do is make the cost of noncompliance high enough that it over rides the value of skipping out. The value of a juror can only be determined by getting rid of the current system and seeing just what people would be wiling to pay to have a professional jury system. Such a system isn't unheard of through history though it is rare. But a juror is in effect no different than a private arbiter of some kind with slight differences in what would be expected from them.

The expertise required to practice medicine in each specific field necessarily means that random selection is impossible.

Then all government licensing must be thrown out. If being licensed and certified to be a cardiologist doesn't make one fit for entry into a pool to be randomly called on for heart surgery, then it's even more useless to have licensing that I've thought up until now. It's not like we're dealing with a bag with every conceivable doctors and specialties in the world in it and we're going to call Jim the Proctologist to do heart surgey. Jim will deal with the ass, someone else will deal with the heart. As such qualifications should already have been dealt with. At most a convening of said doctors might be necessary to be added to the list of callable doctors for X services.

On an economic note, the market effects would be both broad and deep. In the most basic sense, compulsary doctor-service provides a disincentive for both business owners and doctor-laborers. Prospective investors would be detracted from starting operations in the private healthcare sector knowing their human capital can be appropriated at anytime; and likewise, students are disincentivized from becoming doctors knowing that they may be conscripted for service in this specific field.

Incorrect. This is true of the system you're advocating, not mine. In mine doctors get paid market price, or slightly below. The marginal limits of anyone's decision making process can't be known. However, being paid slightly less than you would have otherwise earned isn't going to offer a massive disincentive to the profession to provide service. It is how they are paid and mnore to the point who and how the bill is presented to that is important. If there is a public option like you want you have a pool of docs there and they necessarily lower the salaries other private docs can pull. There is no avoiding this. However if you leave the market alone and when the docs are pulled for service they are paid roughly what they would have otherwise earned for the same work in the private sector, there is no major disincentive in place. A little, yes. That's unavoidable. But the nature of my system minimizes that.

Obviously, given the excessive demand for healthcare services in the United States, this type of convening would happen ad infinitum.

The convening isn't an issue, if you're qualified you're in, if not, you're not. If you're a practicing doctor in this field - GP, cardiology, proctology, etc. - you're viable. And there is no excessive demand here. There are shortages thanks to obstacles to raising supply. Key difference.

Again, your opinions here surprise me. This type of conscription is nothing more or less than a de jure claim by the government to appropriate healthcare contracts at will: the free market ostensibly continues unabated, but only as a guise when the government can eliminate any contract in fascist-esque manners. Obviously, this type of system completely delegitimizes the valuation of a doctor in the private sector.

My plan does not such thing. Yes, it impresses people into service. No government program to provide health care can avoid this, that is the nature of any government system that redistributes supply. Someone is always going to be working against their will. In my system the value is determined on the market. When and how society at large gets the bill is the main difference along with what doctors you can go to. Right now doctors have a choice as to whether or not to accept medicare or medicaid, permanently budgeted forgovernment plans. I take away that choice, pay them market or just a bit under, and leave the budgeting off so the whole bill with no means for hiding costs is presented to the tax payers after the fact and as is, so their true tolerance for offerring such health care can be assessed, and so no marginal users are incented to use the public system as opposed to the private.

A far more logical option is to simply maintain a scaled-down, permanent public option that does not appropriate provisions and laborers from the private sector. Now, I realize you feel "scaled-down" and "public option" are mutually exclusive, but I digress.

They can start that way, they can't end that way. In any event, what will you pay the doctors in the public option? Full market value I hope. If not, how do you plan to get good doctors? If not, how do you plan on maintaining quality, or will you accept lower skilled doctors, or impress the higher skilled into service for prices they don't find adequate? How would you stop such a system from growing in perpetuity? However you ration service, there is no historical record anywhere anytime of any such government program that hasn't progressively grown. How would you short circuit the 'forced first purchase' issue that incents marginal users to head for the public option in perpetually greater numbers over time?

Yes, I agree. However, the the Fed artificially introducing liquidity - and subsequently market uncertainty - would be the exact same as the ad hoc public option artificially modulating supply/demand by removing laborers from the market at will. The nominal price for any service at any one time would be massively skewed if the supply is in constant artificial fluctuation.

Supply and demand are always in fluctuation and prices are supposed to be changing. That's their purpose. My system doesn't change supply or demand, it just changes the conditions under which one may use the public system, how it is accessed, and how it is billed.

Yes, exactly. And this is precisely why an ad hoc system would have disastrous consequences on the market. The value of any particular doctor is measured by the labor consumed in his production [school], the complexity of his work, and the demand for his type of labor.

It is only the latter which in the end determines his value. A heart surgeon makes more than a GP not because of his schooling or such, rather heart surgery is more specialized which is why he goes to school to get that training to earn more. All values flow back from the price, not the other way around. If there were a sudden glut of heart surgeons on the market because of a weird health kick on the part of Americans, their prices would drop like rocks regardless of their specialized knowledge and the cost of their schooling.

I completely agree. However, the exact same concept applies when 'customer A' pays for 'service Y' from a certain doctor, but that doctor is conscripted to perform the same service on a consumer of the safety net. The money 'customer A' invested in 'service Y' is lost and non-recuperable, and payed for 'service Y' to be performed on the safety net consumer via proxy. What motivation does 'customer A' have to use the private sector when the government can complete negate the contract 'customer A' has with his doctor at any time? If your doctor can be conscripted to work on the public dole at any time with no foreknowledge, the obvious choice is to simply get on the public dole yourself.

You are assuming exclusivity of contract which does not exist in my system and never exists in reality either. Just as your doctor does not have to stop serving you to serve any other customers, he does not have to stop serving you to serve any customers the state throws his way.

As I say, the far more viable disincentive is to provide extremely limited access to the public option: five GP visits, five ambulance rides, etc., etc., Knowing that you may not be able to get to the hospital during a heart-attack b/c you consumed your allotted visits is a far better deterrent than having your wages garnished. And, even if by your logic the public option is more attractive, the restricted use means the vast majority of users will have to seek private means anyway.

What you are describing though is merely rationing, and it doesn't work to limit the problems associated with establishing a permanent public service. There's always going to be someone who doesn't need all the rationed service but takes them anyway, and someone who legitimately has a claim to say more than 5 ambulance rides and who dies as a result. This type of denial of service is exactly what is trying to be avoided. And what you seem to be trying to avoid is passing society the bill they say they want to pay.

 

[CDB]

Yeah, thats not a bad idea, could be possibly less time, even same structure as national guard - 2 days a month plus 2 weeks 1 month out of the year. And thats the price you pay to be able to practice private medicine the rest of the year.

Durational would be a bad idea as that would affect supply. If doctor X has to 'serve' during this time period or that and nothing else, you get problems. However our current system works more reasonably and I just suggest a modification: doctor X has to be on call and accept randomly assigned patients - appropriate to his field of course - at market price. His time is no more or less occupied than if that person came to him with the same problem with private insurance.

The real issue is billing, the establishment of permanent bureacracies, etc., and budgeting. Budgeting is the enemy of cost constraint in government. The only way to really restrict a service is make the bill unpredictable and transparent. So, at the end of the year when the ta payers get hit with a bill for X, they then say, "Holy ****, we spent that much? We need to restrict access, say here, here, and here..." However establishing a permanent bureau to deal with the issue in terms of facilities and doctors on call will only get you the same result as our education system, everyone in public except those who can afford to pay a lot more for their own option.

 

[Mulletsoldier]

I avoided quoting, as our verbatim quoting is becoming a bit excessive; and so, I will leave you with this. The economic theory of your plan is well and good, but it will fail on prima facie examination due to a few basic, yet fundamental realities. The first one being that your system requires something which by definition cannot exist: a self-organizing, self-sufficient, and self-dissolving bureaucracy. Bureaucracies are by definition externally formed, externally maintained, and externally dissolved. (And by externally, I of course mean external to the profession/service/market at issue.) Unless the doctors in your system spontaneously organize and assign themselves to case studies, and subsequently return to the private sector unabated, a large amount of oversight is necessary to properly organize your system into a functioning social institution - i.e., a bureaucracy will eventually be formed around it. Where will this oversight come from? Of course, from nowhere else than a state-run bureaucracy which knows absolutely nothing about medicine. What does this produce? It produces waste, inefficiency, poor quality product, a complete decimation of rights - on the level of the business owner, the doctor, and the end user - and ever-rising costs from the cluster-fuck that would most certainly ensue. (All things existent in my system, but at least the right of choice is maintained.) It will also produce nothing more than the expansion you dread, which leads one to the choice that permanently establishing a limited-access public option would have been easier in the first place.

Second, it will fail due to the inevitable backlash the private-sector will unleash on the government from having their human capital appropriated at will. The voluntary contract on the private sector becomes irrelevant when the U.S., government can pluck your doctor at the precise time you need him to complete another task; and unfortunately, that is the ugly reality of the system you are proposing. The inherent advantage of a primary-private system is increased patient-to-doctor access, increased quality of care, decreased waiting times and so forth. All these things are externally dismantled by the random assignment of pay-later patients to doctors, or vice-versa. It completely disincentives the use of the private sector, and will only make people wonder, "Well why I am first-paying these higher premiums, when they are getting my doctor for "slightly below" market value? I will just renege my contract and get on the dole myself!" At least in my system, access is restricted as opposed to unlimited-pay later, which means that, despite their intentions, the public is restricted to a certain amount of visits.

Third, it will not work because conscripting from private markets is impossible. Conscription only works because the government holds monopolies where conscription is necessary/desirable. In the case of our hypothetical, government does not hold a monopoly, and conscription is therefore a poor idea for all the reasons mentioned above.

Fourth, it assumes that the wage-bill is the only aspect of his/her job a doctor is concerned with. Almost every opinion poll surrounding job satisfaction in this industry does not list wage as the most important factor; instead, autonomy is the more desirable trait, and I would say this holds for most occupations. Removing this to a large extent certainly disincentives prospective doctors. When the government says "when, where, who and how" they will serve, autonomy is lost. This becomes especially problematic when juxtaposed against the possibility for absolute autonomy in our private-sector hypothetical. In my system, they are at least given the choice to serve publicly. (Which many do anyway.)

Finally, it completely ignores the factors that make a doctor proficient at his/her job: personal relationships, attention-to-case, and a thorough knowledge of a patient's medical history. Bouncing patients around from doctor-to-doctor produces nothing more than a broken system of misdiagnoses, malpractice and lack of safety. Meaning what, exactly? Two things: a) those who actually need help do not get it, and; b) economic waste. This inefficient system would end up costing more than a permanent public option, in which case one should ditch it entirely.

If this system was instituted for a wide-range of other services, it would certainly work; however, for medicine, it is a poor choice.

 

[CDB]

I avoided quoting, as our verbatim quoting is becoming a bit excessive; and so, I will leave you with this. The economic theory of your plan is well and good, but it will fail on prima facie examination due to a few basic, yet fundamental realities. The first one being that your system requires something which by definition cannot exist: a self-organizing, self-sufficient, and self-dissolving bureaucracy.

Prima facie it succeeds. The market is, essentially, a self organizing, self dissolving bureacracy. Self sufficiency isn't required. As with any government program I merely suggest redirecting existing resources. I just do it in a way to limit dependency and disincentivize use of that redirection. Little to no oversight is necessary beyond the oversight already provided for and which has come about naturally. At most what needs to be handled is billing.

There will be no backlash anymore than there is now. As long as doctors are getting market rate there need be none in the future either. What backlash will be, will be where it should be, with those who are paying the bill restricting services further until they are happy with the deal they are getting. And the system I proposed does not negate your or anyone else's right to contract with a doctor of their choice anymore than the current system does. It's not like your doctor will be halfway through your heart transplant and say, "Oh ****, sorry, I have Medicare duty. I'll get someone else to tidy up..." That's ridiculous. Joe Plumber has no insurance, he's deemed worthy for government help for whatever hard luck reason, doctor X's name is pulled from a hat as appropriate for what Joe needs checked out, Joe goes to Doctor X, tax payer gets the bill. Since when is it possible for a doctor to only take one patient? My doctor has multple patients. So does his doctor. The people he shares his practice with have multiple patients. Exactly where does this objection come from where somehow a doctor who is chosen to administer care under my proposed system somehow disappears into a black hole, never to be seen again apparently?

This your oddest objection because, to be blunt, it makes no sense whatsoever. How is Doctor X seeing Joe for an appointment on the tax payer's dime any different from you seeing Doctor X on your dime? More specifically, why does the former totally and abolsutely stop Doctor X from seeing anyone else for some minimum time period while he has absolutely no problem carrying a multiple patient load with the latter situation?

(All things existent in my system, but at least the right of choice is maintained.)

Only quoting a couple of things because they need to be specifically addressed. One is your system guarantees the wrong choice will be made. Your system shorts out the pricing mechanism. That is the only way to make rational economic decisions as to what resources to assign where. Once this system is gone all economizing action stops, overuse is the inevitable result. You can't make rational decisions absent a pricing system, which is why I don't touch the price system in my model.

The inherent advantage of a primary-private system is increased patient-to-doctor access, increased quality of care, decreased waiting times and so forth. All these things are externally dismantled by the random assignment of pay-later patients to doctors, or vice-versa.

You have yet to explain how this would happen.

It completely disincentives the use of the private sector, and will only make people wonder, "Well why I am first-paying these higher premiums, when they are getting my doctor for "slightly below" market value? I will just renege my contract and get on the dole myself!" At least in my system, access is restricted as opposed to unlimited-pay later, which means that, despite their intentions, the public is restricted to a certain amount of visits.

And you've completely missed the point. They don't pay the premium until after care is delivered. That is one of the key aspects of my plan. Couple that with the built in disincentives to use the public option to begin with such as the vetting and approval process including the means test, possible wage garnishment and pay back being gotten once the tax payers get the bill, etc., and you get reduced demand for the public option. Having a permanent established alternative to which people can turn, and for which in their minds they have already paid for through taxes, is what causes marginal cases to tip more and more into the public option.

Regarding your third point, there is no place where a monopoly is necessary or desirable, nor are there special circumstances under which conscription is a better option. The issue isn't even the nature of the system, it's how it's paid for, by whom and when.

Fourth, it assumes that the wage-bill is the only aspect of his/her job a doctor is concerned with. Almost every opinion poll surrounding job satisfaction in this industry does not list wage as the most important factor; instead, autonomy is the more desirable trait, and I would say this holds for most occupations.

Then systems should perform fine when not based on compensation. Quite frankly I find such surveys bullshit. They remind me the economists who used to claim we lived in a post scarcity world, but who upon asking refused to tear up their paychecks, indicating that just maybe scarcity was still an issue in the modern world. But, it sounded nice at the time, like the 'right' answer. As does saying salary isn't your main concern at your job. Fine, take it way and try to pass off 'autonomy' as a person's compensation for work. You'll find out pretty quickly how little they give a **** about autonomy and how much they desire to pay next month's rent. Even granting this problem, you could make registration as a possible charity doctor voluntary then. Even if not, I don't buy this objection at all. I know in my current business were they to have some random work sent their way by the government to do at market rates they wouldn't turn it down in good times or bad, it's guaranteed income.

As for the other factors that make a doctor proficient, that's one of the trade offs you get when using the public system and a further disincentive to use it over having your own GP. Per the misdiagnosis part, incorrect. Doctors would still be responsible for their actions under my system. Same for safety/malpractice. And it would certainly not end up costing more than a permanent public option because of the cost control of being a tax payer and actually having to pay a bill that isn't yours.

If this system was instituted for a wide-range of other services, it would certainly work; however, for medicine, it is a poor choice.

The rules that govern economics are not incidental to the market sector or specific product or service. They either do or do not apply in all cases. As such what is true for rubber dog crap is true for heart surgery.

 

[Mulletsoldier]

In saying I wanted to avoid excessive quotation, I meant just that. At any rate, this will be my last essay-length post.

Prima facie it succeeds. The market is, essentially, a self organizing, self dissolving bureacracy. Self sufficiency isn't required. As with any government program I merely suggest redirecting existing resources. I just do it in a way to limit dependency and disincentivize use of that redirection. Little to no oversight is necessary beyond the oversight already provided for and which has come about naturally. At most what needs to be handled is billing.

No, it does not. You have not provided a viable explanation for several things which are necessary for your plan, and all necessitate bureaucracy: a) How a patient is determined 'worthy' by the state; b) who decides what condition he has; c) who decides which doctor he should go to; d) who decides which doctors are selected; and so and so on. Your plan runs into logistical nightmares, and is rife with begging its own questions. If the state assigns a patient to a doctor, but a doctor is initially who diagnoses a condition anyway, how do they assign a patient to the right doctor? Answer: they do not. They most likely assign the wrong patients to the wrong doctors and vice-versa.

What you are proposing is in no way self-regulating or forming, because it is dependent on state oversight to in the first place redirect the resources to the customers, and then go about distributing cost. You are trying to have your cake and eat it too: have something which depends on bureaucracy not be a bureaucracy.

This your oddest objection because, to be blunt, it makes no sense whatsoever. How is Doctor X seeing Joe for an appointment on the tax payer's dime any different from you seeing Doctor X on your dime? More specifically, why does the former totally and abolsutely stop Doctor X from seeing anyone else for some minimum time period while he has absolutely no problem carrying a multiple patient load with the latter situation?

You misunderstand. It is the exact same which is precisely the point. Why would I pay my premiums up front for exclusive care - the point in having a private sector - when any Tom, **** or Harry can get my services rendered on either; a) a dollar I help to provide; b) his own dollar which he need not provide until later, or worse yet; c) a combination of both. It absolutely makes the private sector irrelevant when the public accesses the same doctors, at the same rates, with the same waiting times. And yes, patient load affects quality-of-care which is why private hospices and hospitals in the States offer a higher quality of care than your public hospitals; if they did not, there would be no purpose in going to them.

You have yet to explain how this would happen.

Yes, I have.

And you've completely missed the point. They don't pay the premium until after care is delivered. That is one of the key aspects of my plan. Couple that with the built in disincentives to use the public option to begin with such as the vetting and approval process including the means test, possible wage garnishment and pay back being gotten once the tax payers get the bill, etc., and you get reduced demand for the public option. Having a permanent established alternative to which people can turn, and for which in their minds they have already paid for through taxes, is what causes marginal cases to tip more and more into the public option.

No I did not, and you need to take more care in reading. The point is that you have a group in the private sector purchasing their care up-front, maybe on a month-to-month basis, and then you are subsequently offering that exact same care to the public sector, except giving them the option to pay after the care is delivered. It's like looking at two people and saying, "I am going to sell you both the same hot dog, of equal quality. The only difference is that Person A has to pay now, and Person B has to pay later. Plus, Person A has to pay a little for Person B's as well". Who in their right mind would stay with the private sector? In least in my system, the access to the public option is restricted, so this margins tipping to the mainstream is irrelevant - access is blocked after a certain number.

Regarding your third point, there is no place where a monopoly is necessary or desirable, nor are there special circumstances under which conscription is a better option.

Where did I say a monopoly is necessary or desirable? I said that conscription is only functional in monopolies, such as jury duty. Conscription is completely non-functional in your system, despite the fact conscription is at its heart.

Then systems should perform fine when not based on compensation. Quite frankly I find such surveys bullshit. They remind me the economists who used to claim we lived in a post scarcity world, but who upon asking refused to tear up their paychecks, indicating that just maybe scarcity was still an issue in the modern world. But, it sounded nice at the time, like the 'right' answer. As does saying salary isn't your main concern at your job. Fine, take it way and try to pass off 'autonomy' as a person's compensation for work. You'll find out pretty quickly how little they give a **** about autonomy and how much they desire to pay next month's rent. Even granting this problem, you could make registration as a possible charity doctor voluntary then. Even if not, I don't buy this objection at all. I know in my current business were they to have some random work sent their way by the government to do at market rates they wouldn't turn it down in good times or bad, it's guaranteed income.

The bolded is absolutely the only way this would work. As well, I did not say compensation is irrelevant, and this Red Herring does not detract from the point. Nobody acquiesces to 8-12 years of school, only to have their future dictated to them by the government. Period. The objection is not bullshit, whatsoever. You take two people and offer them the same wage, but offer 'Person A' autonomy and choice in their work, and dictate work to 'Person B' there is no mystery as to the happier and more productive worker. The attractiveness of so-called, "high level" education is the wage and autonomy it brings, and your system completely negates the latter.

Per the misdiagnosis part, incorrect. Doctors would still be responsible for their actions under my system.

No offense, but responsibility is utterly irrelevant to mis/diagnosis. Whether or not a potential doctor is responsible for his diagnosis is completely secondary to the issue. Misdiagnosis will occur because medical history is the primary determiner of a modality a doctor chooses. Having that medical history tossed from here to there has only one logical conclusion.

Same for safety/malpractice.

Again, totally irrelevant. Both instances occur now, and this is with seeing the same doctor consistently.

Approximately 20% of major illnesses are misdiagnosed, mostly because doctors are not payed to find the "right" diagnosis, but to find "a diagnosis" and dispense care in the form of therapy, pharmaceuticals, treatment and so on. The private sector provides an advantage here, because an economic incentive provides motivation to find the "right" diagnosis, lest they lose a paying customer. In your system, these pay-later public option customers provide absolutely no incentive whatsoever for the proper diagnosis, and couple that with no patient-doctor relationship, misdiagnosis would be even more rampant. There is technically no economic incentive in my system either, but at least the patient-doctor relationship is maintained. This is more or less Medical Ethics and Effectiveness 101.

The rules that govern economics are not incidental to the market sector or specific product or service. They either do or do not apply in all cases. As such what is true for rubber dog crap is true for heart surgery.

Precisely. So if you insert a worker who doesn't give a **** about making rubber dog crap, then you get crappy crap. You insert a doctor who has no reason to care about a random patient - again, at least in mine the humanist incentive remains - and, well...

 

[CDB]

a) How a patient is determined 'worthy' by the state;

Means testing. That's really the only question. And to disincent overuse by the poor, if you go for a ridiculous reason the government garnishes your wages until you'd paid the bill in full. The doctor he sees decides what condition he has. Which doctor he goes to is determined, once more, by the random pull. Whoever is on duty for that time. I see no reason to second guess the selection of doctors. If you're licensed you're in. His doctor decides what condition he has, just like yours does. It's not like you check yourself into a hospital, tell them you're having a spontaneous pneumothorax or something. **** like that gets diagnosed. When you have a cough, do you immediately go to someone who specializes in parasites because you knows there's some odd species of worm in your lungs? No, you go to your GP, he figures out what's wrong and fixes it, or sends you on to a specialist if he feels it's warranted. Perhaps you could explain why my system has to work any differently. I don't know a single person that diagnoses themselves before going to a doctor, nor do I know a single person who goes straight to a specialist unless it's something like a knee or foot guy, and that's what's giving them problems. You're putting requirements on my system that are completely irrational and unrequired.

Your plan runs into logistical nightmares, and is rife with begging its own questions. If the state assigns a patient to a doctor, but a doctor is initially who diagnoses a condition anyway, how do they assign a patient to the right doctor? Answer: they do not. They most likely assign the wrong patients to the wrong doctors and vice-versa.

Mullet, this is really disingenuous at this point. I've already explained nearly ad nausseum that I'm not talking about tapping a cardiologist and making him take GP visits, nor am I tapping a proctologist to do open heart surgery. Undiagnosed people will start in the ER or with GP, as they do now. Diagnosed people will be pushed on to specialists in the field required to treat them, as happens now. I fail to see what is so complex about this, it's already done a million times a day.

The state oversight is already there is what you are missing. Licensing will determine which doctors qualify. Resources do not need to be directed towards customers. The state is incapable of doing that anyway. Customers choose to go the doctor when they need to, as demand manifests the only thing the state has to do is call physicians in to serve those who want an appointment and are allowed through. The only bureacracy there is the means test. Distributing cost is handled by the doctors, who already have someone handling their billing. Instead of sending the bill to the insurance company or the individual, they send it to the state office for medicare. We need a whole new bureacracy just to let doctors write a different address on an envelope? Somehow that doesn't seem like a massive cost to be imposed. I'm pretty sure the doctor's admin staff can handle it in fact. Maybe they'll just need an extra thirty or forty people per doctor to accomplish that...

In the end I am not trying to get a bureacracy to not be a bureacracy, I am trying to limit bureacracy and that seems to really be what's getting you, because you seem to assume nothing is possible without it. The bottom line is my system limits the state's involvment to very few areas: One, they apply a means test to see if you really can't afford medical care; two, they require doctors to serve to make sure people get care; three, they follow up on the means test to ensure no fraud is being gotten away with; four, they accept the bills, tally them and present them to the tax payers at the end of the year. Hell, if we wanted this could simply be a public insurane plan, no doctors have to serve but all have to accept it. But I'd rather keep the original design because, as I said before, it's a disincentive to use the plan. The real issue is making the real costs of using the public plan high enough to disuade use so the only people who do use it are those who are really in need. My plan does that. Other plans don't. You think that's a weakness of my plan, I say it's my plan's strength and what will make it last longer than any other system.

You misunderstand. It is the exact same which is precisely the point. Why would I pay my premiums up front for exclusive care - the point in having a private sector - when any Tom, **** or Harry can get my services rendered on either; a) a dollar I help to provide; b) his own dollar which he need not provide until later, or worse yet; c) a combination of both.

Because you can't. One, there's a means test. Two, the doctor you're seeing is not your own. Three, if it's found you can pay, you will. Plus interest, plus a penalty, plus a prison term for trying to defraud the government. So you see the cost of using the public option if you really don't need it is pretty damn high all things considered. Monetary costs can be the same, money is not the only incentive. In fact it is crucial that the money costs be the same so the public knows the real cost of providing public care, and to ensure no weird shortages or surplusses of care or capacity. My program is the simplest government program possible. It determines if people are elligible, and then pays their way at market price if they are, rejects them if they're not, and throws their asses in prison if they defraud.

"I am going to sell you both the same hot dog, of equal quality. The only difference is that Person A has to pay now, and Person B has to pay later. Plus, Person A has to pay a little for Person B's as well". Who in their right mind would stay with the private sector? In least in my system, the access to the public option is restricted, so this margins tipping to the mainstream is irrelevant - access is blocked after a certain number.

Analogy is off. Actually it's this. "You want a hot dog? You have two options. One, you can go to a restaurant you know and buy one yourself, end of story. Two, you can petition me to prove you are hungry and can't afford one yourself. I'll investigate this. If it's true I will then buy you a hot dog from a pre determined restaurant. I don't care whether you like the cook or not. Afterward the tax payers will pay your hot dog bill. If you have defrauded the system in any way your wages will be garnished until you pay the bill back in full, including admin costs, plus interest and penalties, and you'll spend some time in jail."

Nobody acquiesces to 8-12 years of school, only to have their future dictated to them by the government. Period.

This is a fault of any public system, more so with yours though. I'm not dictating any doctor's future anymore or less than any other public system.

The objection is not bull****, whatsoever. You take two people and offer them the same wage, but offer 'Person A' autonomy and choice in their work, and dictate work to 'Person B' there is no mystery as to the happier and more productive worker. The attractiveness of so-called, "high level" education is the wage and autonomy it brings, and your system completely negates the latter.

One, this assumes you can compare utility interpersonally. You can't. Even if you could, you've got the wrong analogy again. I never said autonomy wasn't valued all else equal, I said offer the choice between wages and autonomy and see what gets picked time and time again. Of course if all else is equal people would prefer being autonomous to not. That's not ]\=the question. The question is whether or not they would prefer autonomy in place of cold hard salary.7

pproximately 20% of major illnesses are misdiagnosed, mostly because doctors are not payed to find the "right" diagnosis, but to find "a diagnosis" and dispense care in the form of therapy, pharmaceuticals, treatment and so on. The private sector provides an advantage here, because an economic incentive provides motivation to find the "right" diagnosis, lest they lose a paying customer. In your system, these pay-later public option customers provide absolutely no incentive whatsoever for the proper diagnosis, and couple that with no patient-doctor relationship, misdiagnosis would be even more rampant.

Assuming this is correct, you just link their payment to proper diagnoi

There is technically no economic incentive in my system either, but at least the patient-doctor relationship is maintained. This is more or less Medical Ethics and Effectiveness 101.

And thus you have added to the incentive to use the public system rather than to avoid it.