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The following books by Robert Paul Wolff are available on Amazon.com as e-books: KANT'S THEORY OF MENTAL ACTIVITY, THE AUTONOMY OF REASON, UNDERSTANDING MARX, UNDERSTANDING RAWLS, THE POVERTY OF LIBERALISM, A LIFE IN THE ACADEMY, MONEYBAGS MUST BE SO LUCKY, AN INTRODUCTION TO THE USE OF FORMAL METHODS IN POLITICAL PHILOSOPHY.
Now Available: Volumes I, II, III, and IV of the Collected Published and Unpublished Papers.

NOW AVAILABLE ON YOUTUBE: LECTURES ON KANT'S CRITIQUE OF PURE REASON. To view the lectures, go to YouTube and search for "Robert Paul Wolff Kant." There they will be.

NOW AVAILABLE ON YOUTUBE: LECTURES ON THE THOUGHT OF KARL MARX. To view the lectures, go to YouTube and search for Robert Paul Wolff Marx."





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Saturday, February 29, 2020

TWIDDLING MY THUMBS

There is nothing I like more than watching election results come in, and nothing I hate more than waiting for the polls to close.  The political commentary on TV, when it is not simply offensively anti-Bernie, is fatuous.  The polls close at 7 pm this evening.  Results will be coming in by eight.  There will then be fifty-nine hours until the polls open Tuesday morning in the East on Super Tuesday.  Leaving to one side the vast  number of early votes already cast, the notion of "momentum" between tonight and Tuesday morning is nonsense.  Biden is toast.

If the latest California poll is right, then Bernie may actually bag all 144 of the at-large delegates there, and a sizable fraction of the 271 delegates awarded CD by CD.  I suspect he won't win all 144, but he could.  He will also almost certainly win the preponderance of the 226 Texas delegates.  

We shall see.

29 comments:

Jerry Brown said...

Yes it is difficult waiting for the polls to close. Well it will only be a couple more hours at this point. I think I can hang in there...

jgkess@cfl.rr.com said...

Hey, Jerry, hang in there---give yourself a brandy and a cigarette. Always the recommended solution to election anxiety. The key is not to over-indulge in optimism. Anyway, go Bernie!

Danny said...

I am apprehensive to Sanders's policies, and hesitant to fully embrace his rigid style of politics, although I suppose I could try to ignore those issues
for the sake of an ability to draw new voters into the political process, and/or for the sake of an ppeal to working-class voters who have strayed from the Democratic Party in the era of Trump. Or, in sum, an ability to assemble the diverse coalition needed to beat Trump.
But in the general election, California won’t be enough.

Want to ban fracking? Goodbye, Pennsylvania and Ohio.

And of course, adios, Florida if you're planning
on praising aspects of the Communist Cuban revolution.

And, Bernie has not transformed the primary electorate whatsoever.

And, I notice how hard Republicans and President Trump and the Russians are trying to make a Bernie nomination happen. While Sanders' rise has moderate Democrats nervous, Republicans are practically cheering it.

Also, party stalwarts believe a socialist Democratic nominee would be manna from heaven for Donald Trump who has already painted Democrats as a party of crazed socialists. Sanders hasn’t made a secret of any of this stuff; after all, he brands himself a European-style democratic socialist. His list puts “a chicken in every pot” to shame: Medicare for all. College for all. Housing for all. Free child care and pre-K for all. Jobs for all. High-speed internet for all. Medical and student debt relief for all.

So why aren’t these empty promises? Several Democratic presidential campaigns agree with the premise that Sanders' candidacy is bad for the party.

The problem for the Democratic candidates is that it may be too late, and there are still too many candidates left in the race for moderates to coalesce around one standard bearer.

Jerry Brown said...

Well at this point it looks like Biden got a pretty big win. But it ain't so bad for Bernie I think. It isn't like any Dem candidate has a chance of winning in S Carolina anyway. I guess we will see.

So Professor Wolff- I do have a question. You are always bringing up your great age (and I assume great wisdom)- why is it that it seems most people closer to your age do not like Bernie and more of the younger people really seem to like him? Have you ever seen that before? It is curious to me kind of being 'middle aged' myself.

R McD said...

My guess--to propose an answer to Jerry's question at 8:58 pm--is that age isn't really the variable we should be looking at. Rather, we should be looking at the political commitments of the old and everyone else. Some people--e.g., RPW and Bernie Sanders--have had a certain political commitment their entire adult life. I certainly know others almost as old as RPW who also stand as they always have done on the left. Maybe we get caught up in a misunderstanding of age because we misunderstand the Sixties, when the left enjoyed a resurgence in the USA. But it would be very wrong to think of the "sixties generation" as entirely or even predominantly on the left. Even back then, at the height of the anti-war movement, we on the left were still in a minority. So it's no surprise to me that so many of the survivors of those times are pretty wishy-washy when it comes to their politics.

Danny said...

I am 50 years old, and I would zero in on the whole idea of the rise of the far left, and calling for a revolution, versus calling for a return to stability.

I think of how the notion that aging beyond adolescence and young adulthood leads to conservatism is part of the conventional wisdom. I can understand theoretical reasons here -- a diffuse liberalism-humanitarianism is, perhaps, likely to be overshadowed, or maybe aging persons, their attitudes and values become more resistant to change. I don't know of definitive empirical evidence on the topic..

But I do know that Biden isn’t the flashiest candidate or the most ambitious in his proposals.

Part of 'stability', is tangible policy ideas -- and here I'm thinking, for example, of how Medicare-for-all has pretty much no chance of becoming law and it’s likely to spark a damaging intraparty fight.

What do we think of careful, pragmatic campaigns? Well, maybe that depends on whether the Democratic nominee must appeal to a broad swath of voters — including Trump voters. Note that McConnell controls the Senate by three votes (plus the vice president’s tie-breaker). Most Democrats believe their best bets for flips are in Colorado, Arizona, Georgia, and Maine. Biden has earned about a dozen endorsements across these states. Vulnerable Democrats defending seats include Sen. Gary Peters in Michigan, a state where Biden has consistently polled above Trump by a higher margin than any other candidate. He’s earned some half a dozen endorsements from sitting lawmakers there, too. Hanging on to the House is not a given, either. If Biden is best for down-ballot Democrats, as many Democrats who’ve won in those states believe, then okay, maybe consider that Trump has been running — and losing — against Biden for months.

Jerry Brown said...

R McD, I wasn't even around until the very end of the 60s and I am not a young man. But I understand when you say that certain people have always had a commitment- I for sure always had a political/economic commitment such that when Bernie Sanders came along- well he has been closest to matching that than any other presidential candidate ever.

But I still find it strange that people 10-20 years older than me seem to be so much more 'conservative' about this than me and much more than younger people and I wonder why. And I wonder how much of it is due to people 'normally' becoming more conservative as they get older if that is a thing , or whether there is other things, or whatever.

Thanks though for the response and I do appreciate it a lot. Thanks

Jerry Brown said...

Danny the thing is- the thing is that so many other countries have managed to do something like medicare for all and seem to have had good results- its just too much for me to think the USA can't do that also. Of course we can if we want to. And I would think most people already want to. But I guess we will see sort of.

Danny said...

'the thing is that so many other countries have managed to do something like medicare for all and seem to have had good results- its just too much for me to think the USA can't do that also'

I tend to suppose that introducing a single-payer system is not a serious option. One point is 'We don't want it'. Public opinion certainly supports this idea. Americans, and conservatives in particular, have a strong belief in individualism and limited government. But hey, we can agree to disagree about that one. Of course, interest groups don’t want it. You thought of that, I imagine. Have you also considered, then, that trying to dismantle the current system would be a mammoth task? Let us suppose that you have. For one thing, it would cost a great many jobs. But okay, you've thought of that.

Then it becomes relevant that actually, when I look into this, most universal coverage systems offer narrow benefit packages and incorporate cost-sharing for patients. Even those countries with the most comprehensive benefit plans, such as Denmark, the U.K., and Germany mandate copayments for outpatient pharmaceuticals and a cost-share for inpatient hospital stays.
And then we might look at the notion that single-payer health care is proven to be consistently plagued by massive waiting lists and dangerous delays for medical appointments, life-threatening delays for treatment, even for patients requiring urgent cancer treatment or critical brain surgery, delayed availability of life-saving drugs, worse availability of screening tests, significantly worse outcomes from serious diseases, to no one's surprise, and I mean, virtually all serious diseases, including cancer, heart disease, stroke, high blood pressure and diabetes compared to Americans, and put it the other way around -- Americans enjoy superior access to health care -- whether defined by access to screening; wait-times for diagnosis, treatment, or specialists; timeliness of surgery; or availability of technology and drugs.

Let me say that I'm not so very dogmatic about any of this, just curious if you are familiar with such talking points?

Danny said...

I haven't given any figures, and I emphasize that I am aware of this, but what I can do, is consider some of Sanders's figures from the last debate, where '87 million Americans' have no health insurance or are under-insured. Where did he get that number? The Census Bureau lists this or what? He made it up. Also, '500,000 people tonight are sleeping out on the street', but that's not true. Including '30,000 veterans', not true either. These figures were all offered in the span of under a minute, as I recall. Is this surprising is the real point here, is it shocking how ignorant he is? I state the point rather tendentiously. I am not shocked, but at what, exactly, am I not shocked? Bogus statistics. I complain about Sanders though of cours he is in good company. Just, something to think about if you were about to request figures from *me*..

Jerry Brown said...

Yes Danny I'm familiar with all those talking points. "we don't want it" -well I do and a lot of us do and a lot of us think that it is not only smart but also the ethical or moral thing to do. Yes American conservatives will not be happy- but to a large extent I don't care about that kind of unhappiness.

Medicare for all would eliminate a lot of jobs. Yes- A lot of jobs in the health care insurance business, and a lot of jobs that doctors and providers have to pay for just to bill that insurance business. None of those jobs provide health care or anything else of benefit to the rest of us. We can ask them to do more far useful things if they would like to and that would be a great benefit for us all.

What's a fair estimate of the popularity of the Brit's health care system? Or the Canadian system? Pretty sure it is very popular in either case.

I want to point out in the strongest possible terms that Americans are plagued by delays in health care all the time- especially those who don't have the freaking money to go to the doctor. These constitute waiting lists also. Danny, I really do think a country should guarantee some level of care to the extent it can. And the United States is the richest most productive country in the world at least as far I have been told all my life. And I don't think this is a unpopular argument. And I think it is the right argument. So yeah I'm all for it.

Danny said...

'Yes Danny I'm familiar with all those talking points. '

I see.

'I want to point out in the strongest possible terms that Americans are plagued by delays in health care all the time- especially those who don't have the freaking money to go to the doctor. '

Sanders's point, that 87 million people are uninsured or underinsured. I looked it up -- according to the annual U.S. Census Bureau report, 8.5% of the U.S. population went without medical insurance for all of 2018. So that's 27.5 million people. Of course, 'the U.S. population' is 7% non-citizen, and Sanders was talking about 'Americans'. His words, not mine. I'm in California which is 14.1%
non-citizen. Perhaps quibbling about this is adding insult to injury or somesuch..

I do wonder, though, how to picture this. After all, the Medicaid program covers 1 in 5 Americans, including many with complex and costly needs for care. Moreover,
rates of access to care and satisfaction with care among Medicaid enrollees are comparable to rates for people with private insurance.

Then, who are these millions of people who lack health insurance coverage? Are they young or old? Are they more likely to live in one region of the country? Are they
poorer or less educated than those who are insured? I am guessing that they have less than a high school education and/or have lower incomes. But, I'm guessing.

I'll move on to guess how many adults are underinsured.
What's considered underinsured? Sure, if most people could afford better health coverage, they'd pay for it. But
our numbers are that, like, over 25% of people are uninsured or underinsured. The point being, what does 'underinsured' mean? Just, that the limits may not be high enough to cover the full expenses of a claim?
They have high out-of-pocket expenses or skimpy benefits?

Fine, but the only way, I suppose, that we can get anywhere near what Sanders is talking about is if are are contemplating 'underinsurance' rates that are very high in the public insurance programs of Medicare and Medicaid. If that's true, then I'll try not to feel misled about it,
when I consider Sanders's idea of a panacea for this problem.



Jerry Brown said...

You know Dan- you didn't address or refute any of the arguments and especially about what is morally required of us as a nation.

Simple question- so many other countries seem to be able to do this- is there some reason the United States of America can't manage to do it? You know the answer.

David Palmeter said...

There is so much wrong in our health care system that it’s difficult even to think the problem through. Physicians in this country are paid more than in other countries, but they usually start out with massive student loan debt, something that their lower-paid counterparts abroad don’t face, at least to the same degree. The NY Times a week or two ago published an op-ed that noted that in the period 2005 to 2015, the average salary for CEOs of non-profit hospitals went up more than 90%. The average salary for nurses at those hospitals went up 3% in the same period. The per capita average cost of health care in the US is $9,892; in Switzerland it’s $7,919; in Norway, $6,647. Average life expectancy is 78.9 years in the US; 83.6 years in Switzerland; 82.3 in Norway. Looks like we’re paying more and getting less.

True story: a number of years ago I became ill while on a business trip to Geneva, Switzerland. I went to an emergency room, they checked me over, and gave me a 30 day prescription. The Swiss pharmacy did not, of course, take my insurance so I had to pay the full cost—the Swiss franc equivalent of $22 and change. When I got home, my own doctor agreed with the Swiss and gave me a prescription for another 30 days. This was covered by my insurance. My copay was $25—more than the uninsured price for the same drug manufactured by the same company (Pfizer). My non-profit insurance company, with its multi-million dollar salaried CEO, was, of course, charging me a premium reflecting their costs for that drug, so I was paying a good part of that full cost. The lesson seems to be that, when it comes to prescription drugs, it’s better to live in Switzerland without insurance than in the U.S. with it.

Danny said...

'You know Dan- you didn't address or refute any of the arguments and especially about what is morally required of us as a nation.'

If I am reading closely enough, I can paraphrase your view here, something like this: 'Why must your 'mixed system' muddle along? Your system is grossly unfair, unequal, profit-oriented, cost-ineffective, opaque, and wasteful.'

And that might work against my original objections to Sanders' plan, to the degree that they seemed to amount to it being politically unfeasible. This still strikes me as a good point. It's rather more involved if we try to settle the issue of what is the 'best' system of health care, socialized medicine or whathaveyou? People are going to disagree about this, and I don't have all the answers. I do not think it is clear, then, what is morally required of us as a nation. For example, if the choice is between access to the best parts of the American health care system versus the best parts of any other system, I’d rather be in the United States.

And here, you might say: 'A system that tilts so heavily toward the rich is unjust in my mind. People should be not be denied health care because they don’t make enough money.'

And if you’re one of those people shut out of this system for financial reasons, you don’t give a damn about all that innovation and high-quality treatment that others are enjoying. There is the fact that low-income people don't have the resources to pay for access to health care. Although actually, I suppose that in the United States, Medicaid does a pretty good job for low-income people. I want to just review the fundamental starting point, the idea that when people have exceptionally low incomes, we use Medicaid, and then we have a graduated system of subsidies that allow people to use the private market to access health insurance until they increase their income.

Also, I can admit that of course, 'Medicare for All' will not turn America into Venezuela overnight. However, I do still believe that all it would take is a series of catastrophic policies. Thus, I ponder the socialist economy instituted by dictators Hugo Chavez and Nicolas Maduro -- the welfare programs, many minimum-wage hikes and nationalizations implemented by their regimes.Is it too simplistic to blame Venezuela's collapse on socialism? Well, maybe, but I buy the notion that economic management is a misnomer, and that it is not a coincidence that extensive state control of the economy is inevitably accompanied by gross mismanagement. And certainly a lot of superlatives can be attributed to the U.S.

Perhaps, then, I still seem to be quibbling over irrelevant details rather than just recognising the inherent injustice and inefficiency of the American model, which is profit-driven rather than welfare driven. But, - my top idea in this area is currently one of merely slouching towards “regulated competition”. Social insurance versus private insurance versus no health insurance is not my idea of an irrelevant detail, it's the financing of health care. And government versus private but non-profit, versus private and commercial, this is ownership of providers and again, not an irrelevant detail. don't think it's an irrelevant detail that there will always be trade-offs, and also, I think that clearly, there is room for disagreement about the relative merits of health systems, and different experts would surely reach different conclusions.

Danny said...

'Simple question- so many other countries seem to be able to do this- is there some reason the United States of America can't manage to do it? You know the answer.'

I do know my answer, but not I am not thinking that it is what you are guessing is obviously the answer here. I get that the U.S. system is a bit of a mess in that it is quite expensive and doesn’t offer complete coverage to its populace. That's obvious, sure.

But I can buy the argument, though maybe your mileage may vary with it, that the system really does have the strongest incentives for innovation on medical technology — which provides an amazing amount of welfare for citizens around the globe. Now, maybe, nevertheless, it’s hard to justify the very high level of U.S. spending based on innovation alone, particularly without mechanisms to steer innovation toward technologies that are cost-effective. Maybe we can pine for a far more equitable system, with few delays and reasonably good outcomes. However, it might be plausible to say that the U.S. delivers a superior quality of care on the measures that matter most to patients, and maybe even that the system is far more dynamic and innovative than you might be supposing. On the other hand, maybe the U.S. is just too expensive for what it delivers, and includes too much financial insecurity to boot.

However, there is also the issue of what sounds silly, false, and delusional me. I don't mean to question whether, shall we say, Denmark has remarkable quality of life. But I talk about tradoffs, and about how I'd certainly rather have the Western European world contributing their fair share of innovation. It might be that the innovation we’re getting isn’t worth the human costs, and that’s a conversation we can have, but there’s absolutely a trade-off, and I’m not sure everyone understands that. People who support single-payer health care in the United States don't consider the innovation effects at all. It'll get longer, if I work up a whole case, which ends with 'that's why we need a competitive insurance market'.

I'll try an analogy -- the United States spends more per student on education than any other country. All the Nordic countries – Denmark, Finland, Iceland, Norway and Sweden – all these countries remain real exceptions in a world where international students are often a lucrative source of income for universities. We know that education is expensive everywhere – including in Nordic countries – and that someone has to pay for it. The crucial question is who. The Nordic higher education systems are almost entirely publicly funded. However, I figure that the Swedish-style, state-led solution will be a nonstarter in the US of A. This all angles around, for me, to considering ideas like '(why) Nordic socialism won't work in the U.S'. Or, that is, reasons we can’t, and shouldn’t, be Nordic..

Getting back to health care, I'm interested in the Germany idea or the Switzerland idea, as opposed to just defending the way things are, but that still doesn't add up to 'Medicare for all'.

Danny said...

David Palmeter :

'There is so much wrong in our health care system .. Physicians in this country are paid more .. the average salary for CEOs of non-profit hospitals went up more than 90% .. The per capita average cost of health care in the US is $9,892; in Switzerland it’s $7,919; in Norway, $6,647. Average life expectancy is 78.9 years in the US; 83.6 years in Switzerland; 82.3 in Norway. Looks like we’re paying more and getting less.'

I've noted that I'm interested in Switzerland, and of course its outcomes are hard to beat — arguably the best in the world. And Switzerland has a universal health care system, requiring all to buy insurance. The plans resemble those in the United States under the Affordable Care Act. I mean, offered by private insurance companies, community rated and guaranteed-issue, etc. So I don't really mind bringing up Switzerland myself, but I bring it up as an argument against 'Medicare-for-all'. There’s heavy, but quite regulated, competition among insurers and an individual mandate, and again, the Swiss system looks a lot like a better-functioning version of the Affordable Care Act.

Danny said...

So, I've been stressing that the “rest of the world” is not all alike. Wealthy nations have taken varying approaches to universal coverage. Some relying heavily on the government (as with single-payer), of course. My view is that experts don’t agree on which is best; a lot depends on perspective.

If we are considering Medicare (more like Canada), then in Canada, the government ends up paying for about 70 percent of health care spending in all. Many Canadians have supplemental private insurance through their jobs to help pay for prescription drugs, dentists and optometry. Canada does not rank near the top in the usual international comparisons on quality, and does not excel in terms of access. Access problems can be profound in Canada — nearly one in five Canadians report waiting four months or more for elective surgery, which can be more than just an inconvenience.

Danny said...

Also, I got this reply about how 'You know Dan- you didn't address or refute any of the arguments and especially about what is morally required of us as a nation', when I had been dialing out about false claims from Sanders. Cuz what, if he makes false claims, this is irrelevant, a red herring? Well, and *you*, didn't address or refute any of *my* arguments, which of course, it's not like Sanders doesn't make false claims. Should I be patient about it thought, if his claims are false? For another example, he says that the US spends twice as much on health care, per capita, as any other country in the world. That sounds like 'double every single one'. The claim has been a staple of Sanders' rhetoric during his campaign.

He tweeted in April that, despite the failings of the US system, "we still spend twice as much per capita on health care than any other country." He said on CNN in June, "Right now, we spend twice as much per capita on health care as do the people of any other nation."

Well, I have David Palmeter's numbers from up the thread, that 'The per capita average cost of health care in the US is $9,892; in Switzerland it’s $7,919; in Norway, $6,647.' So, Switzerland and Norway and, I'll add, Germany ($5,986 per person) are substantially above half the US level. I might quibble even if were were talking about 'very slightly above half', because my point is that Sanders could have accurately said the US spends more than twice the average for OECD countries or something, and what treatment then shall I give his rally speeches? This is not just about an exaggeration about health care Sanders has repeated for more than a decade. Even as fact checkers have repeatedly debunked it. It's more that I am not thrilled to defend Sanders by saying that Sanders make far fewer false claims than Trump tends to make at rallies. Your mileage may vary, if you can get excited about Sanders clearing such a low bar.


I was talking about the recent debate, actually, and off the cuff, as I recall, Sanders said something like this: 'Sanders said of Trump: "...the economy is booming for his billionaire friends. Since Trump has been President, billionaires have increased their wealth by $850 billion."'

So I take that for an inaccurate figure, and I am distracted by such stuff -- I ask myself, are such things provided to him or what? When I try to look up such figures, I do find that there are supposedly 607 US billionaires with wealth totaling about $3.1 trillion or such, and while I am at it, sure, I guess there is no doubt that the wealthiest Americans have gotten wealthier under Trump. Sanders wouldn't choose to stress it, but he may not be disputing that the combined wealth of the bottom 50% of households increased 55%. From a much smaller starting point, of course, spread out across many more households. Note that I'm not simply shifting emphasis though, I'm saying who cares if these are false claims? The point isn't even about Sanders, who I have mentioned, is in good company. Not even is the point about lying politicians. The point, for me, is that if accurate numbers are part of the solution then do we even deserve a solution?

Jerry Brown said...

Danny, at least you are obviously thinking about this and that's good. One other thing to consider is that single payer health care does not necessarily say anything about how high a quality that health care can be. The US has a single payer military system and it is supposedly the most powerful and effective military that the world has ever seen- but we do spend an awful lot on it. One system designed to kill people the other designed to heal them- its kind of strange to think about.

I have enjoyed our discussion and hope you have as well.

Danny said...

'The US has a single payer military system and it is supposedly the most powerful and effective military that the world has ever seen- but we do spend an awful lot on it. One system designed to kill people the other designed to heal them- its kind of strange to think about.'

Well, I've conveyed that I don't like Medicare for All. Why not? One point here is simple -- the fact that Medicare for All is electorally toxic. Whatever its abstract promise of cost control, supposing, shall we say, that that’s true in theory, there is also this matter of how to overcome voters’ aversion to higher taxes or losing their insurance. What is politically salable? What requires Medicare for All, seems therefore insurmountable.

I get that this leaves open the question of what to do about it, and maybe especially, as Mark Twain reputedly said about the weather, everybody talks about waste in the U.S. healthcare system, but nobody does anything about it. You say:

'Medicare for all would eliminate a lot of jobs. Yes- A lot of jobs in the health care insurance business, and a lot of jobs that doctors and providers have to pay for just to bill that insurance business. None of those jobs provide health care or anything else of benefit to the rest of us. We can ask them to do more far useful things if they would like to and that would be a great benefit for us all.'

Well, say that we put numbers on the scale of that waste and nail down its sources. Maybe, indeed, making the American healthcare system more efficient isn’t a technical problem, but a political one. But it doesn't seem to me that you have in mind, here, when you talk about this source of waste that you have identified, that it has nothing to do with failure of care delivery, which includes hospital-acquired illnesses and other “adverse events” and lack of preventive care. Also, it has nothing to do with failure of care coordination, which includes unnecessary hospital admissions and avoidable complications. And, it has nothing to do with overtreatment or low-value care, such as using branded drugs instead of generics and prescribing unneeded screening or tests. Nor do you seem to have considered, actually, per se, pricing failure, such as excessive payments for drugs and excessive insurance reimbursements for services. Indeed, as you state your diagnosis, I take fraud and abuse to be, actually, a separate issue from your issue.

You have an issue though, you call it 'a lot of jobs in the health care insurance business, and a lot of jobs that doctors and providers have to pay for just to bill that insurance business.' But I don't think this can, in itself, be construed as anything like, shall we say, 25% of all U.S. healthcare spending. You haven't, then, highlighted, to my satisfaction, the sources of inefficiencies in the U.S. health care system, let alone cited opportunities to address those inefficiencies. What might be a reasonable estimated range of total annual cost of waste, which can simply be atrributed to what you are talking about -- which is none of the things that I have mentioned? Heck, I won't try to be conservative, let's say that there is some $300 billion dollars that you see as being wasted due to the *existence* of the insurance industry, I guess, or at least, you blame the insurance industry for unintended administrative complexities or somesuch. My number is not trying to be conservative, I think it's high. But heck, making it a high estimate serves to stress that it might well be the greatest source of waste. The idea, I take it, is that some of this waste is due to a fragmented health care system. But more seamless data interoperability, for example, might help (produce new savings), without simply eliminating the health insurance industry. Etc.

Danny said...

Also, waste is not a pleasant thought, but neither is the thought that health care costs overwhelm government budgets. For example, some Canadian provinces spend almost 40% of their budgets on health care. Thus, the government may limit those services with a low probability of success. This includes drugs for rare conditions and expensive end-of-life care. Say that I am talking about disadvantages, when it would be as easy to talk about advantages. Similar thinking is involved in the notion that doctors may cut care to lower costs if they aren't well paid by cost-cutting governments. Also, there is the notion concerning how this works in practice, that the government focuses on providing basic and emergency health care. Thus, there are long wait times for elective procedures.

I'll review -- the public solution runs contrary to the political culture of the United States, is adamantly opposed by powerful interest and ideological advocacy groups, and for the present, our mixed system must muddle along. But, I don't bring this stuff up simply to defend the United States. And I am actually confident that for somebody like me, by taking an international perspective and looking to other advanced industrialized countries with nearly full coverage, much can be learned.

tbc

Danny said...

I don't mean to jerk you around about something like how you are used to reading, and so am I, about how anyone interacting with the U.S. health care system is bound to encounter examples of unnecessary administrative complexity—from filling out duplicative intake forms to transferring medical records between providers to sorting out insurance bills. This is juxtaposed to the point the United States spends supposedly double the amount per capita on health care compared with other high-income countries even though utilization rates are similar. U.S. administrative care spending is indisputably higher than that of other comparable countries, let us say. Not that I'm sure how much of the difference is excess and how much of that excess could be trimmed. Surely, all estimates of administrative costs are inherently sensitive to what portion of health care spending one considers administrative. But, fine, say that administrative costs contribute to the high expenditures in the United States. That doesn't actually mean that they are the primary reason for the health care spending gap, does it?

For example, I gather that overall, expenditures in the high resource patients population are more than 10-fold higher compared with the full population. I remember somebody saying that back disorders and osteoarthritis contribute the largest share of expenditures. I dunno. It seems likely that chronic renal failure, heart disease, and some oncology treatments account for is proportionately higher expenditures in the high resource patients population..

Personally, I am thinking that it's difficult to pin down just what's driving the increase in prices. But okay, let us say that many experts argue that competition among providers, or the lack thereof, is a major driver of healthcare price increases in a market. I take that to be your point of emphasis. I muse that we can agree that our experiment in market-driven health care has gone awry, but I also tend to suspect that in the end, medical services are expensive.

There is no getting around it.

It seems to me that efforts to define and eliminate waste have proven elusive. I am not an expert, but I gather that consumers bridle at attempts to limit their access to treatments, and the public in general appears conflicted about health spending, in that there is less support for efforts to directly control total health spending, which is viewed as potentially reducing people’s health benefits or threatening the quality of care provided.

Danny said...

'One other thing to consider is that single payer health care does not necessarily say anything about how high a quality that health care can be. The US has a single payer military system and it is supposedly the most powerful and effective military that the world has ever seen- but we do spend an awful lot on it. One system designed to kill people the other designed to heal them- its kind of strange to think about.'

While we are at it, maybe think about the point that Veterans care in America gets a pretty bad rap. It has been plagued with controversy for years -- reports of excessive and contradictory spending, allegations of inadequate health care, a massive backlog of benefits claims and a secretary position that nobody can seem to hold down. It occurs to me to stress this, because the VA runs the facilities, including hospitals, clinics, and long-term care facilities. Thus, one might argue that VA care means long waits for care, a bureaucracy that treats its clients more like “inmates” than like “customers” and all too often a deadly reminder that health care delayed can mean health care denied. Think of this, maybe, as and island of socialized medicine in a for-profit sea. It's for the nine million men and women who qualify for medical benefits from the Veterans Health Administration.

if it's relevant, the VHA is far from perfect. One could maybe defend it somehow, I'll save you the trouble of saying that the VA is the only large US health system (other than Kaiser) that has electronic medical record – theoretically linking all phases of care, from primary care through specialist visits and hospitalization. In other words, in the best of worlds we all would be getting veteran’s care, courtesy of the U.S. government! Before you buy that idea try a Google search. The last time I did that I found these unsettling headlines: “Vets Not Getting the Care They Need, “One Million Vets Waiting on VA for Disability Claims,” “‘Never Event’ Occurs at VA Hospital,” “Federal Court Challenges VA Mental Care,” and “Veteran Suicides Becoming Epidemic.”

If it seems relevant, or, shall we say, 'strange'..

Danny said...

I spitballed a number, $300 billion, as how much could be saved by eliminating the health insurance industry, or, by medicare-for-all eliminating jobs, per your claim that:

'Medicare for all would eliminate a lot of jobs. Yes- A lot of jobs in the health care insurance business, and a lot of jobs that doctors and providers have to pay for just to bill that insurance business. None of those jobs provide health care or anything else of benefit to the rest of us. We can ask them to do more far useful things if they would like to and that would be a great benefit for us all.'

I certainly was rounding up to $300 billion from what I find plausible here, but I expect a retort that actually, if we are contemplating eliminating it entirely, then the Health & Medical Insurance in the US has a market size of $1 trillion. Indeed, I might seem rather perverse, in apparently not realizing that more generally, the finance sector is destroying the economy. I mean, no one thinks oil spills are good. Maybe something like that criticism can be applied to the financial services industry. I expect, around here, that finance, insurance and real estate, none of it is, like, 'popular'.

So okay, finance and insurance was 7.0 percent of GDP in 2014. Actually, employment in finance and insurance has been on a downtrend since 2003, but, hey, you might say 'good'. Yet, it's currently 4.25 percent of total nonfarm payrolls -- making me skeptical that at this point, the financial industry really is large enough to crowd out other parts of the economy or somesuch.

I might also, just, like, ingenuously, suppose that the insurance industry serves an important social purpose providing life, property, and casualty insurance.I admit that perhaps I seem to digress a bit, but I realize where I am, a place, indeed, a specific thread, where market-making, deal-making and the creation and trading of derivatives on Wall Street, or totally a bad thing.

Waste not?

More narrowly, sure, wasting fewer health care dollars could drive down insurance premiums and out-of-pocket costs and maybe even free up resources for education, retirement and wage increases, among other things. So I can picture this idea, of the medical industry needlessly gobbling up money, and how it dovetails with a broader idea -- should we worry about 'unproductive' financial sector gobbling up our best?

To some people, the question is a moral one.

Well, I'm all for developing the ability to recognize waste. But I am not buying what might be called a general knee-jerk comportment that I encounter, a Marxist thing, more or less, that we can see capitalist services as ‘insignificant’, and in relation to the finance sector we can argue that because value is created only in production and never in realization, commercial services are unproductive. It's all rather abstract and takes us afield, but sooner or later the point might come to seem relevant.

More specifically, what is the need for insurance? If I have to defend the mere notion of health insurance, then I have to wonder how radical does this get? What about life insurance? Auto insurance? Sure, insurance is expensive and certainly takes a chunk out of your budget, but so does housing.

Danny said...

I've mentioned 'so does housing'

And about that..

Bernie Sanders is talking about housing, as I have mentioned -- his platform is Medicare for all. College for all. Housing for all. Free child care and pre-K for all. Jobs for all. High-speed internet for all. Medical and student debt relief for all.

And if it somehow ends up being the case that housing does become enshrined as an explicit right or a right by extension, how do we comprehensively solve the problem of housing scarcity?

Suppose that one answer is by socialist views and deep suspicion of the profit motive. Then I suppose, that it's a no-brainer -- all the elements for good housing policy are in plain sight. We are missing political will, a curious press, and a real estate industry that can’t see beyond the edge of a spreadsheet. And it's true in my experience, that one of the more popular ways for progressive candidates to excite a crowd or for pro-housing advocates to frame their arguments is to assert “Housing is a human right.”

Fine.

Anyone want to step up and argue that single family zoning is a right? Or shall we use “Housing is a human right” as a shield against having to engage with specific housing policies? Maybe the idea is that a slogan provides cover for avoiding hard discussions about how to move forward. Recognizing that housing is a human right makes certain arguments off limits. Now, sure, for low-income individuals in America, affording adequate housing can be difficult. What do you think – should the U.S. government guarantee the right to housing? We’re not accustomed to seeing housing as a basic right for everybody, but why isn’t it?

It's further afield, of course, but goes to the apprehension -- how radical does this get?

Jerry Brown said...

Danny, I think maybe you need to do some research rather than relying on a commenter on a blog such as me (even though I believe what I write and am honest about it). I already told you I think it is more an ethical issue than an economic issue even though I can make very reasonable economic cases for something like Medicare for All that Bernie proposes.

The estimates I have seen are that 10 to 20+ percent of the costs of 'private insurance' health care are due purely to administrative costs (including profits) which really don't help anyone much at all outside of those receiving them. This is compared to administrative costs of 3% or less for currently existing federal programs such as Medicare or Medicaid. I believe that Obamacare law now requires private insurers offering those policies to pay out at least 85% percent of their total premium charges to providers which is actually some improvement over the previous situation- but that doesn't necessarily account for the wasted efforts of patients and healthcare providers to navigate the sometimes onerous paperwork required by many multiple insurance plans. And that costs too.

My comment about the military being single payer was about the actual military force that we Americans pay for and not how we sometimes provide health care for veterans and soldiers. Supposedly by all accounts we get a fantastic military force despite it being paid for by the federal government and not private insurances. But the VA is also single payer that is true as far as I know. And to the extent we don't provide excellent health care to them in a timely manner would be a shame on our country.

Danny said...

David Palmeter: 'Average life expectancy is 78.9 years in the US; 83.6 years in Switzerland; 82.3 in Norway. Looks like we’re paying more and getting less.'

btw, That's what might be called the myth of Americans' poor life expectancy. It’s one of the most oft-repeated justifications for socialized medicine. Life expectancy is an appealingly simplistic way to think about the quality of a country’s health-care system. If we would just hop on the European health-care bandwagon, we’d live longer and healthier lives. The only problem is it’s not true.

I meant to get back around to this, in terms of the explanatory power of drugs, car accidents, and homicides on US life expectancy gaps, and I mean, that which can be mathematically estimated through the actual causes of death instead of its statistical association with life expectancy more broadly.

Among men, US death rates from injuries account for more than 50% of the life expectancy gap with Austria, Denmark, Finland, Germany, and Portugal. This wipes most of the life expectancy gap with several of the most highly developed countries with “universal health care”, low income inequality, extensive safety nets/cradle-to-grave welfare states, and so on, such that by all appearances the life expectancy differences between well developed countries of predominantly European extraction are mostly idiosyncratic and are very poorly explained by health system factors like expenditures, physicians per capita, and the like.

I might not actually argue that health systems are necessarily unimportant, but more that past a certain point diminishing returns kick in. What really I get a kick out of here is simply what is in light of the actual evidence, and that is, that we ought not to expect high US health expenditures to produce statistically apparent gains in these sorts of broad aggregate measures. I'm just thinking, then, of what naive comparison of death rates might lead you to believe.

I could bother with the particular estimates, but I guess it won't be hard to clearly suggests the US stands apart from the rest in these categories, and again, the idea is that motor vehicle accidents, homicides, and drug overdose deaths can explain a large fraction of the US life expectancy gap as compared to several highly developed countries.

If you really want to measure health outcomes, the best way to do it is at the point of medical intervention. If you have a heart attack, how long do you live in the U.S. vs. another country? If you’re diagnosed with breast cancer? I brought this up, actually, and I think I simply wasn't believed. Well, In 2008, a group of investigators conducted a worldwide study of cancer survival rates, called CONCORD. They looked at 5-year survival rates for breast cancer, colon and rectal cancer, and prostate cancer.

http://www.thelancet.com/journals/lanonc/article/PIIS1470204508701797/abstract

U-S-A! U-S-A! What happens if you remove deaths from fatal injuries from the life expectancy tables? Among the 29 members of the OECD, the U.S. vaults from 19th place to…you guessed it…first.

Don't get me wrong, though, as I have stressed that if we look at Switzerland, a country with private-sector, market-based universal coverage, we see very good health outcomes data. Yet, if we compared the life expectancy of Americans on private insurance with that of centrally-planned Europeans, I’d bet that the U.S. would come out on top. And if that’s true, the argument that socialized medicine leads to longer life evaporates.







Danny said...

'Supposedly by all accounts we get a fantastic military force despite it being paid for by the federal government and not private insurances.'

You're demanding to know the difference between something like our fantastic military force, which is paid for by the federal government, justifiably, and other things such as health care coverage, which might be just as fantastic as everything else that the government does, if the government did it. Frankly I might have supposed that you've heard all the arguments here, because I'm not making anything up, and you have so far claimed to be familiar with my points already, but okay, the way that these dots get connected to answer your question is with headlines like 'Pentagon buries evidence of $125 billion in bureaucratic waste', and, more generally, yes, when it comes to military spending, our defense budget is astronomical. The United States spends as much as the next nine countries combined on the military. However, part of the reason that is, is probably because we are wasting a huge amount of money in a lot of different ways. The military has some of the most awesome research projects ever conceived. But all that cool stuff comes at a huge cost and is almost never on budget. I'll even say, seriously, that I ponder a question: what if we were to spend that much money on infrastructure, health care or any other area of purview that the government has.

The military has almost zero financial institutions, nor does it have a fiduciary responsibility to maintain an accurate assessment of their books.


'But the VA is also single payer that is true as far as I know. And to the extent we don't provide excellent health care to them in a timely manner would be a shame on our country.'

Yes, and rest assured, fixing the VA isn’t a partisan issue -- nobody wants to be on the wrong side of it. I mentioned 'a secretary position that nobody can seem to hold down', and I mean, for example, how In late March 2018, President Trump fired Dr. David Shulkin. It seems, that Shulkin began the process of privatizing some VA services, although most observers believe his firing was the result of Trump’s desire to expedite and expand that process, an outcome he knew Shulkin would resist. I don't mean to have an opinion about that, or, to be especially dogmatic about how to run the VHA, but I notice that you seem totally blindsided by how the VHA can be used as an argument that 'More bureaucracy is not the answer'.