Highly Progressive Approach to Deficit

They are not included in the proposed deficit when the budget is proposed since the expenditures have not been requested or funded, but they are counted for that fiscal year, so the deficit includes any additional spending for that fiscal year. I don't know how to explain it better than that. I think you have a block on this because you are looking for some sort of scam that Bush pulled off that hides expenditures.

Boehner: I'll Drop Tax Cut for Rich If I Have To

Either Obama caved while holding all the cards or he really wanted to extend the Bush tax cuts for his own purposes.

The situation kind of exists now between regular Medicare and Medicare Advantage. The Medicare Advantage plans compete by offering better services and differing copay/coinsurance/deductible tiers. Contrary to liberal propaganda, Medicare is not that great a plan compared to private insurance. In general it's an 80/20 plan, so the member out of pocket amounts can be pretty huge for prolonged hospitalization and treatments. Competing private plans would (and this is the hope) by competition lower the annual plan cost amounts to match the decline in the percentage increase of the per member costs. So the plans should be able to provide services at a cost level that is lower increase than the baseline increase.

That administrative overhead is one of the reasons that Medicare fraud is a multi-billion dollar crime spree every year (estimates of 40-60 billion a year in fraud) and is negligible for private plans.

People already buy into Medicare. You pay FICA your entire working life and then you pay a premium deducted from your Social Security check. So I'm not sure why that would make a difference since that is only a fraction of the actual cost of the plan, which is why Medicare is going broke. As I asked before, why would any sort of government health care control costs when the government plans we already have don't?

 

Not a scam, just politically motivated bookkeeping. The issue with your explanation is I just am not seeing a source for it here or anywhere. I asked for one earlier because I honestly wasn't sure and you said the budget couldn't be broken down that way. From my own research, it appears to me that the emergency supplemental expenditures for the wars were not included in the $161 billion deficit. That is the budgeted deficit, not that actual one. If we look at the numbers, actual receipts were $2.4 trillion and actual expenditures were $2.8 trillion.

That's a $400 billion deficit, not $161. And this is at the peak of the Bush economy, right before the bubble burst. The 2009 budget was also Bush's, with a $1.4 trillion deficit. A considerable amount of this deficit was from lost revenue from the collapse of the bubble. This is the deficit Obama took over. Part of that deficit is from the stimulus, yes. Obama deserves a measure of responsibility. But you can't seriously sit here and say that we had a nice, tidy, balanced budget from Republicans and then Democrats screwed it all up. It was the exact opposite: Clinton had a nice surplus and Bush screwed that up, big time. In the midst of a serious economic meltdown, Obama has essentially kept spending and the deficit flat; in fact, the deficit has receded slightly as revenues pick up.

I'm not arguing Obama is perfect. You've seen my budget proposal in this thread. That's what I would have led with for the stimulus. Obama deserves responsibility for what he has done. But conservative demonization of him is intellectually dishonest, just as demonization of President Bush from liberals is intellectually dishonest.

Thanks for the source, but it turns out it was a moot point: it was Senate Republicans who held up the issue with a threatened filibuster. House GOP was being very reasonable.

But have we seen this success with Medicare Advantage like you describe? On the contrary, Medicare does alright compared to private health insurance. It isn't perfect, of course, but it's healthcare for our neediest demographic. To have a private healthcare plan that wouldn't have out of pocket costs for prolonged treatments would cost astronomically more than Medicare.

Let's work out a plan to end fraud then. I hear the GOP talk about ending waste and fraud, which is great, but then never propose a solution other than ending Medicare gradually. I don't understand how that prevents fraud. If you don't like the program, say so. Don't dismantle it under the guise of preventing fraud, however. Obama's move to stop duplicitous payments for tests extended Medicare solvency by several years with no cut in benefits. Yet Republicans opposed that. Why? That's the very definition of tackling fraud because it tells doctors they aren't going to get paid for ordering the same test five different times. That's a fantastic idea and I don't understand the opposition.

I mean if we extended it to a Medicare-for-all. More people would be paying a premium and/or we could raise the FICA tax for those that opt into the program. Whichever one pays the bills the best. But it would definitely result in increases in revenue greater than the loss from expenditure because if I'm 25 and buy in, I'm going to face less health issues than someone 75. By broadening the pool and including more healthy people, you'll automatically make the program more solvent.

 

The potential of the public option lies in its ability to influence the process by which private payers and providers negotiate the prices of the latter's services.

There's sort of a paradox: lowering the cost of care seems to require more seamless, coordinated delivery of services, but the consolidation of health care providers that this approach implies results in greater market clout for providers that can drive up the prices they charge payers for those services. For instance, see this remarkable series of questions and answers from a sit-down the CEO of the Cleveland Clinic recently did with the Wall Street Journal:

Despite denying that consolidation raises 'costs,' he explicitly says 1) that his organization uses its market clout to get more money (via higher prices) out of health insurers, and 2) despite the fact that the Cleveland Clinic's delivery model is lowering the cost (to it) of providing care, those savings are not passed on to the insurers paying for those services.

The public option was one way to try and resolve the paradox. Large providers could continue to organize themselves in ways that allow them to provide lower cost care, even if it drives up their market power, because a new dynamic would be present in negotiations between those large provider systems and the insurers that have to contract with them.

The so-called robust public option would, at least for the first few years of its existence, have reimbursed providers at Medicare + 5% rates. That means if private payers were unable to get large provider groups to pass along the savings from more efficient care delivery to the payer--who could in turn lower premiums (or at least mitigate increases)--then the private payers risk losing customers to the public option, which is more or less immune to the market clout of the provider organizations. The payers thus have a little more leverage when negotiating with providers: if providers continue to extort high prices there will be market pressures in the direction of the public option, which in turn would reduce the providers' revenues.

The public option wasn't just about keeping private payers honest, it was also about keeping providers honest in their negotiations with private payers.

 

OK here is what you are looking for: http://www.usgovernmentspending.com

I think you were looking at the numbers backwards.

The 2007 projected budget deficit was $354.3 billion dollars. The actual deficit was $160.7 billion dollars. So the net spent for that fiscal year was less than projected when the budget was submitted.

For the 2009 budget, it's disingenuous to say that's Bush's budget. Bush never got to sign the budget since the senate wouldn't submit it to him for ratification. You can blame Bush for the half of the $700 billion TARP program, but that FY also includes the stimulus.

The Medicare Advantage plans are not really a model for reducing health care costs. They are basically the subcontractors for Medicare, they are not really private plans. I think the Medicare Part D is probably a better model. That actually reduced costs in the real world.

As for waste-fraud-abuse, good luck trying to root it out. Everyone is in favor of ending it, but the tried and true methods of handling it are the very methods that cause the private insurance administrative overhead which you oppose.

I'll just wait and sit back until the government figures out how to control the health care costs it actually is responsible for before I actually take seriously the idea that government healthcare will control healthcare costs. Medicare has been around since 1965 and they have not started figuring out how to do that yet.


But I think I've proved my point that ground zero for controlling the national debt is getting control of healthcare. So far, Ryan's plan is the only one out there that tries to do that. What Democratic proposals are trying to control costs?

 

Ryan's proposal was less about controlling costs than it was shifting costs around: it would've made the federal balance sheet look better, but those costs didn't actually go away.

The Democrats, on the other hand, have focused on ways to actually lower the cost of care delivery and their approach is now law.

 

What section of the "Affordable Care Act" actually reduced costs?

 

Aside from putting together better-functioning insurance markets, the real potential of the ACA for long-term cost control is in its delivery system reforms. These are structural changes, primarily to the way Medicare does business, that are intended to ultimately improve the way care is delivered. The general approach is to: (1) shift the way Medicare pays for services away from encouraging high-volume, low (or mediocre) value service provision, and (2) promote and assist health care providers in delivering better care more efficiently and less expensively, while holding them accountable for quality outcomes.

If you want lists and discussions of specific sections of the law on delivery system reform, Sheldon Whitehouse's office produced a good report on the subject: Health Care Delivery System Reform and The Patient Protection & Affordable Care Act. The whole thing is worth reading but you can skip to chapter four (page 19).

And if you want to explore some of the things being done to promote better, higher-value care delivery, I'd recommend starting with some of these:

• What We're Doing | Center for Medicare & Medicaid Innovation
  
• Hospital Value-Based Purchasing | Centers for Medicare & Medicaid Services
  
• AHRQ Effective Health Care Program
  
• Shared Savings Program | Centers for Medicare & Medicaid Services
  
• EHR Incentive Programs | Centers for Medicare & Medicaid Services

There's lots of stuff going on, not exclusively through the ACA but in conjunction with its philosophy.

 

Have your read those reports? The Democrats think the problem is mismanagment.

We pay twice what the rest of the first world does for healthcare, admin makes up the difference?

The problem is our isolation from cost. We have no idea what a doctor visit, or a medication, costs. All we know is the co-pay. Few of us know what our company pays for our medical insurance.

Make auto insurance work like health insurance. Pay a $10 copay to fill your gas tank, or to get your car repaired. Would gas mileage matter, would we spend any time on preventive maintenance? Lets say a car, no matter what you get, costs $2500. How many would be driving econo-boxes?

Medical insurance companies can keep 30% of the money they pass through as admin costs. How hard do they push back when a doctor asks to double his fee? Being the states regulate insurcance providers to only a few, there is little competition to keep costs low.

You want to control costs, provide insurance for catastrophic care, and a maximum, per year limit, for out of pocket costs. Let competition drive prices down, not single payer "orders from on high" (we see how well that works, as doctors drop Medicare).

 

No, let economies of scale achieve greater efficiency. Its single provision that enables an efficient outcome, particularly in health care which suffers from market failures associated with asymmetric information

 

I'm not entirely sure where this assertion is coming from. The report from Whitehouse's office is a pretty good and succinct summation of where current thinking on this is, particularly this paragraph:

Much inefficiency can be traced to misaligned incentives, lack of price and quality transparency, and inadequate mechanisms for coordinating and optimizing health care across the continuum of care. Realigning the delivery system to drive out inefficiencies in the health care system will be key to reducing costs and improving the quality of care. Five priority areas for delivery system reform commend themselves: (1) payment reform; (2) primary and preventive
care; (3) measuring and reporting quality; (4) administrative simplification; and (5) health information technology. This chapter reviews in each priority area relevant research and relevant reforms included in the ACA.​

Inefficiency from administrative complexity is only one component of high costs they point to and it certainly isn't the most important.

It's not an either/or proposition. The problems I've referenced don't go away just because people have to pay more out of pocket; the deficiencies in existing insurance and care markets don't vanish just because you feel a greater pinch. There's a piece called "Consumer-Driven Health Care: Promise And Performance" whose conclusion is worth repeating in full:

Health care should be consumer driven for reasons of both efficiency and ethics. When in possession of adequate information and faced with appropriate incentives, consumers make better choices for their own health than does any third party, be that third party motivated by the most praiseworthy of intentions. Moreover, as a matter of ethics, it is the patient and consumer, not the physician or insurer or employer or regulator, who should be vested with the right to make tradeoffs in the emotionally and sometimes spiritually charged domain of health care.

That said, one must acknowledge that consumers often need support if their choices are to promote their well-being and constraint when they are spending other people’s money. Health care is complex at best and not infrequently rife with nontransparent, anticompetitive, and even fraudulent behavior on the part of the many self-interested agents. Individual consumers can benefit from some of the efforts by governmental and employer sponsors, health insurance plans, provider organizations, and medical management programs. Consumers need others to create meaningful products and processes from which they can choose—bundles of products and services that can be measured, priced, purchased, and used not only by the highly educated and motivated individual but by those who are sick and scared, of only modest means and financial sophistication.

The blind spot in the consumer-driven analysis of market performance concerns the importance of coordination in insurance, delivery, and sponsorship. The obdurate insistence on á la carte choice and retail purchasing pushed the theorists of consumerism into positing organizational and market dynamics that have not been observed in the real world. The important issue is not, however, the current status and structure of health care and health insurance but the trend into the future. It seems safe to say that insurance product design will continue to move toward consumer-driven elements and that managed care elements will be recrafted into forms in which consumers choose but are subject to incentives structured by insurers. Enrollees will have more information but also more financial responsibility at the time of receiving care. Products will continue to proliferate and differentiate to accommodate the preferences and purses of potential enrollees. Health plans will specialize in data collection, aggregation, and analysis that can be used not only to support patient choice but also to evaluate provider and product performance through registries, observational studies, and clinical epidemiology.

As it moves further along the consumer pathway, health insurance is likely to strengthen rather than weaken some vestiges of its managed care heritage, especially the development of programs seeking to improve the care of enrollees along the spectrum from full health to dire illness. These include preventive and wellness programs for healthy enrollees, service coordination for patients needing acute care, disease management for enrollees with chronic conditions, and intensive case management for enrollees with severe conditions. These likely will be presented as options rather than mandates, consistent with the consumer-driven ethos, although perhaps with higher cost sharing for those who are eligible but choose not to participate. What is unclear, over the long term, is the extent to which more choice for consumers will prevent health insurers from being able to continue to offer the steep discounts they currently wrest from their provider networks.

The market is no more stuck on first-generation high-deductible insurance products and individually purchased coverage than it was stuck on HMO products and employment-based sponsorship models under managed care. The market continues to pioneer hybrid forms that incorporate elements of both managed care and of health care consumerism. We can name the emerging system “managed consumerism” or “facilitated consumerism,” or we can find some more felicitous phrase.30 The important point is that for choice to be meaningful, it has to be choice among meaningful options, and meaningful options need to be designed, built, and managed.​

Hybrid approaches are the direction in which we're going and if you aren't seeing the trend toward the higher-deductible plans you're pushing then you're not looking very closely. But that by itself isn't necessarily a good thing. That may be a piece of the puzzle but there's more to it than that.

If by this you mean movement toward relatively high deductibles, this is what's being done.

 

My point is that government is "administration". Therefore, they only can improve administration, so, by golly, that has to be the problem. They added a boatload more regulation and government programs.

That misses 70+% of the cost difference. For a reason, that 70% is what the medical industry (care givers as well as insurers) use to finance political campaigns - politicians don't want to lose that golden goose.


Am I seeing higher deductables, yes, they went from $10 to $20. That isn't what I propose.


My company spends $15K to insure me. Lets assume (to keep the math simple) a catastrophic care plan with a $12K max out of pocket plan cost $3K a year. The company increases my income by $1K per month. I pay for all medical costs out of that $1K per month. If I spend less, I keep it. If I spend more, I have to pay that out of pocket until $12K is reached (catastrphic care is an attempt to keep that from occuring in the first half of the year).

Health care providers are shopped based on price and quality of care by millions of individuals. Those providers that can cut costs while maintaining quality win more business, those that don't go away. Over time (unlike gooberment mandates), medical costs fall to a minimum level, then increase at a rate closer to inflation (like lasik and cosmetic surgery has).

 

You'd need a utopia where asymmetric information doesn't exist, otherwise you get numerous aspects of agency costs that directly harm well-being.

 

Do you work in the insurance industry?

 

Have economies of scale driven the price of military hardware down? Has it even reduced the price of Apple products?

Without competition, what is the motivation to reduce cost?

 

Computers, cars, automation equipment, etc. etc., have had as much an effect on the productivity, therefore the well being of the common man. They are just as prone to assymetric information as medical care, yet competiton keeps improving the product, and reducing the cost.

No utopia needed, just competion.

 

First, they aren't! Second, the likes of cars are heavily regulated.

The evidence shows otherwise: competition generates inefficient rent seeking whilst reducing the opportunities from benefits such as economies of scale

 

Health care isn't? If not, there is a significant difference between the US and UK

You keep saying that, and then don't provide any.

Why does competition work on improving the quality, and reducing the cost, of Lasik and cosmetic surgery?

 

The point is that cars are heavily regulated because of potential health and safety concern' whilst is easily done as we are focused on production within a oligopolistic framework. Health care regulation can reduce some excessive abuses but it cannot eliminate race to the bottom (as shown through the horrendous results in plastic surgery; see, for example, the additional costs to the British NHS as it 'corrects' the problems created through rent seeking)

Its nothing new and I've provided numerous times. Look up the DEA analysis into the subject (e.g. Mobley and Magnussen, 1998, An international comparison of hospital efficiency: does institutional environment matter?, Applied Economics, Vol. 30 Issue 8, pp 1089-1100)

Innovation improves quality; competition generates rent

 

Then you're in a rather unusual situation. The trend in group coverage is unambiguously toward higher-deductible plans, and I don't mean $20:



It was less than two months ago that Mercer was suggesting we're reaching a "tipping point" when it comes to consumer-directed health plans.

More than that, there are new incentives in the ACA for employers to continue moving in the direction of high-deductible plans. For instance, see this article from Workforce: Reform Could Accelerate Shift to High-Deductible Plans.

The same is true for individual coverage in the new exchanges.

For better or worse, the trend toward high-deductible plans is going to continue.

 

and the answer was??????

 

Greenbeard says what?

 

Sadly, no.

 

The auto regulation, as told by the Top Gear program, has less to do with safety, and more to do with the refusal to update roads.

As far as the UK cosmetic surgeons, too bad. But, that doesn't apply to my point about US medical care.

Another pay to read paper - the abstract mentions nothing about cost - just efficiency. And it compares Norway's medical care to the "highly unregulated medical care in California" - that statement alone eliminates any credibility you think the paper had.

Encarta had better quality than Encyclopedia Britannica? Now I understand why you don't understand entrepeneurship.

What has more rents, a monopoly (no competition), or the computer industry (highly competitive).

What had more innovation, FedEx, or the US Postal service before UPS / DHL / FedEx?

 

I see that as better, I assume you see that as worse.

Insurance only averages out the cost of care over our lifetime. The more we spend, the more expensive it has to be.

Socialized medicine reduces cost by increasing wait time enough that those that aren't really serious give up.

 

Top Gear? You're kidding me aren't you? You wouldn't honestly refer to such dross in a serious conversation!

There's no British specific aspect; its a general result of asymmetric information

A highly ignorant respond. The use of efficiency analysis is key for our understanding of costs. Is the US more market orientated than the Norwegian counterpart? Certainly! But its the latter that delivers a more efficient outcome, completely at odds with the usual market force tails.

You show your innocence again. We cannot make any simple unambiguous conclusion. Creative destruction for you!