What, you want actual information about health care reform?

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Re: What, you want actual information about health care reform?

Postby Garm » Thu Aug 20, 2009 8:58 pm UTC

Heisenberg epitomizes everything that's wrong with the anti-reform crowd. It's Criticism without comprehension. Often the lack of understanding is more willful than anything.
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Re: What, you want actual information about health care reform?

Postby Okita » Thu Aug 20, 2009 8:58 pm UTC

I've kinda been poking around trying to find an actual draft of the bill. Are there any copies to be found online?
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Re: What, you want actual information about health care reform?

Postby Garm » Thu Aug 20, 2009 9:00 pm UTC

Okita wrote:I've kinda been poking around trying to find an actual draft of the bill. Are there any copies to be found online?


You can find most bills here:
http://www.opencongress.org/bill/111-h3200/text

Of course it helps that I know the number of the bill. And keep in mind that this is just the house version.
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Re: What, you want actual information about health care reform?

Postby sophyturtle » Thu Aug 20, 2009 9:03 pm UTC

Meaux showed it to me and I downloaded it to my home computer, but I am not home.
So I know it is out there, I need to remember where...
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Re: What, you want actual information about health care reform?

Postby Vaniver » Thu Aug 20, 2009 9:06 pm UTC

Will wrote:A week's stay at a hospital can easily cost tens of thousands of dollars. Most people do not have enough wealth to cover those kinds of costs, so the money has to come from somewhere. It either comes from taxes, and the sick benefit disproportionately, or it comes from premiums paid and (gasp) the sick benefit disproportionately. There is no way for the sick to not benefit disproportionately from health coverage.
You're missing an option- individuals pool wealth to lessen their risk. Also known as insurance.

The problem is that insurance is a service that the market can provide because it benefits both the insured and the insurer. Coverage is a service that benefits just the covered, at the expense of the coverer. The difference is that the sick are a readily identifiable group in one case, and not in the other- the insurer doesn't know which of their customers will develop diabetes (if they did, they'd charge them more or not insure them). The coverer knows, because the customer already has diabetes.

Will wrote:The entire point of this is for us as a people to fucking grow up and accept that it's worth the burden on society to take care of our sick instead of damning them to financial ruin.
How big is the burden on society?

I mean, I'm willing to accept a social safety net of some sort, because I think the argument on whether or not something like that will exist in America is over. But what I'm not willing to accept is a social safety net with unlimited liability. At what point do we stop saying that health care for the sick is worth paying for with everyone's dollars? Who makes that decision? How much damage will that do to everyone else?

I'm also mildly amused that embracing a paternalistic society is cast as 'growing up.'
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Re: What, you want actual information about health care reform?

Postby EMTP » Thu Aug 20, 2009 9:08 pm UTC

That's the difference between insurance and coverage. Insurance is a small, certain payment now for a large, uncertain payout in the future. Replacing that with a small, certain payment now for a large, certain payout in the future makes the system win/lose, which means that private organizations won't touch it (unless they're charitable or have some other benefit from doing it). . .

Now, if everyone is getting covered, you can afford to charge the person who you know will cost $500 a month less than $500 a month- by overcharging other people. If you've got one old person with costs of $500, and two young people with expected costs of $50 each, you can charge everyone $200 a month. But, that's just income transfer from the healthy to the sick, from the young to the old- and I'm not sure that's reform I agree with.


Medical insurance companies are making money hand over fist with an ROI in the stratosphere. It would take a lot to make them simply pack up and go home. Even if the changes make their business less profitable, as long as it continues to be profitable, they will continue to do it.

Reform also has the potential to shift the insurance companies' business model in a favorable direction from the point of view of the public good. Right now, insurance companies have incentives to spend money in destructive and wasteful ways. For example, they have incentives to spend a large amount of money identifying people likely to be sick in the future, and denying them coverage (either flat-out, or via setting a price point they cannot afford.) This saves the individual insurance company a lot of money, but socially it is unproductive. The person still needs healthcare. The insurance companies, when they deny such a person coverage, are merely cost-shifting, either to a less savvy insurance company, to a provider who will treat them and not get paid, or to the state (after they go bankrupt and are eligible for Medicaid).

Another example is the practice, in the face of an expensive claim, of retroactively identifying a preexisting condition which the insurance company argues the patient should have known about (somehow) and should have informed them about. On the basis of that, coverage gets denied. This can be lucrative. If a claim is going to cost a half a million dollars to pay out, the insurance company can spend $250,000 on auditors, investigators, and fighting the claim in the courts, and they and their shareholders come out winners. Society is the loser, because the half a million in costs has not been eliminated -- just shifted.

So reform is not purely a redistributional enterprise. It's also about directing the insurance companies incentives to control costs and increase revenue towards real cost-saving rather than cost-shifting.

I mean, if you know that someone has a chronic condition that costs $500 a month to deal with, why would you offer that person medical care for less than $500 a month? Assuming it's your money that you're losing, not other people's.


You might do so if you think you have a model that will let you treat the $500/month condition for $300/month. Efficiency and innovation, remember? The purpose of regulation is not to eliminate the profit motive, but to give the corporate actors incentives in better accord with the public good.
Last edited by EMTP on Thu Aug 20, 2009 10:11 pm UTC, edited 2 times in total.
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Re: What, you want actual information about health care reform?

Postby Mr. N » Thu Aug 20, 2009 9:09 pm UTC

Vaniver wrote:I'm also mildly amused that embracing a paternalistic society is cast as 'growing up.'

*giggles*

Yes, once the "cost" word enters the picture someone is labeled evil. Or uncaring. Selfish?

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Re: What, you want actual information about health care reform?

Postby Belial » Thu Aug 20, 2009 9:13 pm UTC

Vaniver wrote:I'm also mildly amused that embracing a paternalistic society is cast as 'growing up.'


Yeah, everyone knows that being a grown up just means eating ice cream whenever you want and not having to do homework.
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Re: What, you want actual information about health care reform?

Postby Will » Thu Aug 20, 2009 9:23 pm UTC

Vaniver wrote:How big is the burden on society?

I mean, I'm willing to accept a social safety net of some sort, because I think the argument on whether or not something like that will exist in America is over. But what I'm not willing to accept is a social safety net with unlimited liability. At what point do we stop saying that health care for the sick is worth paying for with everyone's dollars? Who makes that decision? How much damage will that do to everyone else?

That burden has to be paid by society whether it's being paid in the form of taxes or insurance premiums. The cost is always there, and someone has to pay it. The only way to reduce that burden on society as a whole is to deny coverage--which is how the system works now. That's what half of this fearmongering is about--you hear about "rationing" of healthcare and similar lies; people don't seem to want to bear the burden that the sick place on society (until they find *themselves* sick and unable to deal with their healthcare bills.)

My argument about growing up is accepting that that burden is there and that it's worth bearing for, if nothing else, the sake of having compassion for those who are sick. It's not about paternalism, it's about realizing as individuals that we're a part of society and have a responsibility to it and that it's not all about ME ME ME.
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Re: What, you want actual information about health care reform?

Postby Darkscull » Thu Aug 20, 2009 9:25 pm UTC

Vaniver wrote:But what I'm not willing to accept is a social safety net with unlimited liability. At what point do we stop saying that health care for the sick is worth paying for with everyone's dollars? Who makes that decision? How much damage will that do to everyone else?


To make a useful reference to the British NHS for once: This is why countries with UHC have people like the British NICE, who decide in what sort of cases treatment will be given on the NHS, what medicines are worth the cost considering their benefits, etc.

So people who drank their way to liver failure aren't as likely to get another one (unless they're George Best :P), and the type of useless proscription medicines that are advertised on tv in the US aren't funded.

Sarah Palin calls this a 'death panel'.

Obviously, it would be different for whatever system is eventually in place in America, because you people insist on making things so complicated*, but I don't think anyone is suggesting unlimited liability. That would be silly and only exists in political arguments and the heads of delusional people (same thing).


*lighthearted ribbing, so don't get offended.
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Re: What, you want actual information about health care reform?

Postby Kizyr » Thu Aug 20, 2009 9:34 pm UTC

EMTP wrote:Another example is the practice, in the face of an expensive claim, of retroactively identifying a preexisting condition which the insurance company argues the patient should have known about (somehow) and should have informed them about. On the basis of that, coverage gets denied. This can be lucrative. If a claim is going to cost a half a million dollars to pay out, the insurance company can spend $250,000 on auditors, investigators, and fighting the claim in the courts, and they and their shareholders come out winners. Society is the loser, because the half a million in costs has not been eliminated -- just shifted.

I want to draw attention to this, since I think the point too-often gets ignored (particularly in the discussion on pre-existing conditions). The determination of a pre-existing condition isn't generally made by a physician, but by someone playing doctor. This prevents me from getting insurance, for example, since according to a few insurance companies (two specifically) I have a 'pre-existing condition', despite the fact that according to my doctors, I don't.

Luckily, I'm insured through my employer. But if I left this job and my insurance, I'd be screwed if I got sick or injured before finding a new job that provided insurance.

Hence, I'd be in full support of regulation to prevent insurance companies from denying coverage because of a (sometimes arbitrarily-defined) pre-existing condition, since it means that I'd actually be able to get insurance on my own if need be. That's worth a possible increase in premiums.

There're tons of other reasons why the healthcare and insurance market is markedly different from any other, but I'll stick to one issue per post here. KF
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Re: What, you want actual information about health care reform?

Postby chaosspawn » Thu Aug 20, 2009 9:35 pm UTC

Darkscull wrote:So people who drank their way to liver failure aren't as likely to get another one (unless they're George Best :P)

Is this actually codified into law somewhere? Deny medical care based upon how at fault the person was for causing it? It'd seem to me that determining the cut-off line seems rather... arbitrary?
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Re: What, you want actual information about health care reform?

Postby Vaniver » Thu Aug 20, 2009 9:41 pm UTC

EMTP wrote:This save the individual insurance company a lot of money, but socially it is unproductive.
Only if there's no benefit to early detection/prevention ('hm, the actuaries say you've got a heightened chance to get heart disease. These are the things you should do to minimize your risk'), and the pricing schedule doesn't reduce the cost for healthier people. If my chance to get sick is 1%, and the insurance company knows that, then they'll charge me the 1% rate (if they try to overcharge me, and another company doesn't, I go with the cheaper company).

EMTP wrote:You might do so if you think you have a model that will let you treat the $500/month condition for $300/month. Efficiency and innovation, remember? The purpose of regulation is not to eliminate the profit motive, but to give the corporate actors incentives in better accord with the public good.
First, innovation happens mostly on the provider side (all that insurers can do is reduce overhead, which rarely results in 40% savings), and second, profit caps reduce the amount invested in improving efficiency and innovation.

Belial wrote:Yeah, everyone knows that being a grown up just means eating ice cream whenever you want and not having to do homework.
No, being a grown-up means moving out of your parent's home, paying your own bills, and working at a job. Being responsible for other people falls under being a 'parent.'

Will wrote:That burden has to be paid by society whether it's being paid in the form of taxes or insurance premiums. The cost is always there, and someone has to pay it. The only way to reduce that burden on society as a whole is to deny coverage--which is how the system works now.
My point is that the amount of coverage that can be provided is finite, and the more coverage we provide, the less we can have of other things. So arguing down from providing all coverage to everyone doesn't make a whole lot of sense to me- not only is the original position impossible, I don't particularly want to live in a Cuba with above-average medical care and below-average quality of life.

Will wrote:My argument about growing up is accepting that that burden is there and that it's worth bearing for, if nothing else, the sake of having compassion for those who are sick. It's not about paternalism, it's about realizing as individuals that we're a part of society and have a responsibility to it and that it's not all about ME ME ME.
What you're saying describes paternalism well- it's caring for other people without giving them responsibilities. I don't see any reason to interpret "THEM THEM THEM" as anything besides someone else saying "ME ME ME"- and so I don't see too much moral difference between them.

Darkscull wrote:To make a useful reference to the British NHS for once: This is why countries with UHC have people like the British NICE, who decide in what sort of cases treatment will be given on the NHS, what medicines are worth the cost considering their benefits, etc.
NICE is the apparatus of decision-making, not the decision-maker. Someone tells NICE how much to value lives, and then they apply that standard to treatments (or they do the same thing in a more convoluted and less effective way). Who decides how much the public is going to pay to extend lives?
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Re: What, you want actual information about health care reform?

Postby Crius » Thu Aug 20, 2009 9:42 pm UTC

EMTP wrote:Medical insurance companies are making money hand over fist with an ROI in the stratosphere. It would take a lot to make them simply pack up and go home. Even if the changes make their business less profitable, as long as it continues to be profitable, they will continue to do it.
sophyturtle wrote:The bill limits insurers to 15% profit maybe? and the rest of what is collected has to go back into patient care. I like that idea a bit. Also, not being able to turn people down or drop their coverage is a nice bit too.


Healthcare insurance already has a low profit margin (3.3%). You're not going to get much savings relative to the total cost by squeezing lowering their profit margins. (The total profits have risen in relation to total healthcare costs, but I believe the profit margin has actually been going down)

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Re: What, you want actual information about health care reform?

Postby Darkscull » Thu Aug 20, 2009 9:46 pm UTC

chaosspawn wrote:
Darkscull wrote:So people who drank their way to liver failure aren't as likely to get another one (unless they're George Best :P)

Is this actually codified into law somewhere? Deny medical care based upon how at fault the person was for causing it? It'd seem to me that determining the cut-off line seems rather... arbitrary?


Nope, it isn't.
NICE makes the decisions, and can change them easily when they decide it's right.

And care isn't actually denied due to it, transplants are the only example where it currently affects it, and then it just puts you at a lesser priority if it's your own fault (which is the same in America, if House and Scrubs are to be believed).
Smokers still get treated even when it's demonstrably their own fault and such.

It's mainly deciding which treatments will be funded that is covered currently, and only the tabloids think it's not done well.

However that's not really relevant to this topic, was just clearing up that misconception.

edit:
Vaniver wrote:NICE is the apparatus of decision-making, not the decision-maker. Someone tells NICE how much to value lives, and then they apply that standard to treatments (or they do the same thing in a more convoluted and less effective way). Who decides how much the public is going to pay to extend lives?


Wrong.
They're given an estimate of the budget (the NHS always goes overbudget), and decide which treatments to license for use.
Whenever a new treatment is proposed, they see whether it's cost is worth it's benefit.
A new, expensive drug which is aspirin with a tiny adjustment that makes 1% of those allergic to it less likely to have a negative reaction (or something stupid like that) will be rejected, and stuff like that.

Valuations are not made on a person by person basis, and no one is denied care because they've been costing too much.
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Re: What, you want actual information about health care reform?

Postby chaosspawn » Thu Aug 20, 2009 9:51 pm UTC

Darkscull wrote:A new, expensive drug which is aspirin with a tiny adjustment that makes 1% of those allergic to it less likely to have a negative reaction (or something stupid like that) will be rejected, and stuff like that.

Valuations are not made on a person by person basis, and no one is denied care because they've been costing too much.

To play a bit of devil's advocate, aren't they effectively deciding who's covered by what treatments are covered. I mean if you're in that 1% (assume it's something more critical than aspirin), it'd certainly feel like you were denied coverage because you were too expensive to treat.
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Re: What, you want actual information about health care reform?

Postby Darkscull » Thu Aug 20, 2009 9:55 pm UTC

chaosspawn wrote:
Darkscull wrote:A new, expensive drug which is aspirin with a tiny adjustment that makes 1% of those allergic to it less likely to have a negative reaction (or something stupid like that) will be rejected, and stuff like that.

Valuations are not made on a person by person basis, and no one is denied care because they've been costing too much.

To play a bit of devil's advocate, aren't they effectively deciding who's covered by what treatments are covered. I mean if you're in that 1% (assume it's something more critical than aspirin), it'd certainly feel like you were denied coverage because you were too expensive to treat.


There are almost always alternatives to each treatment.
If not having that drug meant a lifetime on dialysis, you'd still get that on the NHS, and could appeal to get the drug (or get it privately if you could afford it). That doesn't make sense when you consider that one case, because it will have cost more for the dialysis than however many doses of the drug, but it would still work out countrywide.

I'm going to stop talking about this now because this is a useful thread and there is little point in comparison to the NHS especially as a derailment.
I mentioned it in the first place as an example of why unlimited liability doesn't have to be the case, but obviously raised too many questions with my wording.
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Re: What, you want actual information about health care reform?

Postby Will » Thu Aug 20, 2009 9:59 pm UTC

Vaniver wrote:
Will wrote:My argument about growing up is accepting that that burden is there and that it's worth bearing for, if nothing else, the sake of having compassion for those who are sick. It's not about paternalism, it's about realizing as individuals that we're a part of society and have a responsibility to it and that it's not all about ME ME ME.
What you're saying describes paternalism well- it's caring for other people without giving them responsibilities. I don't see any reason to interpret "THEM THEM THEM" as anything besides someone else saying "ME ME ME"- and so I don't see too much moral difference between them.

That is what the individual mandate is about. It is holding people to the responsibility of helping pay for our healthcare system in exchange for being covered by it.
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Re: What, you want actual information about health care reform?

Postby chaosspawn » Thu Aug 20, 2009 10:11 pm UTC

Vaniver wrote:But, that's just income transfer from the healthy to the sick, from the young to the old- and I'm not sure that's reform I agree with. Particularly because transfers from the young to the old are regressive.
Hmm, that is an interesting point really. I had basically realized that the healthy subsidize the sick in the system. But that is an interesting point, since the sick are usually older (80% of medical care comes in the last few years of life is what I've heard bandied about) and the young/old dichotomy does have a regressive nature in it. I really can't see too much of a way around that, maybe the health care only applies while you're not on Medicaid?

One thing I do like about my current coverage is the Health Savings Account. I'd like to see it be more standard and not just limited to certain sets of plans. Mostly because this type of plan covers the drastic expenses, while still encouraging regular use of preventative care, and letting you build up a safety net.
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Re: What, you want actual information about health care reform?

Postby Vaniver » Thu Aug 20, 2009 10:20 pm UTC

Darkscull wrote:Wrong.
They're given an estimate of the budget (the NHS always goes overbudget), and decide which treatments to license for use.
Whenever a new treatment is proposed, they see whether it's cost is worth it's benefit.
The two are separate. The first is saying "instead of pricing lives, we're giving you X pounds to treat people with, try to maximize the number of lives you save"- which is pricing lives, just one step removed (so, whoever decides NHS's budget is pricing lives). Liability is limited by an annual cap on funds (NHS can go overbudget, but not by an unlimited amount).

For the second one, you need to have cost and benefit in the same units to compare them- and you need to know the opportunity cost for the treatments.

Will wrote:That is what the individual mandate is about. It is holding people to the responsibility of helping pay for our healthcare system in exchange for being covered by it.
But that's making both of your children chip in to replace the lamp that one of them accidentally broke, not making the one that broke it pay. Communal responsibility and individual responsibility are perceived very differently, and have very different impacts on behavior.
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Re: What, you want actual information about health care reform?

Postby Will » Thu Aug 20, 2009 10:31 pm UTC

So what you're saying is...you think that a single person should have to shoulder the entire burden for their healthcare cost? Even if they're not able to do so?

"Taking care of people" is not about affecting their behavior, it's about taking care of people.
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Re: What, you want actual information about health care reform?

Postby EMTP » Thu Aug 20, 2009 10:31 pm UTC

Vaniver wrote:
EMTP wrote:This save the individual insurance company a lot of money, but socially it is unproductive.
Only if there's no benefit to early detection/prevention ('hm, the actuaries say you've got a heightened chance to get heart disease. These are the things you should do to minimize your risk'), and the pricing schedule doesn't reduce the cost for healthier people. If my chance to get sick is 1%, and the insurance company knows that, then they'll charge me the 1% rate (if they try to overcharge me, and another company doesn't, I go with the cheaper company).


The pricing schedule has no effect on the cost to care for other people. Insurance company physicals rarely produce useful information of the sort you suggest. People are bombarded with messages about a healthy lifestyle, and if they have access to healthcare, they will probably get both the physical and the lecture in short order. The very small (but non-zero, you're correct as far as that goes) amount of useful information such investigations produce is dwarfed by the amount expended. There are other costs to the practice as well -- such as creating incentives to be less than honest with your doctor, given that what the doctor records could negatively affect your ability to get health care coverage in the future.

Vaniver wrote:
EMTP wrote:You might do so if you think you have a model that will let you treat the $500/month condition for $300/month. Efficiency and innovation, remember? The purpose of regulation is not to eliminate the profit motive, but to give the corporate actors incentives in better accord with the public good.
First, innovation happens mostly on the provider side (all that insurers can do is reduce overhead, which rarely results in 40% savings), and second, profit caps reduce the amount invested in improving efficiency and innovation.


As to the first point, I agree. Insurance companies are not really in a position to serve a productive role. They're parasites. But the insurance model can be combined with the medical home model to produce the kinds of efficiencies I'm talking about (Kaiser, the Mayo Clinic, the Cleveland Clinic).

The second point is libertarian boilerplate that doesn't address the specific case. First, a regulation that costs money is not a profit cap. Second, in market theory, reduced profits will reduce capital investment. But capital investment can decrease whilst the amount spent on efficiency and innovation increases in the proposed regulations make measures to increase efficiency and innovation comparatively more attractive. And an industry with low margins -- like the semiconductor industry -- has more powerful incentives to change and improve than one in which margins are high. If your are succeeding under the present market structure, you have to think twice before introducing an innovation that will upend the market in which you operate: the "Dreadnought" phenomenon.
Last edited by EMTP on Thu Aug 20, 2009 10:32 pm UTC, edited 1 time in total.
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Re: What, you want actual information about health care reform?

Postby athelas » Thu Aug 20, 2009 10:31 pm UTC

chaosspawn wrote:Hmm, that is an interesting point really. I had basically realized that the healthy subsidize the sick in the system. But that is an interesting point, since the sick are usually older (80% of medical care comes in the last few years of life is what I've heard bandied about) and the young/old dichotomy does have a regressive nature in it. I really can't see too much of a way around that, maybe the health care only applies while you're not on Medicaid?
Heh, if you really want to get your mind blown, read this post. I'm not sure I buy it but it's an interesting perspective on progressivity and lifespan.
The "poorest" people are not those with low incomes but rather those with low human capital endowments. That includes the elderly because, even if they are very talented, on average they will die sooner. A typical 23-year-old lower-middle-class immigrant has a higher real endowment than does Warren Buffett.

Through Medicare, the U.S. government subsidizes the health care of the elderly. Given the embedded incentives in the system, the subsidy is especially large for people in the last year of life or so, namely the very poorest. Western European welfare states may be more efficient, because they do more to expand routine health care access for the relatively young and this may have a higher rate of return. But those same systems are in critical regards less egalitarian. Bravo to them....

A few of these people also confuse "high social status" with "well off." Since old, high-bank-account white males have lots of social status and power, these onlookers cannot bring themselves to regard those males as holding very poor overall endowments. They substitute in assessments of social status for assessments of absolute endowments (another sign of the claim that "politics is not about policy" but rather it is about whom we should admire and condemn).

From the comments: "Let us say you are a twenty three year old immigrant living in New York. Would you want to trade places with Warren Buffett?

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Re: What, you want actual information about health care reform?

Postby Vaniver » Thu Aug 20, 2009 10:35 pm UTC

Will wrote:So what you're saying is...you think that a single person should have to shoulder the entire burden for their healthcare cost? Even if they're not able to do so?

"Taking care of people" is not about affecting their behavior, it's about taking care of people.
I think that the burdens of others should only be shouldered voluntarily. I think it makes a difference to many people whether they are working for themselves or for others, and people often are more productive when they get the benefits of their production.
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Re: What, you want actual information about health care reform?

Postby Will » Thu Aug 20, 2009 10:43 pm UTC

And the benefit of everyone having health coverage is that everyone has health coverage. This is not some two-sided system where some people are paying for others to get the benefit. Everyone pays into the system and in return everyone gets covered.
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Re: What, you want actual information about health care reform?

Postby (╯°□°)╯︵ ┻━┻ » Thu Aug 20, 2009 10:43 pm UTC

Vaniver wrote:
Belial wrote:Yeah, everyone knows that being a grown up just means eating ice cream whenever you want and not having to do homework.
No, being a grown-up means moving out of your parent's home, paying your own bills, and working at a job. Being responsible for other people falls under being a 'parent.'


Am I not my brother's keeper?

Also:

http://energycommerce.house.gov/Press_1 ... /aahca.pdf

The Bill: America’s Affordable Health Choices Act of 2009, as it is in the Energy and Commerce Committee of the House. Released July 14.
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Re: What, you want actual information about health care reform?

Postby Princess Marzipan » Thu Aug 20, 2009 10:45 pm UTC

Vaniver wrote:
Will wrote:That is what the individual mandate is about. It is holding people to the responsibility of helping pay for our healthcare system in exchange for being covered by it.
But that's making both of your children chip in to replace the lamp that one of them accidentally broke, not making the one that broke it pay. Communal responsibility and individual responsibility are perceived very differently, and have very different impacts on behavior.

And here we see the boisterous "Vaniverous incorrecticus" equating 'getting sick' with 'misbehaving'.
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Re: What, you want actual information about health care reform?

Postby EMTP » Thu Aug 20, 2009 11:14 pm UTC

Vaniver wrote:I think that the burdens of others should only be shouldered voluntarily.


Believe me, we know. Where I differ from you (well, one area) is in not regarding outcomes of social interactions to be necessarily fair or just. Your wealth or lack thereof is a social construction. So is another's lack of those things. So taking some of "your" resources to address "his" burdens is not an enforced transfer of wealth, but a condition attached to participation in the social contract without which your property rights do not exist. In other words, under our social contract property rights are limited, and one of the limitations is that your government may intercept wealth on its way to you, or require you to accept the transfer of some of "your" wealth to the government.

You might compare it to a poker game in which the house gets a share of the pot (the rake). The house is not stealing money out of the pot; without the house, there is no game, and one of the conditions of the game is the rake. Social safety nets are akin to an enlightened house that wants to keep its customers happy and uses a portion of the rake to make sure the losers, while they don't keep pace with the winners, aren't left with nothing.

Libertarians would object that our participation in society is forced and involuntary, unlike a game in which we voluntary accept a condition like the rake. My reply is that participation is involuntary for both winners and losers. Not only is the winner losing a share of the take someone who has been forced to play, so is the person who stood up with nothing. Unless you feel the game is entirely fair, with no injustice to the advantage or disadvantage of anyone, and you believe that destitution in the midst of great wealth is an appropriate consequence for not being very good at a game you are being forced to play, can you, I think, make a serious argument that there should not be some mechanism within the structure of the game (prior to the charity of the winners) to mitigate its harshest consequences.

I think it makes a difference to many people whether they are working for themselves or for others, and people often are more productive when they get the benefits of their production.


I think that's broadly true, but the continued presence of Sweden, Denmark and Norway among the ranks of the ten most competitive economies of the world demonstrates that one of two things must be true: 1) You do not need to capture anything like 100% of the benefits of your production to get most of the benefits of the incentive, and/or 2) A strong social safety net contributes greatly to a society's overall productivity, mitigating the effects of the dilution of personal incentives.
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Re: What, you want actual information about health care reform?

Postby JBJ » Thu Aug 20, 2009 11:44 pm UTC

Vaniver wrote:I think that the burdens of others should only be shouldered voluntarily. I think it makes a difference to many people whether they are working for themselves or for others, and people often are more productive when they get the benefits of their production.

Do you have insurance? If so, others are helping pay for your health care and you are a hypocrite. If you've have it, drop it and never sign up for it again. When you reach the age for Medicare, refuse it. Can't have others involuntarily pay for your care. Go on, I'll wait.

If you're healthy now, you could stash away some money for an emergency. Lots of people do this, it's quite a responsible thing to do. My family and I incur relatively low health costs. We have a plan with a health savings account and have a few grand in it already. You could probably even invest that money and get a nice return. Stock market seems to be leveling out now, it might be great time to get in. If you're lucky, you may never have to touch that money. If you do get ill, hopefully you won't have to take out too much. And here's really hoping that you don't need something that costs more than you saved up. If you do, I'm sorry. Say hi to St. Peter for me.
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Re: What, you want actual information about health care reform?

Postby Vaniver » Fri Aug 21, 2009 1:30 am UTC

EMTP wrote:Insurance companies are not really in a position to serve a productive role. They're parasites.
I'm sorry for missing your post before! I'll answer it now. In general, consumption-smoothing can increase the lifetime utility of everyone involved, and the improvement is related to how risk-averse the customers are and how expensive the risk is. So health insurance is desirable, and so the organizations that provide it aren't parasites, if they're actually providing consumption-smoothing.

EMTP wrote:First, a regulation that costs money is not a profit cap.
Back when this thread was about Obama, sophyturtle mentioned that there might be a profit cap of 15%- that's what I was responding to.

EMTP wrote:But capital investment can decrease whilst the amount spent on efficiency and innovation increases in the proposed regulations make measures to increase efficiency and innovation comparatively more attractive. And an industry with low margins -- like the semiconductor industry -- has more powerful incentives to change and improve than one in which margins are high. If your are succeeding under the present market structure, you have to think twice before introducing an innovation that will upend the market in which you operate: the "Dreadnought" phenomenon.
This is true, but I don't think your example is convincing. The semiconductor industry requires significant innovation because of the nature of the business, and has its own Dreadnought problems (though I might have that impression just because my source are scientists whose innovations got sidelined because they weren't incremental improvements).

Will wrote:Everyone pays into the system and in return everyone gets covered.
But coverage is not binary. Coverage, both its quality and its cost, varies heavily in between individuals. If only get back, on average, 25% of the amount of money I have to pay for coverage, 75% of my bill is paying for the coverage of others. Since we're talking about insurance as well as coverage, very few (if any) people will get back exactly the amount of money they spent on health insurance- but average return should be calculable.

Princess Marzipan wrote:And here we see the boisterous "Vaniverous incorrecticus" equating 'getting sick' with 'misbehaving'.
One can accidentally break a lamp without misbehaving- but is there an example of personal responsibility you would prefer I use? The point remains that personal responsibility and communal responsibility are different, and saying that I have a personal responsibility to fund the communal responsibility to fund other's personal responsibility is a train of argument that I do not agree with.

EMTP wrote:Unless you feel the game is entirely fair, with no injustice to the advantage or disadvantage of anyone, and you believe that destitution in the midst of great wealth is an appropriate consequence for not being very good at a game you are being forced to play, can you, I think, make a serious argument that there should not be some mechanism within the structure of the game (prior to the charity of the winners) to mitigate its harshest consequences.
The first part of this statement interests me. What makes a game fair? What makes a game unfair? In the simplest sense, a game is fair if the rules are enforced equally for all players- in an another sense, a game is fair if the rules do not alter a player's outcome (that is, they do not advantage some players over others). So, in one sense, a house that redistributes the rake to players based on their winnings (rather than just funding the maintenance and operation of the house) makes the game less fair.

I do have some trouble with the idea of the economy as a poker game- because while skill and luck are significant factors for both situations, one is zero-sum while the other is not. The rake, however, is zero-sum.

That all are forced to play the game is a potent point- but it brings into question artificial and natural constraints. None of us can wish ourselves into a better world, or wish hungry bellies full- but we can decide to appropriate or buy with appropriated funds to fill bellies. Are our duties to our fellow man constant, or do they depend on our ability to fulfill them? Our willingness to fulfill them?

EMTP wrote:I think that's broadly true, but the continued presence of Sweden, Denmark and Norway among the ranks of the ten most competitive economies of the world demonstrates that one of two things must be true: 1) You do not need to capture anything like 100% of the benefits of your production to get most of the benefits of the incentive, and/or 2) A strong social safety net contributes greatly to a society's overall productivity, mitigating the effects of the dilution of personal incentives.
That's true- as pointed out by Alan Greenspan, both American-style capitalism and Scandinavian-style welfare capitalism work. The increased social stability has a cost (and the worst bits for the Scandinavian countries on the GCR ratings were their nonwage costs of labor) of maybe a point of annual GDP growth- enough to make a difference over a lifetime, but not enough to give one country a significant edge for a decade.

JBJ wrote:Do you have insurance? If so, others are helping pay for your health care and you are a hypocrite. If you've have it, drop it and never sign up for it again.
While doubtless some of the people who are serviced by my HMO would not buy in if the tax incentives were different, I tend to count that as voluntary for practical reasons. As stated, insurance is the voluntary pooling of capital to defray uncertain future costs.
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Re: What, you want actual information about health care reform?

Postby EMTP » Fri Aug 21, 2009 2:47 am UTC

Vaniver wrote:In general, consumption-smoothing can increase the lifetime utility of everyone involved, and the improvement is related to how risk-averse the customers are and how expensive the risk is. So health insurance is desirable, and so the organizations that provide it aren't parasites, if they're actually providing consumption-smoothing.


Health care is desirable. Health insurance is not. We could, if we wanted, have private insurance companies who would truck out water to you if your well dried up, or your local supply became infected with cholera. But a better way to "smooth" that risk is to pay your taxes and demand low-cost clean water be provided by the government or a tightly regulated utility. Health insurance is better than paying out of pocket. It's not as good as using the government to pool risk.

Back when this thread was about Obama, sophyturtle mentioned that there might be a profit cap of 15%- that's what I was responding to.


I see that now. As far as I know, there is no profit cap in the legislation, and I don't think it would be a good idea if there were.

This is true, but I don't think your example is convincing. The semiconductor industry requires significant innovation because of the nature of the business, and has its own Dreadnought problems (though I might have that impression just because my source are scientists whose innovations got sidelined because they weren't incremental improvements).


What is it about the business, do you think, that creates structural pressure for innovation? Low margins would seem like they could be part of it. With a low margin, you have to seize every advantage. If you're making lots of money, especially in a market dominated by a few large companies, you can hang back a little, and see if the other companies (which are also making money) want to rock the boat. Our laws against collusion were designed prior to the explosion of behavioral economics, and it seems to me they (the laws) do not really reflect all the possibilities for unspoken, even unconscious collusion which we now understand to exist in such a market.

But in any case, I don't think that's where the greatest social benefit is in reform. Whatever the absolute magnitude of the incentives, the most important thing is to enhance the incentives for cost-saving by blunting the incentives for cost-shifting. (Another way to do that, theoretically, would be to get the government out of the business of being the insurer of last resort, and hope that the resulting calamities shame the insurers into better behavior. I don't believe the benefits of such a strategy justify the risks.)

The first part of this statement interests me. What makes a game fair? What makes a game unfair?


Good question, but one that might take us far afield. One basic test of fairness is whether everyone starts the game from the same place. If I start Monopoly with $1,500 dollars, and you start with $3,000 dollars, that's unfair. Not only is it unfair to the tune of $1,500, but it is unfair because in Monopoly, as in many other games, as in life, a small advantage at the beginning can be converted into a huge advantage by the end.

So, in one sense, a house that redistributes the rake to players based on their winnings (rather than just funding the maintenance and operation of the house) makes the game less fair.


A couple things. In the metaphor, adjustments occur after the game is decided. They don't reflect on the outcome of the game, only the consequences. Like a game of marbles, the economic system can be "keeps," or we can mitigate that somewhat so no one goes home without any marbles. But that doesn't change who the winners and losers are. Changing the stakes does not affect the fairness of the contest.

I don't think even a bias in the game, applied universally, is unfair. Are "loser's outs" in basketball unfair? That's a systematic bias in the game against those that make their shots.

I do have some trouble with the idea of the economy as a poker game- because while skill and luck are significant factors for both situations, one is zero-sum while the other is not. The rake, however, is zero-sum.


It depends on what you do with the rake and what exactly you're summing. If you take my new-porsche money and use it to pay for a hundred kids' asthma medications, one could reasonably argue that while you have not increased the amount of dollars, you have increased the amount of value.

That all are forced to play the game is a potent point- but it brings into question artificial and natural constraints.


Exactly, I think the difference between artificial and nature constraints is exactly on point. I see the allocation of the productive capacity of our society as artificial, and as such, it's subject to our modulation by means of our democracy. If you see our economic system as arising from natural laws pertaining to property, you can make the argument that society merely interferes, or refrains from interference, in a natural process whose rules predate the social contract. I think there are many problems with the latter account.

None of us can wish ourselves into a better world, or wish hungry bellies full- but we can decide to appropriate or buy with appropriated funds to fill bellies.


The term "appropriated" is one I disagree with. If you lose a civil suit, has your money been appropriated to be transferred to the other party? No. Not in the sense that is usually meant. If according to the rules of the game, we lose control of an asset, "our" property has not been confiscated. It's simply not ours anymore.

Are our duties to our fellow man constant, or do they depend on our ability to fulfill them?


They depend on our ability to fulfill them. If you cannot swim, your duty to pull a drowning man to shore does not exist. If you come upon a baby drowning in a 5-gallon bucket, your duty to act does exist.

Our willingness to fulfill them?


In practice, unless enough of us are willing, we will not act, but no duty ceases to exist because we feel unwilling to act as it would oblige us to. Such a concept of duty would be self-contradictory.

That's true- as pointed out by Alan Greenspan, both American-style capitalism and Scandinavian-style welfare capitalism work. The increased social stability has a cost (and the worst bits for the Scandinavian countries on the GCR ratings were their nonwage costs of labor) of maybe a point of annual GDP growth- enough to make a difference over a lifetime, but not enough to give one country a significant edge for a decade.


Agreed. The wonderful thing about command economies, as ideological foils, was that they failed. Completely. Massively. In every sphere. We can't always be so lucky in our choice of antipodes. It would be convenient for social democrats if the Anglo-Saxon model led inevitably to social upheaval and cascading market failure. It would be nice for small-government types if social democracy led inevitably to stagnation with masses trapped in poverty. But the uncomfortable truth is that both models can succeed by those measures of success which are common to us both. Which means we have to confront the question of what kind of society we all want to live in without the comforting illusion that all other paths lead to failure.
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Re: What, you want actual information about health care reform?

Postby Will » Fri Aug 21, 2009 2:49 am UTC

Our civic duties are about more than your individual ROI. This is what I mean when I talk about growing the fuck up; you have to realize that you're not the only person in this society and because you benefit from living in society (by, for example, being able to live at all) you have certain duties to that society that might not give you, individually, a positive return on investment, but nonetheless benefits you because you are a member of that society.
Also, you have failed to consider the (very real) possibility that YOU will end up being someone who needs medical care outside of your means (if you need ANY kind of significant medical care, it WILL be outside of your means. I don't know anyone who could afford to pay for a $10,000 night in the hospital out of pocket.) So the healthy subsidize the sick, because any one of us healthy people might end up being sick tomorrow. This safety net is there for you, too. And even if you only have a 25% chance of ever needing it? Guess what, you have ONE life to live. You don't get to diversify that risk away, none of us does.

Vaniver wrote:One can accidentally break a lamp without misbehaving- but is there an example of personal responsibility you would prefer I use? The point remains that personal responsibility and communal responsibility are different, and saying that I have a personal responsibility to fund the communal responsibility to fund other's personal responsibility is a train of argument that I do not agree with.


Seriously? You seriously believe that getting sick has anything at all to do with personal responsibility? How the hell do you figure that?
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Re: What, you want actual information about health care reform?

Postby Princess Marzipan » Fri Aug 21, 2009 3:03 am UTC

Vaniver wrote:One can accidentally break a lamp without misbehaving- but is there an example of personal responsibility you would prefer I use? The point remains that personal responsibility and communal responsibility are different, and saying that I have a personal responsibility to fund the communal responsibility to fund other's personal responsibility is a train of argument that I do not agree with.

Here the Vaniverous Incorrecticus mumbles incoherently and simply makes the same primitive gestures more and more forcefully. MMPH, it says. MMPH, MMPH! What's that, Vaniverous? Being born with a genetic disease or a predisposition to cancer or being unlucky enough to be knocked into a coma through some entirely accidental trauma contains an element of personal responsibility? Yes, of course, Vaniverous! How silly of the Terri Schiavos of the world to do such silly things like fall into comas without first ensuring they have the wealth to pay for it!

Haha, silly Vaniveri.
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Re: What, you want actual information about health care reform?

Postby JBJ » Fri Aug 21, 2009 3:16 am UTC

Will wrote:Also, you have failed to consider the (very real) possibility that YOU will end up being someone who needs medical care outside of your means (if you need ANY kind of significant medical care, it WILL be outside of your means. I don't know anyone who could afford to pay for a $10,000 night in the hospital out of pocket.) So the healthy subsidize the sick, because any one of us healthy people might end up being sick tomorrow. This safety net is there for you, too. And even if you only have a 25% chance of ever needing it? Guess what, you have ONE life to live. You don't get to diversify that risk away, none of us does.

That.

I don't have the figure, but I seem to recall that a good portion of the uninsured in the US are people in their 20's. Healthy people who have no significant chance of needing medical care even when it is available to them. I admit it, I was one. Back then I would have rather had the extra $50-$100 in each paycheck. In hindsight I was rather foolish. I was extremely lucky that I didn't get seriously ill. The medical care I did receive during that time I paid for out of pocket. One was a rather hefty bill for an ER visit with a dislocated shoulder. Fortunately it was fixed with some pain medicine, muscle relaxants, and some manipulation. If surgery was required, there would have been no way I could have afforded it. As it was, my 2 hours at the ER cost in the neighborhood of $4,000.

So, if it should be voluntary, then only those who anticipate that they'll get equal or greater benefit should participate? That is counter-intuitive. It seems wiser to have a larger base of lower risk participants. Their contributions will lower the rates for everyone else. And as they age and their risk increases they benefit from the same lower rates due to incoming groups of new lower risk participants.
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Re: What, you want actual information about health care reform?

Postby EMTP » Fri Aug 21, 2009 3:34 am UTC

I don't think personal responsibility is unrelated to sickness. Most of the things that kill us in a modern society are closely related to our lifestyle. We can be understood to have some responsibility to save our money and prepare for a rainy day, as well as to educate ourselves about our health and our healthcare so as to make informed choices. I work in the ED, with a group of people who are self-selected to accept responsibility for caring for a lot of people society has turned its back on. Nevertheless, everybody is frustrated with people who refuse all personal responsibility for their health, don't take their medicines, do take other things that are not good for them, etc. Responsibility should, with some understandable exceptions (the profoundly mentally ill, minors, etc) be a two-way street.

The better question is, what should the consequences be of acting irresponsibly? As a citizen, I have no problem with there being negative consequences for irresponsibility, I just don't accept that a slow, painful, unnecessary death (which is what a purely "free market" approach would condemn many to) should be one of them. It's part and parcel of our obsession in this country between the "deserving" and "undeserving" poor. Who cares? Even if you are lazy and foolish, the proper penalty for that is to live in a crummy apartment and crossing the street to avoid the people you went to high school with. It's not to go hungry in the midst of an obesity epidemic, or to be homeless when there's plentiful shelter for all.

PS: I think Vaniver is expressing very modestly and cogently a worldview shared by a lot of people, especially on the interwebs. I don't see anything he's written here that justifies the angry, dismissive denouncements that are starting to show up. There's a reason Cain asked if he was his brother's keeper. It's a fair question, even if you feel you know the answer.
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Re: What, you want actual information about health care reform?

Postby Belial » Fri Aug 21, 2009 3:37 am UTC

EMTP wrote:There's a reason Cain asked if he was his brother's keeper.


So what you're saying is that vaniver has killed the entire lower class, and is now trying to act surly to deflect the suspicions of his omnipotent creator?
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Re: What, you want actual information about health care reform?

Postby Lumpy » Fri Aug 21, 2009 3:50 am UTC

I think if you are going to say you wouldn't donate to a fund (for simplicity's sake let us say it is a charity, rather than being taxed by the government) because there is a chance the money you donate could go to drunk drivers and people that injure themselves playing with nail guns, then if there were a foolproof way to divine these people from those that got sick through no fault of their own, then what percentage of the money you donate being spent on the aforementioned groups would you say is too high for it to be worth donating to help out those that need heart surgery? In the absence of statistics, how would you be able to assume that the imagined "idiot rate" is too high?

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Re: What, you want actual information about health care reform?

Postby The Great Hippo » Fri Aug 21, 2009 3:52 am UTC

I also object to the notion that society is responsible for your health; one of the notions that goes along with responsibility is authority - I can't be responsible for something unless I have some sort of authority over it - and so the notion that society is responsible for our health comes with the notion that they have authority over what we can and can't do to impact that health. For instance: If society is obligated to deal with my diabetes, doesn't society have a right to demand I don't eat so many sugar-based products?

I don't like the notion of discussing these things in terms of 'responsibility' anyway; we aren't obligated to help our fellow man - it's just in our best interest to do so. Healthy societies are productive societies, and productive societies are better at reaching the end goal of immortality + jetpacks.

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Re: What, you want actual information about health care reform?

Postby Dazmilar » Fri Aug 21, 2009 5:45 am UTC

Princess Marzipan wrote:How silly of the Terri Schiavos of the world to do such silly things like fall into comas without first ensuring they have the wealth to pay for it!


To be fair, while someone in a vegitative state may not have been responsible for whatever made them comatose, they're certainly responsible for whether or not they prepared for such with a living will, health care proxy, or whatever end-of-life decision making is available in their area.

Will wrote:Seriously? You seriously believe that getting sick has anything at all to do with personal responsibility? How the hell do you figure that?
As Barney Frank recently said, what the hell planet do you spend most of your time?


We live on a planet where alcoholism can lead to cirrhosis of the liver, pancreatitis, epilepsy, polyneuropathy, alcoholic dementia, heart disease, increased chance of cancer, nutritional deficiencies, sexual dysfunction, and death from many sources. Where excessive body weight is associated with various diseases, particularly cardiovascular diseases, diabetes mellitus type 2, obstructive sleep apnea, certain types of cancer, and osteoarthritis. Where Tobacco is a major risk factor for heart attacks, strokes, chronic obstructive pulmonary disease (COPD), emphysema, and cancer. Where a slight moment of inattentiveness while driving could lead to major injuries or death. Where not having the common sense to not be in certain neighborhoods at night can lead to getting stabbed. Where preventable diseases make comebacks because Jenny McCarthy doesn't like vaccines and "warrior moms" buy into her bullshit. Personal responsibility has a great deal to do with sickness and medical costs.

Princess Marzipan
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Re: What, you want actual information about health care reform?

Postby Princess Marzipan » Fri Aug 21, 2009 5:53 am UTC

Dazmilar wrote:To be fair, while someone in a vegitative state may not have been responsible for whatever made them comatose, they're certainly responsible for whether or not they prepared for such with a living will, health care proxy, or whatever end-of-life decision making is available in their area.

Man, if you don't have one fuck of a thorough living will, you really have no right to pick this bone. And in the event that you do (or say you do) have one, having a living will isn't going to suddenly make it cheaper to keep you alive if that was your choice.

Dazmilar wrote:Personal responsibility has a great deal to do with some sickness and medical costs.
Until we live in a world where literally every possible medical problem is preventable, you might have an argument that makes it okay for being hit by a drunk driver to lead to bankruptcy for the victim. Actually, even then you wouldn't. For what I would hope are obvious reasons.
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