Tag Archives: Medicare

false trichotomy, hollow man

Grown ups

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People acquainted with media narratives know that the "adults" and the "grown ups" and the "serious people" are very often the Republicans, especially when we're talking about entitlements.  Democrats and their union friends, we're often told, are childish or immature for wanting something–public benefits such as medicare and social security–at no cost.  Click here for a funny illustration of that sorry meme. 

We have something along these lines in this Steve Chapman column from the Chicago Tribune.  The "real world," of course, demands cuts and reforms just like the Republicans want:

After House Budget Committee Chairman Paul Ryan, R-Wis., unveiled a plan to overhaul Medicare, Democrats announced that despite its minor flaws, it was a brave and thoughtful attempt to grapple with a serious problem that has been ignored for too long.

Just kidding. They said it was the worst thing they've seen since "Sex and the City 2."

House Democratic leader Nancy Pelosi accused Ryan of offering "a path to poverty for America's seniors." Rep. Chris Van Hollen, D-Md., said Ryan's proposal would not reform Medicare but "deform it." The White House faulted Ryan for "placing a greater burden on seniors."

The chief outrage, in their minds, is his proposal to restructure Medicare for Americans currently younger than 55 while keeping the old version for older folks. Instead of guaranteeing a certain set of benefits regardless of cost, the government would pay a fixed premium so recipients could choose their own packages.

The other meme is the "brave" or "courageous" meme.  This one, unfortunately, has even been adopted by Democrats.  On the unity of the virtues theory, however, you can't be stupid and courageous, or wrong and courageous. 

Back to the point.  The "reality" meme usually requires that you show that someone else's plan is unrealistic.  You can do that by carefully demonstrating the shortcomings of their views or their presuppositions, or you can do that by misrepresenting them.  The second is faster.  Here's Chapman again:

I have news for people old enough to be thinking about retirement: Your children may love you, but not enough to be taxed into poverty. Ryan's detractors pretend we can go on enjoying the status quo indefinitely. But it's only a matter of time before we hit a fiscal wall, hard.

There are three basic choices. We can keep on just as we have in the past until the program collapses of its own weight. Or we can restrain costs by letting the federal government ration medical care. Some patients would have to wait months or years for procedures now taken for granted — and some wouldn't get them at all. Death panels, anyone?   

"Ryan's detractors" sure seem stupid, don't they?  There's a reason they don't have a name–they don't exist.  They're hollow men.  Whatever you say about the opposition to Ryan, you'll have to admit that they tried to have a discussion about health insurance reform in light of the problems of rising health care costs, an aging population, and, of course, the limitations of the private insurance model.  Whatever you say about them, you cannot say that they embraced the status quo indefinitely. 

One more thing along these lines.  Notice that Chapman considers three options for reforming medicare: (1) do nothing; (2) death panels; (3) Ryan's plan.  That's a false trichotomy.  It's like a false dichotomy, only you add two unworkable choices rather than just one.  Since (1) and (2) are ridiculous, ergo, ipso fatso, (3) is our only realistic option. 

A courageous adult conversation about the realities of health care systems in the industrialized world, however, would consider many other empirically tested options.  Would it be immature to want that?

George Will, Plain Bad Arguments, Weak Analogy

You’re on your own

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It wasn't long ago that George Will called Obama's very catchy "you're on your own" line (from his acceptance speech) a straw man of the (discredited) Republican philosophy of government.  So I was struck when I read this encomium to being on one's own (creepy lines in bold).

When Medicare was created in 1965, America's median age was 28.4; now it is 36.6. The elderly are more numerous, and medicine is more broadly competent than was then anticipated. Leavitt says that Medicare's "big three" hospital procedure expenses today are hip and knee replacements and cardiovascular operations with stents, which were not on medicine's menu in 1965.

After being elected to three terms as Utah's governor, but before coming to HHS, Leavitt headed the Environmental Protection Agency. He came to consider it a public health agency because the surge in Americans' longevity in the last third of the 20th century correlated with cleaner air and fewer waterborne diseases. Longevity is, however, expensive, and demography is compounding the problem.

In the 43 years since America decided that health care for the elderly would be paid for by people still working, the ratio of workers to seniors has steadily declined. And the number of seniors living long enough to have five or more chronic conditions — 23 percent of Medicare beneficiaries — has increased. Many of those conditions could be prevented or managed by better decisions about eating, exercising and smoking. The 20 percent of Americans who still smoke are a much larger percentage of the 23 percent who consume 67 percent of Medicare spending. Furthermore, nearly 30 percent of Medicare spending pays for care in the final year of patients' lives.

If only we could find some kind of completely tone-deaf market analogy for how medicare should work:

Suppose, says Leavitt, buying a car were like getting a knee operation. The dealer would say he does not know the final cumulative price, so just select a car and begin using it. Then a blizzard of bills would begin to arrive — from the chassis manufacturer, the steering-wheel manufacturer, the seat and paint manufacturers. The dealership would charge for the time the car spent there, and a separate charge would cover the salesperson's time.

Leavitt says that until health-care recipients of common procedures can get, upfront, prices they can understand and compare, there will be little accountability or discipline in the system: "In the auto industry, if the steering-wheel maker charges an exorbitant price, the car company finds a more competitive supplier. In health care, if the medical equipment supplier charges an exorbitant price, none of the other medical participants care."

The auto industry?  The one with the huge bailout?  Anyway, back to the ice floe:

Rather than ruining the new year by dwelling on Medicare's unfunded liabilities of about $34 trillion (over a 75-year span), ruin it with this fact: In the next 50 years, Medicaid, the program for the poor — broadly, sometimes very broadly defined — could become a bigger threat than Medicare to the nation's prosperity.

This is partly because of the cost of long-term care for the indigent elderly, some of whom shed assets to meet Medicaid's eligibility standard — sometimes as high as income under 200 percent of the federal poverty level. And many states, eager to expand the ranks of the dependent with the help of federal Medicaid money, use "income disregards" to make poverty an elastic concept. For example, they say: A person who gets a raise that eliminates his eligibility can disregard the portion of his income that pays for housing or transportation.

Governments with powerful political incentives to behave this way will play an increasingly large role in health care. As is said, if you think health care is expensive now, just wait until it is free.

Indigent elderly, since you're a threat to our nation's prosperity, "you're on your own."