bullet points on the speech for later

Heading off the President's speech later, I'd like to call attention to some relevant issues on the health care "debate" as it stands

1)It is perfectly acceptable for mostly old white people to stand up and complain about changes to a system that is heavily advantageous to themselves. Money for government health care for senior citizens is little more than an unsustainable pyramid scheme in the long run. That is precisely why there must be a debate over cost. Much of that cost is wasteful or, more precisely, is not tied to any sense of value that it imparts to people receiving services. I don't think it is too much to ask that people should have to think about the procedures they get, perhaps ahead of time, for difficult and expensive treatments and how this cost is more often paid by others instead of themselves. Sure nobody wants to die, and I'm not recommending that old people should have to just lay down and die either. I am suggesting that we think harder about the costs of keeping people alive versus the cost of making them healthier, or, heavens no, happier. It does not seem unreasonable to assign these decisions to the people who have to make them (namely the elderly and their doctors and closest relatives). I'm sorry they're hard to make, but we (the working generation) are tired of paying for people who don't want to make them at all.

2) Some of the points raised by "descenters" are perfectly legitmate questions. What will it cost? Who will pay? How will we pay? What does this do to what I have now? And so on. I think it is reasonable to ask these. What I have a problem with is that many of the people who commonly make them do not seem to have thought through that there are legitimate problems with the present system that REQUIRE action and thought to resolve. They have put forward an untenable position that suggests there is nothing wrong with the situation now. It is in fact, unsustainable, costly, wasteful, and often dangerous. When pressed, these questions should hint at follow up questions on what might be ways to better allay these concerns for example. Perhaps even put forward a coherent plan instead in opposition to the present vague one.

3) I don't expect this of normal everyday people who work and receive their benefits from work. In fact, I am finding unsurprising that nobody wants to challenge the status quo. Most people do not think that their health benefits cost them something, or if it does that it costs them very much. In addition they will then proceed to believe that it provides them with a higher standard of care. It does not. It provides them with access to a more expensive standard of care but it does not automatically provide people with access to better health care outcomes. This is a prime reason why the recent Atlantic article was so useful. It was a story, something most people will relate to, about the costs of the current system in terms of producing poor quality outcomes and high cost relative to its actual value. People may disagree freely with his prescriptions for resolving this, but I don't think you can argue that the present incentives for good quality outcomes for health care consumers are messed up and that a good reason for this is the third party payment system we use for most everything medical (employer provided or government benefits). There are additional costs in the way of receiving wages in the form of benefits that should be obvious, but apparently aren't.

4) We will probably continue to hear a lot about preventive care and costs. I have decided this is a useful thing to include, but not because it will reduce costs. What it appears to do is transfer the cost of high maintenance chronic care ailments and injuries with the possibility of more expensive problems that can be prevented thus adding to the overall expense, to people who have low health care consumption needs. Those people will, by some extension, be encouraged to go more often and consume more health care than at present to better insure themselves against catastrophic events, say cancer or heart disease. This it can be argued is a desirable outcome. Indeed it is very likely that a balanced preventive care methodology would produce much greater value from quality of care outcomes. But it is difficult to argue that it actually reduces cost in a substantial way. Particularly if there are not methods used that re-capture some preventive costs as disincentives upon the public to require them in the first place (like high excise taxes on tobacco or alcohol). These methods have come up for discussion, but they are not that commonly included in the legislation at present, meaning it's not clear if there would be a net benefit to a national emphasis on preventive care as far as reducing our costs.

5) Most of the public debate has centered around insurance reform. I do think it is a legitimate and vital discussion to have on how we pay for health care through the device of insurance. That's not really the discussion we've been having of course. And for the most part, medical care itself has not been up for debate. It is assumed that the right wing talking point "we have the best medical care in the world" is widely believed and hence accurate. It is not actually the best in terms of patient outcomes (though we have some good stories here to tell in particular ways, like extending the lives of old people by about a year over other societies and generally good, but expensive, cancer treatment). America has been second before in other things like for example the space race (we're still way behind the ball in education) and it survived this humbling experience. And more importantly it's certainly not worth the price we pay for what we get. Nor the price we will continue to pay in the future if we do not head off the causes of these rising costs.

6) I'm really confused as to how a party that was all over entitlement spending as a problem/ talking point first passed a massive increase in it (Medicare part D) and now seems content, rather than coming up with their own way to reduce entitlements, to demagogue the attempts to tackle this essential question. It's fine to want to stop bad legislation. It's not helpful however to push against resolving essential and pervasive problems. I think stalling the initial push to pass health care reforms immediately was a good thing. But then, that wasn't a stall coordinated by Republicans in the first place. Any reasonable observer should note that the only place there appears to be a debate over the important questions at all in this country is between moderate Democrats and less moderate Democrats. We effectively have no "two party system" because the other party has no ideas of its own. Whether you think Republicans are hell spawn of some sort or not, this is not a good thing for a democracy to have no major differences of ideology and opinion upon which to rely on giving it real choices on how to resolve its public issues.