Subscribe via RSS Feed

Very Serious Health Care Analysis From Bret Stephens, Man of Seriousity

[ 128 ] July 1, 2017 |

Bret Stephens is allegedly a unique, challenging voice because he proposes slightly different terrible ideas that the Republican congressional leadership. Let’s see him in action:

It costs as little as $10 and as much as $10,169 to get the same blood test in California. A lower-back M.R.I. priced at $199 at one Florida clinic goes for $6,221 in San Francisco. A shoulder X-ray can run anywhere between $21 and more than $700 across the United States.

In Spain, a 30-day supply of Truvada, which helps prevent H.I.V.-AIDS, costs an average of $559, according to data compiled by the International Federation of Health Plans. In the United States it’s $1,301. In Britain, the average price of an angioplasty is $7,264 versus $31,620 in the United States. Hip replacement in New Zealand is $15,465. The United States figure is $29,067.

Many things about health care delivery in the United States are insane. The economist Kenneth Arrow crisply described the biggest insanity back in December 1963. “Insurance,” he wrote, “removes the incentive on the part of individuals, patients, and physicians to shop around for better prices for hospitalization and surgical care.” When did you last go bargain-hunting for a urinalysis?

So, to summarize, systems that rely more on public insurance than the United States are much more efficient. The takeaway, obviously, is to misleadingly quote an economist who made a famously prescient argument that markets in health care don’t work to suggest that the solution to American health care is more markets. Hard to quibble with that logic!

What is it that Americans don’t like about their health care? Chiefly, skyrocketing insurance premiums, higher deductibles and decreasing access to services. Obamacare has made all this worse.

This is, of course, ludicrous nonsense. The Affordable Care Act has made premiums and deductibles lower and health care more accessible than it would have been under the status quo ante. Stephens tries to defend this claim with egregious rube-running, citing absolute cost increases with an implicit (and obviously false) baseline of a status quo ante in which costs aren’t increasing. Certainly, there is substantial room for improvement — but this would require more public insurance and/or regulation, not less.

But wait, things are about to get a lot worse!

This was predictable. “Obamacare was sold using the language of choice and competition, but it is actually reducing both,” a Wall Street Journal editorial warned back in 2010, when the law was months old. Health insurance doesn’t work when it isn’t allowed to operate as insurance: when it cannot tailor its products to the preferences and budgets of consumers, and when it cannot make business decisions based on considerations of risk.

You do not get to insure your house after it’s on fire. Why should Americans have the unalienable right to wait till they get sick (at least during open enrollment) before buying health insurance?

Yes, if only Congress had thought of this problem when crafting the ACA, and included what we might call a “mandate” incentivizing people to maintain insurance. I mean, it’s just amazing that Stephens is unaware of this. There was a whole Supreme Court case about it and everything!

It’s true that the mandate has not functioned as well as intended, because the subsidies were not generous enough — this would be a fair criticism. Republicans, of course, want to address this problem by making the subsidies much less generous. Also, the House bill had no mandate at all.

Here, however, is where the philippic against the Affordable Care Act ends. Barack Obama inherited a broken health care model and made it worse, unless you count shunting millions of people into Medicaid as a triumph. For all the liberal angst about the Republican House and Senate bills, they are only tinkering with the same unfixable formula.

Where to begin?

  • The ACA inhereted a broken model and made it much better. For all its flaws it’s one of the most successful social welfare bills ever enacted by the United States Congress, which is why (despite its effectiveness having been reduced by a ludicrously incoherent Supreme Court holding) the consequences of its repeal would be so dire.
  • I do, in fact, regard “shunting millions of people into Medicaid” as a triumph, particularly given the Republican alternative of offering them no insurance at all.
  • Any elite pundit who describes a bill whose savage cuts to public insurance, individual subsides and regulatory requirements would strip more than 20 million people of insurance and make insurance for most of the people who retain is worse as “tinkering” should “upper-class twit of the year” tattooed on their forehead

His superior solution to the ACA? Why, tax shelters for the rich health savings accounts, of course!

The only genuinely promising reform in the Republican health bills are proposals to nearly double contribution limits for heath savings accounts and allow them to be used to pay for premiums. Enrollment in tax-deductible, investable H.S.A.s has roughly doubled since Obamacare took effect, to about 20 million, because they help cover out-of-pocket costs for low-premium, high-deductible plans.

But as Peter Ubel of Duke pointed out last year, they’re mainly attractive to wealthier people with income to spare. Government subsidies of H.S.A.s for low-income people, Ubel writes, could turn H.S.A.s into something other than “another tax break for the wealthy” and “make our health care system more responsive to consumer needs.” This is what Singapore does, along with mandates for employees to set aside a portion of their income for H.S.A.s, and for employers to match it.

For a certain type of conservative pundit, “Singapore” functions in healthcare the way “France” functions in abortion law —  i.e. taking one isolated aspect of another country’s regulatory framework and suggesting liberals should therefore like it nyuk-nyuk while ignoring critical differences. Singapore’s model wouldn’t be my first choice if I was Prime Minister of the United States, but like every system in an advanced economy it’s certainly superior to the current American one. I’ll sign for it right now! Only of course Stephens wouldn’t, because what makes the Singaoprean system an efficient and universal one is that the mandatory savings accounts are combined with 1)very generous public subsidies and 2)very aggressive price controls directly imposed by the state. Not only do American conservatives not favor either of these critical aspects, they want the state to spend and regulate less. And without the regulatory and subsidy framework, health savings accounts (even if we assume fantasy Republicans who would actually fund them for poor people rather than just keep them as tax shelters) aren’t going to have a significant impact on American healthcare spending.

This has been “800 words of stepping on rakes” with Bret Stephens.

FacebookTwitterGoogle+Share
  • N__B

    When did you last go bargain-hunting for a urinalysis?

    It’s hard to do so when I have to drag a wet mattress around with me.

    • Warren Terra

      Isn’t that what Uber is for?

      • McAllen

        I’d heard Uber had some shady business practices, but I had no idea they were peeing on people’s mattresses!

        • rm_rm_rm

          Another twist to the Russia investigation.

    • Pseudonym

      These college protests are really getting out of hand.

  • saraeanderson

    Stephens is amazingly ignorant.

    • Warren Terra

      “amazingly”, or “conveniently”?

      • maxdi

        Deliberately.

    • Bizarro Mike

      The comparison to Sideshow Bob maligns the simple dignity of that noble character.

      • YNWA40515

        Right? I mean, there’s no way Stephens knows the entire score of The HMS Pinafore.

        • SFAW

          Perhaps not, but at least he knows enough about it that he chuckles at Frederic’s nursemaid Ruth mistookening “pilot” for “pirate” (or vice versa).

    • I don’t know if he’s ignorant, stupid, or dishonest, and frankly it doesn’t matter which it is or how they combine. Bottom line is he’s spectacularly wrong.

      • SFAW

        “I don’t know if he’s ignorant, stupid, or dishonest,”

        All of them, Katie.

  • Warren Terra

    I am not a “Very Serious Health Care Analyst”, but I’d call a few of his assertions into question:

    A shoulder X-ray can run anywhere between $21 and more than $700 across the United States.

    I simply do not believe a shoulder X-ray costs $21 anywhere in the USA. I believe people are paying that, even getting billed that – but only because that’s how co-pays work, and the subdividing of a bill is elastic.

    When did you last go bargain-hunting for a urinalysis?

    Never! I’d probably do a terrible job, and certainly spend more in time than I saved in money! But you know who did go bargain-hunting, and was probably pretty good at it? My health insurance company. It’s what they freaking live for, especially since the ACA says they can no longer make their money by screwing over policyholders with rescission, pre-existing conditions, and caps – at least two of which the AHCA / BCRA would bring back.

    In short: no-one could be as dumb or as ignorant as Stephens pretends to be. He’s lying, plain and simple, and that’s entirely the New York Times‘s responsibility.

    • Hells Littlest Angel

      Yeah, you can get one of those bargain urinalyses if you want, but you get what you pay for. I got one once and the results came back: “liquid, yellow, salty, did not get me high.”

      • You always need to check out the Yelp review. “Wilma, my collector, was very attentive and did not embarrass me, but I was bothered by the bright lights and lack of mood music.”

    • Dr. Ronnie James, DO

      “Florida patients get MRIs liiiiike thiiiiisssss….
      And California patients get MRIs liiiiiikkkke thiiiiisssss!!!!…”

    • Hob

      I’m not as confident as you are that no one could be that dumb, but I agree that Stephens almost certainly either a) is lying or b) decided early on that he doesn’t care about being accurate, and therefore didn’t bother to read his sources for understanding.

      The “$10 vs. $10,169” thing is a giveaway – it’s particularly easy to find the source for that one because of that very specific second number. $10,169 is the price a hospital might charge for an uninsured patient; they might not be able to collect all of it, but they’ll jack up the prices for anything and everything for people without insurance, because their contracts with insurers prevent them from doing so for the rest. That Vox story I linked to doesn’t do a great job of explaining this (it sort of starts to, but then it fucks up by saying “If [the patient’s] plan covers the bill, it doesn’t matter to them, personally, whether they get the $10 test or the $10,000 one,” when the whole point is that the $10,000 version doesn’t exist as far as the insurance company is concerned)… but anyone who’s spent more than five minutes looking into health insurance issues would understand it. “Shopping around” is completely meaningless in that context— anyone who’s in a position to be charged the $10,169 price has literally no ability to get the $10 price no matter where they go or how much “shopping” they do.

      This is David Brooks/Megan McArdle-level bullshit.

      • Stella Barbone

        The hospital also writes off the bad debt as charity as a for-profit institution or to cover their real profit if they are operating as a non-profit.

        • Warren Terra

          That’s an interesting notion. I think there must be limits to it, though. If someone doesn’t pay for their procedure, and they mark it up as a loss, they can’t claim they lost the inflated list price, can they? Only their actual expenses? Which they’re claiming as a business expense anyway?

          • Hob

            I don’t know what category of write-off it is, but the bad debt amount they’re claiming isn’t technically an “inflated” list price— it’s just the price. What the insurers are paying is a different, “discounted” price that was negotiated by contract; if an insurer failed to pay, they could claim a bad debt for that smaller amount.

        • david spikes

          They sell the debt to a shyster “law firm/debt mill” and make the persons life hell forever after.
          Odd to describe that as charity.

          • Hob

            Wait– wouldn’t they have to choose one or the other, either write it off as uncollectable or sell the debt? If you sell it, then you’ve been paid.

            • Warren Terra

              Maybe someone who knows some accounting or tax law can weigh in, but this whole notion of claiming a huge loss / charitable donation for tax purposes doesn’t make any sense to me. For accounting purposes surely they have revenue and expenses, and nothing else? And uncollected debts – or debts sold at a steep discount to modern-day loan sharks – wouldn’t actually alter that calculation, would they? I mean, for purposes of annual profit status and the like?

              I get how such a claim could be useful public relations. I can see how having the debts still unclaimed on the balance sheet could affect the hospital’s balance sheet, maybe even its borrowing capacity. But its annual profit or loss? I don’t see that. The amount they spend, and the amount they take in, aren’t affected by any fanciful claims on their books.

    • Stella Barbone

      I’m not sure that insurance companies are that well incentivized to control costs. After all their profit is a function of their total spending. They are, however, in a strong position to control costs, if they want to. In addition, they are not run by elected officials subject to provider lobbying. If someone invented a carrot or a stick that caused them to exercise their power, we might see some serious cost savings. Individual providers are easy to squeeze, hospitals are medium sized businesses and nearly as easy to squeeze, but if you could get the insurance companies to take on big pharma, they just might earn their keep.

      • sanjait

        One of the benefits of ACA is that it put non-group insurance policies on an open exchange. People could see and compare prices, and this created a strong push for insurers to lower prices.

        It’s one reason we have seen coverage networks in those kinds of policies contract. They were already contracting, as part of a long term trend, before ACA, but it accelerated the process. Insurers went bargain hunting so they could lower premiums …

        • And there was the all-too-infrequently reported 20% cap on overhead imposed by the ACA on insurers, which had previously been running 40% or higher in many cases.*

          For comparison, Medicare’s overheads are about 4%. Medicaid’s roughly 8%.

          — Steve

          * It’s telling that insurers talk about this in terms of the Medical Loss Ratio, the fraction of premiums distributed to physicians; implying that the portion of revenues spent actually providing the service they promised to consumers is a *bad thing* that should be *minimised.*

      • andrekenji

        There are dozens of stories of foreigners and tourists that were billed thousands and thousands of dollars for simple hospital visits. Medical and hospital costs, not insurance, is the main problem. On the other hand, any solution to that would involve the big and bad government, in a much higher level than in Obamacare.

    • Sly

      “Honey, I know little Timmy is having trouble breathing and his face is turning blue, but we should really shop around for the best deal on emergency medical services before we commit to this ER.”

      • Hogan

        Is that the best you can do? Because Mount Sinai will take $350.

      • Jon Hendry

        I always feel I haggle best when under duress, especially if in serious pain.

        • jim, some guy in iowa

          my dentist is freaking *putty in my hands* when I have a serious toothache. I get tough enough with him, he throws in the nitrous for free

          aside: has anyone else noticed nitrous doesn’t seem to have the same punch it used to?

    • Bruce Baugh

      I’ve gotten more than one right-winger very angry at me for pointing out how their arguments against universal health care blithely dismiss both the value of the division of labor and economies of scale, two things that in other contexts they are keen to tell me are genuine laws of economics. And the fact is that they are real things, though not godlike principles we must venerate, just facts about human action in groups that we do well to keep in mind, and take advantage of when we can.

      I was in my teens when the first 401K plans went for sale, and I remember my Dad being kind of drawn by the shiny but Mom profoundly skeptical of pitches that rested on the assumption that a random (in Dad’s case) aerospace engineer was reliably going to do a better job managing his retirement funds than professional insurance people with years in their specialties. As she pointed out, it obviously wasn’t the case that those insurance folks would design better ranging systems than Dad would; why was there the slightest reason to expect it’d work the other way around?

      She was right.

    • AlanInSF

      My wife once got diagnosed with, and provided with prescription drugs for, severe bronchitis, for $8, but that was in Italy.

  • Steve LaBonne

    New York Times delenda est.

    • [email protected]

      Diarium Novi Eboraci delenda est

  • kindasorta

    The NYT, putting that whole “paper of record” business to the least optimal use yet again.

    When can we reclaim that title for someone else? The Post, maybe. At this point, maybe Buzzfeed.

    • Surely, Teen Vogue is in the running, at least.

  • McAllen

    unless you count shunting millions of people into Medicaid as a triumph.

    I like how this is supposed to be self-evidently horrible. One imagines that whenever Stephens dares utter the word “Medicaid” he hears thunderclaps and horses neighing.

    • Hogan

      Yes, poor people were “shunted” from not having insurance to having insurance. As one may say Bret Stephens was “shunted” into an op-ed gig at the NYT.

    • stepped pyramids

      Same rhetorical trick as when Gingrich kept calling Obama “the food stamp president”.

    • Bruce Baugh

      I’ve said this before, but not recently: the Medicaid I get thanks to SSI is vastly better than the insurance a lot of my friends get, and I regard moves that make it possible for any significant number of them to join me on it as really solid steps of progress.

      Sure, Medicaid has a lot of weaknesses. None of them are fixed by giving it less money, and even with all of them fully considered, it’s a huge improvement over a) no insurance at all and b) the crappy individual and group policies available to a lot of low-income folks, particularly people like freelance writers of genre fiction.

      • Bitter Scribe

        As I understand it, the biggest problem with Medicaid is finding doctors who will take it. This is largely because many states, which by some astonishing coincidence happen to be run by Republicans, are laggard in paying Medicaid bills.

        • Bruce Baugh

          I’ve heard that too. I would certainly be willing to agree with someone who said that I’ve been lucky in always living in areas where good Medicaid coverage applied.

        • Warren Terra

          The numbers I saw some random place – so I’m not guaranteeing they’re gospel – are that for the same procedures Medicaid pays the provider ~2/3 of what Medicare does, and Medicare pays on average ~2/3 of what private insurance does. So, Medicaid would pay ~1/2 of what private insurance does. You can see why a doctor who can fill their schedule with privately insured patients might spurn Medicaid.

      • Zagarna_84

        “freelance writers of genre fiction”

        You mean like Bret Stephens?

        /rimshot

        • Bruce Baugh

          No, no, I mean people who admit it. :)

      • e.a. foster

        why not put everyone on Medicaid and be done with it. Then pass a law which requires all doctors to accept Medicaid patients. Its really, really easy. In Canada each province negotiates with their particular doctor association to set the fee structure and the government pays the doctors directly and very quickly. You see we have computers and they do most of the work. Even before we had computers doctors received payment every month.

        • Bruce Baugh

          Because the way it’s set up now, it doesn’t pay enough or cover enough. Medicare would be a better foundation, but it doesn’t pay enough or cover enough, either. And expanding either to do the job would be a huge leap with a lot of complexities. There are good posts over at Balloon Juice by someone who’s an actual expert in the field.

  • Denverite

    Here, however, is where the philippic against the Affordable Care Act ends. Barack Obama inherited a broken health care model and made it worse, unless you count shunting millions of people into Medicaid as a triumph.

    Also not a triumph:

    – About 12 million people buying insurance that otherwise probably would have gone uninsured.
    – About 2 million people getting insurance through their employer that otherwise probably wouldn’t.
    – Dramatically lower rate of medical inflation vis-a-vis the medical inflation rate this century.

    What a fucking moron.

    • Warren Terra

      It’s interesting how much the Republicans like to talk, sneeringly, about what the ACA has done for poor people (which is real, and is easy for them to dismiss, because poor), but somehow they never talk about the huge amount it did to make health insurance meaningful for everyone. The regulations about pre-existing conditions, about rescission, about annual and lifetime caps, about free checkups and guaranteed coverage of important issues including reproductive, mental, and addiction health – all of these transformed an industry under which it was impossible to get reliable, usable coverage on the individual market, and low-income employer-provided insurance was frequently little better. You can do the numbers on the pre-ACA health insurance market, and see it was almost entirely a mirage and a fraud on people seeking coverage.

      That all the politicians and almost all the pundits have benefited all their lives from generous, robust insurance provided by the government and by wealthy employers seems relevant.

      • hypersphericalcow

        Hell, the fact that children can stay on the parents’ plans until 26 is something that a lot of them are probably taking advantage of!

        • BiloSagdiyev

          Yes. That one’s damned popular, I am certain. I think we need to circulate a list of “Things You Might Not Know Democrats Did For You” to the apolitical and anitpolitical. With some footnotes about how the GOP fought it every step of the way and has been pissing and moaning about it ever since. Starting with Social Security.

      • rm_rm_rm

        Fuckin A, yes. All the ACA needs is Medicaid expansion everywhere (Fuck you, Roberts Court), a tougher mandate and bigger subsidies, and add a ban on balance billing (which kind of makes a joke of insurance coverage in states where it’s legal, as the provider just bills you for that extra $2000 they wanted that the insurer said was unreasonable, after all the insurance and copay payments are done with).

        • Zagarna_84

          It also needs a public option (to avoid the problem of insurance-free counties), a guaranteed budget stream, and some heavy-duty reductions in administrative discretion to prevent Republican regulatory ratfucking.

          As an administrative lawyer, I get the impulse to write laws that say “let’s just leave it up to the Executive Branch regulators”– I really, really do– but that strategy’s just not going to fly anymore. Not with this Republican Party as an apparently-serious electoral contender. The sooner Democrats figure that particular lesson out, the better.

      • DocAmazing

        Anecdotally: Treatment for asthma has become more systematized since the passage of the ACA, not because new treatment protocols have emerged, but because we pediatricians are no longer afraid to actually write down the diagnosis of “asthma” instead of all of the weaselly terms we used to use, so that kids wouldn’t get thrown off of their insurance for having a pre-existing condtion.

        • busker type

          wow.

    • Bitter Scribe

      Give Stephens credit — at least he’s being consistent. He used to write all the time in he WSJ about how it was wrong to judge the ACA by how many more people were getting coverage, because the real outrage was that rich people had to pay extra taxes for it.

      • weirdnoise

        This is likely why the NYT hired him — to go after the WSJ demographic.

        • DAS

          Yep. There are a large number of people (at least in my corner NYC) who are nominally center left but who don’t like the NYT because their coverage on Israel is not only wankerific, but it also dares not agree 100% with the Likud perspective is so “left wing”. OTOH, being at least nominally left of center, they are not 100% on board with the WSJ. This crowd, BTW, are the sorts of “liberals” that NYT decision makers are most likely to know.

          Brett Stephens is this crowd’s favorite conservative writer, so bringing him to the NYT brings exactly the “balance” this crowd would love to see in the NYC.

  • hypersphericalcow

    Regarding the mandate subsidies, would it have been possible (legally, not politically) to build in some kind of automatic adjustment mechanism, like Medicaid and Social Security have? So that two years after the bill passed, they could be moved up or down, without Congress being involved at all?

    I’m sure such a thing could never have passed, because it would give Joe Lieberman the vapors, but I’m curious as to whether it would be possible.

  • efgoldman

    This has been “800 words of stepping on rakes” with Bret Stephens.

    No-one with more than two brain cells to rub together can ever take the FNYT seriously again. Ever.
    Christ what an asshole!

  • Dr. Ronnie James, DO

    This is a level of hackery that would have Avik Roy shaking his head. Does the NYT even employ fact-checking to it’s op-ed writers? Can we expect a bone-dry correction near the bottom of Page A23 next Tuesday? In particular, to handwave the major accomplishment of the ACA as “shunting people into Medicaid” is breathtakingly facile (it’s shunting them away from emergency rooms and charity care).

    But it could be seen as accurate if he’s using “shunt” in the medical sense, i.e. creating a novel avenue for a pathological buildup with no outlet to be relieved, thereby mitigating serious mortality. That would be brilliant, but he is…not brilliant.

    • sanjait

      Stephens has a talent. His talent is making facile arguments and arguments that imply but (usually) don’t unambiguously state things that are false.

      Thus, he escapes the fact checkers.

      Though of course, “usually factually accurate?” should not be the only standard qualification for a NYT columnist.

      • Dr. Ronnie James, DO

        That’s the MO of the entire WSJ op-ed page & I have to think that was part of the package NYT thought they were getting.

      • hypersphericalcow

        So in McArgleBargle style, he is an expert at saying things that are “technically true, but collectively nonsense.”

      • It’s as if Pinch, Baquet and Bennet all saw Fred Hiatt’s omnishambles as something to be envied.

      • DAS

        Brett Stephens has way too many admirers, even among people who are nominally left of center because he makes “arguments that […] don’t unambiguously state things that are false” sticks to the facts.

  • cpinva

    i was at the dr’s just yesterday morning, getting a cortisone shot in my left shoulder (frozen shoulder syndrom, don’t ask.). while they were setting up, the dr. and i were discussing ER problems, he had taken his dad to the local hospital one the week before, for a possible clot in one leg. we both noted how, regardless of how empty the waiting room is, you will spend at least 3 hours there. he had even called ahead, to see what the wait time was, and was told it was practically nothing, come on down!

    the ACA did have an effect on hospital ER’s, many actually closed, for lack of patients to support them. however, the dr. told me that people who now have insurance, and could go to a regular dr’s office for minor issues, still tend to see the ER as their “regular dr.”, and insurance will cover it. but, they are still getting treatment they might not have gotten otherwise.

    • Dr. Ronnie James, DO

      This happened in Massachusetts after RomneyCare passed. Other contributing factor include: a lot of PCPs aren’t open outside of business hours (poor people with jobs/kids etc. can’t often arrange/ afford to miss work, even with insurance), and it can be hard to get an appt with a PCP even when you do get time off: PCPs tend not to have offices in medically underserved areas, and many even refuse to take new Medicaid patients at all (NJ where I work is, interestingly enough, the worst in this regard).

      Hospitals are dealing with this by opening urgent cares that operate on nights/ weekends and setting up “fast track” areas in their EDs for low-cost cases. One ED in Camden has 1/4th of its floor space set up just for this purpose, bc there is no urgent care in the area. It’s rarely empty. To give you an idea, my wife’s ED is in a low-income area and she says 1/3rd of her cases on weekends are STD checks.

      • rm_rm_rm

        Every parent knows medical emergencies never happen when the primary care office is open. It’s the ER (where you’ll be glared at for wasting ER time) or wait until business hours (hard to do with a screaming kid, harder if you cannot take off work, and you may be glared at for waiting so long), or the after-hours walk-in clinic, if available.

        Imperfect. Yet so incredibly much better with insurance than without.

        And this Bret guy is one more in the long parade of demonstrations that there is no such thing as meritocracy. That much idiocy has to be purposeful. The sneering at Medicaid is insufferable. I dream of guillotines. Fucking murderous twit.

        (I am usually rm, but I am on a device that remembers a disqus name for a site where my name was already taken, and I don’t dare try to fiddle with it.)

        • France has emergency GP services. These work fine. GPs are independent contractors and compete with each other for patients, though they are reimbursed on a single scale.

          • DocAmazing

            Heck, France’s emergency GPs make house calls.

          • Dr. Ronnie James, DO

            Telemedicine (which my wife does) is becoming bigger and bigger for this type of thing in the US.

            • DAS

              I betcha she does a better job with remote diagnoses than Bill Frist does! ;)

        • efgoldman

          I am on a device that remembers a disqus name for a site where my name was already taken, and I don’t dare try to fiddle with it

          Careful, or you’ll blink out of existence :::poof:::

          • DocAmazing

            I actually thought rm_rm_rm had kind of a cool motorcycle sound to it.

        • DAS

          Our pediatrician’s office always has a doctor a phone call away. This is useful because most of the time, you don’t actually need a physician in person: the physician (a nurse could also do this) can walk you through what needs to be done and even phone/internet communicate in a prescription to the local pharmacy. Sometimes (speaking as a doctor, although the Ph.D. in biochemistry kind) you already know how to treat the kid’s issue, but the kid won’t cooperate with you until a licensed physician says “just cooperate with your dad … he knows what he’s doing”.

          Of course, this model assumes that you go to a pediatric practice with multiple physicians/nurses (so they can alternate who has to stay up to be on call) and live in an area with a 24 hour pharmacy. So if you are in a rural, exurban or otherwise medically under-served community, medical care for your suddenly sick kid is not only a phone call away.

          *

          BTW, relevant story — I grew up before the age of ubiquitous urgent care and on call pediatricians, although my parents had (and still have) platinum medical insurance (my dad was an optometrist for an HMO). Relevant background: I was the only person in my family not have had strep throat one year when it was going around. I did get what seemed to be a minor case of flu, so I was taken home from school. But suddenly, late in the evening when the pediatrician’s office closed, my fever started going up and I started turning red. So my dad took me to the ER.

          What did the ER do? It was a busy night, so they didn’t actually get around to seeing the kid who merely had a flu or something. Eventually I was seen: as soon as an actual medical professional saw me there was screaming, recriminations (“why wasn’t this kid seen earlier?”), etc. Why? I had scarlet fever!

  • sanjait

    Three things:

    One – health savings accounts are just a subsidized way to pay out of pocket expenses. It is wacky to complain about deductibles, which exist to incent patients to manage their own small medical expenses, and then say that HSAs are somehow the answer.

    Two – insurance actually does perform a bargain-hunting function. It also performs a bargain-creating function. Insurance entities negotiate with providers to set prices, resulting in prices that are otherwise lower than patients would get as individual payers. These result in limited networks, but the point of those limited networks is essentially to direct patients to the best prices. Patients are limited in their choice of providers, and they might prefer certain out of network providers for reasons other than price, but literally the insurance company has done the job of bargain hunting for you.

    Three – about 50% of healthcare spending comes from 5% of patients. The ability of the rest of the population to impact net healthcare expenditures by trying to save nickles and dimes shopping for medical services below the deductible threshold is almost insignificant. Even in a bronze ACA plan, with its famously high deductibles, only 40% of medical service costs are paid out of pocket. We’re essentially talking about how to whittle a point or two off that fraction.

  • Hells Littlest Angel

    A shoulder X-ray can run anywhere between $21 …

    If you don’t mind having your X-ray done by a teenager in a kiosk at the mall.

    • Warren Terra

      Even then, it can’t possibly be the complete bill. Rent on the space and furnishings, rent on the machine, ten minutes of the teenager’s time, a minute of a doctor somewhere’s time as they look at it – no way that’s all $21.

  • Stella Barbone

    Low those many years ago before I retired* or four years, as the case may be, our cash urgent care prices started at $80ish for a single view xray, topped out at $120ish for multiple views. X-ray aren’t all that expensive.

    *I wore an onion on the belt of my lab coat. It was the style.

    • rm_rm_rm

      Lo, not low. [/spellingtypospellchecknazi]

  • MariedeGournay

    Anything to turn public services into slush funds.

    • Dr. Ronnie James, DO

      Now those good-for-nothing Medicaid dollars can be shunted into football stadium!

  • hypersphericalcow

    Also, I must say Scott, your use of Simpsons stills for header images continues to be on point.

    (Although Erik’s post last summer about Jill Stein and Harambe remains my favorite.)

    • spencer_e9876

      Jonah Goldberg could learn many, many things from Scott, not the least of which is how to work a Simpsons reference.

    • When all is said and done, though, neither of those beat Erik’s post about Glenn Greenwald’s unhinged rantings about Neo-McCarthyism. That post illustration is a most triumphant example of FUCK YEEEAAAAAAAAHHH idiocy (although I still have no idea where Putin’s right leg is).

      • hypersphericalcow

        Oh, that’s a good one. I will never tire of photoshopped pictures of Vladimir Putin riding wild animals.

  • Sly

    SANE PERSON: “Well what about this clause in the Senate bill… doesn’t it say, ‘Die America, Die?'”

    BRET STEPHENS: “No, that’s German for ‘The America, The!'”

    NYT: “No one who speaks German can be an evil man.”

  • econoclast

    In a weird way, the US health care system functions much less like a market than in Europe. In Europe, a procedure costs some amount of money, and you can find out this amount of money ahead of time. There isn’t fantasy billing for the uninsured that no insurance company pays. There’s just a price, and either the government pays it, or the insurance company pays it, or you pay it.

    Once in the US when I didn’t have insurance there was an elective procedure that might have been helpful, but I didn’t absolutely need. I asked how much it would cost, and after a week they were able to come up with a price, but it was very clear that this was a special favor to me, as a sympathetic case. It’s insane.

  • Rattus Norvegicus

    When did you last go bargain-hunting for a urinalysis?

    I can’t, all the labs in my town are owned by the same company. 120 miles to the next town.

    • Shantanu Saha

      Silly, you could have gone to a meth lab to have it done.

  • DigMed

    Yes, forcing people who couldn’t afford health insurance into voluntarily applying for and getting Medicaid was cruelty beyond description.

  • MasterD

    Shorter Bret Stephens: I want my tax cut.

  • Jake the antisoshul soshulist

    In the US, the shopping for healthcare meme is the sort of idiocy you expect from the right.
    If they actually believed that , there would be something to incent providers to post prices. You can shop for a doctor. You can shop for insurance, but as has been pointed out, you are unlikely to shop for an appendectomy.
    I do think it would be good for medical providers to actually show the price.
    But patients and insurers would have to demand it

    • LosGatosCA

      I think I’m starting to see the brilliance of the conservative Republican market driven, outsourced delivery model. For example, consider a massive heart attack strikes a 55 year old man without a health insurance policy but a HSA with 6 month’s of contributions.

      Step 1 – call Uber, not 911. Pay the peak pricing gladly – it still beats a fully loaded EMT response . Plus, if they don’t show up you get a $5 credit, should you survive

      Step 2 – remember to not go comatose. Such lack of discipline at this critical pricing decision point could adversely impact your ability to make a rational decision on the services you may be willing to pay for and which supplier in your particular market you may want to utilize. You can ignore this if you live in a rural market and the nearest regional hospital with an ICU is 25 miles away.

      Step 3 – direct the Uber driver to the nearest accredited hospital while you use your iPhone to solicit quotes from alternative medical retail establishments (hospitals, clinics, etc) don’t forget to read the reviews. At these times it’s also especially helpful to bring up your pre-defined Excel template that you cribbed from Consumer Reports to plug in the quotes as you are making your way to the first medical retail establishment in your itinerary for this medical emergency. Be glad you aren’t a rape victim so you can be sure that whatever fully informed facility and treatment path you decide on, the hospital won’t refuse to treat you according to your wishes. OTOH, the medical retail establishment might not treat you unless you can produce a current liquid net worth and credit score that meets their patient treatment scoring index. Subprime can lead to restricted options.

      Step 4 – If you are alive and still conscious when you reach the first medical retail establishment remember ‘you don’t get what you deserve, you get what you negotiate.’ Just think of the ER staff and attending physicians as Turkish rug merchants. They need your business, keep in mind that you may need to just walk away if they refuse to bargain in good faith. Beware of hardball negotiation and scare tactics like:

      You should have called 911 instead of Uber, now it’s going to cost you an extra week in ICU.

      If you had been getting regular checkups and lowered your cholesterol from 525 you wouldn’t need the bypass and the stent.

      You should take our offer because you won’t make it to the next medical retail establishment.

      Don’t let these medical financial predators stampede you in to making rash split second decisions that they claim are life or death. Take your time, gather all the data, read all the reviews and make a carefully considered, rational decision. Don’t treat this like that impulse buy when you bought that overpriced, red convertible that had that incredibly hot model in the magazine ad.

      Good luck, with a solid plan and the patience to not panic under pressure you’ll be able to get a great deal. Should you die, it’s not your problem anyway. If you have severe brain damage, you might still have gotten a bargain by not paying for services you didn’t get. Plus using Uber is a major savings opportunity. Not everybody needs trained medical technicians administering CPR, oxygen, or other stabilizing procedures.

      Next week: how to determine if you really even need Uber to reach your local medical retail establishment.

      Previous articles: How to have physicians bid for your business when your appendix has burst

      Thinking of selling your blood, plasma, organs – read this first!

  • smott999

    CANCEL your subscription, link this article in and tell them why.
    FTNYT.

  • I suggest that the things that people hate most about health care is dealing with bullshit when they are sick and not knowing if this trip to the doctor is the one that is going to bankrupt them. Also, you know, life saving drugs priced at $1000 because that’s what the market will bear.

    • DocAmazing

      We call that “being Shkrelied”.

  • tacitus voltaire

    mr invisible hand of the market is never there when you really need him

    the hustlers and snake oil salesmen scared him off

  • vic rattlehead

    OT: Donde esta Murc? Wanted to tell the Rochester man I’m currently getting hammered on Genesee Cream Ale.

    • Denverite

      Drinking Comrade Superpower IPA myself. Quite good.

      We had to eat at a chain in Castle Rock on the way home from the softball tournament. Not a single Colorado beer (other than Coors) on tap, and nothing other than Fat Tire in the bottle. That’s shocking. Like a restaurant in the Bay Area not having a California wine on stock other than Mondavi and Sutter Home.

      • efgoldman

        Drinking Comrade Superpower IPA myself. Quite good

        You still on a less-alcohol regimen? You should save your quota for football season.

      • vic rattlehead

        Maybe I’ll check it out. I love IPAs, but not really a beach house drink. My wife eventually caught up to how many empty bottles there were and asked me to slow down ;)

        *checks room, no wife* time to crack open that porter.

        Haven’t had a vacation in a while, what can I say.

        Also, restaurants with crap beer selections are an atrocity.

  • Facebones

    I wonder how many copy editors could be paid with what they’re wasting on Bret.

  • mortimer2000

    Is demonstrating that your entire premise is bullshit right before the eyes of your readers a thing now, like counting a trillion dollars twice in the budget or making a simple mathematical error that negates everything you’re saying after it?

    Right off the bat, Stephens lists a handful of foreign countries where prices for various drugs and procedures are a fraction of the absurdly high cost for the same items in the United States — foreign countries all with some form of universal health insurance, mind —- and concludes that insurance is the problem?

    Fuck. What the?

    • Zagarna_84

      It’s a common phenomenon on the right. E.g. they look at other countries with far more universalized public school systems and far better educational outcomes, and somehow draw from this the lesson that schools should be further PRIVATIZED.

      None of this is about logical argument; it’s just a “Network”-style series of atavistic screams.

  • Mike Toreno

    Him saying “shunting” proves he’s dishonest. The word “shunt” in this context is not descriptive; it was chosen for a negative emotional flavor. It doesn’t tell us anything about what happened; it tells us how Stephens feels about what happened. He chose to try to color the analysis with a negative word about how he feels, disguised as a descriptive word. That proves he knows his argument is bad and his conclusions are wrong, but he’s making it anyway.

  • randykhan

    It’s not even an original bad argument. I see more or less the same thing from righty types all the time.

    And mandating that poor people set aside money for HSAs would be really great if they weren’t spending that money on food and rent already.

    • Lizzy L

      Uh, Anatole France, holding on Line 1.

    • econoclast

      HSAs are the dumbest fucking policy idea. Why do we have insurance, dumb-ass? To spread the risk around. If you get cancer, you’re going to blow through your HSA unless you’re Mitt Romney.

      HSAs just make it easier for rich people who can pay out of pocket to save money on taxes (which will probably just drive the cost of health care up).

    • Scott Lemieux

      This is Stephens’s trademark — making terrible conservative arguments you’re already heard 20 other hacks make. Pulitzer here he comes!

  • MassMan

    The “free market” solution to the cost of health care is to LOWER DEMAND for health care. How is that accomplished? Here are the easy steps (steps which will never be enacted because they work and make total sense):

    Subsidize super foods (spinach, kale, broccoli, beets, garlic, onions, etc) until they are nearly free
    Kick the sugar industry out of our schools and required food label honesty from it
    Offer Medicare for Everyone (or at least a public option)
    Negotiate drug prices with Big Pharma
    Air PSAs that educate/encourage people to eat healthy foods (see above)
    Rinse, repeat

    If the US population gets healthier, health care costs will fall. Simple economics. Lowering demand will lower costs, and this scares the H E L L out of the GOP because it truly solves the health care crisis. The GOP wants fat, stupid, unhealthy, gullible voters because that’s exactly who votes republican. If the nation wants to make a huge difference in its health care costs, it will go back to the simple solution in this post.

  • Incogneato

    Why are we shunting people on to Medicaid when it’s proven to be far more cost effective to shunt them into the potter’s ground?

    • Warren Terra

      If the Republicans get to enact their budget ideas, people on Medicaid would be lucky to get a pauper’s burial out of their benefits.

  • maxdi

    Stephens also refuses to criticize here the max-profit-seeking doctors, clinics, hospitals and insurance companies feeding at the trough of the broken market syndrome of an outmoded, feeble, patchwork system derived from a quirk of WW2 history when companies seeking more labor (and hindered by the ability to offer more wages) offered healthcare insurance. That got codified postwar in spite of good advice to the contrary. The AMA, among others, argued against socialism in the red-scare era, and so it’s now frozen, even though >60% of total healthcare expenditures are now socialized.

  • cpinva

    “What is it that Americans don’t like about their health care? Chiefly,
    skyrocketing insurance premiums, higher deductibles and decreasing
    access to services.”

    no dumbass, what i don’t like are Dr’s who automatically go for the single most expensive diagnostic tool, when there are less expensive, and just as efficient, alternatives. i’ve had this happen twice in the past year, with both my wife and daughter. two different Dr’s, two different issues, both wanted an MRI to “double check, just to be sure”. my daughter’s i didn’t catch, because they did it with her already in the room, and i was waiting in the hall. i did catch my wife’s, i suggested we go with an X-Ray first. if that wasn’t sufficient, then go with the MRI. amazingly enough, the X-Ray was just fine. that cost me $11 out-of-pocket, not a problem. my daughter’s MRI chewed up all of her annual deductible, to the tune of $5,000. I haven’t, and don’t plan on paying for that, because they’ve not proven it was absolutely the single best diagnostic method.

    • Warren Terra

      My grandfather, who was a primary care doctor and diagnostician for a half century, despaired of young doctors who relied on tests, scans, and procedures, instead of spending more time talking to a patient, doing a physical exam, and trusting their own judgment. Difficult to make that into policy, though, now that the tests and scans are available, are in some ways safer career-wise, and are reimbursed by insurers – which more time spent with the patient typically isn’t.

  • Professor Fate

    The Times must be so proud.

  • John Ash

    You’re an idiot. Truvada, for instance, costs under $200/month in Mexico. And it isn’t because the socialist government mandates it, that’s the free market price. And the last time someone went shopping for a urinalysis was when THEY HAD TO PAY FOR IT. Guess what, you can EASILY look up what a urinalysis costs, which is a few dozen dollars pretty much anywhere cash is accepted.

    Don’t try to pretend you’re as smart as Bret. You’re not. But you’re too fucking stupid to realize it.

  • John Ash

    “The Affordable Care Act has made premiums and deductibles lower and health care more accessible than it would have been under the status quo ante.”

    For SOME. Not for actual taxpayer though. Many are seeing their premiums skyrocket to pay for those being given very expensive health care without anything like an amount to help cover it.

  • John Ash

    BTW, if people are loving and wanting insurance so much, why does it take a mandate to force them into it and why do so many people tell the mandate to kiss off? Because insurance is so affordable?

  • John Ash

    First Party Pay is the only proven way of dropping health care costs. Even government mandates, at best, slow down the increases, but do not magically cause them to decrease in price. Medicare/Medicaid is a massively expensive program which doesn’t react quickly to the market and allows prices to be sticky. Doctors will leave the system when told that not only do they make little money, but they have to do a mountain of paperwork to get paid weeks or months later. What interests them in cash on the barrelhead. THEN they will drop prices voluntarily.

    Basic economics, try it some time. But I imagine you know just as little about the Constitution.