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United Kingdom13775 Posts
On March 31 2022 10:33 ChristianS wrote:
So you’ve highlighted a policy proposal with really regrettable drawbacks, the worst of which you figure somebody would stop you from enacting anyway. It’s not as ambitious as implausible policy goals like universal healthcare, but also the whole thing is such political suicide that you’d need “30 points of approval in reserve” (so 80%?) to even attempt it. So what the fuck are we talking about then? As long as we’re advocating impossible-to-pass policies let’s at least imagine something fun like UBI or abolishing the police or something.
Any major policy change is going to have at least a couple drawbacks. I won't sweat the details when we're mostly dealing with it at the level of acknowledging that a program whose cost quintupled in two decades - and still growing steadily - is a huge problem. If I were to theoretically campaign on the promise of killing the VA but after careful consideration keeping 10% of the budget intact - I doubt anyone would seriously consider that a broken promise.
On March 31 2022 10:33 ChristianS wrote:
I’m a little sympathetic to the argument that *any* budget cuts are going to be politically unpopular. Fiscal conservatives often bemoan this when they say they want to balance the budget by cutting spending, but people never actually support cutting spending because the benefits to them are too theoretical and diffuse, while whatever the funding was for was at least facially valuable, even if the actual program is a boondoggle. But I always thought fiscal conservatives did themselves no favors by responding with the least nuance possible. Let’s cut the department of education! Let’s cut the IRS! Aren’t those doing something? I don’t know, let’s just kill them and find out if something breaks!
I mean sure, you should ultimately have some nuance when it gets to the point of drafting actual legislation. But premature nuance does no one any favors. For example (not reflecting my actual position on this particular issue): You can't really campaign on "let's get rid of the department of education, mostly, but keep a couple of the parts that actually do some good, and maybe a couple more caveats that we concede to when looking to gain consensus." Going from "kill the DoE" to "kill most of the DoE" is best done after we agree in principle that the DoE is bad.
On March 31 2022 10:33 ChristianS wrote:
Like, okay, the VA budget is ballooning out of control. Why? Is it because veterans’ healthcare costs are ballooning out of control? Because if so I don’t think “just make the veterans themselves pay for it” is a very good solution - they’re not exactly rich as it is. Is there a significant amount of waste or redundancy or inefficiency in the VA’s systems? Then why don’t we address those things instead of kicking veterans out in the cold? More generally, shouldn’t we understand the nature of the problem so we can best prescribe a cure?
I don't think that even the strongest possible anti-VA position - veterans' healthcare is provided only to the extent that a civilian could expect to receive similar care - is going to be that much more of a disaster than the existing US healthcare system. Regarding their relative wealth compared to civilians - it's not really a grim picture (not spotless, but not bad either). If they can't afford it (in the loosest sense of "it's a lot of money for me") - that just puts them in the same bucket as anyone else of a 70th percentile or lower income in the country.
I'm sure we'd find some interesting details by digging into the specifics. At least one approach - look at the article I linked earlier, compare the various groups, look at the conditions that get people into those groups. Lot of depth you could pursue following that, and maybe some interesting findings come out of it. But that seems about as fruitful at this point as "incremental improvements" or "get rid of the waste" - a wholly inadequate response to a program that will, at current rate of growth, exceed $500B annually before 2030. In any other program (say, for example, a new military procurement), that'd be about time to give the whole thing the axe in a big way and find other ways to meet the intended objective. But VA gets no such scrutiny, primarily because it's political suicide to give it scrutiny.
On March 31 2022 10:33 ChristianS wrote:
I also think, to change the subject a little, our government should come up with solutions sooner or later regarding how to effectively and efficiently administer healthcare to citizens. Not only for if/when we enact universal healthcare, but also I’m fairly worried we’re going to have a few more pandemics before this century is through, and this first one has gone pretty horribly.
Don't think anyone would disagree that healthcare in the US is deeply broken in some very fundamental ways. Socialized healthcare in some form would be a good start. 2020 was interesting in that it showed that that's now a comfortably majority position.
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Realizing now when I said “administer healthcare efficiently” etc. I wasn’t very specific and it sounded like I just said “I think good healthcare is better than bad healthcare.” I meant administer *directly* and I meant it a little differently than just calling for M4A or some such. What I mean is, it’s apparent that there are some situations that even Republicans tend to agree the government should just guarantee everyone healthcare (e.g. when Covid first hit, 9/11 first responders, veterans excepting LL’s objections). But we’re bad at it. It’s a bit like when they decided to send everyone checks but it took months to actually get them out because the government didn’t know how to do it.
The whole system is built on private healthcare of one form or another, and a few systems like Medicare exist and have worked out how to do some portion of it, but when, say, Congress wants to declare “everybody’s Covid care will be covered by Uncle Sam” they don’t know how to actually do it. And I don’t think that’s the last time we’ll see the government trying to try to cover everyone for something (be that UHC, another pandemic, some natural disaster, etc.)
So I think systems like Medicare or VA are valuable, not just for themselves, but also as systems development for when the government does actually decide it wants to sidestep the free market and just make healthcare happen.
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The 2 trillion price tag is also misleading. Most of the programs in that plan don't start for several years and we pretend we are funding them for 10 years.
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United Kingdom13775 Posts
On March 31 2022 13:50 ChristianS wrote:
Realizing now when I said “administer healthcare efficiently” etc. I wasn’t very specific and it sounded like I just said “I think good healthcare is better than bad healthcare.” I meant administer *directly* and I meant it a little differently than just calling for M4A or some such. What I mean is, it’s apparent that there are some situations that even Republicans tend to agree the government should just guarantee everyone healthcare (e.g. when Covid first hit, 9/11 first responders, veterans excepting LL’s objections). But we’re bad at it. It’s a bit like when they decided to send everyone checks but it took months to actually get them out because the government didn’t know how to do it.
The whole system is built on private healthcare of one form or another, and a few systems like Medicare exist and have worked out how to do some portion of it, but when, say, Congress wants to declare “everybody’s Covid care will be covered by Uncle Sam” they don’t know how to actually do it. And I don’t think that’s the last time we’ll see the government trying to try to cover everyone for something (be that UHC, another pandemic, some natural disaster, etc.)
So I think systems like Medicare or VA are valuable, not just for themselves, but also as systems development for when the government does actually decide it wants to sidestep the free market and just make healthcare happen.
The government funded healthcare programs that the US actually has basically pay for the costs of healthcare in the US at full price, with a much more easily visible total cost (because government budget) than you’d get with standard private health insurance, and as part of that do little to actually systematically reduce cost in a way that governments would be capable of doing. I see it as primarily a shining example of how NOT to socialize healthcare. They decided some things should be covered by the government but essentially just put all the bills that the common man can’t afford on the government credit card - and turns out the government can’t afford that either, even if it can pretend it can for a few decades.
In that light, M4A or VA4A sound like a bad idea. Their cost structures are fundamentally broken in the same way the private system is; the biggest difference is who pays for it.
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Is that… true? There’s quite a few VA clinics and VA hospitals in my city. Near as I can tell the VA owns them and they provide care to veterans. To my understanding Medicare is more of a “just keep using the private providers and we’ll foot the bill” situation.
If you just mean “they’re just buying buildings and putting clinics in them and hiring doctors same as a private provider would,” well… yeah? That’s how you provide healthcare? I’m not asking them to reinvent the industry, I’d just like them to have some experience providing it directly instead of negotiating with some private providers to do stuff they can’t.
I’m not pretending to be very informed, are the VA facilities still owned and operated by Aetna or something?
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On March 31 2022 23:16 ChristianS wrote:
Is that… true? There’s quite a few VA clinics and VA hospitals in my city. Near as I can tell the VA owns them and they provide care to veterans. To my understanding Medicare is more of a “just keep using the private providers and we’ll foot the bill” situation.
If you just mean “they’re just buying buildings and putting clinics in them and hiring doctors same as a private provider would,” well… yeah? That’s how you provide healthcare? I’m not asking them to reinvent the industry, I’d just like them to have some experience providing it directly instead of negotiating with some private providers to do stuff they can’t.
I’m not pretending to be very informed, are the VA facilities still owned and operated by Aetna or something?
From a well-cited wiki on the subject:
The Veterans Health Administration (VHA) is the component of the United States Department of Veterans Affairs (VA) led by the Under Secretary of Veterans Affairs for Health that implements the healthcare program of the VA through the administration and operation of numerous VA Medical Centers (VAMC), Outpatient Clinics (OPC), Community Based Outpatient Clinics (CBOC), and VA Community Living Centers (VA Nursing Home) Programs.
Many evaluations have found that by most measures VHA care is equal to, and sometimes better than, care provided in the private sector, when judged by standard evidence-based guidelines.
The VHA is distinct from the U.S. Department of Defense Military Health System of which it is not a part.
The VHA division has more employees than all other elements of the VA combined.
The Veterans Health Administration is a form of nationalized healthcare service in the United States that provides healthcare to Veterans. What makes this type of healthcare different from other forms in the United States is that everything is owned by and operated by the Department of Veterans Affairs as opposed to private companies which is what we see in other parts of the health care market. This means that all the medical facilities that are part of the VHA are owned by the US Government and all the doctors and workers at the facilities are paid by the government. What is a more common model in the United States is that consumers have private health insurance and the medical facilities used are all privatized. As of 2017 the Census found that 67.2% of Americans have private health coverage. Since the VHA is nationalized they receive funding from the Department of Veterans Affairs, which is allocated funds by the federal government. Because of this, Veterans that qualify for VHA healthcare do not pay premiums or deductibles for their healthcare, but may have to make copayments depending on what procedure they are having. The funding the VA receives is split into mandatory, which is an amount of spending dictated by law, and discretionary spending, which is spending that can be adjusted year to year. In 2020 the budget given to the VA was $220.2 billion, of which 56% was mandatory spending and 44% was discretionary. From the discretionary funding, 87.6% was allocated to medical programs which came to a total VHA budget of $85 billion.
Veterans Health Administration
As has already been shown or implied at numerous stages of this discussion, LL has absolutely no clue what he's talking about.
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United Kingdom13775 Posts
On March 31 2022 23:16 ChristianS wrote:
Is that… true? There’s quite a few VA clinics and VA hospitals in my city. Near as I can tell the VA owns them and they provide care to veterans. To my understanding Medicare is more of a “just keep using the private providers and we’ll foot the bill” situation.
If you just mean “they’re just buying buildings and putting clinics in them and hiring doctors same as a private provider would,” well… yeah? That’s how you provide healthcare? I’m not asking them to reinvent the industry, I’d just like them to have some experience providing it directly instead of negotiating with some private providers to do stuff they can’t.
I’m not pretending to be very informed, are the VA facilities still owned and operated by Aetna or something?
I am, I suppose, talking about Medicare first and foremost here. Don't think anyone has seriously considered VA4A as an option, nor should they if we are to expect the same level of boundless cost growth. In fact, if anyone wants to ensure UHC never happens, they should go out and advocate for VA4A so that saner people can shoot the idea down with vicious attention to that same cost growth.
I'll admit that the previous post is a bit sloppy in that the systems are both broken, but in decidedly different ways. I nevertheless will stand by that I'm not sure you would want to see this as an example of what could be, unless you're really looking to build a Republican caricature of UHC as a counterexample to convince people to steer clear.
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I’m not saying “works great, now just scale it up for everyone.” I’m saying “whether we get UHC or not the government is going to get in situations where it wants to guarantee medical care in the future, and it’s good for them to develop systems for doing that now.” If VA is broken let’s fix it and learn some lessons for how to directly provide care in the future. That’ll be better for veterans in the short run and better for all of us in the long run.
Farv’s sources seem to confirm my vague recollection that veterans are generally pretty happy with the quality of their care. Are VA costs growing in a way that outpaces healthcare costs generally? Or are you just complaining that they’re facing the same problems as the rest of the industry?
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On March 31 2022 21:48 LegalLord wrote:Show nested quote +On March 31 2022 13:50 ChristianS wrote:
Realizing now when I said “administer healthcare efficiently” etc. I wasn’t very specific and it sounded like I just said “I think good healthcare is better than bad healthcare.” I meant administer *directly* and I meant it a little differently than just calling for M4A or some such. What I mean is, it’s apparent that there are some situations that even Republicans tend to agree the government should just guarantee everyone healthcare (e.g. when Covid first hit, 9/11 first responders, veterans excepting LL’s objections). But we’re bad at it. It’s a bit like when they decided to send everyone checks but it took months to actually get them out because the government didn’t know how to do it.
The whole system is built on private healthcare of one form or another, and a few systems like Medicare exist and have worked out how to do some portion of it, but when, say, Congress wants to declare “everybody’s Covid care will be covered by Uncle Sam” they don’t know how to actually do it. And I don’t think that’s the last time we’ll see the government trying to try to cover everyone for something (be that UHC, another pandemic, some natural disaster, etc.)
So I think systems like Medicare or VA are valuable, not just for themselves, but also as systems development for when the government does actually decide it wants to sidestep the free market and just make healthcare happen. The government funded healthcare programs that the US actually has basically pay for the costs of healthcare in the US at full price, with a much more easily visible total cost (because government budget) than you’d get with standard private health insurance, and as part of that do little to actually systematically reduce cost in a way that governments would be capable of doing. I see it as primarily a shining example of how NOT to socialize healthcare. They decided some things should be covered by the government but essentially just put all the bills that the common man can’t afford on the government credit card - and turns out the government can’t afford that either, even if it can pretend it can for a few decades. In that light, M4A or VA4A sound like a bad idea. Their cost structures are fundamentally broken in the same way the private system is; the biggest difference is who pays for it.
M4A will lower costs. Medicare already sets the payout for procedures. Prescription drugs are a glaring omission from Medicare price caps currently, due to corruption in our country, but that can be addressed in a M4A bill. If you want to enter the US drug market this is the fair price we will pay. Its exactly what would happen if everyone was on the same insurance plan. Insurance companies negotiate prices and theoretically the more people under their umbrella the better rate they get. The best possible rate is having the whole US on a single plan, negotiating as one block. Having government handle it makes the most sense since they carry the big stick and dont have perverse incentives that the insurance industry has.
I agree just flipping the current fucked up system to M4A is not a good idea. They need to implement cost controls and M4A is the best way to do that. If you have health insurance it will be a net gain for you since you wont pay ever increasing Premiums, deductibles, co pays, etc. Itll just be a tax that will be less than your current costs.
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United Kingdom13775 Posts
On April 01 2022 00:11 ChristianS wrote:
I’m not saying “works great, now just scale it up for everyone.” I’m saying “whether we get UHC or not the government is going to get in situations where it wants to guarantee medical care in the future, and it’s good for them to develop systems for doing that now.” If VA is broken let’s fix it and learn some lessons for how to directly provide care in the future. That’ll be better for veterans in the short run and better for all of us in the long run.
Farv’s sources seem to confirm my vague recollection that veterans are generally pretty happy with the quality of their care. Are VA costs growing in a way that outpaces healthcare costs generally? Or are you just complaining that they’re facing the same problems as the rest of the industry?
Eh, I guess it's experience of a form. I personally don't think that experience doing something badly counts as experience worthy of receiving some form of credibility. We wouldn't want to emulate it or employ any of the leadership of a program that was fundamentally unsuccessful like that. The problem is more fundamental than can be solved with mere incrementalism.
I might go through the numbers in more detail later as I simply don't have the time now, but I would indeed say that the expense growth of the VA does significantly outpace regular healthcare cost growth in the US in an alarming way (and the latter is itself quite alarming). There's enough nuance to what costs more that I couldn't really be fair without digging into said numbers, but even at a glance it's clear that VA cost is far more comparable to US private healthcare costs than to countries-with-UHC costs. Which may or may not seem all that bad, but it's hardly something we can afford to put on a credit card in the long run. I suppose you could counter that Medicare is in the same boat, which is certainly true.
That veterans are fond of it is not a surprise to me. I also don't consider that to be indicative of good policy in that sentiment matters less than who pays the bill, how big it is, and to a lesser extent the outcomes of treatment. I'd be happy if I received a million dollars a year in free money checks from the government, but don't think that's good policy either.
On April 01 2022 00:45 Sadist wrote:
M4A will lower costs. Medicare already sets the payout for procedures. Prescription drugs are a glaring omission from Medicare price caps currently, due to corruption in our country, but that can be addressed in a M4A bill. If you want to enter the US drug market this is the fair price we will pay. Its exactly what would happen if everyone was on the same insurance plan. Insurance companies negotiate prices and theoretically the more people under their umbrella the better rate they get. The best possible rate is having the whole US on a single plan, negotiating as one block. Having government handle it makes the most sense since they carry the big stick and dont have perverse incentives that the insurance industry has.
I agree just flipping the current fucked up system to M4A is not a good idea. They need to implement cost controls and M4A is the best way to do that. If you have health insurance it will be a net gain for you since you wont pay ever increasing Premiums, deductibles, co pays, etc. Itll just be a tax that will be less than your current costs.
I don't doubt that some reforms and the advantage of market power will help M4A be more cost-efficient than regular existing Medicare. I am somewhat skeptical that Medicare is the right program to use as a foundation. Certainly could use some of its institutions in the final system - the Medicare tax, for example, is a good funding mechanism to preserve - but to really be effective I expect that M4A would have to take direct control over much of the healthcare infrastructure to enough of an extent that it'd be Medicare in name only. And maybe that is the case and "M4A" is just good marketing from the Bernie group, but I certainly don't think the final answer should look a whole lot like Medicare except for more people having it.
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On April 01 2022 00:54 LegalLord wrote:Show nested quote +On April 01 2022 00:11 ChristianS wrote:
I’m not saying “works great, now just scale it up for everyone.” I’m saying “whether we get UHC or not the government is going to get in situations where it wants to guarantee medical care in the future, and it’s good for them to develop systems for doing that now.” If VA is broken let’s fix it and learn some lessons for how to directly provide care in the future. That’ll be better for veterans in the short run and better for all of us in the long run.
Farv’s sources seem to confirm my vague recollection that veterans are generally pretty happy with the quality of their care. Are VA costs growing in a way that outpaces healthcare costs generally? Or are you just complaining that they’re facing the same problems as the rest of the industry? Eh, I guess it's experience of a form. I personally don't think that experience doing something badly counts as experience worthy of receiving some form of credibility. We wouldn't want to emulate it or employ any of the leadership of a program that was fundamentally unsuccessful like that. The problem is more fundamental than can be solved with mere incrementalism. I might go through the numbers in more detail later as I simply don't have the time now, but I would indeed say that the expense growth of the VA does significantly outpace regular healthcare cost growth in the US in an alarming way (and the latter is itself quite alarming). There's enough nuance to what costs more that I couldn't really be fair without digging into said numbers, but even at a glance it's clear that VA cost is far more comparable to US private healthcare costs than to countries-with-UHC costs. Which may or may not seem all that bad, but it's hardly something we can afford to put on a credit card in the long run. I suppose you could counter that Medicare is in the same boat, which is certainly true. That veterans are fond of it is not a surprise to me. I also don't consider that to be indicative of good policy in that sentiment matters less than who pays the bill, how big it is, and to a lesser extent the outcomes of treatment. I'd be happy if I received a million dollars a year in free money checks from the government, but don't think that's good policy either. Show nested quote +On April 01 2022 00:45 Sadist wrote:
M4A will lower costs. Medicare already sets the payout for procedures. Prescription drugs are a glaring omission from Medicare price caps currently, due to corruption in our country, but that can be addressed in a M4A bill. If you want to enter the US drug market this is the fair price we will pay. Its exactly what would happen if everyone was on the same insurance plan. Insurance companies negotiate prices and theoretically the more people under their umbrella the better rate they get. The best possible rate is having the whole US on a single plan, negotiating as one block. Having government handle it makes the most sense since they carry the big stick and dont have perverse incentives that the insurance industry has.
I agree just flipping the current fucked up system to M4A is not a good idea. They need to implement cost controls and M4A is the best way to do that. If you have health insurance it will be a net gain for you since you wont pay ever increasing Premiums, deductibles, co pays, etc. Itll just be a tax that will be less than your current costs. I don't doubt that some reforms and the advantage of market power will help M4A be more cost-efficient than regular existing Medicare. I am somewhat skeptical that Medicare is the right program to use as a foundation. Certainly could use some of its institutions in the final system - the Medicare tax, for example, is a good funding mechanism to preserve - but to really be effective I expect that M4A would have to take direct control over much of the healthcare infrastructure to enough of an extent that it'd be Medicare in name only. And maybe that is the case and "M4A" is just good marketing from the Bernie group, but I certainly don't think the final answer should look a whole lot like Medicare except for more people having it.
That veterans are fond of it is not a surprise to me. I also don't consider that to be indicative of good policy in that sentiment matters less than who pays the bill, how big it is, and to a lesser extent the outcomes of treatment. I'd be happy if I received a million dollars a year in free money checks from the government, but don't think that's good policy either.
You keep using this refrain. I don't think you know what it is you're saying. Veterans get disability for injuries that range from $200/mo to $1000/mo depending on the severity and where they live. It's more or less an early SSI payment. It's also not free as those disabilities could keep them out of the workforce or severely limit what jobs they can perform.
The VA provides more services than just paying injured veterans, such as unique mental health services tailored to them, support groups for those that need it, and resources for jobs, housing, and rehabilitation that would literally bankrupt most people if they had to go through them. You see these people receiving compensation for services rendered and dislike it. I assume you would also be willing to gut any and every form of welfare that the government provides simply because it doesn't benefit you in some way. As inflation and costs rise through the years, so will the amount of money required to keep them going and make sure that those who served are taken care of. Sure, you foot the bill, but guess what? So does every veteran. We're not tax-exempt from anything else. We pay into everything like everyone else.
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Yeah, among other things, I find framing their benefits as free money just to call it bad policy is not a good faith position.
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United Kingdom13775 Posts
On April 01 2022 01:55 NewSunshine wrote:
Yeah, among other things, I find framing their benefits as free money just to call it bad policy is not a good faith position.
I believe the term I used was "economic rent" which is appropriate. Even if they also pay into it, it's almost trivially true that as a class veterans will get more out than they put into the system by virtue of the fact that the taxpayer base is significantly larger than just veterans.
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On April 01 2022 01:59 LegalLord wrote:Show nested quote +On April 01 2022 01:55 NewSunshine wrote:
Yeah, among other things, I find framing their benefits as free money just to call it bad policy is not a good faith position. I believe the term I used was "economic rent" which is appropriate. Even if they also pay into it, it's almost trivially true that as a class veterans will get more out than they put into the system by virtue of the fact that the taxpayer base is significantly larger than just veterans.
You getting free money is not the same as receiving compensation in the form of physiological and psychological care owing to what you experience during military service. I stand by bad faith on your part.
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That’s why I explicitly framed it in terms of quality of care, not cost to veterans. If VA was wasting a ton of money and providing poor care, veterans might say “just give me a plan through Anthem or something instead,” but apparently they tend to like the VA standard of care quite a bit.
Surely some economists have done a comparative analysis of what it would cost to insure veterans privately versus the cost of direct care through VA. If the same standard of care could be achieved much cheaper over there, then the rent-seekers in this system aren’t the veterans. If VA is comparably efficient and it’s just providing a higher, more expensive standard of care, then LL is ultimately just saying “we should put veterans on a shittier health plan to save taxpayers money.” “Rent” would still be kind of a shitty framing of compensation for a job, but at least “let’s take money from veterans and redistribute it to everyone else” is coherent.
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It's the comparison between care provided to veterans who have been through trauma and injury, and taxing people a billion dollars to give only a million to some rando that's incoherent to me. It's a bizarre analogy that seems purposely drawn up to make the VA's care seem as wasteful as possible, not to be accurate to the essence and nuance of the situation. Hence bad faith.
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United Kingdom13775 Posts
On April 01 2022 02:07 NewSunshine wrote:Show nested quote +On April 01 2022 01:59 LegalLord wrote:On April 01 2022 01:55 NewSunshine wrote:
Yeah, among other things, I find framing their benefits as free money just to call it bad policy is not a good faith position. I believe the term I used was "economic rent" which is appropriate. Even if they also pay into it, it's almost trivially true that as a class veterans will get more out than they put into the system by virtue of the fact that the taxpayer base is significantly larger than just veterans. You getting free money is not the same as receiving compensation in the form of physiological and psychological care owing to what you experience during military service. I stand by bad faith on your part.
Only in how blatant it is in order to prove a point. Ultimately, it's all money given under specific conditions, some conditions of which are more justifiable than others. Very little of the discussion from actual veterans posits the possibility that maybe they shouldn't receive certain services because it's an outsized benefit relative to good policy, or that they should be treated the same as civilians, and the vast majority of the response is emotional. If we had something more blatant, like me receiving free money, the response would be the same but it sounds silly when you would put it exactly the way I put it. Give it some nice cover and bury it under several layers of misdirection (say, by burying it in a "Support the Children Act" but keep it as a rarely-advertised position that doesn't actually contribute to supporting the children), and it'd be the same thing.
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EPT
