Gruber Doesn't Reveal that 21% of MA Residents Can't Afford Health Care

Picture 178I was intrigued to see Gruber link–in his response to Ben Smith–to his May 2009 analysis of how to measure affordability for a national healthcare reform plan. After all, I’ve been debating with people who love to cite Gruber on affordability for months, and I’ve never seen them cite it. Now there are several reasons they might not want to rely on this paper. It might be that he starts out by arguing that you can still call something “affordable” even if it isn’t affordable for everyone.

In considering affordability for a group, we need to establish a sensible benchmark whereby insurance is considered affordable if “most of” a group can afford it. We can disagree about what “most of” means, but it would be wrong to define “most of” only as “very close to 100%.”

This, of course, accepts as a baseline some continued medical debt (at least) or even bankruptcies in your definition of “affordable.”

Or maybe it’s the fact that Gruber insists that health insurance (not care) be considered as the same kind of necessity as food and shelter.

Second, it implicitly assumes that health care is less important than these other categories; that is, that if individuals have to spend their resources on these other categories, then they should not have to spend resources on health care. It is unclear why health insurance should take a lower position on the priority scale than other necessities.

But the thing I’m most troubled by in this paper is something Gruber neglects to mention: real data from MA on the number of people who forgo necessary medical care because it is not affordable.

In March 2009–two months before Gruber wrote this paper–MA released the first results [PPT] of how that state’s health care reform had improved access. It showed that 21% of the total population–and even 12% of children–forgo necessary medical care because they cannot afford it. Of the 21% forgoing care, most (something like 18 or 19%) have health insurance–but it is health insurance they can’t afford to use. In a paper contemplating what constitutes affordability for a national plan that resembles the MA plan in many ways, Gruber uses national Kaiser/HRET data, rather than the MA data that is much more directly on point.

Now, I might excuse other analysts for ignoring the MA results, except for two things. First, Gruber boasts of his involvement in the MA program as part of his explanation for his qualifications for the HHS contracts.

Throughout this year I have provided technical assistance to the administration and to Congress with my micro-simulation model, as well as based on my experience as a member of the Massachusetts health connector board.

Also, when the facts from MA suit his argument, he uses them, as he did in a November analysis of how much the Senate plan would reduce premiums.

So rather than looking at a real world study showing what happens when a program very similar to the Senate plan goes into effect–which shows that a significant number of people can’t afford to use their health insurance–here’s what Gruber says about how out-of-pocket expenses affect affordability.

A very conservative response would be to say that a plan is only affordable if the premiums plus the maximum out of pocket exposure does not exceed available resources. This is very conservative because while premium payments are certain, out of pocket payments are not, and a sizeable majority of enrollees will not reach the out of pocket limit.

Moreover, there is a strong argument that out of pocket costs should not be incorporated into a discussion of affordability of insurance. After all, individuals face more out of pocket risk without insurance than they do with coverage. Thus, if an individual is very ill and faces large out of pocket costs under an insurance plan, they would have faced at least those same out of pocket costs, and likely more, had they remained uninsured. So it would be wrong to say that those out of pocket costs were responsible for making insurance unaffordable. That is, it is nonsensical to argue that very sick individuals cannot afford insurance because they will have large out of pocket costs under the insurance plan; indeed, the problem is that these individuals cannot afford not to have insurance.

This is analysis that Jonathan Cohn, with data from Gruber, expands upon here.

But it all comes back to that underlying premise. So long as you define “affordable” in such a way that accepts ongoing medical debt for at least some of your sample in your definition of affordable, then this approach–looking at total risk, rather than whether insurance equates to care, makes sense. It transforms the question of whether health care (not health insurance) is affordable into one that measures degrees of indebtedness for using health care.

But then again, that’s what a lot of bill apologists do: consistently oversell what this kind of reform does, by conflating health insurance with health care.

Update: Fixed percentages forgoing care for clarity.

Marcy has been blogging full time since 2007. She’s known for her live-blogging of the Scooter Libby trial, her discovery of the number of times Khalid Sheikh Mohammed was waterboarded, and generally for her weedy analysis of document dumps.

Marcy Wheeler is an independent journalist writing about national security and civil liberties. She writes as emptywheel at her eponymous blog, publishes at outlets including the Guardian, Salon, and the Progressive, and appears frequently on television and radio. She is the author of Anatomy of Deceit, a primer on the CIA leak investigation, and liveblogged the Scooter Libby trial.

Marcy has a PhD from the University of Michigan, where she researched the “feuilleton,” a short conversational newspaper form that has proven important in times of heightened censorship. Before and after her time in academics, Marcy provided documentation consulting for corporations in the auto, tech, and energy industries. She lives with her spouse and dog in Grand Rapids, MI.

  1. tejanarusa says:

    What? Hunh? WTF?

    And I’ve only read down to the part about it being “unclear” why health care should be a lower priority than “other necessities.”

    Assuming other necessities would be, say shelter, food, clothing – I am reduced to sputtering inarticulateness trying to respond to someone who wouldn’t see the obviousness here.

    I think I was in fourth grade when I learned that people need food and shelter first and foremost, followed by clothing, and that pretty much everything else comes after those are satisfied. Fourth f’ing grade!

    Well, I was doing a drive-by before heading out, but I’ll be back. Never heard of this guy Gruber. EW, you do educate us all. Thanks.

    • solerso says:

      the san andreas sized fault line between the classes in the US is starting to rumble and show itself more plainly, i hope when it goes, all of they’re million dollar condos, and italian cars, and ridciculous overpriced fad electronic devices wind up buried in it.

    • ghostof911 says:

      The logic of the bloviated BS artist is circular, but his career trajectory has been consistently upward.

      The frauds need to be knocked off their perches.

    • earlofhuntingdon says:

      I’m intrigued, too, by his preface to that paragraph:

      A very conservative response would be to say that a plan is only affordable if the premiums plus the maximum out of pocket exposure does not exceed available resources. This is very conservative because while premium payments are certain, out of pocket payments are not, and a sizeable majority of enrollees will not reach the out of pocket limit.

      Gruber claims that it is “conservative” – obvious code for unrealistic, unpragmatic and politically naive – to measure affordability using real world impact, that is, best estimates of what money would be left each month to pay foreseeable expenses.

      Gruber implies that doing so would be unaffordably generous to some households. He too conveniently ignores the other half of that observation, Marcy’s point: His definition of “affordability” would send other households to the wall and the unforgiving arms of unregulated debt collectors and perverse bankruptcy court rules.

      That last item is important in that since 2005, bankruptcy rules give credit card debt – the debt of first and last resort for the financially overburdened – absurdly high priority as an obligation that must be repaid for anyone above the FPL. Combine that with the inability to cram down a mortgage and the middle as well as working classes will get short shrift when trying to make a desperate and humiliating “fresh start”.

      Second and third chances for corporations and their failed CEO’s abound (AIG, GM, Carly Fiorina). Second chances for working families are a moral hazard Americans cannot tolerate.

      • hijean831 says:

        “credit card debt – the debt of first and last resort for the financially overburdened”

        It’s not even that anymore. Due to a combination of ugly loan and unemployment I lost my home this year. I *never* missed or was late on a cc payment, in fact, when I couldn’t pay the house anymore, I almost paid them off (fair, since the balances were racked up in the first place trying to save the mortgage). As soon as I did, the paid-off account was closed by WaMu, the other (FIA) had the limit reduced to just over the remaining balance. And they jacked up my rate another 5%.

        Unfortunately, I’m not alone. If I don’t find a job with benefits before (stim-discounted) COBRA runs out, we’re screwed.

        • earlofhuntingdon says:

          Unfortunately (for borrowers), you’re not alone; there are millions in the same boat as lenders jack up fees and rates and cut lines of credit to the amount of the outstanding balance and one month’s interest (effectively, stopping you from using the card until current debt plus interest payments make a hole big enough to pay for new charges).

          Those are predatory business practices that the proposed credit card reforms will do little to address. As it is, Congress gave CC issuers about a year to think up new scams before the current legislation closes old ones – and to make a killing before several of the current practices become illegal.

          This constant “make nice” with banksters at the expense of the public is carving a hole in more than the public’s nearly empty pocketbooks. It’s carving a great hole in the heart of what was once the Democratic Party’s base. Its current leaders will retire fat, rich and happy. Their successors will have as hard a time doing that as the public.

        • temptingfate says:

          Sorry to read this. Your situation is being replayed all over this country and it is not fair. Nearly nothing has been done to bring lending practices back into line and you know the job market as well as anyone. It hard to be very optimistic in the short term about any of this. If instead of bending the curve on insurance policies we were doing the same thing to the banking industry and using the bailouts to fix our job problems we would be headed the right way. The size of the problems that are being used as excuses for giving even more money to the undeserving rich keep getting bigger.

          Hopefully things will work out better in the future.

      • Acharn says:

        I can’t seem to make it compute. Let’s see: if you don’t reach the limit of out of pocket costs on your insurance policy, so that your insurance policy actually starts to pay some of the medical costs, you are somehow better off having an insurance policy for which you have to pay premiums on top of your out of pocket costs.

        That is, it is nonsensical to argue that very sick individuals cannot afford insurance because they will have large out of pocket costs under the insurance plan; indeed, the problem is that these individuals cannot afford not to have insurance.

        How does paying premiums to a private insurance company, on top of out of pocket costs, make the risk smaller? Risk of what? Risk of bankruptcy?

        • earlofhuntingdon says:

          It would be more accurate to say these people cannot afford to be without health care. How that’s paid for, and whether its costs are appropriate or as overblown as insurance costs, would seem to be the questions that need addressing.

          The arguments become skewed when, as this government has done, it mandated that only private insurers would sell health insurance before it mandated that we had to buy their poorly- or unregulated products. The worst of all possible worlds.

  2. fatster says:

    Good! Keep nailing them on their BS, EW. Please. The American people are confused enough by all the “info” bombarding them from every direction. You deliver an invaluable public service to them each time you engage your keyboard (or grab your hammer, to continue the nailing image). Excellent!

  3. tejanarusa says:

    Oh, and this guy is from MIT? He’s smack in the middle of the MA plan then; he lives there! He’s subject to it! Grrrrr.

    Okay, I must get going. Every day, a fresh outrage re health care/insurance.

    • eCAHNomics says:

      Wow. The stoopid, it hurts.

      And then when HCR doesn’t create jobs and raise growth, these authors will be on all the talk shows. And the ones who got it right will be nowhere to be found.

    • MarkH says:

      When corporations like GM are tied down with HC costs so they lose to foreign car makers and when individuals can’t afford ANY insurance or care and when HC costs are bankrupting individuals, cities and states then it’s unaffordable.

      Where it becomes affordable is hard to pin down precisely except to say we should do the obvious things which improve care as well as lower costs. that includes covering more, if not everyone. It includes everyone having insurance, so they can get regular care instead of ONLY ER care. It includes more options for small businesses to insure their workers. It includes ‘best practices’ to guide care and that will also lower redundancy and wasteful spending.

      We know a lot of things to do to improve the whole system which ALSO lower costs. That’s a start. Let’s do that.

      Just arguing over dollar amounts is fine in the context of % of GDP being spent and balancing this against that, but it’s not as important as the whole process moving along. After all, this reform will take decades to be fully integrated into the economy and we probably save more by getting it done 17 years ago instead of now and we save more by starting now than dilly-dallying until next year and so on.

      And, after this is done we can really put our shoulders into JOBS JOBS JOBS.

  4. BoxTurtle says:

    Gruber will apoligize for failing to disclose the relationship, saying that it was public record and he didn’t know he needed to mention it. ObamaCo will forgive him. He will continue to serve ObamaCo. MSM will not notice it.

    I’m amazed at the amount of money flying about on this issue. In my entire life, I’ve never seen so much money flow around a political issue. Heck, this is worse than any of the base closing bills!

    But it’s all Rahm’s fault. Obama would support single payer public option, paid by a tax on millionaires, with drug re-importation if it wasn’t for the Evil Rahm.

    Boxturtle (Willing to pretend to believe that, if it’ll make Rahm fall on his sword sooner)

      • BoxTurtle says:

        When you’re making your boss (Obama) happy, apologies need only be sufficient to redirect the media away.

        Since the media doesn’t really want to pursue anything that would annoy their corporate masters, I’m sure that apology will be fine.

        Boxturtle (I’m sure an annoyed grunt would also have served)

  5. klynn says:

    Great job EW.

    What you end up doing here is taking away any party-vs-party blame game and address the real issues followed by asking about the overselling of the reform.

    Whether it was the GOP in the 2008 election overselling Romney and his health care reform as a candidate or this effort nationally under Obama, both sides of the isle are to blame. Quite honestly, the repugs being so quiet is a bit manipulative because they know all to well what is going down in MA.

    But it all comes back to that underlying premise. So long as you define “affordable” in such a way that accepts ongoing medical debt for at least some of your sample in your definition of affordable, then this approach–looking at total risk, rather than whether insurance equates to care, makes sense. It transforms the question of whether health care (not health insurance) is affordable into one that measures degrees of indebtedness for using health care.

    But then again, that’s what a lot of bill apologists do: consistently oversell what this kind of reform does, by conflating health insurance with health care.

    (my bold)

    Again, both parties own this and the model data. Quiet or verbal.

  6. earlofhuntingdon says:

    Gruber’s argument about the priority of health insurance seems jesuitical. It is health care whose priority should be debated and around which we should build national policies. Building an awareness that what Americans need is health insurance, then making only private insurance available, is high order fraud.

    As to the point about perceptions of priorities, health care may not be regarded as high a priority as food or housing, jobs or children’s education. That may be because obtaining it is a constant worry, but actually getting it is not a daily need. In any case, on a point critical to his argument, I would expect Gruber to cite credible research rather than anecdotal evidence.

  7. AZ Matt says:

    Marcy, you are really going to town today, beating Gruber the Grubber like a drum! I just sent $60 to the donation page for you to help beat him even harder!

    • selise says:

      Marcy, you are really going to town today, beating Gruber the Grubber like a drum!

      amen! and there is just no way i can describe how happy i am that she is.

  8. ghostof911 says:

    With those changes, employers could then reallocate money now spent on ever-growing premiums to other business priorities.

    Other business priorities maeaning sweetened compensation packages for top management.

  9. openhope says:

    Thank you, Marcy. It’s disgusting to learn this shill gets $400,000 of HHS money for pure bullshit while local community programs for Women Infants and Children, along with a host of others, are being cut back so drastically.
    Maybe that was the President’s Health Plan.

  10. MadDog says:

    From a commenter called Gooznews over at that Ben Smith Politico piece:

    Gruber Once Argued Against Higher Health Care Cost Sharing

    …Hmmm. What about this March 2007 paper for the National Bureau of Economic Research, which he co-authored. It looked at the effect of higher out-of-pocket co-pays for retired public employees in California. Gruber found that they led to higher hospitalization rates as old folks with chronic diseases like diabetes and heart disease cut back on physician visits and necessary drugs.

    These offset effects are concentrated in patients for whom medical care is presumably efficacious: those with a chronic disease. . . Our findings suggest that health insurance should be tied to underlying health status, with chronically ill patients facing lower cost-sharing.

  11. sinestar says:

    All these pundits and all politicians should be forced into Medicare because they are obviously disabled. MENTALLY! Pathological lying is a mental disability.

  12. anwaya says:

    So if Gruber’s figures scale, then about 12 million people (19% of 21% of 300 million) will have insurance and won’t be able to afford to use it, and about 51 million will not have insurance and won’t get healthcare.

      • earlofhuntingdon says:

        So 57 million people pay through the nose, under penalty of law, for private insurance they can’t afford to use. And they stay unhealthy and at their financial wit’s end, with all the ramifications for family stress, lost productivity and poor public health.

        No big deal. Defense contractors sell weapons systems like that all the time.

  13. selise says:

    Also, when the facts from MA suit his argument, he uses them, as he did in a November analysis of how much the Senate plan would reduce premiums.

    i have to dispute the use of the term “facts” with regard to gruber’s nov paper (unless surrounded by scare quotes). first he used cbo data in way they specifically said it shouldn’t be used. and second, he relies on ahip (insurance industry lobby) for his data (this was all pretty well hashed out in the diaries. for some background on previous discussions see these comments/threads: here, here, here and here)

  14. klynn says:

    EW (and selise)

    Have there been any current examples of MA making sound corrections on their health care policy in order to address whether there is affordable care and “what care” is defined as and whether the policy is meeting the definition?

    • selise says:

      i’m sorry. i should know enough to answer your question, but i don’t. (i’ve only been paying a little bit of attention to the policy and coverage cut backs, but nothing like enough to know the answer your question.)

  15. ccusick says:

    Just Must Say.
    Yes, health insurance should not be conflated with health care.

    Those who seek to fleece us say we need H.Ins. We actually need H.Care.

    ….what a hack. of course you stop paying premiums for some future need in the face of actual current needs, like food. Or heat.

    The fact that he misses the difference ….. I guess I don’t need to go on. Should not be listened to, that Gruber. Attempting to mislead.

    Further, the idea that a TAX will be good for us is just utter nonsense. There are those who believe that tax cuts for the rich would trickle down to the rest of us. Later. In a way that is not measurable.

    Now a tax on the middle class is good b/c — you’ll get more money. Later. In a way that is not measurable or immediately attributable. I have more erudite terms, but this ^bullshit^ does not deserve them.

    Lies supported by complicated, secret models are still lies. I don’t need to see the code to know that.

  16. MadDog says:

    More Grubernews via Ben Smith at Politico:

    Gruber’s disclosure

    …POLITICO has also quoted him without referring to his administration work.

    Gruber told me in an interview this afternoon that he hadn’t given the matter of disclosure much thought, but had disclosed whenever asked.

    “I’m an ivory tower guy at heart and do my thing and figure I’m an honest guy and people will trust it,” he said.

    The New Republic’s Jonathan Cohn, who knows Gruber well, once mentioned in passing that the economist had “advised” the administration, suggesting he didn’t see it as a secret. But other plugged-in health care reporters didn’t, from my colleague Carrie Budoff-Brown to Post blogger Ezra Klein, who has used Gruber to back his arguments, and who now says he’ll be disclosing the contract in the future.

    “The [New England Journal of Medicine] asked me, so I disclosed it. Nobody else really asked,” Gruber told me a few minutes ago, adding that the journal article was “the most important” to disclose because it was an explicit defense of the plan…

  17. grayslady says:

    Marcy, FOX News and Atlantic Online have picked up your story on Gruber and are running with it. It’s now on the front page of Google News.

  18. unionave says:

    Before RWR and his VP ruined the not for profit health care facilities we had until he arrived and turned them in to for profit facilities one person could work and support a family and live quite comfortably . Today many families must have two or more people working to support the family and the biggest expense the family has is insurance . Auto , home , life , and health insurance adds up to a substancial part of cost of living . When we pay an insurance coropration we are handing our money to them so the corporation will pay for possible future charges . In order for the insurance corporation to make a profit they must take in more than they pay out and any hard working corporatist will find ways to manage that problem . The insurance corporations have so much of our money they own our government and have told our government to mandate that we pay the insurance corporations even more of our national income . I am having a very difficult time trying to find the legitmacy is this . A federal judge claimed the auto insurance mandate was illegal but he placed in some dark room and has not been heard from since . This is a mandated tax on every young healthy American that is collected by insurance corporations . In other words , we are being taxed by the stock holders of certain corporations .

  19. hotdog says:

    Thanks for exposing the paid liars for the sock-puppets they are but we need to zoom out. What service do insurance companies provide? They ride herd over a pool of money and in the process, chastise healthcare providers, limit service, antagonize, berate, and abuse their customers, and then they take a huge cut. Don’t get lost in the argument of whether either of these two give-away bills has any merit. Back up and get out of the framing these crooks have constructed around the debate and hit the bastards where it hurts: people can identify with a table full of bills and claim rejections. Who is the bad guy? The insurance crooks who have been scraping 30% off the pile for the last 40 years. Subsidizing the same inefficient and crooked system and securing its hegemony is not an acceptable solution. The media machine is forcing us to waste effort debating fabricated items laid out line by line, while the time to deliver the critical message that this is an absolute criminal take-over of one fifth of our economy is evaporating. The extortionists should not be allowed to gain total control.

  20. Becca says:

    It’s like you take a bunch of starving people with a little money — confiscate that money in exchange for catalog books showing pictures of food and membership cards to buy it — and then throw up your hands when the poor sods have no money to actually BUY the food.

    Meanwhile, the ‘catalog’ company remains free to charge older people 3x what young people pay, to demand outrageous co-pays and deductibles, and simply refuse to sell certain things to certain people based on byzantine rules the company can invent and change at will. (“Oh, you wanted an insulin side-dish with that Twinkie? Sorry — insulin isn’t in our formulary.”)

    But hey — 9 people out of 10 will have a catalog and membership card! That’s called Solutions We Can Believe In!

  21. temptingfate says:

    Much like figuring out that many Ds are defending the idea that health care is the same as health insurance we should thank Gruber for this little tidbit as well. Gruber wants us to understand that having 21 percent of a population not covered under the MA mandate / excise tax plan is a good thing. Good we can assume because the important part of the population has been covered and they are busy growing the health insurance industry. His belief that being in debt for insurance is an acceptable replacement for health care puts the whole thing into context. His phrase “indeed, the problem is that these individuals cannot afford not to have insurance” is a great closer because it ends the question of priorities. We must find ways to force people to buy insurance, whatever the cost, because it is the only way to save them. As he says, out of pocket costs does not make insurance unaffordable.

    Rules to remember. Affordability has nothing to do with how much a person can pay and not being able to afford something which may not do them any good does not mean that they should not be required to purchase it.

    With an ideology like this it is hard to imagine why we are in such serious financial straits.

    Coming back to why Obama hired him as their taxpayer funded spokesman then becomes clear. Gruber and other like minded people, have abandoned any pretense of rational thought because the siren song of greed has turned their minds into incoherent mush. The Obama administration thought it was such a nifty concept they paid hundreds of thousands of taxpayer dollars to spread the word and make it policy.

  22. maryo2 says:

    Comments at FAUX are along the line “Liberals prefer educated elite, and Gruber proves that you can’t trust the educated elite.” They don’t understand that Gruber did not subject his model to review by the educated elite. And in fact, it is the educated elite (liberal bloggers) who noticed this fact and exposed him and the Obama Administration.

    proprietary model – bleh

    • Jim White says:

      proprietary model – bleh

      Yup. That means he’s not going to share enough details of the method for it to be reviewed by those with the appropriate expertise.

      • temptingfate says:

        Or that he has just been hand waving because it’s easier than building a model and always returns the result you expected.

      • BoxTurtle says:

        In defense of the proprietary model: There are many such out there. Weather forecasting. Business planning. Subatomic behavior. And so on.

        And much like an Author controls (or should control) their writings and profit from them, so a software modeler controls his code. And hopes to profit from it.

        As for review, well, for a model like this the review is to see how closely it matches real world conditions given real world data. The math and logic behind these things can be very theoritical, and it might not be fully understood why that function so closely tracks the real world.

        And software code is easy to steal. Publish it for peer review and somebody is going to quietly copy it and undercut your market. Then your profits go to your lawyers from that point forward.

        That said, a hidden model is also a good way to sell a bridge or other national landmark. And if a bogus model gives you the results you want, you can hide behind it even if it subsequently shown as bogus.

        Boxturtle (Disclaimer: I’m a Software developer…does it show?)

          • BoxTurtle says:

            Yeah! Just like that!

            Boxturtle (Looks like Bush left some notes about operational techniques in the Oval Office desk)

  23. klynn says:

    proprietary model – bleh

    Do we know where the funding for developing the proprietary model came from?

  24. buckinnm says:

    Why is any of this surprising? This is not the only burn happening. For the truth, follow the money. But you know this already huh?

  25. ondelette says:

    This is analysis that Jonathan Cohn, with data from Gruber, expands upon here.

    The chart used by Jonathan Cohn uses the “conservative estimate” of risk, modulo premium reductions predicted by Jonathan Gruber for the Senate plan, which you cite as having accessed MA health care data. If you want to argue that there is something wrong with the study that produced the premium figures, you can’t argue that he didn’t access the MA data. The reason he argues that this is a conservative estimate is because it is the maximum cost, at least he thinks so, of the health care plan for the year. Maximum cost estimates are by their nature conservative in this case. Argue instead that he has mis-estimated maximum costs, or mis-estimated the premium reductions, and then you have a legitimate criticism of the figures, otherwise don’t argue the figures.

    But it all comes back to that underlying premise. So long as you define “affordable” in such a way that accepts ongoing medical debt for at least some of your sample in your definition of affordable, then this approach–looking at total risk, rather than whether insurance equates to care, makes sense. It transforms the question of whether health care (not health insurance) is affordable into one that measures degrees of indebtedness for using health care.

    Where does the presumption of “medical debt” come from here, and what do you mean by it? The second part of the para is a different argument or not? I’m not understanding the indebtedness costs altogether. I’m trying hard to relate it to my own health care situation, which is: difficult to afford health insurance coupled with large out of pocket costs, which causes foregoing care if at all possible, and payment plans when the costs are too high. I think it recently improved somewhat, but I am afraid to find out by using the new plan. But the health care provider isn’t charging interest on the payment plans (I’m presuming they aren’t allowed to, since they are for profit) so I don’t understand the debt cost. For debt to be factored into cost, it must be payment on the debt, i.e. interest.

    But then again, that’s what a lot of bill apologists do: consistently oversell what this kind of reform does, by conflating health insurance with health care.

    Precisely the opposite. Because they don’t conflate health care with the debate over how to afford the private insurance, they don’t look at ways to have health care other than private insurance.

    However, even a single payer plan will cost those who don’t currently pay for health care because they are rarely sick, more than what they currently pay under out-of-pocket direct payment. I’m seeing way too many people arguing that they shouldn’t pay at all if they don’t get sick often. That’s called the free rider problem, and such people will always get ignored by people trying to set up universal coverage, whether the coverage is bad or good. That happens to be as it should be, because those people are not factoring the costs of keeping the herd healthy into their own costs because they aren’t paying for it currently, nor are they factoring in ongoing expenses to keep the system up and running. They are ‘free riders’ on the current system, and their costs necessarily go up in universal coverage regardless of how it’s construed, unless it’s inherently unfair to someone else.

    • selise says:

      The chart used by Jonathan Cohn uses the “conservative estimate” of risk, modulo premium reductions predicted by Jonathan Gruber for the Senate plan, which you cite as having accessed MA health care data. If you want to argue that there is something wrong with the study that produced the premium figures, you can’t argue that he didn’t access the MA data.

      i think you are misreading marcy’s post (or i am). cohn’s article is not about MA or MA health care data and marcy doesn’t write that it is (it’s based on subsidy data gruber says he got from cbo estimates).

  26. temptingfate says:

    And software code is easy to steal. Publish it for peer review and somebody is going to quietly copy it and undercut your market. Then your profits go to your lawyers from that point forward.

    Which is to say the Diebold explanation. Which, like this circumstance assumes that things that affect public policy or worse yet determine election winners should be kept proprietary. Which begs the question of who in the world would seal this code? In Diebold’s case the code and it’s application was obvious. For Gruber we must be talking about VisualBasic (which I think was the case with Diebold as well) and a boat load of goto jump tables and single context condition tests.

    There are massive amounts of good open source code. If he did open source here I doubt he would get a lot of interest except from critics.

    • BoxTurtle says:

      Absolutely. And some source code CAN be open. Any security or encryption should be able to be published without risking security. You can get the source code and encryption algolrithms for PGP, for instance.

      But the diebold code and software models are apples and oranges. I publish the code behind my models, you can steal it. If deibold publishes their code, it’s very unlikely that someone would try to profit from it by remarketing.

      Diebold is trying to use “security by obscurity”. They suspect a good hacker could break their system if he had the code. If you’re a paranoid type, they’re keeping it secret because the backdoors they’ve placed in there would become obvious.

      Boxturtle (Security by obscurity does not work)

      • temptingfate says:

        But the diebold code and software models are apples and oranges. I publish the code behind my models, you can steal it. If deibold publishes their code, it’s very unlikely that someone would try to profit from it by remarketing.

        We aren’t disagreeing for the most part. Well perhaps on the apples and oranges thing.

        Whatever kinds of tricks Gruber is playing to generate some graphs, assuming they aren’t being created in photoshop, the algorithm should be somewhat obvious and testable in some way. Even, which I doubt, if there was someone who wanted to steal his code and he needed to protect the source, if it were remotely well written it should be possible to use the current test cases to build other cases and determine its predictive usefulness. For any application I can imagine simple copyright notices would be all that is necessary. This code is not going to be the basis for the next version of Word.

        Since I doubt there is any there there my guess is that he’s pretending there is a model.

        • BoxTurtle says:

          The key things with models is that they are typically VERY expensive and have a very small customer base. If even one underfunded research group decides to copy it and use it for themselves, I’ve lost a lot of money. And I’ll probably never know. Copyright notices don’t even protect Windows, it’s just another skipped page in a manual.

          Like I said, the normal way to validate such a model is to feed it real world data and see if it matches what the real world does. In this case, they fed it real world data and it gave them the answer that they wanted.

          I’m pretty sure there is a model that he could present and defend in court if he had to. And I suspect that model is as valid scientifically as Yoo’s legal opinions were legally.

          Boxturtle (But since it gives Good Answers, that’ll be valid enough)

  27. earlofhuntingdon says:

    We need real consumer financial reforms, not the pablum this government is attempting to feed an adult.

  28. liberalarts says:

    This isn’t a surprise for some of us on Medicare, who are in exactly the same leaking boat. I am now paying $1,000 a year, which doesn’t sound like much but I could certainly use it for other things, for Part B insurance I mostly can’t use because I can’t afford the co-pays. The annual deductible is nothing, really. Now think about that: very low deductible, relatively low co-pays as these things go in this country, piddly squat yearly premium of $1,000, and anything over a low few hundred co-pay is out of the question. Forget about the seniors in attractive condos edging warm weather golf courses. There are lots of less affluent oldsters getting by in more reduced circumstances who can’t afford to use their Medicare benefits. Which certainly reduces costs, doesn’t it.

  29. maryo2 says:

    Look at the contract award to Gruber that EW linked to in an earlier thread.

    The synopsis was written to see if anyone other than Gruber wanted to apply for the task, but the requirements to apply included already having an existing model specific to health care. Requirements:
    1. must be a recognized expert
    2. must have a proven model
    3. must be seamlessly available to HHS immediately

    It has been mentioned that Gruber worked for McCain in the past so he was known to some people in Washington. My question is — did Obama Admin seek this guy out specifically?

    Click on the original synopsis dated May 21, 2009 and it explicitly says that they intend to work with Gruber “on a sole sources basis for technical assistance” by “restricting competition”.

    The Department of Health and Human Services (DHHS), Assistant Secretary for Planning and Evaluation (ASPE), intends to negotiate with Jonathan Gruber, Ph.D. on a sole sources basis for technical assistance in evaluating options for national healthcare reform. The basis for restricting competition is the authority of 41 USC 253(c)(1) 106-1(b) because there is only one responsible source and no other supplies or services will satisfy DHHS requirements. The anticipated contract period will be eight months.

    https://www.fbo.gov/index?s=opportunity&mode=form&tab=core&id=ff3e0b204ae1fd5343ab19cf3a62f160&_cview=0

  30. MsAnnaNOLA says:

    In Louisiana we had (pre-Katrina) a public hospital “charity” system. Normal folks with insurance could go there. But indigent and low income could go to. They even had specialty clinics like “neurology”, etc.

    Well since the storm the powers that be have insisted that we go to a system of neighborhood clinics. I think partially they don’t want to pay for the Charity specialty clinics and they want to build a fancy hospital in Charity New Orleans’ place (one I don’t think our state can afford).

    The problem is all the people in the neighborhood clinics have no experience with these specialites. So folks that need a prescription for an anti-seizure medication end up going to the emergency rooms despite all the “reform”. The reform did nothing but take the publicly funded, run, subsidized hospital out of commission. People are getting less care. This was their goal. They are not trying to get care for sick people. They are passing the buck down the road.

    They are trying to get more money for insurance companies.

    Don’t let anyone fool you insurance is not care. I have a good plan I can afford to use but I am also afraid of becoming uninsurable. Remember these reforms don’t curb costs so even getting rid of their abilty to drop you for being sick does not mean they can’t raise your rates to oblivion. Raising the rates to unaffordable levels is not any better than dropping you.

    We need competition. Period.

  31. maryo2 says:

    Can anyone find this 106-1(b) subsection about no need for competition in awarding contracts?

    41 USC 253(c)(1) 106-1(b)

  32. allie says:

    This guy is an idiot. We paid him $400,000 to tell us that out of pocket expenses should not be considered in affordability. So we should give the CEO’s our money whether we will be able to afford care. That is the stupidest thing I have ever heard.

  33. Surtt says:

    After all, individuals face more out of pocket risk without insurance than they do with coverage. Thus, if an individual is very ill and faces large out of pocket costs under an insurance plan, they would have faced at least those same out of pocket costs, and likely more, had they remained uninsured.

    But if they remained uninsured they would not have the additions premiums to pay and 8% more income.

  34. mikew67 says:

    The gap in the chart between elderly and non-elderly, tells you those figures are cooked. Neither stat adds up.