Necessary and Improper?

The big news this week was the health care reform law's first defeat in court: the individual mandate to buy health insurance is unconstitutional, says a federal judge in Virginia.

I actually found this ruling to be something of a relief, not for what it did but for what it didn't do. And what it didn't do is rule the entire law unconstitutional. In fact, it didn't even halt its implementation, as the plaintiffs had requested. Until now, I had been worried by the lack of a so-called severability clause in the reform legislation--a provision saying that if part of the law should be struck down as unconstitutional, the rest of the law will still stand. I was afraid that a ruling against the individual mandate might necessarily mean all of the law has to go. But the judge who ruled on Monday severed the individual mandate from the rest of the law which demonstrated--much to my relief--that, hey, they can do that. So even if the individual mandate was ultimately struck down by the Supreme Court, they could at least preserve the rest of the law.

But what's really interesting is the treatment of the Necessary and Proper Clause in this ruling, which has come under criticism in some quarters. The Necessary and Proper Clause, of course, is the elastic banding in the underpants of the Constitution, the provision that says: "The Congress shall have Power - To make all Laws which shall be necessary and proper for carrying into Execution the foregoing Powers, and all other Powers vested by this Constitution in the Government of the United States, or in any Department or Officer thereof."

What that means is that Congress can indeed do things that aren't explicitly written in the Constitution as long as those things are "necessary and proper" to carrying out one of the enumerated powers. And that isn't just me saying this, here's Madison in Federalist 44:

Had the convention attempted a positive enumeration of the powers necessary and proper for carrying their other powers into effect, the attempt would have involved a complete digest of laws on every subject to which the Constitution relates; accommodated too, not only to the existing state of things, but to all the possible changes which futurity may produce; for in every new application of a general power, the particular powers, which are the means of attaining the object of the general power, must always necessarily vary with that object, and be often properly varied whilst the object remains the same.

Shorter Madison: "We didn't write down every conceivable power needed in pursuance of the enumerated powers, but they're still in there. Use some common fucking sense, people."

One of the arguments the government used in defending its requirement that almost everyone either carry health insurance or pay a penalty was that this individual mandate is necessary and proper for executing its power to regulate health insurance under the Commerce Clause. This is a reference to the reason the individual mandate exists in the first place. The new law seeks to regulate the individual market for health insurance (i.e. the market in which you buy insurance if you're not getting it through your job) by eliminating unpopular practices like charging sick people higher premiums or even rejecting them entirely if they have a pre-existing condition.

But those practices exist for a reason. If 1) no insurer can turn you away for having a health condition when you want to buy insurance, and 2) that same insurer can't "penalize" you for being sicker than average by making you pay more for your insurance policy, there really isn't much reason to buy insurance if you're healthy. If you choose to go uninsured, you're not taking much of a risk if, should you get sick, insurers can't turn you down or charge you more to punish you for your irresponsibility. Take away the reasons a healthy person would pay for health insurance and lots of them are going to decide to drop out and stop paying premiums until they get sick, at which point they can just sign up again without any hassle. It just makes sense for healthy people to free ride in that situation. That will leave the insurance pools disproportionately full of sicker people and thus increasingly expensive. Bad news. Hence the individual mandate. It steps in to serve the function that was previously being served by medical underwriting. So if you want to regulate underwriting out of existence and you don't want premiums to explode, it seems you have to legislate an individual mandate into existence.

So you can argue that an individual mandate is necessary and proper to regulating the insurance market. And here's where it gets a little odd. At one point the ruling says:

The Commonwealth does not appear to challenge the aggregate effect of the many moving parts of the ACA on interstate commerce. Its lens is narrowly focused on the enforcement mechanism to which it is hinged, the Minimum Essential Coverage Provision.

The Commonwealth argues that the Necessary and Proper Clause cannot be employed as a vehicle to enforce an unconstitutional excercise of Commerce Clause power, no matter how well intentioned.

You can see in that first paragraph that Virginia wasn't challenging the federal government's authority to regulate insurance under the Commerce Clause. But then they argue that the Necessary and Proper Clause doesn't apply because, in their minds, it's being "employed as a vehicle to enforce an unconstitutional excercise of Commerce Clause power." Except they've already conceded that the Commerce Clause power being exercised--the regulation of insurance markets to eliminate pre-existing condition exclusions and the like--is constitutional. And since the individual mandate is instituted in furtherance of that power and its aims, one would think the Necessary and Proper Clause would indeed be relevant.

But get this bit of the ruling, where the judge is mulling whether or not to sever the individual mandate from the rest of the law:

Having found a portion of the Act to be invalid, the Section 1501 requirement to maintain minimum essential health care coverage, the Court's next task is to determine whether this Section is severable from the balance of the enactment. Predictably, the Secretary counsels severability, and the Commonwealth urges wholesale invalidation. The Commonwealth's position flows in part from the Secretary's frequent contention that Section 1501 is the linchpin of the entire health care regimen underlying the ACA.

Get that? The anti-reform plaintiffs argued that the whole law should be struck down if the individual mandate is unconstitutional because, of course, they accept that it's a "linchpin of the entire health care regimen." But this is a bit of a Catch-22 for them. As I already noted, they didn't actually challenge the "entire health care regimen." In their laser-like focus on taking down the mandate, they implicitly accepted that the insurance regulations in the law are constitutional. But if they're arguing that the mandate is the "linchpin" needed to make those insurance regulations work, they're making the "necessary and proper" argument. However, if they accept that argument, then the mandate should be valid. Bad news for them. If, on the other hand, they reject that argument (as they did), then there's no reason the individual mandate shouldn't be severable from the rest of the law. Also a bit of a defeat for them.

It's tough to see how they could get everything they want, in a logically consistent fashion, using these arguments.

Et tu, fuel gauge?

Driving an hour to and an hour from work every day has caused me to become borderline obsessed with the fuel efficiency of my car. A few weeks ago I flipped through the manual, found the capacity of my gas tank, drove to and from work until it was nearly out of gas, filled it up again, and compared how much gas was left to how many miles I had driven (for the more science-y guys here, is that rigorous enough? I wasn't sure if I was leaving something out). Through all that I got a rough picture of the miles-per-gallon on my car: about 30 on a good day, not amazing considering it's a Honda Civic driving mostly on the highway; not horrible when you weigh in on the car's age ('93, with more problems than I have money to fix). It may be an unfair comparison, but just for fun the 2010 Prius or the Civic Hybrid got about 40-50 just on city driving. Sounds pretty nice right now...

However, through all that I was still worried that I wasn't being thorough enough. Maybe the gas station pump shuts the gas off before the tank is full, maybe there's more gas left than I think when the needle reaches E (or less than I think when it says full), maybe the air pressure in the tires isn't exactly where it needs to be, etc. Well, seems like a few of my concerns were justified when I stumbled on to this today. Even though everything else on our cars has been computerized and improved over the years, it seems that people like the illusion and comfort of knowing that our tanks have a little extra fuel in them than what the gauge tells us despite the fact that it messes with just how fuel efficient your car really is (kind of like the illusion of more safety on airplanes by adding more and more inefficient security). Things apparently get even more confusing if you top off at the gas station, something I don't do but according to the article can add almost another full gallon of gasoline. All-in-all it's not that big of a deal, but I always wondered why they didn't just put a digital number there that tells you how much gas is left. I guess nobody likes to hear the truth.

I don't know if this actually ends up improving my car's fuel efficiency or not. I just don't know what to think knowing that my fuel gauge is lying to me. I thought we were cool, gas tank...

The YouTube Funnies

TJ and I spend a lot of time hunting down a certain kind of art and it's time we shared some of it with you guys, assuming you're not already familiar with it. YouTube has enabled some talented folks to distribute a new class of amateur video that, when done well, can really leave you breathless. And your sides aching. As I am wont to do, I'll try and fit these videos within a loose classification scheme. They tend to fall into one of three broad categories: Recuts, Overdubs, and Splices.

Recuts

Recuts reshape what's already there, crafting a new story out of the ingredients of the old one. The new story is itself likely to be pretty funny but often the true hilarity comes primarily from the contrast with the source material. I started writing this post a long time ago and inserted here the absolute, hands down best example in existence, a Jaws recut called "Nobody Cares About Quint" in which the Orca crew's indifferent reactions to Quint's violent death are on display. I think TJ will vouch for the fact that this video was simply amazing. I'm leaving the embed in here even though, as you can see, it's been taken down. Maybe someday it will come back.



In the meantime, you can see what I'm talking about with the Stars Wars sex scene, Tarkin not taking shit, and this terrible miscalculation by Han Solo. And yes, quite a bit of this new art form revolves around Star Wars (though, again, the Jaws series is was the greatest I've ever seen).

Overdubs

Overdubs leave the action of a movie scene unaltered but radically alter the character of it with some fun sound editing. These are a way of inserting another film into an existing scene without altering the action of the existing scene in any way (no recut necessary). The juxtaposition of old action with new dialogue can be great fun. Probably the best example around today is Dude Vader:



Other Vader overdubs, like Darth Schwarzenegger, also exist since he's an easy target, given that you can't see his lips moving. The classic HAL Pacino also falls into this category, as does Reservoir Turtles. And of course, the Ninja Lebowski series qualifies:



And a few more choice picks for you to peruse: Agent Sagan Smith almost breaking Morpheus, Han Solo vs. Greedo Quintana, and C-3PO Strikes Back.

Lastly, as a general rule, overdubs that use original dialogue (i.e. instead of just inserting sound from another movie) are usually not very good. The most notable exception is the overdubbed (and sometimes recut) series of G.I. Joe public service announcements, known for such classics as Porkchop Sandwiches!

Splices

Splices take two different (often radically so) movies and find a way to make them interact in a way that not only sort of makes sense but is hilarious. Exhibits A and B are two Back to the Future-themed splices:





Another favorite is the splice of Batman and Titanic.

Some splices use different movies from the same actor(s) to give them that feel of authenticity. You can see that in Han Solo's Blaster and in Batman's unlikely alliance with the Green Goblin.

Some intrepid souls even try to splice live action and cartoon, as in Speed vs. The Magic School Bus.

Cross-Cutting Categories

There are also a few sub-classes of YouTube Funnies. While these aren't anything we haven't covered, these don't easily fit under just one of the above three categories because they tend to wander between them (they choose not to respect my careful classification scheme). These include:

Alternate Endings

Alternate endings, of course, take the movies we love and resolve them in an entirely new way. Some alternate endings are recuts, like this one:



Other alternate endings are splices, like this Matrix-Crocodile Dundee scene:



There are probably hundreds of alternate movie endings on YouTube (although many of them aren't very good). Most notable is the series of Indiana Jones alternate endings (like this one) and the many, many Star Wars alternate endings (like this one), though again the quality varies. As a general (though not absolute) rule of thumb, if an alternate ending is longer than two or three minutes, the payoff probably isn't enough to warrant spending the time watching it.

Fake Trailers

These are exactly what the name suggests: trailers for movies that, tragically, don't exist.

They can be silly splices like A Hard Day's Night of the Living Dead:



Or they can be recut overdubs like Must Love Jaws:



I'm probably killing the bandwidth so I'll stop there. I have to say, I'd really love to develop some video editing skills so I can start making some YouTube Funnies of my own. But we'll see.

If I've left out anything noteworthy or you've got more you want to share, put some links in the comments.

Perpetual Union

Can you break the unbreakable? Truncate the infinite? End the perpetual?

I ask because I want to briefly wade into history (I'm pretty confident I'll be revealing some serious ignorance in this one). Some time ago, our Confederate friends believed that states could choose to leave the Union and, apparently, some states' rights folks still think this. The Civil War, then, apparently decided only that if your state wants to leave, it better be packing more firepower than the states that want it to stay.

We know that the Articles of Confederation was the first real governing document for the United States. But if you read the Articles, you'll notice repeated references to itself as the "Articles of Confederation and perpetual Union." In fact, the Articles stressed no less than six times that the union it was establishing between the states was to be perpetual.

I'm compelled to raise the questions in this post because one day while looking at the wiki page on the Constitution, I saw this:

On September 17, 1787, the Constitution was completed, followed by a speech given by Benjamin Franklin, who urged unanimity, although the Convention decided that only nine states were needed to ratify. The Convention submitted the Constitution to the Congress of the Confederation, where it received approval according to Article 13 of the Articles of Confederation.[10]

I didn't remember that bit about receiving approval from the Congress of the Confederation from history class (should I? perhaps this is an embarrassing admission) and the reference they give for that assertion is the National Archives page on the Constitution; it wasn't immediately obvious during a brief browse where on the site that factoid could be found.

But, assuming it's true, it seems to raise an interesting philosophical question. Though the Constitution didn't require unanimity for ratification and the Articles did require unanimity for the adoption of amendments (as you can see from Article 13 below), it's worth noting that the Constitution did ultimately receive unanimous ratification so at least in practice that discrepancy is without consequence.

Article XIII. Every State shall abide by the determination of the united States in congress assembled, on all questions which by this confederation are submitted to them. And the Articles of this confederation shall be inviolably observed by every State, and the union shall be perpetual; nor shall any alteration at any time hereafter be made in any of them; unless such alteration be agreed to in a congress of the united States, and be afterwards confirmed by the legislatures of every State.

The first question that occurs to me is pretty straightforward. If the Constitution was indeed adopted in accordance with Article 13 of the Articles of Confederation (right down to actually being submitted to the Congress of the Confederation), then is it indeed what it was originally supposed to be: an amendment to the Articles of Confederation? Perhaps I was zoning out during this bit of American history but I had always thought that the Constitution was written only after the Framers decided that amending the Articles was a lost cause and an entirely new document, written outside the context of the Articles, was needed. But if the Constitution is itself only a legitimately passed amendment to the Articles--granted, an entire overhaul but one done within the context and conceptual framework of the original document--then it is part of an unbroken chain that started with the writing of the original Articles.

And that leads to my second question. Is the "perpetual union" bit not still in full force? I ask because the Articles contained a very odd thing: An Infinity. A perpetual union is one that will exist for all time and presumably cannot be undone. The only way, then, to overcome that would be to deny the legitimacy of the Articles and supplant them with something entirely different. Which is what I had always thought is what happened.

But if the Constitution is technically just an amendment to the Articles, then it still acknowledges the legitimacy of the original document; again, this hinges on whether its passage was actually done in compliance with amendment rules set forth in Article 13 of the Articles but for the purposes of this post I'm assuming that's true. And since that document contained An Infinity, I would think that even a complete re-write couldn't scrub that Infinity out of existence. That is, it seems to me that under the original Articles, you couldn't have an amendment passed under Article 13 that said "oh, about that perpetual union thing? nevermind." The reason being that you can't create An Infinity and then later decide that you want to cap it, even retroactively. If the original document is valid and it creates An Infinity, then I would think that Infinity will persist for as long as the validity of the document is recognized. Even the full power of the document can't undo what it has done. You can't close Pandora's Box.

And if that's true then even under the current Constitution its parent's commitment to a perpetual union of states must still be in effect. Because you can't uncreate The Infinity contained within the Articles without rejecting the Articles, which the Constitution doesn't seem to have done (again, assuming its ratification was done with the assumption of the Articles' validity, i.e. as an amendment to the Articles). The reason being, quite simply, that if you could end something with a simple amendment, then it couldn't have been perpetual in the first place. Similarly, if you could simply cap the infinite whenever you felt like it, it couldn't have really been infinite to begin with. "Perpetual" means a very specific thing and, I think, implicit in that definition is that nothing at all can end it. And if the Constitution is cut from the same cloth as its predecessor, then even though the words "perpetual union" are no longer in the governing document they must still be operative anyway.

Does any of this make sense? Am I way off base here?

Escherian Finances

Not too long ago, Republicans were complaining that billions were being taken out of Medicare to pay for a new entitlement (subsidies for low income people buying insurance in new health insurance exchanges).

Today we learn that Senate Republicans and Democrats have agreed on a novel way to deal with the perennial problem of finding money to prevent Medicare physician reimbursements from going down next year: by taking billions out of that new entitlement and funneling it back into Medicare.

I went with the Escher "Drawing Hands" analogy because it comes with a nice visual but truly the first reference that came to mind was Milo Minderbinder's economics. That said, in its strange way, this all does make sense.

On Pissing Contests

I'm a Time Warner subscriber and it seems like every few weeks they run a commercial (or, occasionally, send an email) exhorting me to lend my voice and help them stand up to some particular channel offerer. At the moment, it seems they're having trouble with at least two companies that offer some particular set of channels and, if an arrangement can't be worked out, subscribers (like me!) face a blackout of those channels. Here's part of their explanation about what's happening with one of those companies right now:

We are currently negotiating with the parent company of those channels, ______. And if we don’t reach a new agreement before December 15, ______ is threatening to stop allowing Time Warner Cable to continue carrying its stations. We’re working hard to reach an agreement that will prevent any interruptions in these channels, and are optimistic that we can do so. [...]

We’re talking about it because the single largest expense we have in delivering you video service is the price we must pay to the companies that own the programming. And customers have told us they don’t understand why the price they pay each month continues to rise. We want to give you the information that helps you make informed decisions about programming. Time Warner Cable buys programming from hundreds of different companies that run TV stations and cable networks. The contracts to buy that programming come up for renewal from time to time, with dozens up for renegotiation every year. Most are negotiated in private between the companies, without event. But sometimes some of those negotiations become public.

So I pay a monthly fee to this particular company (Time Warner), which then has to negotiate contracts with various companies that are actually providing the thing I want: TV channels. This sounds just like something else... (he said thoughtfully, stroking his beard and staring off into the distance).

Indeed, the superficial similarity I'm noting is to the dance that your health insurance company does with health care providers. And just as, sometimes, Time Warner's negotiations with the companies offering TV content spill into the public sphere, sometimes the negotiations between health insurers and health care providers become ugly public pissing matches. There was a story out of North Texas just last week about Blue Cross Blue Shield and a provider network called Texas Health Resources airing their dirty laundry in public. It seems if Texas Health Resources doesn't get the contract it wants from Blue Cross, its hospitals will charge patients/Blue Cross the much higher out-of-network fees (blackout!) and the hapless doctors caught in the crossfire "have sent letters to their patients encouraging them to contact Blue Cross" ("If you think it’s unfair for your local stations to black out your programs from Time Warner Cable customers while demanding significant increases that will eventually impact the price you pay for cable, let them know!" says Time Warner).

Instead of cooperating, the region's largest insurer and hospital system are taking jabs at each other.

Blue Cross says Texas Health is demanding an additional $120 million over three years to cover cost increases. The insurer has declined to say how much it is currently paying Texas Health.

The insurer says it contributes $178 million to Texas Health's annual profits. It also says the hospital system makes a 30 percent profit margin from Blue Cross members.

"This kind of runaway spending on medical care is one of the main causes of higher health insurance premiums for our members," Blue Cross said in a recent letter to members.

For its part, Texas Health says Blue Cross wants to pay its millions upfront in a lump sum. Instead, Texas Health wants its money reimbursed traditionally, after a claim is filed. The hospital system also points to the insurer's accumulated wealth.

"Blue Cross Blue Shield of Texas is sitting with about $7 billion in reserves. And they don't provide any patient care," said Wendell Watson, spokesman for Texas Health. "In fact for many of their customers – the self-insured ones – they don't do much more than manage the paperwork on claims."

Both are nonprofit companies. Texas Health had $2 billion in assets at the end of 2008, according to its latest financial reports.

The power struggle between insurers and hospitals has intensified in recent years as hospital consolidations created mega-health systems. These companies, emboldened with leverage, began going head-to-head with insurance companies for better rates.

"As we've grown we've gained a larger network of providers that provide care in a variety of settings," said Barclay Berdan, Texas Health's vice president for system alignment. "We get some economies of scale because of that."

Blue Cross' vice president for network management, Shannon Stansbury, said the company negotiates with smaller health providers across the state every day. Blue Cross has contracts with more than 400 hospitals in the state. [...]

Same shit, different channel.

Z

It's tough to find much redeeming content in Thursday's Cavs-Heat game but I think my favorite part was seeing Z's reception when the Heat starting line-up was being announced. Deafening boos were momentarily replaced by thunderous applause.



Sucks that Z chose the Heat but at least he said goodbye with a nice Sunday ad in the Plain Dealer and not a nationally televised middle finger to the city.

Dear Cleveland,

When I came to this country 14 years ago, I was a young man who barely spoke the language and had no idea what to expect of this great country.

As I look back on those early days, I realize how lucky I was to have grown up in a place like Cleveland. All of you have taught me the importance of family and friends; of pulling together to get things done; of loving your country.

I’ve never felt as proud as when I’ve pulled on the wine and gold and stepped onto the court.

I’ve tried my best to return that support by playing as hard as I could each and every game.

The decision to play for Miami was not an easy one to make for either myself or my family.

But as I enter the last few years of my career, I felt I owed it to myself and my family to chase my dream of winning an NBA championship.

I hope you understand.

I also hope you realize that Cleveland will always be home to me.

With love and appreciation,

Zydrunas “Z” Ilgauskas

Godspeed, Z. Lose, retire, and come home.

On "Costs"

Back to musing about health care. The issue of rising costs comes up again and again whenever health care is the topic of discussion. But the word "costs" is, confusingly, often used to mean two fairly different things (often simultaneously) so it's worth thinking about the difference. They are:

1. Costs are the prices we pay for procedures or devices. They're a measure of how expensive the units of health care we're buying are.
2. Costs reflect total (national) spending on health care. This is the aggregate amount (>$2 trillion) we're spending every year, or the percent of GDP we put toward health care services. This number, however, depends both on how much individual units of health care cost and how many of those units we buy (volume).

To illustrate the difference, I'll use a mundane example from my weekly routine. I live in an urban area and don't own a car. As such, I shop in a nearby urban grocery store. If I had a car, I could shop slightly further from home at one of the larger grocery chains prevalent in this area.

Given that when I do my weekly grocery shopping I do so on foot, there is a natural limit to how many groceries I can buy. Even if I wanted to buy more than 3 or 4 bags of groceries (not that I do), I wouldn't be able to carry them all home. At the same time, it's worth noting that as a small, independent grocery store, the prices at my grocery store are in fact a bit higher than the prices across town at the larger chain grocery stores.

So let's consider two scenarios. The first is my current routine, in which the amount of groceries I can buy at one time is limited but the prices of individual items is higher than the alternative. In the second scenario I have a car and can load up my trunk as full of groceries as I please. As such, I start shopping at one of the larger chains or even a Costco and give in to the urge to buy in (greater) bulk. What's the cost of my groceries? Or, as a separate question, what are my groceries costing me? If I wanted to answer the first question, I'd probably check my receipt to see item-by-item what everything costs. On that kind of per-unit analysis, the bigger stories with lower unit prices will look better than my independent grocer. But if you ask what groceries are costing me, say per year, I might be spending more money if I'm shopping at the chain stores, simply because I can (and thus am tempted to) buy more every time I go shopping. When I'm not limited to buying only what I can carry home, I might buy lots of extraneous goodies.

The point here, of course, is that while these are very different questions, when it comes to health care people tend to conflate "how much does this cost" (unit price) with "how much is this costing me" (unit prices x volume). I myself am guilty of not specifying what I'm talking about and bouncing between meanings in different posts. As such, alarm over health care costs sometimes manifests itself as disbelief at an outrageous bill for a given procedure, and sometimes as alarm bells sounded over an uptick in national spending and increases in the fraction of our national income we're directing into the health care market.

When I wrote The Case Against Providers back in the summer, I was talking mostly about the component of the cost issue that stems from providers bargaining up the reimbursements (prices) they get for procedures from payers. The Demi-Decade of Coverage, on the other hand, discussed some of the long-term cost containment potential of the reform law and that touches more on the "how much is this costing me" issue. And that's because the tools offered by the Affordable Care Act--the scalpels and chainsaws I mentioned--are aimed largely at reducing unnecessary volume: comparative effectiveness research, payment reforms, more efficient and effective delivery models, efforts to reduce medical errors, and the like are all aimed at streamlining the health care system and make it better at doing what it does (read: achieve good results without flushing huge amounts of money down the toilet for no reason). What the scalpels and chainsaws "cut" for the most part is unnecessary volume. By and large, however, those reforms don't lower the unit costs of procedures. That doesn't mean they're not important steps to slowing our national cost growth, since total spending will equal the prices of our procedures multiplied by the volume of them we consume very year. But still, room for improvement.

This disparity between the two conceptions of "cost" was the subject of a Washington Post article in October entitled "The price problem that health-care reform failed to cure." In it the author argues:

The 2010 law does little to address this. Its many cost-control provisions are geared toward reducing the amount of care we consume, not the price we pay. The law encourages doctors and hospitals to join "accountable care organizations" that have financial incentives to limit unnecessary care; it beefs up "comparative effectiveness research" to weed out inefficient treatments; and it will eventually tax the most expensive insurance plans to restrain consumers' superfluous use of health care.

Such measures could reduce redundant tests, emergency room visits and hospital readmissions, which would help control the costs of Medicare, where the government sets rates. But they are less likely to lower prices outside Medicare and stem the growth of private insurance rates.

The author astutely points out something I've noted before: the robust public option that was proposed in early incarnations of the health care bill (but ultimately was dropped) was targeted at bringing down the actual prices of procedures charged by providers. This is something liberal supporters and conservative opponents alike failed to recognize, with the two camps wrangling over whether this would put the fear of God into insurers or drive them out of business with nary a word about providers.

And make no mistake, the prices of the medical services we buy from providers in this country can be substantial (relative to our counterparts in the rest of the developed world). The International Federal of Health Plans' Annual Comparative Price Report came out a week or two ago and it's full of charts like this one:



The average price for something here is generally more than almost anywhere else but not by a ridiculous amount; it's the huge variation in prices we experience/allow here--where prices are often a jealously guarded trade secret and vary depending on who's buying (the same hospital can charge two different insurance companies different prices for the same procedure in every state except Maryland)--that allows some of what we spend to stretch into the stratosphere.

And while I expressed optimism that the reform law provides the tools to get serious about cost containment--particularly after the first "demi-decade"--the actual prices of services are something we still have to address. And to leave this post with a cliffhanger, I'll note that in some future post I'm going to mention one possible tool for doing that.