Devastating News for ObamaCare Backers

Within the White House, within the Democratic chambers in Congress and among the (overwhelmingly liberal) health policy community there was considerable anguish last week. The reason: a new study finds that (as far as physical health is concerned) there is no difference between being in Medicaid and being uninsured.

It’s hard to exaggerate what a blow this is to the people who gave us the Affordable Care Act (ObamaCare). Everything about ObamaCare ― from the money we are spending to the damage being done to the labor market to the hassles the whole nation is going through ― depends on one central idea: that enrolling people in Medicaid will give them access to better health. (Tens of thousands of lives will be saved every year, the president told us.)

It gets worse. Beginning next year, ObamaCare is expected to newly insure about 34 million people. About half of these will enroll in Medicaid. The other half are supposed to get their insurance in health insurance exchanges, where most will qualify for generous premium subsidies paid for by federal taxpayers. If the Massachusetts health reform is precedent, however, these people will be in health plans that pay doctors only about 10 percent more than what Medicaid pays. Think of these plans as Medicaid Plus.

Yet, if Medicaid doesn’t make people any healthier than they were when they were uninsured, that implies that the entire ObamaCare program could be one huge waste of money.

[Actually, the results weren't a complete disappointment. There was less depression among the Medicaid enrollees; they reported that they were a tiny bit happier; and among those who had out-of-pocket expenses, they spent about $215 less out of pocket each year. But, remember, we could have reimbursed out-of-pocket spending and spent far less than was actually spent on this program.]

[Aaron Carroll and Austin Frakt argue that the study may have been "underpowered" ― failing to show significant effects because there were too few people in each disease category. However, as the Wall Street Journal editorial page pointed out, if this were a drug, it would fail to get FDA approval.]

The study released last week is not the first to find that enrollees in Medicaid do no better than the uninsured. In fact there are studies that show that Medicaid enrollees find it more difficult to get a doctor’s appointment and have worse outcomes than the uninsured. Each of these studies has been subjected to a lot of nitpicking on various grounds, however, and a fair-minded person would probably have to say that how much difference Medicaid makes is an open question.

Until now. Thanks to a budget crunch in Oregon, scholars had the ability to do a double-blind study (the gold standard for researchers) and it came out very, very badly for the supporters of the new health reform law.

The study doesn’t speculate on the reasons for its findings, but I will.

The uninsured in this country have access to a patch work system of free care when they are unable to pay for it out of their own pockets. In Dallas, Texas, where I live, for example, the entire county is part of a health district which makes indigent health care available to needy families. It covers people up to 250% of the poverty level, with sliding scale co-payments, based on family income. Parkland Memorial Hospital and its satellite clinics is the primary provider.

You could argue that uninsured, low-income families in Dallas are actually “insured” in this way, although they face the problems of rationing by waiting and other non-price barriers to care. Officially, they are counted as “uninsured,” however. When these very same individuals enroll in Medicaid, they enter another system of patchwork care and are classified as “insured.” However, a third of the doctors aren’t taking any new Medicaid patients. There is rationing by waiting in Medicaid along with its non-price barriers to care. Often, the uninsured and Medicaid enrollees are getting the same care from the same doctors at the same facilities ― even though one group is labeled “insured” and the other “uninsured.”

Here is what I wrote in the Handbook on State Health Reform:

[C]onsider the case of Parkland Memorial Hospital in Dallas, Texas. Both uninsured and Medicaid patients enter the same emergency room door and see the same doctors. The hospital rooms are the same, the beds are the same and the care is the same.

As a result, patients have no reason to fill out the lengthy forms and answer the intrusive questions that Medicaid enrollment so often requires. Furthermore, the doctors and nurses who treat these patients are paid the same, regardless of patients’ enrollment in an insurance plan. Therefore, they tend to be indifferent about who is insured by whom, or if they’re even insured at all. In fact, the only people concerned about who is or is not enrolled in what plan are hospital administrators, who worry about who will pay the bills.

At Children’s Medical Center, next door to Parkland, a similar exercise takes place. Medicaid, S-CHIP and uninsured children all enter the same emergency room door; they all see the same doctors and receive the same care.

Interestingly, at both institutions, paid staffers make a heroic effort to enroll people in public programs — even as patients wait in the emergency room for medical care. Yet they apparently fail to enroll eligible patients more than half the time! After patients are admitted, staffers valiantly go from room to room to continue this bureaucratic exercise. But even among those in hospital beds, the failure-to-enroll rate is significant — apparently because it has no impact on the care they receive [or the financial burden they incur].

If what happens in Dallas is similar to other cities, “insuring the uninsured” is not going to make a great deal of difference anywhere.

For the country as a whole, one third of all people who are eligible for Medicaid have not bothered to enroll, indicating that millions of potential beneficiaries do not view the program as very valuable. In Oregon, the situation is even more dramatic. As Avik Roy explains:

Of the 35,169 Oregonians who “won” the lottery to gain enrollment in Medicaid, only about 30 percent actually enrolled. Indeed, only 60 percent of those who were selected bothered to fill out the forms necessary to sign up for the benefits — which tells you a bit about how uninsured Oregonians perceive the Medicaid program.

Consider Massachusetts. RomneyCare cut the official “uninsurance” rate in half. But it created no new doctors or nurses or clinics. As far as I can tell, the same people are going to the same places and getting pretty much the same care that they got before. Hospital emergency room traffic is higher than ever. The traffic to the community health centers has changed very little.

But since they have expanded health insurance in Massachusetts, the demand for care has grown, even as the supply has remained unchanged. As a result, the time price of care has increased. The wait to see a new doctor in Boston is two months ― the longest waiting time in the entire country. People are getting the same care they got before, but they are paying a higher “price” for it.

I expect to see the Massachusetts results replicated nationwide.

In the developed world, the health policy community is excessively focused on health insurance, even to the point of ignoring health care. In fact, studies of waiting times and inability to get care are often derided as right wing attempts to undermine the concept of social insurance. The less developed world has the opposite vision. Almost all the countries south of our border generally offer free care to the general population. But they don’t go around handing everyone an insurance card.

I believe this difference in vision is partly explained by the difference in income and wealth. Middle- and upper-middle income families need insurance to protect their assets. Poor families don’t have assets. They don’t need insurance. They may need health care, however.

ObamaCare was designed by middle- and upper-middle income people. They chose for poor people the same thing they would want for themselves. They didn’t think about access to care because they have never had a personal problem with it.

C’est la vie.

Comments (73)

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  1. Ralph Weber @ MediBid says:

    “Coverage” increases demand. Demand increase prices. Increased prices decreases access.
    Econ 101

  2. Desai says:

    “In the developed world, the health policy community is excessively focused on health insurance, even to the point of ignoring health care.” This is a key quote, so true, and it is tragic that the national debate is so focused on the insurance rather than the actual care we experience.

  3. Ken says:

    Excellent post.

  4. Buster says:

    The findings are consistent with a long body of research that shows people who are insured use more medical care and much of this care doesn’t improve their health.

  5. Ralph Weber @ MediBid says:

    @Desai, that is the key focus of the second edition of medicrats

  6. The true results may be even worse. The 30% of the lottery winners who actually enrolled are plausibly those who need health care the most, hence, those with the most to gain. If all 100% of the winners had enrolled then it’s plausible that average objective health would have declined!

    The fact that enrollees subjectively felt that their health was better helps explain some of the political enthusiasm for ACA.

    The decrease in depression is plausibly explained by the reduced risk of bankruptcy. This would be more easily solved by a very high deductible “policy”.

  7. Mike says:

    This bill will waste billions of dollars that could be used at the local level. Central Planning never works like Obamacare.
    I lover the line at the end. Obamacare was designed by upper and middle income people who think they would want this for themselves.
    I have always said the exchanges are a big waste of time and resources $$$. Just google health insurance and if people want to buy insurance, they can find a thousand agents to write it.

  8. Taylor says:

    I don’t think the main purpose of the bill was to improve people’s health. I think it was to make sure people were at least insured instead of dying in their beds in fears they can’t afford financial collapse by going to a doctor. Speaking about the millions of uninsured. Whether the bill will work on that end or not, I guess it’s still a matter of time.

  9. Ronie says:

    It’s true that it’s a shame that the bill’s focus wouldn’t be solely on providing greater quality care for people not receiving care instead of insuring everyone at any expense, which is showing won’t do much of anything to reduce costs and provide greater and higher quality care to everyone.

  10. Perhaps there’s another way of looking at the 30% than the one I gave above. If they are the sickest, then perhaps they’re on a downward trajectory. Possibly therefore their condition is worse at the end of the measurement period than it was at the beginning but perhaps less worse than it would’ve been had they not been enrolled.

    Solving selection bias is hard!

  11. Patel says:

    The medicaid demographic is probably a difficult group for analyzing health trends and benefits. Currently, most people who are on medicaid have a lot more external issues that hamper them from a healthy life style. For most of the people who don’t have insurance, I think it is fair to say they are relatively healthy.

  12. Kumar says:

    I think a fair comparison would be a comparison of people without health insurance vs people who have private health insurance. Doing this, we get rid of the confounding variables that makes the medicaid population difficult.

  13. Brian says:

    Until we can address two fundamental problems, both Medicaid and Obamacare remained doomed:

    —First, we must remove the safety floor supporting non-compliance by removing the emergency must-see mandate. This will serve several purposes: It will reduce the write-offs for hospitals, increase availability of emergency personnel for those who “play by the rules” and provide an incentive (albeit harsh) for all eligibles to sign up for whatever program they qualify for–Medicaid, CHIP, Obamacare, whatever. This will create immedicate need, actions and consequences.

    —Second, once America’s attention is raised, we must teach people that what they want (free care) is not what they need or will get (insurance).

    As long as we coddle the masses with programs which are ignored without consequence (and a $95 penalty tax is a joke) we cannot expect people to be motivated to act responsibly.

  14. Gabriel Odom says:

    Actually Taylor, you’re dead wrong. “The purpose of Medicaid in [the United States] is to improve the health of people who might otherwise go without medical care for themselves and their children.”

    That’s straight from the U.S. benefits website, benefits.gov

  15. Peter Ferrara says:

    The real problem in health policy is the same as in economic policy more generally. It is that the rest of us cannot even talk to people who call themselves progressives. They restrict themselves to publications and media outlets that uniformally agree with them and these publications and media outlets will not air any market based arguments or facts or studies with results that are sympathetic to market based reforms such as what John talks about here. So it means our country is denied a true national debate regarding public policy andespecially market based reforms and the real truth is it is costing our nation literally trillions in lost economic growth and prosperity. Obamacare is part of that.

  16. Doctor Tom says:

    @ Ralph Weber:

    As a sole provider of my surgical service in a rural setting I can tell you straight out that your Econ 101 lesson does not exist in medicine. I have more patients than I can handle and my fees stay frozen or are being reduced by the government and privaste payment programs.

    I have not seen a fee increase in 15 years. This means , adjusting for inflation, I have seen a decrease in real money reimbursement every year for the past 15 years.

    In addition, every time I have to sit down and negotiate my fee schedule with the private payors, they point to Medicaid /Medicare reimbursement and demand parity. Medicare just reduced my reimbursement for my most commonly performed procedure by 15% and then took another 2% in sequestration.

    This is why in a very short time I will take down my shingle and find a new line of work.

    In mediceine your lesson should read:

    “Coverage increases demand, demand increases entitlement, entitilement leads to rationing, rationing leads to decreased reimbursement and decreased reimbursement leads to decreased access.”

    Only the “time price” of care is increased.

  17. Patty says:

    Mr. Goodman,

    You are exactly right about health insurance, it is a middle class commodity that is coveted by people with assets. People without assets want free health care, rather than insurance.

  18. Frank Timmins says:

    It seems to me the question is which of the GOP “leaders” in congress will grab the facts of this new study and organize legislative opposition to implementation of the ACA based upon its findings.

    How much economic damage will we suffer before someone pushes the reality of all this before the public?

  19. Ralph Weber @ MediBid says:

    Doctor Tom,
    I agree with your lesson from your perspective as a physician. Perhaps I should have elaborated more. My reference to “increase in prices” does not trickle down to providers. Much of it is kept by BUCAH. If you google “Blue Cross hidden fees case”, you will see that what they charge the employer is usually not the same as what they pay the provider. I do not think this is moral, nor do I agree with it, however I do know that it happens.
    Instead of taking down your shingle (which I would not blame you for), have you considered converting more of your practice to 3rd party payer free?

  20. Harley says:

    Have to agree with Doctor Tom. We aren’t seeing the true price of care because it’s a heavily regulated vertical market. Fixed prices from Medicare and Medicaid mean that the privately insured carry more of the burden.

    More importantly, Information Asymmetry would argue that price markers have little to do with actual demand, but are misinterpreted as quality of care. The NCPA and Reinhardt have both posted extensively on how impossible it is to get an actual price for services from a hospital in order to shop around.

  21. Jordan says:

    So if this bill was designed by middle and upper income folks, why are there meetings being held by the legislature to figure out a congressional exemption?

  22. Al Baun says:

    Forgive my naivety, but as a layman i was under the impression that Medicaid was a payment mechanism, not a wellness program. Shouldn’t one conclude that wellness training must originate with the provider and be continued by the patient? I have a difficult time blaming a payment mechanism for wellness failure; however, this will be addressed under Obamacare.

    The good doctor was remiss in letting the readers know that ‘The Study’ was in part funded by HHS through grants made available through Obamacare? also, what is missing in the report is the reduction in the number of unpaid procedures the hospitals and doctors had due to patient participation in Medicare (and subsequent county/government costs).

  23. Don McCanne says:

    Of the three purposes of health insurance, the Oregon Experiment confirmed that Medicaid fulfills two: improving access to care, and reducing the financial burden of health care. Although the study was underpowered to confirm the third purpose – improving health outcomes – that result was not necessary to demonstrate since a multitude of other research studies have already confirmed that the interventions studied are effective. The Medicaid program does not change the pharmaceutical benefit of drugs used to treat diabetes and hypertension.

    Showing favorable trends in outcomes that fall short of statistical significance because of an underpowered study (too few people with the disorders, studied for too short of a period), is not the same as showing “no difference between being in Medicaid and being uninsured.” On outcomes, the Oregon Experiment would be better characterized as a non-result rather than a negative result. On access and financial burden, the benefit is clear.

  24. APEXHCR says:

    for more information on health care reform and access to free HCR webinars, please visit link below:

    http://www.apexhcr.com/apex-hcr-webinar-series/

  25. Doctor Tom says:

    @Ralph Weber

    Many of my colleagues in other medical disciplines are doing just that, esp in uban centers.

    Unfortunately, for me, I prectice in a county that ranks 2nd in the state in poverty and my practice make-up is 85% MC/MD. Only about 50% of those with Medicare have supplemental coverage and better than 50% of those have Medicaid as their supplement. So as reimbursement contiunes to fall so does the ability of my practice to stay open and still provide the level of care I feel is moral and ethical.

    Like the old saw “I may lose a little on each service but I make it up in volume.”

  26. Doctor Tom says:

    @ Don McCanne

    I would have to disagree with you on several of your premises.

    One of Medicaid’s lofty goals was to improve access to care, as you describe. However, you are wrong to state that the goal has been attained. More and more physicians are closing their doors to Medicaid patients due to severe declines in reimbursement imposed on their practices forcing more and more of these patients to use the ED as their primary care clinic.

    Additionally the financial burden of healthcare was not reduced or eliminated it was simply shifted onto the backs of the hospitals who run the EDs and the caregivers who are lining up to dump that burden. In many cases the reimbursement fails to cover the cost of care or in some cases barely allows the caregiver to break even.

    Medicaid is notorious for declining coverage on a claim requiring the caregiver to expend addtl sums to refile and appeal those claims or face setting a precedent that Medicaid has no problem abusing.

    Medicaid does change the pharmaceutical benefit of drugs to treat hypertension and diabetes because w/o access to those medications, the patient dooes not derive benefit. Medicaid does however severely restrict what medications the physician may use in the patient’s treatment to the point that the patient may not derive benefit because the medications available on Medicaid’s approval list may be ineffective for that patient.

  27. Ralph Weber @ MediBid says:

    @Doctor Tom,
    Yikes 85%. That does leave you in a very precarious situation.

  28. Linda Gorman says:

    I think that the attempts to put a positive spin on the has been most interesting.

    In response to the attempt above, I’d observe that The financial burden was not removed. It was shifted.

    And apparently the increased access did little more than result in increased waste.

  29. Studebaker says:

    Maybe I can combine Don McCanne and Linda Gorman’s comments and say that Medicaid in Oregon increased access to wasteful care and shifted the costs by paying for it with OPM — Other People’s Money.

  30. Bob Deuell says:

    As a physician who takes care of insured, uninsured, Medicaid, Medicare, and CHIP I would submit that bad lifestyles played an important part in the “no difference” in uninsured and Medicaid. The point is that no amount of medical care can overcome a poor lifestyle. Having said that, Dr. Goodman’s points are well-taken.

  31. Ralph Weber @ MediBid says:

    There are 2 kinds of guests who stay at a hotel. The first type turns the lights out and returns the key when they check out. The second type leaves all the lights on, and the TV, uses all of the towels, and coffee, takes a monogrammed towel and does not check out.
    The second type is typical of Medicaid benefitciaries

  32. Wanda J. Jones says:

    John and Friends:

    This is a symphony of good sense. One of my puzzles for the years in which Obamacare was gestating was why the government cancelled a plan to build 1500 more Community Health Centers. These are specifically designed to be located where the most poor families are, offer sliding scale and free care, and are able to pay health professionals enough to get them. They lean heavily on part-time volunteer physicians–not ideal, but better than the ER. Why was this cancelled?
    I can only speculate that its timing would have reduced the enthusiasm for the new law.

    In the Seventies, there was a new health planning law, the third since the Hill-Burton Act, which gave capital grants for new hospitals. The new one had no grants to give but gave the planning agencies more responsibility–to plan for all levels of care, and for major equipment, and more. I helped a private consulting firm that was alarmed by what it saw as a really costly regulatory effort for its clients. We invited the young people who had written the law as staff to one of the Congressional committees on health. At lunch, I asked one of them “You’ve mentioned all the interest groups that were against this law; can you tell me who was for it?” His answer: “I guess we were,” meaning his fellow committee staffers. This is just like Mark Twain’s “The Mysterious Stranger” where some boys happen upon an old man in the woods, watching a village of tiny people move around, occasionally taking a stick and stirring them up to see what would happen. When they asked him why he did that, he answered “These are just like ants to me. but with more variety in their reactions.” God, as he was meant to be, just stirred the village for the heckofit.

    The public has had plenty of time to observe Congress making sausage, and feeling the impacts. It does no good to say, “elect different people.” The mechanisms of making laws are at fault. There should be more attention paid to the OMB or other technical bodies, who attempt to tell us in advance what something will cost. An equivalent responsibility should be to tell us the effects it will have on the various parties involved. Obamacare did not have that benefit before passage, and the corrupt administration obviously had no interest in passing an effective, and unharmful bill.

    Just imagine a scenario where the Democrats beg for repeal before the next election so they are not tarred with the serious unintended consequences of this law.

    As for access, the government does not seem to understand the renewal process going on among healthcare providers, where merger after merger is producing large-scale healthcare systems that have two roles: operating what exists and preparing the healthcare system for the future population. Since the country will have a doubling of its senior population and a huge uptick in its lower income population, a delivery solution that can be organized and operated by these regional healthcare systems can help a uninsured low income segment of the population via budget allocations to community health centers, backed up by the hospitals and medical groups in the system. In other words, go where the development talent is and give them incentives to upgrade the delivery system, including paying doctors enough to keep them in practice.

    As stated above, having or not having insurance does not matter much if the target population has a dangerous lifestyle.

    Cheers…

    Wanda J. Jones, President
    New Century Healthcare Institute
    San Francisco

  33. Erik says:

    Wasn’t the Oregon study conducted by Katherine Baiker who was on GW Bush’s Council of Economic Adfvisors? After the Austerity debakle I would caution anyone to accept another partisan opinion study.

  34. MarkH says:

    This is the third time you’ve posted on that study, with the fundamental understanding of the purpose of health insurance. Health insurance exists for financial protection, not health improvement.

    Despite Gabriel’s constant quoting of the BS from the medicaid website, this does not change the fundamental purpose of insurance. Car insurance does not prevent accidents, homeowner’s insurance does not prevent fires. Despite all the glowy warm and fuzzy nonsense the insurance companies would have you believe in their ads, for the most part, they don’t have any role in making you physically healthy aside from the occasional initiative. They exist to prevent financial ruin from illness.

    Further, the Oregon study was not adequately powered to detect the effects that might be expected as benefits of higher utilization, although the trends in the study suggested a benefit of better blood pressure control etc. Other examples from the literature suggesting negative health effects of being uninsured (trauma being notable) required the analysis in the order of hundreds of thousands of patients to identify significant effects. How would one possibly expect to see these effects with these numbers considering the majority of the enrollees are going to be healthy?

    I realize this fits with an ideological objective of opposing all attempts to socialize medicine, but it’s not an honest read of the study, and it’s not an honest interpretation of the role of health insurance. It is possible that health insurance, because it also includes potential preventative access could improve health if universal, but that would just be icing on the cake. The reason for universal insurance is to financially protect us when we get sick, and to avoid the costs of healthcare for the uninsured being constantly foisted on those who do buy insurance.

  35. Frank Timmins says:

    @MarkH

    “..The reason for universal insurance is to financially protect us when we get sick, and to avoid the costs of healthcare for the uninsured being constantly foisted on those who do buy insurance..”

    I think you are correct with your assessment of the role of “insurance” Mark, but I’m a bit confused. If we have “universal healthcare”, where is the cost for the (previously) uninsured being hidden? Does the healthcare expense for these people simply evaporate?

  36. John Sweeney says:

    Amen, brother!

  37. Tom C says:

    I just got finished reading the Times Magazine’s adticle by Stephen Brill, A Bitter Pill. We have a gigantic problem that is not being told?? Hospitals, Pharmaceutical companies and doctor groups are driving the cost of medical care to astronomical levels. They are ripping off all of us!!! And the main stream press, legislatures, and those that should be regulating these groups are not doing anything to expose this tragity??? If you think Bankers are greedy you have seen nothing yet compared to the suposed Non Profit Hospital behemoths with out landish revenue profit margines. They are by far the largest spenders for special interest lobbying to our complacent legislatores. John, I suppect that you have talked about this but it needs far more light then it now is getting!!!!

  38. MarkH says:

    @Frank says:

    I think you are correct with your assessment of the role of “insurance” Mark, but I’m a bit confused. If we have “universal healthcare”, where is the cost for the (previously) uninsured being hidden? Does the healthcare expense for these people simply evaporate?

    It’s currently being hidden in many of the mark-ups in the chargemaster, higher fees for procedures, imaging etc. We already have universal healthcare, just in the stupidest fashion imaginable. Because Reagan passed EMTALA, everyone who needs a doctor can get medical care. However, it was an unfunded mandate. As a result, the ERs (the most expensive place to provide care) are full of primary care complaints, and fully 50% of ER visits are never paid for.

    We’re already paying for this nonsense, just in the dumbest way possible. If people are uninsured and sick, they don’t just stay home and die. They go to the hospital (usually after the problem has gone from minor to critical) and get treatment that they then can’t pay for, and if they don’t have any assets the hospital just eats the bill.

    @Tom C, you missed the point of the bitter pill article. No one actually pays those rates. The chargemaster is largely irrelevant to the excess costs in US healthcare which are actually extensively studied. I would suggest you google the McKinsey report that Brill cites in the article, but sadly does not incorporate into much of his conclusions.

    Brill missed the point. Yes the chargemaster is a particularly horrible object to a specific group of people – the uninsured who have some assets that the hospital can grab at to make people pay their bills. But that’s just because they don’t know that you don’t have to pay the bill the hospital sends you – hence the payment negotiators mentioned in the bill.

    The chargemaster is just a symptom of the broken payment system, in which none of the payers will pay for the actual cost of treatment, and the incredibly difficult problem of figuring out the “cost” of a hospital stay. It’s a war between the hospital and the payers, where the payers will only pay a fraction of a bill, and have the power to fight back against the chargemaster, and the hospital, trying to cover their expenses, has to increase chargemaster costs to force payers to pay a larger fraction. When an uninsured patient gets caught in this mix, it’s tragic, but it has little to do with excess costs, because no one actually pays those amounts.

  39. Ralph Weber @ MediBid says:

    @MarkH,
    Another thing that no one is even addressing is PPO Networks and “allowables”. This will become a much larger problem under obamacare as plans have to meet the MV threshold. In the second edition of MediCrats, I have an entire chapter on it.

  40. MarkH says:

    I don’t know about that, seems off-topic. But this is the third time Goodman has stated that this study is somehow “devastating” to Obamacare.

    It’s totally nonsense. He’s pushing a false notion of the function of health insurance, and then blaming health insurance for not providing that function. Worse, even if it were the primary function of health insurance to make us healthier, this study would not be even remotely powered to detect it.

    There is evidence that being insured has beneficial health effects, because unlike other types of insurance it allows for routine access to physicians which could enhance health. But really, for most healthy people, routine physicals and access makes little difference, so there’s going to be a lot of noise in your signal.

    Additionally there are lots of data that being uninsured is bad for your health, especially once you’re actually sick or injured, you will do worse than an insured patient. But these studies required the analysis of tens or even hundreds of thousands of patients who were already sick, hospitalized etc. Goodman ignores all the other data that is in the literature that documents these effects in order to score a partisan point.

    If he keeps pushing this nonsense I think we have to call him out for frank dishonesty.

  41. Bob Hertz says:

    Avik Roy had the best suggestion — give each Medicaid recipient $150 a month in medical food stamps, and then have public catastrophic insurance for hospital stays.

    All the haggling over the fees paid on drugs and office visits would disappear.
    Medicaid would have no fee schedule for ambulatory care.

    This would not be cheap in tax dollars but it would be far more efficient.

    Incidentally, no one would then measure whether Medicaid had improved blood pressure or cholesterol or blood sugar. Any more than anyone measures whether food stamps lead to regular bowel movements.

    Although I am normally on the left for health care, I am a downright libertarian on the issue of ambulatory care. I do not think it is any business of government what adults show for blood pressure or cholesterol. Government should first be superb in regard to contagious diseases and accidents/injuries.

    Most adults with chronic illnesses have earned them with years of poor health habits. (me included) There is nothing wrong with giving financial aid for treatments, but it is pure charity.

  42. Frank Timmins says:

    @MarkH

    Mark, oddly enough I think you make good points and I agree with how you describe the “problem”. There is little question the hospital chargemaster fiasco a thorn in the process, and yes, we do currently pay for all this in the “second” dumbest way possible.

    And the very dumbest way to remedy the situation is the utterly inane approach of the PPACA. Price/benefit fixing and the bureaucracy that is necessary with centrally planned healthcare doubles down on the waste you correctly cite in the current system. Moreover, A single payer system simply guarantees a lower quality healthcare system for all (except the bureaucrats and friends of the state). No one can possibly make a case for efficiency in such a system unless one is willing to ignore the quality of the system. It is simply an economic and operational impossibility.

  43. Tom Chapman says:

    Hey John – excellent piece! As anyone that has studied the numbers on this Socialist FARCE will tell us – this program will be a fatal blow to the future of the US economy and future generations will never forgive us for allowing this to happen to them!

  44. Tom C says:

    MarkH, Yes having health care is far more advantagious then not having it. Its the affordability that is where the problem lies. But our healthcare is not set up under free market principals or anything close. Thus the Charge Master as a starting point with no relation to real costs? You can’t insure 30 million more people with out dramatically expanding the number of health care providers like doctors and nurces. You need far more hospitals/clinics. Its called economics 101, greater demand requires more supply. Why is the supply of health care providers and facilities being artifically limited/controled to limit the supply?? Then the patient needs to know the cost of his health care. What does it cost to get his case of indigestion treated, before you treat it, what does it cost to fix a particular broken arm again before you fix it. Why is the health care provider giving me a c scan and not an exray and what is the difference in the cost and outcomes? Then there is the very real problem of pernicious, special interest, Lawyers,and their law suites that require doctors like OBGYN’s to carry multi 100 thousand dollar insurance policies. You can’t watch TV with out seeing some law group pleading for clients to file law suites?? You can’t fix a broken system until you deal with what are the causes to the disfuction, Free market principals is a place to start NOT universal socialized Big Government principals that Obama Care and what our current Health Care system is based on!!!

  45. MarkH says:

    Wow. Some crazy towards the end there guys.

    A single payer system simply guarantees a lower quality healthcare system for all (except the bureaucrats and friends of the state). No one can possibly make a case for efficiency in such a system unless one is willing to ignore the quality of the system. It is simply an economic and operational impossibility.

    You guys are confusing nationalized healthcare with single payer health care. Most nations worldwide have some version of single-payer. Some have mixtures of public and private spending like the Dutch, with subsidized health insurance as the ACA proposes. Interestingly the Dutch enjoy one of the best systems in the world, with better access, wait times, and quality than we have. There is nothing wrong with single payer intrinsically, nor is it necessary in order to provide universal care. But we already have universal care, we just don’t acknowledge it, or pay for it sensibly, so the costs of all that healthcare are hidden and filtered. It’s a stupid shell game that we have to stop playing, and acknowledge there has been a cost to EMTALA. I would say there is a problem with nationalized care (3 countries – Canada, UK, NZ), but many single-payer systems (France, Japan, Sweden etc.) with mixtures of public and private healthcare systems provide superior care to that in the US, cost 1/2 as much, and still provide care to 100% of their citizens. I somehow thing that America can do as well if we get our act together.

    Tom C, you are wishing for a pipe-dream. Healthcare is always going to be tightly regulated, government is fundamentally enmeshed in the process from resident training (they actually pay for residents through medicare) through dialysis coverage, to medicaid and medicare, to licensing and monitoring quality of care. Why don’t we operate in the realm of the possible and realistic, rather than the revolutionary fantasies of free market fundamentalists? The pure free market is gone and not coming back. We’re going to have regulatory agencies, JCAHO (blegh), BPQAs, the FDA, OSHA, ACGME, safety-net programs (medicaid/medicare) and a whole bunch of other alphabet soup and there’s nothing we can do about it. No one is going want to return to a system where you have no idea whether your doctor is well trained, whether their license means anything, whether the drugs have been tested for efficacy, whether the hospital follows basic standards for safety. We’re not just going to let people die in the street if they don’t have insurance.

    Why don’t we just get over the fact that there is going to be government regulation of this system and in a mature way discuss what form it should take.

  46. Tom C says:

    MarkH, A free market approach DOES NOT mean a world with out regulations? Why would you jump to that conclusion?? We need effecient simple regulations that deal with real world circumstances. That are not written by some special interest group! But Big Gov. Regulations guided by special interest create croney capitolism and distroys real price discovery. And as for not knowing if your Doctor or Nurse practisioner has the training….Never said that or implyed that?? Of course healthcare practisioners need proper training and regulations that guid that training? But do you really need a doctor for a sore throught or a common cold persciption? Why do we not have more walk in clinics to eleviate the need for emergency room visits? Free market principals may be gone in your world but not mine!! when you don’t have a free market you get what we have today in our colleges and our healthcare. A system that does not work at its best and costs that have no representation to real world pricing. A Big Gov. solution is NEVER a good solution!! Why do you not get that?? What do the DUTCH do? I am all for looking at systems that works. But France you really have to be kidding right?? Beleiving in a Socialist system that NEVER has work at any time in history is the definition of being crazy.

  47. MarkH says:

    Running the system on free market principles suggests that rather than government regulation, capitalism and consumer choice will control healthcare decisions.

    Socialist suggest that government owns or significantly controls the the means of production of the industry.

    France is actually a wonderful place for medical care because of the extreme freedom medical professionals enjoy from government intervention and payer control of their practice. How can you say their system doesn’t work? Their citizens enjoy excellent care, excellent access (unlike truly socialized systems such as UK, Canada), it costs less per capita than our system, it is a mixture of public and private and for-profit hospitals, and most GPs are private and no one tells them what to do. read about it for yourself, it’s not “socialized”. It is compulsory insurance, a mixture of public and private hospitals, with government subsidy of the poor. It is nothing like the truly socialized NHS in which doctors are employees of the state, hospitals are owned by the state etc.

    Get over the Francophobia and try reading about how some of the rest of the world does this stuff rather than just dismissing it all as “socialized”. Medical care in France is not socialized, nor in the Netherlands. In fact, most countries have figured out how to deliver universal care without government taking the reins and controlling the provision of medical care like in UK, Canada, and NZ, the three truly “socialized” systems. Try reading about Japan or Singapore which I’m pretty sure Goodman thinks is the ideal system (it is actually a really good system). In many ways, single-payer simplifies the process and allows a true market for superior care exist. Rather than the big corporations and crony capitalists controlling medical care (read insurance companies) it’s the people.

    And how have socialized systems never worked? You’re just an ideologue if you believe that. Has the UK collapsed under the weight of socialism? Or Canada? Those hellholes we call Sweden, Norway, Denmark or the Netherlands? Have you ever traveled beyond the borders of your country? Or your state?

    Total nonsense. Read a book.

  48. Ralph Weber @ MediBid says:

    @MarkH,
    Actually I am from Canada, I left there after my wife was crippled by a 2 1/2 year wait for surgery. I lived in Thailand for 10 years, in Nepal for 2 years, and in Germany for 5. So rather than “reading a book”, I actually lived it.
    You might want to stop believing everything you read in print and actually experience it for yourself.

  49. Frank Timmins says:

    @MarkH

    “Running the system on free market principles suggests that rather than government regulation, capitalism and consumer choice will control healthcare decisions.”

    You miss the point of the free market approach to healthcare if you think it is about insurance companies. It is about centering on the true buyer and seller of healthcare services in order the get the best for the least. Start with that premise and build from there. Yes, there is some necessary regulation, but it should be there to promote the individual consumer’s education on how to manage his particular needs while protecting all parties from illegal activity. It should not be for the purpose of attempting to fit individuals’ needs into a “one size fits all healthcare matrix” bureaucratic wet dream. Nor should it attempt to dictate prices and services.

    Now we can toss around anecdotes about socialism and capitalism all day, but the crux of the debate starts with the rights of choice of patients and those who provide services to same. Start with that premise Mark and we can go from there.

  50. Tom C says:

    MarkH, Ralph and Frank pretty much have laid out my thoughts. But you Comments that “running the system on free market principals …..means that free markets and consumer chioce will control healthcare decisions” Boy! if you are against that then I am at a lose to try and imagine what world you want to live in??

  51. MarkH says:

    @ Ralph, which is why I’m against truly socialized health care. The fully nationalized systems fail to perform as well as the mixed private-public systems you find in countries from Australia to the Netherlands.

    Based on the described “free market” approach, it’s so far out there, and so nebulous as to not be descriptive. I described multiple systems, from subsidized insurance (US, Netherlands) to what I consider free-market (Singapore with health savings accounts, co-pays, and government catastrophic insurance) and I’m in favor of basically any of those over what we were doing here previously, or what they do in Canada, UK, and New Zealand.

    My dispute is that France has a “socialized” system any more than our system is socialized, or more than other systems around the world. UK, Canada, that’s truly socialized, and nationalized medicine. Single payer is not synonymous with that, nor is it required for universal coverage, nor does it rule out a health-care market. I’m all for private hospitals, private physicians, and patient choice. I simply despise inefficiency, and the shell game that EMTALA creates in this country, where we have universal access, but not universal payment into the system. If we are going to guarantee access, we have to acknowledge everyone has to pay.

  52. Bob Hertz says:

    My understanding is that France, Switzerland, the Netherlands, Germany, Scandinavia, and Canada all have binding national fee schedules for nearly every aspect of medical care.

    In America, doctors and drug companies and hospitals usually charge whatever the market will beat, outside of Medicare and Medicaid.

    Americans with some means then buy health insurance to negotiate with providers and get discounts.

    Those without insurance are then sometimes subject to the chargemasters.

    But the sheer effort to regulate health insurance is enormous already, and will get worse under the PPACA.

    The natiional fee schedule is the ‘socialized’ elements in the European countries and Canada.

    It is frankly hard for me to imagine that this sort of national action would be any more wasteful than the circus in American health care.

    Bob Hertz, The Health Care Crusade

  53. Frank Timmins says:

    @Bob Hertz

    Bob, IMHO the market domination of two or three carriers (primarily the Blues) via their exclusive “contracts” with healthcare providers is almost as anti free market as Medicare price fixing. These competition restraining practices do indeed create unfair advantages over other healthcare financing options (including those with and without insurance), In addition, these contracts discourage any kind of transparency in pricing as a result of restrictions built into the provider agreements.

    Given the elements inherent in the ACA, I would certainly agree with your last statement. But the important thing is we can do much much better. We don’t have free market healthcare here, and we didn’t really have it before the advent of Obamacare. This fact seems to be the hardest one to make people understand.

  54. Ralph Weber @ MediBid says:

    Bob,
    We have large groups of people without insurance, and also large self funded employers who get much better prices at MediBid.com than any PPO discount will ever provide.

  55. Bob Hertz says:

    Good points, Frank, but I wonder if we are missing a significant point from “beyond the nine dots.”

    Namely, what if large numbers of patients as well as doctors do not want a free market in health care……..when troubled by illness, maybe people do not want to shop for price and negotiate a discount. The practice of medicine is hard enough without having to run specials and having to lay off your nursing staff if you do not have enough volume.

    Arnold Kling has made points of this nature in his excellent columns, check him out.

  56. Ralph Weber @ MediBid says:

    Bob,
    Although I doubt that there are as many non-capitalists as you think, so what if a large number dont want to shop!? So what, a small number will start free market operations, and may franchise it so they exist in many states and will market their business.
    Just because you think a large number of doctors and patients don’t want to shop, does not mean that no one should be allowed to

  57. Don McCanne says:

    Shopping for health care?

    The following is from our blog (pnhp.org) in response to the CMS release on transparency of hospital charges:

    So now we have access to hospital chargemaster prices – meaningless numbers that nobody pays. And that is going to make us better health care shoppers?

    What matters are payments, not prices. Actual payments are negotiated prospectively by private insurers, and even more effectively by Medicare. Cash paying patients usually feebly attempt to conduct negotiations retroactively, if they pay at all.

    This CMS effort on hospital price transparency will have almost no impact on controlling total health care spending since chargemaster prices are a fabrication.

    There is a far better way to control spending without forcing patients to make unwise health care decisions in their efforts to avoid the financial burdens of health care. Each hospital should be placed on a global budget, just as we do with our police and fire departments. That way, services are rendered simply when needed, without having an associated price tag.

    Requiring price shopping as a prerequisite to health care access is anathema to health care justice.

  58. MarkH says:

    @Bob

    The natiional fee schedule is the ‘socialized’ elements in the European countries and Canada.

    It is frankly hard for me to imagine that this sort of national action would be any more wasteful than the circus in American health care.

    That’s not socialism, that’s just price-fixing, and it’s not as broad as that. For one, in the French system, the government will only reimburse at a predefined rate, however the doctor can charge what they want for a service. 85% of French carry additional insurance on top of the nationalized insurance to cover these costs. This isn’t different at all from medicare’s fixed compensation for procedures in this country. To expand the metaphor, it’s as if everyone in their country is covered by medicare, which provides a baseline of coverage for all, but is really only adequate coverage. As a result most people buy additional coverage. I wouldn’t have a problem with that system. Everyone pays, everyone is covered for the most basic medical needs, but if you want to go above and beyond that you can pay for it.

    Socialism is government control over medicine, ownership of the hospitals, employment of the physicians, nurses etc. I don’t want to spend 17 years training myself out of college to become a government employee, trust me. I’ve worked at the VA, and while it works, I don’t think it’s the ideal delivery system, if only because it’s impossible to fire anyone who works for the government, and if there’s one lesson I’ve learned from medicine, it’s that some people really need to be fired. However, there are some things about the system that are highly effective. For instance, the VA can negotiate drug prices, and as a result, pays almost 50% less than what insurers or medicare pay.

    I don’t know what the best system is. I’ve studied systems in dozens of other countries, though, and they all work better than ours, for less money – usually fully 50% less cost normalized to GDP. Some, however, would not be a good cultural fit, and that’s why I’m so critical of the UK system and Canada’s. I think we’d do better with a system like that in the Netherlands (which the ACA approximates) or Singapore, or Australia, or a mixture of these innovations. The system I will not continue to tolerate is the existing one, in which there is universal access from Reagan passing EMTALA (it’s all in ERs – so primary care and non emergent medicine is treated inefficiently, and expensively, while burdening a critical resource) but not universal contribution. The people worried we won’t have the resources to cover the uninsured are missing the point. We already are covering the uninsured, only we wait until their problems are critical, we treat them in the most expensive place possible, and because they can’t afford the bill, the insured end up eating it with higher premiums and procedural costs. People without insurance don’t just sit at home and die, or suffer with illness. They go to the ER, and we all pay for it.

    It’s a shell game. It’s inefficient. It’s unfair to the uninsured who have some assets and get screwed by the charge master. If it takes the ACA to make insurance universal, fine, it’s better than the alternative.

  59. Ralph Weber @ MediBid says:

    @MarkH, the system we have is based on a fascist model. I make the case on page 80 of MediCrats, and provide the evidence for that. I was once a key note co-presenter with Yuri Maltzev (Gorbachev’s chief economist), and he agreed that fascism is far more sustainable that socialism

  60. MarkH says:

    Fascist? Please. Instead of name calling, how about ideas? This is the problem with these debates, when people start childish labeling of anything different from the status quo as socialist, or fascist, without offering any useful criticism other than such hysterics. There is no care to the application of these labels. There is no precision in definitions. Nor is there any attempt at offering ideas that are pragmatic or ultimately workable in a pluralistic democracy. What do we have instead, people crying fascism! Socialism!

    How tedious. I think I’m done here.

  61. Frank Timmins says:

    @Don McCanne

    “So now we have access to hospital chargemaster prices – meaningless numbers that nobody pays. And that is going to make us better health care shoppers?”

    Don, the answer to that question is without any doubt, yes. Placing myself at the top of the dummy list, how many of us understand anything about the electronics and half the functions of our cell phones, television sets, automobiles (or mechanics that repair them), etc., but we seem to be pretty good shoppers when we have to write checks.

    What you are actually saying by asking that question is there would be a huge market out there for consultation expertise for figuring out the ins, outs and efficiencies of various hospitals. You can bet your last stethoscope that the market need would be met. In fact, there are already very competent organizations that evaluate medical services for HSA holders, and they compete with one another for the business.

    Once the contents of the chargemaster mystery meat is exposed, uncontrolled pricing disruption will break out everywhere. When this happens the quality of services will become the justification for higher prices instead of the patient not having the insurance company with the “best” provider contract.

  62. Frank Timmins says:

    @Bob Hertz

    “Namely, what if large numbers of patients as well as doctors do not want a free market in health care?”

    I agree with Ralph. I think once people have choices to make, they will try to make the best choices. Patients have been continually “dumbed down” regarding their own healthcare for decades.

    In the past people have been operating under the assumption that they are using “house” money to pay for healthcare (even though it is mostly untrue). Once the public is weaned off “Daddy’s money” it will be very interested in the cost of the services. Moreover, I think “quality” will be strongest attraction to consumers once they get in the game, and that will create a great deal of excellence in the services provided. Proof of this can be found in the evolution of just about any product or service you can name.

  63. Ralph says:

    @markh
    I am not “name calling” I am using an accurate description of the economic model. If you can’t handle the truth then you really are done here

  64. Bob Hertz says:

    Although I am a leftist on health care, like Don McCanne,
    I do not mean that choice should not exist in health care. I am a great fan of tiered pricing for discretionary care.

    What I think you are missing, Frank, is that enforcing price disclosure and consumer choice in discretionary care will take some serious laws and will step on some big toes.

    Say that a patient needs hip surgery, asks for a price quote, and does not receive one.

    His pain worsens rapidly and he goes to the hospital where his doctor is certified.

    It happens to be a Boston teaching hospital and his deductible + coinsurance comes to $10,000.

    Are you prepared to enable him to deny liability?
    That is what it will take. American courts for many decades have been very friendly to hospitals on bill collections. This will not be a peaceful change!

    Bob Hertz, The Health Care Crusade

  65. Frank Timmins says:

    @Bob Hertz

    Bob, you may have lost me on this one. I guess I don’t understand why price disclosure incurs liability for anyone where the absence of same would not.

    I would certainly agree that enforcing price disclosure would step on some big toes, and those big toes certainly need to be stepped on. If we have a system corrupt enough that it depends upon hidden (undisclosed) pricing we are in more trouble than we imagine.

  66. Bob Hertz says:

    We are making some progress here.

    Many of the largest and most expensive hospitals in America depend totally on secretive pricing.

    In a world of price disclosure, their revenues would collapse in six months. Their staff includes renowned doctors and professors earning $300,000 or more a year, sometimes for part time work.

    Do not think that they would go quietly.

    In the non-medical world, an auto mechanic who fixes a $3000 transmission without telling the auto owner in advance can literally be kept from collecting.
    There are consumer protection laws in many states to prevent this.

    In about 98% of cases today, American courts will stand behind a hospital’s right to collect its bill, even if the patient has to mortgage or sell their house.

    This is a million miles from car repair.

    My point is that some hospital bills will have to be made uncollectible by the courts in order for us to enforce price disclosure.

    If I am in error let me know, no problem.

  67. Frank Timmins says:

    @Bob Hertz

    Not being either a physician or an attorney I can’t speak from experience or extensive case knowledge, but I have been assured by both that hospitals have extreme difficulty in trying to collect charges in excess of defined benefit plan limitations (from patient or carrier). Most do not even try.

    The problem is that the hospitals cannot prove in court that their costs exceeded the allowable (paid) benefit. I am talking about “defined benefit” plans that have no pricing agreements with healthcare providers.

    I don’t know about the largest and most expensive hospitals you reference. I am sure you are correct that there would be problems. Perhaps we have different sets of rules for some of these larger facilities. On the other hand, if Medicare can get away with its pricing limitations at these facilities, why would the same not be true of commercial health insurance coverage with allowables greater than those of Medicare?

  68. Bob Hertz says:

    When commercial insurers are asked why their rates keep going up, many of them say that large hospitals are charging them more than ever.

    If the insurers were just paying “Medicare plus 20%,” as your last parapraph implies, then their excuse for raising rates would be a lie.

    In the 1990′s, some aggressive HMO’s made a real push to restrict patients to the cheapest local hospital. Now THAT is how free markets are supposed to work.

  69. Ralph Weber @ MediBid says:

    Bob,
    Who said insurers are paying Medicare plus 20%?
    Insurers and hospitals are in bed together on pricing. Its a codependent relationship. Remember, the hospitals set up Blue Cross in 1929. Have you read the second edition of Medicrats? I talk about all of this in there.

  70. Rick Weber says:

    RE: http://healthblog.ncpa.org/devastating-news-for-obamacare-backers/comment-page-1/#comment-177424

    Socialism is government direction of economic activity and can take different forms. Prices direct economic activity and controlling prices gives government indirect control. If dams and levies allow the army corp of engineers to control the flow of a river then price fixing allows government to control the flow of spending in medicine. This is socialism. If the government owns the hospitals, that’s nationalization which is just one form of socialism.

    The (political) issue with price fixing is that what’s happening isn’t obvious to the electorate and so is less likely to be tossed out than outright nationalization. As a result the entrenched interest groups are much safer in the U.S. than they would be under any other system.

  71. Frank Timmins says:

    @Bob Hertz

    “If the insurers were just paying “Medicare plus 20%,” as your last parapraph implies, then their excuse for raising rates would be a lie.”

    You might presume that, but it would be ignoring other factors such as increased utilization and new services and procedures. The only way to control insurance “rates” is the same way as healthcare services rates should be controlled – competition.

    Bob, I disagree that the HMO methodology of restricting patients to “cheaper facilities” is an example of how free markets work. HMO’s can be a part of free market choice (for those who wish to utilize them), but the concept of restricting access does not represent “free market” methodology. In fact, it is its antithesis.

  72. Bob Hertz says:

    In a free market, goods are available in many price ranges. You can buy a used car for $2000 or a Lexus for $60,000. You can fix your transmission for $2500 or make do with a rebuilt for $1200. You can live in a trailer or a mansion and stay out of the rain either way.

    Health care will never be quite this flexible, because there are no used drugs or home-brew brain surgery.

    Yet I suspect you will agree with me that health insurance could be far more competitive than it is.

    We could have health insurance policies that did not cover open heart surgery or stage 4 cancer, and they would be dramatically cheaper.

    We could have health insurance policies that sent you to Mexico or India for discretionary surgery.

    Etc etc. What I was trying to get across with my remark about HMO’s is that true competition is not polite. Look at the clothing and food industries world wide. Low prices are achieved by screwing many of the workers.

    Health care is expensive in America because we protect the doctors and nurses and hospitals.
    All I am saying is that if we opt for more competition, this will be rough for the producers of health care even as consumers benefit.

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    Greetings from Ohio! I’m bored at work so I decided to
    browse your site on my iphone during lunch break.
    I love the knowledge you present here and can’t wait to take a look when I get home. I’m
    shocked at how fast your blog loaded on my cell phone .
    . I’m not even using WIFI, just 3G .. Anyhow, awesome blog!
    Good day! I know this is kinda off topic however I’d figured I’d ask. Would you be interested in exchanging links or maybe guest writing a blog post or vice-versa? My site addresses a lot of the same subjects as yours and I feel we could greatly benefit from each other. If you are interested feel free to send me an email. I look forward to hearing from you! Awesome blog by the way!
    Currently it seems like Expression Engine is the top blogging platform out there right now. (from what I’ve
    read) Is that what you’re using on your blog?
    Fantastic post but I was wondering if you could write a litte more on this topic? I’d be very
    thankful if you could elaborate a little bit further. Bless you!

    Hey there! I know this is kind of off topic
    but I was wondering if you knew where I could find a captcha plugin for my comment form?

    I’m using the same blog platform as yours and I’m having trouble finding one?
    Thanks a lot!
    When I initially commented I clicked the “Notify me when new comments are added” checkbox and now each time a comment
    is added I get several emails with the same comment.
    Is there any way you can remove me from that service? Bless you!

    Hi! This is my first visit to your blog! We are a collection
    of volunteers and starting a new project in a community in the same niche.
    Your blog provided us useful information to work on.
    You have done a extraordinary job!
    Howdy! I know this is kinda off topic but I was wondering which blog platform
    are you using for this site? I’m getting tired of WordPress because I’ve had issues with hackers and I’m looking at alternatives for another platform. I would be great if you could point me in the direction of a good platform.
    Hi! This post could not be written any better! Reading through this post reminds me of my previous room mate! He always kept talking about this. I will forward this post to him. Pretty sure he will have a good read. Thanks for sharing!
    Write more, thats all I have to say. Literally, it seems as though you relied on the video to make your point. You definitely know what youre talking about, why throw away your intelligence on just posting videos to your weblog when you could be giving us something enlightening to read?
    Today, I went to the beach front with my kids. I found a sea shell and gave it to my 4 year old daughter and said “You can hear the ocean if you put this to your ear.” She placed the shell to her ear and screamed. There was a hermit crab inside and it pinched her ear. She never wants to go back! LoL I know this is entirely off topic but I had to tell someone!
    Today, while I was at work, my cousin stole my apple ipad and tested to see if it can survive a 40 foot drop, just so she can be a youtube sensation. My apple ipad is now broken and she has 83 views. I know this is totally off topic but I had to share it with someone!
    I was curious if you ever considered changing the page layout of your site? Its very well written; I love what youve got to say. But maybe you could a little more in the way of content so people could connect with it better. Youve got an awful lot of text for only having 1 or 2 images. Maybe you could space it out better?
    Hello, i read your blog from time to time and i own a similar one and i was just wondering if you get a lot of spam feedback? If so how do you stop it, any plugin or anything you can advise? I get so much lately it’s driving me mad so any support is very much appreciated.

    This design is steller! You obviously know how to keep a reader entertained.
    Between your wit and your videos, I was almost moved to start my own blog (well, almost.
    ..HaHa!) Wonderful job. I really loved what you had to say, and more
    than that, how you presented it. Too cool!
    I’m really enjoying the design and layout of your blog. It’s a very easy on the eyes which makes it
    much more pleasant for me to come here and
    visit more often. Did you hire out a developer to create your theme?
    Exceptional work!
    Howdy! I could have sworn I’ve been to this site before but after reading through some of the post I realized it’s new to me.
    Anyways, I’m definitely delighted I found it and I’ll
    be book-marking and checking back often!
    Hello there! Would you mind if I share your blog with my myspace group?

    There’s a lot of people that I think would really appreciate your content. Please let me know. Cheers
    Hi, I think your blog might be having browser compatibility issues. When I look at your blog in Ie, it looks fine but when opening in Internet Explorer, it has some overlapping. I just wanted to give you a quick heads up! Other then that, amazing blog!
    Sweet blog! I found it while surfing around on Yahoo News. Do you have any suggestions on how to get listed in Yahoo News? I’ve been trying for a while but I
    never seem to get there! Thanks
    Hello there! This is kind of off topic but I need some guidance from an established
    blog. Is it very hard to set up your own blog?
    I’m not very techincal but I can figure things out pretty fast. I’m thinking about creating my own but I’m not sure where to begin. Do you have any ideas or suggestions? Many thanks
    Howdy! Quick question that’s totally off topic. Do you know how to
    make your site mobile friendly? My site looks weird when browsing from my iphone4.
    I’m trying to find a template or plugin that might be able to correct this problem. If you have any suggestions, please share. Thank you!
    I’m not that much of a internet reader to be honest but your blogs really nice, keep it up! I’ll go ahead and bookmark your site
    to come back in the future. Cheers
    I love your blog.. very nice colors & theme. Did you make this website yourself or did you hire someone to do it for you?
    Plz respond as I’m looking to design my own blog and would like to find out where u got this from. thanks
    Wow! This blog looks exactly like my old one! It’s on a entirely
    different subject but it has pretty much the same
    layout and design. Excellent choice of colors!
    Hey just wanted to give you a brief heads up and let you know a few of the pictures aren’t loading correctly. I’m not sure why but I think
    its a linking issue. I’ve tried it in two different internet browsers and both show the same results.
    Heya are using WordPress for your site platform? I’m new to the blog
    world but I’m trying to get started and set up my own. Do you require any html coding expertise to make your own blog? Any help would be really appreciated!
    Hello this is kind of of off topic but I was wanting to know if blogs use WYSIWYG editors or if you have to manually code with HTML. I’m starting a blog soon but have no coding experience
    so I wanted to get advice from someone with experience.
    Any help would be greatly appreciated!
    Hi there! I just wanted to ask if you ever have any issues with hackers?
    My last blog (wordpress) was hacked and I ended up losing a
    few months of hard work due to no data backup.
    Do you have any solutions to protect against hackers?

    Hi there! Do you use Twitter? I’d like to follow you if that would be ok. I’m absolutely enjoying your blog
    and look forward to new posts.
    Hi there! Do you know if they make any plugins to protect against hackers?
    I’m kinda paranoid about losing everything I’ve worked hard on.
    Any tips?
    Hi there! Do you know if they make any plugins to assist with Search
    Engine Optimization? I’m trying to get my blog to rank for some targeted keywords but I’m not seeing very good gains.
    If you know of any please share. Thanks!
    I know this if off topic but I’m looking into starting my own weblog and was curious what all is needed to get set up? I’m assuming having a blog like yours would cost a pretty penny?
    I’m not very web savvy so I’m not 100% sure. Any recommendations or
    advice would be greatly appreciated. Thanks
    Hmm is anyone else encountering problems with the pictures on this blog loading?

    I’m trying to figure out if its a problem on my end or if it’s the blog.
    Any feed-back would be greatly appreciated.
    I’m not sure exactly why but this web site is loading incredibly slow for me. Is anyone else having this issue or is it a problem on my end? I’ll check back later on and
    see if the problem still exists.
    Hello! I’m at work browsing your blog from my new iphone 3gs! Just wanted to say I love reading through your blog and look forward to all your posts! Keep up the great work!
    Wow that was strange. I just wrote an extremely long comment but after I clicked submit my comment didn’t appear.
    Grrrr… well I’m not writing all that over again. Anyhow, just wanted to say fantastic blog!

    Check out my blog – Bleacher Report – Front Page