Thump. Thump. Thump. Rep. Kristi Noem continues to thunk her noggin against the wall of good sense. She will vote for the 37th time to repeal the Patient Protection and Affordable Care Act.

The vote will have no impact on anyone's well-being except for that of current House freshmen who haven't had a chance to shout "Aye!" for repeal.

But if Noem's vote did have a chance of overturning policy, it would be a vote to increase the national deficit:

Congressional budget analysts said Wednesday that repealing ObamaCare would increase the deficit by scrapping the law's taxes, fees and spending cuts.

The notice from the Congressional Budget Office (CBO) came ahead of Thursday's House vote on full repeal of the Affordable Care Act.

The CBO refused to provide a new cost estimate for repeal, saying there is too little time before the vote. But Director Doug Elmendorf pointed to an estimate from July 2012 that abolishing healthcare reform would raise the deficit by $109 billion over 10 years.

"Although [we] have not updated that estimate to reflect the most recent baseline projections, we anticipate a similar result were we to do so," Elmendorf wrote in a letter to House Budget Committee Chairman Paul Ryan (R-Wis.) [Elise Viebeck, "CBO: Repealing Obama Health Care Law Will Increase Budget Deficit," The Hill: Floor Action Blog, 2013.05.15].

By the way, a big slowdown in the growth of health care costs is cutting the cost of the PPACA and reducing deficit projections by $618 billion through 2023.

Is that communism or pragmatism I hear from Governor Dennis Daugaard's Medicaid expansion task force? Either way, I like it:

Dan Ellis, CEO of Coteau des Prairies Hospital, said America's approach to health care is a product of its historic emphasis of individual rights. But compared to other developed nations, nearly all of which have taken a more communal approach to health care, it is clearly not working.

"The fact is we pay more for health care in our country than any other developed country in the world and probably get worse outcomes," he said [Daniel Simmons-Ritchie, "Task force wrangles over policy and philosophy as it looks at Medicaid expansion," Rapid City Journal, 2013.05.15].

Dan Ellis is head honcho at a hospital. Making health care work is his job. Hearing him say the same thing about the failing American health care system since the early days of this blog is like hearing the owners of Eagle Creek Software and Bel Brands say that investment in schools and roads would be better for business than corporate welfare.

Medicaid task force member Senator Craig Tieszen (R-34/Rapid City) sends up some hopeful signals. He appears to recognize that the farther-right wing of his party is peddling misperceptions about "lazy" people in Medicaid and higher costs for the state:

Tieszen said that there is a perception that South Dakota's budget would be taking on extra cost, when it may already be paying for uninsured people in other ways. For instance, many poor people can't afford medical care so they put off treatment until they arrive in the emergency room. That is a significantly higher cost for hospitals than providing preventive treatment, a cost that is borne by insured people [Simmons-Ritchie, 2013.05.14].

Tieszen says we need to put a face to the folks whom we can help by expanding Medicaid. That's a lot of faces: 40,164 uninsured South Dakotans in every county of the state, including 14,231 American Indians whose needs an underfunded Indian Health Service isn't meeting.

By the way, another 45,532 uninsured South Dakotans qualify for the ObamaCare subsidies for health insurance. That's the communal approach at work, helping more people get the coverage they need.

South Dakota's implementation of the Patient Protection and Affordable Care Act proceeds apace. Rep. Kathy Tyler (D-4/Big Stone City) notes one more way that President Obama's health care reform act is helping South Dakotans:

A few weeks ago, a desperate lady called me about her insurance issues.  Her husband is retired and had spent his savings on insurance for her since she lost her job during the recession. He is eligible for Medicare.  She now has a part time job, but there’s no money for insurance for her.  She is not currently eligible for Medicaid: they are not parents and own a small home. There might be an answer for her on the horizon.

The state recently announced that about $554,000 in federal funding is being made available to six South Dakota health centers so they can help uninsured people find health insurance coverage under the federal health overhaul law. The City of Sioux Falls Health Department, 605-367-8760, is one of the centers eligible for the grant money along with the Community Health Center of the Black Hills in Rapid City, Horizon Health Care of Howard, Prairie Community Health of Isabel, Rural Health Care of Fort Pierre and the Union County Health Foundation of Elk Point [Rep. Kathy Tyler, "A Quiet Week," Kathy's Corner, 2013.05.13].

Hey, arch-conservatives! Protesting at abortion clinics isn't much fun in South Dakota, since there's only one place to do it and our extremely low official abortion rate suggests most South Dakota women seek their abortions elsewhere. If you're a conservative looking for someplace to shout, you should pick up your ObamaCare signs and picket the six health centers listed above that are promoting the Daugaard-Rounds agenda of implementing the PPACA... because you know darn well that Governor Daugaard and candidate Rounds and President Obama aren't just trying to help people being squeezed by the economy and the absurd costs of health care. They're trying... well, why should I write your copy for you? Get on it, conservatives!

Uwe Reinhardt teaches economics at Princeton and writes about health care for the New York Times. He knows a lot about economics and health care. In an interview with Robert Siegel on NPR Friday (plus a companion blog post on the same topic), he explained why he finds the American system of pricing health care services laughable:

SIEGEL: Is there another market you can think of in which apart from practices of discriminatory, predatory pricing, that the same good or service can cost consumer B a fraction of what it costs consumer A or consumer C, depending on what kind of insurance they have or how rich they are?

REINHARDT: Well, I mean, if you go on an airplane, the person sitting next to you on an airplane probably paid a much different price for that fare than you paid. It depends who you are, whether you're a businessperson, whether you bought it 30 days ahead of time and so on. This is called price discrimination. Hotels do it. Airlines do it. But in no other market is it the case that the customer doesn't even know what they're going to get billed. It's just an unseemly system. You cannot go on the Web and find out if you need a hip replacement what a hospital will charge you for that. You can't get that.

So, I say it's like blindfolding people and then shoving them into Macy's or Lord and Taylor's and say, go and shop efficiently for a shirt. You are looking for a man's shirt. And you may come out with ladies' underwear because you can't see nor can you see the price. The way American hospitals price their services, to me, is a source of amusement, frankly. But if you are uninsured and middle class, it's not funny [Uwe Reinhardt, interviewed by Robert Siegel, "Study Reveals Wild Disparities in American Hospital Pricing," NPR: All Things Considered, 2013.05.10].

Tell me again, capitalist friends: how can free market forces solve our health care problems when producers won't tell consumers how much their products cost?

Reinhardt doesn't advocate my preferred solution of single-payer. But he sees some benefits in making health care costs uniform and transparent with a single-negotiator system:

But my preferred approach would be that all the payers - Medicare, Medicaid, private insurers - would jointly negotiate with all the hospitals in the region a common fee schedule and then everyone would pay that [Reinhardt to Siegel, 2013.05.10].

The same fair and honest prices for everyone, negotiated by all of us working together in our best interest—sounds plenty American to me!

New data from the Center for Medicare and Medicaid Services show that South Dakota ranks 30th in the nation for the average prices charged by hospitals for the 100 most common diagnoses and treatments. Minnesota ranks 31st. Sifting through the CMS data, I find lots of variance from procedure to procedure at the four South Dakota hospitals sureveyed (Sanford and Avera in Sioux Falls, Yankton Avera, and Rapid City Regional) and 14 Minnesota facilities. Treatment for psychoses is 11% cheaper in South Dakota than Minnesota, while treatment for poisoning and toxic effects of drugs averages 23% more expensive here. But on the whole, hospital prices are a bit less than 2% higher in South Dakota than in Minnesota.

Hmm... I'll bet Sanford Health could make up that difference if it quit charging patients extra to fund the millions of dollars spent to promote T. Denny Sanford's name and business interests.

I am heartened to read that hospitals, insurers, and citizens are rallying to ensure that folks injured in the Boston Marathon bombings won't have to bear the financial burden of their computerized prosthetics and other health care:

"We will work to ensure that financial issues/hardship will not pose a barrier to the care that affected members' need," said Sharon Torgerson, spokeswoman for Blue Cross and Blue Shield of Massachusetts, one of the state's largest health insurers.

Harvard Pilgrim Health Care, another big insurer, is changing its policy and will pay for some of the more expensive bionic limbs when there is a demonstrated need, said Dr. Michael Sherman, chief medical officer. He said that 15 blast survivors admitted to hospitals are Harvard Pilgrim customers and that the insurance company is discussing "whether we might absorb some of the copays and deductibles."

"This is a terrorist act, and our only thought here is about providing support," he said.

...At Massachusetts General Hospital, where 31 victims have gotten treatment, chief financial officer Sally Mason Boemer said bills "create a lot of stress. Our assumption is there will be sources we can tap through fundraising." Boemer added: "Now is not the time to add additional stress to patients."

...The fund has gotten more than $20 million in donations. Determining who gets what is still being worked out, but victims' insurance status and place of residence won't be a factor, said Kenneth Feinberg, the fund administrator. He oversaw the 9/11 compensation fund during its first three years, distributing more than $7 billion to 5,300 families and victims.

Grass-roots fundraising efforts include online funds set up by friends and relatives of the victims [Lindsey Tanner, "Boston Victims Face Huge Bills; Donations Pour In" AP via Yahoo, 2013.04.26].

So if criminals cause you bodily harm, hospitals and insurers and all of us as a community believe you should not be saddled with the bill for the medical services necessary to make you whole again, right? Cool. How about if a car accident hurts you? Or cancer? Or a falling tree? Or the physical or mental strain of your job? Or all that beer you drink?

There's the fundamental question in health care policy: what responsibility do you bear for your injury and illness? How much should you have to pay to make and keep yourself, your loved ones, and your neighbors well?

Related, update 09:48 MDT: Chad Haber makes me wonder if we might cut costs by beefing up WebMD and getting rid of 80% of our doctors.

Blog friend Les has been cudgeling our brains on health care with the contention that hospitals don't deny poor people care. That's all great and fine if we want everyone to seek treatment in the emergency room.

But what if working folks deny themselves care because they don't bank on charity and don't want to go bankrupt? That drives up everyone's costs, say the South Dakota health care experts who support expanding Medicaid:

A doctor, directors of medical facilities and other health care workers told a state task force Tuesday they believe South Dakota should expand its Medicaid program to provide health insurance to thousands more low-income people.

They said low-income people without health insurance now delay getting medical care until they are seriously ill because they know they cannot pay the bill. Those people then wind up in emergency rooms and hospitals getting expensive care that could be avoided if they get earlier treatment, they said.

"They are the working poor. These are the people we are trying to help," said John Mengenhausen, CEO of Horizon Health Care, representing the community health centers that provide medical care to people with fees based on patients' income [Chet Brokaw, "SD Health Care Workers Urge Medicaid Expansion," AP via Mitchell Daily Republic, 2013.04.24].

Expanding Medicaid won't increase our costs: according to Brokaw's article, we South Dakotans are already footing the bill for $90 million in unpaid medical bills. That's the hidden tax Senator Stan Adelstein contends we all pay for the uninsured.

Some argue that expanding Medicaid won't expand coverage; it will only take some people off the rolls of private insurance and not result in net improvements in health care access. But the vast majority of folks whom the Medicaid expansion would serve get no insurance from their low-wage jobs, and past Medicaid expansions have not undermined private insurance.

If we take advantage of the Medicaid expansion offered by the Affordable Care Act, we can increase access to health care, take a bite out of that $90 million, and make more sick people well.

My wife and I used a long drive across the state yesterday to read Steven Brill's journalistic magnum opus, "Bitter Pill: Why Medical Bills Are Killing Us." (Erin read aloud while I kept my eyes on the road.) We gagged at the stories of hospitals consistently charging out-of-pocket patients two to three times the cost Medicare reimburses for medical devices and fifteen times the Medicare rates for aspirin, swabs, and other mundane medical items.

Wonkblog's Sarah Kliff sums up Brill's essay in one sentence: "The American health-care system does not use rate-setting." I offer an even shorter summary: "Medicare for everyone" (see also Moyers, McGovern, and others).

Among the barriers to challenging medical vulturism we found in Brill's essay is the vital role high-charging hospitals play in the local economy. The massive profits hospitals turn on pacemakers and pills translate into lots of jobs and charitable donations. Without hospital money, Madison would be short 118 jobs, about 2% of the Lake County workforce. Without hospital money, various charities would lose an important source of revenue. Without hospital money, we'd struggle to build giant sports arenas.

But even if you accept the economic utility of what hospitals spend their money on, the way they get that money is still wrong. If we accept the status quo model of health care, we accept subsidizing jobs and social services and the Sanford Pentagon by taxing the sick. We get those social goods by exploiting the sick as a means to an end (Kantians, unite!).

Instead of submitting to a system that extracts wealth from those least able to bear such burdens, we should seek a more rational and just system that imposes equal burdens on all citizens. Instead of acquiescing to hospitals' exploitative and discriminatory pricing (low prices for the strong, high prices for the weak) for the sake of their purported economic largesse, we should nationalize health care to make it more efficient and use the economic savings to promote the general welfare.