Health Care — Half a loaf now, or try again in 19.5 years?


Cartoon by Jen Sorenson.

Ezra argues that we should grab half a loaf while we can:

There are many themes in the sad and frustrating history of health-care reform. But one of the central ones is that there were many points when Democrats could have accepted a compromise and did not. Richard Nixon, for instance, proposed a plan that could have passed Congress but that liberals thought comically inadequate. It was more comprehensive than anything we will get this year. George H.W. Bush also offered a pretty good proposal but got no support among Democrats.

Opportunities at health-care reform do not happen frequently. The average between major attempts is 19.5 years. That’s 19.5 years in which the uninsured stay uninsured and their ranks grow. Where a situation that is already bad gets a lot worse. This year, Barack Obama is popular, and there are 60 Democrats in the Senate and huge majorities in the House. There is no reason to believe that Democrats will be in a stronger position anytime soon. It is not like when a weakened Nixon, or a fading Bush, offered a compromise.

If reformers cannot pass a strong health-care reform bill now, there is no reason to believe they will be able to do it later. The question is whether the knowledge that the system will not let you solve this problem should prevent you from doing what you can to improve it. Put more sharply, the question should be whether this bill is better or worse than another 19.5 years of the deteriorating status quo.

Most of the liberals I talk to are deeply frustrated with how compromised the health care being discussed in Congress is. The House bill is far from the most lefty bill imaginable — but it’s probably a lot more left than whatever bill the Senate ends up passing, and therefore more left than whatever compromise bill between the House and Senate will eventually be hammered out in committee.

Given the history, I think it may make more sense to get something in place, and then work to improve it over the next 20 years. Single-payer, even if it’s a good idea for the U.S., isn’t something that has any shot of getting through Congress. Elections matter, and progressives and liberals — a much smaller group than “Democrats” — simply don’t have enough elected representatives to get our preferred policy passed, and might not even if our Democracy was better designed. (As it is, the way the Senate in particular is designed leads to extremely undemocratic results.)

Matt Tabbi sees the health care debate as proof of how bad our government is:

It won’t get done, because that’s not the way our government works. Our government doesn’t exist to protect voters from interests, it exists to protect interests from voters. The situation we have here is an angry and desperate population that at long last has voted in a majority that it believes should be able to pass a health care bill. It expects something to be done. The task of the lawmakers on the Hill, at least as they see things, is to create the appearance of having done something. And that’s what they’re doing. Personally, I think they’re doing a lousy job even of that. I lauded Roddick for playing out the string with heart, and giving a good show. But these Democrats aren’t even pretending to give a shit, not really. I mean, they’re not even willing to give up their vacations.

This whole business, it was a litmus test for whether or not we even have a functioning government. Here we had a political majority in congress and a popular president armed with oodles of political capital and backed by the overwhelming sentiment of perhaps 150 million Americans, and this government could not bring itself to offend ten thousand insurance men in order to pass a bill that addresses an urgent emergency. What’s left? Third-party politics?

Ezra (sorry to quote him so much, but he really is a good blogger on health care) agrees, but points out that if congress fails to address the long-care problems but does get 40 million currently uninsured Americans insured, that’s still an accomplishment.

Anyhow, please use this thread is for discussing health care, and in particular the health care legislation that seems like it might plausibly pass Congress this year.

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86 Responses to Health Care — Half a loaf now, or try again in 19.5 years?

  1. 1
    sylphhead says:

    Yeah, Ezra Klein has essentially become a single-issue blogger. I don’t mean that in a bad way, of course.

    I don’t really have a problem with the bills being passed around the House right now, and I wouldn’t consider them half a loaf. As long as it’s not the Baucus bill in the Senate, which uses a nice, soothing word that we liberals like (“Co-ops”! Ooooohhhh… ) to hide a tangle of an incoherent mess that would rather run unworkable bureaucratic loops than dare upset K street by having the simpler, more effective Public Option.

  2. 2
    lilacsigil says:

    To non-Americans, your healthcare system is so remarkably bad that almost anything short of actual gladiatorial contests to see who gets surgery would be an improvement. Maybe a slow, stepped process is the only way forward by now?

  3. 3
    Dianne says:

    your healthcare system is so remarkably bad that almost anything short of actual gladiatorial contests to see who gets surgery would be an improvement.

    Great, now I have that imagine stuck in my head. Might be a nice change from the delay to the death technique favored by insurance companies.

  4. 4
    Brian says:

    No matter what they come up with, since the rulers of our society refuse to give us single payer, all that remains is to see if we’ll be offered a government run watered down non-profit “public option” or not. If we aren’t, then it’s just a giveaway to the health insurance industry, forcing us to buy their substandard product at inflated prices aided by subsides from our tax base.

    Imagine if as a bailout for the generally mismanaged auto industry, we’d all been forced to buy shares of non-voting stock in GM. Oh wait, we did that….

    Imagine if we’d been forced to buy nonvoting shares in evil bloodsucking banks that would take our money and loan it to people who didn’t need it all over again, buy other companies, and pay executives inflated bonuses…. no wait, that happened too.

    We;ll be forced to buy insurance, and in return the insurance industry will change nothing about how they work. People with pre-existing conditions will be “covered” with million dollar deductibles, and $20,000 co-pays.

  5. 5
    PG says:

    I appreciate that Ezra Klein is doing this and that the Washington Post has given him a platform for it. (And it’s certainly better than having him try to be a food critic.)

    In fairness to the Democrats and the Congress generally, I don’t think a majority of Americans favor single-payer. A public option, yes, and if the Democrats can’t manage that — and if Obama can’t stop wishing for bipartisanship from a Republican caucus that has openly stated it wants to defeat him on this issue as a way to cripple his entire presidency, and therefore has said it will oppose any plan with a public option — then even my wholly non-revolutionary and incremental-reform-minded self will have to consider Taibbi’s third-party suggestion, albeit perhaps not for the reason he would.

    The problem of blue dog/moderate Dems, as David Brooks has noted while calling a feature rather than a bug, is that they almost by definition are from swing states or swing districts that elected them narrowly and that have viable Republican competition. Maybe, like Labor in the UK, those Dems need Lib.Dems to push them from the left.

    For simultaneously depressing and hope-giving listening, I recommend the Act 3 of the most recent “This American Life,” about health insurers that engage in rescission, i.e. refusing to honor the insurance contract at the point that the enrollee has an expensive problem, if they find any error by the applicant, no matter how irrelevant it is to the health problem for which the enrollee now seeks coverage. Depressing for obvious reasons, but also somewhat hope-giving inasmuch as the politicians at the Congressional hearing seemed to grasp that this is intolerable.

  6. 6
    FurryCatHerder says:

    I suspect the current attempt at Health Care Reform is going to go down in spectacular flames, held hostage by Lefties who want a whole loaf, whatever the heck a “Whole Loaf” would even look like, and the Neo-Conservative dominated GOP who can’t bring itself to ever do anything that would benefit a minority. Even if it makes financial sense.

  7. 7
    AlanSmithee says:

    It’s the Republicans fault!

    No, wait, it’s the Blue Dogs fault!

    No, wait, uh, it’s the…the sun! Thus sun was in our eyes! Yeah, and that’s why we need mo’betta dems! Sure it is!

    Hope for Change!

  8. 8
    RonF says:

    The situation we have here is an angry and desperate population that at long last has voted in a majority that it believes should be able to pass a health care bill.

    It was my impression that the election turned on the economy (Obama and McCain were pretty much running neck and neck until the economy turned sour), with the war as a secondary issue. I don’t believe that health care issues drove this last election and I don’t think that’s why the Democrats won their majority. A failure to recognize this is one reason why this effort is running into troubles.

    President Obama appears to have taken a longer time to pick out his dog than he has to putting together a national health care plan. What we have ended up with is a 1200+ (IIRC) page bill that almost none of the people voting on it have read – an issue that has legs given the publicity that the same thing happened with the stimulus bill. The planned expenditures are huge. It is perceived that it will create deficits that dwarf anything that any previous administration has dared put into place. “Tax the rich” sounds good, but even the rich don’t have enough money to fund this. Taxing the health benefits of people who current have employer-based coverage may sound good to you but doesn’t sound good to people who have employer-based coverage.

    What this looks like is that the Obama administration, with the effort spear-headed by a politician whose negative public perception is about the same as Dick Cheney’s, is trying to rush through a bill that will make a massive change in health care AND the economy without either adequate investigation and a convincing explanation of what this will do to American’s healthcare. It’s being viewed as a political process (let’s get something passed while we have the votes) rather than a careful consideration of what’s best for America.

    Now, you can argue the facts on a forum like this. But what you need to do is understand the perceptions. By focusing so much on the people in American who are uninsured you lose focus on the fact that the vast majority of people in the U.S. are insured. And you haven’t made those people understand that this will not negatively affect their healthcare. You have yet to gain their support.

  9. 9
    PG says:

    And you haven’t made those people understand that this will not negatively affect their healthcare.

    And those folks are being misled by conservatives like Martin Feldstein to believe that it will negatively affect their health care.

    For the 85 percent of Americans who already have health insurance, the Obama health plan is bad news. It means higher taxes, less health care and no protection if they lose their current insurance because of unemployment or early retirement.

    That’s the first paragraph. His factual support for those assertions is that rich people will change their income-earning behavior in response to a top marginal rate of 45% and therefore taxes must increase on the middle-class; that Minnesotans have superior genetic stock and that’s why Mayo Clinic gets great results for less money than other providers, not because Mayo has an integrated patient care model and physicians who aren’t driven by profit; and that COBRA should be fixed to reduce the cost of keeping one’s prior insurance. (Yes, his “no protection if they lose their current insurance because of unemployment or early retirement” is actually a statement about the status quo, not a statement about what the reform proposals would do.)

    This is on top of Feldstein’s flat-out lie that “Obama has said that he would favor a British-style ‘single payer’ system in which the government owns the hospitals and the doctors are salaried,” when the statement Feldstein cites in support of his claim actually is that Obama supports a “Medicare for all” program in which the government makes payments to private sector providers.

    Then you have people who are so incredibly ignorant that they don’t realize their Medicare is a government program.

    Five floors above him, J.B. Barker, 85, a retired truck driver, sat in a bed recovering from heart and lung congestion problems. Lunching on pepperoni pizza and Pepsi with his wife, Ellen, sitting at his side, Barker said that he does not want Washington meddling with his medical care and that he doubts Congress can craft a better system: “What we have is about as good as we can do.” …

    In other pockets of the state, the reaction to Democratic proposals has been strong, too. At a recent town-hall meeting in suburban Simpsonville, a man stood up and told Rep. Robert Inglis (R-S.C.) to “keep your government hands off my Medicare.”

    “I had to politely explain that, ‘Actually, sir, your health care is being provided by the government,’ ” Inglis recalled. “But he wasn’t having any of it.”

    Lies and stupidity certainly create an uphill battle here.

    (I don’t expect everyone to be a health care policy wonk. Hey, I know next to nothing about truck driving. But I also don’t volunteer opinions about truck driving policy. Should we allow Mexican trucks into the U.S.? What’s the optimal amount of time drivers should be on the road without sleep? I don’t know and I don’t pretend to know.)

  10. 10
    RonF says:

    Elections matter, and progressives and liberals — a much smaller group than “Democrats” — simply don’t have enough elected representatives to get our preferred policy passed, and might not even if our Democracy was better designed. (As it is, the way the Senate in particular is designed leads to extremely undemocratic results.)

    We are not designed to be a democracy. We are designed to be a Federal Republic, where the States and the Federal government each had separate spheres of sovereignty and where the jobs of those governments are to protect and elevate individual rights over the majority will. John Adams, our 2nd President and one of the designers of our current form of government addressed this:

    “If a majority are capable of preferring their own private interest, or that of their families, counties, and party, to that of the nation collectively, some provision must be made in the constitution, in favor of justice, to compel all to respect the common right, the public good, the universal law, in preference to all private and partial considerations… And that the desires of the majority of the people are often for injustice and inhumanity against the minority, is demonstrated by every page of history… To remedy the dangers attendant upon the arbitrary use of power, checks, however multiplied, will scarcely avail without an explicit admission some limitation of the right of the majority to excercise sovereign authority over the individual citizen… In popular governments [democracies], minorities [individuals] constantly run much greater risk of suffering from arbitrary power than in absolute monarchies..”

    Now, just about everybody here will say that in this case the public good is to have universal healthcare. But there are a great many who are likely to never post here who disagree; who think that their individual right to get the best health care they can afford without governmental interference is the public good and that this bill is an attempt by a majority to restrict their access to health care and represents injustice. I expect you will disagree, but debating that is not my point. My point is that the system is designed to make sure that the point is debated, and that it takes more than a simple majority to decide what’s justice and what’s tyranny.

  11. 11
    RonF says:

    Well, PG, you’re not going to win that uphill battle by acting like you know better than other people and that you’re going to give it to them whether they like it or not. And there’s a lot of people who have that perception right now, which is why the Blue Dog Democrats and just about all the Republicans are able to oppose this health care plan without having to worry about losing their seats over it.

    I have seen a theme here – and heard it in the President’s speeches – that the opposition to this health care plan is motivated by a desire for political leverage rather than by a considered belief that the plan is undesirable and will not work as proposed. Maybe some of it’s opponents do have the former as their motivation, but I don’t think that’s what’s motivating most of the politicians, nor do I think that it’s motivating anywhere near a significant number of the electorate that oppose this. The proponents are shooting at the wrong target.

    You’re not a truck driving policy wonk. You don’t drive a truck. Fine. But if there are 40 million uninsured people in the U.S. that means that around 87% DO have insurance. They’re all “truck drivers” with regards to this issue. And a whole lot of them are scared that the government is about to screw their insurance up. “We’re from the government and we’re here to help you” is not a positive cliche.

  12. 12
    RonF says:

    Oh, and Mr. Yglesias’ proposition that the ability of a few members in the Senate to craft legislation means that it’s undemocratic is flawed.

    Focusing on those six conveniently obscures the fact that their votes only mean something because the rest of the Senate is closely split. If there was a strong majority one way or another then it wouldn’t matter what they thought. It also neglects the fact that those 6 were chosen by their fellow representatives for this purpose.

    Right now we have two groups of people reasonably evenly split who have strongly opposing views on this subject. Mr. Yglesias apparently would have it that a majority however slim should carry the day over strongly felt opposition from the minority. I propose that it’s far better in the long run for the country if the two sides are made to compromise rather than one side to be able to impose drastic change on the other by a few votes. Consider that it’s not too long ago that conservatives held sway in the government, and it’s not at all unlikely that at some point they will again. I imagine he’d be singing a different tune in such a case.

  13. 13
    FurryCatHerder says:

    RonF,

    We already have “Universal Health Care” in the form of the Emergency Room. What we need is a way to capture the costs of that “Universal Health Care” from the people who are using it, as well as those who take advantage of the loopholes in the tax code that make Health Care Benefits be a form of tax free income.

  14. 14
    JaneDoh says:

    I actually agree with RonF on one point–healthcare reform has to improve the situation for the vast majority of people with insurance right now. That shouldn’t be hard–eliminating recission, making health insurance plans more portable so you don’t lose coverage when you change jobs, and preventing health problems from locking you into a particular job due to health care coverage are all things most people would love.

    I am only in my 30′s, and already I have several friends who can never quit their jobs due to insurability issues. They work for either large corporations or government, so their employers can either eat any tack on fees or negotiate out of them in a way a small company never could. 2 of them had cancer likely from on the job exposures, which makes their situations even worse, since they are still exposed on the job and can’t leave it.

    If healthcare reform does something for portability and removing the worst of insurance co abuses, most people would be interested in at least considering it. I moved to Canada last year for work, and I am constantly amazed on how much less energy I need to spend on our family’s health needs due to lack of insurance hassle. Wait times are no worse than what I experienced in DC with Fed Gov BCBS insurance, and it is actually easier to find a doctor taking new patients, since I don’t need to worry about who takes my insurance. And if something expensive happens (like my last pregnancy), I don’t keep getting the same stupid forms to fill out over and over in the hopes I will fail to do it, and have my claim denied due to lack of information.

    Even a small improvement in the US system would make a big difference, I think. But someone needs to tell currently insured (non-rich) people how reform will impact them. No one is doing that right now. Currently insured non-upper class people and Medicare recipients have the most to lose, because Warren Buffet doesn’t need insurance and things can only get better for the uninsured.

  15. 15
    Ampersand says:

    Brian writes:

    We;ll be forced to buy insurance, and in return the insurance industry will change nothing about how they work. People with pre-existing conditions will be “covered” with million dollar deductibles, and $20,000 co-pays.

    FWIW, I think that’s an element of the current system that is likely to be reformed.

    But Obama is now going on the road with these promises for what “reform” will deliver:

    * No Discrimination for Pre-Existing Conditions: Insurance companies will be prohibited from refusing you coverage because of your medical history.

    * No Exorbitant Out-of-Pocket Expenses, Deductibles or Co-Pays: Insurance companies will have to abide by yearly caps on how much they can charge for out-of-pocket expenses.

    * No Cost-Sharing for Preventive Care: Insurance companies must fully cover, without charge, regular checkups and tests that help you prevent illness, such as mammograms or eye and foot exams for diabetics.

    * No Dropping of Coverage for Seriously Ill: Insurance companies will be prohibited from dropping or watering down insurance coverage for those who become seriously ill.

    * No Gender Discrimination: Insurance companies will be prohibited from charging you more because of your gender.

    * No Annual or Lifetime Caps on Coverage: Insurance companies will be prevented from placing annual or lifetime caps on the coverage you receive.

    * Extended Coverage for Young Adults: Children would continue to be eligible for family coverage through the age of 26.

    * Guaranteed Insurance Renewal: Insurance companies will be required to renew any policy as long as the policyholder pays their premium in full. Insurance companies won’t be allowed to refuse renewal because someone became sick.

    Despite his many, many other flaws, Obama is a canny politician, and I doubt he’d be making promises that he didn’t think he has a fair chance of delivering on. So my bet is that most or all of that will be included in whatever reform package finally passes.

    Which is good — although it still doesn’t address the long-term problems that the US as a society can’t afford medical costs to keep rising the way they’ve been doing.

  16. 16
    Ampersand says:

    held hostage by Lefties who want a whole loaf, whatever the heck a “Whole Loaf” would even look like

    I think a whole loaf would look like France. (Or like its health care system, anyway.) But that’s not going to happen, I know.

    It looks to me that the liberals in congress aren’t likely to hold the final plan hostage, as long as it includes something like a public option and an insurance exchange. (Even if it’s a lousy public option (or co-op substitute) and a lousy insurance exchange.)

  17. 17
    Ampersand says:

    And there’s a lot of people who have that perception right now, which is why the Blue Dog Democrats and just about all the Republicans are able to oppose this health care plan without having to worry about losing their seats over it.

    Actually, Ron, I think the Blue Dogs do have to worry about it, which is why in the end many or most of them will vote for health care reform (or, in the Senate, vote for closure).

    If Health Care goes down in flames, that’ll be very good for Republicans, and a lot of Democrats will lose office as their fortunes decline with their party. But the Democrats who lose office won’t be my representative, the very liberal Peter Defazio. No matter how unpopular the Democrats are, the seats belonging to folks like Defazio are safe from Republicans.

    The people who have to be worried are disproportionately Blue Dog democrats, who are mostly in districts where — unlike where I live — Republicans have a shot at winning elections. So they have to be able to demonstrate to their conservative voters that they resisted the so-called Obamacare — but at the same time, they need Health Care to pass. They can’t afford to be seen as tools of Obama, but neither can they afford for the Democrats to lose badly.

    One more thing — I think it would be a bit naive not to notice that most of the Blue Dogs (and many other Dems as well) are are getting a lot of money from medical and insurance industries. That’s not the only factor that matters, but it is a significant factor. It’s why really big reforms — reforms that would make the big industry players not just unhappy, but furious — are not on the table.

  18. 18
    PG says:

    RonF,

    Well, PG, you’re not going to win that uphill battle by acting like you know better than other people and that you’re going to give it to them whether they like it or not. And there’s a lot of people who have that perception right now, which is why the Blue Dog Democrats and just about all the Republicans are able to oppose this health care plan without having to worry about losing their seats over it.

    Sure, it’s Joe-the-Plumberism: The opinion of people who have never troubled themselves to learn about the subject on which they opine should be taken just as seriously and have just as much impact on a policy discussion as the opinion of people who have troubled themselves to learn about the subject. You say we’re not a direct democracy, but you apparently think that the perceptions of people who don’t know what they’re talking about (and someone who doesn’t know whether his Medicare comes from the government really doesn’t know what he’s talking about) are relevant to the debate.

    I have seen a theme here – and heard it in the President’s speeches – that the opposition to this health care plan is motivated by a desire for political leverage rather than by a considered belief that the plan is undesirable and will not work as proposed. Maybe some of it’s opponents do have the former as their motivation, but I don’t think that’s what’s motivating most of the politicians, nor do I think that it’s motivating anywhere near a significant number of the electorate that oppose this. The proponents are shooting at the wrong target.

    I hadn’t heard it in the President’s speeches so much as I heard it directly from the mouth of Sen. DeMint (R-SC): “If we’re able to stop Obama on this, it will be his Waterloo. It will break him.” Or from Sen. Inhofe (R-OK), about how the defeat of President Clinton’s health care reform “started the demise of Bill Clinton that led to the 1994 Republican takeover of the House and the Senate. … we are plotting the demise on a week by week basis of where Bill Clinton was in 1993 and where Obama is today and his demise ratio is greater than Clinton’s was in 1993.”

    You’re not a truck driving policy wonk. You don’t drive a truck. Fine. But if there are 40 million uninsured people in the U.S. that means that around 87% DO have insurance. They’re all “truck drivers” with regards to this issue. And a whole lot of them are scared that the government is about to screw their insurance up. “We’re from the government and we’re here to help you” is not a positive cliche.

    Nope. I *interact* with truck drivers’ work, and I am either a beneficiary of good work or a victim of bad work by truck drivers, but I am not a truck driver even though truck drivers have tremendous impact on my life.

    A health care truck driver, in my analogy, would be someone who actually does something in health care: is a care provider, works in insurance or for a hospital or clinic, in the pharmaceutical industry, is an analyst in the private sector or for government or for . In health care, I have driven a few different trucks (done policy analysis, also worked for one of the largest health insurance corporations in America) and I have lots of family members who are current truck drivers (physicians, hospital employees, clinic managers, etc.). People who are truck drivers know more about it than just Well, somehow the stuff gets moved from point A to point B and all I care about is that I get my stuff at point B the way I want it.

    Just as I can learn more about the issues that affect truck driving policy without actually being a truck driver — I can read up on it and talk to drivers and so forth — people whose work isn’t in health care nonetheless can become well informed about it. But the idea that merely by needing health care, I must actually know something substantive about how the system works, is as ridiculous as the idea that merely by using UPS ground delivery, I must know something substantive about how truck driving works.

    What bothers me is the idea that I, based solely on my need for truck driver services, must have useful input on truck driver policy even though I’ve never looked at a study on the rate of accidents of non-U.S. truck drivers on American highways; nor hired truck drivers and set their wages; nor had the personal experience of getting goods safely and efficiently from A to B. I’ve just been at the end of the trip, complaining about the tear in the box or happily surprised that I got my intact box earlier than expected.

    If your entire experience of health care in America is as a patient, and particularly as a patient who’s gotten everything you need thus far (and as a relatively young and healthy person, that’s been my patient experience), then you don’t really know anything useful about health care other than I got mine, and I’m scared of anything that would change things in case it somehow means I don’t got mine anymore.

  19. 19
    PG says:

    JaneDoh,

    If healthcare reform does something for portability and removing the worst of insurance co abuses, most people would be interested in at least considering it.

    I never quite understand what people mean by portability unless it’s going to be a matter of insurance being attached to the person instead of to the job. And if it’s attached to the person, that means either the person is responsible for obtaining the insurance (and not only is that market expensive and health-discriminatory, but overt rescission is most common for individually-purchased insurance), or the government is responsible for providing it (which is the situation you have in Canada, as well as with Medicare in the U.S.).

    People who perceive no downside to employer-based insurance are just not going to see much of a benefit to reform. People who do see some downsides, like their anxiety about being able to change jobs without losing coverage, should be rooting for a public option that they’d be able to use if they somehow lost employment coverage, or even for a single-payer, “Medicare for All” system on which they have the option of buying additional coverage (something that only recently became a right in Canada).

  20. 20
    Robert says:

    The political balance of the Congress means that a left-leaning proposal is going to have a very hard time.

    It also means that proposals that use right-wing means to achieve left-wing ends are going to have a much easier time. Why not try and get a few of those through? I’m thinking of things like laws to make it easier for insurers to offer coverage, vouchers for health care insurance (tax everybody 2% flat rate, divide the money evenly among the bottom 90% as an insurance voucher), etc.

  21. 21
    FurryCatHerder says:

    Robert,

    I have the exact opposite fear — that the Congress has moved enough to the Left that any sanity in the Reform bills is going to be outweighed by a lack of adherence to reality.

    Back in the 80′s when “Liberal v. Conservative” debates were less complex, my friends and I used to describe things very simply –

    A Liberal is a Conservative who’s never had their pocket picked.
    A Conservative is a Liberal who’s never been sick.

    I’m all for having plans that do something for preventative health care. Definitely, let’s encourage that. But “preventative health care” should NEVER EVER EVER be covered by insurance, and it should be REQUIRED in order to receive coverage. Why the hell are we getting the government, or insurance companies, involved in what should be an annual, predictable, regular medical event? Maybe way, way, down at the poverty level people should get free routine physicals, including all the anatomy-specific checkups. But I shouldn’t be sending the cost of an annual checkup to a business just so they can tack on administrative expense and then it on to some other business with still more administrative fees tacked on.

  22. 22
    RonF says:

    Amp, those changes you mention Pres. Obama as having stated are very desirable. I’m sure that enacting them will affect me favorably. But what will the costs be to the insurance companies? They’ll make less money, surely. They can/should have to find some way to cut back on internal expenses just like my own company has to. But at some point – and I don’t know where that point is – you would think that they only have so much fat to cut and they’ll have problems.

    Insurance companies have to make profits. They don’t necessarily have to make a clear profit on claims vs. premiums, because they can invest cash on hand. As long as investments pay, they can make money there. But nobody’s made a lot of money on investments recently. And they have to pay investors. Do you propose that insurance companies be forced to become not-for-profits? Because otherwise they go out of business, which we have been repeatedly told is not the object of this legislation (although it would be warmly welcomed by a number of posters here). How does the President expect those changes to be paid for? Will costs be cut concomitantly with service increases?

    It would be an interesting proposition. I worked for a hospital that had been a not-for-profit. Then while I was working there it was bought up by a for-profit chain. Long story short, they f’d it up. Lawsuits brought against them in other states, lawsuits with considerable merit it turned out, didn’t help. Then an order of Catholic nuns bought it up and things improved again, but by that time I was gone. My revulsion at government control would not be triggered by requiring (or at least heavily favoring) hospitals, insurance companies, etc. to go NFP.

  23. 23
    RonF says:

    You say we’re not a direct democracy, but you apparently think that the perceptions of people who don’t know what they’re talking about (and someone who doesn’t know whether his Medicare comes from the government really doesn’t know what he’s talking about) are relevant to the debate.

    It doesn’t provide useful input to the debate. It does mean that those people care about the result and that their perceptions will affect whether or not their representative gets re-elected. God help us get to the point that our representatives could count on their constituents actually getting informed on the topics of the day.

    But the idea that merely by needing health care, I must actually know something substantive about how the system works, is as ridiculous as the idea that merely by using UPS ground delivery, I must know something substantive about how truck driving works.

    Oh, you’re right. More’s the pity.

  24. 24
    Jake Squid says:

    … my representative, the very liberal Peter Defazio.

    DeFazio’s your representative? Not the very liberal Earl Blumenauer? How does that work? Did you recently move south and not tell me?

  25. 25
    Jake Squid says:

    They don’t necessarily have to make a clear profit on claims vs. premiums, because they can invest cash on hand. As long as investments pay, they can make money there. But nobody’s made a lot of money on investments recently.

    Look! RonF has spotted one of the main reasons for absurdly increasing healthcare costs. Good for you. Seriously. You’re the first rightist I’ve heard acknowledge that fact.

  26. 26
    Ampersand says:

    DeFazio’s your representative? Not the very liberal Earl Blumenauer? How does that work?

    I’m in denial about how often my representative wears a bow tie.

  27. 27
    Ampersand says:

    Ron, the costs of the provisions which give insurance companies less ability to be choosy or to refuse to cover people, will be counteracted to some extent (and maybe more than 100%, for all I know) by the large increase in young, healthy people being covered by insurance, especially if we end up with mandated coverage.

    Since the insurance companies haven’t been screaming bloody murder, I assume they believe they’ll be able to survive this legislation while still making a profit.

  28. 28
    PG says:

    Jake @25,

    Yeah, people in Texas are still in denial about the fact that medical malpractice premiums skyrocketed … right when the tech bubble burst and the stock market tanked in 2001 and again in late 2002.

    “Oh, they must have raised the rates because there have been some huge frivolous lawsuits that nonetheless succeeded in obtaining massive awards!”

    Er, wouldn’t we have heard about those?

    “But why else would ALL the insurance companies say they need to raise premiums?”

    You’re right, nothing influences insurance company profits other than the ratio of premiums to payouts. Good thing we’re capping non-economic damages for all tort claims by state constitutional amendment.

  29. 29
    FurryCatHerder says:

    Amp writes:

    Ron, the costs of the provisions which give insurance companies less ability to be choosy or to refuse to cover people, will be counteracted to some extent (and maybe more than 100%, for all I know) by the large increase in young, healthy people being covered by insurance, especially if we end up with mandated coverage.

    BINGO! We have a winner!

    Keep making posts like that, Amp, and someone might mistake you for a realist.

    RonF writes:

    Amp, those changes you mention Pres. Obama as having stated are very desirable. I’m sure that enacting them will affect me favorably. But what will the costs be to the insurance companies? They’ll make less money, surely. They can/should have to find some way to cut back on internal expenses just like my own company has to. But at some point – and I don’t know where that point is – you would think that they only have so much fat to cut and they’ll have problems.

    Very not likely, for the reasons Amp gave. A lot of what makes insurance expensive, for people who get insurance, is called “The Death Spiral”. People who pay more in premiums than they receive in benefits opt out (if they can), increasing the claims experience of the group or company. This results in the company increasing rates, thereby making it so a new group of policy holders are now paying in more than they receive and opting out. Which further screws up the claims experience, lather, rinse, repeat.

    The problem is that people who opt out don’t actually “Opt Out” — they just stop paying into the system, because as soon as John and Mary Healthycouple have a claim, they head off to the Emergency Room where they cannot be refused care. If the cost of the visit is more than they can afford, it will eventually be written off as a bad debt, thereby raising the costs of care. The fact that John and Mary Healthycouple “opted-out” increases the insurance costs for everyone else, and their failure to pay their hospital bill raises the costs of services. Which also raises the cost of insurance … for everyone else.

    The key benefit of Mandatory Coverage is that while some people may “opt out” of the plan suffering from “The Death Spiral”, they can’t completely “opt out” of paying for what they use. And, the Invisible Hand of Adam Smith ensures that both plans — the “You gotta take everyone who applies” and the “You get to pick and choose, but you can’t dump people just because they get sick” — eventually reach an equilibrium. Healthy people in either plan eventually get sick, and that plan’s rates go up. Healthy people in either plan who think they aren’t going to get sick switch to the cheaper option, it’s rates go down, then they get sick anyway. Whichever plans do the most to improve preventative health care realize big savings, etc, and it becomes — for the first time ever — much more profitable to push routine physicals and other methods proven to reduce costs.

  30. 30
    Robert says:

    The down side of mandatory coverage is the massive civil disobedience it will inspire.

    Health care reformers of all stripes need to bear in mind that if the people don’t like their system, the people won’t play nice. If you’re unhappy right now because Robert Hayes isn’t buying health insurance, imagine how unhappy you’re going to be when Robert Hayes is still not buying health insurance and you’re also paying the taxes to keep him in jail – where he gets free, if terrible, health care.

  31. 31
    PG says:

    Robert,

    Does the penalty for failing to purchase health care insurance in ANY of the plans introduced on the Hill include imprisonment? That would be unusual. Are you aware of any state that mandates insurance purchase — e.g., requiring drivers to carry accident insurance — that imposes jail time as the penalty for failing to do so? Or does the state merely impose financial penalties, which have the nifty benefit of allowing the state to collect the money necessary to cover the events that insurance otherwise would be covering?

  32. 32
    Robert says:

    When I don’t pay the fines, you’re going to have to imprison me or let me be a scofflaw, and if you do that, there will be millions doing the same thing.

  33. 33
    FurryCatHerder says:

    Robert,

    That assumes that people will choose to be scoflaws because there is something horrible about having insurance.

    Most people who can afford insurance — forget the ones who can’t, because they just flat out can’t — don’t have insurance because they are taking a gamble. Take away the ability to gamble and the equation changes.

  34. 34
    Dianne says:

    If you’re unhappy right now because Robert Hayes isn’t buying health insurance, imagine how unhappy you’re going to be when Robert Hayes is still not buying health insurance and you’re also paying the taxes to keep him in jail – where he gets free, if terrible, health care.

    If you feel that strongly about it, I won’t say you don’t have the right to practice civil disobedience. Or risk you life by putting yourself in a situation where you don’t feel free to get medical care if you feel you need it. However, I do think it’s a little unfair of you to freeload off the taxpayers this way. If you don’t buy insurance and you get seriously ill who’s going to pay for your hospitalization and treatment? The taxpayers. Welfare queen.

  35. 35
    Ampersand says:

    When I don’t pay the fines, you’re going to have to imprison me or let me be a scofflaw, and if you do that, there will be millions doing the same thing.

    There are also millions of people who cheat on their taxes. That’s not a reason not to have taxes.

    If the result of mandated health insurance is that we wind up with about 27 million of the uninsured, insured, while the other three million refuses*, I’d find that an acceptable outcome. And I don’t think the population of far-right folks who’d actually have the courage of their convictions, if push comes to shove, is as large as you may be imagining, Robert.

    (*We don’t really know exactly how many uninsured Americans there are, but 30 million is a reasonable estimate.)

  36. 36
    PG says:

    Robert,

    When I don’t pay the fines, you’re going to have to imprison me or let me be a scofflaw, and if you do that, there will be millions doing the same thing.

    Not necessarily. People who fail to pay child support have their wages garnished. Even if you run your own business, unless you go purely on cash (in which case, tax cheating bonanza!), you have to go through banks and other financial institutions, which will cooperate with the government to subtract the necessary amount of money from your accounts. Heck, the Obama Administration is even trying to get info out of the notoriously secretive Swiss banks, and UBS apparently is going to roll over and give it to them. So where will you keep this money such that it won’t be susceptible to fines, except under your mattress?

    I really am not clear on where you get the idea that the next step, after refusing to obey a requirement to buy insurance, is the jailhouse. It might be true if you’re John Galt living in a valley and working on the gold standard, but that’s not an option for “millions.”

  37. 37
    Jake Squid says:

    I really am not clear on where you get the idea that the next step, after refusing to obey a requirement to buy insurance, is the jailhouse.

    Probably from the thousands we’ve locked up for not purchasing auto insurance.

    What’s that? Oh.

  38. 38
    Robert says:

    Jake, I’ve actually been locked up for not purchasing auto insurance. I eventually decided that the game wasn’t worth the candle, and since the state was in fact the entity building the roads, the state has the moral standing to require certain behaviors of the people using their roads. So they win that round! But the Federal government neither created the doctors and hospitals I would hypothetically use, nor do they have the slightest shred of Constitutional justification for taking over the healthcare industry, so I’m unlikely to yield a second time.

    PG, I have no eagerness to go to jail (the baloney sandwiches are terrible). But I ain’t paying. If you try to take it out of my bank accounts, I’ll close them (and throw twenty people out of work). And so forth. If the state is willing to back off and decide that it’s a rule for everybody except Robert, that’s fine too. But I don’t see any realistic path of disobedience that doesn’t end up in prison; if they steal the money from me, I’m going to steal it right back and that will certainly be enough to do the trick. But it’ll be a long court and PR battle first, and that IS something I’m eager to do.

    Dianne, I didn’t ask the taxpayers to pick up my slack and so I do not bear any moral responsibility to them. If I decide that it’s my obligation to pay for your college tuition, does that give me the right to come poking around your house and demanding that you do your homework? Not unless I can guilt you into it; I was raised by Italians so good luck pushing THOSE buttons on me. You’re also assuming that I’m incapable of paying for any serious medical condition on my own.

    Amp – you can’t allow three million people to disregard the system when the whole point of the system is forcing the people who currently pay no premiums to start paying premiums. Well, you CAN, you can do anything you like, including drinking Mt. Dew as a whiskey chaser – it just won’t make any sense. The three million people (say) who decide they aren’t going to play ball are just like me – people whose premium contributions would be enormous. They’re not able to make the numbers work well even assuming all us ripe sucks get the shaft; if we get to continue not playing the losing numbers game of health insurance, then the “reform” will fail even quicker.

  39. 39
    PG says:

    Robert,

    Jake, I’ve actually been locked up for not purchasing auto insurance.

    Do you mind saying in which state this was, and approximately at what time?

    since the state was in fact the entity building the roads, the state has the moral standing to require certain behaviors of the people using their roads. So they win that round! But the Federal government neither created the doctors and hospitals I would hypothetically use

    The state doesn’t build *all* the roads. And the federal government subsidizes the existence of the doctors: do you know how much money the government gives teaching hospitals that run residency programs? or loans and grants to medical students? If you find a doctor who has evaded any federal assistance in the course of his education, he’ll be even rarer than privately-built and -run toll roads are.

    If you try to take it out of my bank accounts, I’ll close them (and throw twenty people out of work). And so forth. If the state is willing to back off and decide that it’s a rule for everybody except Robert, that’s fine too.

    Since most Americans are not self-employed and would not consider the burden of paying premiums to be greater than the burden of losing access to the national financial system, I don’t think your mythical three million will appear. If the only people who refuse to buy health insurance are those who are willing to make the sacrifices you say you would, that’s going to be a very small number of people.

    Lots of men don’t believe they have a moral obligation to pay child support for a child they would have paid for the woman they impregnated to abort. Somehow the garnishing of their wages to fulfill this responsibility nonetheless occurs, and without the state appearing to have lost the PR battle enough to rescind the laws requiring men to pay child support for children they don’t want. See also seatbelt and helmet laws (or do you consider those also morally justified by the state’s having built the roads?).

  40. 40
    Ampersand says:

    Amp – you can’t allow three million people to disregard the system when the whole point of the system is forcing the people who currently pay no premiums to start paying premiums.

    Actually, the systems being designed take into account that a minority of people won’t participate, for whatever reason. And the plans are already assuming that some of the folks will manage to avoid paying the fine (or will be too poor to pay). You say “the numbers won’t work” as if it’s a fact, but it’s not; that’s just an opinion you just now pulled out of your rear end.

    If it’s true, of course, that there are three million Americans who currently have no health insurance, and who would rather go to prison for tax evasion, pull all their money out of banks and stuff it into their mattress instead, etc.., then either get health insurance or pay a fine, then that would be a problem.

    But it would also be very, very surprising. I think there will be 3 million or so who end up paying fines rather than getting health insurance (the fines are cheaper), but we won’t see people go to prison over this in mass numbers. (But if they do, then by all means write me from your cell block to say that you told me so.)

  41. 41
    FurryCatHerder says:

    Robert,

    Not to pry, but what is wrong for paying what you use? If you have the wealth to self-insure — fine. The policy I had 20 years ago had a $2,000 deductible with a maximum of $10,000 per year out of pocket. That’s pretty close to “self-insured” and it didn’t cost me all that much — I think the premium was something like $25 a month. And, go figure, I never made a claim.

    For someone who claims to be a conservative (for some value of “conservative”), your position sounds pretty much like “I want my free lunch, and you can’t make me pay for it!!!” Which isn’t the least bit conservative (for any value of “conservative”).

    Care to explain? Because, to be honest, I’m surprised a Liberal administration is talking about getting the Free Health Care Entitlement teet-sucking-at-the-pork-troth crowd to start ponying up.

  42. 42
    Ampersand says:

    FCH, I’m going to ignore your last paragraph. But maybe if you’re tired of being mistaken for a conservative, you should stop reciting boilerplate right-wing rhetoric. Just a tip.

    Regarding what Robert has in mind, I believe that his plan is to not buy insurance, and pay for all medical expenses for himself & his family out of pocket. Then, if he or his family has a catastrophic medical expense (god forbid), he’s planning to pay out of savings, selling the value of his business, selling the house, etc..

    What I don’t know is what Robert plans to do if the hypothetical ongoing medical expenses cost more than all the money he can get through selling and borrowing against what he owns.

  43. 43
    FurryCatHerder says:

    Amp,

    How would you describe in more politically correct terms the attitude that the Emergency Room is ones own private physicians office? And, no, I have no desire to stop being confused for a Conservative. But I’d really like it if people would stop confusing me for whatever it is that y’all seem to think “Conservative” means. When I was little, “Conservative” meant “boring”, “predictable”, “not all that exciting”, not “bigot”. I’m the “boring” kind of Conservative, not the “bigot” kind.

    And while I might have framed the question more carefully (“calibrated my words”), the basic premise that “I will pay for what I use some other day (even though the cost is completely unbounded)” has proven time and again to just not work. And not to put too fine a point on it, but “doing what is proven to work” is much more of a Conservative value than “Gee, I hope this works out!”

    Conservativism is METHODOLOGY, not IDEOLOGY. Which is another way in which Those Other People aren’t Conservatives.

  44. 44
    Robert says:

    Ampersand and FCH – my plan at that point is to die. Or throw myself on the mercy of the taxpayers, if they’re taking mercy applications. I wouldn’t feel bad about it at that point, since I’d have blown through several million dollars in personal and family assets first. I don’t think the sum total of people entering Medicare in my situation is large enough to warrant social concern over our money-leeching ways.

    I think the perception has arisen that I have some objection to paying for health care (I don’t – I semi-gladly pay the taxes to cover the poor people like me, above, who need gummint help, and gladly pay for the care I use on a routine basis), or some objection to insurance. I do object to insurance as a practical matter; it is rarely a paying proposition. But that’s on a par with my objection to Hannah Montana; I’m not going to the show, but I have no objection to your attending. Go crazy.

    My objection is 99.9% purely the mandatory aspect. If your system is viable and decent, perhaps I will join it of my own free will, particularly if it conserves capital for my descendants. But I will certainly not be coerced into it. Hell, no. (And what does it say about a system that it requires blatant coercion, lest the victims make different choices?)

    Also, you are assuming (and the CBO is also assuming) the payment of an awful lot of fines. I doubt penny one of such fines will be collected; there is simply no Federal authority to fine people for declining to make a business deal. It will either be tied up in court for years, or possibly thrown out so hard it bounces – depends on the judge(s). Besides, the problem isn’t so much the number of people who would go Galt on you – I don’t know exactly of course, but it’s more than you suspect – it’s the type of people. The CBO’s already-dismal figures are assuming some slack, yes – but I doubt very much that they’re assuming a cherry-picked bunch of crazy white libertarians, many-to-most of whom are the grade-A bacon of the risk pool – the people who will pay $10,000 a year into the system (if it’s income-proportional – and if it’s not i-p overall, then how is it possibly going to pay the bills?) but who currently pay nothing to the insurance model and self-finance all their care, of which they use very little. Yes, there are some guys in cabins whose main capital asset is a dubious title to their half-acre plus shack, but for the most part those guys checked out a long time ago.

    PG – It was Washington state, maybe 10 years ago. Re: child support, that appears to be a matter of the state exercising its responsibility to enforce the implicit contract between father and mother. Not the same situation at all. And yes, there are few “pure” private-sector doctors – but the situation is vastly different than when I was quarreling with the People’s Republic out west. The PR really did build all the damn roads. I didn’t want to drive my clapped-out Buick only on the 12.3 miles of privately-built tollway between East Nowhere and the airport, I wanted to drive it on the city, county, and state roads – and the creators and maintainers of those roads demanded a certain level of fiduciary responsibility from the people who wanted to use them. If you didn’t care to meet this burden, you were free to decline the use of the roads. An evening with the contents of the drunk tank was sufficient to clarify my recognition of this cogent implicit contract, and I decided to sign on. (WA at the time was a bit indulgent towards purists like myself, and would allow you to bond out in lieu of car insurance, but I didn’t have the $50k back then. Don’t know if that’s changed or not.)

    In the case of the medical state, no such near-exclusivity of creation or manifest control of the commons exist in the US. It may exist someday, God help us all, but not today.

  45. 45
    Dianne says:

    Ampersand and FCH – my plan at that point is to die. Or throw myself on the mercy of the taxpayers, if they’re taking mercy applications.

    They are. Basically, you’re gambling that you won’t get AML or hit by a bus or develop some other exotic, expensive, deadly, but treatable condition. Fine, except that you’re gambling with our money, not your own. Ok, so you’re gambling with your money too if you really intend to go through all your money before applying for medicaid. But unless your real name is Bill Gates you don’t have the kind of money you’d need to self pay for something like complete AML therapy. And even if you do shouldn’t you be keeping it for your family. What if you died from your illness? You’d leave them grieving and without resources instead of just in mourning.

  46. 46
    FurryCatHerder says:

    Robert,

    Dianne is right — the American Taxpayer decided, decades ago, that when it comes to sick people, it is very much accepting mercy applications. The other thing is, unless you have a DNR on file (and even that might not work) just about everywhere, you can’t guarantee that “Die” is the option that’s going to happen if you’re found somewhere in a state where you can quickly sign a DNR.

    But the other thing is that people who INSIST they’d rather die than experience some horrible illness often change their mind as the Grim Reaper loads up his Death Wagon (or whatever it is) and starts heading in their direction. And if you think trying to save money by avoiding treatment is expensive, try treating that same condition a while later — usually much more expensive.

    The problem with your attitude is that it violates the Social Contract that has come into existence between The People, and The Government. The People have decided that it is desirable for the poor to be able to receive health care, even if they cannot pay. The People have made the same decision in many other areas — providing for the General Welfare, the Common Good — is desirable, even if the people who benefit most don’t pay for all of it.

    As Locke explained, The People give up some of their rights in exchange for mutual protection. One of the rights you give up being a part of this society is that you’re bound by the decisions of the Electorate, even if you don’t much like them. Libertarianism and Objectivism are nice philosophies if you want to believe in them, but you being a Libertarian or an Objectivist doesn’t mean you aren’t a part of this society.

  47. 47
    Robert says:

    Basically, you’re gambling that you won’t get AML or hit by a bus or develop some other exotic, expensive, deadly, but treatable condition. Fine, except that you’re gambling with our money, not your own. Ok, so you’re gambling with your money too if you really intend to go through all your money before applying for medicaid.

    So by you, it would be LESS like gambling if I went out and paid hundreds of dollars every month for a policy that – in the unfortunate eventuality of the AML bus hit – would give the care providers hundreds of thousands of dollars. After which, I would be expected to (as I would do now) pay my own way as much as possible, after which the taxpayer would again come to my rescue.

    So the difference associated with the “less gambling” option involves the socially beneficial action of…me giving money to insurance companies in exchange for a chance at a much larger payout?

    How is this private economic transaction a matter of state policy, anyway?

    The problem with your attitude is that it violates the Social Contract that has come into existence between The People, and The Government.

    Then fuck the people, their government, and their social contract. I’m a signatory to lots of contracts, and I honor them. I’ve got a perfectly good EXPLICIT social contract between the peepul and the gummint called the Constitution, and it works OK.

  48. 48
    FurryCatHerder says:

    Robert @ 47:

    Yes, and the Constitution of these United States permits the Congress to pass Laws, and their means of enforcement, for a limited set of purposes, including promoting the General Welfare.

    So, perhaps it’s time you started using the Constitution for something other than a piece of toilet paper?

    And if you hate this society so much, you have the right to pack your things and leave. Don’t let the screen door hit ya where the Good Lord split ya.

  49. 49
    Robert says:

    Wow, FCH, so if I can convince a judge that you personally should toil as a slave laborer for the common good, that’s OK since it’s right there in the welfare clause?

    The welfare clause gives the feds a little bit of wiggle room on WHY they’re doing something. It doesn’t give them any power not enumerated in the other clauses, and there is no Federal power to control health care.

    I like this society just fine, and I have no intention of letting it turn into another crappy collectivist anthill. People who think that we should be a CCA, THEY can let the door hit ‘em on the way out.

  50. 50
    PG says:

    Robert @44, Re: child support, that appears to be a matter of the state exercising its responsibility to enforce the implicit contract between father and mother. Not the same situation at all.

    Robert @ 47, Then fuck the people, their government, and their social contract. I’m a signatory to lots of contracts, and I honor them. I’ve got a perfectly good EXPLICIT social contract between the peepul and the gummint called the Constitution, and it works OK.

    But you don’t mind the state enforcing the “implicit contract” that apparently arises when a man has sex with a woman and doesn’t 100% ensure that a pregnancy can’t result. Why are implicit contracts OK for some people, but you can’t be bound by any except explicit contracts?

    Robert @49,

    Wow, FCH, so if I can convince a judge that you personally should toil as a slave laborer for the common good, that’s OK since it’s right there in the welfare clause?

    Now you’re just being silly. See the 13th Amendment.

    I like this society just fine, and I have no intention of letting it turn into another crappy collectivist anthill. People who think that we should be a CCA, THEY can let the door hit ‘em on the way out.

    But you haven’t said anything about what you’ll do to prevent this legislation from passing. You live in a form of democracy where, if the majority prefers a course of action and it is not deemed unconstitutional by the courts, that’s the law you have to live under. Your entire shtick has been about civil disobedience that you seem convinced will be joined by millions of others (despite the fact that neither your wealth nor your lack of concern about how racing through that wealth will affect your family are as common as you might think). Even if you succeeded in being the one ant who doesn’t live in the anthill, that doesn’t prevent the existence of the hill; that just leaves you out there as the ant who is happier dying without the help of his fellows than living under their majority rule.

  51. 51
    FurryCatHerder says:

    Robert @49:

    You’re absolutely right — the Federal government has no power, enumerated under the Constitution, to control Health Care.

    Fortunately, the Bills before Congress don’t control health care. Requiring people be insured for health care is NOT the same as controlling it. It’s requiring people to pay for what they are entitled to use, under the Social Contract that The People made when The People ratified the Constitution.

    And if you don’t so much like the Constitution, you really are free to leave. You have my blessings. But as long as you stay, and derive the benefits which accrue to you under the Social Contract that governs this Republic, kindly stick to it.

  52. 52
    Ampersand says:

    So, perhaps it’s time you started using the Constitution for something other than a piece of toilet paper?

    And if you hate this society so much, you have the right to pack your things and leave. Don’t let the screen door hit ya where the Good Lord split ya.

    Tone the rhetoric down several notches, please, thanks.

  53. 53
    Robert says:

    But you haven’t said anything about what you’ll do to prevent this legislation from passing.

    That isn’t really my role as a citizen in a democracy. I’m free to advocate, of course, but my real input comes in the selection process; I vote(d) for legislators who wouldn’t pass this type of law. I already did that.

    As for what I’ll do in general, that seems clear; I will disobey if coerced. Announcing that ahead of time is intended to serve a signaling function; “this proposal has an additional cost you may or may not have contemplated: I’ll say no and take the consequences.”

  54. 54
    FurryCatHerder says:

    Robert,

    What you’ve described is not a “Democracy”. The minority doesn’t get their way in a Democracy just because they stomp their feet.

  55. 55
    Jake Squid says:

    An evening with the contents of the drunk tank was sufficient to clarify my recognition of this cogent implicit contract, and I decided to sign on.

    What were you charged with? Were you arraigned? Those certainly aren’t the rules now, though, so my point stands.

    From the Washington State Department of Licensing:

    Penalties

    Operating a vehicle without the required coverage, other than the exempt vehicles listed above, is a traffic infraction punishable by a fine of at least $450.

    The fine is simply more than the annual cost of the minimum coverage you can get in the state. Makes sense to me.

  56. 56
    PG says:

    A good piece from Paul Krugman that makes the point that the health care most of us have already and will have in the future is dependent to some extent on the government.

    The key thing you need to know about health care is that it depends crucially on insurance. You don’t know when or whether you’ll need treatment — but if you do, treatment can be extremely expensive, well beyond what most people can pay out of pocket. Triple coronary bypasses, not routine doctor’s visits, are where the real money is, so insurance is essential.

    Yet private markets for health insurance, left to their own devices, work very badly: insurers deny as many claims as possible, and they also try to avoid covering people who are likely to need care. Horror stories are legion: the insurance company that refused to pay for urgently needed cancer surgery because of questions about the patient’s acne treatment; the healthy young woman denied coverage because she briefly saw a psychologist after breaking up with her boyfriend.

    And in their efforts to avoid “medical losses,” the industry term for paying medical bills, insurers spend much of the money taken in through premiums not on medical treatment, but on “underwriting” — screening out people likely to make insurance claims. In the individual insurance market, where people buy insurance directly rather than getting it through their employers, so much money goes into underwriting and other expenses that only around 70 cents of each premium dollar actually goes to care.

    Still, most Americans do have health insurance, and are reasonably satisfied with it. How is that possible, when insurance markets work so badly? The answer is government intervention.

    Most obviously, the government directly provides insurance via Medicare and other programs. Before Medicare was established, more than 40 percent of elderly Americans lacked any kind of health insurance. Today, Medicare — which is, by the way, one of those “single payer” systems conservatives love to demonize — covers everyone 65 and older. And surveys show that Medicare recipients are much more satisfied with their coverage than Americans with private insurance.

    Still, most Americans under 65 do have some form of private insurance. The vast majority, however, don’t buy it directly: they get it through their employers. There’s a big tax advantage to doing it that way, since employer contributions to health care aren’t considered taxable income. But to get that tax advantage employers have to follow a number of rules; roughly speaking, they can’t discriminate based on pre-existing medical conditions or restrict benefits to highly paid employees.

    And it’s thanks to these rules that employment-based insurance more or less works, at least in the sense that horror stories are a lot less common than they are in the individual insurance market.

  57. 57
    PG says:

    Incidentally, I’m surprised that people who are ready to go to prison rather than let the government deduct money from their paycheck in order to pay for their insurance today, are OK with the government’s doing so to pay for their insurance in the future (i.e. Medicare). Or are such people already breaking the law requiring the self-employed to pay FICA taxes?

  58. 58
    Elusis says:

    How would you describe in more politically correct terms the attitude that the Emergency Room is ones own private physicians office?

    I’m not sure anyone who has postponed care until the (bleeding, coughing, pain, numbness, vomiting, voices, etc.) became absolutely impossible to ignore, then sat for anywhere from 4-24 hours in a hard plastic bucket chair with the sting of industrial-strength cleanser in their nostrils, listening to the moans, rants, and crying children of their fellow sufferers, frantically hoping/praying that the cost can be turned into payments small enough that they can still afford to put food on the table and wondering whether they should just go home and tough it out some more, is mistaking the ER for “ones own private physicians office [sic].”

    I’m stunned someone could think so.

  59. 59
    FurryCatHerder says:

    Elusis,

    The world of the uninsured is not just the tragically and hopelessly poor. A growing number of working to middle class people are uninsured because “The Death Spiral” prices them out of the market. I’ve explained how Universal Health Care will help fix the Death Spiral.

    The result is that when a child or adult gets sick, if it’s too much in their mind for a visit to the family doctor (if they have one), they wind up going to the ER.

    I also think your categorization of ERs as these “Wait in line FOREVER!” places is probably limited to a very small number of hospitals. My last trip to a public emergency room (it was a fairly nasty cut and needed attention faster than a drive to the ‘burbs — besides, they are a hospital and I’m not a snob) took less than an hour from the time I walked in until I was seen, then less than another hour to get my finger stitched (cut to the bone with a power saw — it’s a great scar). I do dangerous things, so I go to the ER more than many and I can’t recall ever, in any city I’ve ever lived in, spending more than a few hours (I think the worst was 4 hours once for a very severe case of food poisoning — it required several liters of IV fluids and several more hours wired to monitors because I dehydrate like nobody’s business when I get that sick). And, yeah, that includes places like New Orleans’ Charity Hospital, not exactly well known for good service.

    That the ER gets abused is not in dispute by anyone in the industry. Even insured people go to the ER when an illness could wait for their personal physician to open the office in the morning. Most of the Yuppies I know still think “ouie on head” means “go to ER”, along with “yellow colored sniffles”, “low grade fever”, and a host of other ailments which an ER can’t do a thing for. We learned about the “BRAT” diet (Bananas, Rice, Apple Sauce, Toast) during one visit to the ER at 2AM with our 1 year old. I don’t know what the insurance shelled out — I think it was a $50 co-pay. Certainly not enough to cover the cost of the visit. That’s a fairly recent development — decades ago the ER wasn’t so heavily used.

    People knew the difference between a break and a sprain years ago, and I’ve taped more than one of my own injuries that others would have taken to the ER. It’s part of the mentality that is causing skyrocketing insurance costs. The problem is that doctors in an ER can’t say “Sorry, you need to go see a personal physician.” because the ER cannot turn anyone away. And that’s a large part of why we need universal health care — so the ER can go back to being for emergencies and people who don’t need the high cost services offered there can go see a doctor in a far less expensive setting.

  60. 60
    Joe says:

    To get back to the original point, passing something rather than nothing is bad if the something has systemic flaws. Once they’re in plae we begin to strengthen the constituency for the bad rules and that makes it MUCH harder to change later. Look at employeer pays, NO ONE would want that to be the way most people paid for medical care if they had a choice. Yet it’s what we have no so changing it very hard.

    (Note, anyone wishing to make the case that employer pays is the best way to go is free to do so but the inherent flaws are both huge and obvious.)

  61. 61
    Ampersand says:

    To get back to the original point, passing something rather than nothing is bad if the something has systemic flaws.

    This is only true if the “something” with systemic flaws, is worse than the status quo — which also has systemic flaws. Comparing “something” to “nothing,” rather than to “status quo,” is not the relevant comparison.

    Given the realities of our political process — and of large systems — I can’t imagine any reform could be passed that didn’t have systemic flaws of some kind.

  62. 62
    PG says:

    Yes — Medicare has huge systemic flaws, most prominently that the taxes that purportedly pay for it don’t actually suffice to do so, and it is a burden on the public fisc. Ditto Social Security. Does that mean they never should have happened, or that we should have waited until we had a more perfect plan? Was Reagan right after all?

    That’s a somewhat sincere question, not an entirely rhetorical one, because Medicare and SS also provide good examples of entrenchment. The elderly are the most fearsome political bloc in the country because they vote more consistently than the rest of us. Touch a program on which they rely — or even be accused of doing so — and a politician can forfeit reelection. If we institute a highly flawed change that becomes heavily entrenched and difficult to fix down the road without rousing massive (and poorly-informed) opposition, is that necessarily better than the status quo?

  63. 63
    FurryCatHerder says:

    Amp @ 61:

    This is only true if the “something” with systemic flaws, is worse than the status quo — which also has systemic flaws. Comparing “something” to “nothing,” rather than to “status quo,” is not the relevant comparison.

    True enough, but in the Libertarian mind-set, “nothing” really is better than anything else, because only “nothing” doesn’t involve coercion. Or rather, only “nothing” doesn’t involve coercing someone who cannot see the interdependency (or refuses to see it) of the various members of society.

    Dittos for many Objectivists. From Wikipedia (not that anyone here is likely to be unfamiliar with the concept, just saying …)

    Objectivism is the philosophy developed by the Russian-American philosopher, writer, and novelist, Ayn Rand (1905–1982).[1] Objectivism holds that reality exists independent of consciousness; that individual persons are in contact with this reality through sensory perception; that human beings can gain objective knowledge from perception through the process of concept formation and inductive and deductive logic; that the proper moral purpose of one’s life is the pursuit of one’s own happiness or rational self-interest; that the only social system consistent with this morality is full respect for individual rights, embodied in pure laissez faire capitalism; and that the role of art in human life is to transform man’s widest metaphysical ideas, by selective reproduction of reality, into a physical form—a work of art—that he can comprehend and to which he can respond emotionally.

    It’s not an accident that Libertarianism and Objectivism often come across as absolute self-centeredness and greed. In Libertarianism, the State exists to protect those who have things which need protection, rather than being the entity which makes “Society” possible. In Objectivism, “Full respect for individual rights” is more about others respecting THAT person’s rights, rather than some garden variety Objectivist respecting the rights of others. And “rational self-interest” seldom looks much past the end of the person’s nose. Objectivism is also anti-Society.

    In times of conflict or natural disaster the bankruptcy of both philosophies become painfully obvious. I remember all too well working with several Katrina victims here in Austin (we got 10 or 20 thousand after Houston and Dallas filled up) who were very well-to-do white people who expected everyone around them to make accommodations. One of the greatest things about being a volunteer is being able to tell people to get stuffed.

  64. 64
    Grace Annam says:

    FurryCatHerder Writes:

    I’m all for having plans that do something for preventative health care. Definitely, let’s encourage that. But “preventative health care” should NEVER EVER EVER be covered by insurance, and it should be REQUIRED in order to receive coverage. Why the hell are we getting the government, or insurance companies, involved in what should be an annual, predictable, regular medical event?

    In an ideal world, where everyone is a rational informed consumer and has enough money to afford basic preventative care, I might agree.

    However, this is a case where perhaps practicality trumps ideology. I know from my own experience that people who are paying out of pocket for preventative care often defer it, and I am given to understand that statistically, people who defer preventative care end up costing the system (taxpayers, ultimately) more, because they then present with very costly illnesses which could have been prevented or minimized with basic preventative care.

    So, on the basis of economic practicality, perhaps we should pay a penny for preventative care now, so that we don’t have to pay a pound for extensive care later. Because taxpayers will pick up the tab on the extensive care, like it or not.

    (Side note: Using “consumer” to refer to someone who needs health care is a usage which is starting to annoy me. Health care is not cars, potatoes, or even CDs. It’s a different animal. I’m not referring to anyone else, here; I’m just commenting on my own post as I read over it.)

    Grace

  65. 65
    FurryCatHerder says:

    Grace @ 64:

    You raise a very significant point — we don’t have a well-informed and rational consumer populace. But just the same, insurance should be for exceptional, unplanned events. If there needs to be some sort of subsidy for people who can’t afford the basics — fine. Much cheaper in the long run. But it’s also much cheaper for people who CAN afford the basics to pay for them on their own, without running the money through a bureaucracy. And that’s one of those financial decision things that we’ve just GOT to get the general public to understand — budget for the expected, insure for the unexpected.

  66. 66
    Grace Annam says:

    FurryCatHerder writes:

    You raise a very significant point — we don’t have a well-informed and rational consumer populace. But just the same, insurance should be for exceptional, unplanned events.

    I agree, and I used to make that point myself. But I think that’s why the medical establishment moved away from calling it “insurance”, and toward calling it “healthcare”, so that they could talk about things like funding preventative care without meeting that objection.

    If there needs to be some sort of subsidy for people who can’t afford the basics — fine. Much cheaper in the long run. But it’s also much cheaper for people who CAN afford the basics to pay for them on their own, without running the money through a bureaucracy.

    This would be true if they would all act rationally and get the check-ups and whatnot. But that’s not the way the population behaves in the actual case. They defer the check-ups, and then we have greater costs.

    So, practically speaking, we should pay for preventative care for the same reason that auto insurance companies cover, for free, a chip in the windshield. Because they know that if they do that, people will get the chip fixed and they won’t have to replace the window a few months down the line when the chip becomes a crack.

    Talk about rational actors, now, the insurance companies are rational actors. Everything they do is about maximizing the number on the bottom line, and (in the political arena) maintaining as much as possible their freedom to maneuver in order to do that. When free preventive or early care minimizes their expenses, averaged over the population, they roll with the facts on the ground.

    (An aside – I also feel a bit of moral outrage that we are the wealthiest society in all of human history, and yet we have a system where health coverage for children, who had no choices, rational or not, is dependent upon the demonstrated irrationality of their parents. A society as wealthy as ours should damn well be ensuring the health of our children, at least until they can make their own irrational choices.)

    And that’s one of those financial decision things that we’ve just GOT to get the general public to understand — budget for the expected, insure for the unexpected.

    I’m sceptical that anyone can get the public, generally, to understand rationally anything which is complex. The hurdles are large: investment of time and energy, etc. This is the same public containing the quoted octogenarian who furiously wanted to keep the government out of his Medicaid.

    But, clearly, a better general understanding of the problems in the system would help hugely toward an effective solution.

    Grace

  67. 67
    La Lubu says:

    This would be true if they would all act rationally and get the check-ups and whatnot. But that’s not the way the population behaves in the actual case. They defer the check-ups, and then we have greater costs.

    Sometimes, not getting the healthcare that you know you need is the most rational decision you can make—given your limited choices and limited cash. Housing, food, utilities, etc. have a way of trumping healthcare. Don’t believe me? Go do some people-watching. Working class folks don’t have the same teeth that middle-class and above folks do. Trust me, no one is making the “choice” to let their teeth go to hell.

    FurryCatHerder, the plan you propose—catastrophic health insurance for all, and budget for the “basics” has this as it’s major flaw: it seriously screws people with chronic health conditions. I’m hypothyroid. I didn’t ask for this disease, but I have it anyway. It’s genetic. If insurance didn’t cover my costs, I’d have to shell out a few thousand dollars out of pocket, between endocrinologist visits, lab work, and prescriptions. Add in the fact that both my daughter and I are nearsighted (she sees a specialist because of her laser surgery for ROP she had as a preemie), dental appointments and dental work (yeah, my daughter will probably need braces), routine visits (pap smears, mammograms—yeah, family history of breast cancer that I didn’t ask for either), and at least a couple of routine illness/accident visits to the urgent care clinic…..

    And damn! That’s a whole hell of a lot of money I’d have to pay out of pocket each year, in addition to paying for insurance. In a shitty economic environment (I’ve already been dealing with on-again, off-again employment for the past decade—-and no, unemployment benefits do not qualify a person for medicaid). Would it be “irrational” of me to forego the catastrophic insurance, in order that I can pay the costs that I know I’ll need? Prioritize my present needs by gambling on my future?

    The medical field has a term for it—-triage. Do what you can, when you can. Some things have to be let go. And that’s a part of why health care costs go up. Folks are performing triage on their bills, and taking risks with their health. Elders on fixed incomes take partial doses of their maintenance medicine, for example. Or in my earlier example—don’t see a dentist because keeping a place to live or the utilities on is more important.

    Frankly, I don’t gamble. I really hate being without insurance, but there were times in my past when I didn’t have it—because I couldn’t afford the COBRA. You’re proposing that the burden of healthcare costs be shifted to the sickest among us. You are proposing that the average family be required to spend the equivalent of say, the price of a new car every year or two on “basic” healthcare needs. Think about that. New cars are usually bought over a period of four or five years. How are people going to come up with that kind of money each year?

  68. 68
    PG says:

    The medical field has a term for it—-triage. Do what you can, when you can. Some things have to be let go. And that’s a part of why health care costs go up. Folks are performing triage on their bills, and taking risks with their health. Elders on fixed incomes take partial doses of their maintenance medicine, for example. Or in my earlier example—don’t see a dentist because keeping a place to live or the utilities on is more important.

    It’s interesting that you use the word “triage,” because that’s exactly what some people find objectionable about the British and Canadian health systems (which are not merely “single payer,” but in which the government actually owns the hospitals and employs the doctors and nurses). They produce a longer average life expectancy because they triage people based on how important a treatment is to saving/extending their lifespan. So treatment of hypothyroidism, accidents and cavities will happen promptly, but braces and other quality-of-life treatments go onto the infamous Waiting Lists. Some of these quality-of-life procedures, such as hip replacements, would go a long way to reducing someone’s pain and disability, but they don’t have a significant effect on how long someone will live.

  69. 69
    FurryCatHerder says:

    La Lubu @ 67:

    FurryCatHerder, the plan you propose—catastrophic health insurance for all, and budget for the “basics” has this as it’s major flaw: it seriously screws people with chronic health conditions. I’m hypothyroid. I didn’t ask for this disease, but I have it anyway. It’s genetic. If insurance didn’t cover my costs, I’d have to shell out a few thousand dollars out of pocket, between endocrinologist visits, lab work, and prescriptions. Add in the fact that both my daughter and I are nearsighted (she sees a specialist because of her laser surgery for ROP she had as a preemie), dental appointments and dental work (yeah, my daughter will probably need braces), routine visits (pap smears, mammograms—yeah, family history of breast cancer that I didn’t ask for either), and at least a couple of routine illness/accident visits to the urgent care clinic…..

    Some of what you describe — routine medical exams, routine dental exams — should be paid for out of pocket. I’m sorry, everyone in this country has a body. Paying for a ROUTINE checkup, not the extra trips to the endocrinologist[*], is just the price of doing business. And unless your near-sightedness is somehow really all that different from my astigmatism, hyperopia, and presbyopia, well, millions of Americans wear glasses. Your daughter — doesn’t sound routine to me.

    Disease? That’s a different matter. Wearing glasses, if your eyesight is in the “can be fixed with +/- a couple of diopters here and there” — not “disease”. Crooked teeth that merely look bad, but aren’t a structural problem — not “disease”. Family history of breast cancer that requires more frequent mammograms to prevent advanced breast cancer from going undetected — disease.

    I’m sorry that being poor means the poor person doesn’t get all the same stuff as the rich person. I’ve been unemployed for 6 months — I’d love to be able to buy the things I could 7 months ago. I’ve been rich, and I’ve been poor, and while I frankly prefer being rich, whenever I’ve been poor, I’ve not been deluded all that often. I’ve made stupid decisions — like, never borrow money from loan sharks. And do not think that pawn brokers know the actual value of anything.

    A big part of the reason the economy is in the giant ditch we’re in is because people of all economic classes wanted “stuff” they couldn’t afford. And that goes for insurance as well — the more people want “insured” the more “insurance” costs. And the more people decide things other than basic food, clothing and shelter are more important than health care, the more fixing the problems caused by ignoring the body are going to cost.
    —–
    [*] My endocrinologist kept trying to get me to stop seeing him and get my GP to run the tests instead. My GP didn’t feel “comfortable” doing them, so I started buying those meds from offshore pharmacies. Not all “endocrine tests” really do require an endocrinologist — getting GP’s to stop sending people to specialists for problems they studied in med school would also cut costs. Specialization is for insects — including, in the case of my GP, specializing in not being a specialist …

  70. 70
    Grace Annam says:

    Sometimes, not getting the healthcare that you know you need is the most rational decision you can make—given your limited choices and limited cash. Housing, food, utilities, etc. have a way of trumping healthcare. Don’t believe me? Go do some people-watching. Working class folks don’t have the same teeth that middle-class and above folks do. Trust me, no one is making the “choice” to let their teeth go to hell.

    This is an excellent point, and I know it from my own experience. My comment, which I made without considering your point, illustrates a difficulty in all of this judgement of other people’s rationality: it’s tricky to balance competing harms even when you’re merely discussing a hypothetical.

    Ideally, our system would not provide an incentive toward preventive care, it would remove all possible disincentives, which is actually a very different thing. If there’s a cost, that’s a disincentive, and we should remove it if possible. Since it also profits the system, literally, to pay preventive care, the choice seems pretty plain to me.

    As to the bulk of this discussion, I don’t know enough about the system to feel comfortable opining.

    Grace

  71. 71
    La Lubu says:

    Some of what you describe — routine medical exams, routine dental exams — should be paid for out of pocket. I’m sorry, everyone in this country has a body.

    Well, yeah. Everyone has a body. However, not everyone has the same body. Some folks’ bodies require more medical care than others, and it seems that you are copasetic with those bodies bearing the burden for—what is for them, routine healthcare, even though it would not be “routine” for people without those health conditions.

    I’m not necessarily opposed to paying more healthcare as a cost out of my own pocket. It’s just that I can easily see that with your proposed plan, my healthcare costs would increase exponentially, as I could count on healthcare costs being somewhere between $7000-$10,000 per year for my two-person family—out of pocket. I’m not paying that out-of-pocket now, although I was for the first three years my daughter came home from the hospital. Part of those costs did not qualify as “healthcare costs”, like the Pediasure that she needed pumped into the g-tube in her stomach all night. How did I do it? Easy. I stopped contributing to my 401k, and I depleted all of my savings that I built up over the course of my working life. I still wasn’t able to pay off the bills that had racked up from her hospital stay that weren’t covered by insurance—over $25,000. I paid a little each month (sometimes $5, sometimes $10). Over six years went by, and eventually the bills were “forgiven”. I got real, real lucky. Not everyone is so lucky. If they had taken me to court, I would have had no alternative other than bankruptcy.

    Everyone has a body, but we also have stages in life. For the first three decades of my life, I had negligible medical bills. Then my daughter was born premature. Then, after ignoring my symptoms for years, I finally saw a doctor and was diagnosed hypothyroid. You’re right—I may not need an endocrinologist, but G.P.’s are currently paid bonuses by insurance companies for limiting care. The G.P. I was seeing was not interested in bringing my t-4 level to where I needed to be in order to not gain weight, be dizzy/lightheaded (feeling “high” all the damn time is not a good feeling for me—I found it scary, and was afraid I’d have an accident), painful joints, etc. That’s another thing that drives up healthcare costs—repeat tests as people go from physician to physician trying to find one that will help (I’ll make this short by not launching into a dissertation on how physicians tend not to take women’s healthcare symptoms seriously, the long history of women being told “it’s all in your head”, etc.).

    What national healthcare would do is spread the burden, so that it doesn’t fall on the limited shoulders of individuals, some of whom (like me), don’t have shoulders broad enough to carry the cost. Even though I’m not poor. Sometimes, we (collectively) will bear the burden for others. Sometimes, we (individually) will be that burden. Right now, we have a stand-or-fall on your own system. Regardless of whether or not one has insurance. A critical mass of people are falling. That isn’t sustainable.

    Healthcare costs have risen exponentially. Going to the doctor isn’t as “cheap” as it once was, in terms of individual earning power. Neither, of course, are utilities, food, housing, education,—–anything. Something has to give.

    CEO wages have risen exponentially. Average worker wages have fallen (in terms of purchasing power). When the average worker can’t pay for average needs (healthcare among them), we’ve got a problem, no?

  72. 72
    FurryCatHerder says:

    La Lubu @ 71 –

    Sorry if I wasn’t completely clear — by “routine” I don’t mean “routine for you”, I mean “routine” for everyone.

    I think Grace summed up my position best — I want to remove all the disincentives from getting a checkup.

    And once you get that checkup, I want you to be able to acquire the treatments you need at a reasonable / affordable price, based on your income level, so you can be healthy, have a job, pay taxes, and stimulate the economy by spending money.

    If you want more than “healthy”, then you get to pay for it. But I want you to be healthy because a sick taxpayer ain’t much of a taxpayer.

    As for the other expenses, a lot of the rising costs are just plain bad choices. I know that’s impolitic, but I run across people who have plenty of money to pay “later” but not enough to pay “now”. Even though “later” is a lot more expensive. So, they keep paying “later” and keep complaining it costs more. And I just keep shaking my head …

  73. 73
    JaneDoh says:

    PG

    Just a clarification–the Canadian system is single payer, not government owned. It is just like everyone having Medicare in the US (in fact, that is where the US got the name for it). And many people have secondary insurance (in many cases provided as a benefit by employers) to cover things not covered (i.e. drugs)/minimally covered (i.e. physical therapy) by government insurance. Each province runs their own health system (which leads to headaches if you get sick out of province as an aside), so what you have to wait for depends on where you live.

  74. 74
    PG says:

    JaneDoh,

    Thanks for the information — you’re right that I shouldn’t refer to the Canadian provincial governments as directly owning hospitals or employing physicians.

    However, while the name “Medicare” is shared between the U.S. program for the disabled/elderly and the Canadian universal program, my understanding is that there are some significant differences. For examples, in the U.S. Medicare only sets the fees that it will pay; it doesn’t dictate what doctors can charge otherwise. In contrast, the Canadian Health Act of 1984 denies federal support to provinces that allow extra-billing within their insurance schemes and effectively forbids private or opted-out practitioners from billing beyond provincially mandated fee schedules. It was also my understanding that Canadian hospitals mostly get their operating budgets from the government. That’s not how American Medicare works; our Medicare is simply insurance that, like private sector insurance, decides what it will cover and what rates it will pay, with no further interaction between the government and the health care providers. Medicare doesn’t just give hospitals money on which to run; it pays them based on each service provided to a Medicare recipient.

    Moreover, until the Quebec law was struck down by the Canadian Supreme Court in 2005, Quebec and five other provinces actually forbade the sale of private insurance to finance services covered by Canadian Medicare. That’s way beyond what U.S. Medicare does.

  75. 75
    La Lubu says:

    Sorry if I wasn’t completely clear — by “routine” I don’t mean “routine for you”, I mean “routine” for everyone.

    Ok, so in the interest of clarity, you propose: routine yearly physical, or annual routine eye exam, or annual teeth cleaning/checkup =out of pocket; visit to pediatrician for ear infection, or annual mammogram, or annual pap smear, or visit to physician for maintenance of chronic condition (be it hypothyroid, diabetes, depression, etc.), or dental fillings/root canal = fully covered under national healthcare program.

    Or am I misunderstanding you? I am left with the impression that you would consider some of the things I listed above as “fully covered” as something a person should budget for and pay out of pocket, unlike the impression I’m getting from Grace, which is that all of the things I listed as “fully covered” should be, in the interest of pay-less-now to avoid paying more later.

    See, where I’m skeptical of having any decent national healthcare plan, is that any plan likely to be floated in the political climate of the U.S. (with the strong emphasis on individualism and bootstrap theory), is that poor people would be covered, wealthier people will be covered (even if more money is coming out of their pockets), but working class people like myself are going to be left high and dry—not poor enough to receive assistance, not rich enough to afford the cost ourselves. I don’t want to see a plan where people who make 200% of the Federal Poverty Level are expected to be able to afford healthcare just the same as if they were rolling in six-figure dough. That’s what we have now, and it isn’t working.

    Let’s get back to the braces that I’m not sure my daughter will need (I strongly suspect it, but hey—she’s still growing. We’ll see). I was lucky. I have had straight teeth all my life. I even had two wisdom teeth come in with no problem (I was only born with three wisdom teeth; the other one was pulled because of lack of room—the tooth was fine, but I kept getting gumline infections around it). I even lucked out on the dental caries front—I have one filling; I had another filling in a baby tooth. The filling in my baby tooth was the only visit I ever had to a dentist until reaching adulthood and having my own insurance. Why?

    Because my folks came from a background where the only time you go see a doctor is when it’s about time to call a priest. Seriously. If you aren’t in complete agony, or visibly dying—that’s boutique shit that can just wait until you can afford it. That’s the mentality. And I inherited that mentality—I have to consciously remind myself that health isn’t a “boutique” want, rather than a real, physical need. I grew up with the assumption that as an adult, of course you’re going to feel like hell! Hence, my years of trying to ignore my hypothyroidism.

    So, I read these various critiques of national healthcare that assert people will run to the doctor every time they stub their toe—and that’s not what I see in reality. At least, not where I come from. There is a huge antipathy towards going to the doctor, and not just because of cost. It’s like….an admission of weakness. An admission of failure. A feeling of….”if only I worked harder, I could work myself out of illness” type of thing. Not to mention the difficulties of getting a physician to take you seriously if you present with anything but the most visibly obvious acute symptoms (double that if you’re female, quadruple that if you’re old and female).

    Now, one of the problems I’ve experienced with how health care currently works in the U.S., is that even on non-HMO plans, there is a strong incentive for physicians to limit or even deny care for preventative care (or, for care that can help prevent small, temporary conditions from becoming big, semi-permanent or permanent ones).

    So it is with say, braces. Teeth that aren’t aligned correctly are more likely to develop permanent problems. My mother’s parents were dirt-poor, so there was no thought of braces for her. She managed to get them herself as an adult—but by then, a lot of damage had already been done. She’s had at least eight root canals, despite not being a heavy sweet eater and being religious about brushing. I’ve heard similar stories from other folks I know who got braces as adults. What is considered “boutique” care because it has a side effect of improving one’s appearance—-meant higher costs down the road in adulthood (most of which was covered by insurance). Expensive as braces are, they’re cheaper than root canals, caps, and periodontal care (not to mention that periodontal disease is related to other serious healthcare issues too).

    I’m with Grace—ounce of prevention, pound of cure. I just don’t think that idea is going to sell to a U.S. public that still hasn’t accepted that same thought (ounce vs. pound) in the educational system. The U.S. is too wedded to “rugged individualism”, meaning the many will fall and the few will stand—just like in today’s economy.

    But I want you to be healthy because a sick taxpayer ain’t much of a taxpayer.

    I want you (and me, and everyone else) to be healthy because providing healthcare is the humanitarian thing to do, regardless of how well people are going to be “stimulating the economy”. I don’t mean this in a snarky way—it’s just that…..I don’t like being judged on my income level. Realistically, I’m never going to be stimulating the economy all that much. My cable TV/Internet service probably represents the biggest outlay of non-essential consumer spending I do. If the only worth I have as a human being is being a “taxpayer” or “consumer”—hell, just shoot me now, y’know? I thoroughly suck as a human being under that standard of measurement.

  76. 76
    FurryCatHerder says:

    La Lubu @ 75:

    Ok, so in the interest of clarity, you propose: routine yearly physical, or annual routine eye exam, or annual teeth cleaning/checkup =out of pocket; visit to pediatrician for ear infection, or annual mammogram, or annual pap smear, or visit to physician for maintenance of chronic condition (be it hypothyroid, diabetes, depression, etc.), or dental fillings/root canal = fully covered under national healthcare program.

    I’d say “sliding scale premiums”, but yeh — you’re not going to go broke. And if you’re working class no one is going to say “Hey, you earn 200% of Poverty, so you have to pay full boat.”

    I want you (and me, and everyone else) to be healthy because providing healthcare is the humanitarian thing to do, regardless of how well people are going to be “stimulating the economy”. I don’t mean this in a snarky way—it’s just that…..I don’t like being judged on my income level. Realistically, I’m never going to be stimulating the economy all that much. My cable TV/Internet service probably represents the biggest outlay of non-essential consumer spending I do. If the only worth I have as a human being is being a “taxpayer” or “consumer”—hell, just shoot me now, y’know? I thoroughly suck as a human being under that standard of measurement.

    Well … I’m not a bleeding heart Liberal and I think the State has no business getting involved in emotions and feel-good-isms. Personally, individually — yeh, it’s the humane thing to do, G-d said so, etc. But in the political domain? I don’t care if it’s humanitarian or not. I only care if the program benefits the State, and I believe there is a sound argument that a universal health care program makes economic sense. Healthy workers are more productive, put less drag on the economy, etc.

    Hey — I thought you were an IBEW sister. Please tell me your Local is treating you better that what I’m hearing.

  77. 77
    La Lubu says:

    Well … I’m not a bleeding heart Liberal and I think the State has no business getting involved in emotions and feel-good-isms.

    FurryCatHerder, I’m not particularly interested in emotions and feel-good-isms either. I am interested in societal stability however, and from a practical standpoint, valuing human beings as human beings, rather than quantifying human worth based on net worth leads to more stability, not less. Look what you said back here:

    A big part of the reason the economy is in the giant ditch we’re in is because people of all economic classes wanted “stuff” they couldn’t afford.

    That particular mindset didn’t happen in a vacuum. And it doesn’t exist everywhere. It is particularly evident in the U.S. because U.S. society assigns human worth on the basis of net worth—you are what you earn, you are what you own, you are what you spend. In that environment of style over substance, is it really any wonder that people prioritize image? If success in our economic system rewards style over substance, and fashion over function, then we can expect more people to outspend themselves trying to gain that image-based success. In a sense, it’s a perfectly rational choice. We even have terms to describe it: “fake it till you make it” or “dress for success” or “keeping up with the Joneses” or “he who dies with the most toys wins.”

    Valuing people over profits isn’t about feel-good-ism. It’s about valuing people at a higher level than the tools people create. Money is a tool. People created it. Money has no value outside of what human beings assign to it. I can’t think of any good reason why a human tool should be valued more than a human being. Put it this way: if our host here, Ampersand, were in a burning building along with his pens and drawings, what should be saved? Granted, the pens and artwork would be easier to carry out than Amp, but I still think we oughta cart him out first.

    You can’t have it both ways. You can either value humanity above profits, or you can look forward to more dysfunctional behavior in human affairs. Our survival is literally going to depend on cooperation and rebalancing the needs of the individual with the needs of the collective. Period.

    As for my Local, there isn’t any work here. There isn’t any work in our sister Locals. There isn’t any work damn near anywhere. The times are tough in the rust belt. What can I say? I’m fortunate to be working now, but times have been really tough over the past decade for everyone in the Local. I don’t have “consumer confidence” because my job is unstable—for me, it makes more sense to save than spend—I may need that savings to live off of (as I did in 2005). I don’t see that changing anytime soon, and at my age (I’m over 40) I need to be socking as much money as possible into my retirement so I’ll have something to live on when I am physically unable to work. Both my pension and 401K have taken a huge hit, and there were times I was not able to contribute to my 401K (such as when my daughter’s medical bills were high and when I was out of work). So. Yeah, I suck as a consumer. Still a valuable human being, tho’. ;-)

  78. 78
    Schala says:

    “[*] My endocrinologist kept trying to get me to stop seeing him and get my GP to run the tests instead. My GP didn’t feel “comfortable” doing them, so I started buying those meds from offshore pharmacies. Not all “endocrine tests” really do require an endocrinologist — getting GP’s to stop sending people to specialists for problems they studied in med school would also cut costs. Specialization is for insects — including, in the case of my GP, specializing in not being a specialist …”

    May be a bit of side-tracking here. GPs knowledgeable about trans issues and hormone dosages for anyone else than menopausal women (and even then, you’d ask yourself wtf they learned in med school about it) are very rare. In my experience and opinion, better to ask an endo who knows what he’s doing, and who doesn’t consider 8 nmol/L a “good level” for total testosterone, when the adult female range is 1~3.5 nmol/L.

    Simply put, I know a LOT more about trans endocrinology than my family doctor could ever bother to read about, and he’s also pretty much “I’m not comfortable with that” to boot. I only went with him temporarily cause my other doc wasn’t much better (and I was left without any hormones as it was). Then I found my endo, and I stuck with him. He’s a thousand times better, and has experience with trans patients (which I don’t expect a family doctor to have).

  79. 79
    FurryCatHerder says:

    La Lubu @ 77:

    FurryCatHerder, I’m not particularly interested in emotions and feel-good-isms either. I am interested in societal stability however, and from a practical standpoint, valuing human beings as human beings, rather than quantifying human worth based on net worth leads to more stability, not less. Look what you said back here:

    A big part of the reason the economy is in the giant ditch we’re in is because people of all economic classes wanted “stuff” they couldn’t afford.

    Right, and if the State cares too much, then the State goes broke.

    It’s definitely not either / or and there are definitely ways to make sure that people have their needs met in ways which make financial sense. And that’s the point — the State MUST care about the financial bottom line because there really are no money trees out there.

    That particular mindset didn’t happen in a vacuum. And it doesn’t exist everywhere. It is particularly evident in the U.S. because U.S. society assigns human worth on the basis of net worth—you are what you earn, you are what you own, you are what you spend. In that environment of style over substance, is it really any wonder that people prioritize image? If success in our economic system rewards style over substance, and fashion over function, then we can expect more people to outspend themselves trying to gain that image-based success. In a sense, it’s a perfectly rational choice. We even have terms to describe it: “fake it till you make it” or “dress for success” or “keeping up with the Joneses” or “he who dies with the most toys wins.”

    I’ve known a lot of incredibly rich people — billionaires even. With very few exceptions, the people who are out there valuing “style over substance” are the ones that have less substance. It’s the great irony of “society values style over substance”. Americans are like teenaged boys and sex when it comes to money. The ones who are having sex, don’t generally run around bragging about it, and the ones who brag about it are frantically downloading Internet pr0n. What you see are the braggarts, and they neither have wealth, nor are they getting laid. So why the hell would you want to emulate THEM?

  80. 80
    FurryCatHerder says:

    Schala,

    I think that when I was just starting, about 14 years ago, that might have applied. Definitely go see the endo. But I’ve been a postie for so long now that pretty much there isn’t anything new and interesting going on. And certainly nothing so interesting that it really does require an endocrinologist.

  81. 81
    La Lubu says:

    So why the hell would you want to emulate THEM?

    That’s the point. I don’t emulate them, nor do I want to. That makes me a bad consumer—and you specifically pointed out that any interest you had in seeing a government-sponsored universal healthcare (as opposed to the age-restricted plan available now), was solely so that people could be good taxpayers and stimulate the economy. For the past twenty years, our economy has been built on a house of cards. The big players were investing in things that weren’t there; a big-ass Ponzi scheme. Little people were cashing out savings and home equity—some of them, yes, to keep up a lifestyle they couldn’t afford. But many of them (especially in the rust belt) were doing it to keep their heads above water—like my cashing out of savings to pay my daughter’s medical bills, because I didn’t earn enough to pay them (nor could I take on a second job).

    Sure, I think we should care about the bottom line. But I sure don’t see anyone giving a damn about the bottom line when it comes to bailing out the Big Boys. There isn’t any worrying about the bottom line when it comes to the long-term effects of restructuring that either accepts or requires more outsourcing of the good-paying jobs that provide stability to communities and economies. And there damn sure isn’t any concern about the bottom line of keeping the War Machine running, so color me extra-skeptical.

    If you really believe the “few exceptions” of style over substance you wrote above, perhaps you’d like to give a patient explanation of the behavior of Wall Street players in recent history. Doesn’t look to these eyes like Enron was much of an exception—it just had a faster timeline, is all. Looks to me like a goddamn game of three-card monte, or a shell game. Something for nothing. When the Big Boys do it, it’s called “the economy”. Can’t berate folks for cashing out home equity to buy shit they can’t afford, when we reward the people who created the game for roughly doing the same damn thing—with our money.

    Again, it’s not about touchy-feeley “caring”—it’s about stability. People in unstable situations have unstable, irrational behavior. The folks earning a decent living aren’t the ones spending a large percentage of their incomes on lottery dreams.

    We can afford national healthcare, and not a bare-bones “we’ll keep you from dying, but that’s about it” version. And you can bet your ass there will be a hell of a lot more oversight of the spending and cost-benefit ratio than there is in Afghanistan or Iraq.

  82. 82
    Grace Annam says:

    FurryCatHerder writes:

    I think Grace summed up my position best — I want to remove all the disincentives from getting a checkup.

    But at the same time, you’ve said that you don’t want any government coverage, ever, of basic maintenance medical care. Well, for the “consumer” of medical care, having to pay for it is a disincentive to buying it, when the same money could go to other priorities.

    La Lubu writes:

    Ok, so in the interest of clarity, you propose: routine yearly physical, or annual routine eye exam, or annual teeth cleaning/checkup =out of pocket; visit to pediatrician for ear infection, or annual mammogram, or annual pap smear, or visit to physician for maintenance of chronic condition (be it hypothyroid, diabetes, depression, etc.), or dental fillings/root canal = fully covered under national healthcare program.

    Or am I misunderstanding you? I am left with the impression that you would consider some of the things I listed above as “fully covered” as something a person should budget for and pay out of pocket, unlike the impression I’m getting from Grace, which is that all of the things I listed as “fully covered” should be, in the interest of pay-less-now to avoid paying more later.

    La Lubu, it sounds like you understand my opinion.

    Grace

  83. 83
    Schala says:

    “Schala,

    I think that when I was just starting, about 14 years ago, that might have applied. Definitely go see the endo. But I’ve been a postie for so long now that pretty much there isn’t anything new and interesting going on. And certainly nothing so interesting that it really does require an endocrinologist.”

    My endo said I was on “hormonal cruise control”, basically only seeing once a year and getting a lab once a year (he also gives me a year worth of pills) because my hormone levels are stable. Still, even though my family doctor could manage that, he’s not interested to learn the slightest about it, thinks my straight boyfriend is gay because I’m pre-op (and he isn’t) and tries to stay pretty far from managing trans issues. He’s not hostile, but he’s also not helpful.

    Really, with the amount of doctors who “aren’t comfortable” dealing with hormones to a trans patient, I’m lucky my endo even cares. He’s one of two in the whole province who accepts to deal with trans patients. Probably only a handful of generalists do, and most don’t know what they’re doing (very common to be prescribed too low dosages, to the point that someone with a doc might switch to those overseas pharmacy to get proper care).

  84. 84
    FurryCatHerder says:

    Grace,

    The keyword is “Basic”. It’s also starting to remind me of my kid brother who couldn’t put $5 in a jar once a week, but could buy junk food, beer, crap, etc.

    If you look at people who survived the Great Depression, they weren’t the high rollers of their era. And if they weren’t, they weren’t afterwards. That’s what we have to get back to because we’re broke.

    If we don’t get the message of “Pay as you go” across to people, and that includes every economic class, we’re just screwed and we’re going to keep being screwed and the people who will be hurt the most are the ones you and I want to help the most.

  85. 85
    La Lubu says:

    FurryCatHerder, here’s the thing. I have good insurance. My problem is, I don’t always have it. Let me describe my insurance plan.

    It’s a self-funded, non-profit ERISA plan (a PPO, not an HMO) that covers 18 Locals and their signatory contractors. It covers the plan participants and everyone in their family. It has a deductible of $500 per person or $1500 per family. Out of pockets are $1500 per person, $3000 per family (90% for in-network, 75% for out of network). This is a contractor-paid negotiated benefit, so neither workers or employers are taking a tax hit (like the folks who purchase private insurance with their after-tax paycheck take). We have vision and dental coverage, and we just started a wellness and disease management program that provides financial incentives (via a Health Reimbursement Account) for folks who meet health goals (weight loss, cholesterol reduction, blood sugar management, quit smoking, etc.). Those reimbursements to the HRA can be used to enhance benefits (for example, pay for better glasses than one would normally get through the vision plan) or assist in paying COBRA if a person is unemployed and doesn’t have enough bank hours to continue coverage.

    In order to stay covered, one has to work 150 hours per month. Anything over that goes into “bank hours”. A person can bank up to six months of hours. Like most plans that cover tradespeople, it has an income benefit if one is too sick or injured (not via on-the-job injury) to work. It’s a small benefit—less than unemployment, but it helps. It will pay up to 26 weeks. It also has an accidental death and dismemberment benefit.

    Now, about the folks it covers. We are, on average, older than the average U.S. population. Electricians tend to be exposed to more environmental toxins over the course of our lifetimes than the average U.S. resident—not just via on the job, but we tend to live closer to things like factories, powerhouses, highways, etc. (we make a decent enough living to afford the older homes in working class neighborhoods, but not enough to afford the cleaner air that comes with suburban communities). Our jobs are physically intensive, and over a lifetime, that leads to a higher statistical average of degenerative breakdown—lots of back surgery, knee surgery, shoulder surgery, etc. There’s a class component to our hobbies and avocations; we tend to prefer doing things that are statistically more likely to lead to injury—for example, motorcycles (riding or racing). It’s probably worth mentioning that we have a higher divorce rate than average; that has a negative correlation with health. I’ve heard (but only from old-timers….y’know, the people that are older than me! ;-) that we have a higher rate of alcoholism than the general population, but I haven’t seen any proof of that. I think we’re average there. Our DNA probably represents the average cross-section of the USA (these 18 Locals are pretty much limited to the 6th district/rust belt; Illinois mostly).

    And yet, we manage to keep our fund solvent, despite a shitty economy and the inherent healthcare drawbacks of our population. It costs over $10,000 grand a year per person (again—pre-tax income); it pays for preventative care as well as vision and dental. Remember, this is a non-profit plan. The Trustees are beneficiaries as well (half Business Managers, half contractors). They have a personal stake in keeping a cost-benefit ratio, not just a fiduciary responsibility. In other words, there is no incentive for them to screw the plan participants.

    I have no doubt that we can afford a national healthcare plan that would have similar benefits (sans the death/dismemberment—Social Security would already have that covered). And without the problems of:

    losing insurance due to unemployment
    losing coverage due to pre-existing conditions or past history
    losing coverage due to exceeding the maximum lifetime benefit
    getting screwed because you happen to be injured or ill in a place that has no “in-network” options for healthcare

    Think about the economic benefits that would come from a national healthcare plan that would eliminate the added costs of fighting insurance companies. That would lower the average cost of healthcare, because everyone is covered, hence no need to charge higher rates to folks who happen to have insurance, to make up for those that can’t be collected from. That would eliminate over half of all bankruptcies in the U.S. overnight (remember, bankruptcy keeps one from being a “good consumer” not just the year of filing, but the next 10 solid years, not to mention the effect bankruptcy has on those seeking employment or those needing to say, buy a car to get to work when the old clunker breaks down). That would eliminate the high costs of healthcare to employers, the better to allow them to complete on the global stage (where the are competing against companies that have the hearty advantage of nationalized healthcare).

    Yeah, we can effortlessly afford this. We can’t afford not to.

  86. 86
    Schala says:

    The way national insurance works, at least in Quebec province, is that you’re on the default provincial plan (69% meds coverage, no dental, no eyes) if you’re not on any other insurance. You HAVE to have an insurance somewhere, so this is the default if you don’t have any other. The cost is taken when you get your tax return, and is pretty low.

    Now, if you do have another insurance, it replaces the national one, and no doubt has better coverage, like 80% dental, 80% eyes, and 80+% meds. You pay at your employer like normal, and don’t pay anything on your tax form at the end of the year. It probably costs more, but people usually prefer those.

    The thing is, if I’m unemployed, like now, I’m still covered. If my employer has no plan (like before I got laid off), I’m still covered. And no pre-existing BS, because I’m never really without insurance either.

    Certainly the system needs an overhaul, we’re also losing doctors to the US because they’re paid a lot more there. But overall, the health is a lot better. I get my medicare card out and I don’t worry about a bill when I can barely make ends meet already.

    You don’t need to wait until you need a priest to go see a doctor – though most people still don’t go see for hurting their toe and pretty rarely for a flu (unless old where it can matter). I very rarely go see my doc unless I’m pretty sure it needs antibiotics, points or something worst that I’ve never had yet. The government insurance pays for my doc visit, not the time off work. If I had to pay (or compensate in case of time off work) for both though, I’d endure it longer and might make it worst.

    Our province might not be the best model, but I’d like to know what flaw there is in that model.