A Credible Threat To Default Is Unprecedented

The hostage scene from Blazing Saddles

James Fallows writes:

…there is no precedent for serious threats not to honor federal debt — as opposed to symbolic anti-Administration protest votes, which both parties have cast over the years. Nor for demanding the reversal of major legislation as a condition for routine government operations.

At Volokh, Jonathan Adler responds:

There’s never been a “serious threat” to refuse to increase the debt ceiling? Glenn Kessler’s already shredded that claim.

Adler is mistaken. Kessler was addressing President Obama’s claim that never before have non-budget items been attacked to the debt ceiling. Obama either misspoke or was just plain wrong, but Fallows is making a different claim than Obama – that previous threats not to honor federal debt were symbolic, not serious. That claim isn’t refuted by Kessler.

Adler goes on:

As this paper documents, “the use of the debt ceiling vote as a vehicle for other legislative matters,” had become a “pattern” in the mid-1970s and 1980s. Indeed, as Kessler notes, “Congress has used the debt limit to repeal a key legislative priority of a president,” and liberal lions like Senators Ted Kennedy and Walter Mondale sought to attach substantive legislation to a debt ceiling increase in the 1970s.

Fallows is right, and the academic paper Alder links to refute Fallows, written by Linda Kowalcky and Lance LeLoup, shows that Fallows is right. That paper makes it clear that those past votes against the debt ceiling being raised were symbolic (emphasis added by me):

A substantial number of legislators in both houses may speak and vote against the debt limit with the knowledge that it will ultimately pass.

But no one thinks it’s certain that Republicans will allow the debt ceiling to be raised. That’s why the US recently had its credit rating lowered, and that’s why the current situation is unprecedented.

The paper Alder links documents that in the past, the pattern has been that the majority party accepts that it has a responsibility to protect America’s credit rating (and the world economy) by gritting its teeth and raising the debt ceiling, while the minority party has traditionally taken the opportunity to grandstand, safe in the knowledge that the minority party would be outvoted, and the debt ceiling would be raised.

Another method used to symbolically oppose the debt ceiling (while still making sure it would pass) was allowing moderate party members to vote as they please, so that a coalition of minority and majority party members pass the debt ceiling while other members cast symbolic votes against it. That’s what the House GOP did under Reagan. Although there was plenty of exciting grandstanding (filibusters, even!), the members of Congress were still certain that the debt ceiling would be raised.

In the House right now, however, it is the majority party that is threatening to push the US into default, and it appears that the GOP leadership intends to not allow centrist Republicans to vote with Democrats to raise the debt ceiling. As a result, the US actually appears to be heading into default.

This is indeed a new and unprecidented situation – at least, during the decades documented by the paper Alder linked to.

And it’s irresponsible to credibly threaten to tank the world economy, and the nation’s economy and credit rating, in order to achieve a legislative victory that could in principle be achieved by more responsible means (i.e., winning elections).

EDITED TO ADD:

Two points:

1) I think that even a symbolic vote to default – such as many congressfolks have cast, including Obama when he was in the Senate – is also irresponsible. It’s not nearly as irresponsible as a credible threat to refuse to pay the US’s bills is, but it’s still irresponsible. The best thing to do is to simply get rid of the debt ceiling altogether (as has been done in the past).

2) Although I wrote this post, I also think the question of precedent is largely irrelevant. A credible threat to put the US into default is inexcusable and irresponsible regardless of if it’s precedented. Whether there’s precedent or not isn’t what’s important.

If I go outside and kick the crap out of the neighbor dog, I won’t be the first person ever to abuse a dog, but that won’t make what I’m doing right.

Hat tip: Ethics Alarms.

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199 Responses to A Credible Threat To Default Is Unprecedented

  1. 101
    Conrad says:

    Peter Beinart (in the Daily Beast) makes an important distinction about how, although the GOP may appear to be losing the political battle, they are winning the ideological struggle. The ideological battleground in this case is over the appropriate level of government spending. I think the GOP has pretty clearly staked out the position that the level of spending to which the government has become accustomed is excessive and unsustainable and that it’s making us poorer and less free. I think the Dems are generally associated with the position that the status quo is fine, i.e., we can continue to increase the size and role of government and never have to worry about running out of money.

    I’d be interested to hear from the left-wingers here on this. Which of those two general positions in the ideological debate do you think is faring better at the moment and which do you think is likely to fare better over the next few years?

  2. 102
    Jake Squid says:

    I think the ideological war continues to be stalemated. Much as it has been for the last 25 years or so. Politically, however, the right has been much more successful over that same period.

  3. 103
    RonF says:

    Jake:

    I don’t think anybody is arguing that. We are arguing that it is ethically illegitimate.

    I don’t see how. The system was deliberately designed to permit and even encourage exactly what has happened, as a parallel to the British system.

    We are arguing that the correct response is a refusal to pay the ransom.

    What ransom? There’s no kidnaping here. The most immediate representatives of the people were deliberately given the power to refuse to fund programs. The rest of the government was expected to fall in line if the House stayed firm in their resolve. Again, it’s not a bug, it’s a feature.

    We are arguing that if this becomes an accepted way for the minority party to act, we’re all fucked.

    If they were truly a minority party then they wouldn’t have this power. But while the Democrats won the Executive Branch in the 2012 election, they lost it in the House. And as President Obama told the Congressional leaders after the 2008 election, “elections have consquences”. Those consequences obtain when Democrats lose elections as much as when they win them.

  4. 104
    JutGory says:

    Amp @99

    The agreement includes a provision for further negotiations

    Then, it depends on how those negotiations go. And, a December deadline gives everyone plenty of warning about the consequences of not reaching an agreement.

    However, just because they meet and have discussions doesn’t mean they’ll come to an agreement, of course.

    Of course. And, that is why I don’t really look at this as a matter of who “won” and who “lost.” They did not agree; the Government shut down; they reached an agreement; and the Government re-opened. The Republicans did not shut down the Government any more than the Democrats did (not that that prevented everyone from pointing fingers). That is the consequence of not reaching an agreement. If they do not agree, it will likely happen again.

    -Jut

  5. 105
    Jake Squid says:

    “Get rid of that piece of legislation you passed that we have been unable to repeal for years or we will not vote to keep government funded nor vote to raise the debt ceiling,” is extortion.

    “We will not get rid of legislation that you don’t have the votes to repeal, no matter what you threaten to do,” is not shutting down the government.

    Refusing to put a bill on the floor to fund government when that bill has the votes to pass is shutting down the government.

    This was a huge loss for the GOP and we can hope that holding the domestic and global economies hostage will never be used in this way by a similarly positioned party again.

  6. 106
    Conrad says:

    i think you’re confused as to what “extortion” means. It can’t be extortion for the House to threaten to vote or not vote a certain way where it’s the legal right of that body to vote however it wants. Extortion requires the threat of some illegal action.

  7. 107
    RonF says:

    Did the House threaten not to vote to fund the government at all? Or did they simply threaten not to vote for a bill including funding for the ACA and send bills to the Senate that the Senate refused to pass and the President said he would not sign because they did not fund the ACA?

  8. 108
    Jake Squid says:

    Call it what you want, make excuses for it all you want. I think it’s pretty clear to most of us as to what happened.

  9. 109
    Conrad says:

    Fine. I’ll call it an act of heroic statesmanship aimed at restoring America’s fiscal integrity.

  10. 110
    Ampersand says:

    The most immediate representatives of the people were deliberately given the power to refuse to fund programs.

    Yes – but the House already voted to fund Obamacare, and the Senate agreed.

    The Constitution gives the House no power at all to unilaterally defund Obamacare, once they’ve already voted to fund it.

    The House can, of course, pass a new law revoking the funding they’ve already passed, but it has no force of law at all unless the Senate passes it too.

    You’re discussing this as if the status quo is that Obamacare isn’t funded, and the House was simply declining to fund it. That is not true. Obamacare was funded, by a vote of the House and Senate. The GOP tried, but failed, to pass a new law defunding Obamacare. And when they couldn’t get what they wanted through ordinary means, they threatened to tank the economy unless they got what they wanted.

    Look at the polls. Lie all you want about what actually happened, Ron; you folks aren’t fooling anyone but yourselves.

  11. 111
    Ampersand says:

    Conrad:

    The ideological battleground in this case is over the appropriate level of government spending. I think the GOP has pretty clearly staked out the position that the level of spending to which the government has become accustomed is excessive and unsustainable and that it’s making us poorer and less free. I think the Dems are generally associated with the position that the status quo is fine, i.e., we can continue to increase the size and role of government and never have to worry about running out of money.

    That’s a silly straw-man version of the Democrats position.

    That aside, I certainly agree with Beinart that on this matter, the Democrats are badly losing the ideological war over what the US debt means. (I don’t think that the shutdown, or the default threat, helped the GOP, but that’s just one battle, not the war.)

  12. 112
    Charles S says:

    Amp:

    I think it’s too early for you to be declaring victory on Obamacare. It’s been a clusterfuck disaster so far – but if it’s working well a year from now, no one will care that the rollout was abysmal. It may be that the GOP’s worst-case scenario – which is poor people having the medical care and security that they need – will yet happen.

    The federal exchange website, which applies only to those states that refused to set up their own exchanges, is a mess (although you can still enroll by phone). The state exchanges seem to be doing fine, as far as I’ve heard. In what other ways has it been a disaster besides the failed Federal website?

    RonF:

    We are arguing that it is ethically illegitimate.

    I don’t see how. The system was deliberately designed to permit and even encourage exactly what has happened, as a parallel to the British system.

    It was not ethically illegitimate as a procedure within Congress (although the change of rules to prevent a vote on the Senate’s version of the CR made it very clear that the shut down was the goal), it was ethically illegitimate because it forced people to go hungry, to miss out on cancer treatments, to miss a year of research in the Antarctic, to go without mine safety inspections, to eat uninspected food, plus an estimated $26 billion in other damages to the economy, in order to accomplish little besides building Ted Cruz’s mailing list (and reducing the popularity of the Republicans to that of the Tea Party). You know, seriously hurting millions of actual people, something that most people find unethical unless clearly necessary. Surely, “was it the framers intent?” is not the only question you ask to evaluate ethics?

  13. 113
    Ampersand says:

    Charles – I was referring to the failed Federal website. But since the majority of states are using the Federal website, rather than setting up their own, I think the problems we’ve seen so far qualify as a disaster.

    In the British parliamentary system, I don’t believe that it’s possible for the lower house to threaten to unilaterally make the country default on its debts.

  14. 114
    Robert says:

    “In what other ways has it been a disaster besides the failed Federal website?”

    It’s a little early to be definitive – so Amp, I’ll thank you if you don’t reward my candor here with ten years of saying “but you said…in 2013″ if I prove wrong on the details – but from what I can tell there are two slow-mo trainwrecks.

    The first one is, nobody is signing up. Some of that can be attributed to the bad website but while its an explanation, it isn’t a mitigator; a lot of these folks are people for whom the government had one shot at getting easy compliance, and that was when signup issue was fresh-hot-now in the media. They aren’t going to be coming back fast. The administration signaled that they expected 500,000 signups in October on all exchanges combined – and that’s a pretty crappy, expectation-dampening number, given that 25 million people or so are supposed to get coverage, and by the end of the year no less.

    Actual signups to date this month: optimistically, 150,000. (http://www.washingtonpost.com/blogs/wonkblog/wp/2013/10/17/the-white-house-wants-500000-obamacare-sign-ups-this-month-can-that-still-happen/)

    They can’t get 50% submission to the mandate and have this thing work. 80% would be pushing it. There are four months until the penalties start kicking in – unless they get waived of course. There isn’t a good scenario once mass civil disobedience starts happening, for proponents of the law anyway. Again, too early to say for sure but it’s kind of looking like mass civil disobedience now.

    I’m certainly not going to comply.

    The second area is political. People who hate the ACA hate it a lot. People who love it love it a lot – usually because it is doing something great for them, like providing coverage on a condition that blocked them from insurance before or cut their huge medical expenses down to size a bit. That second category isn’t trivial in number, but it’s not huge either. The bulk of the ACA’s supporters are mildly in favor of it because they think, or thought, it would make things a lot better for some folks while not making things worse for themselves, or at least not very much worse.

    Now in fairness, at least from the Administration’s statements, premiums are coming in at a fairly reasonable level. Might not seem reasonable to the people having to pay them, some of whom don’t know what insurance cost and others of whom just don’t make a lot of money, but the subsidies should help with all of that. What I am hearing is that the deductibles on those reasonable plans are crazy high. A $6000 deductible, to someone making $120,000 a year, seems pretty reasonable; they like having the premium be hundreds less a month and having to cough up a two-week paycheck if something major happens isn’t catastrophic.

    To someone making $20,000 a year, a $6000 deductible more or less means not having health insurance at all. Even if the premiums are low or zero, just the knowledge of having that dead albatross of an insurance plan is demoralizing. “Great, if I get cancer, I can get treatment for it just a week or two after I starve to death.”

    A lot of the people in the ‘lukewarm but sincere supporter’ camp are also peopl who are getting boned in the ass with mega-deductibles or shock premiums. They ain’t happy. The ACA is spectacularly popular, to the people who are seeing a net gain; that’s a relative minority of people. There seems to be a bit more pain than people anticipated and that’s a slow-moving, subsurface disaster for the law’s proponents.

    That’d be my two cents as to ‘what’s going to go wrong first’.

  15. 115
    Conrad says:

    @ &:

    “That’s a silly straw-man version of the Democrats position.”

    How so?

  16. 116
    Ampersand says:

    There are many examples of prominent Democrats, such as Obama, saying that the debt is a serious problem, so I don’t think you can claim Democrats say “we can continue to increase the size and role of government and never have to worry about running out of money.”

    Obviously, there is no one position shared by every member of either party. But generally speaking, the Democratic position is Keynesian, i..e, we should borrow money during times of recession and high unemployment, and pay down the debt during times of low unemployment.

  17. 117
    Conrad says:

    @ 116: “There are many examples of prominent Democrats, such as Obama, saying that the debt is a serious problem,. . . .”

    That may be true, but it doesn’t contradict what I said. I wrote: “I think the Dems ARE GENERALLY ASSOCIATED WITH THE POSITION THAT the status quo is fine, i.e., we can continue to increase the size and role of government and never have to worry about running out of money” (emphasis added). Do you really dispute this? Do you really contend that Democrats have staked out the position in the public debate over fiscal and economic policy that government spending is alarmingly high and needs to be reined in? If that IS the authentic Dem position, then they’re not doing a very good job in terms of messaging.

    As for your suggestion that our current levels of government spending are justified by Keynesian economic theory (which I think misrepresents what Keynes was preaching), doesn’t that support exactly the point I am making? If Dems openly advocate spending vastly more than we are taking in because unemployment is high, that means the high levels of spending are not something we should be worried about, right? So in fact I’m correct to associate Dems with the position that our current high levels of spending are not something to worry about.

    BTW, when can we expect all this “Keynesian” spending to finally yield some noticeable improvement in the nation’s economic fortunes? Unemployment is still sky-high (especially taking into account the number of people who have left the job market) and economic growth is sluggish at best. Clearly, Obama’s economic policies aren’t working.

  18. 118
    Jake Squid says:

    This NY Times article gives some examples of Republican voters who think that the GOP attempted extortion.

    Sam Eppley, a Republican, said he supports Mr. Lamborn. But he was worried about the shutdown’s toll, fearful of the effect it could have on the cooking store he owns in Colorado Springs, and he disagreed with Mr. Lamborn’s vote against the deal to reopen the government.

    “Whether you’re for or you’re against Obamacare or some variation of it, it should not have been tied to a government shutdown,” he said, adding, “I don’t think the nation should have been held hostage over one issue like that.”

    If even members of your own portion of the political spectrum believe that the GOP used extortion/hostage taking/ransom demanding/what have you, chances are good that at least a large plurality of the nation believe the same thing.

  19. 119
    Jake Squid says:

    Damn. Forgot to blockquote or end blockquote the middle two paragraphs.

    Alas, for an edit function…

    [Fixed! --Amp the human edit function.]

  20. 120
    Conrad says:

    Although I would note that the gentleman in the article you quoted doesn’t characterize the House’s role in the funding impasse as “extortion,” I would readily concede that not every single person who calls himself a Republican has precisely the same opinion as I on this or any other issue. By the same token, not every Democrat supports Obama’s priorities and tactics down to the last, minute detail.

    By the way, I read this morning that there’s a petition being circulated via Daily Kos to demand that Eric Holder have GOP House members arrested and charged with crimes against the U.S. for refusing to vote to fund full government operations. I guess if you believe Boehner et al committed extortion, then it naturally follows that they should be rounded up and imprisoned. You don’t have a problem with treating criminals as criminals, do you? Besides, think of how much easier it will be for Obama to enact his agenda if his AG can jail the opposition.

  21. 121
    Ampersand says:

    Here’s that thread on DKos. As I understand it, a “diary” on Kos is analogous to a “comment” on Alas – anyone can come along and post one, it doesn’t represent the opinions of the siterunners. The comments are split about 50/50 between the comments of “Bud,” the diary-writer, and the comments of others, nearly all of whom disagree with Bud (“If Holder actually did what this petition asks him to do, he’d be impeached — and he SHOULD be impeached! “).

  22. 122
    Jake Squid says:

    btw, extortion does not necessarily refer to a crime. It can also be used in contexts other than legal:

    ex·tort
    [ik-stawrt] Show IPA
    verb (used with object)
    1. Law.
    a. to wrest or wring (money, information, etc.) from a person by violence, intimidation, or abuse of authority; obtain by force, torture, threat, or the like.
    b. to take illegally by reason of one’s office.

    2. to compel (something) of a person or thing

    (my emphasis)

    (Please note that order of definition does not make one definition right and the other wrong or one more right than the other. I learned this many years ago during another online argument about the definition of a word.)

    Unsurprisingly, I’ve been using it in a context other than a legal one.

  23. 123
    Ampersand says:

    Conrad – I think that trying to talk about “positions generally associated with” groups, rather than positions actually advocated by those groups, is silly. I’m sure that among Republicans, the position you describe is “associated” with Democrats. But it’s not actually the position actually taken by many (if any) democrats at all, and that makes it uninteresting to discuss.

    The current situation hardly represents a pure experiment of Keynesian theories, since the government has laid off government workers in mass, which is exactly the opposite of what Keynesian policies would be – by laying those people off, we’re destroying economic recovery. Nor was the stimulus as large as it ought to have been. That said, there’s very little doubt that it did help the economy. Here’s a comparison of the UK and US. In the UK, due to conservative government leadership, there was no stimulus.

    Job numbers in the US are still bad – but they’d be worse had there been no stimulus.

    Economic experts from a wide range of ideologies agree that the stimulus reduced unemployment. Only 4% disagreed.

    We should have had a lot more stimulus – by NOT laying off large numbers of government sector workers, and by following up the 2009 bill with further stimulus bills. If we had, the economy would be in much better shape today.

    There are three ways to lower debt – we can lower spending, we can raise tax rates, or we can have a growing economy (in which case, tax revenues will increase without having to raise tax rates). Or we could go for some combination of the three. But use of the third option – reducing debt through a growing economy – is by far the least painful of the three alternatives.

    As for the “so in fact I’m correct…” etc, if the best you can do is strawmen, then yes, that is exactly the sort of argument you’d make. But if you actually care about honestly understanding and responding to the actual positions of those you disagree with, and have any ability to comprehend nuance, then no, that is not correct.

  24. 124
    closetpuritan says:

    Eytan @94:
    Not only was the media mostly covering the shutdown rather than the problems with the health exchange website, at least one conservative predicted it would happen and that therefore pursuing a shutdown was a bad strategy. And some people think that the reason why the websites had problems was because of the shutdown. (I imagine that at least some of them would realize that’s not the case now that the shutdown has stopped, though.)

    Conrad & Robert @95 & 96: Would you say that it’s more important to demonstrate that the Republicans can fight to fellow Republicans or to Democrats? I’m seeing it spun different ways by different people. But actually, on second thought, I’m not sure that the different takes neatly align with the two different parties. Anyway, I’m seeing some people say that it demonstrates that this strategy blew up in Republicans’ faces and they will know better than to try it again, and others saying that even a slight concession like greater income verification for Obamacare subsidies is enough to encourage them to keep trying this strategy.

    Conrad & Amp: Another important difference is the use of the word “never” in Conrad’s initial description of the Democratic position. Countercyclical spending=spending more during a recession and spending less/taxing more during times when the economy is strong.

  25. 125
    Conrad says:

    It seems to me you’re arguing out of both sides of your mouth. On the one hand you seem to reject the idea that Dems are perfectly ok with high levels of govt spending and the resulting massive deficits. OTOH you are arguing for even higher levels of spending and presumably higher deficits as a matter of economic policy. Clearly, you are not exactly what someone would call a deficit hawk, but if I SAY, in effect, you’re not a deficit hawk, I’m somehow being silly and engaging in straw man arguments.

  26. 126
    Ampersand says:

    Conrad, the difference between (emphasis added by me) “we can continue to increase the size and role of government and never have to worry about running out of money,” which is the position you attribute to Democrats, and “in the current economic context, we should be spending more money, but in a different context we should pay down the debt” is too enormous and substantive for me to bother explaining the difference. If you don’t see a difference between those two positions, you’re being willfully obtuse.

    Edited to add: Or, perhaps, you’ve simply forgotten that you included the word “never” in your summary of the Dem position, or have missed the significance of the word “never.” (Thanks, ClosetPuritan.)

  27. 127
    Conrad says:

    I think it was clear from my phrasing that I wasn”t intending to speak with mathematical precision in describing the position associated with the Dems on fiscal policy.

    Furthermore, I have a bit of trouble accepting the suggestion that the Dems are only interested in high levels of spending as a keynsian response to hard economic times when there wasnt exactly a big dem push to cut spending in the years immediately preceding the economic crash.

  28. 128
    Jake Squid says:

    Furthermore, I have a bit of trouble accepting the suggestion that the Dems are only interested in high levels of spending as a keynsian response to hard economic times when there wasnt exactly a big dem push to cut spending in the years immediately preceding the economic crash.

    What? There was a big D push to cut spending during the boom of the 90′s. A boom during which the deficit vanished and the debt (as a % of GDP) began to fall. That happens to be the last time there was a Democratic POTUS during an economic boom. In the years immediately preceding the economic crash of 2008, the GOP was the majority party and insisted on spending enormously on things like nation building. Your perceptions are suffering from confirmation bias.

  29. 129
    closetpuritan says:

    I think it was clear from my phrasing that I wasn”t intending to speak with mathematical precision in describing the position associated with the Dems on fiscal policy.

    Mathematical precision? Yup, it’s like the difference between 5+5+5+5 and 5+5-5-5.

  30. 130
    Conrad says:

    @ 128: “What? There was a big D push to cut spending during the boom of the 90′s. ”

    I wasn’t referring to the 1990s, obviously. The crash was end of 2008. The years immediately preceding it were, like, 2005, 2006, 2007.

    Also, you seem to be treating the Clinton-era budget deal as typifying the recent Dem approach to fiscal policy, but it was clearly an anomaly arising out of Clinton’s (and Dick Morris’) attempt to recast the Dems as a centrist party. And let’s not pretend the role of the GOP in pressing for that brief interlude of comparative fiscal responsibility.

    By the 2000s, Pelosi and Dems were in full “spend” mode and any restraint in that regard has clearly been imposed on them by the GOP.

  31. 131
    RonF says:

    Charles, those things were NOT forced. The House passed bills to fund a number of things and would have been perfectly happy to pass bills to fund all of them. It wasn’t an issue of the House not being willing to fund them. It was an issue of the Senate and President refusing to fund them as long as the ACA was not going to get funded.

  32. 132
    Charles S says:

    RonF,

    You are making excuses, and they won’t convince anyone except the true believers. I wrote a bunch more in detail about this, but you aren’t worth it.

    [Moderated by Amp.]

  33. 133
    Ampersand says:

    I think it was clear from my phrasing that I wasn”t intending to speak with mathematical precision in describing the position associated with the Dems on fiscal policy.

    Obviously, it wasn’t clear, Conrad. We don’t have secret mind-reading abilities, so if you mean something else, other than what you write, there’s no way for the rest of us to know that.

    Geez, would it kill you that much to say “okay, what I wrote wasn’t accurate?” Because you actually DID say something interesting, about how Republicans are winning the ideological fight over the meaning of the debt. But now that interesting point, and the potentially interesting discussion, has been completely lost under the debris of your inability to admit that the way you summarized the Democratic party’s view of the debt was a little bit inaccurate. And the discussion, far from interesting, has been beyond tedious.

  34. 134
    Ampersand says:

    The GOP’s worst case scenario…charming. I guess that it is, in the same way that a brilliantly functioning economy is a socialist’s nightmare. Because nobody can want good things for the country or their countrymen, that aren’t delivered the way that a particular ideologue wants to see.

    Yes, that’s precisely right, Robert. In exactly the same way as an extreme socialist who is so dedicated to the idea that markets always fail that he can’t even acknowledge – or even stand – the fact that markets are, in many cases, by far the most effective and useful tool for distributing resources effectively so they get to people who need them. That person would rather embrace a failed non-market approach than even allow a market-based approach to ever be tried, because that person’s entire ideology is wrapped up in the certain knowledge that markets always fail.

    And you’re just like him, with the nouns reversed.

    I can certainly think of cases where two parties both want – say – people like me, who have jobs that involve working well over full-time but nonetheless don’t have much money, and who have chronic pre-existing conditions – to be able to afford health care. But in reality, that’s not what we have. We have one party who has a record of spending years working again and again, trying to get medical care available to all, and is currently working for an idea which will plausibly increase coverage by about 25 million; and one party that has never once made a serious proposal that would plausibly bring medical care and coverage to anywhere near that many people, let alone sick people without much money like me.

    If you want credit for wanting good things for your countrymen, you actually have to have tried to make those good things happen at some point. And your party never has.

  35. 135
    Ampersand says:

    It wasn’t an issue of the House not being willing to fund them. It was an issue of the Senate and President refusing to fund them as long as the ACA was not going to get funded.

    “It wasn’t an issue of me holding a gun to John’s head and demanding that he give me the money I’d already agreed to pay him; it was an issue of John stubbornly refusing to open his wallet and hand me the money.”

  36. 136
    Robert says:

    “We have one party who has a record of spending years working again and again, trying to get medical care available to all, and is currently working for an idea which will plausibly increase coverage by about 25 million; and one party that has never once made a serious proposal that would plausibly bring medical care and coverage to anywhere near that many people, let alone sick people without much money like me.”

    Medicare Part D. 27 million beneficiaries – actual beneficiaries, not fairies-in-the-garden promised beneficiaries – as of 2007. $100 billion a year or so outlays.

    Passed in the House 216-215, with 195 Democrats and 19 Republicans voting against it. Similar trend in the Senate. The Democrats, by the way, practiced some sharp parliamentary maneuvering in the process of trying to kill the bill, narrowly failing in the effort.

    But that’s crazy, because trying to kill prescription drug coverage for sweet little old ladies would seem to go against the lovely narrative of “working again and again, trying to get medical care available to all”.

    Or possibly that narrative is complete self-serving bullshit. Hard to tell.

  37. 137
    Conrad says:

    @134: “We have one party who has a record of spending years working again and again, trying to get medical care available to all, and is currently working for an idea which will plausibly increase coverage by about 25 million;.. . .”

    I don’t give ANY credit to Dems simply for “TRYING to get medical care available to all” if the result of those efforts is a system that’s worse than the status quo. Obamacare is hurting far more people than it’s helping, whether through higher premiums, higher deductibles, the dropping of employer plans, forcing people to pay for “benefits” they do not want and will never use, higher overall health care costs (e.g., due to the medical devices tax), and its general negative impacts on jobs and the economy. Sorry, but no amount moral preening over being the party that cared more about the uninsured makes up for taking an imperfect system and making it vastly worse for the majority of people it affects.

    “. . . and one party that has never once made a serious proposal that would plausibly bring medical care and coverage to anywhere near that many people, let alone sick people without much money like me.”

    I don’t know if this is even true as a matter of historical fact, but it’s incredibly tendentious to treat the insuring of a small fraction of Americans as the sole criterion for a successful HC reform. If we extended insurance coverage to 25 million* more Americans, but in the process raised HC costs across the board and killed millions of jobs, then it simply wouldn’t be worth it. Sure , such a reform might be of personal benefit to some, but we have to consider the overall impact.

    Also, Obamacare wasn’t exclusively sold as a measure to cover the uninsured: It was supposed to LOWER insurance premiums by $2,500/year, “bend the cost curve,” and allow people to keep their existing coverage if they wanted. To focus solely on its impact O’care may have on extending coverage to the fraction of people who were previously uninsured ignores these other STATED measures of its success and amounts to goalpost shifting on an epic scale.

    “If you want credit for wanting good things for your countrymen, you actually have to have tried to make those good things happen at some point. And your party never has.”

    Right, the Republicans have never, at any point, tried to make any good things happen for their countrymen. Except for jobs, a strong economy, freedom, ending slavery . . . boring stuff like that.

    *I seriously question that there were 25 million American citizens who wanted HC insurance but could not afford it, weren’t qualified for Medicaid, Medicare, or some other form of subsidized coverage, and, as a result, were unable to get health care when they needed it. Of course there are anecdotal horror stories, but the extent of the problem of the uninsured was vastly overstated by counting millions of people as uninsured who were in fact illegal aliens, who were voluntarily uninsured, and/or who were already eligible for govt-subsidized insurance but simply weren’t aware of it or didn’t sign up. Moreover, as has been drilled into our heads over and over again, when uninsured people do get sick or injured, they still get HC by going through emergency rooms. For this reason simply reducing the numbers of uninsured doesn’t have a major effect on overall health care outcomes.

  38. 138
    Jake Squid says:

    A true story from one week ago:

    My friend’s sister-in-law worked full time at minimum wage. Her employer didn’t offer health insurance and she couldn’t afford health insurance. She was sick for a few weeks but didn’t go to see a doctor because she couldn’t afford it. Last week things got really bad and she went to the emergency room. It was too late. Her kidneys had stopped working, her body shut down and she was dead a couple of hours after arriving at the emergency room.

    Had Obamacare been in effect chances are good she’d be alive today. Oh, well.

  39. 139
    Conrad says:

    Clearly, she should have gone to the ER sooner. Or perhaps your friend should have lent his sister-in-law $200 so she could have gone in for a doctor’s visit.

    Anyway, I’m not sure how Obamacare would have helped. Someone who can’t afford a visit to the doctor’s office at all is hardly going to be helped by an insurance plan that has a $4,000-$6,000 deductible.

  40. 140
    Jake Squid says:

    Yeah, she deserved to die. I expected that comment from you.

    Anyway, I’m not sure how Obamacare would have helped. Someone who can’t afford a visit to the doctor’s office at all is hardly going to be helped by an insurance plan that has a $4,000-$6,000 deductible.

    You don’t know how paying only a portion of a doctor visit instead of the full amount would have helped? Wow.

  41. 141
    Robert says:

    She wouldn’t have paid only part of the visit; she’d have paid 100% because she hadn’t reached the deductible. If anything she would have been worse off under Obamacare, because not only would she have still had to cover the visit herself, she would have spent the prior months paying her (admittedly subsidized) premiums.

    If your friend had died from lack of a $100,000 procedure, you would indeed have an argument that this is a person Obamacare helped; as I noted above, it’s going to help some people. People who can’t afford $200 to see a doctor aren’t among those people.

    She died from lack of a $200 doctor visit where her condition would have been diagnosed. Obamacare doesn’t really help with that.

  42. 142
    Conrad says:

    @141.: Thank you for sparing me having to explain that.

    @ 140: “Yeah, she deserved to die. I expected that comment from you.”

    Touché! Oh, except I never said she deserved to die. I think she and her family owed it to herself and themselves to get her in to see a doctor early so she perhaps wouldn’t die. See the difference there?

  43. 143
    gin-and-whiskey says:

    Conrad and Robert, I don’t think you’re correct. Most insurance doesn’t place normal MD visits and ER visits in the deductible.

    For example, I have a deductible of thousands of dollars. That said, there are certain defined things for which I only have to make a COPAY. If I go to my primary doctor, it costs me $50 or so. if I go to the ER, it costs me $150, I think. Vaccines are free, even though I have a deductible. Etc.

    From what I have read about Obamacare, it seems very likely that this person would have been able to get reduced-cost medical assistance under the same theory.

    Would she have been able to afford even those costs? I have no idea; certainly some folks can’t afford co-pays either. But I strongly doubt she’d have had to pay 100% of costs up front to get an exam, so it would have been more likely she would get help.

  44. 144
    Jake Squid says:

    The difference between “she deserved it” and, “it’s her fault,” is so insignificant as to be meaningless.

  45. 145
    Robert says:

    G&W – Point taken. I haven’t had health insurance in many years. I should also acknowledge that ‘wellness’ appointments don’t carry a co-pay, so it IS at least possible that this person would have seen a doctor at some point which might have made a difference to the final outcome.

    Jake – Only if you have a moral viewpoint that is bound and determined that nothing that happens is ever the result of chosen action. I have a friend who died two months ago; she was driving drunk, and went off the highway, and hit a tree. I’m still mourning it. If you tell me “that was her fault” I have to say that yes, it was. If you tell me “she deserved it”, you are going to be paying a visit to the ER yourself.

    The difference is not trivial or small.

  46. 146
    Conrad says:

    @ 143: We don’t know anything about this person’s situation other than she purportedly didn’t have the financial resources to go the doctor when she was feeling ill and she waited too long to go to the ER. I believe a regular doctor’s office visit would have cost her something like $200.00 (although it’s far from certain she would have gotten an appointment in time to save her life). Alternatively, she could have just gone to the ER in the first place, and if she didn’t have money or insurance, they would have treated her anyway and she would be alive today (although we don’t know this either, actually).

    If she had been on your insurance plan, she evidently would have incurred a $150 co-pay by finally going to the ER, which admittedly is $50 less than a visit to the doctor’s office would have probably cost her in the absence of insurance. Perhaps that $50 savings accounts for her decision to forego going to the doctor instead of the ER, although it doesn’t account for her delay in doing the latter.

    Clearly, even under Obamacare, people are expected to shell out money for their own care, whether in the form of premiums, deductibles, and co-pays. Let’s say the hypothetical sister-in-law who didn’t have $200 to go to the doctor enrolled in Obamacare. Let’s stipulate that her initial doctor’s visit wouldn’t have counted at all toward her deductible (although any tests or actual treatments needed to prevent her kidneys from failing undoubtedly would have required her to exhaust that deductible). Even with those assumptions, she still would have needed to pay a significant co-pay for that doctor’s appointment. More important, she would have had to be paying hundreds of dollars a month, EVERY MONTH, for her plan. So to get to the point where her life-saving doctor’s visit only cost her say a $35 co-pay, she has to beg, borrow, or steal many times more than that.

    Of course, if she’s so destitute that she couldn’t spend $200 on a doctor’s visit, she probably qualified for Medicaid. If she didn’t qualify for Medicaid, then she certainly could have come up with the $200 somewhere, somehow (I mean, seriously). And in order to have reduced that $200 cost to a more manageable $35-50 co-pay, she would have had to come up with a lot more than that in the form of a monthly premium.

    Again, she always had the option of going to the ER (which she apparently knew, since that’s what she eventually did), where, as we all know, the uninsured get treated for free. So this wasn’t a failure of the status quo health care system to save a dying lady; it was a case of a dying lady and her family failing to take urgent action for no good reason at all.

  47. 147
    Robert says:

    Point of order – the uninsured are not treated for free. They are not denied care for inability to pay; that doesn’t make it free. It means they can go in without money in their pocket. The hospital will still try to collect. There are judgment-proof individuals who cheerfully exploit that fact and use the ER as their primary care physician on a whim – though not very many of them. But mostly, you’re on the hook for the care you use either way.

  48. 148
    Conrad says:

    @ 144: Nonsense. “Deserved it” implies that the outcome — this woman’s death — was somehow just. “It’s her fault” just goes to the issue of causation, i.e., whether something she did or failed to do led to her death. I don’t even know if this woman really existed, but if the facts are as you say, then she obviously caused her own death by waiting until it was too late to go to the E.R. If she really didn’t have any money, then she would have been treated immediately at the E.R. Therefore, her failure to go to the E.R. didn’t even save her any money!

  49. 149
    Conrad says:

    @ Robert: That may be true in fact, but I think it’s fair in this context to call such care “free” because for 20 years we have been told that the reason HC is so expensive is because the uninsured get to go to the E.R. for free and everyone else has to pay their tab through higher prices. So I’m simply taking it as a given that this premise is correct.

  50. 150
    Jake Squid says:

    Sure. It’s her fault for not being qualified for a better paying job and not having family members in position to pay for her medical care. It’s her fault for not realizing how serious her condition was and opting to wait until there was not question that she needed assistance. It’s her fault for not realizing how serious her condition was and not shelling out money she didn’t have for an office visit rather than relying on an emergency room visit where she didn’t have to pay up front.

    I’m really having trouble seeing where any part of her situation was her fault.

    This:

    We don’t know anything about this person’s situation other than she purportedly didn’t have the financial resources to go the doctor when she was feeling ill and she waited too long to go to the ER.

    and this:

    I don’t even know if this woman really existed…

    Nice way to subtly say that I’m lying. If that’ll help assuage your conscience, I guess that’s what you need to do.

    (I’m known ’round these parts for just making shit up) /sarcasm

  51. 151
    RonF says:

    “for 20 years we have been told that the reason HC is so expensive is because the uninsured get to go to the E.R. for free and everyone else has to pay their tab through higher prices.”

    So now instead of everyone paying their tab through higher prices we’ll have to pay their tab through higher taxes. It still has to be paid for, right? Plus, we add a whole new layer of bureaucracy.

  52. 152
    nm says:

    BTW, not being able to afford insurance premiums makes it highly unlikely that the woman in Jake’s story would have been OK if only her in-laws or someone had come up with $200 for a doctor’s visit. A doctor sets the rate for an office visit, at, say, $300; an insurance agency negotiates with the physician or medical group that the agency’s clients will be billed only $200 for the visit (and, depending on the clients’ policies, they will be charged anything from a relatively small co-pay to [if they have a large deductible] the full $200). But the woman in the story, with no insurance, will be billed the full $300. And probably the doctor will want to run some tests — simple bloodwork or urinalysis can be set at a rate of $400 (with insurance companies negotiating the amount their clients will pay down to $280 or so), and anything requiring a CT scan, MRI, ultrasound, or anything else involving large equipment will run to twice that. So the poor woman is going to be facing a bill of $1,000 or so, just for the diagnosis. (You can add in the hours of work she would have had to miss to be at the appointment [where she might have been kept waiting for an hour or so because some emergency had come up] and have the tests done, but at minimum wage that’s not going to come to all that much more.) Then there’s the “we need more tests, come back in,” and the “you’re going to have to see a specialist [at a much higher charge for an office visit than a GP charges] about this,” and any medication or other treatment she would need. All of those billed to her at a much higher price than to anyone insured. It really isn’t as simple as “a bunch of people could have helped her come up with $200.” I don’t see how she could have cured the problem, even if it had been caught much earlier, for less than $2,000, and it might well have been more. I don’t see how her going to the ER sooner would have solved her fundamental problem, which is that she can’t afford health care.

  53. 153
    Robert says:

    ” I don’t see how her going to the ER sooner would have solved her fundamental problem, which is that she can’t afford health care.”

    A problem which still exists and which has not been substantively addressed by the legislation. OK, now at some expense to the taxpayer (which we can probably shrug off as being not that much) and at some expense to herself (which is probably a significant hardship and a blow to settled expectations about what lifestyle her earnings bring in), she has health insurance – which will relieve *society* of the cost of taking care of her if something major goes wrong, but still leaves her on the hook for much of the hard-to-afford day to day spending that she is used to foregoing.

    The ACA may, if things pan out, make the fiscal situation better for the government. It may, if things pan out, make the health and fiscal situation better for a numerically small but not huge group of people who were genuinely boned under the previous paradigm.

    But for people like Jake’s deceased friend, it doesn’t do much and what it does do comes with a cost.

  54. 154
    Jake Squid says:

    But for people like Jake’s deceased friend, it doesn’t do much and what it does do comes with a cost.

    Well, it does do something. She can go to the doctor without having to shell out money up front. Since she has insurance, she either need only come up with her copay (if it’s a fixed dollar amount) or be billed for what insurance doesn’t pay long after she’s left the office. This is how insurance works.

  55. 155
    Ampersand says:

    Of course, if she’s so destitute that she couldn’t spend $200 on a doctor’s visit, she probably qualified for Medicaid.

    This probably isn’t true. Before Obamacare kicks in, this coming January, just being poor will not qualify you for Medicaid in the large majority of states.

    Even after Obamacare kicks in, being poor will only qualify you for Medicaid if you’re in a state that accepted the expansion of Medicaid to cover the poor. A bunch of states with Republican governors have refused the Medicaid expansion, so someone living in one of those states won’t qualify for Medicaid, even after Obamacare.

    Incidentally, the Medicaid expansion is the single largest component of Obamacare (measured by spending). That you didn’t even know about it – or about how Medicaid operates in the status quo – says a lot about how little you know what you’re talking about.

    If she didn’t qualify for Medicaid, then she certainly could have come up with the $200 somewhere, somehow (I mean, seriously).

    I’m not sure how to respond to this sort of reality-denying nonsense.

    1) Some people really can’t come up with $200. (Or the far more than $200 a doctor’s appointment without insurance could plausibly cost).

    2) You don’t get to know ahead of time that your sickness is fatal. So it’s not “I’d better use every last favor I have, burn bridges, put myself in debt to everyone I know, beg, scrounge, do WHATEVER IT TAKES because I’ll be dead if I don’t come up with $200, or $400, or whatever.” It’s “I’d better do all that because I’m feeling under the weather and bad, and then in a month when I’m feeling bad again I’ll be in the exact same hole except I’ll owe everyone I know money.” Lots of ordinary people aren’t going to do that – one of the most common ways of being frugal, if you’re poor, is to put off going to the doctor until you’re POSITIVE that you really really HAVE to. (Which is what this woman did.)

    I’m not prepared to argue over whether or not people do this, Conrad. People do this. It’s extremely well-documented.

    And in order to have reduced that $200 cost to a more manageable $35-50 co-pay, she would have had to come up with a lot more than that in the form of a monthly premium.

    Not if she was on Medicaid, which she might well have been had Obamacare been in place – in that case, she wouldn’t have had premiums at all.

    And if she wasn’t on Medicaid, for a lot of people, a subsidized monthly premium of (say) $80 a month is much easier to come up with than a lump sum for a doctor’s visit.

    The plans under Obamacare all include a free annual check-up. This is important, because it means that even without money, people using Obamacare can have a GP who is “their” doctor. This means you have an office you can call and ask “does this sound like I should come in?” It’s a gateway to the health care system that makes a big difference.

    In 2007, I had no medical care because I was youngish and (as far as I knew) healthy and hadn’t planned well. Then I started having a searing, overwhelming pain in my left forearm, a pain so intense that the only thing I had ever felt to compare was tooth pain that required a root canal to fix. Since I didn’t have a primary care doctor, I was using urgent care and ERs for treatment. The treatment I got was lousy, because those folks really aren’t there to do the job of a primary doctor.

    Someone at an urgent care (or was it an ER? I can’t remember now) finally told me that I needed to get a primary care physician, because they’d provide routine care – specifically, a cortisone shot. And I did, but it felt like an epic struggle. Because I could barely think or focus on anything, and simple tasks – do a google search, figure out bus routes, call offices and find someone who can see me ASAP, keep legible notes so I knew who I had already called, etc – had become mind-bogglingly difficult. And either out of pride or out of pain-besotted bad judgement, it didn’t occur to me to tell Charles (or my mom, even) “I’m having a lot of trouble managing finding a doctor. Help me.”

    And, to be fair, I was right in the end – I did manage to find a doctor, on a bus route I could use, who had a Physician’s Assistant who could see me right away. She gave me a shot, and the pain went away. She also gave me my first general physical exam in many years, and that’s how I started getting treatment for my diabetes.

    A couple of years later, I had a similar episode. Mysterious pain sucks, and I’m not going to claim that the second time around it was great. But it was much easier, because I had a primary care doctor. I had someone I could go see, whose instructions I could follow, who told me things like “here, this is the name of a physical therapist who can take you this week.” It was much less frightening than dealing with ERs.

    You guys obviously have a political reason to pretend that the things Obamacare provides – free care if you’re poor enough, subsidized care if you’re not, the inducement of a free annual exam to get people to get a primary care doc, etc – make no difference. And in some cases they wouldn’t. But it’s ridiculous to ignore that there are many cases where these things do, in fact, make a difference.

  56. 156
    Robert says:

    “Well, it does do something. She can go to the doctor without having to shell out money up front.”

    She could do that before.

    “Since she has insurance, she either need only come up with her copay (if it’s a fixed dollar amount) or be billed for what insurance doesn’t pay long after she’s left the office.”

    The first is not her not having to shell out money up front; it is her having to shell out a probably lesser sum of money, but money nonetheless.

    The second would seem to be rather at the discretion of the doctor’s office; I have been in more than one where the signage made it crystal clear that you were going to be making your copays, or not seeing the doctor. Possibly the actual human staff people would be more merciful; either way, though, it’s not a guarantee that you’ll be seen.

    And that all leaves unsaid the question of what treatment was needed to save her life. If it was something awful that was going to cost tens or hundreds of thousands of dollars, then yes – the ACA would have given her a better outcome. If, as is equally possible, it was something kind-of awful that was going to cost two or three thousand dollars, then the ACA wouldn’t have done diddly, other than to retrospectively make it harder for her to save up money for healthcare expenses.

    Nobody is usually wrong about things but he (perhaps inadvertently) struck a primary vein of Truth when he said that your friend’s problem was that she didn’t earn enough money to pay for health care. That is a real problem. It’s one that the ACA, focused as it is on being a corporate welfare program for the insurance business, doesn’t do a lot to substantively address.

  57. 157
    Jake Squid says:

    I have been in more than one where the signage made it crystal clear that you were going to be making your copays, or not seeing the doctor.

    If your copay is in the form of a percentage, the office can’t tell you how much it is up front. They need to wait for payment from the insurance company and an EOB in order to know how much to bill you. In the case of your copay being a percentage, you pay no money up front.

    This is the way that insurance works.

  58. 158
    Robert says:

    “And if she wasn’t on Medicaid, for a lot of people, a subsidized monthly premium of (say) $80 a month is much easier to come up with than a lump sum for a doctor’s visit.”

    It’s easier to plan for; I don’t see how it’s easier to come up with. Say I’m barely making expenses; if you tell me that I have to come up with $80 a month going forward, OK at least I know about it. But I go to the doctor maybe once a year, and it costs me $100 or $200. That premium needs to be subsidized down to $15 a month or so for it to be easier to come up with.

    Regarding the person not on Medicaid being able to come up with $200 – I believe that what Conrad is saying is that an employed person who earns a little bit more than the Medicaid cutoff for their state – $15800 for a single person in Oregon – obviously has $200 in their hands at some point, and the question is what do they have to give up to be able to hand $200 to the doctor. There is probably a fairly good social consensus on what we hear the person has to give up before we think it’s reasonable to ask that of them.

    As for being unwilling to acknowledge the benefits – I think I’ve been quite fair, and have been explicitly taking pains to be so, to mention the things like wellness exams which are ‘free’ under the ACA. You are right that we should not ignore the places where it could make a difference – and similarly, you and your ilk should recognize that the rhetorical tests which have been bandied about on the left about ‘people having access to care’ and ‘medical care that people can afford’ have not in fact been fixed – or in many cases, even addressed – by the ACA.

    Jake is convinced that access to a high-deductible insurance policy would have saved his friend. I can’t and don’t deny the possibility; all I ask is that there be recognition that her policy was far from a panacea and that the cost that it required her to bear would well have

  59. 159
    Ampersand says:

    She could do that before.

    Do you mean the ER? Because a general practitioner, if they accept an uninsured patient at all, will want payment up front.

    If it was something awful that was going to cost tens or hundreds of thousands of dollars, then yes – the ACA would have given her a better outcome. If, as is equally possible, it was something kind-of awful that was going to cost two or three thousand dollars, then the ACA wouldn’t have done diddly, other than to retrospectively make it harder for her to save up money for healthcare expenses.

    You’re ignoring the possibility that she would be able to get on Medicaid because of Obamacare, in which case there’s no deductible.

    Even if she doesn’t qualify for Medicaid, something that would have gotten her diagnosed earlier would be of enormous value, because it would have let her know that this was a life-or-death matter. For some people, that wouldn’t help, because there’s no way they could come up with a maximum out-of-pocket of $2500 even if they knew their life depended on it. But there are other people who, if they had a doctor saying “you need this treatment or you will die,” who would be able to come up with it.

    Furthermore, if you have a diagnosis of a life-threatening problem, no ER will turn you away. So as an absolute worst case option, you can take that diagnosis and go to an ER and get billed. (The same ER would turn you away if you showed up saying “I feel under the weather.” ERs will turn down people who don’t appear to have urgent needs.)

  60. 160
    Ampersand says:

    Incidentally, just two years ago, conservatives were saying that greater access to high-deductible plans were just what was needed. “Skin in the game” and all that.

  61. 161
    Robert says:

    “In the case of your copay being a percentage, you pay no money up front.

    This is the way that insurance works.”

    That is the way that some insurance works; most people would hate the unpredictability of cost under that model for something like doctor’s visits. In fact, in the industry, what you describe is not a copay, it’s coinsurance – and they generally use it for things like procedures and drugs, rather than fixed-service units like doctor’s appointments.

  62. 162
    Robert says:

    “Incidentally, just two years ago, conservatives were saying that greater access to high-deductible plans were just what was needed”

    For relatively rich people, who do have some ability to self-finance health care, to get them to exercise price discrimination, yes, some conservatives said this.

    I myself made high-deductible cat care plans one of the cornerstones of my rough-sketch proposal for a market-based health care reform system – though in my scheme those plans were used to amortize the cost of major care episodes, not to finance routine care.

    Routine care ought to be paid out of pocket, and subsidies given to those who are too poor to cover their own routine care.

  63. 163
    Ampersand says:

    “And if she wasn’t on Medicaid, for a lot of people, a subsidized monthly premium of (say) $80 a month is much easier to come up with than a lump sum for a doctor’s visit.”

    It’s easier to plan for; I don’t see how it’s easier to come up with.

    I said “a lot of people,” not all people. For someone in Oregon who earns $16,000 a year, they could get a silver plan for $45 a month, or a bronze plan for $10 a month.

    Now, there are people out there who cannot manage $45 a month or $10 a month. But for most people with low incomes, coming up with $45 a month – or $10 a month – is much easier than coming up with $300 in a lump sum. This is because most employers pay once every two weeks, or once a month; you don’t pay for expenses out of your annual income, you pay for expenses out of your bi-weekly or monthly income. If you have $175 a month left over after all your expenses, then you can afford to pay $45 or $10 a month, but that doesn’t mean you have $200 on hand (or that even if you do, you can risk spending it all in one place).

    Obamacare is not a panacea, and would not solve 100% of all problems. (Nothing would do that, of course.). But it is a huge improvement over the status quo, for many people. And although it’s not certain, it’s not at all implausible that the person Jake is talking about would have been helped now be alive if Obamacare had been in place.

    This year, I have no realistic long-term plan for how I can keep getting crucial medical care I need. Starting next year, I can afford it, because of Obamacare. As a result, I will (probably) live years longer (assuming that I am typical in being helped by my medication and that I don’t get hit by a bus). People like me do exist.

  64. 164
    Ampersand says:

    In the case of Medicare Part D, Republicans weren’t actually extending coverage to those who don’t have it; rather, they were increasing coverage to those who already had it. Democrats didn’t object to the principle of expanding Medicare coverage, and have supported policies to do so (for a recent example, Obamacare’s closing of “the donut hole”); the objection was to the method of Medicare part D (i.e., not paying for it), not the principle of helping people on Medicare.

    With hindsight, the GOP was right, because Medicare Part D ended up being so much cheaper than anyone (including the CBO) was predicting at the time.

    (Wait, my spell checker doesn’t know “donut”? Seriously?)

    In contrast, the GOP has never offered any legislation that would plausibly help bring health coverage to the tens of millions of Americans who don’t have it. So, yes, I stand by my earlier claim. The GOP can’t credibly claim to be in favor of poor and low-income Americans having health care because it has opposed every plan to make health care available to those Americans, and never once offered a plausible plan of its own.

    (The only exception is that decades ago, the GOP once offered an “individual mandate” plan – and they offered that only as an alternative to Clinton’s plan, when they knew it couldn’t pass. As soon as the individual mandate because politically plausible, the GOP not only opposed it but suddenly said it was obviously unconstitutional. So I don’t think the GOP support of the individual mandate was genuine.)

  65. 165
    Jake Squid says:

    Doughnut. D-O-U-G-H-N-U-T. Doughnut.

  66. 167
    Jake Squid says:

    That’s not what your spellchecker things, wise guy.

  67. 168
    Robert says:

    “In contrast, the GOP has never offered any legislation that would plausibly help bring health coverage to the tens of millions of Americans who don’t have it. So, yes, I stand by my earlier claim. The GOP can’t credibly claim to be in favor of poor and low-income Americans having health care because it has opposed every plan to make health care available to those Americans, and never once offered a plausible plan of its own.”

    http://www.heritage.org/research/reports/2008/10/the-mccain-health-care-plan-more-power-to-families

    Amp, I will grant you that Democratic presidents have taken more of a leadership role in creating and expanding Medicaid/Medicare, and I will grant you that on balance, Democratic Congresses have been more generous and Republican Congresses less generous in their willingness to expand and extend those programs.

    But until the ACA, every major national healthcare bill has had bipartisan support to a greater or lesser degree – usually a greater. The ACA is the first major social reform legislation in the modern era to pass on a party-line vote. It is not one in a long series of Democrats-give-Republicans-withhold policy struggles; it is a stark exception to a long and generally honorable bipartisan process.

    For you to state that the Democrats have always been trying to give away more healthcare and Republicans have been saying no, is either profoundly ignorant of the legislative bipartisanship that has in fact been the pattern for the last 75 years (at least), or deeply dishonest.

  68. 169
    Myca says:

    That’s not what your spellchecker things, wise guy.

    I think you mean “thinks,” wise guy.

    ;)

    —Myca

  69. 170
    Grace Annam says:

    Jake Squid:

    A true story from one week ago:

    Her kidneys had stopped working, her body shut down and she was dead a couple of hours after arriving at the emergency room.

    Jake, that is terrible. My heart goes out to you. I sorrow to hear that you have lost a friend.

    Grace

  70. 171
    Jake Squid says:

    Hee, hee!

  71. 172
    Conrad says:

    The problem with trying to use this woman’s situation as an example of why Obamacare is such a great thing is that we don’t know her financial situation (beyond the fact she was a fulltime, minimum wage worker); we don’t know whether she could have been on Medicaid; we don’t know what her O’care plan (if any) would have cost; we don’t know what it would have provided in terms of doctor’s visits/co-pays, etc.; we don’t know if she would have elected O’care coverage or balked at the price/deductibles and remained uninsured; and we don’t know what her specific diagnosis was, treatment options; the cost of those, etc. So there doesn’t appear to be any factual basis for the conclusion that earlier enactment of Obamacare would have saved this particular person’s life.

    I would also point out that, as a result of Obamacare, there are undoubtedly going to be a lot of people who PREVIOUSLY had either employer-paid or self-paid HC insurance who will now go uninsured because their employer dropped their insurance plan and/or they will decide they cannot afford the high-premium-high deductible plans that are being offered by the exchanges. Some of THOSE people will now die because they didn’t go the doctor and find out that their kidneys were failing.

    Keep in mind that, under the exchange policies, a person is going to under up paying from 40% (bronze) to 10% (platinum) of their own HC costs, with the vast majority paying in the 30-40% range. So we are still going to see a lot of people going uninsured and thus taking the chance on not getting seriously ill.

    As for the comment above that conservatives wanting to see people bear a higher percentage of the costs of care (“skin in the game”), that’s true as far as it goes, but that goal assumes a free market where people can shop, across state lines, for essentially whatever coverage they want. To the extent we are operating withing a regulatory frameword (Obamacare) where individuals are forced to pay say $12,000/year with $6,000 deductibles, then I don’t really see how it advances any particular policy objective of conservatives for people who are captive within that govt-controlled system to have to pay 40% of their own costs. IOW, I’d like to see us go back to a market based HC sector, which would mean that while people would be paying most of their own HC expenses, they would have the ability to pay only for what they wanted from providers/insurers who had the flexibility to engage in real competition with other providers/insurers to meet the demand.

  72. 173
    Jake Squid says:

    Thanks, Grace. It’s actually my friend’s sister-in-law, so not somebody I know personally. I feel exactly the sentiments that you expressed for my friend and her brother.

  73. 174
    Mandolin says:

    I don’t even know if this woman really existed…

    Hi Conrad,

    After discussing the matter with Ampersand, I’ve come to the conclusion that we’re going to have to ask you to leave Alas. Thank you for your contributions thus far, and we wish you best of luck on your further internet travels.

  74. 175
    RonF says:

    The correct spelling is “doughnut”. The acceptance of the word “donut”, obviously invented by someone too cheap to spell the whole word out on their bakery’s sign or in their newspaper ad, is the result yet once again of corporatist corruption of American culture. Have we sunk so low that even the left uses this meme of the 1% to oppress us all?

  75. 176
    Jake Squid says:

    Ron,

    The left wholeheartedly endorses Kwality with a capital “K”.

    Also, “donut” is an efficiency. One may as well call out automation as “cheap” if one classifies “donut” as anything other than increased productivity due to the efficiency of the proud American union laborer. The real corrupt corporatism here is the refusal of those corrupt corporations to allow “donut” through their spellcheckers.

  76. 177
    Ampersand says:

    I wrote, “The GOP can’t credibly claim to be in favor of poor and low-income Americans having health care because it has opposed every plan to make health care available to those Americans, and never once offered a plausible plan of its own.”

    Robert responded by linking to John McCain’s health care plan.

    1) Robert, it’s hard to accept a health care plan that McCain offered only to counter Obama’s health care plan as a sign of any serious commitment by the GOP to extending health care to those that don’t have it. McCain had no interest in health care before running for President, and has done nothing to work for his plan in the years since losing the election; it’s naive to think that his plan was anything other than a cynical political ploy.

    2) IIRC, McCain never developed his plan in enough detail to submit it to the CBO for scoring (which is a sign of how unserious he was). But independent health care economists, including a panel of economists at the journal Health Affairs, found that the McCain plan would decrease the number of uninsured Americans by only 1 million – and that only temporarily.

    3) McCain’s plan cynically used accounting tricks to make the plan cheaper, at the cost of reducing the tax credit gradually. It did this by linking the tax credit to regular inflation, rather than medical inflation. Since medical inflation is higher than regular inflation (especially since McCain’s plan, unlike Obamacare, had no serious attempts at cost controls), the result of the plan is that those people who could have afforded health insurance due to a $5000 or $2500 in 2012 would find themselves priced out of the market by 2017, because the value of the tax credit would go down every year.

    In fact, because McCain’s plan would have forced about 20 million Americans off of employer health plans (by reducing or removing the tax subsidy for employer health plans – something I would find to be a good idea if it were part of a better plan) on to the individual market, and then gradually reduced the tax credit, the long-term result of his plan would have been to increase the number of uninsured Americans.

    So no, McCain’s plan never would have helped many Americans at all – certainly not in comparison to what Obamacare is projected to do – was cynically designed to provide only the illusion of aid, and never seemed to be taken very seriously by McCain or other powerful Republican legislators.

    Robert, you’re right to say that in the past there are some examples of Republicans supporting programs to help poor people who lack health coverage, such as the Republicans who voted for Medicare a half century ago. That is true; for example, 13 of the 32 Republican Senators then in office voted for Medicare. But let’s be clear – the only reason Medicare came up for a vote at all is that the Democrats had Johnson in the White House and massive majorities in both the House and Senate. (Not a single Republican in the House committee voted to let Medicare out of committee – although when time came for the final vote, 70 Republicans in the House did vote for it).

    Because Republicans realized they couldn’t stop Medicare from passing, some of them compromised; they voted for Medicare in exchange for Medicare including some of their ideas. That’s the way the system ideally works – and the way it would have worked for Obamacare, if there were any Republicans who were willing to support compromise legislation in exchange for their votes. However, there weren’t any, even though Obama was obviously desperate for even a handful of GOP votes and would have given away a lot for them.

    Why the difference? First of all, in 1965 there were conservative Democrats and liberal Republicans in Congress, which helped facilitate cross-party deals. Nowadays, there are no liberal Republicans at all in Congress, and only a bare handful of conservative Democrats (Lieberman isn’t even officially a Democrat anymore). Second of all, the parties were less powerful, and members felt freer to cross party lines on votes.

    But those liberal Republicans who voted for Medicare are (almost?) all dead now. The current group of Republicans in Congress is, in fact, ideologically opposed to the idea of government massively expanding the number of insured Americans, which is why none of them were willing to sell votes in exchange for (say) HSAs. Apart from those 13 long-dead Senators 49 years ago, Republicans have not earned any credibility on this issue.

    Remember “repeal and replace”? There’s been something like 30 votes to repeal in the House, but not one serious replacement proposal. Because Republicans in the House genuinely have no credible legislative ideas for helping the sick and needy. (Indeed, I suspect they’re afraid that if they pass any such legislation, Democrats would support it and it might pass.) They’ve demonstrated, over and over, that it’s not something they care for or about, and you’re fooling yourself if you think otherwise.

    If you want a Republican party that can speak to health care with credibility, then Republicans have to elect better representatives – ones who will support serious health care policy. That the best you can offer is McCain’s joke of a plan, offered only because he was trying to compete with a Democrat, says it all.

  77. 178
    Robert says:

    It’s not the “best I can offer”; it’s what came immediately to mind when you said there wasn’t anything at all. Yes, it’s true that John McCain didn’t try to advance the reform plan that was part of his Presidential campaign; it’s also true that Dennis Kucinich didn’t to pull the US out of NAFTA and CAFTA (one of his signature issues) after his presidential losses. When you don’t win the election, generally speaking your policy proposals don’t get a lot of traction. Particularly when you are a Senator and the policy in question is one that would be initiated in the House.

    There have been dozens of Republican health care proposals, some of them crap on a stick, some of them decently interesting, over the past couple of decades. There have similarly been dozens of Democratic proposals. Like most legislation that gets proposed, most of the proposals from both parties went nowhere. There are undoubtedly a lot of Republican proposals (expanding voucher programs for example) that you wouldn’t think were “serious” because they didn’t align with your preferences for how to get things done, but the proposals were floated. Getting legislation passed is hard.

    I’m not going to go into the weeds on the McCain proposal, but it was less grimly worthless than you suggest, as a starting point. It would have successfully decoupled insurance from employment, something that nearly everyone agrees is the sine qua non of any health care reform, but which was in and of itself an enormous heavy lift at the time, and it was lauded by all sides on that point when McCain made the suggestion.

    You’ve made some absolutist statements, and they’re complete rubbish. Your characterizations are true in the sense of of direction – Democrats have made health care reform a higher priority than Republicans have – but then you blow it by making crazy statements in the sense of magnitude; Republicans have not ignored health care forever and never voted to help anybody and stomp kittens for fun. You ruin your credibility by insisting that the other side is Satan when even a stringent ideologue would say that the other side is just Charles Manson, and a neutral person would say the other side is the guy who invented Comic Sans.

    Although, fuck that guy.

  78. 179
    gin-and-whiskey says:

    Yoghurt?
    Or Yogurt?

  79. 180
    RonF says:

    I call it spoiled milk and I don’t care how it’s spelled.

  80. 181
    Ampersand says:

    Robert:

    Your characterizations are true in the sense of of direction – Democrats have made health care reform a higher priority than Republicans have – but then you blow it by making crazy statements in the sense of magnitude; Republicans have not ignored health care forever and never voted to help anybody and stomp kittens for fun.

    Robert, there’s something ironic about you making extreme and untrue statements what I’ve said in order to claim I’m making extreme and untrue statements. I never said that “Republicans have ignored health care forever,” nor that they “never voted to help anybody.” Please try quoting what I’ve actually said next time, rather than making up nonsense that I didn’t say.

    I didn’t say that Republicans are against all heath care proposals; obviously, they are for some things, such as tort reform. But they are opposed to using the government to create universal, or near-universal, health coverage for uninsured Americans. Doing what Obamacare does – expanding care to 25-35 million uninsured Americans – is something that the currently-in-Congress Republicans 1) have not proposed and 2) ideologically disagree with as an appropriate goal for the government.

    This isn’t at all far from what Ross Douhat just wrote, characterizing the difference between conservative and liberal health care policy goals:

    While Obamacare may be using neoliberal rather than New Deal-style means, it’s still chasing essentially left-of-center ends: It seeks a level of universality and comprehensiveness that conservatives don’t think is necessarily worth pursuing. [...] in the conservative alternative… You aren’t trying to get everyone comprehensive coverage…, Now the cost of this more decentralized approach is, admittedly, that it leads to something less than universal, comprehensive coverage.

    Re: Kucinich vs. McCain:

    Kucinich actually has a long track record, both before and after running for President, of speaking out against NAFTA and the like, so he’s not comparable to McCain, whose interest in expanding health care coverage was opportunistic and ended with the election. And I agree, proposing to decouple insurance from employment is good, but I don’t think that contradicts what I’m saying about GOP opposition to universal or near-universal coverage.

  81. 182
    Robert says:

    “I never said that “Republicans have ignored health care forever,” nor that they “never voted to help anybody.” ”

    Aha, so you cop to accusing us about the kitten stomping.

    You:
    “[Republicans have] never once made a serious proposal that would plausibly bring medical care and coverage to anywhere near that many people”
    = Republicans have ignored health care forever

    You:
    “The GOP…has opposed every plan to make health care available to those Americans”
    = Republicans never voted to help anybody

    “Doing what Obamacare does – expanding care to 25-35 million uninsured Americans – is something that the currently-in-Congress Republicans 1) have not proposed and 2) ideologically disagree with as an appropriate goal for the government.”

    First, Obamacare doesn’t expand care to 25-35 million uninsured Americans. It may end up there, though I doubt it. Instead, it provides subsidies for some and penalties for others and attempts to persuade, bully, or nag 25 to 35 million Americans who do not currently participate in the corrupt and criminal enterprise that is health care insurance, and many of whom do not want to, into becoming part of the sucker pool . Your statement is akin to saying that the Miami Dolphins win the Superbowl. That is their stated intention; it is not yet mathematically impossible for it to happen; that does not make the goal into an active truth.

    You are correct that Republicans do not think that bullying people into buying a shitty product sold by evil people on the private market is an appropriate goal for the government. Damn right, skippy. It’s a badge of honor.

  82. 183
    Ampersand says:

    “[Republicans have] never once made a serious proposal that would plausibly bring medical care and coverage to anywhere near that many people”
    = Republicans have ignored health care forever

    Robert, those two statements are obviously not interchangeable (ditto for your other example).

    First, Obamacare doesn’t expand care to 25-35 million uninsured Americans. It may end up there, though I doubt it. Instead, it provides subsidies for some and penalties for others and attempts to persuade, bully, or nag 25 to 35 million Americans who do not currently participate in the corrupt and criminal enterprise that is health care insurance, and many of whom do not want to, into becoming part of the sucker pool .

    And you accuse me of being the one engaged in emotional ranting.

    One way or another, providing universal health care means making everyone but the lowest-income folks pay for health care. The Heritage Foundations idea of using the individual mandate was chosen as a sop to “moderate” Democrats, and so people will be forced to either pay an affordable penalty, or to buy health insurance. (If it were up to me we would have tax-funded single-payer instead.)

    Nonetheless, the loss of choice for someone forced to pay an $80 or 1% penalty, or to buy health insurance, seems pretty trivial compared to the losses suffered under the status quo to people who can’t afford to get needed health care, such as the example Jake brought up, or some of these folks who have been helped by the early-starting provisions of Obamacare.

    About half of the people Obamacare is projected to help will be on Medicaid – free health care, not a subsidy. There are also millions who are eager for insurance, but have been kept off it by lack of money, or by pre-existing conditions. They count, too.

    You are correct that Republicans do not think that bullying people into buying a shitty product sold by evil people on the private market is an appropriate goal for the government. Damn right, skippy. It’s a badge of honor.

    Compared to what?

    Any system intended to reach 30 million people is going to have some problems; there is no large health care system in the world where you can’t find anecdotal examples of it sucking, due to the fact that the numbers involved are so large. If Obamacare works as designed, it won’t be perfection, but it’ll be hugely better than the status quo. And that – not some imaginary world in which nothing ever goes wrong – is the relevant comparison.

    In the status quo, millions of people are go through the stress and misery of not being able to afford the health coverage they need. Some of them die; some just suffer. There’s no reason in the world Americans should continue to settle for less health care than (say) the French get. There’s no reason at all, in America, that a sick person should feel that she can’t go to the doctor to get checked out because she doesn’t think she can afford it and she isn’t yet suffering enough so that she feels she has no choice.

  83. 184
    Robert says:

    “One way or another, providing universal health care means making everyone but the lowest-income folks pay for health care.”

    This is a strange new definition of the word “providing” that I am not familiar with. So if I come to your house, make you and the kiddies and everybody go out into the backyard and plant crops and harvest veggies and raise a cow, at gunpoint, I am “providing” you with food?

    I’m not being pedantic here. (Or if I am, it’s for a purpose.) Words mean things. You’re taking a word that means “give” and using it as the justification for coercion.

    “We can’t have universal health care unless everybody…” is one thing. But that’s not provision, it’s having.

    “Nonetheless, the loss of choice for someone forced to pay an $80 or 1% penalty, or to buy health insurance, seems pretty trivial…”

    In 2016, the penalty becomes 4.5% of income or $695, whichever is greater. Some $10/hour hard-working blue-collar single mom who doesn’t want to be on Medicaid and who doesn’t want a handout is going to be paying $900 a year for the privilege of disagreeing with you about what her health care options ought to be. That doesn’t seem trivial to me.

    “If Obamacare works as designed, it won’t be perfection, but it’ll be hugely better than the status quo.”

    Is there the SLIGHTEST SHRED of evidence that Obamacare is going to work as designed? That millions of healthy young people are going to flood into the insurance marketplace, waving their premium checks above their heads and demanding that they be allowed to get high-deductible insurance?

    They can’t get a damn website to work as designed, and you persist in thinking that they are going to successfully pull of complete overhaul of health-care financing? That optimism would have been a sign of faith five years ago; today it is near schizophrenic in the distance from reality that maintaining it must require.

    “In the status quo, millions of people are go through the stress and misery of not being able to afford the health coverage they need. Some of them die; some just suffer.”

    Nobody needs “health coverage”. Health coverage describes one way, among infinite millions, of *FINANCING* a health-care need. People need health care, period. Again with the words. Again with the sloppy descriptors enabling sloppy thinking.

  84. 185
    Ampersand says:

    So if I come to your house, make you and the kiddies and everybody go out into the backyard and plant crops and harvest veggies and raise a cow, at gunpoint, I am “providing” you with food?

    I’m not willing to have the “paying taxes for things I don’t agree with in a representative democracy is the same as being enslaved at gunpoint” argument.

    In 2016, the penalty becomes 4.5% of income or $695, whichever is greater. Some $10/hour hard-working blue-collar single mom who doesn’t want to be on Medicaid and who doesn’t want a handout is going to be paying $900 a year for the privilege of disagreeing with you about what her health care options ought to be. That doesn’t seem trivial to me.

    Since she is voluntarily choosing to pay $900, when she could instead sign up for Medicaid for free, that does seem trivial. Much more trivial than the problems of someone who is involuntarily without medical care because she can’t afford it.

    It’s too early to know how Obamacare will come out, although the website has certainly been a disaster so far. But websites can be fixed (Medicare Part D’s was). The last two presidential elections in a row, Republicans at this time were declaring McCain/Romney a sure shot to win; they were premature in counting Obama out then, and they’re premature in counting Obamacare out now.

    I don’t need to predict, or prove, that Obamacare will work. We just need to wait a while and see. If there are millions of Americans getting coverage through Obamacare by the 2014 elections, then I think Obamacare will be here to stay.

  85. 186
    Robert says:

    “I’m not willing to have the “paying taxes for things I don’t agree with in a representative democracy is the same as being enslaved at gunpoint” argument.”

    Then don’t say the government is GIVING something when it is in fact ordering people to provide it themselves.

    “Since she is voluntarily choosing to pay $900, when she could instead sign up for Medicaid for free, that does seem trivial. ”

    But she’s not going to be paying for her own care either way. What is the point of a system that obliges her to have the taxpayers carry her, to avoid the dreaded intolerable status quo outcome of…the taxpayers carrying her?

    “If there are millions of Americans getting coverage through Obamacare by the 2014 elections, then I think Obamacare will be here to stay.”

    There undoubtedly will be. The vast majority of them will be new enrollees to Medicaid, and Obamacare will become a huge budget buster, “here to stay” until the whole mess collapses in the shamble that the left apparently hopes for. But as a side benefit, the health insurance industry will be bankrupt too, so yay.

  86. 187
    Grace Annam says:

    Robert:

    Then don’t say the government is GIVING something when it is in fact ordering people to provide it themselves.

    Robert, in what way is Obamacare different from taxation to provide unemployment assistance, or disaster relief services, or roads and bridges?

    In the first two cases, we all pay taxes into the pot and the people who benefit are those struck by calamity … even if they had some hand in their own misfortune, for instance, by building or buying in a known flood zone.

    In the latter case, some people use roads and bridges more, and some use them less, and that amount of use has little relationship to the taxes we pay. Some people use them almost not-at-all, and still have to pay taxes. Others have four-hour commutes and pay not a lot more.

    What I’m getting at is that the whole IDEA of taxes is that we pay, somewhat according to a means, into a common pot, which then gets parceled back out for the benefit of all, in complex ways which tend (TEND!) to give more benefit to those who have more need.

    Now along comes Obamacare, and here you are, talking about slavery.

    Is all taxation and forced servitude?

    If a Quaker deliberately makes less than the minimum taxable income to avoid what I have heard them refer to as the “war tax”… are they free?

    It seems to me that the basic point: pretty much everyone pays, and pretty much everyone benefits, with more benefit going to those who lost the medical lottery (genetic, epigenetic, toxic exposures, blind luck, what-have-you)… that’s the same thing taxation does.

    Your objections strike me as terribly specific and overwrought, but I have not examined this issue closely (beyond being very, very glad that the law has levelled the playing field for medical care insurers by saying that they ALL have to accept pre-existing conditions, which struck me as a no-brainer fix to all the insurance companies complaining that they couldn’t compete if they couldn’t deny me coverage for knee reconstruction after an auto accident because it might all have something to do with my pre-existing diagnosis of transsexuality, which makes knee surgery VASTLY more medically complex).

    So why is Obamacare qualitatively different from taxation?

    Grace

  87. 188
    Robert says:

    I’m not sure where you think slavery comes into it; that was in the other thread. Amp used the word slavery to avoid having to defend his position that forcing me to do something is the same thing as giving me a gift, but it wasn’t my metaphor.

    “What I’m getting at is that the whole IDEA of taxes is that we pay, somewhat according to a means, into a common pot, which then gets parceled back out for the benefit of all, in complex ways which tend (TEND!) to give more benefit to those who have more need.”

    Yes. That’s the basic social contract for the liberal (classical sense) state. I have no objection to it.

    “Robert, in what way is Obamacare different from taxation to provide unemployment assistance, or disaster relief services, or roads and bridges?”

    Does unemployment assistance tell you that a technocrat in DC believes that your best use of your employment time is as a kindergarden teacher, and fine you with differential income taxation if you choose another path?

    Does disaster relief make it so that everyone – whether they built on a flood plain or on top of a mudslide-prone mountain or in the safest most geologically stable area on Earth – is to pay the same insurance premium for ‘disaster assistance’ regardless of the wisdom or foolhardiness of their local siting of property? Are people obliged to purchase disaster insurance regardless of their personal situation or risk tolerance or financial situation? Are companies obliged to provide flood insurance to residents of the Mississippi valley at the same premium that they charge residents of the Front Range mountains?

    Do the road and bridge taxes apply equally to everyone? Does it cost the same to register a bicycle as a Yugo as a Mercedes as a Mack truck? When bicyclists pay $10 for their vehicle license tax, is there a constituency saying “those guys need to be paying more licensing fees, because some day they’ll be driving a Mercedes or even a Mack truck, and it wouldn’t be fair if they only start paying the higher rates once they’re driving the bigger vehicle.”?

    The problem with mandating coverage of pre-existing conditions is not that there is something wrong with sick people getting health care or that – as a good Republican – I can’t get an erection without visualizing a minority group member being denied care for a terrible disease. The problem is that such mandated coverage, when not accompanied by a genuinely stiff individual mandate, leads to a dreadful moral hazard and places nearly all of the burden of the new entrant’s medical care on the shoulders of the people who behaved the MOST responsibly in the preceding years.

    (I dislike the individual mandate we have, and unlike Amp think it is a nontrivial wrong to force people to buy something they don’t want, and so on. But it isn’t a mandate so coercive as to create compliance; I don’t plan to comply, for example.)

    So let’s take the example of me and you and the rest of our little town. In Ampville, population 100, 99 people obey the Obamacare law and get health care insurance at varying expense to themselves and to the public fisc. But the budget balances thanks to a 85% tax on poptart sales, and everything is reasonably happy. The system incurs a total of $990,000 in medical expenses each year (about $10k per head) and the premiums total about the same. As in your example above, though some pay more and some pay less, the total tax + premium paid by the residents averages about $10k, and all is fiscally sound.

    But Badactor Bob, the 1 guy who did not comply, has been laughing each year and just paying the 4.5% of his income in tax penalties annually. Badactor Bob makes $30,000 a year, so his total tax penalty each year has been $1350; an average Ampvillian of his income would have been paying $4350 a year for health insurance had they participated. He has lived in Ampville for 10 years now, so he’s payed $13,500 in taxes+premiums, instead of $43,500. Every year of perfect health that passes, he banks $3 grand which he spends on liquor and loose women.

    Suddenly, Badactor Bob is struck with Testiculorectalthyroiduterine cancer, and oh my god is he gonna die. However, although TC is incurable, it would be wrong for Ampville to just stick Badactor Bob in a cheap hospice and wait for the miserable sonofabitch to pass. No, he has to be allowed to – right then, right there – buy into the Ampville exchange’s health insurance program, and pay his $4350 to get insured. Now he’s insured; hooray! treated. At an expense of $1,000,000, Badactor Bob gets chemotherapy and radiation beam dispersal treatments and uranium penile implant sheathings and everything else. Then he dies. Good riddance.

    More than 100 percent of the healthcare budget for the whole town has gone to fund treatment for one bad actor, who relied on the must-issue provision of the Ampville Cares Act to demand insurance treatment even though he had a pre-existing condition. The insurer goes bankrupt. Little Gracie, who had been counting on penicillin shots to cure her cooties, instead has to go to an aromatherapist that her mother finds on the Internet. The town falls into chaos and ruin. Everyone dies.

    Now – that is obviously exaggerated for (you must admit) comedic effect, AND a lot of the people who show up with pre-existing conditions are NOT intentionally bad actors. But once there IS a must-issue provision, it becomes *economically rational* to behave as Bob did. Why wouldn’t you? 3 grand a year is a lot of whisky and floozies.

    So that’s why must-issue is, at least some of the time in some systems, an issue. Yes, it seems like a no-brainer. But it isn’t.

    So why’s Obamacare different than taxation? Because it isn’t about taxation. I might have problems with a tax-and-redistribute system like you describe. I’m sure I’d be a jerk on Amp’s forum, pointing and laughing when the system broke in unexpectedly grimly amusing ways. But it would be a different set of beefs that I had. Tax-and-redistribute doesn’t oblige people to make a certain set of economic decisions the way that a certain set of technocrats think they ought.

  88. 189
    Ampersand says:

    Robert, I never said “gift.” If you’re going to be this techy about language use, then the least you could do is not baldly lie about what I said.

    Provision” is not the same as “gift”; it is commonplace among English speakers to speak of paying people to provide services, for instance, or to contract for provision of supplies.

    (And although I think describing people being forced to farm against their will at gunpoint as “enslaved” is reasonable, since you seemingly disagree, I withdraw the term.)

    The problem is that such mandated coverage, when not accompanied by a genuinely stiff individual mandate, leads to a dreadful moral hazard and places nearly all of the burden of the new entrant’s medical care on the shoulders of the people who behaved the MOST responsibly in the preceding years.

    *shrug* The penalties in Massachusetts were lower than they will be in Obamacare for most people, yet this has not been a problem in Massachusetts. True, Massachusetts is not identical to Obamacare, but the penalty size doesn’t seem to have been an issue there.

    (The biggest difference between Romneycare and Obamacare, for purposes of your argument, is that Romneycare has a six-month enrollment penalty for people who don’t sign up until they’re in need of treatment. However, that makes less of a difference than it might seem to at first glance. For instance, in your example, Badactor Bob has to wait six months before getting paid-for treatments – but unless he dies before treatments begin, that doesn’t save the state money, it just delays the spending by six months, and may will increase it if Badactor Bob’s treatment becomes more expensive because he got sicker during that six month pause of the six month delay in beginning treatment.)

    Furthermore, the premium prices on the health care exchanges have been set by private insurance companies, who set those prices according to a much more sophisticated analysis than yours, based on the size of the penalty that exists in law. (In other words, the insurance companies actuaries projected that the penalty will encourage at least X number of people to get insurance, and have set premium prices accordingly; if they projected that the penalty would not encourage at least X to sign up, they would have set premiums higher).

    We won’t know for sure for years – remember, if Obamacare works as planned, huge numbers of people who will eventually get insurance, won’t do so in the first two years as the penalty gradually gets larger (and that’s something insurance companies knew and incorporated into their projections) – but I think it’s very plausible that the penalty will work fine.

    Here’s what I’m wondering: If the mandate penalty does turn out to be too low, does it take an act of Congress to fix that? Or can that be fixed by the executive? Anyone know?

  89. 190
    Robert says:

    It’s written into the statute, so theoretically an act of Congress. Other things written into the statute have been waived or changed by executive whim, however, so who knows.

  90. 191
    Grace Annam says:

    Robert:

    But once there IS a must-issue provision, it becomes *economically rational* to behave as Bob did. Why wouldn’t you? 3 grand a year is a lot of whisky and floozies.

    So you’d be in favor of Obamacare if they raised the non-participation penalty, to make participation more economically rational?

    (Here I must confess to a fond love for the rational actors of economic theories. “Bob wants to enter into economic transaction AB with Jane. At what price point does it make the most sense for him to do so? Assume that Bob is a completely rational human being. Also assume a completely spherical and frictionless Jane. Hint: treat Bob as a point source of economic gravitas.”)

    Grace

  91. 192
    Grace Annam says:

    Robert:

    Does disaster relief make it so that everyone … is to pay the same insurance premium for ‘disaster assistance’ regardless of the wisdom or foolhardiness of their local siting of property?

    No, and rightly so, because people have much more choice when it comes to land ownership (total choice, in the strictest mathematically rational sense – near-total if you factor in actual human beings) than they have when it comes to body ownership. You get issued a randomly-generated body, and there are strict limits on how much you may change it, and many of those limits depend on — wait for it! — medical coverage.

    Apples and kumquats.

    Do the road and bridge taxes apply equally to everyone? Does it cost the same to register a bicycle as a Yugo as a Mercedes as a Mack truck?

    Not perfectly, but the taxation difference between a Yugo and a Mercedes is basically a form of means-scaling. Both put equal wear on roads.

    But once there IS a must-issue provision, it becomes *economically rational* to behave as Bob did.

    It was economically “rational” to behave as Bob did before, too — that’s why young people typically play the medical lottery and old people typically don’t. So Obamacare makes it economically more rational to participate than before – people closer to the “I think I better have medical care” line are more likely to sign up, and as Amp points out, the incentive becomes more powerful with time.

    If you’re saying that you want single-payer and pretty-much-everyone taxation to pay for it, and that Obamacare is a cobbled-together monstrosity, well, I agree on both points, but it was the best we could get with the paralyzed, tottering, bloated government we have. I am hoping fervently that the electorate, in ten years, will say, “Damn, this system is screwy. Let’s make it a lot simpler by enrolling everyone and move on to arguing about who gets how much care.”

    Grace

  92. 193
    Robert says:

    So you’d be in favor of Obamacare if they raised the non-participation penalty, to make participation more economically rational?

    No. I don’t favor collective solutions to individual problems. But it would be less destructive of the existing order. I don’t much like the existing order, either, but it has the virtue of having known flaws. The devil we know, etc.

    You get issued a randomly-generated body, and there are strict limits on how much you may change it

    Can you smoke? Mainline heroin while having unprotected sex with sketchy British pop stars? Jump out of perfectly good airplanes on the theory that a wad of silk no thicker than a handkerchief is going to somehow keep you alive? Vote Republican in Oregon?

    Yes, there are many things that happen to your body which are no fault of your own, for good and for ill, but the situations are not as non-analogous as you are holding. And you’re the one who analogized them in the first place with the original question.

    it was the best we could get with the paralyzed, tottering, bloated government we have.

    Indeed, for a particular, terrible, and terribly particular definition of “best”.

    One might also theorize that the paralyzed, tottering, bloated government we have is more on the problem side of the ledger than the solution side, and that “hey, let’s load another eight tons onto this spavined, dying, epileptic camel” is possibly not the ideal veterinary practice. If one wishes to heighten the contradictions, bring the capitalist edifice down in splinters, etc., then fine – load more onto the state and wait for the crash. But even if I had a socialist or Marxist endgame in mind (and I don’t), I’d be very hesitant to assume that the wreckage, or the people living among it, was going to be the ideal breeding ground for democratic-socialist utopia. Brutal thugocracy, rather, dollars to donuts.

  93. 194
    Grace Annam says:

    Robert:

    Can you smoke? Mainline heroin while having unprotected sex with sketchy British pop stars? Jump out of perfectly good airplanes on the theory that a wad of silk no thicker than a handkerchief is going to somehow keep you alive?

    Yes, obviously in a discussion about healthcare, when I was clearly talking about how little control we have over our ability to have perfect health in order to get into the system, it’s relevant to point out that in fact we have LOTS OF CONTROL over our health and have it within our grasp to make our health EXACTLY AS BAD AS WE WANT TO, even to the point of killing ourselves.

    I actually have other things to do which matter more to me than to try to keep this discussion on the Rails of Good Faith.

    Robert, the field is yours.

    Grace

  94. 195
    Robert says:

    I’m not speaking in bad faith; you are arguing that the two areas of life are radically different because in one of them we have a vast section which is not controllable. I’m arguing that the two have substantial commonality, because they both have large sections which are not controllable, and large sections which are.

    The significance of “perfect health” is that naturally, an insurer wants to minimize their prospective cost of providing care, and people in perfect heath are the identifiable group most likely to achieve that minimum. But it’s very difficult to “fix” this aspect of insurance by requiring insurers to ignore data (someone’s existing health care needs are probably a good predictor of their future health care needs).

    Insurance is gambling; gambling is constituted on the foundational truth that dice have no memory. But humans aren’t dice; our pasts are in some good measure a prediction of our future. Someone in good health walks through the insurance company door, and a little icon appears above their head: “99% likely to pay premiums for 60 years then drop dead of a relatively inexpensive cardiac event, 1% likely to cost a kajillion dollars”. Someone in poor health walks through the door, and the icon reads “98% likely to cost us $0.03 kajillion dollars per year until they die, 2% likely to cost us a kajillion dollars a year until they die.”

    An insurer cannot charge these two people the same premium in any vaguely fair price system; someone who is going to pay $5k a year in premiums and take out an average of $4k a year in services is a fundamentally different customer than someone who is going to pay $5k a year in premiums and take out $50k per year. As my friend David Jones, a Denver area libertarian blogger of considerable compassion notes, with the first guy the insurance company is taking a risk. With the second guy there is no risk; they know they’re going to lose.

    Obamacare attempts to square this unsquarable circle by requiring the insurer to recalculate the premiums so that they are the same for everybody in the same general geographical boat. Young, healthy people end up paying way more than they get (at the time); old, sick people end up paying way less. Then the pot is sweetened further for the insurers by requiring a bunch of people to buy insurance who have little use for it at all. This is certainly beneficial to the people getting a break, but the benefit comes at an equal harm to people who are getting jacked, and foments political resistance to the system itself. People who are getting jacked by a pricing regime that has literally no relationship to how well they treat their bodies, or how much medical care they use or forgo, are inevitably going to grow (or start out) resentful.

    That risk conundrum is one good argument (among many) for why insurance is a dumb way to finance health care. We want the guy who had cancer last year to get treatment this year too, but rational insurers want to drop that guy and pronto. To me this speaks for a need to have a system where the people with genuinely unknown risk use insurance (if they wish) to hedge against unpredictable costs, while people with genuinely known problems have some help to marshal the resources that their health problems demand for treatment.

    Making insurers pretend that they’ve forgotten about math, and making health insurance buyers pretend that nobody cares about getting screwed every month on their insurance bill, seems a poor kind of policy innovation. But it’s the kind of innovation at the heart of all the Obamacare ‘improvements’ – mandate what is wished for and then expect markets to somehow deliver that. It doesn’t work out that way in practice.

  95. 196
    Charles S says:

    I can not tell you how much I love a bunch of libertarian hand-waving about how the basic concept behind the Massachusetts health care system and the health care systems of multiple countries are not possible that ends with “It doesn’t work out that way in practice.”

    No, Robert, it does work out that way in practice. You may think it is stupid, you may think it is immoral, but you really don’t get to claim that it doesn’t work, when it demonstrably does. Will the US-wide version of it work? Almost certainly. Do the existing examples of the class work? Obviously.

    All this libertarian hand-waving and ridiculous nonsense examples from you don’t demonstrate any sort of counter to the actual fact that systems very similar to Obamacare are demonstrated to work (where work means: successfully provide access to large numbers of people, specifically more than the current US system).

    When both Grace and Amp are telling you that your arguments are ridiculous nonsense (not just wrong, but pointless and not worth engaging with), maybe you should take a break and actually think about why your arguments are receiving that reception rather than just insisting that your arguments are the greatest (and funny too!).

  96. 197
    Robert says:

    The Massachusetts plan does indeed enroll more people in coverage than the US average (16 percent in the US, versus 4 percent in MA; Mass had 90% insured before Romneycare and has 96% now).
    http://kff.org/other/state-indicator/total-population/

    Tragically, that significant jump of 6% more people being insured has carried a relatively hefty price.

    Luckily for Massachusetts, the vast majority of the expense for the program has been borne outside the statehouse. As of 2011, the program had imposed $8.6 billion in costs over status quo ante. Massachusetts’ state government paid $414 million of that. Medicaid paid $2.4 billion. Medicare covered $1.4 billion. Individuals and businesses paid $4.3 billion. (http://www.realclearpolitics.com/articles/2011/09/22/romney_health_plan_a_bust_for_massachusetts_111436.html)

    I’d blather on about how it doesn’t really save us money on a federal level to move all the expenses from these “very similar” programs to different parts of the Federal machine; the money still gets spent. I don’t want to bore you with ridiculous libertarian handwaving, though.

    Surely, though, Massachusetts is bending the cost curve down though, right? The way that Obamacare absolutely must, if it is to solve the explosive growth in health care expenditures that Amp, to his credit, does acknowledge as a serious fiscal issue for the United States? Alas. Including the Federal expenses, since 2006 the system in MA has seen costs climbing by about 12% a year. It turns out – libertarian handwaving shock alert – that community rating, shall-issue, mandated coverages and premium subsidies cost enormous amounts of money. Luckily, the state’s coffers are swelling because…the system provides large incentives to work less and pay less tax. Oops. On the plus side, predictions of employers dropping coverage didn’t come true in Massachusetts, where a cunningly-designed system of penalties made it not pay. Instead, those coverage drops are now only predicted to occur, as the penalty system frays from the increased costs of coverage and it becomes more and more rational for companies to throw their employees onto the exchange. (http://money.cnn.com/2010/06/15/news/economy/massachusetts_healthcare_reform.fortune/)

    But you’re totally right, there’s no disputing that Obamacare is going to get a lot more people to be insured. Other than, of course, the 7 to 10 million people who are going to lose their insurance coverage in the next year, according to those partisan hacks at…um, the Obama Administration. (http://investigations.nbcnews.com/_news/2013/10/29/21222195-obama-administration-knew-millions-could-not-keep-their-health-insurance?lite)

    In the medium term, of course, many of those millions of people will have replacement policies. Sure, those policies have twice the deductible of their old one, or have a doubled baseline premium – surely some innovator in the insurance industry could do a twofer and give us a policy with BOTH – as they mandate things like pediatric dental coverage for senior citizens and “free” birth control for gay couples and so on.

    And if folks don’t like those policies, they can go right online and find new ones, just as soon as the nice people at Obamacare figure out how to record someone’s name and password. Maybe they should use a “database”. I hear good things about those.

    But you’re absolutely right, and my moment of reconsideration has led me to understand that a health care financing system that adds a few percentage points to the insured pool, at the modest cost of doubling the cost of health care every seven years and striking a hammer-blow at the concept of individual people making decisions for themselves, is the greatest legislative achievement of our time. How wrong I was.

    We should get a Peace Prize for these guys.

  97. 198
    Robert says:

    “If you like your health insurance plan, you can keep it! Unless, you know, *I* don’t like your health insurance plan, in which case, you know, fuck you.”

  98. 199
    RonF says:

    “If you like your health insurance plan, you can keep it! Unless, you know, *I* don’t like your health insurance plan, in which case, you know, fuck you.”

    Robert, I know it’s frustrating that the edit function is broken here, but I’ve jumped in and fixed your comment for you.