There’s really not much in this Karoli post that I disagree with. Is Joe Lieberman odious? Yes. Should the Democrats strip him of everything, up to and including his jowls? Yes. Is there a good way to work around him? No. Has he effectively killed the public option and/or a Medicare buy-in, at least for this session? Yes. He has.
But does that mean health care reform, even without such an option, should simply be killed dead? No, it does not.
As Karoli points out, even after the public option is killed dead, the health care plan still ends banning people based on pre-existing conditions. It still provides significant subsidies. It still will mean the difference between millions of Americans being insured and uninsured, and that will save tens of thousands of lives a year. Is it perfect? Hell, no. Would it be better with a public option or Medicare buy-in? Hell, yes. But you pass the bill with the system of government you have, not the system of government you want, and for good or ill, the American system of government is designed specifically to kill big, sweeping changes, to whittle bills down into small, incremental, piecemeal steps.
This is, incidentally, the biggest problem with the liberal opprobrium aimed at Obama. (Reid — well, he’s another story, and I’ll talk about him at another time.) Barack Obama is the President of the United States, not the Prime Minister. He commands large majorities in both houses, but those majorities are fractious, and have grown up under the American system in which each legislator is a free agent, whose votes are up for grabs on every bill.
Yes, the Republicans are moving away from that to perfect parliamentary lockstep — we know, we know. But the Republicans were not much more unified when they held Congress, and were forced to actually govern. Remember how the Bush Administration muscled through Social Security privatization right after the 2004 election? You don’t? Right, because it didn’t happen. Without Democratic support for privatization in some form — support that was non-existent save, maybe, for Joe Lieberman — the Republicans in Congress were so disorganized, so fractious, so disunited, that they couldn’t even get a bill through the House. Had it made it to the Senate, it would assuredly have died, as the Democrats — who held more than 40 seats — would have filibustered it to death.
The last major piece of domestic legislation the GOP got through Congress was Medicare Part D in 2003 — which only passed because the Republicans were willing to play major games in both houses to get the bill over the top, going so far as to hold the roll open in the House for two and a half hours in order to wheedle for the final votes for passage.
The GOP got no major bills through congress in the last five years of the Bush presidency. For all the vaunted unanimity among the Republicans, Bush Administration efforts on everything from Social Security to immigration reform failed, due to a lack of party support.
So while it’s both tempting and true to complain that the health care bill has been whittled down to less than half a loaf, and maybe down to a single slice, we shouldn’t ignore the fact that said single slice contains more health care reform than has passed since Medicare itself was enacted. And that even in its very watered-down form, it will save lives and save families from penury. This is not a minor accomplishment. As Nate Silver notes, the public option was always a long-shot in the Senate, but keeping the focus on that still managed to allow a pretty decent bill to get to the brink of passage.
Bill Clinton couldn’t get get a bill this far. Jimmy Carter couldn’t get it done. Lyndon Johnson, Jack Kennedy, and Harry S Truman couldn’t get it done. No great Democratic majority leader ever muscled health care reform through the Senate. And until Nancy Pelosi, no Democratic speaker ever had shepherded health care reform through the House.
Quite simply, this watered down, attenuated, imperfect, tenth-of-a-loaf bill still represents one of the greatest legislative triumphs by either party since the Great Society programs passed under Johnson. And while it will need to be improved in the future, it will establish the baseline from which all future discussions begin: Every American deserves health insurance, and no American should be denied health insurance because of pre-existing conditions. Once that is enshrined in law, changes will only make coverage more robust. Just as Medicare once failed to cover prescription drugs, just as Social Security once failed to cover large swathes of workers, so too will this bill need to be improved. But there will be nothing to improve if we fail to pass this now, and there will be no chance at improving it if, in our pique at imperfection, Democrats choose to allow the same forces that have been trying to kill this bill to gain ground in Congress. Imperfect isn’t fun. It’s frustrating and annoying and it means we have to endure Joe Lieberman. But it’s better than a perfect bill that doesn’t pass. Better by far.
“Insurance” is a bad idea. What people need is health care, not health insurance. I’d be very surprised if very many people in the U.K. or Canada have “health insurance”. If car insurance was sold like health insurance, you’d end up billing your gasoline to your insurer. We don’t have “health insurance” in the U.S., we have cost insulation. This satirical article illustrates some of the problems. Furthermore, most people don’t have a choice of health insurer; their employer chooses which insurer they use, and employers don’t exactly have an incentive to choose the one their employees would prefer. My parents complain endlessly about poor customer service, saying that if their car insurance company treated them as badly as their health insurer, they’d switch immediately.
John McCain’s campaign proposal to end the tax break for employer-provided health insurance was a step in the right direction. The fact that health insurance is provided by employers, and that said health insurance is used to pay for everything, even things that aren’t “insurable risks”, is one of the biggest problems with health care in the United States.
This article is right on the money.
I agree 100% on the importance of banning recission and getting rid of the very idea of preexisting conditions. (Hey, we’re mortal, and that in itself is a preexisting condition!)
My fear is that we’ll mandate insurance for a large group of people, yet the subsidies they receive won’t make insurance truly affordable, especially since we’re not hearing much about any meaningful cost controls. If we force people to decide between buying groceries or paying premiums (or fines), it’ll breed real suffering and resentments. Now, I don’t know what the final plan is going to look like, but for the Republicans, this would be a great outcome. They could run in 2010 with commercials showcasing the plight of ordinary families forced into poverty due to their insurance premiums.
So while I generally agree with you, Jeff, that we’ve got to be pragmatic, I worry about possibly ending up with an even worse system than we’ve got today.
He commands large majorities in both houses,
A misnomer. His party has majorities in both houses, but he sure doesn’t commmand them. Parties are, thankfully, not nearly as dominant in our democratic republic as they are in a parliament.
i>Yes, the Republicans are moving away from that to perfect parliamentary lockstep — we know, we know.
Hah! In the U.S. Congress unanimity is generally only found in the minority party. When – not if, when, these things go in cycles – Republicans gain a majority they too will be fractious and the Democrats will unite. Besides, if you frequent the conservative blogs you’ll find that the Republicans are not so unanimous as you might think.
What people need is health care, not health insurance.
True. But if the government provides health care then you get the health care that the government decides to give you. Which might exclude things you want such as abortions. Whereas if you have your own health care insurance, you have more choice as to what health care you get independent of the government and the will of the majority. Now, if you are dependent on the government for health care insurance then you are still subject to some constraints – but that provides encouragement to raise your standard of living to a point where you are no longer dependent on the government. It is a legitimate government function to see that American citizens have equal opportunity to exert their resources and seek to exercise their rights. It is most definitely not a legitimate function of government to guarantee the results of that exertion, or to guarantee that citizens will have equal resources regardless of their level of exertion.
It’s desirable that all people should have access to quality health care. It’s also desirable to keep the government out of that process. I should think that the Stupak Amendment demonstrates that latter point quite nicely to those of you pressing for a greater governmental role in health care. Thank God for Sen. Joe Lieberman. There’s a lot to be said for having legislators who are not inextricably tied to a given political party.
That’s not to say that the current system doesn’t have flaws – it certainly does. I see no particular need for one’s health insurance to be provided through one’s employer. I do see a need for better competition among the health insurance companies; which a government-run health insurance option would kill, not improve.
This argument would only make sense if conservative opposition to reproductive freedom for women were caused by liberal support for universal health care. As it is, however, the tradeoff you imply — “if liberals would stop pushing for universal health care, then abortion rights would be safe” — does not exist. Conservatives have been hysterically opposed to women’s reproductive liberty for decades, and they will continue to use every legislative chance they get to oppose it, regardless of what happens with universal health care.
As for Stupak, it now looks fairly likely that Stupak will fail. So if the big cost of getting this bill passed is that Stupak will be proposed, but not become law — well, that’s something I think most liberals can live with.
This is one of the many ways that Republicans lie to themselves — whatever awful thing their party does, they say “if the Democrats were in our position, they’d do the same.”
That’s simply not true. Democrats were not the “party of no” when they were in the minority; there were lots of Democrats who crossed the party line to support Republican votes. The situation that happened this week — when 100% of Republicans in the House, without even one exception, voted to protect wealthy banks against financial regulation — would not have happened were the roles reversed. (How many Dems in the House voted for Stupak, again? 40? 60?).
There’s a level of irresponsibility involved in saying “we don’t care if it means the country is run badly, we’re against absolutely everything the elected majority is for, and would rather bring government to absolute gridlock than work with the majority.” In the health care example, we’ve seen conservatives turning around and opposing policies that they had previously supported, and in some cases, written, because they simply care far more about winning the news cycle than they do about making the policy as good as possible. (“Death panels,” for example, was originally a Republican idea. Just three months ago, for another example, Joe Lieberman supported a Medicare expansion.)
As bad as the Democrats are, they’re simply not that bad. (I’d say just the opposite — they’re wimps who roll over for Republican priorities far too easily).
Yes, it is desirable to eat your cake and have it too. But that’s not how things work in reality. You can have government kept out of the process of providing access to quality health care; or you can have all people having access to quality health care. You can’t have it both ways.
I just want to say that I find the Lieberman=Palpatine meme very funny. I’ve been thinking he looked like Palpatine from the moment I saw the first Clone Wars film.
You can have government kept out of the process of providing access to quality health care; or you can have all people having access to quality health care.
It seems counterintuitive to say that the government must provide access, or the access won’t happen. There are surely margins where this may be true; FedEx isn’t likely to put in a service hub to West Moosejaw, ID, and you may need government intervention there in the form of a Post Office to get adequate access to services. I’m not a no-intervention purist.
But in general, people have access to quality housing (if they can afford it) regardless of whether there’s a government program. People can get quality food. They can get quality clothes. They can get cars and haircuts and skilled trade services. They “have access to” pretty much everything the market allows them to sell. Health care isn’t magically market-proof.
And the government plays a huge role in all that! It’s the government cops who keep stores safe (and thus preserve retail access), government land use and development policies that make it possible to develop new housing tracts, government communications infrastructure support that jumpstarts and maintains things like the Internet and all its glorious commerce. So, plenty of government ROLE – not arguing that.
But government provision of access? My doctor up the street wants my business. If something is wrong with me or my kid, I want to go there. The road is already built, and I have a car. Where’s the government need to come in?
The answer seems to be, not in the provision of access, but in the provision of financial resources in those cases where I (or whomever) cannot afford to go to the doctor. The market provides the doctor and can set a fair price for her time; if I don’t have the cash then perhaps the government needs to step in. Again, although I am sure we’d have a blazing row over how to pay for and administer it, not a problem in concept.
But that isn’t about providing access, it’s about providing essentially charitable help to someone who can’t afford to get what they’d like to get on the market. And it is self-evidently impossible for the government to provide that type of help for any but a minority; we can’t tax ourselves to gives ourselves better benefits than we could have bought on our own. We can only tax ourselves to help out people with less than us – and we should and do, and perhaps that needs to be examined or expanded – but we can’t tax ourselves better off across the board than we were before.
As it is, however, the tradeoff you imply — “if liberals would stop pushing for universal health care, then abortion rights would be safe” — does not exist.
Nope. That’s not what I’m implying. I admit that by using the word “access” I phrased it poorly, but universal health care and abortion rights – as I’ve said previously here – are not related. In fact, as I’ve also said previously, your right to anything is unrelated to whether or not a law exists that says you’re entitled to have the government pay for you to exercise that right if you cannot afford to do so on your own. We’re not talking about abortion rights here. We’re talking about government-funded abortion entitlements.
The press for expanding government control over health care so as to attempt to provide health care for more people did not endanger abortion rights, nor did it galvanize conservatives to oppose abortion any more or less than they already do. What it did do was to galvanize opponents of abortion to ensure that the money that the government takes from them by force will not be used by it to fund abortions. That has nothing to do with abortion rights.
What the Stupak Amendment illustrates is that government involvement in anything is a double-edged sword. If you involve government in something, that involvement is subject to the desires of your representatives in the first order and the electorate in the final order. And that means that funding something by the government may lead to undesired ends regardless of your political philosophies. Better these decisions, and the money necessary to fund them, be left to individuals.
You can have government kept out of the process of providing access to quality health care; or you can have all people having access to quality health care. You can’t have it both ways.
Why not? On what basis do you claim it proved that there are no additional alternatives?
Robert:
I’m not sure we’re disagreeing at all. Did you see that I specified “all people” having access? Just as not everyone will have access to mail delivery without some sort of act by the government, not everyone will have access to quality health care without some sort of participation by the government.
Put another way, health care will exist with or without the government. But universal health care will only exist with the government doing something.
It’s logically impossible to prove a negative, Ron. If you claim that universal access to quality health care is possible without any government intervention at all, then it’s up to you to propose a policy that would realistically have that outcome.
I just can’t decide which part of this wonderful progressive historic victory is my favorite. Is it:
1) The fact that I, amongst thousands of others, will be forced to buy crap insurance from your party’s insurance buddies that cover’s exactly jack / shit or be fined for not doing so.
2) The Christian Science (and other) prayer treatments will be covered as medical expenses.
3) The massive giveaway to biologic drug manufacturers (Big Pharma) extending their patents for at least 12 years. (No generic drugs for you, grandma!)
4) The anemic subsidies for qualified applicants don’t kick in until 2014.
There’s just so much to choose from…
True. Which is why I don’t favor that philosophy. But that presumes that the voters who made that party the majority favored all the policies that the party leaders seem to now favor. Which is hardly the case, as any member of the Blue Dog Democrats will be more than happy to explain to you.
Your comment also presumes that the country is, in fact, being run badly and that the minority party believes that. I should imagine that the vast majority of the minority party, rather than being blindly obstructionist as you paint them, believes that the changes proposed by the majority party will makes things worse, not better, and opposes them on that basis.
Again, this illustrates one of the differences between the American democratic republic and a parliamentary system as implemented in many countries. People vote for individuals as much as they vote for parties. Very often people are voting against a candidate, not for one. The very voters that elect a candidate are often contacting him or her to oppose one of that candidate’s party’s positions. My district is an example of such.
Oh, I admit that I don’t have a comprehensive plan at hand ready to cite. But that doesn’t mean one doesn’t exist, which is a possibility your statement forecloses. You’re quite right – you can’t prove a negative. But that doesn’t relieve you from the responsibility of proving your statement if you wish to make it as the absolute statement you did. Everyone’s entitled to an opinion. If you said”I don’t think/see/know of a way to have UHC without government involvement” there’d be no argument without, in fact, proposing an alternative. But your statement leaves no room for that – you stated it as an established fact. That has to be backed up.
The other thing to consider is that there are competing issues here. The government has a Constitutional duty to do certain things, such as provide for the common defense, coin money, etc., etc. Those things have to be done by the government. They are it’s assigned roles. Health care is NOT a role assigned to the Federal government. So far I haven’t seen an explanation that shows that a) the government can competently fund or otherwise provide UHC at all and b) can do so while adequately funding those things that the Constitution says it’s supposed to be doing. Hell, it’s not funding it’s normal roles now! Then there’s the matter of not taxing the productive part of the citizenry to a point that discourages productivity and innovation and not running up massive deficits. My opinion is that we simply cannot afford any of the current proposals. We don’t have the money.
If something is wrong with me or my kid, I want to go there. The road is already built, and I have a car. Where’s the government need to come in?
Let’s see…the government funded and built road, the g0vernment bailouts of the company that made your car, government subsidies of medical school and residency training, government regulation of MDs to ensure a reasonable level of competence…Insurance is practically the only part of the process not subsidized by the government-or at least a government, whether federal, state or local.
RonF said:
You could imagine it, but it’s flying in the face of the fact that (as Amp pointed out) some of these guys actually supported or even wrote these elements that they’re now standing lock-step against. That hardly sounds like them believing that these things are actually “bad”.
Put another way, health care will exist with or without the government. But universal health care will only exist with the government doing something.
Certainly. That’s why we have Medicaid, so that people who can’t afford any health care can get a reasonable amount. And that’s why we have Medicare, so that old people (who often can’t afford any health care, and who additionally often have very expensive problems) can also get a reasonable amount.
Having made provision for the poor and the aged, who else needs the government’s help to get access to the care that they are able to afford? I’m not arguing against making Medicaid better (much better, even) – I’m wondering how come “universal health care” intended to make sure the marginal can get care, somehow involves taking control of the economic decisions of upper-middle-class me.
Or put another way, if you can’t provide health care for the poor using the big government stick of taxation without regulating MY health care choices into unrecognizability – isn’t it maybe reasonable for me to think that your agenda is more about control than it is about helping the less fortunate?
I can feed the poor people in my town without setting up “beef panels” to determine how much steak rich people are allowed to eat.
And that’s why we have Medicare, so that old people (who often can’t afford any health care, and who additionally often have very expensive problems) can also get a reasonable amount.
Right. Medicare. That runs a deficit now and will be completely bankrupt by about the time I’m eligible to use it. That many doctors won’t accept now because reimbursement levels are too low for them to remain in practice if they have very many Medicare patients. That is driving many hospitals into financial straits because the reimbursement rates are low (and in Illinois, anyway, months behind). That other doctors and hospitals make up for by charging their privately financed patients more – so I thus subsidize it TWICE, both through the Medicare deductions from my paycheck that I’ll never get the benefit from AND from the higher prices I’m charged. And Sen. Lieberman is being criticized for not approving adding a whole new group of people to it?
I can feed the poor people in my town without setting up “beef panels” to determine how much steak rich people are allowed to eat.
That’s because we’ve got more food than we know what to do with and rich people can eat as much as they want without ever depriving poor people of food. If the same is not true of health care*, then might it not be more reasonable to (analogously) ensure that everyone eats and only then worry about whether enough steak is available to satisfy the desires of the rich? Even if that means setting up “beef panels” to examine how beef is being distributed and make sure the distribution is fair?
*I’m not convinced that health care is-or at least that it need be-a limited resource, but that is the basic assumption behind most current health care reform so I’ll leave it for now.
Everything anybody actually wants is a limited resource. However, the problem we observe in our healthcare markets do not appear to be problems of rich people outbidding poor people for the same fixed resource; rather, we see poor people unable to afford the good in question at its market-clearing price, and so the supply for their implicit demand never materializes. That’s why I say we could see additional provision of healthcare with additional resources – but that provision doesn’t require that anything be done to constrain the choices of people for whom the market is working adequately.
I’m wondering how come “universal health care” intended to make sure the marginal can get care, somehow involves taking control of the economic decisions of upper-middle-class me.
Are you sure it would? This article in JAMA compares health care options in the US and Canada. It finds that while the options for health insurance are far fewer in Canada, the options for deciding which phyisican or hospital to be treated at were actually greater. Do you really care whether your doctor is paid by private insurance or the government as long as you can see the doctor of your choice and she does get paid?
Robert, if I understand your argument correctly, you’re saying that providing health insurance for poorer people will cause the market to expand, leading to more people working in and investing in medicine, making more resources available. To give a simplified example, if everyone has health insurance and can afford an MRI when it is indicated then more centers will be built, more people trained as technicians and radiologists, etc and the wait time might actually decrease. Do I understand your position correctly?
Do you really care whether your doctor is paid by private insurance or the government as long as you can see the doctor of your choice and she does get paid?
Yes.
To give a simplified example, if everyone has health insurance and can afford an MRI when it is indicated then more centers will be built, more people trained as technicians and radiologists, etc and the wait time might actually decrease. Do I understand your position correctly?
Yes. It doesn’t automatically happen that way, but it certainly can.
I have to agree with Doug on one thing – ending the tax-exemption for employer-provided healthcare would do a great deal for introducing real, actual competition on service in the health-care industry. The current model of employer-provided insurance is bad for competition.
However, either way the most important part of this bill is the end of pre-existing conditions. Yes, that creates a problem where a person who as just been diagnosed with cancer will suddenly go out and buy insurance, thus raising prices for all his co-insurees… but otherwise, that person’s only option was bankruptcy and then going onto the government dole of Medicare. Given the two options, I definitely pick the former…. and also understand why it is necessary to fine the uninsured.
Or put another way, if you can’t provide health care for the poor using the big government stick of taxation without regulating MY health care choices into unrecognizability – isn’t it maybe reasonable for me to think that your agenda is more about control than it is about helping the less fortunate?
— Robert
Robert, have you ever lived in a country with universal health care? Like Canada, the UK, or any Western European nation?
I have, and I don’t recall seeing any regulation of my health care choices. I could go to pretty much any doctor, any pharmacy, and I never had to think about how it got paid. The same was true for everyone I knew. I never heard of people being denied treatment because the insurance wouldn’t pay, or going bankrupt due to doctor or hospital bills. And there were even private insurance plans available for those with the means to pay for it who didn’t like the state-run plans. I never heard of people being “not insured.” Everybody gets taken care of if they’re sick or injured, even tourists from the USA! Only in the USA do foreign tourists with burst appendices get put onto a plane home rather than being taken to the emergency room.
By contrast, in the USA, every health insurance company that has (supposedly) covered me and my family has jerked me around at least half a dozen times a year, and I’ve routinely had to pay doctor bills entirely out of pocket because the insurance company screwed something up and refused to admit it. They get to decide what they will and won’t cover and to change their mind after the fact; the only real limitation is — get this — government regulation.
And I’ve been fortunate — the only times I’ve been really sick, I was covered by insurance. If I hadn’t, like when I was a student, the hospital bills would have been several times larger, and I would have had to pay them out of my (limited resources.) I would have been financially wiped out.
My suspicion is that the opposition to government-run health care coverage is being pushed by certain people who realize that it would actually save money, because you wouldn’t have this huge billing and insurance burocracy. And that would be positively un-American!
I ran though the Karoli post. He says a lot of things that are already being argued about here. But he also said that preventative care saves both lives and money and, damningly enough, it’s not debatable. Generally when people try to close off debate it’s because their position is vulnerable. I won’t contest that preventative care saves lives. But there’s a fairly robust debate going on regarding whether or not it saves money. Here’s an article from the New England Journal of Medicine, for example, that discusses that there’s very good evidence that there are cases where it does not save money.
Not that I’m going to argue against preventative care or it being covered by insurance. Indeed, these things are not just about money (although if a strategy is not profitable, it will drive up costs). But if people want to be believed and want to engage in debate instead of propaganda they should check their facts and not say “x” is not debatable when it damn well is.
Dianne:
That presumes that the number of people who can and will train as technicians, radiologists, etc. can freely increase with no constraint. Regrettably that’s not the case. In fact the supply of such people and the capacity to educate and train new ones is relatively fixed – especially in the case of doctors (radiologists have to have M.D.s). So what we’ll actually have is an increased demand for a commodity in fixed supply. That means we can expect wait times to increase – and as the load increases on a fixed number of people, quality is likely going to go down.
Wait times are bad enough now! If high demand was going to lead to more people being educated, more devices being purchased and result in wait times going down it would already be happening.
I have, and I don’t recall seeing any regulation of my health care choices. I could go to pretty much any doctor, any pharmacy, and I never had to think about how it got paid. The same was true for everyone I knew. I never heard of people being denied treatment because the insurance wouldn’t pay, or going bankrupt due to doctor or hospital bills. And there were even private insurance plans available for those with the means to pay for it who didn’t like the state-run plans. I never heard of people being “not insured.”
Sounds good. But it turns out that there are plenty of stories about delayed treatment, rationed care, drugs and therapies that the Canadian government won’t pay for that are in fact paid for by American insurance companies, inadequacies of care, etc., etc. Try this and this. It’s under financial stress too and they’re facing the raise taxes/cut costs issue fairly immediately.
Yes, you can go through plenty of anecdotes and official figures about American healthcare as well. But Canadian healthcare is not the unfettered paradise that it’s often painted.
. In fact the supply of such people and the capacity to educate and train new ones is relatively fixed – especially in the case of doctors (radiologists have to have M.D.s)
There’s certainly a lower flexibility in training more radiologists than in training more telemarketers (for example), but I wouldn’t say that the number of doctors available is immutably fixed. In fact, universal health care could encourage an increase in the number of doctors by making university hospitals more solvent and more able to take on new challenges such as increased number of medical students.
That having been said, one problem I see with Robert’s argument, if I understand it correctly, is that there will initially be an increased demand without increased supply (which will take longer to produce) so there is a point to keeping track of the resources used by the wealthy since it will be, temporarily, a zero sum game. I hope that that will change later, but initially (to go back to the food analogy) the only way the rich will be able to get all the steak they want is by allowing the poor to go hungry.
RonF–
One minor point — Karoli is a woman.
Carry on.
Robert, emphasis added
At what point does that become a necessity, though? Is healthcare for your child a mere want? What about life-saving healthcare?
At what point does that become a necessity, though? Is healthcare for your child a mere want? What about life-saving healthcare?
If it’s a necessity, then it’s a necessity. If you couldn’t pay for it as a want, you probably can’t pay for it as a necessity; we should let you try, and then cover you if you can’t manage it.
There would be relatively little opposition to HCR if it were primarily about making sure that very poor people could get their necessary care. That really isn’t the big problem in our health care system, though; for the most part, our poor people CAN get their necessary care. We spend hundreds of billions of dollars every year to make sure of that.
Before you send students to a university hospital to serve their internships and residencies you have to graduate them from medical school. The first couple of years in medical school you don’t spend much time in a hospital, you’re taking Anatomy and Physiology and Biochemistry, etc. And those spots are full right now. You need more medical schools, with facilities and faculties. And most of the latter are doctors. It’ll take years to get an increased supply of those spun up. Until that happens you won’t have more doctors, and I don’t see any impetus in this bill to do that.
Ron: And? All it takes to get more medical school slots is the resources and political will.
Robert:
Which is what? It’s hard not to read your earlier comment as not claiming you consider saving your daughter’s life a want rather than a need, in which case you and I, for starters, have vastly different ideas of what care is necessary.
Sungold writes:
There are a lot of cost controls in the bill, actually. Ezra outlines five of them here.
In addition, the creation of the Health Exchanges will increase competition in the insurance industry, which tends to keep prices lower. That alone would not be enough — competition works, but it’s not the magic fairy dust most conservatives seem to believe it is — but in combination with the other cost controls, I think it could work. At the very least, it’ll do a better job of cost control than the status quo does.
Just to clarify, what you’re referring to here is the universal mandate? Or is there something else you had in mind?
Yes, the mandate.
I already know your counter-argument; apparently, yes, you have to make me do things so that everyone can be covered.
OK – but beyond a certain point that becomes an argument for not covering everyone, because the price to liberty becomes too high.
What would the certain point be? You seem to think that “having to pay a small fine” is too high a price.
There are tens of thousands, perhaps hundreds of thousands, of people trapped in jobs they hate because they or a loved one have a medical condition, and they can’t change jobs because if they do they can afford necessary medical care. “Stick with your job, no matter how awful it is, or your husband loses the medical care that allows him to have some mobility” is not a restriction people should have to face. There are people who can’t get medication that will preserve their ability to walk, to see, or to live a decade longer than they might otherwise (try getting accepted by a new insurance company if you’re already diagnosed as diabetic.)
To me, that sort of thing — which is common in the status quo — is a substantial threat to liberty. The liberty those people lose is far, far greater, by any non-money-worshiping standard, than the liberty you’d lose if you’d have to pay a fine.
But the “small fine” – which could be tens of thousands of dollars, depending on my income – is only the first setting on the phaser of government power. I can get stuck in a bad job because I need to keep my health insurance, but my employer doesn’t have a sliding scale of punitive measures they can take in their role as caretaker of the POLICE POWER of society.
Amp, thanks for liberating my comment from the moderation queue – it was there since yesterday and I’d given up on it appearing! I’m glad I’m not in hot water. :-)
Thanks also for the link to those two columns by Ezra. I didn’t realize that the Health Exchanges would have the power to decertify an insurer. That’s helpful to know, and it’s reassuring. There are still some big-ticket items that will remain virtually untouched as far as I understand it – including pharmaceuticals.
The first mechanism Ezra outlines – bundled payments – is one that I didn’t realize was part of the package, and honestly, though I know it will contain costs, I know from personal experience that it can also create perverse incentives and very seriously harm the quality of care delivered. My husband was admitted to the hospital in Berlin, Germany, in August 2004, right after Germany implemented bundled payments throughout its health system. My husband is German and we were covered by relatively generous American insurance. But what our insurance covered was moot, because the hospital could only bill a lump sum. My husband had a Guillain-Barre-like condition, for which the standard treatment – intravenous immunoglobulin – is quite expensive. If the doctors gave it to him, they’d come out far behind on reimbursements; they’d actually *lose* a lot of money on his case. And so they didn’t give him the treatment until nearly two weeks into our adventure, and then only after I confronted the attending physician. My husband suffered some permanent paralysis, and I’ll always wonder if prompt treatment would have made a difference.
Now, I realize that this is a single anecdote, and that every medical system spawns horror stories. However, it illustrates a systemic problem with bundled payments.
Anyway, I remain on the fence about the Senate bill – whether Howard Dean is right, and they need to start over, or whether it’s better than nothing (but just barely), and we need to hope for a somewhat better bill coming out of the reconciliation process.
To Robert: I’m not going to engage with you at any length, but I will say that liberty ain’t worth squat from beyond the grave. Those of us lucky enough to enjoy good employer-sponsored insurance are just one layoff away from COBRA and then the great black hole of the individual insurance market. If you lose your job and insurance, you are more likely to lose your life prematurely. None of us is immune to this possibility. And that’s why even hard-core libertarians ought to see that it’s in all of our self-interest to support an inclusive system. Not to mention that you can scarcely strike out on your own and start a business right now unless you’re young and perfectly healthy – another major constraint on liberty.
If the existence of government power is an unforgivable insult to liberty, then that’s not an argument against this health care bill; it’s an argument against having any government at all.
What’s your source for the “tens of thousands of dollars” claim, please?
Pelosi’s bill has a fine of up to $250,000 for obstinate refusal to pay.
http://www.washingtontimes.com/news/2009/dec/18/no-mandate-for-government-health-care/
Me and Keith Olbermann, together at last! (He’s said he won’t pay, which I was saying a few months ago.)
It is not the existence of government power that is objectionable here; it is the extension of that government power into a new area of life, where previously the government has not regulated individual behavior. The government can throw me in jail for not registering for the draft, too, but the government has had that power for centuries and it’s part of the settled expectations of society.
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Oh, good. A link to the Washington Times. Which indeed claims:
Boy, that sure sounds like it’s quoting the House bill, doesn’t it?
But it’s not. The House bill calls for a tax of 2.5% of the person’s income, or the cost of the average insurance plan (not sure how they measure that), whichever is cheaper. No way could that be “tens of thousands” of dollars, as Robert claimed upthread. (UPDATE: Well, it might be $20,000, which is two tens of thousands. But only someone earning over $800,000 a year could be charged that much.)
What the Washington Times is referring to, in their deceptive fashion, is that the IRS has a maximum penalty of $250,000 or five years in prison for tax evasion. That law, of course, predates the House health care bill by many years.
(According to the numbers in this article, about one-tenth of one percent of tax violators are ever put behind bars; 99.9% are handled with civil penalties.)
It is extremely doubtful that Pelosi or anyone else in the House had that fairly obscure part of the tax code in mind when they wrote their bill. The Senate version (written later, after right-wingers began their “Demon Pelosi wants to put us in jail!” whining) contains a provision making it explicit that refusing to pay cannot be considered a criminal matter. My guess is that the combined bill will contain that same provision.
Well, let’s hope so. That will leave us with just the (potential) tens of thousands of dollars.
Robert–
I’m not sure how getting stuck in a bad job is better than being fined (I can see that it might be better than prison, depending respectively on the job and the prison). Is it because the government is doing it? But then, as Amp said, your problem isn’t with the health care bill specifically, it’s with government.
I mean, government is a heavy blunt object, but to save lives I’m willing to hit rich people with a heavy blunt object. The phrasing “obstinate refusal,” apparently yours, doesn’t help your case: if you’re not buying health insurance or paying the fine just to be contrary, I really have no sympathy (if you can’t for reasons legislators never thought of or didn’t consider important, that’s different).
“First setting on the phaser” is a common Libertarian argument; in particular, it’s the slippery slope fallacy. If you are sent to jail and try to escape they will eventually use lethal force, so why stop at claiming you’ll be fined a quarter-million dollars? By the same reasoning, if there are mandates and you don’t buy insurance, you’ll be shot.
Robert, you said “but beyond a certain point that becomes an argument for not covering everyone, because the price to liberty becomes too high.”
So if there’s a maximum fine of 1.5% of income, or the cost of an insurance policy, whichever is cheaper; and if prison is not in the mix at all; is that beyond that certain point or not?
How about if the Senate bill’s maximum fine of $750 is put into law? Is that price to liberty too high?
Yes. If you’re fining people for minding their own business and not spending their money the way you want them to, then you’ve gone too far.
Let’s put this in terms you might find more emotionally accessible.
Tomorrow, the Congress passes a law that every artist must do one pro-Obama cartoon every month. If you refuse to do your cartoon, you will be fined $25 that month.
Does the trivial size of the fine obviate the injustice in requiring people to take a positive action that they don’t necessarily want to take?
You might object to the analogy on the grounds that freedom of speech is more important than freedom of economic choice. Fair enough. Congress passes a law requiring you to brush your teeth daily, or you get fined $1 for every day you miss.
Is that a problem? Or just Congress doing its duty to insure the health of the citizenry?
So when you said “beyond a certain point,” you meant “any point whatsoever.” Okay, glad to have that clarified.
As for the loss of liberty, the loss of liberty for people who die for lack of health care — or who even “only” lose the liberty to quit their job — is a much bigger loss of liberty than the loss to you if you get fined $750, or even the loss to millionaire Keith Olbermann if he gets fined $20,000.
If you’re a member of the libertarian religion, money is your god and the government is your devil, so of course for the government to take even one cent seems like the ultimate evil. For those of us who don’t worship money, however, it’s obvious that there are far worse losses of liberty at stake here than a $750 fine.
I agree; the loss of liberty of someone who dies, or is stuck in an awful job, is worse than the loss of liberty I suffer from being fined for the crime of living near those people.
Perhaps we could try to find solutions to the problems of the former set of people that do not involve punishing me (and millions like me) for having a different approach to risk/life management than the one favored by a certain set of elected officials.
Robert:
I have trouble remembering to brush my teeth. If they could enforce ths without invading my privaacy, it would be a useful reminder.
But tooth-brushing isn’t really a public matter (particularly since you don’t ride the subway); health in general is. You’re welcome to un-sign the social contract, but then please stop using my roads.
Which brings us back to the argument you
dismissedacknowledged before: That it’s really not possible to have universal health insurance if there isn’t also some sort of universal mandate.Insurance companies cannot make money only insuring people once they become ill. OTOH, we can’t have universal health coverage if insurance companies — quite rationally — attempt to maximize profits by avoiding insuring sick people, or people who seem likely to become sick.
One way to square that circle is a universal mandate — insurance companies have to cover everyone, even people with pre-existing conditions, but to prevent this from driving all insurance companies out of business we add a universal mandate. Another way is single-payer.
Can you point to a third option that has ever worked, anywhere in the real world?
Another reason for a universal mandate is that those of us lucky enough to have decent insurance are already paying for those who are uninsured! When a hospital charges $2000 for an MRI, it is partly trying to recoup its expenses in caring for the uninsured who turn up in the ER.
So Robert, if you pay insurance premiums, you are subsidizing the uninsured. If you pay for medical care out-of-pocket (especially at a hospital), you are subsidizing the uninsured.
You apparently don’t give a hoot about the social justice argument, but in hard-nosed economic terms, you might regard the uninsured – especially those who can afford insurance but choose not to buy it – as free riders. And you might consider that they are impinging on your liberty to dispose of your wealth just as surely as the government would through the fines you oppose.
Of course, if you are currently 100% healthy and can be sure you’ll stay that way until you drop dead in your sleep someday, then you’re not a consumer of health services and you needn’t worry about the subsidies you’re currently providing.
Can you point to a third option that has ever worked, anywhere in the real world?
Sure. “Don’t have universal coverage.”
There are places that have universal coverage; move there, if you want it so bad.
Alternatively, this is a federal nation, and it’s perfectly viable to have very different social policies in differing states. If you want to provide a universal coverage system in Oregon, I’ll argue against you for the fun of it, but it’s no skin of my nose. Go right ahead. Create universal coverage for yourself, where you live, with the support of the people around you. States are perfectly capable of performing the necessary economic and legal functions; we’ve already had a couple of stabs at universal care. Go out and prove a model that will work in a US state.
(And even if your side wins locally and Colorado becomes a UC state, no unbearable skin off my nose; I can always move to a non-UC state just like you can do the reverse.)
But for everyone in this giant country, including the tens if not hunded+ of millions who don’t want it, imposed over their will? Heck no.
Sungold, I agree that free riders are a problem. I’m sure we could have an interesting discussion of ways to mitigate the problem.
But you’re starting from a fundamentally broken square one. You’re assuming that some enlightened group of people has the right to tell other people how to allocate their resources. Maybe I want to allocate 30% of my income to my health needs and 20% to my housing and 50% to food. Maybe I need to do a 2-96-2 split for a month to fend off homelessness. Maybe I have other priorities. Point is, (a) it isn’t your damned business, (b) it isn’t the damned government’s business, either, and (c) you third parties are not likely to be a better judge of my allocation needs than ME, the guy on the spot. Telling me “you WILL spend [x]” is not a trivial violation of some unimportant right, held in significance only by “money worshippers” – it is a fundamental intrusion onto my private life.
So social justice can bugger off, to the extent that the “social justice argument” boils down to well-meaning liberals getting to tell people how to live their lives, with state power behind their well-meaning smiles.
Again – if you personally want to live in the kind of busybody society where the state pokes its nose everywhere and runs everything – you go right ahead and vote it in, where you live. This is a big country. Massachusetts wants to be Sweden, well, they’ve got the fog and the seafood. Go for it. The rest of us can watch, and hopefully learn, and the people who would like that kind of environment are welcome to go there.
And if you want your busybody state to pay for the healthcare of all the poor suffering masses – even nationally – again, fine. Tote up the tax bill this will entail, present it, and get the voters to approve it as their priority, whether directly or through their representatives.
But on a national level, with no escape, signing Aetna and Humana and every other money-sucking kleptocratic “insurer” up as the collection arm of the state, telling me I am obliged to send my hard-earned dollars to some insurer, or worse yet, some lard-assed bureaucrat, in exchange for services I don’t want, and doing it to boot by trying to ram it through Congress without anything like adequate review or discussion?
Screw that noise. It isn’t even close to Constitutional, it isn’t even close to passing the political smell test, and it isn’t even close to something that people like me will ever live with.
I respect the good motives and intentions of many of the people who started the push for this particular bill and who are still enamored of it, or at least the idea of reform, enough to want to see it passed (hi Barry!), but guys, seriously: Kill it and start over. This is like being tasked with passing a law to protect little kids from sexual predators, and eventually after much logrolling coming back with a plan to license NAMBLA as a pedophile-kindergardener matchmaking service on harm-reduction grounds: no. Even if you were right about all the facts in the briefing, no.
I don’t have time to contribute further to this thread today, but I wanted to briefly point out that under the Senate legislation, Colorado (and all states) have every right to opt out of the individual mandate if they want to, so long as they can provide a similar level of coverage and cost control. (You can thank Oregon senator Ron Wyden for that provision.)
So go for it.
So, Robert, I assume you support single-payer? At least if we define “support” to mean that you think a bill establishing a single-payer system should be put to a vote before each house, and then sit on the steps of the Capitol singing?
I actually agree with you as far as the idea that HCR shouldn’t be a giveaway to the insurance companies — though I suspect we have different proposals about how to avoid that! The current system, overlooking the people who can’t get insurance at all for one reason or another, restricts people’s health care options and constrains their lifestyle choices, just like the reform provisions you take issue with. I’m not clear why when your elected representatives do it, that’s bad, but when unaccountable corporations or uncaring fate do it, it’s acceptable. Or is it because your elected representatives are doing it to you specifcally?
Why don’t we try a social experiment? Everyone who doesn’t want universal health care can stop partaking in the system. Cancel your insurance, go work at a job that doesn’t have insurance, etc. Opting out of your current insurance doesn’t count because chances are you’re still being compensated for that, and you need the kind of job that doesn’t provide insurance so that you’re truly not supporting the system. Make sure your family isn’t covered, either, or you might benefit from the system by their health maintenance by proxy.
Now, live in the glorious freedom of choice that you feel we all should have. Go wait in line for 12 hours at the emergency room because no clinic will take you without insurance. Worry that your daughter might die before she can see a doctor from bronchitis turning into pneumonia. Become a free-enterprising individual!
/end snark
Uh, ST, reality check – I’m already living that life RIGHT NOW. And you know what? My daughter CAN get into pretty much any clinic she needs to get into. We just PAY FOR IT with our own money, instead of hoping that someone else will magically socialize away the cost.
@Robert:
Reality check – until I got this job, that was me for six years. It’s my coworker’s mother right now. It’s my sister right now. It’s going to be my mom after COBRA runs out. Perhaps the difference is not the insurance then, but the location? That’s a little hard to believe since the people I’ve listed off are in three separate locations across two states. The real difference is money.
I’m trying to be civil here, really, but the arrogance you have about this burns me. There can be a lot of fundamental disagreements about how to do things – that’s what a democracy is about – but it just seems to me that you have the same upper/middle-class nose-in-the-air “I pay for it, why can’t they?” attitude that shows no sense of what others go through. Let them eat cake, indeed.
And as I keep saying, ST, I have no problem with finding ways to help people who can’t pay for their care. Heck, those ways might help me one day.
I reject the idea that it can only be done by reducing my freedom. I’m not preventing poor people from getting care now; if anything, the opposite.
Well, if you agree with that, then there’s common ground between you and me. At least we’re not defining “freedom” as something only a (democratic) government can take away, like a lot of right-libertarians do. I can prove anything I want to as well if I get to re-define terms to my liking.
Overall, I’m quite sympathetic to a federalist brand of conservatism that gives more power to state governments at the expense of the the federal government. I think the role of states has been downplayed too much, possibly because the concept of “states’ rights” has had some unfortunate associations in recent historical terms, which I think represented only an extreme case.
But I’m curious as to how you reconcile letting Oregon adopt its state-run universal health care system, with your apparent belief that taxing regular folk to help other people is wrong in principle. Aren’t Oregon taxpayers regular folk, too?
This has always been a contradiction in anti-social justice rhetoric on the Right. If governments taxing others to help a group in need is wrong, then why is it okay to abolish federal welfare programs and replace them with state welfare programs so that each state can decide on its own level? I’d find the latter preferable to the current system, actually, and I support the current system only out of pragmatic reasons, and because the current system is better than nothing. But isn’t this federalist view in contradiction with the more sweeping, absolutist claims made by right-libertarians? Or do state governments not qualify as governments, for whatever reason? Do state governments not exercise a “monopoly on force” within their jurisdiction, or what have you?
Not to mention the added view by many on the Right that helping poor people is wrong, because if you alleviate the poor of their suffering, you’re making it easier to be poor/increasing poverty/decreasing individual responsibility. Which is not just an argument against all of federal, state, municipal, or block association welfare programs, but also necessarily an argument against private charity. Because that also gives money to the poor for no other reason than they’re poor. If anything, it’s worse, because at least government help is usually means-tested. (You have to prove you’re looking for work, etc.)
As for the OP, yes I still support the current Senate bill, and yes I’ve been a bit peeved with some of the hardcore activists, who seem more preoccupied with the symbolism of a victory for the “public option” than actually helping people. I can hardly visit many of the usual blogs anymore. Props to Nate Silver (and Jeff Fecke) for being one of the few voices of sanity out there in the wilderness.
I never liked the idea of mandates, and I like that states can opt out of that if they can prove that they can work out their own system that works better. I also support the idea, that I think I heard from Ezra Klein, to allow individuals to opt out of the mandate, but simply make it much tougher for them to sign back in after they’ve done that. This could potentially push up costs if too many short-sighted people do it at once, but there could be other cost-control measures. I still don’t understand why repealing the anti-trust exemption for insurance companies was taken off the table, or why that was so important to Ben Nelson.
Hawaii has achieved much better results essentially with just a very strong employer mandate, which is the direction I had hoped this bill would go. At this point, I support the current Senate bill only because it sets the baseline for all future debate. Conservatives are (mostly) right when they say that once a social welfare program becomes entrenched, it’s impossible to take it away. (AFDC would be a rather obvious counter-example, but let’s not go there for now.) I tend to agree, except that I see that as a good thing in this case. Once this bill passes, some sort of universal coverage will be a pre-requisite for all future health care discussions. From there, we can work out a better method to achieve universal care, such as Hawaii’s unique public-private setup. (Or Medicare for All, that’s also good. I’m focused on ends, not means. Also, another reason to support more experimenting at the state level: the current bill could actually set Hawaii back. Surely, Obama will grant the state of his birth this obviously justifiable exemption, which will ideally more states will be free to tinker as well.)
And Ron Wyden is awesome. Every time I see a real good proposal for the bill, it’s his name behind it. He once proposed an amendment to require large employers to present at least two different competing insurance options for its employees for their company health plans. I’m pretty sure that’s kaput, but that would have been a great cost control measure, and would have been worth, like, a dozen gutted, piecemeal, purely symbolic public options that have raised such divisions on the Left. Sigh.
If governments taxing others to help a group in need is wrong, then why is it okay to abolish federal welfare programs and replace them with state welfare programs so that each state can decide on its own level?
Mainly, state power can be relatively easily moved away from. It’s not that the policies aren’t bad, it’s that they can be escaped, and thus have a feedback mechanism on them that will often promote reconsideration of bad policy.
In addition, I think that tax-and-redistribute is bad policy and morally wrong, but it’s not like an extermination camp or something, something SO bad that it arises to the level of me needing to go to war to stop you from making that choice. If you want to tax yourself stupid, that’s your business.
Further, a core principle of libertarian governance is the idea that although we each think we know best for ourselves, nobody really does know best for others. It is better to have 50 experiments than 1 correct (IMO), but forced, regime. I would rather have 50 states with a range of health care systems from total free market to total communist womb-to-tomb, than one national system of libertarian goodness. For one thing, under a national system where I get what I want, every single person who doesn’t like that will be working to change it. I don’t want to engage in permanent twilight struggles over the government; I want to get things the way I like them, where they affect me, and then get on with life.
The best way to do that is to have multiple venues and let people sort themselves. All the hippie communists can move to Portland and Barry can pay for their health care, all the libertarian entrepreneurs can move to Colorado and get rich and shake our heads as we watch you guys (metaphorically) slide into the sea.
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