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July 22, 2009

Comments

I find myself on the verge of agreeing. I say on the verge, because I think anytime we start entertaining thoughts of party litmus tests, regardless of the issue, we start down what is truly a slippery slope. Where do we stop? What distinguishes one position from another, in the context of deciding whether or not that position is acceptable for a Democrat to hold? And who decides?

On the other hand, I think the Democratic Party, in the broadest sense, stands for human rights, equality and a sense of collective responsibility. Those principles are at the core of the labor movement, environmentalism, tax policy, and--among other things--the current health care debate. There are disagreements (of both the good faith and the bought-and-paid varieties) about how to implement "universal health care", but I don't think many Democrats disagree that our current system is broken.

On the gripping hand, I think you struck closest to the core of the issue with this:

And the Democrats who are feeling queasy need to grow a spine and get this done.

This is both about universal health care, and not. It is because that's what's at stake, and there are few stakes higher right now for those of us who care about this country's future.

However, it's not about health care in the sense that the larger problem is Democratic spinelessness. We've got a few good eggs, and I have high hopes for Franken's potential to shake up some of the Senate's fossilization. But Reid is worse than worthless--he's an active impediment to progress who behaves as if he's still Minority Leader. The House is a lock, and we have 60 Senators, but Reid and many others still act as if we're in the minority and have to play along with the bad faith antics of the GOP.

Good post.

American public to Democrats: Shut up and Do Your Job.

This is a great argument for making sure that the problem of the uninsured gets dealt with.

So far as I can tell it is no argument at all for this particular bill.

In order for your argument to work you have to show that THIS VERY BILL could pass and NO OTHER BETTER ONE could pass.

And I don't think it is at all clear that moderate Democrats are engaging in 'obstructionism'. This particular bill has been available what one week, did it slip all the way to two weeks? Isn't it even remotely possible that a better bill can be crafted? Is four or maybe even five weeks really too long to talk about the particulars of one of the biggest systemic changes in our lifetime? Really?

It's been debated for years and years -- the White Papers have been out for forever. Generally, i would agree with you. but the foot-dragging is an attempt to kill it.

And I don't think it is at all clear that moderate Democrats are engaging in 'obstructionism'.

It depends. I think some of the House Blue Dogs' objections are cogent. More money for rural areas is a valid want - they are drastically underserved by the present system. And their push for more cost controls is also desirable - the present House bill is almost entirely without them.

On the other hand, it's not clear WTF Baucus and Lieberman et al. are doing in the Senate. I think it's reasonable to presume that something shady is going down.

In order for your argument to work you have to show that THIS VERY BILL could pass and NO OTHER BETTER ONE could pass.

That would be a reasonable argument if no one remembered 1994. When Hillarycare went down, nothing took its place.

A 50 year fight. Perfect the enemy of the good? There could be 'better' amost anything. Public Education for instance. I went to the emergency room for my health care for neary 20 years before I got a good job that offered reasonably priced health insurance. Just offer something in the way of a public plan and iron out the creases later.

Publius: "It's been debated for years and years -- the White Papers have been out for forever. Generally, i would agree with you. but the foot-dragging is an attempt to kill it."

Really? I've been following the health care debate since Clinton and I actually haven't seen this particular weird hybrid of stuff until now. Which papers were generally discussed that you think map closely to this proposal?

Slaney: "That would be a reasonable argument if no one remembered 1994. When Hillarycare went down, nothing took its place."

You talk about this like it is an inevitable law of legislatures that if you can't pass a bill that a non-similar bill on the same topic can't pass. And Hillarycare had other problems (like putting Hillary in charge of it before she had any serious political experience as a leader).

Setting up this particular bill as a make or break moment is precisely the kind of mistake that Clinton made: my way or the highway. Well watch out or you may get the highway. A much better approach would be something like: we aren't going to recess until we get some serious attempt at covering the uninsured well under way.

Regardless of whether you're a Democrat in Oklahoma or in Boston, you presumably are remaining a Democrat because you fundamentally believe that the government can play a role in helping people (particularly poorer people) get the basic human right of health care.

Funny. Among the reasons I left the Democratic Party in the 1990s (and remain a registered independent today) is that I came to realize that the Democratic Party as a party doesn't hold any such commitment to social justice.

Host: Senator, one question, before we go, on health care. How much of this disagreement with the administration is about the policy of health care and how to fix it, and how much of it is Republicans' obviously understandable desire to declaw the president politically. How much does that fit into the equation?

Voinovich: I think it's probably 50-50.

Sen. George Voinovich (R-Ohio) told CNBC in an interview

[H/T Washington Monthly]

I'm not going to get into details here, or arguments about the perfect and the good. I've already posted that my preferred solution is "single payer."

This Congress is producing the bill it can. The Republicans have made it crystal clear that they are treating it as an opportunity for a political victory (see Sen. DeMint for an unabashed declaration).

The Republicans have asked for this fight. The only question at this point is whether the Democrats give it to them.

Is there any PAC or whatever that people can donate to to fund primaries against any Democrat that votes against health care or tries to poison pill it or delay it?

Because if not, there should be. A nice big public fund that says, 'This buck's for you, traitor.'

Sebastian: I have asked you for days, if this bill dies, how long do you think it will take before any other kind of health care reform is even mentioned again? My bet is at least 15 years. You don't seem to think the status quo is okay, so do you think this bill is bad enough to justify 15 years of the unsatisfactory status quo? Yes or no?

Tony: If there isn't already, there will be. ActBlue will be all over it.

What ral and Nate said. Bottom line: unfortunately, we don't live in a world in which sensible Republicans and sensible moderate Dems want to have a real conversation about health care.

The GOP wants to kill it by stalling - that is their stated goal, a goal enunciated repeatedly, in various outlets, including leaked RNC memos. The moderate Dems want to preen, pose and rake in insurance company dough. So stalling is in their interest as well - as is a dead bill that they couldn't bring themselves to support because it wasn't "moderate" enough.

So, stalling or killing this bill will not lead to a future, better bill. It will mean no bill for the foreseeable future. Since the people doing the killing have absolutely zero interest in reviving the patient.

So there is no possibility to improve it then? Impossible to offer any criticism or try to change any detail? Can't even spend two weeks looking over one of the biggest structural changes in our lifetime?

"if this bill dies, how long do you think it will take before any other kind of health care reform is even mentioned again?"

That depends on how it dies. Like everything else in the legislative process there could be a new bill on the topic 3 weeks later.

I think this is a classic problem with 'comprehensive' reform. You want to change an enormous amount about how how we do health care. You want to do it all at once. You want to do it immediately.

"So, stalling or killing this bill will not lead to a future, better bill. It will mean no bill for the foreseeable future."

Well that is certainly true if you all give up and fail to take the concerns of moderate Democrats to heart. But that isn't inevitable right? And precisely which form of this bill are you drawing the line in the sand on anyway? Are you even sure you're drawing the line on the same thing publius is talking about?

If you don't, and if you're unwilling to ever fight for that, then honestly... why the f*** are you still a Democrat? What's the point?

When you go to the bank, do you stand in the short line, or the long line? In half the country, if you're an ambitious young politician, the D line is shorter.

You talk about this like it is an inevitable law of legislatures that if you can't pass a bill that a non-similar bill on the same topic can't pass.

"Inevitable law" might overstate it; let's just say a pronounced tendency.

Example #1: 2007 Immigration reform under George W. Bush
Example #2: 2005 Social security reform under George W. Bush
Example #3: 1994 Healthcare reform under Clinton
Example #4: 1993 Campaign finance reform under Clinton (not passed until 9 years later)
Example #5: 1977 Hospital cost containment under Carter

I could probably name a few more if I had time. This is the way it works. On any major reform, either the bill under discussion passes, or no bill passes. In not one of these cases did an alternative, compromise, or stripped-down bill pass. Instead, the issue went away for years.

This is our concern, dude.

Sebastian: "That depends on how it dies. Like everything else in the legislative process there could be a new bill on the topic 3 weeks later."

Do you honestly believe that? And do you honestly believe that, having killed this bill, any of the Republicans in Congress would decide to support some new bill, or decide to yell SOCIALISM!!!eleventyone as loud as possible and try and kill that bill too, rather than give Obama any kind of credit for passing something even as limited as extending Medicare to the uninsured?

And if you think the Democratic leadership, or the grandstanding "centrists" in the Democratic party would try harder on another bill, you have a much higher opinion of them than I do.

Look, if you oppose doing anything about health insurance, that's fine. But just come out and say it. Because if this bill dies, the chances are much higher it's at least ten more years before anything's done than a better bill being passed in three weeks. And a pony.

How long do you honestly think it would be, given the existing political realities, before anything gets done on health care reform, if this bill dies? Seriously.

So there is no possibility to improve it then? Impossible to offer any criticism or try to change any detail? Can't even spend two weeks looking over one of the biggest structural changes in our lifetime?

How much time is enough? Until the Republicans are satisfied? According to the memos, they will satisfied when it is dead.

To the conservative Democrats? Other than it going away, or being so watered down to not fulfill the goals, I don't see what'll satifice them.

So there is no possibility to improve it then?

Sure. Some slight tinkering is likely inevitable. But there is only a slight possibility to make major improvements: if the GOP and/or the moderate Dems find religion. Chances? Snowball in hell.

Impossible to offer any criticism or try to change any detail?

Sure, see above.

Can't even spend two weeks looking over one of the biggest structural changes in our lifetime?

Two weeks? Perhaps depending on your starting point. But the stated goal of the GOP and the insurance industry is to try to delay this past August which will make it easier to kill when they get the lawmakers on recess and hammer them with ads and other efforts in their home districts. So a delay is a dealbreaker at a certain point.

Significant counterexamples: welfare reform, late term abortion restricitions, adjustments on Fannie Mae's authority.

Significant recent bill which supports both your point about how bills pass quickly and mine about how wise it is: Patriot Act.

"On any major reform, either the bill under discussion passes, or no bill passes."

The perhaps you should be really careful to choose a good bill as your major reform?

I think you dramatically overstate the case anyway. What are the major reform bills that make it all the way through without major changes? Bills get dramatically modified all the time. They often end up with the same name but are very different from how they started out. Are you against that?

And again, why can't we have a more modest bill? Something that takes care of the uninsured without throwing a big monkey wrench into everything else? We could even use it as a test case to see if the standard of care is high and if the alleged efficiencies of the government actually materialize. We could extend Medicare availability to the uninsured to start. We could make a super-basic health care floor with it. The uninsured would be dramatically better off, and the majority of people who actually have pretty good health care already won't feel like they are jumping into the scary unknown.

Seb, two questions:

1. By what means do you only cover the uninsured? Mandate?

2. Wouldn't that mess with the savings to be had by expanding the risk pool?

Sebastian: Because the Republicans will obstruct anything they can, ESPECIALLY if they win and kill this bill, and the grandstanding "moderates" will grandstand and demand cuts to ANYTHING, and/or vote with the Republicans anyways, especially if the Republicans win and kill this bill and therefore it's a "losing issue" (because the @$!#ing Democratic Senate Leadership is a bunch of spineless tools).

If this bill dies, the Republicans, even the alleged "moderates", will not support any other attempts to fix things, and will, in fact, attack harder. And the quivering jellied flesh of the grandstanding "moderates" will be quaking both with glee at their power to show how powerful and wise and "moderate" they are, and with fear at the Republican screaming hooligans.

This is the exact same dynamic that happened in 1994, and all through the Bush years. This is NOT new.

"Two weeks? Perhaps depending on your starting point."

Well what starting point do you use? Did this plan get major play at some earlier time and I missed it?

A month ago the stuff we were talking about looked very little like this plan and were nearly all the abstract. When do you think anything pretty close to this plan was submitted for the general Congress (much less the general population) to think about?

"Sure. Some slight tinkering is likely inevitable. But there is only a slight possibility to make major improvements:"

Sure makes me wish Democrats had come up with a really good proposal then.

"But the stated goal of the GOP and the insurance industry is to try to delay this past August which will make it easier to kill when they get the lawmakers on recess and hammer them with ads and other efforts in their home districts. So a delay is a dealbreaker at a certain point."

First, the argument is with other Democratic legislators, not with the minority party. Second, so what? If this is a good idea *IN THE CURRENT FORM* argue for it. Or hell make scary propaganda about how losing your job means losing your health insurance. I can't imagine why anyone would worry about losing their job these days....

Or make uplifting propaganda about how we as a country can take care of everyone.

If we can't handle looking at a proposal to completely change how we work health care for like 5 or 6 weeks, I don't see any reason to suspect it is a good proposal.

if you're unwilling to ever fight for [health care reform] then honestly... why the f*** are you still a Democrat? What's the point?

Sorry to be literal, but some are still Democrats because they can get elected as Democrats (e.g. some blue dogs). Lest we forget, the GOP is not really a home for conservatives anymore (in the pre-Revolution, American sense of that word), so a lot of conservatives (in that traditional sense) are default Dems now - Obama himself could've been a Republican before the 80s. You could ask why any 'moderates' are still Republicans, and the answer would be, a.) because they can get elected as such (except for Specter), and b.) there aren't actually very many left.

Of course the Democratic Party is a fraud. Both major parties are. I don't think that's cynical, just realistic.

I definitely share publius' frustration and outrage, however. In fact, a commenter at TPM summed up my feelings pretty well:

if this country cannot pass a bill which insures that every citizen has access to medical care, which every developed country has managed to do (and got done many many years ago), there is something very fundamentally and structurally wrong with this country.

Such an event, in my mind, would confirm that we live with a completely corrupt and dysfunctional form of government. Forty nine states, each with bicameral legislative bodies, some of which have distinguished themselves recently with unabashed levels of incompetency and cluelessness. Then, graft a federal government over that, which is also bicameral, the non-representative portion of it being filled with officials who are certifiable morons and/or who are bought and sold like whores by wealthy contributors.

Talk about a Waterloo.

I know a lot of you have read this already, but probably not all. To the conservatives who are here: please try to resist the temptation to read the above as a partisan observation.

"1. By what means do you only cover the uninsured? Mandate?

2. Wouldn't that mess with the savings to be had by expanding the risk pool?"

Probably mandate for the employeed on a sliding scale like the EITC so as not to discourage getting a job. And by providing it outright to the unemployed.

I'm not sure if I understand what you are saying about the savings and the risk pool in this context. The pool we are talking about is already bigger than many European nations with health care systems. I'm not sure how big a pool you think we need.

The pool we are talking about is already bigger than many European nations with health care systems. I'm not sure how big a pool you think we need.

It's not just size, but nature thereof. I'm thinking that leaving out the wealthier and relatively healthier bloc you might create a too costly cohort.

Also, by only covering the uninsured (many of whom overlap with 'the poor'), the program is much more easily demagouged and cut and weakened than a program that includes everyone. Also, there's fewer people involved with it that have the time and/or skills to lobby the government, unlike the big players who'd happily see it cut and more money diverted to them.

And yes, gross political calculations that would keep the program from being killed within a month the next time the Republicans take power are something that should be considered.

Sebastian:

Why the rush? The biggest reason is that 2009 is not an election year, and 2010 is. That shouldn't be a factor, but that doesn't mean it isn't. If health care reform is going to get done at all, it's going to get done this year. Congresscritters aren't exactly known for making principled or easily-demagogued votes during election years.

After 2010, there's no guarantee that the Democrats will still hold majorities, and indeed, if health care DOESN'T get done, they probably won't. And it's clear, to me at least, that the GOP has no real interest in expanding access to health care. So it really does strike me as a case of "2009 or no time within the foreseeable future."

Publius sounds pretty desperate in this post. His world view is showing cracks.

Significant counterexamples: welfare reform, late term abortion restricitions, adjustments on Fannie Mae's authority.

Reagan proposed welfare reform in 1986. Clinton signed it in 1996. Partial birth abortion bans passed both houses like a hot knife through butter; they failed because of presidential veto which is a different issue. Has a big Fannie overhaul passed Congress?

And again, why can't we have a more modest bill?...We could extend Medicare availability to the uninsured to start.

That is a wonderful idea. And here is why it will not happen: Right now the insurance industry is on the verge of forcing every man, woman and child in America to buy its defective product. Your "modest" plan would snatch all those captive customers out from under the gaping jaws. Why on earth would Max Baucus vote for that?

Significant recent bill which supports both your point about how bills pass quickly and mine about how wise it is: Patriot Act.

Good demonstration of both of our points. And for what it's worth, I think all bills under discussion are awful.

Any bill that passes congress will be the Massachusetts plan on a national level, a bailout of the health insurance industry financed by stealth regressive taxation. There will be some ineffective-by-design cost controls, Medicare reforms and disease-prevention measures thrown on. Maybe a crippled public or co-op option.

Really a terrible solution.

The general shape of the eventual law is clear. Why delay? Only reasons can be to kill it entirely or fiddle around at the margins to advance sectional interests. Time to knock that s*$& out and pass the terrible, insufficient final bill so we can fix it six or eight years down the road.

Basically any bill with even a limited public option would be a huge improvement over the current system. Private insurance is incredibly wasteful, with over 30% of premiums going to overhead and profits. Medicare, and the various public schemes, spend less than 10%. At present, if you want health care in America, you have to support the incredibly wasteful boondoggle which is private health insurance. With any form of public plan, you will at least have some option for a more efficient form of insurance.

That, alone, is plenty of reason to support the current bill.

Tgirsch: "Why the rush? The biggest reason is that 2009 is not an election year, and 2010 is. That shouldn't be a factor, but that doesn't mean it isn't. If health care reform is going to get done at all, it's going to get done this year."

Ok, so
a) why didn't get it introduced earlier? The stimulus was passed quite a while ago now;

b) there is still a lot of time in this year too. It is July, the seventh month. And the long recess isn't mandatory if important things are being considered...

Eric "It's not just size, but nature thereof. I'm thinking that leaving out the wealthier and relatively healthier bloc you might create a too costly cohort."

Those people have to be covered under universal plans too, so that cost doesn't go away. Further, it involves a lot of young people in jobs without health insurance. They are actually pretty healthy. The uninsured aren't nearly as expensive as a group as the elderly are, and Medicare already covers the elderly. So it can only improve the pool quality.

Slaney: "That is a wonderful idea. And here is why it will not happen: Right now the insurance industry is on the verge of forcing every man, woman and child in America to buy its defective product. Your "modest" plan would snatch all those captive customers out from under the gaping jaws."

Wow. I'm tempted to suspect that is satire. Is that serious attempt to defend this bill?

I find it hard to understand how the people promoting healthcare reform can argue that people with no insurance have no healthcare. If an uninsured person shows up in an emergency room they must be cared for. According to President Obama's reform we now will fine them for not having insurance, but they will still be cared for.If they can not pay will they be imprisioned for tax evasion? Are we going to have debtors prison finaly in this nation.
We have a universal healthcare system, just not the way we want it. In NY the Commisioner of medicaid fraud and his deputies have discovered 300+ million dollars of fraud, and have made arrangements for the businesses involved to repay the money. Waste is what is driving costs up not the poor. We need to care for the poor and control waste.

I find it hard to understand how the people promoting healthcare reform can argue that people with no insurance have no healthcare. If an uninsured person shows up in an emergency room they must be cared for.

I find it hard to understand how anyone could find it tolerable to have only what healthcare an ER can provide - but then I live in the UK, so I'm accustomed as of right to a far higher standard of healthcare, a far more effective and less bureaucratic system than you Americans enjoy.

Do you have health insurance, Peter, or are you dependent on the nearest ER for getting treated whenever you fall sick?

IMHO I think healthcare reform can be had.

It must be something simple like a single mandatory pool for everyone with a single premium rate for everyone.

Obviously this will not make everyone happy but it is a positive first step. This would put everyone in the same boat. From there you can chip away at the problem of high overall costs since you'd be a single payer.

In my opinion, too many things are being attempted in one fell swoop: a) universal coverage, b) decreased overall costs, and c) income redistribution.

A few little side details:
1. Individuals would pay the premiums, not businesses. This gives portability.
2. I would require any employer that was making contributions toward employee health plans as of July 1, 2009 to continue to make the same payment. But that payment becomes part of the employee's basic paycheck from then on. (The tax code can still treat it as a pretax amount at first. But after a burnoff period there would be no distinguishing between the health component of your pay and your basic pay).
3. Everyone below age 18 is covered for free.
4. Everyone below a certain income is covered for free. if the premium is $400 per month/$4,800 annually then that certain income is $4,800 more than whatever the current EITC cutoff is.
4. The program should be run on a pay-go basis so that the sum of all the premiums equals the sum of all the program expenditures.

Forget the income redistribution stuff. Make that a separate debate; a tax code debate.

Forget the cost savings elements of the plan. You can accomplish that piecemeal, in steps by reducing reimbursements for service.

The insurers will be against it. Oh well.

"Why the rush?" asks Sebstian. Well, the biggest reason for the rush is that there are millions of Aemrcians one ruptured appendix away from complete disaster. What would Sebastian say to a family that undergoes medical bankruptcy, or worse, a death without treatment, while the bill is pending?

And yeah, no bill we pass is going to be perfect--not so much because it is a complicated issue, or because the half century since Truman first proposed this hasn't been enough time to study it, but because there are people making a lot of money from the status quo, and there are other people who are committed to oppose whatever Obama does, regrdless of the merits. So, what we are going to get at best will be an imperfect system, that's going to have to be repaired down the road. Frankly, I suspect that trying something, and seeing if it works, and fixing it if it doesn't, is going to be the best approach in the long run anyway.

//So there is no possibility to improve it then? Impossible to offer any criticism or try to change any detail? Can't even spend two weeks looking over one of the biggest structural changes in our lifetime?

How much time is enough? Until the Republicans are satisfied? According to the memos, they will satisfied when it is dead.//

In my opinion, it is not until now that the lefties have even listened to righties objections. The lefties assumed they could ram it through with every possible bell and whistle, righties be damned. For example, ya'll have acted like I'm an alien for objecting to the 2% paying for the 98% as opposed to the 65% paying for the 35%. Ya'll are so focused on the injustice income inequality that you don't even realize it is a stumbling block.

"Frankly, I suspect that trying something, and seeing if it works, and fixing it if it doesn't, is going to be the best approach in the long run anyway."

Great, so lets experiment with the uninsured and not mess with the rest of the system yet. Then fixing it will be easier than tinkering with farm subsidies.

... *blinkblink* Did D'd'd'dave just come out in favor of single-payer health insurance?

Sebastian:
Ok, so
a) why didn't get it introduced earlier? The stimulus was passed quite a while ago now;

Well, the stimulus was the higher priority; plus, how much "sooner" do you want? Obama hasn't even been in office for six months, and thousand-page bills take some time to draft.

b) there is still a lot of time in this year too. It is July, the seventh month. And the long recess isn't mandatory if important things are being considered...

Agreed on pushing back the recess. There are hints that Pelosi may do just that on the house side (though I have my doubts). That said, I think the end of October is more or less a drop-dead date. Once you get to November, you're effectively in 2010 election season. And that start date has been creeping forward in recent elections.

D^3ave:
It must be something simple like a single mandatory pool for everyone with a single premium rate for everyone.

Boy, I'd love that. But there's no way it's going to happen. The plans currently under discussion are far from ideal, but they're likely the best we can get. Would it be better to do nothing? That depends on whether or not a public option gets through. Without the public option, I think the currently-proposed reforms are fatally flawed, and I'd likely oppose them.

I find it hard to understand how the people promoting healthcare reform can argue that people with no insurance have no healthcare. If an uninsured person shows up in an emergency room they must be cared for.

And if I get cancer, will the ER provide chemo? Surgery? Radiation?

Do you really not understand the limitations of ER-provided healthcare? Really?

I find it hard to understand how the people promoting healthcare reform can argue that people with no insurance have no healthcare. If an uninsured person shows up in an emergency room they must be cared for.

"Keeping you from dying while you're on our property" is not "healthcare." That's what you get in an ER if you're uninsured.

Just chiming in to say d'd'd'dave's proposal looks pretty interesting to me.

Under whose auspices does the "single mandatory pool" operate?

I agree that there are too many issues being conflated into the discussion.

The metric for success for this particular effort should be making health coverage available to folks who don't currently have it, period.

D'd'd'dave: It must be something simple like a single mandatory pool for everyone with a single premium rate for everyone

You've just described the National Health Service (except for the bit about the NHS owns the hospitals and trains the doctors and nurses, but I expect that'll come).

Is this D'd'd'dave, or is this a left-wing troll using his nick to advocate for effective health care reform more leftist than any Democratic politician has dared propose?

russell: "Under whose auspices does the "single mandatory pool" operate?"

The federal govt. Insurance is insurance. I don't think the public cares much what the name of the company is. The mandatory pool policy would cover a palate of services. Things not on the palate could be covered by supplemental private policies i.e. fancy private rooms, whatever.

jes; "Is this D'd'd'dave"

Yes.

jes: "more leftist than any Democratic politician has dared propose?"

I don't see how this is more leftist. Income redistribution is leftist. Spreading risk through insurance is capitalist. The trick is in the single premium amount.

Other benefits with single payer:
- Medicaid and medicare become obsolete. Frees up some taxation. Frees up some state budgets.

"Publius sounds pretty desperate in this post. His world view is showing cracks."

See, now this isn't a troll: it's merely a comment with no substance other than to be (mildly) personally abusive.

Gary
Yes, you are right. My object was to be mildly personally abusive. Good catch.

"I find it hard to understand how the people promoting healthcare reform can argue that people with no insurance have no healthcare. If an uninsured person shows up in an emergency room they must be cared for."

It's when someone shows up with a statement like this, clearly having not read a word of previous discussion on this blog on this topic, that I have to walk away from responding, simply because the idea of again repeating the tens of thousands of words I've written as to what's wrong with this is too infuriating to keep my head from exploding from elevated blood pressure.

Don't post to a blog until you've spent some time reading past discussions on a topic.

Income redistribution is leftist.

Unless it's redistribution from poor to rich. Then it's a state of nature. Right?

Phil

'Unless it's redistribution from poor to rich. Then it's a state of nature. Right?'

That may be what you believe. It is not what I believe and it is not what I've observed. I am an Adam Smith guy, not a Karl Marx guy. In my view everyone exchanges their labor for what they can get. The fact that one receives less than another is not, in my view, a redistribution from the lesser to the greater. It is a result of a diversity of factors most of which are not sinister.

I do believe that the state of nature is that no one, anywhere, at any time in the history of the world has ever had the exact same abilities and opportunities as any other person. And to try to structure things to achieve that is a hopeless task. And to pretend it should be the way things are is like pretending gravity should be gone.

Sebastian: I've got a simple reform that wouldn't take 1000 pages, should pass at 100% and would provide a massive fix to the current system:

If any health "insurance" company practices "rescission", the entire Board of Directors, CEO, CFO, COO and all other C_O's will be have their knees broken by hammers, then be dropped into Guantanomo prison for the rest of their lives.

Would you support that?

I think, as a general rule, if letting a bill sit out in public for a few weeks before voting on it would scuttle it, it should be scuttled. I'd be hard put to come up with an exception, and THIS bill sure as hell isn't one.

And "it's a party line vote" is a hellishly bad reason for voting on anything more substantive than "National pecan waffle day".

Frankly, your whole post has done more to convince me this sucker should sleep with the fishes than anything the GOP has had to say.

That may be what you believe. It is not what I believe and it is not what I've observed. I am an Adam Smith guy, not a Karl Marx guy.

Well, first of all, given your general views on regulation, taxation, etc., I seriously doubt that you've ever read Adam Smith in your life. But in any case, what kind of guy you are has nothing to do with (1) whether you believe redistribution* from poor to rich is possible and (2) whether such redistribution is "leftist." It's a pretty simple question.

(*I use "redistribution" here not to refer to "people buying things from capitalists" but to structural and legal mechanisms which tend to divert wealth from lower to upper classes.)

The fact that one receives less than another is not, in my view, a redistribution from the lesser to the greater.

Well, that depends on the circumstances, doesn't it? What is the "lesser" receiving, and in exchange for what? What is the "greater" receiving, and in exchange for what?

I do believe that the state of nature is that no one, anywhere, at any time in the history of the world has ever had the exact same abilities and opportunities as any other person.

Has someone here argued otherwise? And do you realize that this cuts against many of your prior arguments about, for instance, your trailer park tenants? They may simply be achieving to the maximum extent of their abilities and opportunities, rather than being lazy good-for-nothings, no?

And to try to structure things to achieve that is a hopeless task.

Is someone trying to do that?

Honestly, I look at the insane urgency to enact this bill, most of the provisions of which don't kick in for years, I look at the proponents' indifference to what might be in it, and you know what I see? The political equivalent of Cortez burning his ships when he arrived in the new world.

I think there's the notion there that if you make huge, irreversible changes, even if they're for the worse, you'll take keeping the present system off the table, and thus enable real reform. Well, I think you could succeed in irreversibly destroying the present system. I'm not nearly so confident that, having burned it to the ground, you can actually erect something better.

So I'm writing my representatives, and telling them voting for this sucker is the kiss of death, so far as I'm concerned.

'And again, why can't we have a more modest bill? Something that takes care of the uninsured without throwing a big monkey wrench into everything else?'

I agree with this. Much is made about the fact that surveys show that a majority thinks the system is broken or some such terminology. If I were asked, I would say it is. But I don't think it is completely broken and I would support reform to repair those parts that are not working. But I'm opposed to an effort that does away with a system that three-fourths of our people agree works although many of those believe the costs are much higher than they should be and there are features in the current system that make them anxious about future events like losing a job.

When I was growing up in the forties and fifties, I don't remember much in the way of complaints about the healthcare system. Of course, we didn't have the medicines, medical devices, research facilities, diagnostic capabilities, and life-saving medical procedures that have been developed over the past half-century. So, even though there were rich people and poor people then and health insurance was a product in its early stage of development, there was not much deviation between what healthcare could be bought regardless of what one was able to pay, access to that healthcare, or quality of that healthcare. There were many medical conditions that were simply death sentences and the only real question was how long one would spend on death row.

Fast forward to the present and we see quite a different picture. The quality of available healthcare has reached levels that leave us speechless. Access is much more problematic for the 40 to 50 million people uninsured and a major reason for this is that the costs have escalated dramatically. This is also a potential problem even for many insured who fear they may not be insured at some future time or may incur some catastrophic event that breaks them. Same thing for those with pre-existing medical conditions that makes them uninsurable and for those who hit lifetime limits on their insurance. One needs to be very rich to self-insure with comfort.

So, what we see is those deviations in costs, access, and quality have all become much bigger and this has created some places where the system is broken. If there ever was a time and place where we should be careful 'not to throw the baby out with the bath water'. this is it.

A personal aside, 2 years ago I had open heart surgery to replace an aortic valve (stenosis). The abnormal condition was detected in the fifties but there was not much known about it then and no treatment. If all the things needed to get to the point where this surgery could be successfully done had not occurred, I probably would not be here to make this comment, much less play four softball games a week and walk five miles everyday.

Kudos to our great entrepreneurial system!

Wow. I'm tempted to suspect that is satire.

No kidding, huh? This is what happens when you have to work with "moderates". You pass a little bit of social spending in return for big honking subsidies to dividend-paying corporate interests. In return, David S. Broder goes weak in the knees.

Is that serious attempt to defend this bill?

Dude, I'm for a public option just like you are!

"But I'm opposed to an effort that does away with a system that three-fourths of our people agree works"

What features, exactly, do you think the present proposals will remove? The overwhelming number of people will go right on having health care delivered as it currently is; they'll just have more options, and more rights.

GoodOleBoy, while I'm glad you were able to get the life-saving surgery you needed, your closing sentence in particular is absolutely hilarious, considering what exactly comprises "all the things needed to get to the point where this surgery could be successfully done," and few if any of which had anything to do with "our entrepreneurial system." The history of cardiac surgery took place in large part outside the United States, and entrepreneurial motivations are rarely the driving force behind experimentation in surgical procedures. Surgical innovations take place largely in an academic, research-and-publish context. (As opposed to the development of medical devices, for example.)

Growing up in the 1970s, I also didn't ever worry about health care, because my father was in the Army, and we got great care all the time. No reason why all US children can't get that same care.

d'd'd'Dave, that's a very solid proposal, and if Snowe, Baucus, or the Blue Dogs were pushing that (or another solid proposal) I'd be quite supportive of their foot-dragging. But they're not pushing for anything solid, or for substantive improvements. They're just obstructing - in the case of Baucus, for his contributors and connections in the health care biz. Presumably also for Snowe, the Blue Dogs, and most other "moderates". The Republicans (the ones in office at least) want to stop anything and everything: party before country.

Re handling the uninsured only: You'll notice there are no such proposals coming from the moderates or the right. Why? Partly the above, but mostly because any functional solution to the uninsured will be effectively a public option - broad basic coverage, available to anybody at a low price. Once such a product exists, private health insurance will rapidly be driven into a niche market for the wealthy by its own inefficiencies. This is an intolerable situation for most moderates and conservatives as they are so beholden to the health care industry. They would fight it *harder* than they will fight the current proposal because the current proposal has sops for the industry in the form of mandates. Nobody in office has any reason to push such a plan.

Phil,

Medicines, medical devices, and diagnostic capabilities were all important parts that contributed to that success. I think plenty of that happens in the US marketplace, thank you. I don't think it would be absolutely hilarious if all US deliveries to the worldwide marketplace in these 3 categories were suddenly not there.

"Medicines, medical devices, and diagnostic capabilities were all important parts that contributed to that success."

And the idea that these were largely produced without federal funds for academic research, and largely in the U.S., is silly and ignorant.

"Medicines, medical devices, and diagnostic capabilities were all important parts that contributed to that success."

'And the idea that these were largely produced without federal funds for academic research, and largely in the U.S., is silly and ignorant.'

I've done enough research on where and how we get these products to know that the idea that US private sector contributions are significant is neither silly nor ignorant. Now why don't you address important aspects of issues instead of trivia?

"the idea that US private sector contributions are significant"

Good thing no one disagrees with this in the slightest.

Meanwhile, how health insurance actually works.

The honest Republican approach to reforming health care.

GoodOleBoy:
But I'm opposed to an effort that does away with a system that three-fourths of our people agree works

On what basis do you make this claim? As FactCheck.org points out, the same survey that shows three-fourths of Americans are satisfied with what they have today, almost the same number of respondents to the same poll believe that there should be a government plan (aka public option) to compete against private insurers. And in the same poll, they found an inverse relationship between how satisfied people were with their health care and the extent to which they actually had to use it. In other words, the people who were most satisfied were the ones that rarely or never went to the doctor anyway.

In other words, the people who were most satisfied were the ones that rarely or never went to the doctor anyway.

Well, here's the logic, you see: I've kept paying my premiums and I haven't got sick yet. That must be some good health insurance!

--TP

The trick is in the single premium amount.

...oh, right, you mean you want billionaires and paupers each to have to pay exactly the same sum per year to get health care?

Yes, that's the stuttering dave we know: penalize and punish the poor, reward the rich.

Income redistribution is leftist.

Yet you've just proposed income redistribution from poor to rich... yet not exactly a "leftist" proposal, is it?


GoodOleBoy, who paid for your surgery?

GoodOleBoy: Kudos to our great entrepreneurial system!

It varies between "funny" and "annoying" how Americans selfgratulate orgasmically over what they suppose to be their own country's achievements.

Your life was saved (congratulations) because people working in research centers such as the HELIOS Heart Center Siegburg, in Germany; Toulouse, France; the Glasgow Cardiovascular Research Centre, in Scotland.... but you, ungrateful and insular and ugly-American that you are, prefer to think it was all done at home by Americans who, in your eyes, do nothing without a profit motive.

(You are, fortunately, wrong about that: American researchers are equal to the researchers of other countries, but they would soon not be if they were, as you advocate, tied down to considering that they can only do research where a corporation will fund it in anticipation of profits.)

Holy shit, I think I have not yet ever seen a blogger kill it like you do here.

And again, why can't we have a more modest bill?

Because when the bill is already a sticking plaster, downgrading it to rice paper will not help. Unless you want to do the classic Republican trick of crippling a government program and then pointing at it to point out how ineffectual government is when you have hobbled and hamstrung it.

The question should be why you aren't asking for far more radical policies than are being presented by the current group of conservatives in office. I mean, even d'd'd'dave came out above in favour of something more radical and sane than is on the table.

Something that takes care of the uninsured without throwing a big monkey wrench into everything else?

Between recision and ER as the only form of medical care available to many, it's hard to see how much more damage a big monkey wrench would do.

We could even use it as a test case to see if the standard of care is high and if the alleged efficiencies of the government actually materialize.

When the efficiencies come from methods such as widening the risk pool and your proposal is trying to cut back that risk pool then this criticism is disingenuous.

But we've seen what works better than the US system. Any system used used by any other industrialised nation.

If you're serious about trying to use a system that has been tested to work and don't want to break that much, try arguing in favour of borrowing the German insurance based model wholesale.

We could extend Medicare availability to the uninsured to start.

Rule 1: The profits of the insurance companies shall be protected at all costs?

You've just given an excellent perverse incentive to recise more patients there.

We could make a super-basic health care floor with it.

The purpose of this floor being to socialise the risk faced by the insurance companies. Because they can more easily palm people off on the public sector.

The uninsured would be dramatically better off, and the majority of people who actually have pretty good health care already won't feel like they are jumping into the scary unknown.

The majority of Americans do not have pretty good healthcare. They just don't know it. Largely because they haven't had it tested. And at that point a moth-eaten safety rope can make you feel safer.

Find me the insurance company that covers dialysis. And doesn't try recision. And the hospital that doesn't worry about payment upfront. And then I will admit that they have decent cover. Of course, by "the majority of people who actually have pretty good health care" you could be deliberately excluding HMOs and average insurance and leaving yourself with a pool which includes US representatives, CEOs, senior managers, and other such people. In which case I salute your ability to twist a sentence.

And Jesu, don't call GoodOleBoy an Ugly American. The Ugly American was the one that took time to be nice, listen, and learn.

Now why don't you address important aspects of issues instead of trivia?

Hey, you brought it up. If you don't want issues discussed, don't toss them in as smug rhetorical flourishes.

To the others:

Jesurgislac at 2:47a, July 23 is the perfect caricature of my point.

To her, if two people, one rich and one poor, pay the same price for an identical thing, a transfer of wealth has occurred from the poor one to the rich one.

If Gandhi and Bill Gates both buy tomatoes at the same market. Must the vendor charge Gandhi a penny and Bill Gates $1000? Should there be a continuum of prices for the tomato based on the buyer's wealth? One must submit a financial statement to buy a tomato?

And if things worked this way, it is not even Gandhi who is enriched when Bill Gates buys a tomato. The tomato vendor is enriched. And what would the vendor do? He would refuse to sell tomatoes to Gandhi out of his limited supply. He would keep his tomatoes and wait for a richer buyer to come along and then Gandhi would go hungry.

If there was a government agent standing by to force the vendor to sell the tomato to Gandhi, it would still not have the desired effect. Yes, Gandhi gets his tomato. But the vendor, who is maybe poor himself, is the one who transfers wealth to Gandhi. If this was a common occurrance, the vendor would decide to no longer be a tomato vendor because he cannot profit at it. How then will Gandhi get his tomatoes?

If there was a government agent standing by to force the former tomato vendor to continue being a tomato vendor against his will...

Extend this to every good and service in the entire economy and you have a very poor and unhappy populace indeed. Half of the population would be government agents and the other half would be foragers.

What Jes thinks is fair is absolutely ridiculous in every way. It would work against the best interests of the poor. Even a 4 year old knows this will not work.

"When the efficiencies come from methods such as widening the risk pool and your proposal is trying to cut back that risk pool then this criticism is disingenuous."

This is not a good objection. The risk pool is enormously large already, and adding 20-30 million people to it only widens it. Contrary to popular liberal belief the currently uninsured aren't generally big risks compared to the elderly, which are already covered by Medicare. Adding a large pool of the non-elderly will only help the risk pool of Medicare.

"Rule 1: The profits of the insurance companies shall be protected at all costs?

You've just given an excellent perverse incentive to recise more patients there."

We can clamp down on recission, which is pretty much a hyped for TV issue anyway. It happens, it is bad, and it is not one of the major plagues of our system or else people would never get cancer treatments or AIDS treatments. See for example one of the bad cases--across the entire blue cross/blue shield of CA system (about 7 million members) there were about 2,200 improper recissions. That isn't good, they were fined $15 million for it and forced to reinstate the patients. But that isn't the backbone breaking objection you seem to be making it.

"Find me the insurance company that covers dialysis." Kaiser.

"The majority of Americans do not have pretty good healthcare. They just don't know it. Largely because they haven't had it tested. And at that point a moth-eaten safety rope can make you feel safer."

Well the international health comparison statistics belie that unless you think that all the countries don't have good healthcare too. Insured Americans have pretty much the same health outcomes overall as nationally covered Europeans and Canadians (though no one does as well as the Japanese). So I guess those systems must not have good health care.

Now the uninsured have much worse health outcomes. Which is what I want to fix.

And US health care is ridiculously expensive compared to other systems. But the government has already proven that it isn't a magic wand for that--it already pays as much per capita as Canada yet only covers 27% of the population. So, what are you left with?

"Income redistribution is leftist. Spreading risk through insurance is capitalist."

I'm not that income redistribution is specifically leftist. To be honest, I'm not sure *what* is, specifically, leftist. It's a term without a crisp meaning, which makes it both handy and not of much use.

I'm pretty confident that spreading risk through insurance is not specifically capitalist.

What I'm quite clear about is that a program where the government owns and operates an insurance service is socialist.

I have no problem with that, in fact I think it may well be a splendid thing to do.

I just want to give things their proper names.

"I just want to give things their proper names."

Fine with me. Always keep in mind that english is my second language and I'm not very good at it.

If there was a government agent standing by to force the vendor to sell the tomato to But the vendor, who is maybe poor himself, is the one who transfers wealth to Gandhi. If this was a common occurrance, the vendor would decide to no longer be a tomato vendor because he cannot profit at it. How then will Gandhi get his tomatoes?

Is there some proposal to make doctors charge people based on their incomes? Or are we talking about low-income people getting insurance that is subsidised? I would guess the tomato vendor wouldn't really care if Ghandi bought tomatoes at the market price, regardless of whether or not some of that payment came from the government.

Someone run out and find triple D Dave a 4-year-old.

I have tomatoes that, when rubbed on a tumor, make the tumor disappear. Tis proprietary.

Bill Gates (a leftist income redistributionist capitalist who never let a tax stop him from getting out of bed in the morning to invent the "Fatal Error" message on my computer, and once said "Pretty much everything the government does, they do pretty well"), bought all of my tomatoes.

The rest of you, including the wiseguy 4-year-old, can't afford them.

I want to press home Sebastian's oft-repeated question about the expense of covering 27% of the population in America compared to "universal coverage" in other countries.

The answer to that question, whatever it is, is important.

My feeling is it's cultural --- we are raised to pretty much accede to the individual monads' seeming birthright to wring the other monads dry, whether we're talking fully private, private/public partnership, or fully public.

Everyone must have a taste of the profit, which makes things expensive. Everyone requires choice, which makes any system bewildering (especially in the highly technical medical field and the highly obfuscating and opaque statistical world of insurance) and expensive.

The nice thing about Napoleon and Waterloo was that he went back to France and universal healthcare. Jim DeMint stayed in pre-Bolshevik Russia to rape and pillage until Lenin denied him coverage.


"I would guess the tomato vendor wouldn't really care if Ghandi bought tomatoes at the market price, regardless of whether or not some of that payment came from the government."

I'm not sure who this "Ghandi" fellow is, but he sure turns up a lot in discussions of Mahatma Gandhi.

On the other hand, Waterloo could be in Belgium.

Hey, at least I spelled "tomatoes" right!

"I want to press home Sebastian's oft-repeated question about the expense of covering 27% of the population in America compared to "universal coverage" in other countries.

The answer to that question, whatever it is, is important."

I'm russell, and I agree with this message.

And Jesu, don't call GoodOleBoy an Ugly American. The Ugly American was the one that took time to be nice, listen, and learn.

Valid point.

Someone run out and find triple D Dave a 4-year-old.

So that he can re-enact Torchwood 3?

"So that he can re-enact Torchwood 3?"

Hey, they're broadcasting that on BBC America for the first time this week, and are only up to Day 3.

The answer to that question, whatever it is, is important.

"Bill Gates ... bought all my tomatoes" is part of that important answer.

In a tomato market where all the customers were Gandis, tomatoes would go for one price; if all were Gateses, another. Rich people are just as scared of illness and death as poor people, but they have the money to bid up the price of cancer-curing tomatoes in "the market" for everybody.

If John creates a cancer-curing tomato, he can make a ton of money by selling it cheap to lots of average people, or by selling it dear to a few wealthy people. If the wealthy people are (as in the US) much, much richer than average people, John's incentive skews toward charging more for fewer tomatoes.

And if "the government" tries to subsidize tomatoes for the Gandis, it effectively has to bid against the Gateses.

Of course, Thullen's tomato doesn't really cure cancer. It cures ED. And Thullen is not the only supplier. So he (and his competitors) spend good money hawking their competing tomatoes on TV. That's part of his (and their) "cost structure". So American "tomato spending" includes the cost of the TV ads. But that's okay. The Gateses can afford it.

--TP

Coming late to this thread, I notice a lot more heat than light. In particular, Gary:
And the idea that ... is silly and ignorant.;

and d'd'd'ave
What Jes thinks is fair is absolutely ridiculous in every way

C'mon people, Hilzoy's been gone less than one week and this is how we're acting already? Behave!

"It cures ED."

No, that's the other tomato.

Sebastian:
And US health care is ridiculously expensive compared to other systems. But the government has already proven that it isn't a magic wand for that--it already pays as much per capita as Canada yet only covers 27% of the population. So, what are you left with?

The knowledge that our existing government programs contain way too much corporate protectionism and way too little fraud enforcement. If you think we could get a bill through that would address just the protectionism, I'd be all for it. But good luck with that.

I'm not sure what you mean by protectionism in Medicare. Do you have specific examples that should eat up the entire budget to cover 73% of the population?

I'm also not sure what you mean by too little fraud enforcement. Medicare fraud lands doctors in jail fairly frequently. More frequently than insurance fraud, which unless it involves an enormous amount of money typically ends in you not being able to submit claims for that company. (I don't know if that is because of the federal nature of the Medicare fraud?)

Various folks have asked what the urgency is about passing a health care bill. Setting aside that Democrats have been trying to do that as a specific undertaking since Truman's campaign in 1948, and that even earlier there were debates during FDR's administration, and setting aside that every day people don't get coverage, and suffer, and die prematurely, this is also why, as regards the politics of it.

If a bill is dead if people are given time to find out what's in it, and discuss it, then a bill SHOULD BE dead. That's the bottom line. There's no emergency here, requiring instant action. The urgency is all about getting something done before people can mobilize against it.

That's not a good sort of urgency.

"There's no emergency here, requiring instant action."

I think that depends on your situation.

"The Democratic Party has made it a goal for decades to fix health care coverage in this country."

Since 1935 a National Health Plan has been in the wings.

75 years of waiting and the right wing and their servants the centrists say, "Whoa! Too Fast!"

(From the Broken Record Department*)

In American:

18,000 Americans a year die because of lack of health insurance.

14,000 Americans a day are losing their health insurance.

60% of bankruptcies are tied to medical bills.

75% of those bankruptcies tied to medical bills were of Americans who had health insurance.

The US is behind dozens of other countries on multiple health metrics.

We're behind 49 other countries for life expectancy (how long you'll live).

We're behind 43 other (and the entire European Union combined) for infant mortality rate.

Our US health system is behind 36 other countries.

The corporate-medical-industry is a MONOPOLY that is NOT competitive and loots Americans by rationing health care.

Those that have health care can lose it on the whim of a corporate bureaucrat "rescinding" health care.

25 MILLION Americans are UNDERINSURED.

Over 46 MILLION Americans are UNINSURED.

And America pays twice as much as other industrialized countries for worse results that covers fewer people.

It's time to get health care reform done.

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