Playing Games With People's Health

by hilzoy

Paul Krugman has an excellent article today. (Sorry; TimesSelect.) It begins:

"Let me tell you about two government-financed health care programs. One, the Veterans Health Administration, is a stunning success — but the administration and Republicans in Congress refuse to build on that success, because it doesn’t fit their conservative agenda. The other, Medicare Advantage, is a clear failure, but it’s expanding rapidly thanks to large subsidies the administration rammed through Congress in 2003."

Further excerpts and discussion below the fold.

Krugman continues:

"I’ve written about the V.A. before; it was the subject of a recent informative article in Time. Some still think of the V.A. as a decrepit institution, which it was in the Reagan and Bush I years. But thanks to reforms begun under Bill Clinton, it’s now providing remarkably high-quality health care at remarkably low cost.

The key to the V.A.’s success is its long-term relationship with its clients: veterans, once in the V.A. system, normally stay in it for life.

This means that the V.A. can easily keep track of a patient’s medical history, allowing it to make much better use of information technology than other health care providers. Unlike all but a few doctors in the private sector, V.A. doctors have instant access to patients’ medical records via a systemwide network, which reduces both costs and medical errors.

The long-term relationship with patients also lets the V.A. save money by investing heavily in preventive medicine, an area in which the private sector — which makes money by treating the sick, not by keeping people healthy — has shown little interest.

The result is a system that achieves higher customer satisfaction than the private sector, higher quality of care by a number of measures and lower mortality rates — at much lower cost per patient. Not surprisingly, hundreds of thousands of veterans have switched from private physicians to the V.A. The commander of the American Legion has proposed letting elderly vets spend their Medicare benefits at V.A. facilities, which would lead to better medical care and large government savings.

Instead, the Bush administration has restricted access to the V.A. system, limiting it to poor vets or those with service-related injuries. And as for allowing elderly vets to get better, cheaper health care: “Conservatives,” writes Time, “fear such an arrangement would be a Trojan horse, setting up an even larger national health-care program and taking more business from the private sector.”

Think about that: they won’t let vets on Medicare buy into the V.A. system, not because they believe this policy initiative would fail, but because they’re afraid it would succeed.

Meanwhile, the Bush administration is pursuing a failed idea from the 1990’s: channeling Medicare recipients into private H.M.O.’s. The theory was that H.M.O.’s, by bringing private-sector efficiency and the magic of the marketplace to health care, would be able to do what the V.A. has achieved in practice: provide better care at lower cost.

But the theory was wrong. Years of experience show that H.M.O.’s actually have substantially higher costs per patient than conventional Medicare, because they add an expensive extra layer of bureaucracy and also spend heavily on marketing. H.M.O.’s for Medicare recipients prospered for a while by selectively covering relatively healthy older Americans, but when the government began paying less for those likely to have low medical costs, many H.M.O.’s dropped out of the Medicare market.

In 2003, however, the Bush administration pushed through the Medicare Advantage program, which offers heavy subsidies to H.M.O.’s. According to the independent Medicare Payment Advisory Commission, Medicare Advantage plans cost the government 11 percent more per person than traditional Medicare. Oh, and mortality rates in these plans are 40 percent higher than those of elderly veterans covered by the V.A. But thanks to the subsidy, membership in Medicare Advantage plans is surging.

On one side, then, the administration and its allies in Congress oppose expanding the best health care system in America, even though that expansion would save taxpayer dollars, because they’re afraid that allowing a successful government program to expand would undermine their antigovernment crusade and displease powerful business lobbies.

On the other side, ideology and fealty to interest groups make them willing to waste billions subsidizing private H.M.O.’s.

Remember that contrast the next time you hear some conservative going on about excessive spending on entitlements, and declaring that we need to cut back on Medicare and Medicaid benefits."

As I've said earlier, I am, broadly speaking, pro-markets. But there are cases in which markets don't work well, at least without careful structuring, and present-day health care is one of them. (Health care during, say, the Middle Ages was different: very little of it did any good at all, and most of it wasn't particularly expensive, so if they had had free markets back then, I wouldn't have had the slightest problem with a free market in health care.)

However, why take my word for it? Let's just experiment. Let as many people -- or at least as many veterans -- join the VA system as want to, and let as many people get Medicare Advantage as want to. But there's no particular reason to give Medicare Advantage programs a leg up on anyone else, or to constrain access to the VA. If the VA is as bad as most conservatives think it has to be, then surely the people who use it will get over whatever mass delusion leads people to say things like this -- things we know a priori cannot possibly be true of any government system:

"Most private hospitals can only dream of the futuristic medicine Dr. Divya Shroff practices today. Outside an elderly patient's room, the attending physician gathers her residents around a wireless laptop propped on a mobile cart. Shroff accesses the patient's entire medical history--a stack of paper in most private hospitals. And instead of trekking to the radiology lab to view the latest X-ray, she brings it up on her computer screen. While Shroff is visiting the patient, a resident types in a request for pain medication, then punches the SEND button. Seconds later, the printer in the hospital pharmacy spits out the order. The druggist stuffs a plastic bag of pills into what looks like a tiny space capsule, then shoots it up to the ward in a vacuum tube. By the time Shroff wheels away her computer, a nurse walks up with the drugs.

Life in a big-name institution like the Mayo Clinic? Not hardly. Shroff, 31, a specialist in internal medicine, works at the Veterans Affairs hospital in Washington, where the vets who come for the cutting-edge treatment are mostly poor. (...)

If you're surprised, that's understandable. Until the early 1990s, care at VA hospitals was so substandard that Congress considered shutting down the entire system and giving ex-G.I.s vouchers for treatment at private facilities. Today it's a very different story. The VA runs the largest integrated health-care system in the country, with more than 1,400 hospitals, clinics and nursing homes employing 14,800 doctors and 61,000 nurses. And by a number of measures, this government-managed health-care program--socialized medicine on a small scale--is beating the marketplace. For the sixth year in a row, VA hospitals last year scored higher than private facilities on the University of Michigan's American Customer Satisfaction Index, based on patient surveys on the quality of care received. The VA scored 83 out of 100; private institutions, 71. Males 65 years and older receiving VA care had about a 40% lower risk of death than those enrolled in Medicare Advantage, whose care is provided through private health plans or HMOs, according to a study published in the April edition of Medical Care. Harvard University just gave the VA its Innovations in American Government Award for the agency's work in computerizing patient records.

And all that was achieved at a relatively low cost. In the past 10 years, the number of veterans receiving treatment from the VA has more than doubled, from 2.5 million to 5.3 million, but the agency has cared for them with 10,000 fewer employees. The VA's cost per patient has remained steady during the past 10 years. The cost of private care has jumped about 40% in that same period."

Mass hysteria produced by fluoridation: it's the only possible explanation for so many people being fooled into thinking that a government program actually works well. Because, oddly enough, they do:

"As the reforms produced results, veterans began "voting with their feet," says Dr. Jonathan Perlin, who just resigned as the VA's health under secretary. Hundreds of thousands abandoned private physicians and enrolled in the lower-cost and higher-quality VA care. But that created a new problem. The VA's budget from Congress (currently about $30 billion annually) couldn't cover the influx. By January 2003, with hundreds of thousands waiting six months or more for their first appointment, the VA began limiting access to only vets with service-related injuries or illness or those with low income.

Veterans' groups understandably want the health-care system expanded to accommodate vets with higher incomes and no service-related ailments. Tom Bock, commander of the American Legion, has another idea: allow elderly vets not in the system who are drawing Medicare payments to spend those benefits at a VA facility instead of going to a private doctor, as is now required by Medicare. "It's a win-win-win situation," he argues. Medicare, which pays more than $6,500 per patient annually for care by private doctors, could save with the VA's less expensive care, which costs about $5,000 per patient. The vets would receive better service at the VA's facilities, which could treat millions more patients with Medicare's cash infusion.

But conservatives fear such an arrangement would be a Trojan horse, setting up an even larger national health-care program and taking more business from the private sector. Congress has no plans to enlarge the scope of veterans' health care--much less consider it a model for, say, a government-run system serving nonvets. But it's becoming more and more "ideologically inconvenient for some to have such a stellar health-delivery system being run by the government," says Margaret O'Kane, president of the National Committee for Quality Assurance, which rates health plans for businesses and individuals. If VA health care continues to be the industry leader, it may become more difficult to argue that the market can do better."

"Ideologically inconvenient" isn't the only problem with this. We're talking about veterans here: people who have risked their lives to serve our country. Besides being rated more highly than private health care providers and having better life expectancy figures, the VA also has a lot of programs specifically targeted for veterans. (They are, for instance, experts in prostheses, various forms of rehabilitation, head injury, and PTSD*.) If veterans want to go there, the idea that we would keep them out of the VA, despite the fact that it would be cheaper if they got their health care there, for ideological reasons -- that we would compromise their care, and possibly their health, in order to play ideological games -- is shameful.

Personally, I think it's also shameful that we would treat non-veterans this way. But that's another story.

* Someone might argue that since people with service-related injuries are eligible for the VA, those who need these sorts of specialized programs will get them. But that's true only if everyone whose injury is actually service-related is found to have a service-related injury. This seems pretty likely when it comes to having one's leg blown off by an IED, but a lot less so for, say, PTSD or depression, or for that matter back injuries of a kind that might have been sustained in civilian life.

Comments

[bemused]

The Washington Monthly had an excellent article about the VA medical system about 18 months ago.

[heet]

The ideological hatred for the VA is freaking unbelievable. My father, a vet himself, actually told me that the only people who use the VA are druggies/hippies who can't afford real medical care b/c they don't have jobs. It disgusts me to see someone who should know better take such an unconscionable position. The wingnut opposition only makes sense when you realize they fear its success.

[Gary Farber]

"It disgusts me to see someone who should know better take such an unconscionable position."

Well, in fairness, for decades it was a pretty awful system, according to innumerable reports.

[Jesurgislac]

This seems pretty likely when it comes to having one's leg blown off by an IED, but a lot less so for, say, PTSD or depression, or for that matter back injuries of a kind that might have been sustained in civilian life.

Oddly enough, a friend of mine discovered just that when she came back from Iraq with a back injury that the VA wanted her to prove she had definitely acquired in the course of her military duties, and not doing something civilian-type that she might have done back in the US: and, once that had been established, they also wanted her to prove she had definitely acquired PTSD in Iraq, and not in the six months of civilian life since she got back. (That got resolved too, with the help of her CO: but initially the VA's argument was that women don't do front line soldiering, PTSD is something front-line soldiers get, and there was nothing on her record to show she had been in a combat zone anyway - she'd only spent a year in Iraq. (My guess is that VA person she spoke to that time was a Bush voter who was convinced that the civil war in Iraq is an illusion caused by the pro-terrorists winning the information war, so obviously PTSD just couldn't be a problem caused by 12 months in peaceful Iraq. Yeah, right.)

[hilzoy]

Jes: after the business about playing games with people's lives and health, that's what really burns me about this: making vets prove that they got sick in e.g. Iraq, rather than just saying: right, you took care of us, we'll take care of you.

Again, it also burns me that we do this with non-vets, but the business of asking someone with a condition she might have gotten while risking her life in the service of her country, but also might not, to prove it just adds that little extra dash of odiousness.

[heet]

"Well, in fairness, for decades it was a pretty awful system, according to innumerable reports."

Did I ever say this was not true? I had a different point.

[bemused]

Re "for decades...": Not saying Gary is wrong in his comment, but that it merits saying is another instance of how old information or outright canards become stuck in the minds of the ill-informed, and how hard it is to erase them. (See also welfare queens, all public schools are bad and violent, malpractice suits are the cause of high medical costs, etc., etc.)

[bemused]

Just to be clear, I am not suggesting Gary is ill-informed, but that he calls attention to how outdated information gets stuck in people's minds.

[Jesurgislac]

Hilzoy: Jes: after the business about playing games with people's lives and health, that's what really burns me about this: making vets prove that they got sick in e.g. Iraq, rather than just saying: right, you took care of us, we'll take care of you.

It astonished me, to tell you the truth. I had taken for granted that the one plus point about being a veteran was that you got free health care. The bit about "Prove you got PTSD in Iraq" particularly burned - I mean, when was she supposed to have got it after she came back? Walking in the park?

[liberal japonicus]

If this opens up into another wider health care debate, let me just toss this in, which is Gladwell's flagging of a May Krugman column on a JAMA report comparing the US and the UK health systems. Gladwell posts one or two blogs posts a month, so if you check out more recent issues, notable is the recent fight he had with Jane Galt.

[Gary Farber]

"...but that it merits saying is another instance of how old information or outright canards become stuck in the minds of the ill-informed, and how hard it is to erase them."

Exactly.

[Scott]

I gave you the "the VA is failing vets and the only solution is socialized medicine" quote the last time you tried this leftist bullshit. You ignored the fact that depending on the govt means you risk having 51% of the people who show up to vote not making your problems a concern, and tried to claim that govt doesn't fail - govt has failure 'imposed' on it. Govt doesn't fail, only individuals do.

It's the govt-worshipper equivalent to the evangelicals' responses to why there is evil in a world created by a good God. The god doesn't fail, we fail it.

If govt healthcare is so damn wonderful, you can create the program w/o any mandate to join or pay. Don't enough people trust the Holy and Sacred Government to make the program viable? If not, and you can't get enough people to join voluntarily, doesn't that prove you have no faith in your own claims.

The key to the V.A.’s success is its long-term relationship with its clients: veterans, once in the V.A. system, normally stay in it for life.

Giving the govt no incentive to give a damn, as their 'customers' cannot leave. I don't care to be your fucking hostage. The USSR proved the govt cannot run an economy - it can't run a large segment of it either:

Calgary woman left to miscarry in crowded ER waiting room
A Calgary woman is looking for answers after suffering a miscarriage in a hospital waiting room.

She was three months pregnant with her third child. She says staff told her there was a shortage of beds and she'd have to wait.

"I don't know why it happened that way, but it was wrong," she said....

..."We should not be having such overcrowded waiting rooms in hospitals. The emergency room situation in this province is ongoing and the lack of planning is evident."

Too successful: the hospitals forced to introduce minimum waiting times
After years of Government targets pushing them to cut waiting lists, staff are now being warned against "over-performing" by treating patients too quickly. The Sunday Telegraph has learned that at least six trusts have imposed the minimum times.

In March, Patricia Hewitt, the Secretary of State for Health, offered her apparent blessing for the minimum waiting times by announcing they would be "appropriate" in some cases. Amid fears about £1.27 billion of NHS debts, she expressed concern that some hospitals were so productive "they actually got ahead of what the NHS could afford".

The minimum waiting times, however, dismayed Katherine Murphy, of the Patients' Association, who said last night: "This all stems from bad financial planning and management. No wonder there is a crisis. If staff are available for an operation, they should be utilised."

Andrew Lansley, the shadow health secretary, added that the minimum waiting times shed new light on the Government's target that patients should wait no longer than six months. "It is outrageous that the purpose of the Government's targets is not so much to drive down waiting times, as to impose a six-month wait."...

[hilzoy]

Scott: the posting rules prohibit profanity. This isn't just because we like it that way, and because we find that it helps with civility; some of our readers, and one of our founders, works in a place where they block pages with profanity, and we'd rather allow them to read it at work.

No one is forced to join the VA, or to stay in it. They want to, and many are not being allowed to.

In the US, lots of people wait forever for decent health care, not being able to pay for it out of their own pockets, and not having any health insurance. Most of them have jobs, work hard, but for some unfathomable reason can't come up with the money to pay for, say, cancer treatment.

[Scott]

It's the govt-worshipper equivalent to the evangelicals' responses to why there is evil in a world created by a good God. The god doesn't fail, we fail it.

You can also see this in calls for restricting political activity in the guise of "campaign finance reform". Govt isn't corrupt - it is corrupted by contact w/ outsiders. God forbid the thought that the economic power the left wants it to have would lead to people buying favors and thus to corruption. Nope, it's those rotten civilians who are corrupting our pure govt and once the precious, precious govt has the right to make us just shut up and pay for govt financed campaigns, they will finally show their goodness and moral purity.

[Scott]

No one is forced to join the VA, or to stay in it. They want to, and many are not being allowed to.

What you want is a "single payer" program we're forced to pay into whether we like it or not. I saw the Kos threads during SS the privatization quoting Klugman as saying that programs for the poor are poor programs (i.e. the State must take us all hostage to make us depend on them so we will be 'encouraged' to hold the 'correct' beliefs). It was one of the most disgusting political arguements I've ever run across.

[Scott]

Another problem is that the people pushing for govt healthcare, claiming it's cheaper, have absolutely no credibility claiming any desire to spend less money. These are people who have no desire to see spending controlled.

Once healthcare spending is seen as social spending, we will get an endless round of liberal office seekers claiming we need to spend more "because it's for the health of our children and only selfish bastards would want to spend less money."

Want to earn some credibility? Argue for cuts in govt education spending. Argue for cuts in govt welfare spending. Then you can credibly claim to actually want to spend less on govt healthcare.

[st]

Damn the government! Entrapping me with its superior service and lower death rates! I am a rational actor, thus I am required by my rationality to choose the superior system! I won't stop being rational, thus, I am trapped! Goddamn comsymp health care!

[hilzoy]

Scott: yes, I want a program of universal health insurance. But that's not what this thread is about. Nor do I have any idea why I am supposed to be responsible for what other people say on dKos.

Democrats balanced the budget. The last Democrat on whose watch the federal workforce grew was Johnson; the last Republican under whom it shrank was Nixon. Bill Clinton had a pretty successful program of reexamining government regulations and revising and cutting them. Under Bush, by contrast, spending has ballooned.

It would be hard to argue for cuts in welfare spending now that we don't have welfare anymore. I don't particularly want to argue for cuts in education, since having an educated citizenry matters to me. I have, however, proposed a bunch of other cuts. I don't particularly feel that I have to earn my credibility in your eyes; if you wanted to earn some in mine, you'd address positions I have actually taken, and topics we're actually discussing.

[cleek]

these 'govt-worshippers' Scott's going on about sound pretty scary - i'm glad i've never met one !

[Frank]

Wow thats a real blast from the past! I hardly ever here about Democrat's free spending ways anymore. I wonder why that is? Oh yeah!

Keep the laughs coming Scott. I really needed that one.

[Gary Farber]

If govt healthcare is so damn wonderful, you can create the program w/o any mandate to join or pay.

Don't enough people trust the Holy and Sacred Government to make the program viable? If not, and you can't get enough people to join voluntarily, doesn't that prove you have no faith in your own claims.

[...]

Giving the govt no incentive to give a damn, as their 'customers' cannot leave.

This might be relevant were it true, but since it's completely false, it isn't.

Oops.

"Calgary woman left to miscarry in crowded ER waiting room"

I was unaware that Canada had taken over the VA: when did this happen, exactly?

"Too successful: the hospitals forced to introduce minimum waiting times"

Wait, now it's Britain running the VA?

Scott, it's unclear that you're interested in any actual facts getting in the way of your ideology, but you might want to look into what Hilzoy actually wrote about the VA, and what the actual facts are, and address them, rather then bringing in completely irrelevant cites that have, you know, absolutely nothing whatever to do with the VA.

Also, I suggest blockquoting, or using quotation marks; as it is, you appear -- completely unintentionally, I'm sure -- to be plagiarizing. As I'm sure that's not your intent, I'd suggest you use standard markers to indicate that you are, in fact, quoting.

Lastly, I'd like to bring to your attention a quote on the sidebar of my blog:

"Before impugning an opponent's motives, even when they legitimately may be impugned, answer his arguments."
-- Sidney Hook

Your argument so far consists a) irrelevant cites about programs run in other countries, rather than the VA program under discussion; and b) Irrelevant ad hominems about motivation ("You can also see this in calls for restricting political activity in the guise of 'campaign finance reform'") and against government.

It's nice that you have a conviction that government can't work; whatever rings your chimes; but since the topic of discussion is a program that evidently doesn't work, and how this embarrasses people who insist that government can't work, arguing that no, really, it's government, so it can't work!!!" is what we call "begging the question." It's a fallacy.

Argument-by-fallacy tends to be unconvincing. Try using facts and cites to argue the issues, I suggest.

"What you want is a "single payer" program we're forced to pay into whether we like it or not."

Mind-reading. Another foul.

"Want to earn some credibility?"

Passive voice, assumption of a position of authority you don't have here. Two more points lost.

Hilzoy has tons of credibility here. You can earn it to, via convincing arguments. Go for it.

[Gary Farber]

"but since the topic of discussion is a program that evidently doesn't work, "

This should have been, of course, "does work."

[Gary Farber]

Italics out!

[heet]

"Want to earn some credibility? Argue for cuts in govt education spending. Argue for cuts in govt welfare spending. Then you can credibly claim to actually want to spend less on govt healthcare."

That's pretty rich coming from a Republican these days.

Anyhoo, my point from above was there was an understanding with military service - you do it, you get lifetime healthcare. Even if it sucked, you got healthcare. Servicemen who disparage those who use the VA, hippies or no, show little respect for the sacrifices made by those in uniform. That's pretty sad if you ask me.

[Chuchundra]

Thanks for those comments, Scott. They make me feel like the last five years never happened.

[SomeOtherDude]

Looks like Scott likes to worship the government with right-wing sacraments.

(I’m spiritual! You cultists are religious!)

[Anarch]

Since we have a minor tradition of policing our own here at ObWi... any of you libertarians want to take a shot at this? (:

[Sarah]

I know not people in my surrounding who are vets, but I heard much of them in news,the situation seems to me really awful cause honestly they leave on their own with almost no govt help

[Sebastian Holsclaw]

"Democrats balanced the budget. The last Democrat on whose watch the federal workforce grew was Johnson; the last Republican under whom it shrank was Nixon."

I should probably look up the statistics again (where did I put that in the comments, argh I knew I would want those numbers again), but I'm pretty sure that almost all of the cuts in the federal workforce under Clinton came from dramatically scaling back the military and Defense Department. (If my recollection is correct the feat of scaling back the federal workforce looks impressive with military recruits included, not the impressive with them excluded, and--here is where I most want to see the numbers again--does not exist at all if you don't factor the Defense Department. So for what Republicans sometimes call the Nanny State, employment is always up, up, up. Unfortunately for my preferences that seems to be true under both Republicans and Democrats.

Preemptive reminder--I think the Bush tax cuts were irresponsible, especially considering the war footing he talks about.

[ThirdGorchBro]

I saw the Kos threads during SS the privatization quoting Klugman as saying that programs for the poor are poor programs (i.e. the State must take us all hostage to make us depend on them so we will be 'encouraged' to hold the 'correct' beliefs). It was one of the most disgusting political arguements I've ever run across.

Curse you, Quincy, M.E.!

[hilzoy]

Seb: one of the handy things about having a memory is that I could recall that I looked this up, and cited it, in my first libertarianism post (fairly obscurely, so there's no reason for anyone who did not spend ages trying to find an authoritative source before making a parenthetical comment about Clinton having cut the federal workforce to recall it.) Here are the stats (long pdf; this is from the table on p. 8):

DoD personnel, in thousands:
1994: 879.9 (-14.9%)

1996: 795.9 (-9.5%)

1998: 717.9 (-9.8%)

2000: 676.3 (-5.8%)

Non-DoD personnel, in thousands (I think the post office is excluded):

1994: 1,205.6 (-0.9%)

1996: 1,138.1 (-5.6%)

1998: 1,137.9 (0.0%)

2000: 1,107.8 (-2.6%)

So DoD shrank more, but non-DoD went down by quite a bit as well. (Nearly 100,000, which would be what, 8-9%.)

[Slartibartfast]

Noteworthy is that by 1994, DoD employment had already shrunk by a couple of hundred thousand from 1990.

[Slartibartfast]

Ok, this says 160k, roughly. Serves me right for trying to eyeball it from a plot.

[Gary Farber]

The health care plan bill the California legislature just passed seems worth bringing into the discussion.

Not to mention thanking Dobie Gillis.

[Sebastian Holsclaw]

The CA health care bill is interesting and complicated. Last I heard (and that link doesn't contradict) it had only made it through the Assembly (think House of Reps). I would be most interested to see how it interacts with private health care. From my reading of the bill it allows private insurance for things not covered by the CA health care system. There are odd complications about doctors and health groups that provide uncovered (by the CA system) procedures--they have to do with pricing and administrative costs. I'm not sure what they mean. I'm most disturbed by the bill's proponents in TV interviews suggesting that private insurance wouldn't be allowed. I don't understand why they would think that from the bill as I've seen it.

A link to the text of the bill is here.

Sidenote--one of my major concerns about 'universal' health care in general is foolish pricing on pharmaceuticals killing off research. This is much less of a concern on state by state insurance schemes than it is with national health coverage because states can't break the patents.

[Gary Farber]

"Last I heard (and that link doesn't contradict) it had only made it through the Assembly (think House of Reps)"

Yes, it does.

The state Senate has already approved the plan once and is expected this week to approve changes that the Assembly made to the bill.

[...]

SB840 must return to the Senate, which approved it once, 25-13, for concurrence before going to Schwarzenegger's desk.

Trivially, I hardly think it's necessary to explain to anyone in the U.S. what a bicameral legislature is, Sebastian, given that Nebraska is the only state without one. (Anyone here from the Virgin Islands?)

[Sebastian Holsclaw]

I was actually explaining for our non-US readers, but now that I think about it more, the House of Reps shorthand explanation might not help them much either. :)

As for passing the Senate, we shall see. California politics is notoriously silly. I've seen Senate bills pass when it looks like the Assembly won't pass things only to have the bill fail upon return to the Senate over very trivial changes. Until it gets to the governor's desk I wouldn't hold my breath.

Have you seen any good substantive discussions of the bill? All I can find are the shills talking about it. Both sides are saying things that seem clearly wrong, but I can't find a good discussion of it.

[Gary Farber]

"I was actually explaining for our non-US readers, but now that I think about it more, the House of Reps shorthand explanation might not help them much either. :)"

Plenty of other countries have bi-cameral legislatures, of course, and plenty do not. Some do it in ways where the upper house is weaker, and some are in transition, as Britain more or less is as regards the way the House of Lords has been reformed, and likely remains to be yet further reformed.

See here for various examples.

"Have you seen any good substantive discussions of the bill?"

Not really, as yet. Just some blog posts spouting off without a lot of substance.

I have inquired of Ezra Klein (via e-mail), since he's a health policy wonk.