Unleash Senator Wyden

by von

Senator Wyden (D-Ore.) has a health care bill.  As I've written in the past, it's a pretty damn good bill.   I'm not alone in liking it:  lots of other folks on the left and right do as well.  Moreover, unlike all the other major health care bills out there, Wyden's bill is genuinely bipartisan:  it has a prominent Republican co-sponser in Bob Bennett (R-Utah).

Wyden has been pretty low-key regarding his plan while Sen. Baucus has tried to hammer out an alternative bill with bipartisan support.  (Bennett's been pretty low key because he risks catching hell from some on the hard right for anything that looks like cooperation with the Democrats.)  Now that Baucus' proposed compromise is in trouble -- heck, it doesn't even have the Democratic votes to make it out of committee -- Wyden has started speaking up.  This is a good thing.  His editorial in yesterday's New York Times is particularly worth reading because it hits on the fundamental problem with the other proposed "reforms" that are circulating in Washington:

Under the nation’s current employer-based system, most people have little if any choice about where they get their insurance. They just have to accept the plan that comes with their job. That insurance company, in turn, is provided a captive group of customers, so it has no incentive to earn their loyalty.

Empowering Americans to choose from a broad selection of health plans would turn the tables. Those insurers that charged affordable rates and provided good coverage would attract more customers, while those that treated customers badly would be forced to change their ways or go out of business. To stay competitive, insurers would need to follow the example of places like the Mayo Clinic and offer good, low-cost coverage.

The various bills making their way through Congress would, as the president explained, provide some consumer choice by establishing large marketplaces where people could easily compare insurance plans and pick the one that best suits their needs. Companies participating in these insurance exchanges would be required to offer coverage to anyone who wants to buy it, regardless of their age, gender or health status, and they would be barred from charging someone more for having a pre-existing condition.

The problem with these bills, however, is that they would not make the exchanges available to all Americans. Only very small companies and those individuals who can’t get insurance outside of the exchange — 25 million people — would be allowed to shop there. This would leave more than 200 million Americans with no more options, private or public, than they have today.

Three thoughts:

First, this is exactly the debate that we should be having over health care.  The fundamental problems with the American health care system are all linked, directly or indirectly, to the fact that the vast majority of folks get insurance solely through their employers.  Employers don't necessarily choose health care plans the same way that individuals do.  Having employers provide health care also restricts choice, stratifies the market, and burdens small business.  Insurers need only deal with a handful of potential customers, who vary widely in their bargaining power and position (General Electric = powerful customer; you = not so powerful customer).  

Second, the advantages of Wyden-Bennett exchanges has not been lost on Sen. Baucus -- but he's doing it wrong.  As Publius has noted, one of the good aspects of Baucus' bill is that it provides for a Wyden-like exchange.  The problem, however, is that Baucus' version of the Wyden-Bennett exchanges is fundamentally flawed because it is still linked to employer-provided health care.  It's not enough to let many employers into the exchange.  If we are going to divorce insurance from employment, we have to let individuals into the exchange. 

Third, Matt Yglesias is wrong on the strategy.  Yglesias "[p]ersonally" thinks that Wyden-Bennet "is a good idea."  But:

.... I think it’s pretty clear at this point that the most feasible way to get what Wyden wants is to enact something that falls within the broad Obama/Waxman/Baucus/Dodd family[*] of relatively cautious reform and then have the debate about opening the exchange at some point in the future when people are less freaked out.

The public opinion research indicating that it’s important to promise the insured they can keep their insurance is pretty overwhelming. Ron Wyden is right and the public is wrong, but this is one of these situations in which being right isn’t going to help you very much and tilting at this particular windmill at this moment in time doesn’t strike me as very productive.

(Emphasis mine.)

Assuming that folks are too stupid to know what's best for them is a bad idea.  If Yglesias is right, then you'll never get Wyden-Bennett because the people will never be smart enough to get it.  May as well give up.  And, true or not, you've just insulted the intelligence of the electorate.  You don't pass good bills this way.  You pass good bills by persuading folks ... and assuming that they're capable of understanding why you're right. 

Yglesias' notion that one can use a Baucus-style exchange as a camel's nose is also highly suspect.  I don't know why an exchange that includes only employers would naturally grow to include employees as well.  Indeed, it seems that employer-only exchanges are a step in the wrong direction, particularly when coupled to mandates that employers provide coverage.  Each reinforces the link between employment and insurance -- the opposite direction from where we want to go. 

Wyden might be tilting at windmills, but not for the reasons that Yglesias provides. 

UPDATE:  One of the biggest canards regarding Wyden-Bennett is that it would force people who like their current, employer-provided insurance to give it up.  This ain't true.  There's no forcing in the Wyden-Bennett exchanges. An exchange may give you options, but it won't force you to adopt any one of those options.  You could still choose to be covered by your employer, although the hope is that employer-provided health care would gradually die as individuals find that they can get a better deal through an exchange.

*I have no idea what Yglesias means by "the broad Obama/Waxman/Baucus/Dodd family of relatively cautious reform."  There are deep structural differences between these various Democratic proposals.   I think Yglesias meant to write:  "any bill proposed by a Democrat who is not Ron Wyden."

Comments

[noseeum]

Why does this have to be either/or? Sure, allow the companies into the exchange, but let individuals in as well.

I'd love to have plans offered to me by my employer, but I'd also love to look elsewhere if I didn't like the plans offered to me. Sure, the likes of GE could probably exert some pressure to get nice cost savings for their employees. But smaller companies of less than 1,000 people would have zero leverage.

It just doesn't make sense to build barriers for no reason. They're much harder to take down in the future. This seems like an easy sell to me. If you get on a pulpit and say, "if you don't like what you're employer's offering, you have the right to look at what's available on the exchange for individuals," how could that be demagogued?

[KCinDC]

Von, can you give some hint of how you see it as politically possible to pass health reform if we abandon the idea that if you like your current coverage, then you can keep it?

[von]

Von, can you give some hint of how you see it as politically possible to pass health reform if we abandon the idea that if you like your current coverage, then you can keep it?

I'll put an update in, because this is one of the biggest canards regarding Wyden-Bennett. There is absolutely no reason why an exchange would force anyone to abandon their current insurance. There's no forcing in the Wyden-Bennett exchanges. All you would have is the option to consider alternatives.

[von]

Noseeum, I agree.

[Nate]

von, can you give some hint on how you think this would be politically possible or avoid being instantly demagogued by Republicans?

Because I don't see it. And if we're going to scrap all the work and opportunity costs sunk in the current bill for something that will work better, but piss off Republicans, we may as well go for single payer, which would work better.

[Uncle Kvetch]

Assuming that folks are too stupid to know what's best for them is a bad idea.

I don't assume people are stupid. I assume they're scared to death, as a result of a deliberate campaign of disinformation spearheaded by the Republican Party and its corporate clients.

Big difference.

[brent]

This seems like an easy sell to me. If you get on a pulpit and say, "if you don't like what you're employer's offering, you have the right to look at what's available on the exchange for individuals," how could that be demagogued?

I disagree. I mean, in principle it ought to be an easy sell, but that ignores the fact that even the current cautious approach to HCR has been demagogued to within an inch of its life. How many times have we heard Democrats say that "if you like your insurance, you get to keep it"? And yet everyday I hear flacks on TV braying about how even offering a limited, extremely watered down public option amounts to a govt takeover of health care. The fact is that Wyden-Bennett is far more likely to dismantle the employer based health care system than the public option. If Dems can't even sell the public option, how could this approach be any more successful?

I have no idea what Yglesias means by "the broad Obama/Waxman/Baucus/Dodd family of relatively cautious reform."

I do. He means that all of these bills, despite their differences, seek to basically maintain the status quo of employer based healthcare. Wyden Bennett and say, single payer, does not. Hope that clarifies.

[john miller]

Look, I have never had a problem with Wyden's plan, and the amendment he has sponsored is actually the best. This is something to be attached to whatever bill ends up on top, including a bill with a public option, which obviously makes the most sense.

If anyone thinks that just having a bunch of for profit insurance companies in an exchange is going to bring down prices because of "competition", they are kidding themselves.

[(TO) Francis]

Assuming that folks are too stupid to know what's best for them is a bad idea.

Not really. After all, von, you're a Republican.

[Sebastian]

"This seems like an easy sell to me. If you get on a pulpit and say, "if you don't like what you're employer's offering, you have the right to look at what's available on the exchange for individuals," how could that be demagogued?

I disagree. I mean, in principle it ought to be an easy sell, but that ignores the fact that even the current cautious approach to HCR has been demagogued to within an inch of its life."

I think what he means is that it couldn't be effectively demagogued (at least any more than anything else). If one plan is superior to another in a way that is no harder to demagogue than any other, when deciding between the two plans the fact that both will be subjected to stupid attacks doesn't cut against the new bill.

I don't see the Wyden bill as *harder* to defend than the other bills, and it is much better.

[salacious]

von, given the situation with Sen. Bennett you describe, can we really depend on him to go to the mat for this proposal? It's one thing to burnish your bipartisan credentials by supporting a bill that will never pass, it's quite another to spend your political capital shepherding the bill through Congress.

[John Thullen]

Wyden-Bennett may very well be the way to go, but I think the sunk rhetorical costs the Republican Party (how loudly can Bennett shout at public meetings over the duck-hunters Erick Erickson will dispatch?) has in defeating EVERYTHING will make it ... "difficult" seems too mild of a word.

The public option was optional. No one would be forced to participate because it was optional, which is to say, it was just like the invasion of Poland by Hitler and the Stalinist purges in the Ukraine.

The exchanges would be optional, too, which is to say ... well... who knows what to say any longer?

Good luck.

Is there a seat in Congress you could run for, Von, against one of the individuals in the destructionist wing of the Republican Party?

[Derek]

It's not your choice whether or not your employer offers healthcare. At least not directly.

It basically works like this, if smaller the pool for healthcare your employer has, the higher your premiums go. So if enough people choose the exchange, your company's coverage loses it's advantages. You end up dropping your coverage by default because it's not worth it to keep it anymore.

I also find it amusing that for so much allegedly bipartisan support of this move, Wyden is the only one talking about this openly.

[Derek]

I mean, there is no coercion to use the exchange, but there isn't coercion with the public option either and the same arguments apply. Just like what Brent said above.

Then there is the calculation that businesses will make to drop coverage altogether BECAUSE there is an alternative out there.

These aren't bad ideas coming from wyden-bennet... just easily slapped around. If we can't even have a responsible discussion about end of life rights, then you know damn well the wyden bennet bill can get shitted on.

[brent]

I don't see the Wyden bill as *harder* to defend than the other bills, and it is much better.

Well I guess we will never know but I simply don't agree. The key feature of the Wyden Bennett bill is that it dismantles the employer based healthcare system (not too mention making significant changes to Medicare, Medicaid and SChip). The fact is that despite all the noise, the Democrats have manged to get pretty close to closing this deal by essentially convincing everyone that they won't have to make any significant adjustments. They have, in other words, managed to fight off the demagoguery on this issue because it is based on a fundamentally dishonest argument. I don't think they win this battle if, in fact, the basis of the argument was true. That people would indeed be looking at a fundamental change in the status quo. No chance.

[lloyd]

Yeah, focusing on Bennett-Wyden in the context of the actually existing health care debate is like focusing on parliamentary reform in Poland in September 1939. I mean, maybe there's some worthwhile ideas in there, but the bigger problem is the incoming assault.

I agree with salacious-- it would be a very big surprise if Bennett, or any other Republican, were to come around and work and vote for sensible reform.

[noseeum]

I don't see anyone out there screaming to maintain the employer based health care system nearly as much as maintaining private insurance. It's the dreaded government control that's been the main point of fear out there.

I'm not for a wholesale migration to Wyden-Bennett. I'm thinking more that adopt the Baucus style bill with whatever modifications are required, then at the end, tack on a "personal freedom" amendment, where all citizens have access to the exchange.

Give it the right name, and it will sell!

[Tim Lacy]

I somehow missed the Wyden-Bennett proposal until now. Thanks for alerting me to its existence. It looks promising, but I fear Brent may be right: too much has been invested in the current thread (Baucus, etc.) to leave it behind. Our only hope is that Rockefeller, Wyden, et al can amend the current bill to make it more workable with progressive concerns. - TL

[Point]

One of the really cool things about the Baucas plan* is that it eventually opens up the exchanges to everyone (albeit over a decade from now).

If we could combine that aspect of it with a decent public option in conference, this could prove to be some truly great health reform, all things considering.

*And I did not expect to be saying that a few weeks ago.

[Carleton Wu]

von,
In your earlier post (which you cited) you say:
Wyden-Bennett largely severs health care insurance from employment
And here you say:
One of the biggest canards regarding Wyden-Bennett is that it would force people who like their current, employer-provided insurance to give it up. This ain't true.

It is not the case that, under Wyden-Bennett, it's likely that most employers would terminate their plans? That is, the bill may not force them to do so, but if they're incentivized enough it amounts to the same thing.
In any case, those two statements appear to be at odds- if the employer-provided system is largely brought to an end, most people will see a change in their healthcare. If it isn't, then the first statement is wrong.

[AIMAI]

I think its not possible to grasp how people compartementalize the information in their lives. People who have insurance through their employers are used to being bounced from one insurer to another without any control, are used to being denied access to their former doctors once they are "out of network," are used to seeing new hires and part time hires denied coverage, are used to seeing people like them bounced to "part time" or "contractor" status and then denied coverage, are used to seeing their premiums go up and are used to being denied coverage for " pre-existing" conditions or having coverage reneged on, or delayed, for spurious reasons. In other words--they know in their own lives that "employer sponsored health care coverage" is incredibly fragile and unresponsive to their real needs and likely to end up, eventually, as no insurance at all when you need it.

And yet they are able to separate that knowledge--that real world knowledge--from the debate over HCR and become incredibly frightened that somehow, magically, it is *the government* in the form of the *public option* that will *force their employer to drop coverage.* Its weird but I have this conversation all the time with people on the internet and in real life.

Its not possible to reason with these people, exactly, except very slowly and from some other kind of first principle. First you have to get them to tell you, really, what their health care situation is and that of their friends. Once you are talking nuts and bolts you can get them to agree that a) there is a problem with the current insurance model and b) that something like medicare for all, or single payer, or the public option makes the most sense. At that point, in my experience, if you've done your job right they jump right from "why is obama doing this" to "why not single payer?"

But if you try to have this conversation at the national level, with dems who are not willing to go all the way rhetorically and logically to explain to people why the system that they know and hate is not good enough, you end up at a midway point where people are essentially too scared of their own fragile situation to even listen to the possiblity that someone might be trying to make things better for them.

We need some massive retail politics on this matter but the dems have consistently left that role open to the demagogues on the right. I don't understand it. Its like they are serving steak and cake at the democratic table but they are too modest to say its going to be a good meal while the Republicans are serving up a mix of poison and stale bread and the dems seem forced to keep saying "well, that looks ok to me...I mean, if you like that sort of thing...I can see why you wouldn't like our yummy food because, after all...who knows?"

aimai

[von]

von, can you give some hint on how you think this would be politically possible or avoid being instantly demagogued by Republicans?

Because I don't see it. And if we're going to scrap all the work and opportunity costs sunk in the current bill for something that will work better, but piss off Republicans, we may as well go for single payer, which would work better.

Nate, are you aware of some record of bipartisanship with respect to the other outstanding proposals that I've missed? Because your criticism seems to apply to the current Democratic proposals as least as much, if not more than, Wyden-Bennett.

I don't assume people are stupid. I assume they're scared to death, as a result of a deliberate campaign of disinformation spearheaded by the Republican Party and its corporate clients.

If they are "scared to death," U-K, they are scared to death regarding stuff that's (allegedly) in every Democratic health care proposal. Again, why is this a ding that applies only to Wyden-Bennett.

I do. He means that all of these bills, despite their differences, seek to basically maintain the status quo of employer based healthcare. Wyden Bennett and say, single payer, does not. Hope that clarifies.

If that's his point, then it makes more sense (and he should have just said that).

It is not the case that, under Wyden-Bennett, it's likely that most employers would terminate their plans? That is, the bill may not force them to do so, but if they're incentivized enough it amounts to the same thing.
In any case, those two statements appear to be at odds- if the employer-provided system is largely brought to an end, most people will see a change in their healthcare. If it isn't, then the first statement is wrong.

I don't think those statements are at odds, Carleton. Currently, the only reasonable way to get health insurance for most folks is to get it from an employer. Under a Wyden-Bennett exchange, these folks could get health insurance directly from an insurer.

This may cause some people to choose a different health insurer. It might also create some structural (tax) changes in how employers offer their existing health care plans. It might also require that some folks "opt-in" to their employers existing health care plan if they want to continue receiving it. (Because such an employer provided plan under the current system will become an employer-negotiated plan under Wyden-Bennett.) But it won't terminate any employment-based health care plan.

[russell]

The high points of Wyden-Bennett appear to be the following:

• States set up Health Help Agencies that decide what plans will be available in each state, manage enrollment, etc.
• You pay insurance premiums as part of your federal tax liability. They're withheld from your pay.
• You get a tax exemption for whatever premiums you pay.
• The feds pay the HHA, the HHA pays the private insurer, the private insurer pays your doctor.
• Over time the HHA scheme will replace SCHIP, Medicaid, and the federal health program.

What strikes me about this plan are the following:

• The HHA's get to decide what coverage plans will be available in each state, which private insurers can play, etc.
• It's basically a single payer plan -- you pay taxes for coverage, the feds pay the doctor -- except the private insurers are in the loop.
• What happens if you don't have a job?
• Who's going to pick up the really expensive edge cases that are currently covered by Medicaid?

It's not the worst plan I've ever heard of, but it's completely unclear to me what value the private insurers are contributing, and I don't understand how folks who don't have jobs get covered.

[von]

One of the really cool things about the Baucas plan* is that it eventually opens up the exchanges to everyone (albeit over a decade from now).

No, not exactly. It first opens exchanges to employers with less than 50 employees and then (potentially) to employers with less than 100 employees. It then requires that the exchanges be open to employers with any number employees by 2022: "In 2017, states must develop and submit to the Secretary a phase-in schedule (not to exceed five years), including applicable rating rules, for incorporating firms with 50 or more (or 100 or more for those states that already included firms with 51-100 employees) into the state exchanges."

Note that Baucus never opens exchanges to employees. (It's unclear to me whether the technically self-employed, such as myself, are inside or outside the exchanges.)

Don't get me wrong: I like the Baucus bill a lot better than the competing House bill ... but it's very much in a lesser of two evils sense.

[Turbulence]

But it won't terminate any employment-based health care plan.

Indeed. If I shot you in the head with a handgun, I wouldn't be killing you. I mean, killing someone requires that you strangle them with your bare hands or something; merely taking action which a reasonable person believes would lead to your death is totally different from killing you.

The mind boggles. Whether it bans employment based heath care or not is irrelevant. What matters is that there exists a good reason for Democrats to believe that Wyden Bennet will cause lots of people to lose your insurance. The fact that this loss is an indirect rather than a direct result does nothing to remove culpability.

[von]

The Widen-Bennett plan would quickly become just the Wyden plan if Democrats actually pushed this plan. Repubs won't support any health bill because they want reform to fail. So citing this bill's "genuinely bipartisan" support is just naive.

Whether your prediction is correct or not, BitchPhD, it doesn't change the fact that every alternative suffers from the exact same defect. (Indeed, it's worse for every other alternative: At least with Wyden-Bennett you have an actual Republican named on the bill .... not true with every other Democratic alternative.)

So: If this is a reason to oppose Wyden-Bennett, then it's a reason to oppose every other Democratic bill on offer as well.

[Sebastian]

"The key feature of the Wyden Bennett bill is that it dismantles the employer based healthcare system (not too mention making significant changes to Medicare, Medicaid and SChip)."

The key feature of the Wyden-Bennet bill is that it allows individuals to buy as effectively as if they were in an employer based plan. So far as I can tell it doesn't dismantle the employer based system.

"It is not the case that, under Wyden-Bennett, it's likely that most employers would terminate their plans? That is, the bill may not force them to do so, but if they're incentivized enough it amounts to the same thing.
In any case, those two statements appear to be at odds- if the employer-provided system is largely brought to an end, most people will see a change in their healthcare. If it isn't, then the first statement is wrong."

They aren't required to provide it now, right? So why would it suddently drop?

The right way to deal with the incentive issue is to allow whoever pays for the insurance to take the tax incentive. Right now only the employer can take it. But if you let whoever is paying take it, you haven't reduced the incentive on the employer to provide health insurance (which again is not mandated *now*) but the rest of the bill makes it practical for individuals to go beyond that, or outside of that, or not worry about vanishing coverage between jobs--all of which are good things.

I think von overstates the case with: "Wyden-Bennett largely severs health care insurance from employment". It makes it much more possible to go outside the employment arena. It doesn't make it mandatory.

In any case, this is how the legislative process on this issue should have been going all along--a bunch of different ideas get hashed out. Take the best from them and get a pretty good bill in the end. No Republicans required.

I'm not saying we have to take Wyden Bennet in toto. I'm suggesting that it has some VERY good features that should either form the foundation of the emerging bill or which should be adopted in the emerging bill.

[Warren Terra]

One of the biggest canards regarding Wyden-Bennett is that it would force people who like their current, employer-provided insurance to give it up.

Oh, for heaven's sake. The biggest canard about Wyden-Bennett, one that you seem somehow to overlook, is that it freaking exists. Look, the Republicans - or at least 99% of them, and 38 of them in the Senate, a group that includes your friend Senator Bennett - have made it transparently clear that they will not vote for any health care proposal, or even offer rhetorical defense of any part of any health care proposal, unless they're certain it won't pass. And that includes proposals they themselves wrote (see: Isakson, Johnny, among others).

Talk to me about the Republicans' ideas for health care reform when this changes.

[Nate]

"Nate, are you aware of some record of bipartisanship with respect to the other outstanding proposals that I've missed? Because your criticism seems to apply to the current Democratic proposals as least as much, if not more than, Wyden-Bennett."

von: That's exactly my point. Given that the Democrats made the choice of selling health care reform to the public on the basis of "things won't change for anybody who has insurance", what benefit would there be to dropping the bill they've fought over so far, in favor of the fact W-B has a Republican's name on it, when that Republican probably wouldn't vote for it. And if we're going to change and push a bill that WILL change everybody's insurance, why go for something like W-B, that won't get Republican support, and the Blue Dogs will grandstand into something weaker (like they've already done), and instead go for a touchdown with single payer, which would get the same Republican support (0), attacks (SOCIALFACISM!), and we have many models for programs that work?

And if we did that, something like W-B, with a real public option available to everyone on the exchanges might have ended up being the "compromise". Which would probably be better than what we've got, which is the fundamental flaw of Obama and the Democrat's strategy of starting out trying to compromise with people who aren't interested in compromise.

But if the current bill is dropped, W-B won't be the result, the result will be nothing, and a victory for the Republican lies and hissy-fits.

[Point]

"Note that Baucus never opens exchanges to employees. (It's unclear to me whether the technically self-employed, such as myself, are inside or outside the exchanges.)"

My sense is they do, and even if they didn't, my sense is this would be treated as a technicality to be corrected.

This said, I may need to clarify my position on the Baucus plan:

to be a good reform, you'd still need to kill the free-rider provision; to make it a great health care reform, you'd still need to add a public option (of at least some kind) to the exchanges; and to make it a descendant of my ideal reform, you'd adopt Wyden's Free Choice Amendment.

But of course, that's just one way this could actually pan out.

(link comes via Ezra)

[Marty]

"Indeed. If I shot you in the head with a handgun, I wouldn't be killing you. I mean, killing someone requires that you strangle them with your bare hands or something; merely taking action which a reasonable person believes would lead to your death is totally different from killing you."

The bill never says anywhere in it that anyone would lose their insurance. Read the bill. It never says that. These things are complex so everyone won't understand, but if you say it causes more people to lose their insurance then you are just lying to scare people....or something like that, I'm sure I didn't quote all of those arguments correctly.

[Turbulence]

The bill never says anywhere in it that anyone would lose their insurance. Read the bill. It never says that.

I agree.

These things are complex so everyone won't understand, but if you say it causes more people to lose their insurance then you are just lying to scare people....or something like that, I'm sure I didn't quote all of those arguments correctly.

Sometimes, legislation causes events to occur that are not explicitly written in the legislation. And sometimes those events are easily foreseeable in advance of the legislation passing. For example, the CBPP says:

While the Wyden-Bennett plan would give employers the option to continue offering health insurance to their workers as long as the employer plan otherwise met the requirements for health insurance plans offered through the new state-based purchasing pools, the Wyden-Bennett legislation is likely to lead to a substantial reduction in employer-based coverage over time and to the near-elimination of such coverage outside of some large firms (that may opt, at least initially, to continue coverage to avoid disruption and potential complications for their workers).

Now, maybe you think the CBPP is wrong or stupid or knows far less about health care policy and economics than you and von. But you have to actually make that argument. Right now, some experts have looked at the situation and concluded that W-B will indirectly cause lots of people to lose their employer sponsored healthcare. They'll probably have better options to replace that healthcare, so in a sense, I doubt most of them will suffer, but that means that Dems cannot honestly say that the W-B plan won't cause lots of people to lose their healthcare. And since they can't say that, W-B can be demagogued to death.

[Bruce Webb]

The problem with these bills, however, is that they would not make the exchanges available to all Americans. Only very small companies and those individuals who can’t get insurance outside of the exchange — 25 million people — would be allowed to shop there. This would leave more than 200 million Americans with no more options, private or public, than they have today.

With respect to Wyden this seems to be a profound reading of the House Bill. The relevent section is 202.

SEC. 202. EXCHANGE-ELIGIBLE INDIVIDUALS AND EMPLOYERS.

(a) ACCESS TO COVERAGE.—In accordance with this section, all individuals are eligible to obtain coverage through enrollment in an Exchange-participating health benefits plan offered through the Health Insurance Exchange unless such individuals are enrolled in another qualified health benefits plan or other acceptable coverage.

. 'individuals' is defined in 202 (d)

(d) INDIVIDUALS.—
(1) INDIVIDUAL DESCRIBED.—Subject to the succeeding provisions of this subsection, an individual described in this paragraph is an individual who—
(A) is not enrolled in coverage described in subparagraphs (C) through (F) of paragraph and
(B) is not enrolled in coverage as a full-time employee (or as a dependent of such an employee) under a group health plan if the coverage and an employer contribution under the plan meet the requirements of section 312.

Sub-paragraphs (C) through (F) call out Medicare, Medicaid, Armed Forces, and VA respectively. There is NO restriction against any other individuals whether or not they are able to get coverage in the individual market. In fact except for Grandfathered plans as desribed in Sec 102. there would seem no viable market for individual coverage outside the Exchange, particularly since such plans would not be eligible for subsidies. So that part just seems wrong.

Similary the charge that these plans are limited to smaller employers is based on a similar misreading of 202 (c)

(c) TRANSITION.—Individuals and employers shall
only be eligible to enroll or participate in the Health Insurance Exchange in accordance with the following transition schedule

Where Year 1 (2013) opens the exchange to all individuals and 'smallest employers' (up to 10 employees), Year 2 (2014) adds 'smaller employers' (up to 20 employees), but Year 3 allows

(3) THIRD AND SUBSEQUENT YEARS.—In Y3 and subsequent years—
(A) individuals and employers described in paragraph (2); and 9
(B) larger employers as permitted by the Commissioner under subsection (e)(3).

Subsection (e)(3) allows the Commissioner to meter the admission of very large employers into the exchange but should allow employers in the 20-200 range admission to the Exchange starting on Jan 1, 2015.

Unless this language was stripped out in markup in all three House Committees the premise that Wyden, and also Ezra are working from seems profoundly misguided.

Or can someone point me to the place that these restrictions were added back in?

[Carleton Wu]

I think Yglesias meant to write: "any bill proposed by a Democrat who is not Ron Wyden."

Im not sure why you need to accuse people who don't agree on the feasibility of W-B of bad faith. I know you have your theory about how the real reason this isn't going anywhere is Big Labor (although one wonders- if Big Labor is so Big, why can't they get card check?), perhaps you think that they're (we're?) all just tools of Big Labor?
But your arguments against Yglesias's position are weak or nonexistent- basically,
1)conditions dont change over time so this is as good a time as any for W-B
2)the bill won't actually force people to change insurers (while ending employer-based healthcare somehow), ergo it's immune to fearmongering on that point. Or, as immune as other plans that actually shouldn't have an immediate effect on current employer-based plans
3)inaccuracies such as I don't know why an exchange that includes only employers- W-B is not the only proposal with an exchange that covered individuals. here is Ezra discussing exchanges- you'll notice that both types of proposals ("weak" and "strong") cover the uninsured and the self-employed. Under the recent House proposal consumers can't buy public-option health insurance from the government unless they are granted access to the health insurance exchange; to be eligible, you must either lack health insurance completely or lack adequate and affordable health insurance.
That is, it's the weak kind of exchange. And there are good reasons for wanting the strong kind of exchange. But that doesn't excuse inaccuracies.

[Carleton Wu]

It might also create some structural (tax) changes in how employers offer their existing health care plans....But it won't terminate any employment-based health care plan.
So far as I can tell it doesn't dismantle the employer based system.

I think you're finesseing the language, and this point would be hammered. It doesn't dismantle the system, just change the conditions so that employers will dismantle the system. Again, you cannot reasonably argue that this system simultaneously "severs health care from employment" but that it doesn't dismantle the system of employer-based healthcare. You want it both ways- you cannot have it. And yes, people who oppose this plan (ie the GOP) will not be constrained by the fig leaf that this plan doesn't literally legislate the end of the employer-based system.

This sounds like the people suggested a 1,000,000% tax on firearm ammunition, on the grounds that it doesn't literally restrict the right to bear arms.

So: If this is a reason to oppose Wyden-Bennett, then it's a reason to oppose every other Democratic bill on offer as well.

It's merely a reason to not use possible bipartisan support as a reason to support this particular bill.

[brent]

The key feature of the Wyden-Bennet bill is that it allows individuals to buy as effectively as if they were in an employer based plan. So far as I can tell it doesn't dismantle the employer based system.

The entire point of the bill is that your first sentence leads to said dismantling. The entire bill, every part of it, is structured to make employer based healthcare, and indeed our entire current healthcare disbursement system, less valuable. The point that it doesn't explicitly force that result is entirely immaterial. Now I think this would be a good thing but it would be entirely disingenuous of me to pretend that most individuals wouldn't be facing a change to their current circumstance. Others in this thread have repeatedly expressed this point better than me so just consider this a reinforcement of say, Turbulence's point at 1:28.

[Carleton Wu]

They aren't required to provide it now, right? So why would it suddently drop?... But if you let whoever is paying take it, you haven't reduced the incentive on the employer to provide health insurance...

If the only way I can get access to reasonable healthcare is through employment, then there's a *huge* incentive to provide it to any jobs above a certain level- ie since it might cost me $1200 a month to get bad coverage (eg exclusions) but it only costs the employer half of this to provide me with a better plan, they will do it virtually every time (the alterative that would make the job equally attractive would be to pay me enough so I can buy such a plan with after-tax dollars, a much more expensive proposition).
If the only way we could get cars was through employment, then most jobs would provide cars. Almost no jobs provide cars now, because there's no incentive to handle this via employment.

So they aren't legally required now to provide it, but they are compelled by market forces to do so. If you remove the structures that compel them to do so, they'll very likely stop. So yes, this would reduce the inventive of the employer to provide healthcare- they no longer have to do so to attract employees above a certain level.
Which is a gawd-dang *feature* of W-B, after all.

[Bruce Webb]

"Allow you to keep your current coverage" is kind of a blind anyway.

In the House Bill Sec 102 allows you to keep what they call "grandfathered" coverage and Sec 401 includes coverage under 102 as "acceptable coverage" for purposes of meeting the "individual responsibility" requirements. But you wouldn't be eligible for any subsidies and your insurer would be under limits as to how much they change the terms. And they can't offer that same crappy plan to new customers after 2013 (Sec 102 (a)(1)(A)

For those covered under an employer plan the employers have a five year window to get the plan up to the level needed to make it a 'Qualified Health Benefit Plan' meeting 'Acceptable Benefit Coverage' requirements. Which is to say making it Exchange Eligible anyway. Plus the bill limits companies ability to maintain cadillac plans for certain classes of employees. They can still offer 'Basic' 'Enhanced' 'Premium' and "Premium Plus' Plans but all in all "keep your current coverage" is kind of a fig-leaf.

Mostly there would be no reason to want coverage from outside the Exchange, Sec 102 is just a sop meant to meet Obama's campaign promise. For almost all people you will be able to get better coverage at a lower cost by going with an Exchange Plan, some people just are fearful of the unknown.

[Carleton Wu]

Bitch Ph.D.,
Please don't do that.

[Carleton Wu]

The bill never says anywhere in it that anyone would lose their insurance. Read the bill. It never says that.

But it will cause this. Furthermore, proponents of the bill view this as a feature, not an unanticipated side effect. The entire point of the bill is, as von said before, severing the bizarre relationship between healthcare and employment.
So it's sort of disingenuous to point out that the text of the bill doesn't say this.

[Sebastian]

"Now, maybe you think the CBPP is wrong or stupid or knows far less about health care policy and economics than you and von. But you have to actually make that argument."

But the reason they think that is because of the asymmetric taxing issue which can be easily resolved through providing the tax benefit to the person or entity paying for the health insurance. By not discriminating between an individual paying or the company paying for the individual's insurance, the incentive to drop health care plans vanishes.

"So they aren't legally required now to provide it, but they are compelled by market forces to do so. If you remove the structures that compel them to do so, they'll very likely stop. So yes, this would reduce the inventive of the employer to provide healthcare- they no longer have to do so to attract employees above a certain level."

But the history of the rise of employer health doesn't support your story. It arose in a time when health care was largely provided through charities, out-of-pocket, and mutuals. It arose in response to wage controls during WWII as a way to differentiate between capped salaries. It GREW from there during a time when it was not the biggest way to get health care.

It is a perk. Like vacation time. Most companies provide at least 2 weeks vacation time to the vast majority of their workers despite the fact that it is mandated almost nowhere in the US.

Now if the government provides a definite DISincentive, by providing a tax benefit to personally buying while removing it for companies, then that is likely (in the long run) to force a shift.

But a tax asymmetry isn't one of the key insights of Wyden/Bennet plan. The personal capability to buy into the exchanges is. The size of the subsidy is (capping at 400% of FPL). The scaling of the subsidy is. And those are vast improvements.

[Bruce Webb]

Nate, are you aware of some record of bipartisanship with respect to the other outstanding proposals that I've missed? Because your criticism seems to apply to the current Democratic proposals as least as much, if not more than, Wyden-Bennett.

Uh Von? Have you looked at the websites of the House Tri-Committees and looked at the amendments actually accepted during the markup process? And maybe notice how many of the ones that were accepted were authored by Republicans? Have you looked at the HELP Bill and seen how fair it was adjusted in Committee to get its price down to meet the concerns of Republicans? That none of them voted for it on final does not mean they had no voice in the crafting of the bill.
http://edlabor.house.gov/markups/2009/07/hr-3200-americas-affordable-he.shtml
Here I would not amendments 13 and 39 offered by a certain Mr. Wilson of SC and accepted by voice vote, and number 19 by Duncan Hunter also passed. Sure most amendments offered by R's were voted down, that is what being in the minority means but this was not the closed process represented by the Gang of Six.
http://waysandmeans.house.gov/legis.asp?formmode=item&number=687
Ways and Means a little more streamlined by seemingly following Ed&Labor
http://energycommerce.house.gov/index.php?option=com_content&view=article&id=1722:hr-3200-americas-affordable-health-choices-act-of-2009-markup-day-5&catid=141:full-committee&Itemid=85
Dozens of amendments introduced, debated and accepted or defeated.

Bi-partisanship is not defined by sponsorship, it is what happens while the bill is being brought up for debate in Commitee. The notion that Republicans were shut out in the other four committees in anything like the ways say Rockefeller and Wyden were shut out of the Gang of Six is just off-based.

[Turbulence]

But the reason they think that is because of the asymmetric taxing issue which can be easily resolved through providing the tax benefit to the person or entity paying for the health insurance. By not discriminating between an individual paying or the company paying for the individual's insurance, the incentive to drop health care plans vanishes.

I'm talking about the W-B bill as it is written, not some new bill that you've fabricated. If you think Wyden and Benett actually wish to make the changes you describe, you'll have to provide some evidence for that belief.

But a tax asymmetry isn't one of the key insights of Wyden/Bennet plan.

Tax asymmetry is part of the bill. Your ideas for removing it are not part of the bill.

[Derek]

But the reason they think that is because of the asymmetric taxing issue which can be easily resolved through providing the tax benefit to the person or entity paying for the health insurance.

That's not entirely the issue. Another part of it is that the group discounts employers can bargain for disappear as the group diminishes. And that will happen quickly since the people most likely to move to the individual market will be people that keep the group rates low (the young and healthy).

If the employer can't keep healthcare costs low, they won't hesitate to dump everyone else onto the exchange.

[Bruce Webb]

Under the recent House proposal consumers can't buy public-option health insurance from the government unless they are granted access to the health insurance exchange; to be eligible, you must either lack health insurance completely or lack adequate and affordable health insurance.

Slate which is here relying on an e-mail from Hacker just seems to get this wrong. I don't know how or why Hacker seems to have mis-read the bill but that seems to be the case.

There are two distinct provisions being fatally confused here.
One. People who are in an employer-paid plan can only exit under limited conditions related to affordability, in which case they can enroll in an individual plan through the exchange and the employer has to pay a fee.
Two. There is NOTHING in the bill that says that people currently in the private insurance market cannot cancel their current plan (just as they could today) and enroll in an exchange eligible plan, including the pubilc option.

I am beginning to get paranoid on this issue, the language of the bill as it was released at the time it generated Hacker's e-mail is pretty clear. The restrictions on exchange eligibility seen in the House Bill by just about everyone from Hacker on down to the humblest blogger just do not exist.

Or maybe there is someone out there who can give me an assist and point out what I missed in my reading of Sec 202.

(BTW I got this same reaction when I first started commenting on Social Security back in 2003. What I was claiming seemed so odd that it took months before people, starting with Max Sawicky, realized I was drawing my conclusions direct;y from the language of the Reports and was making valid points. Just as here I am looking at the bill language and not some version of it moderated through someone else's readig.

[Sebastian]

Bitch PhD, please read the posting rules and try to understand the philosophy of ObsidianWings. We aren't perfect. We don't do it all the time. But we really do try to have reasonably civil discussions. I respect your writing on your blog, and it would suck to have to ban you here.

[Turbulence]

Are those Bitch PhD comments actually written by her or is one of her spoofers back? I could be totally wrong, but they don't sound like the kind of thing she'd write, especially the drinking one.

[Carleton Wu]

But the history of the rise of employer health doesn't support your story. It arose in a time when health care was largely provided through charities, out-of-pocket, and mutuals. It arose in response to wage controls during WWII as a way to differentiate between capped salaries.

I don't think that the history of things is always indicative of what they become. Whales are descended from land-dwellers, yet this is not proof that they can still walk on land. England was, at one time, a monarchy; would you argue that this history means that the Queen is anything more than a nominal executive?
The history doesn't need to support my story- the current set of circumstances does. And they do.

It is a perk. Like vacation time. Most companies provide at least 2 weeks vacation time to the vast majority of their workers despite the fact that it is mandated almost nowhere in the US.

We are not discussing mandates, that merely muddies the waters. An analogy to vacation is also inept, since vacations are integral to employment conditions but healthcare is not.
Since you havent actually addressed the point (ie that the employment market changes if employees do not need to get healthcare through their employers), I don't think I need to go further than a restatement- if a valuable service can only be gained through employers (or is much more expensive for individuals), virtually all employers will provide it. If this is not the case, employers will stop. Thus, as I said, very few jobs provide cars or car service. If cars were much less expensive for employers to provide than for employees to provide for themselves, many jobs would provide them.

[Carleton Wu]

I don't see the Wyden bill as *harder* to defend than the other bills...

Im trying to figure out why the conservatives here are seeing this point very differently from the liberals. There doesn't seem to be anything inherently liberal or conservative about the issue.
That suggests to me that it's one of those tribal things- we're all more persuadable to arguments from *our side*.

Which, oddly, doesn't change my conviction that Im right about this. Weird.

[Sebastian]

"An analogy to vacation is also inept, since vacations are integral to employment conditions but healthcare is not."

What does this mean? Vacations aren't intergral to employment conditions in the sense that they are technically essential. So employers don't have them. But they generally suck.

"if a valuable service can only be gained through employers (or is much more expensive for individuals), virtually all employers will provide it."

I'm clearly not understanding your objection to vacation time being considered a counterexample to this rubric.

Or mileage above the federal minimum.

UK employees of US firms often get top up insurance even though they have the NIH available to them. Shouldn't that be exceedingly unlikely under your rubric? (I don't know about UK firms in general, don't many of them also offer top-off insurance)?

"I don't think that the history of things is always indicative of what they become."

Not "always" but you are ignoring the how the actual history contradicts your story. Employer based health care consolidated at a time when it wasn't the only or dominant option for health care. That suggests that other options being available won't kill it off, certainly not in the automatic way you seem to suggest.

[Carleton Wu]

What does this mean? Vacations aren't intergral to employment conditions in the sense that they are technically essential.

That is, vacations are an inextricable part of the employment circumstances. Vacation days from one's job cannot be acquired except from the employer. So, unlike healthcare, we can't easily contrast a situation where vacation days are employer-provided with one where they are acquired on an open exchange.

"if a valuable service can only be gained through employers (or is much more expensive for individuals), virtually all employers will provide it."

I'm clearly not understanding your objection to vacation time being considered a counterexample to this rubric.

It isn't. I wasn't saying that as a constrast to vacation, which is also something that can only be provided effectively by employers under the current circumstances.
The point is that, unlike vacations, healthcare is not integral to the employment circumstances by necessity. Which is why vacations were a bad counterexample IMO. At least with the counterexample of cars, we can easily imagine a world where cars are mostly employer-provided. But I cannot easily imagine a world where vacation days are not.

Things that people want or need that can only be provided by employers will be provided by employers. Things that can be obtained outside of employment (eg cars) will, for the most part, be obtained outside of employment. Occasionally, jobs will entice with perks- free soda, exercise rooms, extra vacation days, etc. But that is easily differentiated from the things which cannot be disentangled from employment such as vacation or (currently) healthcare.

And again, here's the weird part- for W-B, this is supposed to be a *feature*. I have no idea why proponents of this bill would turn around and argue that it really will have little practical effect, most people will stay with employer-based plans. Where's the 'severing of the illogical employment-based healthcare system' if nothing changes?

[Jay Jerome]

The JJ National Health Care Bill
(In Understandable English)

1- It will be ILLEGAL for Health Plan Insurance Providers to to reject anyone from Coverage Because Of Previous Existing Conditions.

2- Any business, corporation, or other entity (governmental or educational or union or military) employing 50 or more American Citizens or Legal Residents of the United States will, by law, be required to provide an approved health insurance plan to those employees (fines and penalties for failing to comply to be determined).

3- Any Citizen or Legal Resident of the United States who does not qualify for health insurance as described in (2) will be eligible for the Medicare-Extension Plan, the cost of their buy-in premiums to be determined on a sliding scale, depending on income.

4- All businesses in the United States that directly or indirectly profit from government subsidized health care patients will be subject to a direct surcharge on pre-tax sales (percentages to be determined).

5- All CEOs, and upper management employees of businesses in the United States that directly or indirectly profit from government subsidized health care patients will be subject to an add-on income tax (percentages to be determined).

This is the best of all possible realistic options. Everybody gets covered. No government take-over of health-care. No incentives for business to drop their employees' health care, and incentives to continue it. And some of the expense for adding millions of members to 'Medicare-Extension' coverage recovered from those who will profit from huge increase in business that 50 million new customers will add to the mix.

[Carleton Wu]

I think I should point out that, while von hasn't articulated this here, he believes that liberals are opposed to W-B because they are beholden to Big Labor. That is, they understand that W-B would be superior and not any harder to sell, but they cannot cross their union bosses.

[matttbastard]

Those comments are almost certainly not from the real Bitch Ph.D. Clean up on aisle 10. Teh spoofer just vomited all over another thread.

[Sebastian]

"That is, vacations are an inextricable part of the employment circumstances. Vacation days from one's job cannot be acquired except from the employer. So, unlike healthcare, we can't easily contrast a situation where vacation days are employer-provided with one where they are acquired on an open exchange."

This seems like a hyper-technical distinction that isn't clearly grounded.

The number of vacation days can vary from zero days to about 30. Healthcare benefits can also vary from about nothing to really good. Nevertheless, in practical reality, they tend to converge onto a relatively similar number: some awful companies offer zero, most companies offer 2 weeks to everyone and a sliding scale based on seniority or work position. Some companies start at three. Similarly some companies offer no health care. Others offer cutrate. Most offer pretty serviceable care. Some offer great care. In many cases those that offer good perks in one area also offer them in the other. So it isn't clear that companies actually distinguish along the lines that you are drawing.

Further you're ignoring the history which directly contradicts your hypothesis.

So from my view you have a bad theory even theoretically, and it doesn't agree with the facts we actually see, nor does it agree with the facts as they played out historically.

[Sebastian]

"Aside from dismantling employer-based insurance, from a feminist perspective, the biggest problem with Wyden-Bennett is that, unlike HR 3200, it would not provide taxpayer support for abortion and other reproductive health measures."

I'm pretty sure that isn't true. I've seen the idea that HR3200 covers abortions reported as a scare tactic myth. Are you sure about this? I think neither plan covers abortions.

[Anthony Damiani]

The right is set to maximum-pissed no matter what's in the bill. The facts have been so discoupled from the actual discourse over healthcare, I don't think there's actually much political cost to anything at this point-- so we might as well back something decent.

[Bruce Webb]

Well no one seems interested in my opinion but I think the difficulty here is that the axis of MY, Klein, and Von have a fatally flawed understanding of HR3200 to begin with.

It does not have the barriers to individuals and larger employers they think it does. Each has fatally misread Sec 202 and skipped the parts that make their arguments moot.

They are working from a faulty premise. HR3200 opens up the exchange to all individuals not enrolled in an employer plan starting Jan 1, 2013. It doesn't have the limits Ezra and Von state. Furthermore the exchange is open to all employers starting Jan 1, 2015 subject only to some power by the Commissioner to meter entry by the largest employers. The following is simply not supported by the actual language of the bill. Wyden and Hacker and everyone taking their lead from them is working from a wrong reading of HR3200. Or someone can prove me wrong using actual bill language.

The problem with these bills, however, is that they would not make the exchanges available to all Americans. Only very small companies and those individuals who can’t get insurance outside of the exchange — 25 million people — would be allowed to shop there. This would leave more than 200 million Americans with no more options, private or public, than they have today.

The first sentence is partially right. The second two are just dead wrong. Or maybe I am. But I seem to be the only one quoting actual bill language.

[Sebastian]

"The Wyden-Bennett bill contains extreme anti-choice provisions, and that is another reason to oppose it."

This whole attitude is just weird. Another option is to modify it, right?

We could take what we like out of various bills and modify them, right?

[Sebastian]

What are these extreme anti-choice provisions anyway?

[Turbulence]

Don't click on the Bitch PhD link above: it takes you straight to a nasty porn image. I'd say that this confirms my earlier suspicion that at least some of these Bitch PhD comments are not coming from the real Bitch PhD.

[matttbastard]

Toldja it was the spoofer -- aisle 10. Clean up. Stat.

[Jay Jerome]

von says: The fundamental problems with the American health care system are all linked, directly or indirectly, to the fact that the vast majority of folks get insurance solely through their employers.

No, there are two main problems with the health care system we have now, and nether has much to do with the way folks get their health insurance.

The first big problem is that everybody isn't covered.

The second really BIG problem is the unstoppable rising cost of health care.

Neither has much to do with health insurance policies, and how or where you buy it.

Health care costs won't go down with single payer, private-payer, or a combo thereof.

Health care costs will keep rolling higher, with or without adding 40 or 50 million uninsured Americans to the health care rolls (the costs to Americans, though, will increase considerably when we do add them to the system).

Anybody here who doesn't get that?

The main increases come from the providers: hospitals, doctors, the pharmaceutical industry. Because of the costly advances in medical treatment, and because people live much longer now, more medical service and care is provided, which in turn drives up the costs.

50 years ago if you had a heart attack all they could provide was aspirin and bed rest. Now you have high tech intensive care for everything from coronary bypass to heart transplants, and a crew of doctors and nurses and specialists and technicians attending to patients 24/7 with million dollar equipment.

Wyden-Bennett, Baucus, co-ops, exchanges -- it's all a lot of blah blah. Just pass a law that makes it illegal for health insurance companies to exclude anyone because of previous medical conditions, and mandate that businesses and other organizations with x-number of employees (50,or 100) have to offer them coverage. And those who aren't covered enroll in a modified Medicare plan. Then tax all the businesses that profit from health care to ameliorate some of the costs, so all of the expense isn't absorbed by the middle-class.

[Eric Martin]

I deleted the spoofer's comments.

[Jay Jerome]

von says: The fundamental problems with the American health care system are all linked, directly or indirectly, to the fact that the vast majority of folks get insurance solely through their employers.

No, there are two main problems with the health care system we have now, and nether has much to do with the way folks get their health insurance.

The first big problem is that everybody isn't covered.

The second really BIG problem is the unstoppable rising cost of health care.

Neither has much to do with health insurance policies, and how or where you buy it.

Health care costs won't go down with single payer, private-payer, or a combo thereof.

Health care costs will keep rolling higher, with or without adding 40 or 50 million uninsured Americans to the health care rolls (the costs to Americans, though, will increase considerably when we do add them to the system).

The main increases come from the providers: hospitals, doctors, the pharmaceutical industry. Because of the costly advances in medical treatment, and because people live much longer now, more medical service and care is provided, which in turn drives up the costs.

50 years ago if you had a heart attack all they could provide was aspirin and bed rest. Now you have high tech intensive care for everything from coronary bypass to heart transplants, and a crew of doctors and nurses and specialists and technicians attending to patients 24/7 with million dollar equipment.

Wyden-Bennett, Baucus, co-ops, exchanges -- it's all a lot of blah blah. Just pass a law that makes it illegal for health insurance companies to exclude anyone because of previous medical conditions, and mandate that businesses and other organizations with x-number of employees (50,or 100) have to offer them coverage. And those who aren't covered enroll in a modified Medicare plan. Then tax all the businesses that profit from health care to ameliorate some of the costs, so all of the expense isn't absorbed by the middle-class.

[Nell]

It takes three hours to get rid of spam filth? Why are any 'BPHD' comments past the one at 1:16pm still here?

[Nate]

Jay Jerome: If that's true, then why do other countries, with high-tech treatments, such as Canada, the UK, Netherlands, Germany, etc, all manage to pay much less than we do, and cover everybody, mostly through some version of single-payer, or exchanges?

[Turbulence]

The main increases come from the providers: hospitals, doctors, the pharmaceutical industry. Because of the costly advances in medical treatment, and because people live much longer now, more medical service and care is provided, which in turn drives up the costs.

Do you have a cite for this assertion? It doesn't ring true. There are areas of the US that have much lower than average health care costs with better than average health outcomes, so if "costly advances in medical treatment" are responsible, we're not talking about treatment that is very effective.

I'm generally skeptical about claims based on complex demographic arguments ("people are living longer now") unless they come from someone who knows something about statistics. Somehow, I doubt you qualify JJ. But prove me wrong!

[Jay Jerome]

nate says: "If that's true, then why do other countries, with high-tech treatments, such as Canada, the UK, Netherlands, Germany, etc, all manage to pay much less than we do, and cover everybody, mostly through some version of single-payer, or exchanges?"

I'm on my way to meet some friends and then to see the Dodgers play, so I don't have time to answer in full now, but here's some things to consider:

Health insurance profit margins in the US: 3 to 5 percent (not a lot to squeeze them for there).

Kaiser, my provider (and a good one) is a nonprofit health insurance organization (they operate something like 40 hospitals and facilities). So, no high salaries, or lavish bonuses. And they monitor their administrative costs. Which means premiums should be close to true operating costs. Still, their rates are comparable to other for-profit insurance in L.A. And costs are still going up there too…

I don't have info available on the other
countries you reference above, but I've looked into the Canadian system, and yes, cheaper there, but:

Doctors make a lot less.
Malpractice insurance is a lot less (better Tort reform then we have).

But their overall medical infrastructure doesn't match ours (they're billions of dollars behind us -- it costs big bucks to build hospitals, money which comes, in good part, from what patients pay).

For example, Canada lacks many of the advanced facilities we have to provide care for angioplasty, leukemia, cancer, bone marrow transplant etc. And to address some of those deficiencies the Ontario Ministry of Health contracted with 13 U.S. hospitals along the Canadian border to treat Canadian patients who require care for the procedures mentioned above.

And, of course, Canadian wait times are longer than US wait times (that's one of the biggest complaints -- you can google that and see for yourself).

So they may be paying less, but they're getting less infrastructure for their bucks. Plus, their costs are on the rise, and they're considering raising taxes to fix some of those problems. (lots of google info on that if you want to investigate yourself.)

I guess what I'm saying is that the health insurance industry is a relatively small slice of the health care cost pie -- and I don't see much savings for consumers in the future, no matter what plan is enacted into law.

[Carleton Wu]

This seems like a hyper-technical distinction that isn't clearly grounded.

That vacation days cannot be seperated from employment circumstances, but healthcare can- this is hyper-technical? This isn't clearly grounded?
I think you're substituting invective for argument.

The number of vacation days can vary from zero days to about 30. Healthcare benefits can also vary from about nothing to really good. Nevertheless, in practical reality, they tend to converge onto a relatively similar number

I will try one more time, then I will give up.
Vacations are a bad example because we are talking about the effect of allowing people to effectively obtain healthcare policies outside of their employment. This cannot happen with vacation days.

That is, I agree, most decent jobs offer some healthcare and some vacation days, and that both of these tend to improve as the jobs improves. But that similarity has nothing to do with the situation we're trying (ostensibly) to investigate- what happens when healthcare can be purchased as easily by individuals as through employer group plans.
I mean, that is what we are discussing. An analogy that cannot conform to the subject is worse than useless.

I maintain that the current situation, in which heathcare is provided by almost all jobs above a certain level, is artificial. It exists only because there is no other effective way to obtain healthcare for individuals.
Expecting this situation to continue when the market forces maintaining it cease to exist is like expecting a plate to stay hovering in the air after you let go of it.

Further you're ignoring the history which directly contradicts your hypothesis. So from my view you have a bad theory even theoretically, and it doesn't agree with the facts we actually see, nor does it agree with the facts as they played out historically.

History has absolutely no bearing on what we are discussing. I am discussing the current conditions of the employment market- if history has an effect, it will exist in a force currently being exerted on that market. Market actors do not respect historical events, they react to simple economic pressures. If history does exert some present-day force on the employment market, explain what that is.
As for facts- what facts have you presented that support your case? You've drawn a profoundly flawed analogy to vacation days- flawed because we cannot divorce vacation days from employment as we can with healthcare. A good analogy is not a fact- a piss-poor one is that much less.

[Sapient]

Health insurance profit margins in the US: 3 to 5 percent (not a lot to squeeze them for there). Cite? I'm finding this: http://www.cnsnews.com/news/article/52745 which quotes Sen. Rockefeller as saying:
“Insurance companies have seen their profits soar by over 400 percent since 2001 when premiums of consumers have doubled.”

Telling us all to google something vague is not instructive. If you have evidence for what you're saying J.J., give it up.

[Sapient]

Oops: I meant to put quotes around J. J.'s assertion: "Health insurance profit margins in the US: 3 to 5 percent (not a lot to squeeze them for there)."

[Turbulence]

Kaiser, my provider (and a good one) is a nonprofit health insurance organization (they operate something like 40 hospitals and facilities). So, no high salaries, or lavish bonuses.

Nonprofit organizations need not have low salaries or stingy bonuses.

Malpractice insurance is a lot less (better Tort reform then we have).

There's no indication that tort reform would significantly lower health care costs in the US. The CBO recently produced a report suggesting it would not. Malpractice insurance premiums and payout constitute a tiny fraction of health care spending in the US and states that have instituted strict malpractice award caps do not see health care cost reductions.

But their overall medical infrastructure doesn't match ours (they're billions of dollars behind us -- it costs big bucks to build hospitals, money which comes, in good part, from what patients pay).

Note that one of the biggest problems with health care in the US is that there is both systemic undertreatment and systemic overtreatment. Overtreatment is actually quite dangerous: every time you perform unnecessary surgery, you risk killing or permanently injuring the patient. We perform a lot of unnecessary surgeries because our pay-per-procedure system biases us towards paying for procedures whether they're needed or not.

For example, Canada lacks many of the advanced facilities we have to provide care for angioplasty, leukemia, cancer, bone marrow transplant etc.

Where is the evidence suggesting that Canadians have a higher amenable mortality rate than Americans? Why should we accept your claims at face value given how much ignorance you've demonstrated on so many threads here?

And, of course, Canadian wait times are longer than US wait times (that's one of the biggest complaints -- you can google that and see for yourself).

I'm not going to waste my time googling because I'm not the one making a claim. You're making the claim, so you give a cite. I want to see a serious scientific study and not some random collection of anecdotes. What are the wait times for someone who needs treatment for a chronic condition but lacks insurance and the cash needed to pay? Emergency rooms don't do treatment for chronic conditions.

[Jesurgislac]

von; The fundamental problems with the American health care system are all linked, directly or indirectly, to the fact that the vast majority of folks get insurance solely through their employers.

No, von. The fundamental problem with the US healthcare system is that it's supposed to be profitable.

I notice, too, that despite your apparently liking this bill from Senator Wyden, you are either unable or unwilling - or possibly both! - to summarize what it actually does. You just keep vaguely flannelling that you like it, whatever it is, presumably because it contains none of that nasty government medicine that makes every other developed country's healthcare system function so much better than that of your own country.

As I noted a couple of days ago, the intellectual incoherency you display whenever healthcare reform is discussed, and your refusal to respond to substantive points made by others kind enough to actually try to engage you in discussion, is fairly obviously the direct result of your ideological need to support profit-driven healthcare conflicting with what brains and compassion you have left: you know that true lifesaving healthcare reform in the US involves not moving insurance away from the employer but moving the healthcare system out of the profit-driven market: but conservative ideology won't permit you to acknowledge this.

Meantime, people keep dying for the sake of your ideological fixation with profit.

[Sebastian]

"That vacation days cannot be seperated from employment circumstances, but healthcare can- this is hyper-technical? This isn't clearly grounded?
I think you're substituting invective for argument."

No. The idea that the distinction is important to the discussion isn't clearly grounded. There are millions of possible distinctions between vacation days and healthcare: that one involves time and the other personal services, that one typically involves scheduled usage and the other often doesn't, that the cost of one is readily predictable while the other is much more chancey. Not all of them are important to the discussion. And it isn't at all clear that your chosen distinction is more important than the similarity that they are both voluntarily provided perks which companies use to compete.

That is, I agree, most decent jobs offer some healthcare and some vacation days, and that both of these tend to improve as the jobs improves. But that similarity has nothing to do with the situation we're trying (ostensibly) to investigate- what happens when healthcare can be purchased as easily by individuals as through employer group plans.
I mean, that is what we are discussing. An analogy that cannot conform to the subject is worse than useless.

Yes like all good lawyers if you can completely control the definitions you can control the outcome. I think we are talking about your claim that certain benefits will not be provided except in an allegedly very fragile structure of support for them. Pay and vacation days and medical benefits are all such benefits. Companies compete with each other over them. You allege that there is a useful distinction to be made between all the other benefits provided by companies and health care benefits and you further allege that this distinction makes it likely that health benefits will be abandoned.

History has absolutely no bearing on what we are discussing. I am discussing the current conditions of the employment market- if history has an effect, it will exist in a force currently being exerted on that market. Market actors do not respect historical events, they react to simple economic pressures. If history does exert some present-day force on the employment market, explain what that is.

That is quite a statement. I'm not even talking about the effect of history. I'm talking about how the history demonstrates that your hypothesis is likely wrong.

You *claim* that companies offer health care because they are the only major way to get health care. But I pointed out that the history of corporate sponsored health care is that it rose during times when people got their health care through case, charity, and mutual associations. So history actively demonstrates that corporate sponsored health care can thrive even when there are other options.

Now it is possible that you believe such history offers useful distinctions that apply. But the assertion that the history has no bearing whatsoever is just astonishing.

[Turbulence]

I think that this whole vacation point is a huge distraction. Do you know why American companies offer vacation time to their employees? Because human beings aren't machines. They can't work without respite indefinitely. Companies offer vacation because workers need vacation to work productively. Vacation benefits benefit corporations.

[joel hanes]

> Health insurance profit margins in the US: 3 to 5 percent

Profit margins are calculated after expenses (such as executive salaries, sales team junkets to Cancun, construction of grandiose world headquarters buildings, and advertising) are deducted.

There's a _lot_ to be squeezed there.

[russell]

I have a question about the Wyden-Bennett bill.

If I understand it correctly, which may not be so, Wyden-Bennett would introduce health insurance pools, where folks who were not otherwise covered could pool together and get a better deal than they would if they bought individual policies.

These pools will be managed and run by a government-sanctioned agency at the state level. Insurance premiums will be deducted from people's pay as part of their federal taxes, the feds will pay the state-sanctioned agency, the state-sanctioned agency will pay the private insurer, the private insurer will pay the doctor.

The types of plans that will be offered in each state, who can join, etc., will be regulated by the state-sponsored agency.

Why is insurance provided by a private insurer, but the terms of which are regulated by the state, and which is funded by the state through tax revenue, preferable to the public option?

It seems like it has all of the regulatory and tax-based funding apparatus of the public option, except the private insurers get a cut of the $$$.

What am I missing?

[John Thullen]

Off topic, but not really, TPM has some video of both MSNBC AND FOX reporters being harassed, interrupted and generally having their news coverage disrupted at the conservative Value Voters Conference.

It's weird. I mean weird in a zombie sort of way.

Ya get the feeling a beast is abroad in the land and is about to eat enemies and enablers alike.

I think we are on a non-reversible course to something to something horrible.

I'd suggest the enablers stop feeding the zombies.

[John Miller]

von; The fundamental problems with the American health care system are all linked, directly or indirectly, to the fact that the vast majority of folks get insurance solely through their employers.

No that isn't the problem. The problem is that people cannot afford insurance, for the most part, unless they get insurance through their employers. Which is why single payer is ultimately the only effective solution.

There tends to be a belief that, if we cut the ties with employers, that somehow or other vthere will be affordable insurance out there without there being a public option. This is BS, pure and simple. The only way to make it affordable without a public option is massive subsidies by the government, which would then be the next target of those against reform.

There will be no real competition in the insurance field if the main players remaqin the same. The BUCAs have it all settled aas to who gets what areas and how they will handle rates, etc.Prices won't be driven down magically due to "competition". Hell, they aren't in competition now, except peripherally, ewven when they do challenge in the same market place. The Blues have a slight advantage because they are non-profit (supposedly) but that doesn't stop them from raising premiums 3 times the raise in health care costs.

Sebastion, employer based healthcare started to become prevalent during an era where there were other supports for 2 reasons. The first is that insurance companies saw a major market and took advantage of it. And secondly, as more medical techniques were added to field, medical care started to become more expensive. And it didn't really start to hit employers on a major level until after WWII when there was a major economic boom going on and major competition for hiring. It was an employees market and insurance became a menas by which to hire them.

Those other types of support you mentioned couldn't compete with what was available from the employers. When the incentive to use insurance as a perc is gone (which would only happen if a public option was available) employers may well drop it.

And von, on your previous thread before last weekend, you were goiing to discuss Medicare reimbursement. I may have missed it, but do you still plan t/o do so

[KCinDC]

John Thullen, my impression was that people were disrupting the reporters because their reporting was keeping the people near them in the hall from being able to listen to the speakers.

[Mike]

Wyden's Free Choice Amendment != Wyden's health-reform bill.

[CharlesWT]

Hospital costs for uninsured Americans are ruinous, like nowhere else in the world. The Wall Street Journal recently pointed to a major reason: Hospitals gain a "charity" tax deduction for the difference between what they collect and their "list" prices. If they can actually collect the money, which they often do by threatening collection lawsuits, they make a tremendous profit. If not, then they deduct from taxable income their phantom "losses" from patients who don't pay.
[...]
How Hospital Costs Ran Amok

[Nombrilisme Vide]

It seems like it has all of the regulatory and tax-based funding apparatus of the public option, except the private insurers get a cut of the $$$.

What am I missing?

Two things: first, the government is spared from paying out benefits, thus cutting costs!

Second, efficiency is increased by inserting an extra layer of administration to make sure no opportunity for cost cutting goes unnoticed!

That it won't sap and impurify all of our our body politic's precious fluids goes so utterly without say that I don't need a "third" point.

[CharlesWT]

(click on image to see full size)
What’S Really Driving the Increase in Health Care Premiums? (.pdf)

[CharlesWT]

"Health insurance profit margins in the US: 3 to 5 percent (not a lot to squeeze them for there)."

"Cite? I'm finding this: http://www.cnsnews.com/news/article/52745 which quotes Sen. Rockefeller as saying: “Insurance companies have seen their profits soar by over 400 percent since 2001 when premiums of consumers have doubled.”"

If profit margins were 0.6% to 1% in 2001 and they went up by 400% since then, they would be 3 to 5% now.

[Jesurgislac]

Charles: What’S Really Driving the Increase in Health Care Premiums? (.pdf)

The pretty graphic you linked to was produced by WellPoint - or rather, by their wholly-owned propaganda subsidiary, the "Institute of Healthcare Knowledge". Like the numbers Sebastian likes to quote that the pharmaceutical industry provides, this is not so much "research" as "advertising".

Were you aware that you were posting an item of health insurance propaganda as if it were a source of useful information, or did WellPoint fool you?

[John Thullen]

KCinDC:

Oh, maybe, but there was something odd about the way so many people got up from different parts of the audience simultaneously to converge on the reporters, and I believe one of the whispering zombies was thrown out of the joint.

Let me get this right: conservatives scream "death panels" at meetings of Democrats but they want a little civilized behavior from the uncivil crackpot journalists at FOX (and MSNBC).

I didn't see any Doogie Hauser types in there dressed like pimps trying to entice the reporter whisperers into purchasing illicit sex.

I want every conservative venue disrupted from now on.

No peace.

But that's just me.

You're probably right.

[Janie]

One of the biggest canards regarding Wyden-Bennett is that it would force people who like their current, employer-provided insurance to give it up.

von, this is moot for an additional reason than the one you mentioned.

I work in an orthopedic/physical therapy office, and every day I look up patients' insurance benefits for particular services and then call the patients and explain these benefits. Over the past two years, coverage levels across the board have plummeted, and my phone conversations have gotten pretty depressing. Within the small group (maybe 10-15%) of people who like their coverage, over half of their employers recently (in the past six months)had to downgrade to a different plan because they could no longer afford to pay the premiums for the good one.

From my observations, the people who would want to keep their current employer-provided health plan are few and far between, and even this group is shrinking rapidly.

Additionally, even people with reasonable coverage are eager for alternatives. One day someone left a door open and the people in the lobby overheard my phone call explaining benefits to a patient who had great coverage, and when I hung up the phone someone came up to the desk and asked me what type of insurance that person had. Everyone in the lobby looked up to hear my answer. Three of them wrote it down.

Some of the best health plans out there are the ones available to employees of the federal government. A lot of our lawmakers can say with sincerity, "All of my coworkers, friends, and family members like their health plan." They have the most to lose from increasing competition among insurance companies. If the demand for good insurance is unleashed, the premiums for their plan would likely go up.

[Jay Jerome]

(re this:):
Because of the costly advances in medical treatment, and because people live much longer now, more medical service and care is provided, which in turn drives up the costs.
Turbulence says:
Do you have a cite for this assertion? It doesn't ring true.

First, you must be really intellectually challenged not to know that life expectancy has been increasing dramatically in the US (in 1950 approx 68 years; in 2009 approx 78 years; projected for 2050, 84 years)

Now try to think this through, concentrate: I know you can do it. If people live ten years longer they will need health coverage an additional ten years. And those people (the elderly) are way more likely to seek health treatment more frequently. More people, more years, more treatments, more money to keep the health care system afloat.

Second, if you don't understand that medical technology has been advancing rapidly, and that it's expensive to buy, install, use, and maintain it, you're as dense as a doorknob. And if you don't understand what I just said, here's a quote from Ezra Klein, spelling it out:

From Ezra Klein
But no matter how good you got at slashing administrative costs, they will never be a panacea to the problems of the system. Rick Kronick, a political scientist at the University of California at San Diego, has done some of the best work on administrative costs, and he summed the situation up quite well. "The main question," he said, "is why are health care costs going up at 2.4 percent a year faster than GDP? And most of the answers to that question have nothing to do with administrative costs. The answers are that we do more stuff and have more technology. Even if we could wring administrative savings out of the system, which I'm all in favor of and would be a good thing, we'd still be facing the question of how to slow the rate of cost growth."

[Jay Jerome]

Sapient asks: "Health insurance profit margins in the US: 3 to 5 percent (not a lot to squeeze them for there). Cite?"

From US News

www.usnews.com/money/blogs/flowchart/2009/08/25/why-health-insurers-make-lousy-villains.htm

Overall, the profit margin for health insurance companies was a modest 3.4 percent over the past year, according to data provided by Morningstar. That ranks 87th out of 215 industries and slightly above the median of 2.2 percent. By this measure, the most profitable industry over the past year has been beverages, with a 25.9 percent profit margin. Right behind that were healthcare real-estate trusts (firms that are basically the landlords for hospitals and healthcare facilities) and application-software (think Windows).

From Health Beat
http://www.healthbeatblog.com/2009/08/who-is-making-the-biggest-profits-from-us-healthcare-you-might-be-surprised-.html

“Among the large, for-profit health insurers” Newman adds, “profit margins line up with the industry as a whole. UnitedHealthGroup, the biggest health insurer, had a 4.1 percent profit margin over the past 12 months. WellPoint, the next biggest, had a 4 percent profit margin. Aetna, Cigna, and Humana came in below that.”

[Jay Jerome]

Jesurgislac says: "Were you aware that you were posting an item of health insurance propaganda as if it were a source of useful information, or did WellPoint fool you?"

Can you point out what's propaganda and contrary to fact? Because the percentages look about right, and are supported by numerous other studies from non-industry sources.

[Turbulence]

OK, now that Jay Jerome has demonstrated, once again, that he is simply incapable of complying with the posting rules, would one of the front pagers please ban him?

[Jay Jerome]

"OK, now that Jay Jerome has demonstrated, once again, that he is simply incapable of complying with the posting rules, would one of the front pagers please ban him?"

What posting rules did I not comply with? Stating that you were as dense as a doorknob for not understanding the relationship between the aging population and rising health care costs?

By that criteria you'd probably ask to have Barney Frank banned for his 'like talking to a dining room table' remark...

Respond to the facts I stated, and stop acting like a cry-baby.

[Turbulence]

What posting rules did I not comply with?

Well, offhand there is:

Be reasonably civil

and then there is:

Do not consistently abuse or vilify other posters for its own sake.

Have you ever responded to me without insulting my intelligence?

By that criteria you'd probably ask to have Barney Frank banned for his 'like talking to a dining room table' remark...

Barney Frank was not commenting on Obisidan Wings. Therefore, the posting rules here do not apply to him.

Respond to the facts I stated, and stop acting like a cry-baby.

When you start paying my salary, then you'll be able to give me orders. I don't feel like wasting my time conversing with people that are so ethically deficient as to be unable to follow such simple rules. There are plenty of people who disagree with me here who, unlike you, are capable of following the posting rules. My time is better spent discussing with them.

Nonetheless, I do find it gratifying to have my intelligence insulted by a man who believed that his blog comments constitute a private conversation.

[russell]

From my observations, the people who would want to keep their current employer-provided health plan are few and far between, and even this group is shrinking rapidly.

How will Wyden-Bennett create a better alternative to the insurance (however deficient) that people get from their employer?

W-B will pool together individual purchasers so that they can have more leverage in dealing with insurers. Don't private employers have that leverage now?

Why will private insurers give folks in the insurance pools, as a group, any better deal than then currently give to corporations representing large groups of insureds?

I understand why folks might want an alternative to employer-provided insurance. What I'm not getting is how the pools created by W-B make that alternative happen.

[Jay Jerome]

"I don't feel like wasting my time conversing with people that are so ethically deficient as to be unable to follow such simple rules. "

"Ethically deficient?"
Humm. Isn't that, like, ya-know, in violation of the rules you just cited?

[Phil]

If profit margins were 0.6% to 1% in 2001 and they went up by 400% since then, they would be 3 to 5% now.

And? Were they? I'm sure you can look back through some of their 10-Ks and let us know.

[Carleton Wu]

First, you must be really intellectually challenged not to know that life expectancy has been increasing dramatically in the US (in 1950 approx 68 years; in 2009 approx 78 years; projected for 2050, 84 years)

You must be intellectuallly challenged if you think LE has changed dramatically in the pat ten years. Yet, healthcare costs have skyrocketed during that period.

Can you point out what's propaganda and contrary to fact? Because the percentages look about right, and are supported by numerous other studies from non-industry sources.

So, we should trust this info because it looks right to you. And it jives with other studies- wait, *numerous* other studies from non-industry sources.

Cites, please. And don't cite your intuition, it's unbecoming.

Humm. Isn't that, like, ya-know, in violation of the rules you just cited?

There's some flexibility when insulted first, afaict.

[Carleton Wu]

No. The idea that the distinction is important to the discussion isn't clearly grounded. There are millions of possible distinctions between vacation days and healthcare: that one involves time and the other personal services, that one typically involves scheduled usage and the other often doesn't, that the cost of one is readily predictable while the other is much more chancey. Not all of them are important to the discussion. And it isn't at all clear that your chosen distinction is more important than the similarity that they are both voluntarily provided perks which companies use to compete.

The reason that the analogy is garbage is that the distinction prevents us from performing the operation on the analogous subject that we're performing on the primary subject. The other distinctions aren't important- we cannot consider a case where vacation days are divorced from employment, ergo the analogy can't help us understand what might happen if healthcare is divorced from employment. Your analogy, if accepted, literally prevents you from losing the argument because of this.
That possible separation is what we are supposed to be talking about. I argue that it will happen. You argue that it will not. It *cannot* happen in the analogy, so toss the analogy.
If you want to find a useful analogy, find something where the employee could provide it for themselves on the open market, at least theoretically.

Of course, those things mostly don't exist. Perks are either part of the job or tied to the job or its location. There is no other major good/service provided as a perk that we could purchase elsewhere other than healthcare. So we ask- why healthcare? Why not cars? Why not home furnishings? why not education for our children?

Of course, as you point out, employers could provide private school for employee children. But they almost never do- instead, they give cash, and the employee decides how best to utilize that cash. Which, I predict, will happen with healthcare once it can easily be obtained elsewhere.

If you'd like to try to explain why you think this set of conditions will continue to hold, perhaps you'd like to suggest reasons why that isn't the case (eg inertia), why healthcare is different than other goods/services that employees purchase for themselves. Or, contrawise, explain why healthcare is covered and education is not (other than the current set of financial incentives).

Yes like all good lawyers if you can completely control the definitions you can control the outcome. I think we are talking about your claim that certain benefits will not be provided except in an allegedly very fragile structure of support for them. Pay and vacation days and medical benefits are all such benefits. Companies compete with each other over them. You allege that there is a useful distinction to be made between all the other benefits provided by companies and health care benefits and you further allege that this distinction makes it likely that health benefits will be abandoned.

Im trying to *start* the discussion about this. I think there are points that could be made against it. But you're not even willing to go there- you insist on an analogy where the perk cannot be separated from the job.
Why do you do this? I speculate that you want to feel that you are engaging in substantive debate, but that you are not actually interested. You want the satisfaction of holding your own in a discussion without the risk of having to make an argument.

That is quite a statement. I'm not even talking about the effect of history. I'm talking about how the history demonstrates that your hypothesis is likely wrong.

Please write more clearly then, that was perfectly unclear from your earlier writing.

You *claim* that companies offer health care because they are the only major way to get health care. But I pointed out that the history of corporate sponsored health care is that it rose during times when people got their health care through case, charity, and mutual associations. So history actively demonstrates that corporate sponsored health care can thrive even when there are other options.

I do not claim that health care is *only* offered by empoyers when it is the only way to get heathcare. Tasty straw.
I argued that the sitution in the US- where virtually all jobs above a certain level have healthcare- is a product of a system where healthcare can only effectively be obtained from employers.
There are certainly other situations where healthcare might get tied to employment- salary caps, as you point out, are a good example. But since I wasn't trying to claim that our sitution was the only one where healthcare would be tied to employment, it's mostly irrelevant. Unless you think salary caps are coming back?