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March 08, 2010

Comments

'But I cannot find anything that I could conceivably construe to include taking over the direct provision of medical insurance to all inhabitants of the U.S. or the direct provision of medical services to all its people.

Well, then, it's a good thing that the Senate bill doesn't actually do any of those things. Not even close.'

I was responding to Russell's specific comments, to wit:

'I don't see anything in the constitution that says the federal government cannot regulate the insurance industry, cannot directly provide insurance if that's what we want to do, or cannot directly provide care if that's what we want to do.'

And I do believe what Russell says represents the ultimate objective of those pushing this legislative effort.

What's wrong with the amendment process?


Actually we have a national system called Medicare through which all of the benefits I referenced are made available.

Sorry if I wasn't clear, I certainly thought our anecdotes were comparing equivalent systems through example.


Last comment was for lj.

Actually we have a national system called Medicare through which all of the benefits I referenced are made available

Yes. And the practical and simple way of providing better-quality health care to all, would simply be to extend your socialist healthcare system (Medicare) to provide for all Americans, not just those over 65.

It's good to know you appreciate good socialist health care when you see it, Marty...

Russell, this is a fairly broad restriction limiting the Federal Government to those powers enumerated in the Constitution

GOB, thanks for the reply.

Yes, I am aware of the 10th Amendment, and agree with what it expresses.

I'm also aware of Article I, Section 8, and of the long and often broadly stated set of powers and responsibilities it expressly grants to Congress.

Those begin:

The Congress shall have power to lay and collect taxes, duties, imposts and excises, to pay the debts and provide for the common defense and general welfare of the United States

"Provide for the ... general welfare" is an extraordinarily broad mandate. It's been interpreted, reasonably, to include a very long laundry list of things.

Most of those things are not explicitly named as a federal responsibility. They're just useful things that can effectively be provided at the federal level, and so that's what we do.

Inspection of food and drugs at the point of production. Establishment and enforcement of standards for weights and measures. Regulation of the financial industry. Workplace safety standards and enforcement. Support for local safety officers.

Standards and support for public schools. Investment in basic research in the sciences. Weather forecasting and analysis. Management of publicly owned land. Regulation and enforcement of standards for clean air and water.

The first 10 that popped into my head. There are probably 10,000 to pick from.

None of these things is explicitly named in the text of the Constitution as a responsibility of the federal government. If the standard is going to be that if it's not named explicitly, then it's out of bounds, then they all have to go.

Every one of them.

Some folks will be happy to see them all go. Some will be happy to see them all stay, and for another 1,000 to be added to them.

Most folks will find some they like, some they don't, and some they kinda like but don't like the way they're implemented.

But a case can be made for all of them.

And unless you want to work from the absolute standard that *any responsibility not explicitly and specifically named in the text of the Constitution is to be forbidden to the federal government*, the case will be made on practical and political grounds, not on grounds of Constitutionality.

Because all of the things I've named above, and hundreds and thousands more, contribute to the general welfare of the United States of America.

So I think the burden is on you to explain what it is about paying for or providing medical care that is different in nature from any of the things I've named, or any of the hundreds of things I could name that the feds do now, every day. Often quite effectively.

I get the fact that lots of people object to the size of the federal government, object to the range of things it has taken on, and believe those things could be better handled at a more local level.

There are lots of points at which I agree with that opinion.

But that's not a Constitutional question. It's a question of pragmatics, and of political preference.

And in point of fact, the federal government today provides insurance for health care, and directly provides health care services, to subsets of the population. If the standard is "it must be explicitly named as a specific responsibility of the federal government", all of that has to go.

All of it.

I don't mind discussing the political or pragmatic aspects of health care reform, but IMO the question of whether the Constitution *forbids* the federal government from being involved in the regulation, funding, or direct provision of health care to Americans is a non-starter.

The Constitution is, I imagine by intent, just not that specific in its language.

Which brings it all back to a question, not of what is absolutely allowed or forbidden, but of what we *prefer*.

There are things that are expressly allowed, and things that are expressly forbidden, in the document. Those things do not include a laundry list of what Congress can legislate or fund in the interest of promoting the general welfare.

The first 10 that popped into my head. There are probably 10,000 to pick from.

The interstate highway system, perhaps?

How about an open thread so Slarti can share his turnip recipe?

Seconded. And I want to try it with parsnips. We love parsnips.

Jes,

It would not be simple or practical.

It would require a huge number of Americans to have less access to services. It would also have many of the advantages you espouse. It isn't going to happen. You chirping here about it in every comment won't make it happen, it doesn't even make it a good solution to the problems in the US.

Me complaining about the Senate bill won't make it not get passed by the House, so I just sit and wait for Pelosi to get the votes.

Every time I say there is something good, or even better, about US healthcare it certainly does not mean I am denying the issues with it.

I do find it interesting that some of those people from other countries seem to think their healthcare is perfect, and defend even other countries systems vehemently. And then accuse us of denying we have a problem even though we are actually in a national debate, no, an international debate over how to fix our healthcare.

We all know we have a problem, we got it.

GOB: And I do believe what Russell says represents the ultimate objective of those pushing this legislative effort.

I really do not think that is true. I think if that was the desire of those pushing this legislative effort, the end result would probably include some concrete measures towards that goal. I think it's what a lot of them might want, but I'm not sure it's a majority even of Democrats, and it is absolutely not a majority of members of Congress.

I honestly, sincerely think if one's real nightmare is a government takeover of all healthcare, one should be thinking very hard about how to do something about the twin problems of American healthcare as it is now: the uninsured, and the cost problem.

Left untouched, with efforts to address them blocked, those two are going to one day cause the whole thing to explode, and what happens after the explosion is unlikely to be a return to laissez-fair free-market provision of healthcare, since that's where the biggest problems are.

It's one thing for poor people to be uninsured; they don't vote much, their political impact is always limited. It's another thing for middle-class people who are self-employed to be unable to find insurance, or for people temporarily unemployed to be unable to pay COBRA.

It's one thing for costs for the federal government and your employer to rise a lot; it's another thing if Medicare starts cutting back heavily on services provided and if your employer healthcare starts to look a lot more like "Go to Walgreens and good luck!"

I'm not sloganeering here, I'm saying that those two problems are growing and unless something is done to address them, they will cause a gigantic crisis. And when it comes, that crisis is likely to prompt a far, far more radical overhaul of the healthcare system in the US than the current health reform bill. That's always how it goes when things are allowed to get really really bad. When things get really really bad, people turn to the government because - sarcasm aside - it really is the only thing that can act fast, tell people what to do, and spend vast amounts of money. The private sector just cannot do that in response to that kind of a crisis, because the incentives do not exist.

The best thing for getting the government out of healthcare generally is to allow the government to get into solving those specific healthcare problems mentioned, at least sufficiently to head off a major crisis.

That's what I really believe is true. I personally would like more government involvement in healthcare, and I especially think that a public option is very desirable if there is going to be a mandate (and the cost problem requires there to be a mandate), but I'm willing to accept the current attempt to solve it without one, and if the day never came that public pressure was sufficient to get the government into providing healthcare for the sort of people - like me - currently covered under private plans, I would not shed a tear.

What matters to me is covering the uninsured and dealing with the cost problem before we go bankrupt with Medicare/Medicaid/low-income-subsidy spending. I do not have an ideological aversion to a mostly-private healthcare system like the one we have right now. (I say mostly-private because even though the government spends a lot of money on healthcare, most of the actual provision of services is still done in the private sector.)

I should say (russell just posted) that I also think that the provision of healthcare is clearly constitutional. The closest thing to a problem is the mandate, which as a matter of liberty actually troubles me a little, though not as a matter of practicality - and even as a matter of liberty, the trouble is fairly small because of the provision of subsidies to low-income people. And I don't think it's unconstitutional in any case.

Marty: I do find it interesting that some of those people from other countries seem to think their healthcare is perfect

Well, I'm from the UK, have lived in the US a long time, and think neither system is perfect. If I had to choose a system for myself without thinking about societal welfare, I'd pick the US system and cross my fingers that I didn't get really sick in ways that would render me unable to receive care, as happened to a friend of mine with cancer who found herself stuck between "having a hard time keeping a job for long because of recurrences" and "not completely destitute and eligible for Medicaid". (Part of the reason I don't worry a huge amount about that is that I could always run away back to the UK anyway...)

But if I had to choose a system based on societal welfare - and when it comes to talking about public policy that's the interest I try to have in mind - the imperfect (but much cheaper) NHS is a winner by a mile, because it simply does not have the problems of people worrying about losing coverage or having a huge number of people who are not insured for care. Everything else is trivial by comparison. The US has lots of cool, high-tech interventions if you have insurance, none of which remotely compensate in QALYs for the huge problem of the uninsured.

But that doesn't mean I think the NHS is the model for the US. As I just posted, I think that a combination of regulation & subsidies will be sufficient to produce a healthcare system that works just as well or better than those in any other advanced country, once it gets rolling. In fact I think it's possible that 30-50 years from now people will be looking at the post-reform US system as a model.

Russell, this is a fairly broad restriction limiting the Federal Government to those powers enumerated in the Constitution which include, apparently to the chagrin of numerous commenters here, the authority to use military force to defend the United States against foreign enemies.

Smear on our patriotism aside, I think the objection is to the clearly unconstitutional use of nebulous CIC powers to trump black-letter protections in the Constitution. It never ceases to amaze me how some people can be so jealous of their liberty to not have health care coverage, but have no concerns about the President locking up citizens or denying them basic Constitutional rights based on his edict.

And I do believe what Russell says represents the ultimate objective of those pushing this legislative effort.

It is a novel, mind-reading based standard of constitutional interpretation that 'bars legislation which GOB suspects is being pushed by people with what he believes are unconstitutional aims'.

It would require a huge number of Americans to have less access to services.

There are two responses to this.

One: you appear to be forgetting (again) that a huge number of Americans (about 45 million) live without health insurance, and as a result they die when they could have lived (about 44 thousand a year).

Two: you have no explanation and no data for your assertion - once again. You are still chirping away without facts on your side. Whereas I can point to a nationwide system of universal health care which is proven to work better than the American system, at less cost.

You claim you know that the NHS wouldn't work in the US. But you can't provide any evidence that it won't: you just assert it as if you know it's true.

It's one thing for poor people to be uninsured; they don't vote much, their political impact is always limited.

Ah, the true face of the pro-lifer at last: let them die, who cares, they're only poor people, they don't matter...

Every time I say there is something good, or even better, about US healthcare it certainly does not mean I am denying the issues with it.

And yet, you can't even back up what you claim to believe is "good" or "better" about US healthcare with any kind of data.

Seconded. And I want to try it with parsnips. We love parsnips.

Thirded.

As an added incentive, if we get the turnip open thread I'll post my wife's parsnip and poached pears recipe, which is both delicious and alliterative.

Turnips - we get tiny turnips early in the season at our farmer's market. They're about the size of a smallish red bliss potato. We just slice them thin, crisp'em up in a frying pan, and eat them like potato chips.

Farmer's market opens in about 12 weeks. Not that we're counting down or anything.

Jes: Ah, the true face of the pro-lifer at last: let them die, who cares, they're only poor people, they don't matter...

A. I posted that, and I am very, very pro-choice, my disagreement with your particular opinion notwithstanding. (You are not the arbiter of who is pro-choice and pro-life based on their absolute agreement with your position; those terms have particular meanings, and I clearly fall on the pro-choice side given that I think there should be no legal restrictions on abortion and subsidized access to abortion for the poor.)

B. I was describing how things are - that poor people genuinely have little political power and their plight is generally ignored - and (clearly!) not how I wish they were. Problems of the poor rarely appear in the popular consciousness as a crisis. I don't like it, but that's how it is everywhere.

It never ceases to amaze me how some people can be so jealous of their liberty to not have health care coverage, but have no concerns about the President locking up citizens or denying them basic Constitutional rights based on his edict.

Not saying that GOB suffers from this species of cognitive dissonance, but it sure as hell is common.

I file it under "if it ain't my ox, I don't care if it's gored".

I posted that, and I am very, very pro-choice, my disagreement with your particular opinion notwithstanding.

I apologize. It's late at night where I am and clearly I should quit responding to threads, if I can't tell whether it was you or Marty who said something.

Seriously. Stupid, late-night mistake, and I apologize for any offense caused.

No prob.

I file it under "if it ain't my ox, I don't care if it's gored".

Yeah, witness the reaction when you suggest that these sorts of methods be applied to domestic, right-wing terrorists.
Pre-emptively, we aren't even supposed to call flying planes into symbolic buildings "terrorism" any more if performed by libertarian jihadis. Only brown people need apply.

Jes, I haven't forgotten anyone, this is your trolling. Giving 40 M access by reducing access for 260M requires more thought than you give.

The quote on poor people was a snide comment from another poster, not mine, norany conservative poster, just another example of name calling.

Marty, I would be interested to know what facet of Medicare mirrors what I described, the 4 times a year interviews (at the patient's home) to determine the level of care that elderly qualify for. This is the Health and Welfare Ministry's page about the 'Gold Plan', a 10 year plan that was revised midway in 1994 to address systemic problems in care for the elderly. I'm not seeing how your father's annual checkups provide an equivalent system.

There is certainly a measure of self interest for me, in that addressing questions that others might have about elderly care in Japan helps provide me with specific things to ask about and follow up on here for my own benefit, but since you have an aging parent, I might suggest that actually describing what the system offers and then comparing it to other places might be useful to you in the future. However, if you feel that your father's once a year checkup sufficiently covers what he needs, and you feel that you can generalize that to the rest of the US population, that's your call, not mine.

Jd,

I was doing this on my phone on a plane, rereading ot was not snide at all and a good point. Sorry.

Marty

It would require a huge number of Americans to have less access to services.

This seems contradictory to me; you're praising the services Medicare offers. But also saying that rolling this out to more people would, in general, reduce access to services.
It sounds like rolling back Medicare from the current situation to zero ought to *increase* access to services for the affected population, if that's your assessment.
Either that, or there's some special reason why Medicare is good for one group, but harmful when applied to other groups. Because I don't see any other reason for privileging the status quo like this.

It sounds like the calculus is something like:

There's a finite supply of health care in the US. Some people do not have access to it, while some others do. Therefore, giving access to those who now do not have it will reduce what is left for those who now do. (Please forgive my beer-soaked grammar, as necessary.)

It's a zero-sum scenario where more players come to the table without contributing to the pot, or something ... I guess.

If you think states can't violate our liberties just as well as the feds, check this travesty out. Is nothing sacred?

Health-care reform is zero-sum if we restrict the view to a short-term financial sense. That is, every penny that is spent on subsidies comes from somewhere else and doesn't get spent there.

It is not zero-sum in a short-term welfare sense, because taxing the healthcare of someone who has a very comprehensive healthcare plan already does very little to affect their welfare, whereas providing healthcare to someone who has none gives them an enormous boost in basic welfare.

It is not zero-sum in a long-term financial sense, because people who are too sick to work contribute nothing to productivity, people who go bankrupt from medical bills suffer a major hit to financial stability and may need public-funded bailouts or transfer payments, and the reduction in use of ERs as primary-care facilities will save a lot of money in itself. The result will be higher productivity, less cost on medical spending for the same benefits, and in the end that means more money for everyone.

The thing that people are most concerned about is that it is zero-sum in terms of access to medical treatment. I am not convinced this is actually true. Yes, there will be increased demand for basic medical care, and if you think about the source of funding for those doctor's visits being a tax on high-end medical plans, that means those plans will be somewhat less comprehensive for the same cost. (Although to some extent regulating medical loss ratios will help with that by reducing insurer profits. I do not believe reducing insurer profits to the levels appropriate to a regulated utility will cause a disaster; for one thing, insurance companies don't do very much, so the potential for underinvestment with the prospect of lower profits is much less of a problem than with actual medical facilities, and for another thing, the proposed medical loss ratios are pretty low and any number of insurers have shown they can survive and run just fine at those levels.)

But it is true that some people with expensive plans will receive less comprehensive coverage. There are two things to say about that: the first is that the source of funding is the removal of the tax exemption for the truly gold-plated plans; that is, to some extent the recipients of those plans were getting a very large tax break from the government - they are paying much less tax than someone with the same income who has a less comprehensive health plan - which seems very unfair when other people are receiving nothing at all from the government to help with healthcare costs. The second is that there are sharply diminishing returns to healthcare spending on a single person (which is part of why subsidizing high-cost plans is so unfair). Yeah, you can have a plan that covers gym membership and massages and god knows what else, but in terms of actual health effect, beyond a certain level of spending additional spending does very little. (I believe this is well-documented but I have a squirming baby in my lap right now so I'm not in the mood for Google...)

So there will be a shift in demand to some extent from the kind of stuff covered by high-end plans to the provision of basic services. In the short-term that may demand some measures to control inflation, but in the medium-long term - as long as the AMA lets there be enough medical schools and immigration is loosened for doctors and nurses - there should be no problem. Demand breeds supply in most markets, including healthcare. In other countries that went universal, the feared instant medical inflation from a horde of new patients did not occur, and in a lot of those places there were far more uninsured than the 10% of the population that will be newly-covered under the reform. The size of the problem of the uninsured means that the actual shock to the system will be around 10%, which is manageable (and another reason to do it now before the problem & the shock get worse).

And of course as mentioned, there will be a reduction in the use of very expensive ERs as primary-care facilities which should free up some medical resources. A lot of the people who will be covered are, in truth, receiving medical care already, and we're already paying for it, whether through hospital fees that have to be inflated to cover the uninsured who never pay, or through government payments for the same kind of thing. And if I'm going to pay for it, I'd rather pay for people to visit a community health clinic for 1/10 the cost of going to the ER, and the best part is, they'd rather do that too.

Government actions can be positive-sum. I think we should judge pretty cynically which ones actually are, but I think it is crazy to think that they cannot be in all cases, and I think that this one will not only be positive sum but not actually do anyone any meaningful harm whatsoever even in the short term.

And I know there are people who think that any government action with a redistributive effect - no matter the positive effect on welfare - is just out of the question. Even those people should not be so worried by this as by other redistributions (like many of those already enacted). The redistributive effect of this bill is pretty mild for the reasons listed above. It may even be nil because the costs of the uninsured will no longer be falling on the insured through ER visits and unpaid hospital bills.

And the effect on welfare for many people with very high-cost plans may even be positive. Conservatives don't like unions for various reasons, but one of the reasons they give is that unions tend to negotiate very high fringe benefits which, they correctly assess, tend to come to some degree at the expense of salaries, and so individual union members are not offered a choice between Super Duper Healthcare or an extra $3,000 in salary, and so parochial interests - the older, sicker union leadership who are more interested in expensive healthcare, say - can drive more spending that way than most people would really care for.

Well, the big tax break for healthcare is one of the reasons that choice is rarely offered. Without the tax break on the last few thousand bucks of that benefit, unions and employers will be under pressure to negotiate a cheaper plan in exchange for more cash, which - if what conservatives say about the problem with collective bargaining is true - will make many of them happier than they were with the gold plated plan. I'm not saying that will be universal, but I think it will be a factor.

And if you don't rule out redistribution altogether but just think the bar should be set high, this reform ought to easily clear it. The harms are great, the cost of the plan is low by comparison, and the amount of redistribution is very modest - $100bn annually, about 0.7% of GDP.

I don't think there will be much pressure to raise the amount redistributed this way once the crisis of the uninsured is out of the way. In Britain, there is little pressure to raise the benefits offered by the public plan to sky-high levels, because most people think that if you want to get coverage that is very expensive with few benefits, you can pay for the damn thing yourself. The pressure to do so here, where most people won't even be receiving the subsidies, will be vastly less.

Most of this - especially the cost of doing nothing - is very apparent to most on the left, partly because, duh, we're on the left, we wouldn't be if we didn't think that there were not major unmet needs that require government action. But I think it's worth explicating for those not on the left who have real concerns about cost and effect on the welfare of those redistributed-from.

I don't know if this is persuasive to everyone, but it's the best I can do.

Jacob,

I appreciate the depth of thought that goes into these comments. I disagree with some of what you say, obviously or I would be, well, on the left. This however is the summary of a reasonable position based on the sum of dataa available interpreted intelligently.

I can't take the time tonight to walk through a similar overview of my, more conservative position, but it would disagree in two ways.

They would be the overall redistributive effect over time and the real impact of taxing "comprehensive" plans.

Thanks for the thoughts.

Thanks.

Of course my own belief goes quite a bit further. I believe it is a collective action problem, and that everyone will be happier when nobody has to go without healthcare. I also believe that everyone will be happier when they don't have to worry about losing healthcare even if they have it now.

I think those effects are extremely strong, and that is partly based on my experience with the NHS. People love the NHS, not just as a system that delivers benefits to them, but they love the fact of it, they love living in a society that strives to provide healthcare to every one of its citizens. You see that with what might seem like over-the-top praise for it. But people are really proud of it; it's something they all got done together, they grasped the nettle, and it ended up not stinging too badly, and the problem got solved.

That kind of effect is never doubted in other areas of national accomplishment in the US. Putting a man on the moon, having the world's most powerful military, being the richest & most productive country on the planet, having a long-lived and thriving democracy - they're all sources of individual happiness through pride and a sense of collective achievement. You don't have to think that the economy should be collectivized - and I certainly do not think that - to think that there may be some other areas where at a relatively low cost, the US can collectively do something really significant, something that people will be proud of.

Giving 40 M access by reducing access for 260M requires more thought than you give.

You have yet to show how providing Medicare to all would reduce access to healthcare for any.

Seriously.

Quit trolling this thread if you can't do more than assert right-wing talking points without even trying to justify them and then calling me a troll!

Marty,

The problem you point to isn't British Exceptionalism. It's that in this area America is exceptional. Exceptionally crap. There is no other first world country with 45 million people without healthcare. If you were to say to me you thought the French or German way was better than ours and should replace ours, I'd disagree unless you were prepared to raise taxes by a few percent of GDP to fund it. But in many ways they actually do have a better healthcare system than ours.

On the other hand if you were to propose replacing the workable if imperfect NHS with the murderously barbarous US system then I'd consider you a dangerous idiot at best. And that applies even if you are going to double the resources in healthcare in the UK for free to match US spending.

Praising the overall US healthcare system makes as much sense as praising the merits of fibreglass dragsters in a demolition derby. There are a few things it does well (the government funded NIH is wonderful). But it's trivially the wrong car to do a good job on the course.

"there may be some other areas where at a relatively low cost, the US can collectively do something really significant, something that people will be proud of."

Interesting that so many Americans have bought some kind of Republican talking point as conventional wisdom that government can't do anything right. An example of this is that I was listening to a podcast of the program "This American Life" a recent episode about FDIC takeover of banks. The narrator of the story of a particular bank takeover, at some point, stated (paraphrasing): "and, surprisingly, the FDIC did this really well - not something people usually say about a government agency!"

But, in fact, most government agencies do things remarkably well. Profit motive doesn't always yield better service, because most employees, whether of government or corporations, aren't earning part of a profit - they're working for a salary, so their motivation is neutral. It galls me to hear the "government does things worse than private industry" meme repeated. There might be examples of that being true, but very few, and I notice that one never hears specific examples.

The "market" works very well for luxury goods and services, but not for basic needs. I so wish we had an NHS.

How about an open thread so Slarti can share his turnip recipe?

That sounds good. It'll have to wait another day or two, though, because I've got stuff going on. Training for a local tournament is just one of many.

I think I'd like to also include some of my other favorite recipes, too. These are mostly out of cookbooks, but few people can own every single decent cookbook on the planet.

Which is not to say you can't try. What would you be if you didn't even try? You have to try.

We love parsnips.

Oh, me too! Parsnips are right up there with beer on my favorite-food list.

Parsnip recipes would be most welcome. I've never had them other than steamed (with just a smidge of butter; really, they don't need much of anything other than their own parsnippy goodness) or in the chicken (or vegetable, if you're chicken-averse) soup.

Marty, I would be interested to know what facet of Medicare mirrors what I described, the 4 times a year interviews (at the patient's home) to determine the level of care that elderly qualify for. This is the Health and Welfare Ministry's page about the 'Gold Plan', a 10 year plan that was revised midway in 1994 to address systemic problems in care for the elderly. I'm not seeing how your father's annual checkups provide an equivalent system.

LJ,

This sounds like a very positive aspect of the Japanese system. But I think it's abundantly clear at this point that introducing something like those quarterly interviews is politically unthinkable in the US, for obvious political reasons. "Some socialist bureaucrat is going to come into your home and assess whether you're still useful to society or can be dispensed with."

We all have to bear in mind that in the "debate" currently taking place in Washington, one side has no intention of arguing in good faith. Their only intention is to defeat the President on his signature issue. Beyond that, they are more than comfortable with the status quo.

Maybe 50 years from now the Republican Party will have regained some semblance of sanity, and a moderate Republican president will be able to introduce something like that Japanese "Gold Plan," Nixon-to-China style. For a Democrat to institute something like that successfully is simply not in the cards.

What a country.

Lj,

Funny what you read sometimes. I never said anything about annual checkups, I said, as referenced below, regular checkups. You assumed annual, but actually based on his age and other factors he does see his doctor about every three months regardless of whether he has a particular issue. I was very specific about the other benefits I was comparing in the parentheses, The availability of his case worker is due to the doctors practice he is associated with, I think the practice picks up that cost rather than charging back to Medicare. When hospitalized there is a separate Medicare paid case worker.

I am still unclear why any reference to some part of the US system as being ok brings such immediate negative response.


"I am not sure the US, in this particular only, is that far behind. My father has regular checkups, a significant amount of similar benefits (transportation to daycare, physical therapy)and a case worker very familiar with his particular issues."

[...]
First, the battle for public opinion has been lost. Comprehensive health care has been lost. If it fails, as appears possible, Democrats will face the brunt of the electorate's reaction. If it passes, however, Democrats will face a far greater calamitous reaction at the polls. Wishing, praying or pretending will not change these outcomes.

Nothing has been more disconcerting than to watch Democratic politicians and their media supporters deceive themselves into believing that the public favors the Democrats' current health-care plan. Yes, most Americans believe, as we do, that real health-care reform is needed. And yes, certain proposals in the plan are supported by the public.

However, a solid majority of Americans opposes the massive health-reform plan. Four-fifths of those who oppose the plan strongly oppose it, according to Rasmussen polling this week, while only half of those who support the plan do so strongly. Many more Americans believe the legislation will worsen their health care, cost them more personally and add significantly to the national deficit. Never in our experience as pollsters can we recall such self-deluding misconstruction of survey data.

The White House document released Thursday arguing that reform is becoming more popular is in large part fighting the last war. This isn't 1994; it's 2010. And the bottom line is that the American public is overwhelmingly against this bill in its totality even if they like some of its parts.

The notion that once enactment is forced, the public will suddenly embrace health-care reform could not be further from the truth -- and is likely to become a rallying cry for disaffected Republicans, independents and, yes, Democrats.
[...]
If Democrats ignore health-care polls, midterms will be costly

If it fails, as appears possible, Democrats will face the brunt of the electorate's reaction. If it passes, however, Democrats will face a far greater calamitous reaction at the polls.

My suspicion that this is not true is based on several things:
1)Many who oppose the bill have incorrect info on what it contains (eg that it adds to the deficit). When these don't come to pass, they will not be as upset.
2)Many who oppose the bill oppose it for not going far enough, but it's becoming increasingly clear that eg single payer isn't going to happen, so I think they'll come around by November.
3)There is no one in the electorate who will vote Dem for them trying to reform health care and failing. Having declared this as their intention they would suffer all of the consequences of their position with no possible upside. If 2010 is going to be bad, then it's going to be bad.
4)But, if the bill does deal with healthcare successfully, even if 2010 doesn't turn out well it will reflect well on the Dems in 2012 and beyond. And *this* is I suspect the real fear of the GOP. That and the hope that the Dems will self-destruct by listening to this bad advice from their politcal enemies.

Finally, in general I find this whole train of thought hilarious- bc it seems to come solely from Blue Dogs and conservatives. Funny that Patrick H. Caddell IDs himself as a 'pollster to Jimmy Carter' rather than as 'guy who left the Democratic Party over 20 years ago and spends his time attacking the Dems using those old credentials'. It's almost like he wants to fool people into thinking he has the best interests of the Democratic Party in mind with his advice.

Marty: I am still unclear why any reference to some part of the US system as being ok brings such immediate negative response.

Oh. Let me explain.

Because you appeared to be arguing that because you can point to an individual case of an elderly man in the US getting the health care he needs to stay well, this somehow proved that the whole US system wasn't so bad.

National figures for how many people 60+ get regular checkups would be more convincing.

Further, bear in mind that in this thread you joined it with the apparent attention of contributing nothing more than arguments by assertion - for example, your assertion that you just knew US wait times were shorter than Canadian wait times - and complaining that in other circles this works and people don't contradict you.

Further, it is more than a little disengenuous when you start claiming I'm a troll for stating my opinion - to then complain that you feel I'm taking offense at your comments.

Also; another American friend without health insurance just got diagnosed with chronic lymphedema. I have no idea how he's going to pay for the tests that eventually established this or the days in hospital prior to this or what his not being able to stand or sit for very long without getting dizzy and keeling over is going to do to his earning capacity, but I tell you frankly, Marty, coming directly from reading his blog post to re-reading your smug little craptastics about how well you think of a health system that leaves 45 million people in the crap, makes me feel I need to quit writing right now before I say something

Jes, Just to be clear, I had no doubt why you were negative. I am just your trigger to complain. It makes absolutely no difference what I actually say.

I am very sorry about your friend, and you seem to constantly forget that I favor extending Medicare to the uninsured and uninsurable. That's because then you couldn't always just assume the worst intent from me.

I am just your trigger to complain. It makes absolutely no difference what I actually say.

Actually, it would if you tried offering reasoning from verifiable facts, as opposed to assertion from I-believe.

I am very sorry about your friend, and you seem to constantly forget that I favor extending Medicare to the uninsured and uninsurable.

Which is what I said earlier and you argued that giving everyone access to Medicare was going to result in diminished access to healthcare. You didn't say how, you didn't say why, and now it appears you actually think it ought to happen anyway.

That's because then you couldn't always just assume the worst intent from me.

Well, you are a pro-lifer. But I was trying to leave that aspect out of your character out of this discussion.

You were abusive, insulting, and silly. Now you're trying to claim that I shouldn't have expected you to be like that just because you were being like that.

Argue from facts and people can argue back. Make assertions of belief and call people "trolls" for pointing this out? Don't complain when people then assume this is what you're like.

I am very sorry about your friend

Thank you. Appreciated.

This thread makes my head hurt.

Part of the problem is that the national dialog on the topic conflates a few very separate issues: the extension of some basic level of health insurance to people who can't afford it or otherwise access it and the fact that the US system(s) are much more expensive than most comparable systems elsewhere, and thirdly the issue of whether or not private or public healthcare payment is better.

The annoying thing to me about the debate is that arguments which clearly support or detract from only one of the three are used to support or attack all of the three as if they were exactly the same argument. And this happens on both sides.

For me, only the first one has immediate importance. Leaving a fairly large portion of the population without any kind of health insurance is either horribly immoral or horribly inefficient depending on what the society does when those people get sick/hurt. If it just lets them suffer, it is horribly immoral. If it treats them anyway, it is horribly inefficient because it ends up treating them in emergency rooms and with poor follow through.

On the second question--high costs in the US, there are lots of ideologically motivated assertions, and very little evidence. A huge portion of the things that people complain about and spend huge amounts of time on, as if they were a large part of the answer, clearly aren't the big deal they are made out to be (tort reform and pharmacuetical costs are clear frontrunners in the overtalked about area). This is an important area, but analytically separate from the first issue. It is also much less understood than the first issue. Dealing with the uninsured isn't the same as trying to fix everything else. I'm irritated with Democrats in Congress who seem more interested in changing the whole system without understanding why it is expensive and I'm even more irritated with Republicans in Congress who use (IMO justifiable) opposition to such wholesale changes as an excuse to avoid dealing with the problem of the uninsured.

On the third issue most people will be irritated to find out that evidence isn't very clear. Lots of countries have mostly private systems, lots of countries have mostly public systems, and quite a few have interesting mixed systems. All of them seem to do very well. There is very little to show the advantage of any particular private/public blend over other ones. Though there seems to be vast evidence that our particular brand is wasting money *both* when privately and when publicly paid for.

Sebastian: I'm irritated with Democrats in Congress who seem more interested in changing the whole system without understanding why it is expensive

Can you say what kind of thing you're concerned about here?

From what I can tell the current bill is relatively limited when it comes to attempts at cost control, which is why I'm not sure what you mean by changing the whole system.

The reform is primarily targeted at covering additional people, which means "subsidies, pre-existing conditions, mandates", roughly. Everything else is pretty minor.

So I'm not sure how to reconcile what I quoted above with your (admirable) belief that the problem of the uninsured is paramount and cannot be ignored. To me that is exactly the big change to the system that the Democrats are pushing for, and it unavoidably touches on cost control to some degree, but in a fairly minor way.

Sorry if I wasn't clear. It isn't "all Democrats in Congress" it is "the Democrats in Congress who..."

The way the bill is shaping up in the end seems non-awful and mostly focused on the right things. The way things started and many of the things that critics-from-the-left seem to be focusing on, not as much. The original, pre-compromise House bill which was much talked about in say June and August (in the lets do this in three weeks rush days) exhibited much of that.

Leaving a fairly large portion of the population without any kind of health insurance is either horribly immoral or horribly inefficient depending on what the society does when those people get sick/hurt. If it just lets them suffer, it is horribly immoral. If it treats them anyway, it is horribly inefficient because it ends up treating them in emergency rooms and with poor follow through.

I think it's actually both, if for no other reason than that people suffer needlessly before going to the emergency room, even if they ultimately end up being treated. And because I think that, I think the cost issue is partly tied to the issue of the uninsured. The inefficiency, itself, is costly. Primary and preventive care are much cheaper than treatment of advanced conditions. I think giving people better access to primary care (whether they're insured or not) will bring down costs. But we need more primary-care physicians to do that effectively.

"Which is what I said earlier and you argued that giving everyone access to Medicare was going to result in diminished access to healthcare. You didn't say how, you didn't say why, and now it appears you actually think it ought to happen anyway.
I still believe that giving everyone access to healthcare would reduce access for a significant number of people. I didn't agree with you, I said what I have said for months. We should extend Medicare to cover all uninsured and uninsurable people. That is a full order of magnitude less complex than trying to convert the other 260 million.
That's because then you couldn't always just assume the worst intent from me.

Well, you are a pro-lifer. But I was trying to leave that aspect out of your character out of this discussion.

No, I am anti-abortion and pro-choice, wrong again.

You were abusive, insulting, and silly. Now you're trying to claim that I shouldn't have expected you to be like that just because you were being like that.

Abusive and insulting is what you do. You should read your self sometime.


As for facts, I believe that is a pretty common red herring for people who don't want to hear the other side of an issue.

Somehow when people are saying what you want to hear you don't demand stats to back up their opinion.

The example with lj was perfect. The sentence structure of our comments were practically identical,never once did I say the US system was superior, I was limited and specific in the areas that I thought were comparable but my comment was attacked.

But you just can't admit you were wrong.

We should extend Medicare to cover all uninsured and uninsurable people.

Interesting thought. But why would I bother buying insurance if I can always get Medicare rates? I mean, I suppose some wealthy people might (like in the UK) get supplemental insurance for perks etc, but it seems like 95% of the people would settle for this.
So maybe Im not understanding your proposal.

"So maybe Im not understanding your proposal."

No, you understand fine.

No, you understand fine.

So when Jes suggested expanding Medicare to all Americans, and you said
It would not be simple or practical. It would require a huge number of Americans to have less access to services.
your endorsement of the proposal was implied?

Marty,
I related my anecdote in response to the discussion moving to the question of end of life care, which, at the point when I discussed it, did not involve you or Jes. I would appreciate it if you didn't invoke my name to try and address Jes' points in this regard. I don't want to be dragged into it, and the only reason that I related my anecdote was because it seemed to be a separate discussion from the exchanges between you and Jes. Thanks.

Marty: Somehow when people are saying what you want to hear you don't demand stats to back up their opinion.

That's childish, Marty, really childish. You're the one who - in this thread - has tried to argue by assertion without reference to facts. I'm not the only one who pointed this out.

Now you seem to think I should have known you wanted to extend Medicare to all Americans even though the only thing you had actually said about it in this thread was that it wouldn't work and would diminish access. You didn't give any reason or backup for this, you just - argued by assertion.

Then you started throwing "troll" around, as if asserting I'm a troll would somehow invalidate the points I was making.

Try arguing by reference to fact. You'll be amazed how well it can work - when you have facts to reference.

For me, only the first one has immediate importance.

Then we should just make Medicare available to anyone who doesn't have, or can't get, insurance through private means and call it a day.

On the second question--high costs in the US, there are lots of ideologically motivated assertions, and very little evidence.

The evidence I see tells me that what most of the money gets spent on is direct care in hospitals, doctor's offices, and clinics, and that the overwhelming majority of that care goes to folks with chronic illnesses, many of which can be improved enormously with simple lifestyle changes.

So, my thought is that we should be focusing on prevention, and on changing people's habits. Especially on changing people's habits. And, ideally, doing so by offering specific public health outreaches to make better habits convenient and attractive.

Cheap and, while not easy, amazingly simple.

That's my thought.

Lots of countries have mostly private systems, lots of countries have mostly public systems, and quite a few have interesting mixed systems. All of them seem to do very well.

I agree.

If we were starting from a clean slate, I'd say just do single payer with private providers. Because it lets government do the relatively low-value-added bean counting, actuarial, administrative grunt work that it's actually pretty good at, and lets medical professionals provide care, which is what they're very good at.

But we aren't starting from a clean slate. So let's just make it *better that it is now*, please, and then lather rinse and repeat as we see what works and what doesn't.

So, you can put me down as one lefty who doesn't particularly care what the mix of public and private is, as long as people get to go to the damned doctor when they need to.

A health care "system" should be about helping people get healthy, and stay healthy. It doesn't much matter who does it, or what it costs, or whose sacred liberty freedom of choice prerogatives are preserved or trampled on, if tens of millions of people don't have useful access to health care, and if tens of millions of people suffer from stupid, debilitating, preventable chronic illness.

Health care should help people get healthy and stay healthy. The rest is noise.

Jes, I included several facts in my last comment and you chose not to address any of them.

As far as others talking about whether I provided cited, I do sometimes and often feel whatever observation or assertion I am making is common knowledge. In the latter case the knee jerk "Cite" means we won't be discussing it in good faith anyway so I am not inclined to waste more effort.

I was told specifically months ago to not insult people by providing cites for things that were common knowledge. I liked that thought process.

I included several facts in my last comment and you chose not to address any of them.

You included one fact in your last comment - that out of 305 million people in the US, 260 million are on some kind of health insurance.

I don't dispute this fact, but I don't see anything to "address". Unless you'd like to get into how for want of any proper competition or regulation, private health insurance in the US is crappy compared with private health insurance in other countries?

I do sometimes and often feel whatever observation or assertion I am making is common knowledge.

People do make assertions from what they think is "common knowledge". That's Family Feud gameplay, as discussed earlier. That "common knowledge" isn't necessarily true - as for example your "common knowledge" that wait times in the US are shorter than in Canada.

Your claim that when you're asked to prove by reference what you just know is true means the argument isn't being carried out in good faith? Maybe having it demonstrated to you that something you just knew was true - something you thought of as "common knowledge" was demonstrably false, will be an education to you.

Because you could have found out for yourself that your belief "US wait times are shorter" was false, quite quickly, had it ever occurred to you to check your "common knowledge" against the facts readily available on the Internet.

One advantage library research has over Internet research is that library research is much more likely to come up with answers to questions you didn't have the knowledge to ask. Armed with only your false "common knowledge" that wait times in the US are shorter than in Canada, you didn't have the knowledge that would have let you ask the Internet about national data on US wait times - and find out that there was none.

What you might want to ask yourself is why it didn't occur to you to wonder how it could be true that the US has shorter wait times than Canada, when the US has 45 million uninsured.

The value of argument - on the Internet or anywhere - is that other people will ask questions that haven't occurred to you. Your reaction to people asking questions that never occurred to you because the answer doesn't fit your "common knowledge" seems to be that those people can't be arguing in good faith because they've got answers you just know aren't true, and when you claim that you know the answer and are asked to prove it and can't because your "I just know it" answer isn't true - you call your questioner a troll.

Jes, besides not recognizing a fact if it bit you, this is very boring. Your assertion that you found some fact somewhere that disproves anything I said is predictable and incorrect. So everyone starts throwing around statistics and sit back and smugly believe they have made some kind of point. When someone has a different assessment of those "facts" then you start name calling.

No one ever showed that US wait times were longer than Canada, and they can't, because it isn't true. You read, say, quote lots of things and then conclude what you like, which I think is fine. But your conclusions aren't facts, as much as you want them to be.

No one ever showed that US wait times were longer than Canada, and they can't, because it isn't true.

Are you arguing that every patient in Canada waits longer than every American patient? Or that for every procedure the wait time averages are longer in Canada? And that this is the sort of common knowledge that everyone knows, so much so that asking you to produce a cite is an insult?

So everyone starts throwing around statistics and sit back and smugly believe they have made some kind of point.

Well, not everyone. To your credit, you did not make the mistake of trying to back up assertions with statistics. Man, you sure made everyone else look foolish there!

But your conclusions aren't facts, as much as you want them to be.

Good to see that you're starting to realize... oh, wait, you were talking to Jes, never mind.

I do agree that this is pretty boring. A debate where both sides are marshaling and contesting facts and theories is more interesting than one where one side claims that it's conclusions are common knowledge and they cannot stoop to supporting them.

No one ever showed that US wait times were longer than Canada, and they can't, because it isn't true.

Oh really? E ancora muoiono...

"No one ever showed that US wait times were longer than Canada, and they can't, because it isn't true.

Oh really? E ancora muoiono..."

I couldn't have asked for a better example of my point. The these two things have nothing to do with each other. Only through your interpretation do they have any relationship at all, which is fine. But it is just an opinion.

Carlton,

" And that this is the sort of common knowledge that everyone knows, so much so that asking you to produce a cite is an insult?"

I am not insulted by a request for a cite. When I don't have one that I think provides any more authority than me saying it then you should translate that as fact or opinion based on my explanation of how I know. I am good with either one you decide.

"So everyone starts throwing around statistics and sit back and smugly believe they have made some kind of point.


Well, not everyone. To your credit, you did not make the mistake of trying to back up assertions with statistics. Man, you sure made everyone else look foolish there!"


You can see the classic example of this in jes's 9:26 pm.

But your conclusions aren't facts, as much as you want them to be.

Good to see that you're starting to realize... oh, wait, you were talking to Jes, never mind.


I am very good with my conclusions being taken as my interpretation, conclusion or opinion, as for jes, see 9:26 pm again.

The these two things have nothing to do with each other.

You may see no connection between the 45,000 people who die each year in the US because they have no health insurance, and the myth you repeated that people in the US get treated faster than people in Canada, but...

But still they die.

[...]
Not to be outdone, the Physicians for a National Health Program (PNHP) repeated the exercise (with all its methodological sins) and boosted the tally to a 40% increase in the probability of dying for the uninsured. That produces a whopping 45,000 premature deaths every year...

As in the previous incarnations, the researchers interviewed the uninsured only once — and never saw them again. A decade later, the researchers assumed the participants were still uninsured and, if they died in the interim, lack of insurance is blamed as one of the causes.

Yet, like unemployment, uninsurance happens to many people for short periods of time. Most people who are uninsured regain insurance within one year. The authors of the study did not track what happened to the insurance status of the subjects over the decade examined, what medical care they received or even the causes of their deaths.

Also, before you go into mourning too quickly, be aware that when former Director of the Congressional Budget Office (CBO) June O’Neill and her husband Dave used a similar approach they found that the involuntarily uninsured (low-income people) were only 3% more likely to die over a 14-year period than those with health insurance. There was no statistically significant effect on the “voluntarily uninsured” (higher-income people).

That’s not too surprising in light of a RAND study finding. People are receiving appropriate care a little better than half the time when they see doctors. According to RAND, the care patients receive is not affected by whether they are insured or uninsured or by the type of insurance they have. People who are uninsured, of course, may delay seeing a doctor in the first place — because of their lack of insurance. But this problem is unlikely to be solved by enrolling them in Medicaid programs that routinely ration by waiting.
[...]

Does Lack of Insurance Cause Premature Death? Probably Not.

You're citing John C Goodman, whose contribution to the health care reform debate in 2009 was that doctors needed to be more entrepreneurial or they risked losing custom to hospitals in India (Seriously.) and whose solution to the problem of the uninsured was (August 2008) ""So I have a solution. And it will cost not one thin dime," Mr. Goodman said. "The next president of the United States should sign an executive order requiring the Census Bureau to cease and desist from describing any American – even illegal aliens – as uninsured. Instead, the bureau should categorize people according to the likely source of payment should they need care. So, there you have it. Voila! Problem solved."

Citing John C. Goodman as an authority on how the uninsured get health care is kind of like citing Brett Bellmore as an authority on how minorities are affected by affirmative action.

Dr. Linda Lawrence, president of the American College of Emergency Physicians, about Goodman's "solution": "Emergency physicians can and do perform miracles every day, but taking on the full-time medical care for 46 million uninsured Americans is one miracle even we cannot perform. Access to care in the emergency department is no substitute for the comprehensive healthcare reform policy that should be at the heart of the platform of any presidential campaign."

Or as someone else with recent experience of cancer treatment on Medicare pointed out: McCain and Goodman Know Nothing about Health Care.

The RAND report which Goodman cites is another example of how US healthcare sucks:

"The differences among sociodemographic subgroups in the observed quality of health care are small in comparison with the gap for each subgroup between observed and desirable quality of health care. Quality-improvement programs that focus solely on reducing disparities among sociodemographic subgroups may miss larger opportunities to improve care."

The larger opportunity was identified in a UK study on "poor quality of data in general practice records, both in terms of its availability and accessibility, represents a significant obstacle to quality assessment in primary care", and a solution: universal electronic medical records. (The practice I registered with in 2004 went online the week I registered, and there was a period of about 10 days during which everything seemed to take about twice as long as the staff and the patients were used to - but it's been great ever since. For non-urgent appointments I really like being able to check the appointments calendar online and pick the time of day / GP / day that best suits me, but most conveniently, my medical records are now not a huge great folder of stuff that goes back to when I was a baby and has to be physically shipped from practice to practice wherever I go.)

Of course, when you have a national health care system you can do things like this... which the US can't.

"Stop the government interference (except when you need to increase it by limiting lawsuits) and costs will plunge."

Last time I looked, lawsuits took place in the legal system, which is part of the government. Therefore, limiting lawsuits, whatever you may think of the merits of it, IS limiting government interference.

I would say that, just as sanitation and hygiene were responsible for more lives saved than antibiotics, most of the difference in health care outcomes between nations of even roughly equivalent economic levels are due to culturally driven lifestyle differences. That's not the sort of thing any government program is going to easily effect, short of measures that I would hope even the majority here would recognize as outrageous.

"But enforced attention rubs me the wrong way.

I guess I was thinking more along the line of carrots rather than sticks."

It's the government: It obtains it's carrots by hitting people with sticks. So the distinction is only where the stick hitting occurs.

"2) The basic mind set of Americans. No I don't have a study. But we tend to think of end of life just like the doctors, as a defeat."

It IS a defeat. It may be an inevitable defeat in a universe with the laws of thermodynamics, but it's no less a defeat for all that.

We're not very intelligent about how we respond to that, but we're quite right to recognize defeat when we see it, instead of pretending it's some kind of twisted victory.

Just an anecdote; I just got my last chemo, probably, for my non-Hodgkins lymphoma. Almost certainly cured, according to my oncologist, because, although it's an aggressive cancer, it was discovered quite early.

Why was it discovered early? Because it was picked up in the preoperative physical for my prostate cancer surgery, which I wouldn't have gotten following the recent recommendations for treatment of early stage prostate cancer. I would have been put into "watchful waiting", while it grew to the point where my prognosis was much worse, before being discovered.

So, I'm really quite happy those recommendations didn't have the force of law behind them.

""Provide for the ... general welfare" is an extraordinarily broad mandate."

No. Precisely no. It's a freaking limit on the exercise of the enumerated powers: They can only be exercised for the general welfare, no "Cornhusker" deals. It doesn't grant even the tiniest additional power.

I mean, think this through: What's the point in enumerating powers, AND having a clause that lets the government do anything it thinks is a good idea? You must think the author of Article 1, Section 8, was a real idiot.

Therefore, limiting lawsuits, whatever you may think of the merits of it, IS limiting government interference.

Yes. The government-run legal system is simply in the way of the private court system we'd all rather use to bring law suits. Anything the government does is, by definition, interference.

It's the government: It obtains it's carrots by hitting people with sticks. So the distinction is only where the stick hitting occurs.

So where does the government get its sticks? There seems to be a chicken-egg problem here. Anyway, let's take your characterization as a given for argument's sake. Wouldn't you rather the government use its sticks to get carrots rather than more sticks? And what if the carrots could be leveraged in such a way that fewer sticks would be needed down the road? (I'm starting to feel lost in a metaphorical forest.)

We're not very intelligent about how we respond to that, but we're quite right to recognize defeat when we see it, instead of pretending it's some kind of twisted victory.

I don't think anyone was suggesting that death was a victory. It was clear to me that people were discussing the inevitability you mentioned. Maybe the use of the word "defeat" didn't quite capture it as well as it could have, but language has its limits.

I'm glad they caught your lymphoma early, Brett. Your circumstances illustrate part of the cost issue. Who wants to be the one out of 13,503 (or whatever) who dies under watchful waiting instead of early and aggressive testing and treatment? The statistics say that we're wasting resources, because the 13,502 (or whatever) would have been fine. That's cold comfort to the one who dies. It's a tough nut, huh?

most of the difference in health care outcomes between nations of even roughly equivalent economic levels are due to culturally driven lifestyle differences. That's not the sort of thing any government program is going to easily effect, short of measures that I would hope even the majority here would recognize as outrageous.

Actually, the easiest way a government program could affect people's general level of health and wellbeing: change the crop subsidy. If the US government spent $7.3 billion a year on provision of fresh fruit and vegetables, locally grown, instead of corn to be fed to animals for cheap meat and dairy, or processed for other cheap, non-nutritious, fattening foods, would that really be "outrageous"? Well, maybe to you, Brett...

You must think the author of Article 1, Section 8, was a real idiot.

Is that better or worse than thinking he was a member of the Mafia?

"on provision of fresh fruit and vegetables, locally grown"

Why locally grown? So that they won't be available in the winter?

" That's cold comfort to the one who dies. It's a tough nut, huh?"

Yeah, that's why I was careful to label that an anecdote; I would have been screwed over under those recommendations, that doesn't mean they would net out worse. OTOH, my doctor says that early detection of this cancer is almost always due to a chest X-ray done for an unrelated condition. Not that you want people getting frequent chest X-rays, of course. I've already gotten enough radiation from CT and PET scans to raise my lifetime chance of cancer several percent, in the course of this treatment.

Why locally grown?

To provide employment to local growers and local stores, rather than supermarkets.

So that they won't be available in the winter?

You know, I'm sure there's several solutions to this problem, and the US government came up with this terrific invention many years ago, called "an Internet", on which you could find out answers to all sorts of things, if you had any interest at all.

But I guess you'll just have to rot in curiosity, since you're too much of a pure-hearted libertarian ever to go online.

Why, wait... what are you doing here?

(Sorry. I forget why there is no real point in trying to have a conversation with Brett.)

It's the government: It obtains it's carrots by hitting people with sticks.

Hey Brett -

First and foremost, very glad to hear your very good news. Excellent.

Re: your comment here, in 1965 a little over 40% of the US adult population smoked. Now it's a little under 20%.

That's a change in habit and lifestyle that will contribute a lot toward good health outcomes.

A lot of that change was driven by specific public policies. Education, tax incentives, prohibition on smoking in certain areas, legal action against tobacco companies for particularly egregious behavior.

You can either see that as an appropriate intervention by government on behalf of public health, or you can see it as tyrannical interference in people's private lives.

No big surprise, I fall on the "appropriate intervention" side of the fence, and I think similar interventions in the areas of diet and exercise would be a great idea.

YMMV.

Why locally grown?

Fresher, more variety, less overhead in the supply chain. Depending on where you live, you might also add helps preserve open land in your area, makes farming a viable profession in your area. Quite often it's better value for the food dollar, sometimes it's even cheaper in absolute terms.

It's obviously limited to what will grow in your area, but nobody's saying it has to be the only thing available.

Freedom of choice, right?

No. Precisely no. It's a freaking limit on the exercise of the enumerated powers

Based on a plain reading of the text, one reasonable meaning is that it is a limit on, specifically, the power to raise revenue. In other words, the only purposes for which Congress may raise revenue are to pay the nation's debts, provide for the common defense, and provide for the general welfare.

Which leaves open the question of what "provide for the general welfare" means.

You could claim that the ability of the feds to act for the general welfare is limited only to those things specifically enumerated in the following clauses in Section 8. That's not actually a reading that the text demands, or even lends itself to, but you could make the claim if you like. If so, you're going to have to cut a lot deeper than whether single payer can be considered.

FAA, national weather service, food and drug inspection, building codes and standards, any civil engineering efforts at the national level other than building roads, and building roads is limited to post roads.

And on and on and on. And on.

None of that stuff is in there.

In for a penny, in for a pound.

I recently bought at a reasonable price some Ya pears from Hebei, China. Very good.

The "general welfare" clause was controversial even at it's inception. However, it was generally taken as a limit on government until during the FDR administrations when the Supreme Court decided it meant just the opposite.

Russel, had it occurred to you that some of that could be done at the state level, which, per 10th amendment, isn't limited to enumerated powers?

had it occurred to you that some of that could be done at the state level

I think that would be fine. I don't really have a bias toward doing things at the federal level.

I don't have much of a bias *away* from that either, though, and especially not when the thing in question is national in scope. And I think I'm just less suspicious of government at any level as an actor than you appear to be. At least, less suspicious of the governments we actually have, in the contexts we're talking about.

Glad your chemo is done, and was successful. May you live long and prosper.

had it occurred to you that some of that could be done at the state level

Another comment, or maybe just observation, along this line:

Discussion of health care reform in the US most often compares our approach and outcomes to OECD nations.

The US has, by far, the largest population in the OECD. Japan's next closest, and we have about three times their population. Most OECD nations have populations in millions to tens of millions. Some have less than a million.

In other words, in general they are comparable in population to a US state.

To the degree that scale is a complicating factor in making stuff like this work, IMO there is a reasonable argument to made for implementing reform at a state or regional level.

The counterargument is that this arguably might make care less accessible in some places.

Personally, I honestly don't much care how it happens, as long as folks can go the doctor without going broke.

I recently bought at a reasonable price some Ya pears from Hebei, China. Very good.

Truly, an incontestable argument for growing all of our food on the other side of the world.

Well played Charles. Enjoy your pears!

No. Precisely no. It's a freaking limit on the exercise of the enumerated powers: They can only be exercised for the general welfare, no "Cornhusker" deals. It doesn't grant even the tiniest additional power.

Nope. It's smack in the list of things "The Congress shall have power" do to. It's closely tied to things which are clearly powers (ie "provide for the common defence and general welfare").
But it's inconvenient for you, so you use a bizarre reading, and then claim that that reading is the only possible one.

I mean, think this through: What's the point in enumerating powers, AND having a clause that lets the government do anything it thinks is a good idea? You must think the author of Article 1, Section 8, was a real idiot.

*You* must think that. You have him making an explicit list of things Congress has the power to do, and throwing in a restriction without any attempt to distinguish it from the powers. And in such a way that it parses out as one member of that list rather than as an exception.

'general welfare' clause creates lots of disagreements. IMO, on the topic of health care, NIH research into possible causes and cures for cancer might fit, but the treatment of an individual cancer case would not. I can see the former falling into the general welfare category but not the latter.

Since many of those in opposition to current legislative proposals like much of the health care they now have and would like to continue to have those choices and those who favor a significant federal presence in health care favor the proposed legislation, why not go for both.

Keep the existing health care delivery system ( work on fixing individual problems with it as suggested many times by republicans.)

Create a second system (a public option?) where those who get service through that option would need a ticket to do so. We could have something like health care registration and classification similar to what was in place for the military draft, but it would work in a opposite manner. All the 1-A's remain in the private health care system and some other classification is required in order to use the public option. Qualifying classifications could include such things as being unable to get private insurance due to pre-existing conditions, income insufficient to pay insurance premiums, veteran's status, etc.

There could be some combination of Public Health Service. VA Hospitals, and NIH to constitute the public option infrastructure. The private option could be migrated away from being related to employment and premiums could be tax deductible for individuals. Health Savings Accounts could continue. Those qualifying and choosing to use the public option should not be able to do so without costs to the user, but those costs, be they premiums, deductibles, or co-payments should be financially reasonable to the user circumstances.

Good Ole Boy: IMO, on the topic of health care, NIH research into possible causes and cures for cancer might fit, but the treatment of an individual cancer case would not.

Each person's health and wellbeing contributes to the general welfare.

Discarding the lives of individuals as unimportant is the corporate attitude: there are always more replacable workers, but each individual who lives or dies is part of a network of general welfare and support.

Or, put another way: letting an individual die of cancer because the wellbeing of individuals is unimportant to the general welfare of the nation seems profoundly backassward reasoning to me.

'general welfare' clause creates lots of disagreements.

I agree. And I think that those disagreements can be made in good faith.
Historically Brett does not agree with this position about disagreements; if you don't agree with him about Constitutional interpretation, then you're lying.

Create a second system (a public option?) where those who get service through that option would need a ticket to do so.

Why "need a ticket"? You're a freedom-lover, GOB. Why would you restrict MY freedom to buy into a public option?

I asked you this earlier, and I ask again: why would my freedom to buy my health insurance from the federal government be any skin off YOUR nose?

--TP

"You have him making an explicit list of things Congress has the power to do, and throwing in a restriction without any attempt to distinguish it from the powers. And in such a way that it parses out as one member of that list rather than as an exception."

Commerce Clause anyone? Yeah didn't think so. :)

"Or, put another way: letting an individual die of cancer because the wellbeing of individuals is unimportant to the general welfare of the nation seems profoundly backassward reasoning to me."

Yeah, kind of like the recent recommendations on breast cancer screening: Stop doing so much of it, it might be saving individual lives, but it's costing too much. Since we have a private health care system here, that recommendation is just a suggestion. You guys win, eventually that sort of thing will be binding.

There's a problem here: So long as Social Security is run the way it is, the government has a serious conflict of interest regulating health care: It costs the government money if the population lives longer.

I, for one, don't like pretending the government isn't effected by such conflicts of interest.

So long as Social Security is run the way it is, the government has a serious conflict of interest regulating health care: It costs the government money if the population lives longer

I, for one, don't like pretending the government isn't effected by such conflicts of interest.

ORLY ?

the US government is also the largest holder weapons in the country - weapons that could be used to get people off SS, so to speak. why don't they ?

the US government is also in complete control of the delivery mechanism of SS checks. they could easily see to it that those checks are not delivered. why don't they ?

the US government is also a large source of funding for road maintenance. it could reduce funding in areas where SS recipients live, thus encouraging fatal car accidents. why doesn't it ?

the US government controls the drugs that are available for use. it could ban, or tax at a sufficiently-high level so as to make them unaffordable, the set of drugs which typical SS recipients are most likely to use. thus, encouraging people to get off SS, so to speak. why don't they ?

the US government, being capable of passing laws, could outlaw old age. why don't they ?

Anyone who wants to pay for more frequent breast cancer screenings for herself, or any other medical testing for that matter, out of her own pocket is free to do so now and will remain free to do so no matter what the outcome of health care reform. Which you know.

So long as Social Security is run the way it is, the government has a serious conflict of interest regulating health care: It costs the government money if the population lives longer.

SOCIAL SECURITY DOES NOT WORK THAT WAY.

NIH research into possible causes and cures for cancer might fit, but the treatment of an individual cancer case would not. I can see the former falling into the general welfare category but not the latter.

So the reason you are a socio-economically backward nation with systems that are an international disgrace is your narrow reading of your Constitution? Interesting.

And even if you acept your definitions, promoting the general welfare covers treating absolutely any infectious disease held by any person living within the United States of America. Becasue by treating them you are eliminating a method of spreading disease.

NIH research into possible causes and cures for cancer might fit, but the treatment of an individual cancer case would not. I can see the former falling into the general welfare category but not the latter.

I actually think GOB is right. Health care reform should not be limited to treating or providing insurance for the treatment of an individual cancer case. It should provide general coverage to the general population to qualify as promoting the general welfare. It would be wrong to pass a bill that would only allow coverage for Mary Smith on Maple St. in Bloomington, IL for her throat cancer. GOB's right.


It's sort of funny how conservatives on the one hand decry the environmental disaster scenarios of the 70s as ridiculous fantasy, and on the other, insist that plotlines about murdering the elderly from Soylent Green and Logan's Run are not only plausible but an imminent threat under a Democratic administration.

'Create a second system (a public option?) where those who get service through that option would need a ticket to do so.

Why "need a ticket"? You're a freedom-lover, GOB. Why would you restrict MY freedom to buy into a public option?

I asked you this earlier, and I ask again: why would my freedom to buy my health insurance from the federal government be any skin off YOUR nose?

--TP'

My idea of individual freedom does not include providing taxpayer subsidies for services for those who are able to acquire needed services in the commercial marketplace. I know we already have such circumstances but this does not convince me. My interest is not so much keeping Tony from purchasing the service through the public option but rather to insure that the existing private service that many prefer will continue to be viable. So, if a 'ticket' is unacceptable, (this is how we do Medicare and Medicaid and VA Medical Services), then we could do the following two things:

1. Amend the Constitution to forbid the federal government from making any law that infringes the right of any individual or other legally organized entity to provide medical services (practitioners, procedures, treatments, facilities, health insurance, etc) or for any
legal residents to avail themselves of such medical services in the marketplace.

2. Require that anyone not qualifying under the criteria resulting in a 'ticket' for entry pay a premium with deductibles and co-pays equal to that prevalent in the commercial marketplace.

I also have some understanding that the existing marketplace, the collusion between state governments, the federal government, and the collective capitalists making up the insurance industry is NOT the competitive commercial marketplace I'm envisioning.

IMO, on the topic of health care, NIH research into possible causes and cures for cancer might fit, but the treatment of an individual cancer case would not.

What about federal efforts to procure and deliver H1N1 vaccinations?

Can the feds produce the vaccine?
Can they pay someone else to produce it?
Can they buy it and distribute it to hospitals and doctors, but federal employees may not actually do the innoculation?
Or can they participate in the whole supply chain from procurement to injection?

Note that *no form whatsoever* or procuring or delivering medical care, from basic scientific research to giving you an aspirin, is named as a power granted to any branch of government, anywhere in the US Constitution, either the original document or any of its amendments.

No form of medical research, no public health effort, no funding for or operation of hospitals or clinics, no support for medical education. Nothing. It's not in there.

Neither is anything whatsoever to do with transportation other than post roads.

Neither is anything to do with any other kind of scientific research, other than securing copyrights and patents.

Neither is there anything about establishing, maintaining, or securing shipping ports, or about aids to navigation, or about weather forecasting.

Neither is there anything about ensuring that anyone has potable water, or electric power, or a sanitary way to get rid of their bodily wastes and household trash.

Really, I could go on all day.

The Constitution grants the feds *no power whatsoever* to participate in *any* of the those things, other than through a liberal reading of the phrase "promote the general welfare".

And there's nothing in that phrase to distinguish between funding research into cancer cures and direct delivery of cancer care to any individual patient.

You object because it will interfere with the free market. But there is not one word about the "free market" in the US Constitution either.

The feds can't take private property without due process of law or just compensation. States can't impair the obligation of contracts.

"Free market" per se, not a peep. It's just not there.

If you don't like the idea of government providing health care, that's fine. It's your privilege to get on the horn with your Senators and your Rep and let them know.

But there's nothing in the Constitution that says your position is either necessary or correct.

'And there's nothing in that phrase to distinguish between funding research into cancer cures and direct delivery of cancer care to any individual patient.'

I was using this example with the intent to test whether any agreement would be forthcoming that certain provisions in the Constitution were written for the purpose of limiting the powers of the federal government, but if you believe there are no such limits, then no example will accomplish that intent.

GOB: My idea of individual freedom does not include providing taxpayer subsidies for services for those who are able to acquire needed services in the commercial marketplace

The commercial marketplace is the worst place in the world to have to buy healthcare.

Your idea of individual freedom may include dying for the worst health care service in the developed world, but again - why should others have to die, 45 000 a year, because you believe that health care ought to be run at massive expense to all so that the companies who provide it as a commercial service make their profits?

What is it about individual liberty that makes you think you're not free unless, as a patient, you can go bankrupt paying for your healthcare, and as a taxpayer, you are required to subsidise the health corporations rather than the health care of your fellow citizens?

I can assure you, that among other benefits, the NHS is the best support a struggling entrepreneur could have. People in the UK don't have to cling to their jobs for fear of dying if they strike out on their own. No wonder the corporations love your system - but it's hardly your freedom they care for.

I was using this example with the intent to test whether any agreement would be forthcoming that certain provisions in the Constitution were written for the purpose of limiting the powers of the federal government

And I, in turn, was challenging your example, because it's not a good example.

If the feds can fund cancer research, they can either fund or directly provide delivery of care. There's nothing in the Constitution to give you a basis for distinguishing between the two.

There may be 1,000 political, practical, and even medical reasons for the feds to do either, both, or neither. But there is not a Constitutional reason for doing one, and not the other.

There are lots of things the feds, correctly, do not do, and which are reserved to the states. Charter corporations, for one.

And there are many, many limitations on federal power that I heartily endorse. The Bill of Rights is nothing but an enumeration of limits on federal power, and I completely support each every one.

The preference for a free market vs a public approach for delivering useful or necessary services is a political, social, pragmatic, and personal one. That's fine, and those provide more than enough basis for having a strongly held position.

What it is not is a Constitutional question.

My interest is not so much keeping Tony from purchasing the service through the public option but rather to insure that the existing private service that many prefer will continue to be viable.

Why would private insurance not be "viable" in competition with a public option? Do you really have so little faith in private insurance companies?

Careful: don't come back with something lame, like "subsidies". The current bill provides for subsidies to (some) people so they can afford private health insurance. If you don't approve of subsidies, you would deprive private insurers of customers.

--TP

Tony: Why would private insurance not be "viable" in competition with a public option?

Anyone in the UK who wants to can and does buy private health insurance.

Private health insurance in the UK, admittedly from strictly anecdotal evidence on either side, provides a far better-quality service in the UK than in the US: because private health insurance and private hospitals must compete with the NHS.

(I've never heard of anyone in the UK who bought private health insurance having to haggle with them to get them to pay up for a pre-agreed treatment, for example, which people in the US report as happening with alarming frequency.)

As seems frequently the case with Americans defending their own system, GOB just seems profoundly ignorant of the health care in other countries...

"Anyone in the UK who wants to can and does buy private health insurance."

Less than 8%, primarily the very wealthy. The equivalent class of insurance and buyers in the US rarely have to negotiate for payment either.

As seems frequently the case with jes defending her own system, she just seems profoundly ignorant of the health care in other countries, particularly the US..."

Less than 8%, primarily the very wealthy.

They must have a really good public system, then.

Less than 8%, primarily the very wealthy.

Why is this even relevant? GOB worries about a public option interfering with people's ability to choose private insurance. Jes points out that in the UK people are perfectly free to forgo the NHS and insure themselves in the private market. I fail to see whose "freedom" is being impinged upon, which was the actual topic under discussion.

I realize that the sparring with Jes is getting very personal for you, Marty, but still.

No uncle, the point was jes insulting GOB for no reason. In fact what the 8% represents is that very few people can afford the expensive and preferable private insurance. The publicly subsidized delivery has reduced competition foe the average person.

Marty, why does it represent that?

Perhaps it represents the fact that very few people find supplemental insurance attractive given the free provision of very adequate insurance, and only the wealthiest 8% spend on such luxury?

I mean, if people were truly upset that they couldn't afford the preferable private insurance, one would expect that the UK's health system would be wildly unpopular.

And yet the opposite is true.

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