ACA, AHCA, DBCFT, Showdown Throwdown

by Ugh

So here we are, 7 years and one day after the ACA was signed into law by B. Hussein O. and after eleventybillion prior votes to repeal the law when it didn't matter, the House might finally vote on an ACA "replacement" bill via a process that actually involves all the mythical process horrors the GOP likes to claim went on during passage of the ACA itself.  As always, it's projection with the GOP.  Meanwhile President of the United States and poor man's Roger Goodell Donald Trump has laid down the Art of the Deal^TM and declared that either the GOP passes this horrible monstrosity of a bill or he will move on to more important things because this whole healthcare business is boring and stupid and who cares anyway?  Wah. 

What's going to happen?  I'm still worried that the AHCA will pass, the Senate then modifies it in a way to move it from absolute horrible monstrosity to just horrible monstrosity, and it eventually makes it's way to Donald's desk for signature.  Hopefully not.  

Meanwhile, whatever happens here the next small item on the agenda is... tax reform!  Easy!  Actually, my guess is that if the AHCA goes down in flames, Trump will tell Ryan to piss-off on the destination based cash flow tax (DBCFT) pipe dream and move to a more "traditional" approach to tax reform because there will be a need for a "win"!  And any significant tax bill that passes, no matter how un-reform like it is, will be declared a glorious victory and shut up.

But hey, maybe 24 million people will lose their insurance and they can declare that glorious too.  

Meanwhile, the flailing about would be amusing if it wasn't so potentially deadly.  Honestly, I'd trade tax cuts for the rich for leaving the ACA alone in a heartbeat (if such a trade could be made to stick, which it can't).  What say y'all?

Update:  Should have noted that the vote is scheduled for 3:30.  Don't know if they will keep it open for hours and hours or what.  If it fails expect Trump to lay all the blame at Paul Ryan's feet.  "He's in charge of the House and he couldn't even get a bill through.  Weak. Sad!"  It will also let Trump take the lead on "tax reform."

Comments

[wj]

The interesting question in my mind is, suppose that Ryan knows that he doesn't have the votes. (Assuming, for the sake of discussion, that the House Republican leadership knows how to do a whip count.)

Does he go ahead with the vote anyway, just to force everybody to take a formal, public stand?

Or does he recognize how toxic a vote might be for some of his members, and try to avoid hanging anyone out to dry? Just to help keep his majority past the 2018 elections.

[Yama]

Who deserves Trump more than Ryan?

[Ugh]

Ryan could pull the bill, and perhaps that's what he told Trump at the WH when they met earlier today when the message was supposedly "we don't have the votes." But Trump and/or his surrogates have loudly demanded a vote from the House on this and insisted that they will move on if it doesn't pass, lots of embarrassment for Trump if Ryan pulls the bill and there's no vote, unless Trump has somehow agreed to that.

I guess it might come down to who Ryan feels he has to answer/respond to, Trump or his Congressional GOP colleagues?

Who deserves Trump more than Ryan?

No one, although it would be nice to limit the damage to the fraud that is the current speaker of the house.

[Nick Schulig]

Trumpty Dumpty sat in his stall
Trumpty Dumpty let twitter turds fall
All Bannon's nazis and all Conway's lies
Can't keep sad Trumpty from his sorry demise

MH Durber

[Yama]

Trumpty Dumpty might be the Gingerbread Man.

[cleek_with_a_fake_beard]

and the vote has been cancelled!

Art Of The Deal, indeed.

suckers.

[Girl from the North Country]

Oh my God, the thrills and spills. Do we think this finally kills it? I don't want to get excited when it might be revived later...

[Ugh]

Sad!

[wj]

I'd say that this kills "health care reform" for this Congress. That is, it won't reappear until 2019 at the earliest.

Now we ask, what impact will this have on the next thing that Trump and/or Ryan want to pass? Because the same divide between the "Freedom caucus" and moderate Republicans occurs on other issues as well.

As we have seen, the Republicans who represent swing districts are not going to set themselves up for defeat by passing something radical. and the "Freedom caucus" is heavily into absolutism: my way down the line or nothing at all; never, ever agree to the slightest compromise.

[cleek_with_a_fake_beard]

they absolutely have to try again at some point.

their Obamacare demon has been an essential component of the GOP's mythology for years. it's been a great motivator for the base - ginned-up fear of their Obamacare caricature is a big part of of their majorities.

they can't just shrug and walk away from it.

[hairshirthedonist]

it's been a great motivator for the base - ginned-up fear of their Obamacare caricature is a big part of of their majorities.

The problem for them is that it's an increasingly popular program (at least when you call it the ACA rather than Obamacare).

The people who will always be against it are the ones who are or perceive themselves to be paying for it and who are looking forward to a nice tax break if it's repealed, regardless of what it means for anyone else. But those people are a small part of either the freedom caucus' or Trump's base.

How does Trump satisfy the rich and the poor? How does he work with the radicals and the moderates among the GOP in congress? Who knew politics could be so complicated?

[Girl from the North Country]

Thanks wj. As I never thought I'd say (because too short-sighted) Thank God for the intransigence and extremism of the Freedom Caucus.

[Girl from the North Country]

Thanks wj. As I never thought I'd say (because too short-sighted) Thank God for the intransigence and extremism of the Freedom Caucus.

[Doctor Science]

So far he's blaming *Democrats*. Says they'll come crawling back when "Obama" (presumably =Obamacare) "explodes".

The question is, how will Fox News pitch this? I suppose they'll probably blame Democrats, too, somehow, even though the Rs had the #s to pass the things by themselves.

I for one am going to seriously celebrate how many friends of mine are not staring death in the face, tonight.

[Girl from the North Country]

Hmmm, I did not double click. Let's hope I haven't got the curse of the rogue double click (which will soon be revealed)...

[russell]

maybe they could do a piranha brothers thing and say the bill passes if they don't vote for it.

as it turns out, governmenting is hard.

meanwhile, in all the noise, the extension on the debt ceiling expired March 15, 2017, which was last Wednesday.

does anyone know what happened with that? I haven't heard anything about it.

(R) House, (R) Senate, (R) POTUS, and an even split in the SCOTUS for the moment, with a conservative majority no doubt on its way.

Ball's in their court.

[Girl from the North Country]

as it turns out, governmenting is hard

And complicated. Who knew?

(Somebody may have made this joke already).

[sapient]

With that done, now we can work on impeachment!

[Yama]

I hope they continue to tear each other apart.

[wj]

Maybe stories about the bill failing to pass are FAKE NEWS!...?

[Tony P.]

russell: meanwhile, in all the noise, the extension on the debt ceiling expired March 15, 2017, which was last Wednesday. does anyone know what happened with that? I haven't heard anything about it.

I believe I heard that the Treasury is operating with "extraordinary measures" so as to stave off actual default for a few weeks(?) as has been done a couple of times before.

When the initiative du jour moves on to tax "reform", I still say the Dems should hold out for increasing the personal exemption on the 1040 to about $50K per person. The "Freedom Caucus" ought to go for that, unless they're complete frauds and swindlers.

--TP

[Girl from the North Country]

By the way, Trump ally the National Enquirer is apparently saying Flynn is a Russian spy.

http://www.huffingtonpost.com/entry/national-enquirer-michael-flynn_us_58d562dae4b03692bea5958b?3i1ikwn7k8kc5wmi&

I guess this means he's the one under the bus. Funny that they think it might stop with him...

[Marty]

In a less giddy tone, I hope this means that, despite the Super Bowl level analysis of winners and losers, that Congress takes its responsibility and authority seriously and passes something that is actually better.

For those of us in the exchanges this is incredibly disappointing.

[wj]

For some of us in the exchanges, this is good news. YMMV, of course.

[Ugh]

Poor Paul:

https://twitter.com/karoun/status/845394011506511874

[Ugh]

WH denies but someone is going after Kushner, wow.

http://www.cnn.com/2017/03/24/politics/jared-kushner-aspen-ski-trip-obamacare/index.html

[Marty]

I suppose if you have a spare 30k laying around or you make less than 45k and the deductible the exchange works fine. I don't know very many in that group.

[wj]

Why Ryan may be on short time:

We were a 10-year opposition party, where being against things was easy to do. You just had to be against it,” the speaker said. “And now in three months’ time we tried to go to a governing party where we actually had to get 216 people to agree with each other on how we do things.

It's probably true. But admitting that, in 7 years of demanding "repeal and replace," you never bothered to work out what "replace" should look like? Not a great way to demonstrate what a great leader you are. Nor a great way to demonstrate that your party is serious about the business of actually running the country.

[Ugh]

It also demonstrates why lying to people about things can end up biting you in the a$$. "Death Panels!" "Government takeover or healthcare!" etc., why are they all of a sudden surprised that a bunch of their colleagues - many elected after the ACA became law - are not willing to go along with an 80% or 90% repeal. I mean, "smaller death panels!" and "partial government takeover!" aren't something to rally around.

Also, forget where I read this today, but another problem with repeal is that the ACA was actually a compromise bill that could have garnered support from some GOP senators - but McConnell was on his crusade to make Obama a one term President and got those GOPers who might have voted for the ACA to vote against. But on substance it was a bill several GOPers could have (and from reports wanted to) voted for - thus repeal is harder because it's not really the one sided, Democratic monster it's been made out to be.

I don't think the fight is over - certainly the Secretary of HHS can do a lot of damage, and nothing keeps the GOP from attaching small provisions that sabotage parts of the ACA to "must pass" legislation (like the debt ceiling increase), and there could be a repeal repeat, but the big fight is done for now - but eternal vigilance!

[Marty]

"Nor a great way to demonstrate that your party is serious about the business of actually running the country. "

I am ok with someone pointing out reality. With a real honeymoon it took a lot longer for the Democrats to agree on a solution than the Republicans have had. The details are hard. And talking about 7 years misses the point they are still trying to solve a problem that has been under discussion for over 50 years. Where every attempt to solve it has failed. Including the ACA.

[sapient]

nothing keeps the GOP from attaching small provisions that sabotage parts of the ACA to "must pass" legislation (like the debt ceiling increase)

I don't think that they'll be able to agree on doing things like that. Breaking the international financial system on a Republican's watch would look kind of terrible.

It's true though that they can do some damage, and we need to be vigilant.

[sapient]

Where every attempt to solve it has failed. Including the ACA.

I have several family members on the ACA and every single one of them is glad to have it. You're exceptional, Marty, in good ways and bad.

[Ugh]

And looks like I was wrong in guessing that Trump would blame the Speaker, and Ryan also noted that Trump did all he could. So, it appears they have agreed not to play the blame game, which means they are going to get along in the coming tax reform process. Should be interesting.

[Marty]

I am not the least bit exceptional, nor is my issue. There are many people glad to have something, but Trump is probably right in this case, its only going to get worse.

But its great that your family and wj have yours. F@ck the 20 mil who have nothing and the rest of us who have little more than manifestly expensive catastrophic insurance. And who cares if the cost curve is bending up instead of down?

Yall are otay today.

[sapient]

So, it appears they have agreed not to play the blame game

They're worried about covering their butts regarding the Putin "situation". I'm pretty sure that the entire Republican Party has been compromised in one way or another. There are a lot of conspiracy theories out there, many of which are quite plausible, but all you have to do is look at what we all know. Pretty gruesome. Especially since disloyalty is punished.

[sapient]

F@ck the 20 mil who have nothing and the rest of us who have little more than manifestly expensive catastrophic insurance

Hahahaha.

Remind me what you would have had before the ACA? Listening ...

[Marty]

One more point, this helps Trump not hurts him. Even if he plays nice with Ryan he gets to say that he was right that all Washington is very bad. I told you so. See why I am so upset?

Then a Gorsuch filibuster gives him huge ammo. He will be adding supporters, not losing them. And Congress ratings will still suck.

[Marty]

"Remind me what you would have had before the ACA? Listening "

a job

[sapient]

this helps Trump not hurts him

Trump is a loser. That's the message being sent. The Art of the Deal? Hilarious!

Sure. His loser supporters and their enablers may dig in. But they will be marginalized by the people who are now quite inspired by this victory.

And, by the way, his people are going to go down. Maybe quickly, or maybe not. And I don't kid myself that there is not going to be some suffering by everybody along the way. But many of us are determined to keep fighting. We are putting everything we have into not going into another dark ages. Because if that happens, it's not on us.

[wj]

So you don't have a job due to the ACA? I'm not entirely clear how that could have had a causal relationship.

[sapient]

So you don't have a job due to the ACA? I'm not entirely clear how that could have had a causal relationship.

As I mentioned, wj, Marty is exceptional.

[sapient]

Honestly, whatever Marty. You seem like a sweet person in some of your comments, so I'm not hating on you or anything.

But how can anyone take you seriously? Most of the people here are around my age (60). I personally know 30, maybe more, people who have lost their jobs, mysteriously, at about Age 60. I've been observing this for the past 20 years among work colleagues, and then family ....

You're blaming Obama? I'm intrigued with restarting a marijuana habit to mitigate my increasing alcohol use, but your views on things give me pause.

[hairshirthedonist]

The landscape on health care (and just about everything else) has changed drastically over the last 50 years, so suggesting that solving relatively current problems has been something anyone has had 50 years to work on is silly. And the Republicans have had just as much time as anyone else to come up with an actual solution. They've done less than d*ck about it. There's not enough lipstick for this pig, but keep trying.

[Ugh]

"And then, when the moment came, when Republicans finally had full control of government, it took barely two months for them to admit they hadn’t really thought it through.

It hadn’t really occurred to them that repealing the individual mandate and cutting the subsidies would result in many millions uninsured or raise premiums massively on people in their 50s and 60s. It didn’t seem to have occurred to them that the demands of the House Freedom Caucus members, the most unflinching ideologues to achieve near-total repeal, the desire by less conservative members to keep at least the basic structure of benefits, and the president’s promise to improve every single thing could not be easily accommodated. They hadn’t considered the possibility, indeed the likelihood, that as unpopular as the ACA remained, their own alternative would be even more unpopular, not least because change alone is terrifying to people when they think about health care."

"If the goal of the campaign against the Affordable Care Act was to repeal the Affordable Care Act and leave millions without health care, it failed, thankfully. But if the goal was to win election after election, and virtually wipe out the Democratic Party across much of the country, while never actually engaging with the tough questions of health care, then it succeeded beautifully. And that success lives on. It is really one of the longest, most coordinated political deceptions in American history, and one in which Trump is only a minor player."

http://www.vox.com/polyarchy/2017/3/24/15055636/aca-repeal-angry

[russell]

they are still trying to solve a problem that has been under discussion for over 50 years.

there are only about 20 other countries who have figured this out. not all the same way, but most with better outcomes than us at order-of-magnitude half the cost.

we are, as a nation, frankly stupid. boneheadedly, mulishly stupid. that's why you can't afford health insurance.

you may be right, trump may come out ahead on this. there's no accounting for what people think.

[bobbyp]

they are still trying to solve a problem that has been under discussion for over 50 years.

Well over 50 years.

If it weren't for the fact that most "middle class" folks and above have some kind of insurance through their employer, this whole debate would take on an entirely different cast. They haz their tax subsidized insurance, f*ck all those morally defective poors, poor women, and the not so white.

[bobbyp]

...then it succeeded beautifully

I would say not. This is a major short term defeat for the GOP. They reveal themselves to be totally incompetent, utterly lacking in serious policy chops.

The major thrust of the con lies elsewhere.

[Marty]

"the Republicans have had just as much time as anyone else to come up with an actual solution"

At least they are still trying.

[hairshirthedonist]

Still? And trying? This is the kind of stuff that makes me suspsect you're pulling a gag at my and others' expense a la Andy Kaufman.

[Countme-In]

I was kind of hoping the thing would pass so Paul Ryan could do a keg stand like the shallow Ayn Rand frat c&nt he is.

Obamacare can be improved, no doubt about it.

But not by Andy Kaufman trying to improve WWF piledriving with the innocent down-turned fake sympatico, neck-braced smile of Ryan calling Marty's denied pre-existings the very essence of, well that Lamborghini is accessible to you now go and get it unemployed, free person by virtue of your unfortunate age, you liability, shareholder-starving you.

If all of us were fetuses, we'd have universal healthcare and full employment.

If we had had universal healthcare, Ryan would would be pro-abortion, because then fetuses would be undeserving on account of their high rate of unemployment.

[russell]

At least they are still trying.

as opposed to the ACA and the Medicare expansion, which were not an attempt.

The (R)'s do not appear to give a crap if you live or die. Why you come to their defense is a mystery to me.

[russell]

If it weren't for the fact that most "middle class" folks and above have some kind of insurance through their employer, this whole debate would take on an entirely different cast.

good point, that.

[Marty]

"as opposed to the ACA and the Medicare expansion, which were not an attempt."

It was an attempt, it failed to achieve any of its stated goals. It did expand Medicaid which insured 14m people, no complaints. Is high cost nigh deductible insurance better than none? Sure. But that doesn't make the ACA good or successful. There are a lot more people not covered or having an expensive policy with little value than are covered. The cost curve is going up, everybody's health care and insurance is still getting more expensive.

But lets defend the ACA at all cost and celebrate that it is now an actual entitlement that will fail expensively because hell, it worked in Massachusetts.

[bob mcmanus]

Nah, yesterday's "failure" while a defeat or show of incompetence by individual ideologues like Ryan, essentially demonstrated that Obamacare, with its fragmentation and reliance on the the states to administer, its surrender to private, corporate, and commercial interests, the coercive funneling of individual income to profit centers,its intentional hollowing out of the middle class, its basic neoliberal and pro-capitalist framework...

...is pretty much acceptable even to the radicals that makeup the current Republican Congress and Party.

[sapient]

its intentional hollowing out of the middle class

Proof?

[bobbyp]

What are the goals of the ACA?

1. Expand access. This has been done to great success. It would be even more successful were it not for the lunatic Roberts Court and GOP state governments who turned down the Medicaid expansion for pure partisan reasons.

2. Protect patients against arbitrary actions by insurance companies. No more rejection due to pre-existing conditions, etc., etc. Undoubtedly a success on this score.

3. Reduce Costs. Possibly. But the problem is the structure of the health care industry and cost pushers such as patents, fee for service, limited entry, private profit. But these institutional relationships cannot be placed at the doorstep of the ACA.

In terms of reaching its stated goals, I'd say it's been pretty successful given the political headwinds it's up against.

[Marty]

Stated goals:

1)Cover all Americans
2)Bend the cost curve on Health CARE
3) Pay for itself

The preexisting conditions stuff was a problem in implementation not a stated goal.

As for acceptable, as soon as it was forced through it became almost impossible to fix, with a second term to protect it the political backlash of removing it became the headwind. Give people something for free its damn hard to take it back.

Obama knew that when he passed it, and never much talked about it in his second term because he was pretty sure it was over the repeal hump and politically safe.

The only real chance to fix it was if enough Republicans felt they should actually deliver on 6 years of campaign promises. But no.

[russell]

IMO the ACA is kind of a shambles. It's the ultimate Rube Goldberg law. And it's the best thing that could be passed at the time. And, for millions of people, it has been literally a life-saver.

The alternative was do nothing, which would have left us in a world where 15% of the population had no coverage at all, and where medical emergencies were one of the main causes of personal bankruptcy.

I have no issue whatsoever with changing the ACA to improve its flaws. The (R)'s are unable to do that, because a significant minority of (R)'s in Congress are committed to unequivocal repeal of every piece of the ACA, lock stock and barrel, and the (R) leadership can't get anything passed without the buy-in of the maniacal hard-liners.

So, as a practical matter, the (R)'s bring nothing to the table.

Were they not palpably insane, the more moderate (R)'s would reach out to the (D)'s, kick the Freedom Caucus knotheads to the curb, and find a reasonable path forward.

With Ryan and McConnell driving the bus, that is not likely to happen.

I'm sorry the ACA sucks for your personal situation. For many millions of people, it's what is keeping them alive.

If you want to change it, call your Congresspeople and tell them to start talking to (D)'s and get something done. The (R) leadership is not going to do it, and doesn't care if you have insurance or not.

[Marty]

D's aren't going to change the ACA, they are going to protect it to the death, claiming victory.

And there isn't a way to fix it without repealing it. It has been inherently flawed from the start.

And 15% of the population still doesn't have insurance.

[Michael Cain]

...GOP state governments who turned down the Medicaid expansion for pure partisan reasons.

Look for more of them to accept the expansion over the next couple of years. The ACA changed the way hospitals are compensated for charity care -- much more through Medicaid, much less through direct payments. Those states' hospital associations have been leaning on the politicians, because absent the expansion they have to absorb a lot more costs. Once the rural hospitals start closing, those states will take the expansion.

[Girl from the North Country]

I have no issue whatsoever with changing the ACA to improve its flaws. The (R)'s are unable to do that, because a significant minority of (R)'s in Congress are committed to unequivocal repeal of every piece of the ACA, lock stock and barrel, and the (R) leadership can't get anything passed without the buy-in of the maniacal hard-liners.

So, as a practical matter, the (R)'s bring nothing to the table.

Were they not palpably insane, the more moderate (R)'s would reach out to the (D)'s, kick the Freedom Caucus knotheads to the curb, and find a reasonable path forward.

This seems absolutely true and inarguable. Marty, you are being blindly partisan, maybe not for the first time (you aren't the only one who sometimes is) but very clearly.

[bob mcmanus]

sapient 9:28

Googling "aca middle class" I get articles, 2016:

Is Obamacare really affordable? Not for the middle class -- CNN Money

Middle-Class Americans Face Biggest Strain Under Rising Obamacare Costs -- NPR

Burden of Health-Care Costs Moves to the Middle Class -- WSJ

Obamacare Crushing Middle Class ...zerohedge, charts maps and graphs

Dilemma over deductibles: Costs crippling middle class == USA Today

ohh, whatever. I was fed up with Clintonites and Obamabots back in 2009 when hilzoy loved tax cuts because they were Obama's. When I noticed the very active and aggressive sapient refused to visit Jacobin I realized that this is not a comfortable environment for me.

[sapient]

And 15% of the population still doesn't have insurance.

Hmmm..

[bobbyp]

Stated goals:

1)Cover all Americans
2)Bend the cost curve on Health CARE
3) Pay for itself

1) Addressed above.
2) Not determined, but not an abject failure as claimed.
3) Pretty much does.

For more on the Act's goals, see here.

You want lower costs? How about publically expanding the number of doctors and nurses? How about single payer? How about telling all those thousands of health insurance clerks, claims adjusters, salespeople, underwriters, actuaries, and hugely overpaid executives to go out and f*cking get "real" jobs?

Our genius political class told that to steelworkers and autoworkers, why no these folks?

[Girl from the North Country]

An interesting piece on the ins and outs of the negotiations:

http://www.politico.com/magazine/story/2017/03/obamacare-vote-paul-ryan-health-care-ahca-replacement-failure-trump-214947

[formerly known as cleek]

D's aren't going to change the ACA, they are going to protect it to the death, claiming victory.

And there isn't a way to fix it without repealing it. It has been inherently flawed from the start

no, the Dems probably aren't going to "fix" it if the only "fix" is repeal. but Dems don't live within the topology of that little knot.

[Girl from the North Country]

I was fed up with Clintonites and Obamabots back in 2009 when hilzoy loved tax cuts because they were Obama's.

I don't know you bob mcmanus, because you post so seldom, but I have seen that you have been greeted welcomingly and with pleasure by main commenters when you have reappeared, and I set great store by that. However, this characterisation of a hilzoy position rings very false to me, she was always rational and measured, could always back up her view in a clear and logical way (whether you agreed with her or not - that is a separate issue), and I would bet good money that she never had an opinion for anything even resembling such an inane reason (if you can even all it a reason). This sounds like you had a difference of opinion due to ideology, and retrospectively have a need to rubbish her point of view.

[Davebo]

"When I noticed the very active and aggressive sapient refused to visit Jacobin I realized that this is not a comfortable environment for me."

Well you can always find cool comfort at ZeroHedge.

[Marty]

"How about publically expanding the number of doctors and nurses? How about single payer? How about telling all those thousands of health insurance clerks, claims adjusters, salespeople, underwriters, actuaries, and hugely overpaid executives to go out and f*cking get "real" jobs?"

Well, I have no problem with some of this, except that your assumption that the government bureaucracy would be some how magically cheaper. It is a silly premise. We cant even reduce the size of a single executive agency without the world coming to and end.

But that addresses insurance costs, not health CARE costs.

[liberal japonicus]

I want to be careful how I phrase this, my last attempt at praise was taken as a backhanded insult, but I hope Bob McManus isn't offended when I point out that he represents part of the spectrum we don't get over here very much and (as a woolly headed liberal committed to diversity), I'm always happy to see him, even if he is rarely, if ever, in the majority. He is incredibly well read and brings a lot to the table. However, with that view (which I hesitate to label) he's not going to be all sweetness and light. While it would be great if everyone were comfortable here, I'm not sure what we could do to make Bob more comfortable here and I suspect that if we did, he might be even less willing to visit.

[Girl from the North Country]

Understood, lj, to the extent that some of that is meant for me.

Now, a sane Republican view on the Healthcare situation. What say you, Marty?

https://www.theatlantic.com/politics/archive/2017/03/the-republican-waterloo/520833/

[wj]

D's aren't going to change the ACA, they are going to protect it to the death, claiming victory.

Somehow every Democrat I know is quite willing to say that the ACA has flaws which should be addressed. (Admittedly they also note that this has been true of virtually every other piece of major legislation.)

Do you know of cases where a Republican in Congress has proposed something that is a fix, rather than a straight repeal? Because I seem to have missed it. And if so, what was the response -- refusal to even consider it, or agreement (perhaps with the caveat that there was no chance of getting it passed), or disagreement with the specifics?

A blanket statement that the Democrats won't consider any changes neds some support.

[Marty]

There is nothing sane about David Frum. In the article he calls us a wealthy Democracy. In a wealthy democracy 1/5 of it's people wouldn't require free health care because they are too poor to pay for it. 1/7th of its citizens wouldn't be on food assistance, and just at 40% of its work force wouldn't be unable to find work.

Fundamentally, I have always believed that every citizen should have Medicaid(or medicare) if they were too poor to afford it or were unable to obtain it on the open market.

But he, like so many on each side, keep pointing to Massachusetts, where Mass Health is down to one provider and is as expensive as any other state these days. MassHealth only worked because the tax load was only to support less than 5% of the population through the system. Massachusetts also passed a law in 2014 that required employers to maintain the level of insurance they currently provided unless they were going to expand coverage significantly. This was to stem the tide of employers offering higher premiums and higher deductibles to their employees as costs continued to rise. In essence they created a new tax on employers to pay for the failing system.

People keep talking about universal healthcare like it is free, but most of those 20 countries that Russell mentioned have the highest real individual tax rates in the OECD, over 60%. Those that aren't over 60% have problems with their systems, it is a continuing challenge for the UK. There is no appetite in the US for those kinds of tax rates on a broad base. And you simply cant keep pretending that the top .1% can fund it.

David Frum is simply saying that he is not a conservative. He is happy to join the ranks of social democracies and provide crappy service in government funded services to relieve the citizenry of its responsibility to be responsible for itself.

[Nombrilisme Vide]

Responsibility for one's self does not preclude collective action, particularly if collective action works better by orders of magnitude than individual action. I will note that conservative credentials are not challenged when a conservative calls for collective governmental implementation of defense policies.

[Michael Cain]

In a wealthy democracy 1/5 of it's people wouldn't require free health care because they are too poor to pay for it.

That's an interesting standard, Marty. Are there any wealthy countries, democracies or not, on the planet?

[Marty]

Well, Michael, I think not. In this case it is supposed to set us apart somehow. Yet, if the rest of the state's had expanded Medicaid, that number could be close to 1/3.

I guess I think that our economy is strong enough that, barring the ACA, that number would be much lower even if it included being poor as a criteria. But, to ensure the numbers to create a broad sense of entitlement it includes up to 1.45 (that's from memory) of poverty level income as the standard.

[russell]

"D's aren't going to change the ACA, they are going to protect it to the death, claiming victory."

my very own rep, from the deep blue heart of the blest state in the union except maybe HI, has changes he wants to see in the ACA.

if you are represented in Congress by a (R), get on the horn and tell them you're sick of the stranglehold the freedom Caucus has on their party, and that they need to start talking to some (D)'s and get busy getting stuff done.

or, you can sit around and piss and moan about obama, the greatest tyrant in American history.

your choice.

[formerly known as cleek]

Mass Health is down to one provider

are you sure?

http://www.telegram.com/news/20170301/mass-health-insurers-report-year-end-earnings

[formerly known as cleek]

People keep talking about universal healthcare like it is free, but most of those 20 countries that Russell mentioned have the highest real individual tax rates in the OECD, over 60%.

so what?

why fret about the path the money takes as it goes from individual to health care provider?

we're going to spend that money, all of us, one way or another.

[russell]

"Well, I have no problem with some of this, except that your assumption that the government bureaucracy would be some how magically cheaper."

as a simple thought experiment, compare the percentage of dollars spent on care to dollars received for Medicare vs any private insurer.

i'll also note that i've probably had fifteen different insurance plans and almost that many different insurance providers over the last 30 years of getting my coverage via employment. how efficient do you think that was?

[Girl from the North Country]

Well said NV,good point.

[russell]

"He is happy to join the ranks of social democracies and provide crappy service in government funded services to relieve the citizenry of its responsibility to be responsible for itself."

and so we come to the reason why the US will continue to blunder around like a wounded freaking moose until we keel over and die from our own obstinacy and stupidity.

having the government participate in making health care accessible to people *is precisely the citizenry being responsible for itself*.

self government in the costitutional republican form is what this country is. it's why we exist.

raising and spending public money for the general public welfare is among the very first enumerated powers listed in article 1 section 8.

there is nothing whatsoever wrong or wrong-headed with people employing public means to address basic public needs. which access to basic health care surely is.

we will not recognize or accept this, and so we will suffer like the dumbasses that we are.

best of luck to you, marty, it sounds like you're between a rock and a hard place. I'm sure it sucks.

[novakant]

OK, since I've joined ObWi more than a decade ago we've been talking about healthcare, healthcare, healthcare and I still have no idea why these crazy people scream socialism all the time and apparently want folks to die in the streets all while the US is spending gazillions more on healthcare than the UK, France or Germany. Are 50% of Americans retarded sociopaths? Get your act together for god's sake, it's getting boring ...

[sapient]

Are 50% of Americans retarded sociopaths?

I think if I answer yes, that will violate the posting rules. But you're definitely on the right track.

[russell]

Are 50% of Americans retarded sociopaths?

Relative to most of the rest of the world, the US is a fairly young nation. We're not that far from times when a lot of people lived in areas where there was minimal or no formal government, and minimal or no public infrastructure or institutions.

In some parts of the country, that distance is as small as two or three generations. There are lots of places in the US that were, at most, minimally settled as recently as the late 19th C. At least by people identifying as American.

That, among other things, feeds an ethos of self-reliance and plucky independence from what is seen as meddlesome government interference.

A lot of that ethos is based on really bad history, but it is what it is.

It's not at all remarkable for Americans to rely on public institutions while simultaneously not only disparaging them but insisting that they ought not exist in the first place.

So, not retarded sociopaths, just enchanted by a mythology that is no longer a fit for the world we actually live in now. And probably wasn't a great fit for, or even an accurate reflection of conditions in, any other time.

We think we're special. It gets in the way.

[sapient]

We think we're special. It gets in the way.

I would argue that this isn't really the problem. Every nationality has its mythologies and "specialness". We would do better to focus on the myth that we are a country founded on ideals such as openness, equality, liberty, tolerance, diversity - that we're constantly striving to embrace and achieve. Yes, it's a myth, but it urges us be humanitarian rather than self-absorbed provincial bigots.

That, among other things, feeds an ethos of self-reliance and plucky independence from what is seen as meddlesome government interference.

Of course, there is some of this throughout our history, culminating in the Civil War, and the repercussions of its aftermath. But its important to remember how sociopathic the South was, in fact. Modern conservatism is a remnant of that, certainly as much as it is the pioneer ethic.

[russell]

I would argue that this isn't really the problem.

I actually think it contributes to difficulty here.

Americans commonly think of ourselves as the greatest country on earth, perhaps the greatest country in history. Not just in a "Yay for our team" sense, but as a serious proposition.

Every country affirms its unique history and qualities, I'm not sure every country on earth insists, as a given, that it is superior to every other country on the planet.

And I think it does get in the way. We're unable to see ourselves accurately because we can't allow for the idea that we might not, in fact, be #1 in every way.

That's my take on it.

[wj]

I would argue that we are not even unique in thinking that we are superior to every other country on the planet. The folks in a lot of countries see things that way.

But you're right, Russell, our handicap (and it is a handicap) is that "we can't allow for the idea that we might not, in fact, be #1 in every way." [emphasis added] Which necessarily makes it difficult to impossible to accept that it might be possible to borrow a good idea that someone else came up with. Not Invented Here, taken to a national cultural level. (I was going to add "pathological", except that NIH is pathological anywhere it occurs.)

[Girl from the North Country]

russell, I think this is exactly right, and what the rest of the world (on the whole) understands the American attitude to be. And, again on the whole, this self-image is regarded, I would say, with varying degrees of amusement, contempt or pity, depending on who is doing the regarding.

[Girl from the North Country]

And regarded in that manner, contra wj, not because the other countries see themselves that way, but because it is really a pretty absurd idea. Which is not to denigrate the wonderful things about America, and particularly the wonderful thing about its aspirations (in the idealistic sense) for itself.

[byomtov]

And I think it does get in the way. We're unable to see ourselves accurately because we can't allow for the idea that we might not, in fact, be #1 in every way.

That's my take on it.

Good point.

Isn't this exactly what keeps us from saying,

"Some of these other countries seem to have health care systems that work better than ours. Maybe we could take a lesson."

[sapient]

Every country affirms its unique history and qualities, I'm not sure every country on earth insists, as a given, that it is superior to every other country on the planet.

I think that people need mythology in order to aspire to greatness. The Enlightenment had its problems, but we were founded on Enlightenment principles which create infinite possibilities for progress.

We're unable to see ourselves accurately because we can't allow for the idea that we might not, in fact, be #1 in every way.

Principles of diversity and tolerance allow us to embrace other people's cultures and ideas. Our country's political system is as good as the collective will of the people. Unfortunately, the collective will of the people has failed the promise of our system time and again. We continue the struggle.

Our being "the greatest country on earth" is not a fact, but is a possibility because of the citizens' ability to make it so. We can't assume it; we have to work for it. The fact that so many of us are so cynical about the possibilities that our government provides is why so many of us gave up on it, and gave it to an oligarch buffoon. We didn't value it, and we let it be stolen.

[sapient]

Isn't this exactly what keeps us from saying,

"Some of these other countries seem to have health care systems that work better than ours. Maybe we could take a lesson."

novakant talked about 50% being sociopathic. That's actually the problem. Many of us see the fact that we can "take a lesson" as part of the "specialness" that we are.

[liberal japonicus]

In addition to the things that Russell mentions, for most other nations, healthcare was part of a bargain that was agreed upon after WW2. For the US, we didn't think we needed it. In addition, we are a country that has elevated doctors to a point where we aren't supposed to question their decisions. Thus, you have Marty's toxic creed of individual responsibility driving an industry that wants to maximize profits regardless of the overall impact on society. For me, it's the American attitude to health care which is really the final straw. That inability to think of your fellow citizen while loudly proclaiming what a wonderful country embarrasses me to no end.

[russell]

I think that people need mythology in order to aspire to greatness.

I don't disagree with this, necessarily - it's good to have an ideal - an aspirational goal - as a motivating image.

When your aspirational goal gets in the way of acknowledging where you are actually at, as a concrete reality, then I think it becomes dysfunctional.

Our being "the greatest country on earth" is not a fact, but is a possibility because of the citizens' ability to make it so.

I don't think it's necessary to have goals like being "the greatest country on earth" in order for us to be our best.

"Being our best" is a sufficient goal.

I would even argue that the burden of the whole "we're number 1" thing is part of what makes people cynical.

If the bar is that you must be better than everyone else, at everything, all the time, you are setting yourself up for disappointment, frustration, and resentment.

QED.

We're not "number 1", and that's fine, because nobody is "number 1". We should strive to be the best that we can be. That will be more than sufficient.

At our best, we're quite good. That's enough.

[russell]

Isn't this exactly what keeps us from saying,

"Some of these other countries seem to have health care systems that work better than ours. Maybe we could take a lesson."

Yes. Among other things.

[sapient]

We're not "number 1", and that's fine, because nobody is "number 1"

That's fair, but some people are motivated by competition. If "doing our best" means that our healthcare outcomes suck compared to countries doing it better, we need to try harder. IMO.

[Girl from the North Country]

Despite my contradiction of wj earlier, by the way, I didn't mean to downplay the undeniable truth that for a large portion of the 18th, particularly the 19th and then part of the 20th century the English or British definitely saw themselves as civilizers of the rest of the world (and particularly "the colonies"), infinitely superior in every way to almost everyone. "To be born an Englishman is to win first prize in the lottery of life" etc etc. And our mythology sees us as the plucky little island (I am using the actual language) that stood alone against the Germans in WW2 until the Americans were ready to come in, thereby saving civilisation etc etc. This part is still felt fairly strongly I would say by a substantial minority of the population. It's very hard to be clear eyed about these national mythologies, they have an undeniable emotional pull.

[formerly known as cleek]

Unfortunately, the collective will of the people has failed the promise of our system time and again

the founders, and everyone watching, knew this was a risk.

[sapient]

the founders, and everyone watching, knew this was a risk.

And yet we persisted.