There’s very few mainstream pundits who rise above the din of the Beltway idiocracy. For me, the list was Paul Krugman, Tom Edsall, and Ron Brownstein. Now it includes Ezra Klein:
If Americans felt the full burden of health-care costs, they’d likely be clamoring for all these policies, and maybe more. They’d want transformational change. But they don’t feel those costs, and so they’re resistant to change. Obama continually promises that most Americans will notice no changes in their existing coverage, and all the bills reflect that vow. So what’s left? How do you reform a system you cannot change?
You ask the wonks. People often complain about the length of bills. But you don’t need many pages to explain a public plan, or set up a death panel (kidding!). Rather, the bulk of these bills amount to hundreds of small tweaks and fixes that make this corner of the health-care system a smidge more user-friendly, or that transaction a tad faster. Rather than saving hundreds of billions of dollars with a single dramatic intervention that transforms the system, they provide for the accretion of modest savings and small efficiencies.
For instance, despite all the fire over the co-op plan, it gets two pages in the Finance Committee’s bill. Pages 75 to 110 are all devoted to delivery system changes that are meant to make the system a bit more efficient but that no one has ever heard of. “Value-based purchasing” alone gets six pages in the bill. The “National Pilot Program on Payment Bundling” gets another five.
Melinda Beeuwkes Buntin, a researcher at the Rand Corporation, and David Cutler, a health economist at Harvard, recently estimated the savings that could be attained by “modernizing” the system over the next 10 years. The changes they examined weren’t dramatic. Replacing paper records with computerized files, making it easier for people to comparison-shop across insurers, “bundling” payments for the treatment of a single illness rather than shelling out separately for each doctor visit — that sort of thing. Added up, they equaled a startling $2 trillion over 10 years. That’s a lot of money for policies that have received virtually no attention in the debate.
The whole piece is great. I don’t know whether I’m happy to see something good like this or sad that 99% of what appears in opinion pages on this topic is such bullshit.
Cris
Kind of cool that a guy who started out as a Pandagon blogger can honestly be called a mainstream pundit.
burnspbesq
I don’t think those are mutually exclusive. And both seem entirely reasonable.
General Winfield Stuck
Ezra has been at the top of my list for a while now, especially on policy wonk-fu, ie healthcare.
John Harwood I would add. When he fills in as anchor like the other day on MSNBC, he then makes me laugh he is so bad at it. Kind of a two-fer star. Serious punditry and comedian too.
DougJ
John Harwood I would add.
Yeah, you’re right.
calipygian
Be sad that 99% is bullshit, because but for the vapidity/stupidity/evil of people at WaPo, WSJ, NYT, etc. it just doesn’t have to be so.
Dulcie
The Black Flag song title rocks, Doug J. That is all.
arguingwithsignposts
Rise Above
SenyorDave
My brother is a doctor, and is one of the senior partners in a very large practice in the Northeast. he is extremely well-versed in medical billing and records. In his opinion, medical costs could be cut at least 5% with a few fairly simple changes to the systems.
Lola
I really trust Ezra on health care. He actually reads the bills!! Lately some lefty bloggers have been trashing Ezra because he is not focused on the public option. Ezra kind of opened my eyes about the subject. A public option would be nice, but it is not the focal point of reform. Reading Ezra has made me smarter.
Martin
Now you know why WaPo gave him the gig.
drillfork
I don’t know. To me, this far more clearly illustrates the true cost of the current system…
http://www.huffingtonpost.com/john-geyman/a-death-every-12-minutes_b_291498.html
Xenos
Public option can always be stage two. If they do the rest of the reforms right profits will be reduced to the point that the truly connected and powerful will get out of the business of health insurance.
cmon
Trillions. Yeah, right. Like these monopolists are going to pass their savings on to the insured. All this chickenshit serves only to divert attention from the sole meaningful insurance reform, antitrust. The good news is, Conyers and Leahy have introduced a bill subject the industry to antitrust laws they’ve been exempted from. If we don’t get competition from a public plan, Federal antitrust jurisdiction would at least let DoJ dismantle the industry and start again.
Montysano
@Lola:
More than that, it is what a clear majority of Americans want, as well as a supermajority of doctors. They/we/I want that option. I appreciate Ezra’s wonkery, but the bigger picture is, for me anyway, extremely depressing. I’ve long suspected that the USA is 75% owned and operated by corporations, but that the remaining 25% might provide enough margin for some progressives to effect some change. If the Baucus bill tells me anything, it’s that we will be given exactly what the corporations are willing to let us have, not another whit more, and that what We The People actually want is completely irrelevant.
The teabaggers, they who were defeated in November, along with a complicit media, have provided the needed cover, ginning up the impression that there is a nationwide groundswell of righteous anger.
I know….. the bill isn’t in it’s final form. I could very well be proven wrong. In fact, I would be overjoyed to be proven wrong.
Martin
The problem with the fed antitrust move is that it’ll fuck up the smaller state-level non-profits to the advantage of the big for-profits. Expect governors to push back strong on this.
If you want Cigna et al to come out on top, the anti-trust move is one way to do it. Accompanying the antitrust effort needs to be a shift of insurance regulation to the feds. Much of the monopoly cause lies on having 50 different regulators requiring compliance with 50 different sets of laws.
Sleeper
I have to disagree with the notion, pushed pretty consistently by Mr. Klein, that a public option is nice but not that important. To me that just makes of Blue Dog Third Way selling out. There’s a reason that the health insurance industry is fighting like hell against a PO and giving way on these other piecemeal reforms. To me, the harder they fight to kill the public option, the more indispensible it’s shown to be.
It’s going to be hard enough to get the PO through (if that’s even still possible) without people who claim to be on the left like Ezra Klein, once again bowing and scraping before the altar of the free market and tripping over themselves to belittle true, state-based reform.
/rant
Montysano
@Martin:
How so?
Comrade Jake
Klein’s been must-read these days.
For example, did you know that the Baucus bill provides two different means for people to purchase insurance across state lines? Nobody’s talking about that. Nobody.
Well, nobody except for Ezra.
Xenos
@Comrade Jake: If people can buy insurance across state lines it will be the biggest violation of federalism since… I can’t even think of when. You would open the door to federal regulation of health insurance, and federal preemption of a lot of state control of insurance.
Hmmm…. now I think on it a bit, maybe it is not such a bad idea. Once the Barack Obama’s people are finished establishing the new regulatory regime for the whole country, introducing a public option may be a simple matter.
Sure is nice of these Republicans to facilitate such a large power grab.
cleek
does this article go back in time and publish itself in March? cause that might be useful.
otherwise, the debate he thinks he’s having has been over for a while: the public lost.
Bill E Pilgrim
If our public discourse were even partially devoted to actually describing facts, were actually committed to investigating, reporting, and analyzing policy itself, then lots of things would be different.
As it is, our obsession with “inside baseball” political gossip and analysis that’s almost entirely devoted to a view from the direction of politicians outward, i.e., “how can Hillary convince people that she’s..” and “what does McCain have to do now to win over the…” and “What should Obama do to show that he…” keeps even the educated among us obsessed with anything but actual policy.
It also creates a vacuum so that people with far less time or interest in these things are easy marks for charlatans like Glenn Beck. Some of those videos from the tea bagger protests showed people saying over and over things like “Well, I’d really like to know what all these “Czars” are doing there!” when answers to things like that are freely available.
(Answer: there are no “Czars” in the White House, it’s a media term and has been for decades. The “Czar” fad wasn’t started by Reagan, as people keep saying, it was started by reporters who were too lazy to pronounce “adviser for economic development for public policy on etc etc etc”.)
The problem goes deep however, left and right. The entire conversation is focused on the wrong things.
Martin
@Montysano:
I have a close relative who is a C-level at one of those state non-profits, so I’ve got a few angles on this.
Every state has a mountain of laws around what can/can’t be covered, etc. Each insurer that writes policies in that state needs to comply with those laws. That requires the actuaries to go through the policy for each state, that requires the underwriters to go though the policy for each state, it requires new agreements with hospitals, doctors, pharmacies in each state.
All of those things cost money up front (it’s basically a fixed cost relative to the size of the market) and one of the benefits of those local monopolies is that they’ve got everything dialed in for their state and have all of those agreements in place. Now, consider a small state like North Dakota. There’s no more than 650K people there, but entering that market requires a similar amount of cost and effort as entering a market like Florida. It’s less, but it’s still significant. Not many companies want to enter such a small market when they have to invest so much to get in there, and they have to compete against a company that essentially owns the place. The company that *does* own the place has no investment in other markets – all they know is North Dakota, so they need to dump a bunch of money to risk getting into the next market – say South Dakota, and somebody already owns that place.
Now, the national for-profits already sell policies into every market. They’ve already made that investment. They already have agreements in every market as well. The for-profits like Cigna are already there and they’re basically being given a mandate to push down the existing local non-profit monopoly. The little guys, however, have to take big risks and dump in money in order to expand their markets – and that’s hard for a non-profit to do. And this is all a byproduct of state-level regulation. Eliminate that, and the local monopolies would probably unravel a fair bit of their own resolve. Some will stay behind because of the cost of setting up agreements (the same effect which causes all manner of other local monopolies) but companies could more naturally move across state lines and enter new markets.
Larger markets like CA, NY, FL, TX already have a fair bit of competition simply due to their size.
RareSanity
@Martin:
Damn that was interesting.
This is why I must read the blog and comments everyday.
P.S.
Are those formatting buttons I see?
John Cole, you sly dog…you almost slid those right by me. Thank you sir!
gizmo
Ezra’s point reminds me that even though most progressives are frustrated with Obama and doubtful that he is on the right track, it’s possible that each day there are small transformations in Washington which have a cumulative weight that we won’t appreciate until some more time has passed. I was hoping for some bold strokes from Obama, but I’m open to the argument that a whole lot of incremental change might get the job done. After, the tortoise beat the hare….
Lola
Ah, I see Ezra Klein is being trashed as a “Third Way” guy here, too. I am not sure where Ezra Klein is on the liberal spectrum, but he seems to base his opinions on actual knowledge. It seems to me that the PO has turned into a way to prove that Obama is liberal or not liberal enough, more than anything.
I was fighting really hard for the PO months ago but then I realized that it would be closed to most Americans (and me) and estimates are that less than 5% of the population would be enrolled in it in 10 years. It kind of puts the whole thing in perspective. The PO is already super watered down and won’t be negotiating drug prices or paying Medicare rates. And, yes, it is sad that this weak-ass PO may not be able to get 60 cloture votes in the Senate.
biblehumper
I agree with Montysano. It’s nice that Klein actually takes the time to, you know, actually read the bills, unlike most other MSM pundits, so when I read him I do legitimately learn something (often, many things). But there’s a reason why WaPo hired him and not, say, Greenwald or Marshall or Hilzoy or Eric Martin of ObWi. Klein does have a high tolerance for Third Way-type politics. I appreciate what he does, but it saddens me that he is as about as liberal a MSM voice that the Villagers will allow into their special little club.
On this healthcare issue, the people have spoken. They want a public option. Klein can show us how the “reform” we get is better than nothing at all, but it doesn’t change the fact that the people we elected are giving us a big “fuck you”, nor the fact that there’s virtually no one in the MSM standing up for us and calling these asshole politicians out.
Jim
I confess a lot of this is bewildering to me, but I don’t see how, without a public option, this bill does not turn into a giant subsidy for the insurance industry.
RareSanity
@Lola:
I just can’t understand why the Dems don’t just say that for the 5% of Americans that could possibly fall through the cracks, we will just allow them to buy into Medicare or Medicaid.
Preferably Medicaid, so the “they’re trying to take benefits from seniors” chorus won’t start.
trollhattan
Klein is definitely a useful fellow. I’d be happy with him just for keeping McMegan wearing Pull-Ups under her Abercrombie night shirts, but he’s actually even more useful than that.
Wolverines!
Bill E Pilgrim
Funny, I don’t see, reading Ezra Klein’s piece, that he’s somehow “against” a public option or pushing for it to be dropped entirely, as others seem to see him. This passage:
Sounds pretty clear-eyed to me.
He then goes on to conclude with this:
I suppose that last phrase could be seen as surrendering in some way or pushing a centrist “third-way” agenda, but it could seen lots of others ways too.
Personally I’d be mortified if after putting itself through near civil war about it, the best the country could do was make things “a bit better” and more agile and etc. However it sounds like he’s reporting that this might be the case, rather than advocating for it explicitly.
Bill E Pilgrim
Arg. Third graf is Ezra, not me.
Banging head on desk. I WILL remember how Balloon Juce blockqoutes work, I WILL remember….
pseudonymous in nc
I’ve criticised Ezra for not seeing the forest for the trees in the current debate, but ever since he decided to concentrate on healthcare, he’s always done his homework; plus, he’s been honest about his focus since the election, which is about the kind of healthcare bill that’s possible to get past a corrupt and bought-off Senate in a political climate dominated by rich lobbying interests.
He’s right that the public option isn’t going to be strong enough, even in a better incarnation. But he misses the basic principle that the insurance corporations have repeatedly failed the population, and they have to face something, however watered down, to keep them a little more honest. They can bend and bribe their way out of regulation, or pay the fines as the cost of doing bidness, but they hate the idea of people being given a taste of the forbidden fruit.
And cleek’s right that it would have been nice to hear a little bit about raw numbers earlier on.
Jim Once
@Jim: Word
Montysano
@Lola:
Or….. in 5 years, the public option would become hugely popular, and hence would be opened to more people.
I get that politics is about compromise, that we rarely get a “home run” in legislation. What bothers me is what/who we’re compromising with. We’re not up against technical issues. We’re not up against budget. The whole discussion is about what corporations are will to give up, and the answer is: not very much.
General Winfield Stuck
@Comrade Jake:
There are over 500 proposed amendments for votes during mark up for the Baucus bill. Some to add stuff to it, and many to strip stuff out of it. What comes out will likely not much resemble what went in.
Martin
Well, the states have created this problem and they aren’t eager to fix it. There’s little real benefit to the public for having such vast differences in health insurance laws from state to state, when the outcome is so similar. Sure, some states will have more open laws for same-sex couples, others more closed laws for abortion, etc. but 95% of the laws are geared to produce precisely the same outcome.
The states like having their control here. The local monopolies are appealing because they guarantee jobs. Anyone serving the state of Nebraska alone is going to have their offices in Nebraska and employing Nebraskans. Who the hell knows what city a national insurer will set up in. Further, as the costs of health care go up, those laws have more and more impact on the local economy. If your state has laws which mandate more coverage, that increases the cost to companies doing business in your state. Some states don’t care about that too much – NY, CA, etc. and tend to have more consumer-friendly laws but others certainly do and have more corporate-friendly laws (or more culturally friendly laws).
Taking that power away from states will be a hard fight.
Bill E Pilgrim
@Lola:
Plus, that is SO depressingly the right wing MO, to turn something into something so watered down and useless and then use that to convince people to vote against it.
They gave away the farm at the start by shelving true single-payer health care entirely, even as a bargaining starting point, and that’s the truth. It’s like going into a Moroccan market and negotiating by offering what the person wanted to begin with. Not a strong starting point.
Martin
BTW, Ezra is pro-public option. His stance is that public option isn’t the make-or-break success of reform – other things are. Public option helps, but that same reform success can be achieved in other ways and he’s trying to make that point by talking about reform in the absence of the public option.
Progressives are losing sight of the myriad of important things that needs to be in that reform package by focusing almost exclusively on the public option.
Sleeper
@Lola:
I agree that this PO is pretty weak tea. But like Social Security, which was pretty restricted early on, a tepid PO can later be expanded. Getting it up and running, even for a small number of Americans, is the crucial first step. It’s a lot easier to go from 1 to 2, or 2 to 3, than it is to go from zero to 1.
I just think that Klein’s dismissive attitude towards it shows his desire to suck up to the Obama White House and the purveyors of “CW” that pass for Our Liberal Media. This has been the Obama approach all along, and it’s maddeningly ineffective and stupid: being reasonable and conciliatory with people who don’t return the favor. Why be reasonable with these pricks? Why offer to give anything up right off the bat? Why come right out and tell people that you’d like certain things but you can live without them? On what points have Republicans offered compromise? Why can’t our side ever play hardball?
There’s just no message discipline on our side. Zero. Too many politicians afraid of their own shadow to stand up for leftist values, no matter how easily they support them during campaigns, and too many young pundits looking to become respectable members of the establishment. It’s goddamned frustrating.
Martin
Actually, that’s unlikely to happen. Corporations don’t roll over so easily. They’ll slash profits, streamline, do anything they need to stay in business (which is the point of having a public option) and they’ll almost certainly move faster than Congress to respond to the marketplace. In the end, the existing slate of insurers will probably do just fine (other than their profit margins) and have more policies than they do now, but the public option will keep everyone more honest than they are now.
General Winfield Stuck
@Martin:
I’m not sure that is true. Some of the stuff, like covering more people who can”t get insurance now for various reasons like pre-existing conditions can be accomplished in other ways. But providing direct competition that is difficult for the powerful Insurance industry to corrupt can only be done with a government run PO, I think. And without the cost lowering effect of genuine competition, the industry can play all sorts of games to suck more and more taxpayer subsidies into their coffers.
Anything can be corrupted by people with cash clout, even a PO, but it would be much more difficult being inside the federal government.
Sleeper
@Martin:
I think in this atmosphere, Democrats are only going to get what they insist upon. So to say that the public option isn’t necessary means, in my opinion, that you’re against it. Same as Obama seems to be. Given the opposition we face, a feeble advocacy for something is practically no different than a denunciation of it.
The reason liberals and progressives are fixating on the public option is that the health insurance industry is spending over a million dollars a day to kill it. That more than anything else tells me how essential even a weak PO is to make true reform possible.
DougL (frmrly: Conservatively Liberal)
IMO, Republican politicians have two reasons to sabotage this legislation:
The first is that it is essential that they sabotage the bill to the point that it is such an abortion that it will easily go down in flames. Then they can go home and tell their constituents that they saved the day, making everyone either happy (repubs) or pissed (the dems). Win-win if they can get it.
The second is that they can’t allow a good bill to come out because if it really is that good then some of their constituents opinions may be swayed, putting the pols in a bad position if it looks like the bill may pass. If this is the case I think it would be possible to peel off a few Repub votes, even if they all now say they are going to vote against it.
Just some musing…
Martin
No, Ezra is saying that other things are more important and nobody is talking about them at all, let alone insisting on them.
If Democrats aren’t careful, all they’ll get is a public option, and the reform will fail. Public option isn’t enough – it’s not a substitute for single-payer in the sense that it’ll reform all of the other things that need reform.
Sleeper
@Martin:
Why talk about things that the Republicans aren’t pushing back on? They know that some kind of bill is going to pass, and they’re willing to live with certain things, so they’re not really bothering to try and gut them. Minor adjustments don’t truly concern them, so long as the solutions are market-based and market-biased. But the PO is different, it’s a real challenge to their free market fundamentalism, weak as it may be. And more importantly, it’s a regulation that private insurers can’t get around. As I said, if the private sector thought that these other reforms could seriously cut into their profit margin, they’d be screaming bloody murder about them as well.
If we can rally the support and political will necessary to get the PO, then the other reforms that no one is mentioning will be ushered in as well. Better to expend our energies fighting the enemy where they are than to reinforce the part of the wall they’re not attacking.
J. Michael Neal
And this is where Klein (and I) completely part ways with you. You seem to see defeating the health insurance companies as the ultimate goal, and so, by definition, anything that they are fighting against is essential to a good bill.
The rest of us think that producing a better health care system is the ultimate goal. If that means defeating the insurance companies across the board, so be it. However, if it is possible to create a better health care system without defeating them, then that’s a good bill. It may not be the best conceivable bill, but it might be the best possible bill. In that case, pouring gasoline on ourselves and lighting a match is idiotic. Take the bill.
It’s so maddeningly ineffective and stupid that the centrist alternative, which is the minimum that we are likely to get, will produce a more thorough overhaul of the health care system than any we’ve seen in at least 40 years, and possibly a lot longer than that.
Steve LaBonne
It’s NOT possible. There’s a reason why no civilized country allows for-profit insurance for basic health coverage (though some do for top-up policies).
jibeaux
No one has yet mentioned the fact that he’s only 25, and also a complete hottie. Nah, he’s a must-read for me, I am sure that many find him less than purebred, but I really appreciate the sheer wonkery. (And at least one of the reasons Greenwald is never going to run in the WaPo is that there is probably a ten million word limit on columns.)
biblehumper
J. Michael Neal,
We’re not yet at the point where there is a single bill ready for a vote. We’re still only in the drafting phase, figuring out what the final bill should contain. This is why it’s so depressing to see certain Dems giving up on the public option. Klein can emphasize all these other positives later on. Your “centrist alternative” is merely lowering the “minimum that we are likely to get”.
Martin
The Republicans in Congress most definitely *are* pushing back on them, but everyone’s attention is so focused on the public option that they aren’t noticing.
Baucus’ plan has no public option and even the moderate Republicans won’t vote for it. Clearly that’s not the make-or-break element for them either. And the serious criticism of the Baucus plan from the left hasn’t really been centered on the public option at all, but on how mandates, subsidies, and the like would be handled.
J. Michael Neal
@Bill E Pilgrim:
Maybe. The problem with counter-factuals, though, is that you have to make a bunch of assumptions about what Would have happened that you can’t test. Here’s an alternative one, for which the assumptions are at least as tight as yours:
Obama proposes a single-payer system out of the gate. Seeing that, *all* of the vested interests line up against it. None of them are bought off. The health insurance companies are against the entire proposal, rather than offering at least neutrality against much of it. The doctors’ lobby is dead set against it, since it means less pay for them. The AARP doesn’t really see much upside for its constituency, and so stays mostly out of the fight. Pharma and medical device makers see their profits going away, and are adamantly opposed.
It turns into June, with none of these people in Obama’s corner. The Republicans, unanimously opposed start screaming socialism, and no one starts laughing at them, because it’s a more plausible argument. The majority of Americans, who, if you haven’t noticed, want to keep the insurance they have right now, buy into this argument wholesale, because single payer really would mean that they have to give up what they have.
With no support to be found anywhere, the whole bill sinks into the depths, never to be seen again.
Am I sure that that’s what would have happened? No, I’m not. However, I consider it a very real possibility of how things would have gone if Obama had done what you accuse him of being a sell out for not doing. With that as a plausible outcome, I think that playing it the way that he has is certainly a defensible approach, and deserves much less scorn and vitriol than you and the other righteous crusaders are throwing at him.
J. Michael Neal
This is a clueless answer. Producing a better health care system than we have now depends not in the slightest on what any other country has done. It depends upon just how fucked up you think our current system is. There is a huge gap between “as good as we have now” and “as good as any European country has now.” Any bill that pushes away from the former and towards the latter is better than the status quo, even if it falls short of what anyone else has accomplished.
Sleeper
@J. Michael Neal:
Pretty much. I’m for single-payer and the dissolution of private health insurance. So, yes, I think their defeat is of paramount importance.
I’m afraid I reject that premise on its face. The health care system here is so corrupt and so rigged in private insurance’s favor that there is no win-win possible. Either they endure a lower profit margin, or we endure either a continued lack of coverage or mandatory admission to a private insurance market with no cost controls. If you want to call me an ideologue because of that opinion, that’s a fair charge and I probably couldn’t dispute it. But I think we’re at a point where we have to play chicken with these companies. They’ll blink, if they think that we won’t.
(Now, do I really think our politicians, even the reliably liberal ones, have the political will to try that? No, not really.)
uh. More thorough even than Medicare? Sorry, not buying that one…
jibeaux
@Sleeper:
Medicare began in ’66, i.e. >40 years ago.
Sleeper
@Martin:
In fairness you are right, I should have said the Blue Dogs, not the Republicans. Finance Committee aside, the Republicans aren’t really a factor in this debate, as they won’t be voting for it anyway.
The make-or-break element is the (D) after the names of the authors of each of these bills. The Republicans are not negotiating here. Their offer is already on the table: nothing. The moderates are playing a game of seeing how much they can get the Blue Dogs in Congress and in the White House to strip out of the bill before they hit their make-or-break point. The GOP leadership tolerates that because it serves their purpose of watering down the bill, one they’re not going to support anyway. The Republicans should just be ignored. I know Obama wants Olympia Snowe to say nice things about him, but the people that voted for him could care less about that.
Sleeper
@jibeaux:
Was there some massive health care development in 1969 that eclipsed the creation of Medicare, then? Because that’s what I assumed was being discussed here. I figured “40 years” was just a rounding off.
Calouste
@arguingwithsignposts:
Black Flag for some pundits, Rollins Band for most others.
J. Michael Neal
@Sleeper: Do you just not know the meaning of “at least”?
J. Michael Neal
That’s nice. I have pre-existing conditions, and think that there most definitely is the possibility of a bill that improves us on the status quo without getting everything.
Sleeper
@J. Michael Neal:
So do I. I don’t really feel like playing “My pre-existing conditions are worse than yours are,” though.
So do I. I also think there’s a possibility of a bill that gives us the least, feeblest improvement possible, and I think we can do better than that. Klein and a lot of other centrists think we should just settle for the least we can get, I think we need to force the issue and get more. The Republicans want no bill, and they’ll accept some kind of reform – but they don’t say that out loud. Why can’t we learn from their political example? Demand a moderate amount of reform and you’ll be lucky to get half of that. If the Dems had made a serious play for single-payer, we’d be debating that right now. The Republicans would be the ones talking up a public option. (Well, they’d let Snowe do it for them, anyway.)
The progressive caucus is playing this the right way. Don’t give an inch, make threats and back them up, and maximize your gains. A lot of them would probably satisfied with just getting the reforms agreed upon so far, but they think they can get more. So they’re playing hardball and making demands. There’s an element of danger in this kind of brinksmanship, but it’s the only way we’re going to see real change here. We need more of them and fewer Reids, Baucuses, and Liebermans, thank you.
Jennifer
A few thoughts: any reform which doesn’t create something the insurers can’t lobby their way around to their advantage is not a really a reform. They’ll just keep chipping away at all the parts other than “everyone is required to buy.” That’s the importance of public option.
Second, I think there is some misinterpretation about how restricted access to public option would be. The president said “5%” and indicated the unemployed, the self-employed and the like, but given that 1/3 of the work force changes jobs in any given 2-year period, that’s an obviously very flexible pool. I’m unclear on whether you would be BARRED from buying into public option if you worked for someone who offers insurance benefits, or if it’s just an assumption that most in that situation would choose to go with employer-provided insurance because the cost of the premium is subsidized by the employer. Ezra, having read this stuff, would surely know.
But in terms of his prediction on how many the public option would serve 10 years from now, he’s probably pretty close to on target. Some 40 – 50% of people would be covered under a plan through an employer or an individual plan costing no more than 10% more than the public option. Any bigger spread in pricing than that for comparable benefits would dampen most people’s enthusiasm for going with a private insurer. Another 5 – 12% will end up with public option coverage – 5% being the low end looking at only the unemployed and self-employed; the upper range if those working for small businesses not required to offer coverage go en masse for public option. Roughly 45% will continue under Medicare, Medicaid, and VA, and probably there are some 3 or 4% who will be the hard-core uninsured…the homeless and the recalcitrant. A few tweaks here and there as time goes by to expand access to public option, and you could easily force the private insurers into keeping their coverage priced no more than 8 – 10% more than the public option.
Last, something most of us who prefer single payer fail to take into account is this: healthcare represents 20% of the economy, and while I’m not sure exactly how many people are employed in healthcare administration, just judging from classified ads I’d be comfortable in assuming that 5 people out of every 300 are employed in pushing the mounds of paper underlying our current system. That translates into something like 1% of the workforce. An abrupt transition to a single payer system, whenever undertaken, could be expected to raise unemployment by .5 – .75% – pretty much unthinkable in our current employment climate.
Martin
I don’t agree with that. I think we’ve just fallen so far from seeing how regulation can work well that we can’t imagine it working right any longer.
There’s a decent article in this month’s Atlantic talking about how California’s energy regulation has turned the private utilities into reasonably good citizens. And it’s happening in a market full of localized monopolies as well. There are several lessons in there, but bottom line is the state has managed to create a system whereby the less energy per capita the utility turns out, the more money they earn.
There’s nothing stopping a similar system from being created that would work for health insurance – incentivize the insurers to make money based on positive metrics. It’s more complicated than a utility setup, and this would represent a *massive* change in how we do business, but there’s no reason why it can’t be done this way.
Now, I don’t think it’s possible to get this kind of sweeping legislation through, but it could be done this way. Unfortunately, the industry and the GOP have poisoned the well – and created an environment where it’s probably easier to kill them off than get them in line. We’ll see what happens.
But a public option isn’t a panacea. There are plenty of markets with public competition where the competition alone isn’t enough to influence the market much. If the pre-existing condition isn’t banned from private insurers, they’ll just dump any moderate to high risk customers to the public option and make a killing while driving the public option costs sky-high and soaking up taxpayer dollars. The private insurers need to be forced to play by the same rules as the public option – but that’s complicated by having so many state insurance laws (that presumably the public option wouldn’t be subject to). Now you have a situation where the public option might be massively cheaper than the private options simply due to state requirements that the public option need not meet, or massively more expensive.
All of these things need to get evened out in the bill – and the mere act of evening them out will get us a long way toward the goal, whether or not that final piece falls in place. And even if that final piece doesn’t fall into place, all of those other things need to get done well, and almost nobody is bothering to talk about them. Everyone is fixated on whether the icing is good or bad, and forgetting all about the cake itself.
Martin
The industry (health services) employs about 500,000 people. There’s an additional pile of people in the health care industry (the folks that file the claims at the hospitals, etc.) but there aren’t that many jobs to reduce there since even if all they were processing was Medicare for everyone, they’d still need most of them.
That’s out of 150M workers (employed or unemployed). It’s a bit of a dent in the unemployment stats, but not enough for Obama to be worried about it. After all, that would take years to transition. The bigger problem is that those jobs aren’t evenly distributed. They represent major chunks of the job market in the midwest – places like Nebraska, Iowa, and so on, which is why senators from those places are particularly shy about the reform bill.
Sly
The value of a large PO exists in its capacity to limit prices and harmful practices. You can do both without a PO, but there’s only one real alternative.
The Netherlands, for instance, has a national risk pool without a public insurance option. They do, however, have hard caps on what companies can charge in terms of premiums, outlaw deductibles and co-pays, as well as prohibit refusing to cover someone seeking (compulsory) insurance due to pre-existing conditions and a minimum as to what insurers must cover. What we are seeking to do through a competitive PO, the Dutch have done with regulation.
Despite all this egregious intervention in the free market, health insurance in the Netherlands is highly competitive (as it is in France, which has a similar system with a PO). You don’t see, for instance, one insurer providing coverage for 75% of people in the Rotterdam metro areas.
But WellPoint covers 75% of the insured in and around Cincinnati, and this is ultimately the problem with limited-access cooperatives. They simply won’t have the bargaining power to put any sort of dent in that level of market concentration. It’s setting up a non-profit competitor without the ability to compete.
As for this:
Its likely less, and the fewer people a company has managing policy claims provides a bigger bottleneck for people getting reimbursed. This is on top of the fact that insurance is not a labor intensive operation, no matter what precisely is being insured. Louisiana has a population of 4.5 million (80% of which have insurance) yet the states largest insurer, BCBS LA, only employs 1,600 people. So those 1,600 employees process the paperwork for 2.1 million people (80% insured, of which 60% are insured through BCBS LA). And BCBS LA is for-profit.
SenyorDave
The Republicans should just be ignored. I know Obama wants Olympia Snowe to say nice things about him, but the people that voted for him could care less about that.
Sleeper,
Bulls-eye! The Republicans have to be ignored, and not just about this, but almost all major policy issues.
Because the current incarnation of the Republican party is not about policy at all, it is about a return to power.
And the amazing part of to me is they make it SO OBVIOUS. Conside that their alternative to the the Stimulus was… tax cuts! Econ 101 says in time of severe recession you don’t cut taxes.
I still return to my basic belief that the Republican reaction to Obama’s election is hysteria to the point of being un-American.
The economic meltdown was the equivalent of an economic 9/11. What was the Democratic reaction to 9/11. They stood arm in arm with the Republicans on the steps of the Capitol and sang. They gave Bush everything he wanted and more. And then those same shitbags used 9/11 politically.
A party run by the likes of Steele, McConnell, Boehner, and Cantor is too dangerously stupid to be allowed to strongly influence policy.
Xenos
@Martin:
Speaking as someone in a very blue state, my state does a much better job of consumer protection than the Federal Government does. For example, we have a usury statute that, because of dishonest bastards on the Supreme Court, does not apply to credit cards. I do not want to see a race to the bottom where I have to buy an insurance policy regulated by South Dakota.
I can’t find any info on how Federal regulation of insurance already works… there must be some agency that is in charge of policies issued in Washington DC, Puerto Rico, and so on. That could be expanded to cover all these interstate policies, but that would be a hella expansion. The insurance industry has lobbied for the creation of a national insurance commission, probably because they expect to be able to write all the new regulation.
If there was an honest conservative in the country, I would expect to see them try to hash out how this proposed shift of power to the federal government, which most conservatives support, can be justified under federalist principles. Instead, the rest of us are left to try to work out how to do this, and as soon as anyone comes up with a practical proposal it will be fed into the Fox machine as the latest fascist proposal from the left. Just wait.
geg6
I’m with sleeper here. Ezra going to the big time at the WaPo has turned his head. I’ve been reading him for years and I have seen him change since he became a corporate tool. Yes, he’s gorgeous still. Yes, he’s smart as a whip. And yes, he still knows the issues behind health care reform better than anyone in the MSM. Which is what makes it so horribly disappointing that he’s decided that to get ahead and become a major pundit, he has watered down his opinion on the public option to the point of making it seem it is not needed. Instead, he’s focused on the things that will be easier to pass and pooh poohed the public option’s importance to drive down costs. He’s been coopted by the Village like almost all progressives do once the Village and its corporate masters got their claws into him. Disappointing, but completely foreseeable. He’s still the hottest pundit ever, though. But I’ll keep Lawrence O’Donnell. He’s hot, too, but closer to my age and he hasn’t been coopted.
bob h
There are times when I get nostalgic for Richard Nixon. He would impose wage and price controls on healthcare, I am sure, and maybe that is what needs to be done here.
Napoleon
@Martin:
Martin said: “There’s an additional pile of people in the health care industry (the folks that file the claims at the hospitals, etc.) but there aren’t that many jobs to reduce there since even if all they were processing was Medicare for everyone, they’d still need most of them.”
That is not true. I recall seeing a comparison with Canadian doctors at one time where the staff they need to process claims is significantly smaller then in the US because all they need to know is one form and one set of codes. In the last year I had an extended conversation with my dentist about the whole subject of his staff and it was pretty clear that a huge chunk of his staffs time was tied up solely because of having to deal with something like 40 insurers.
A Mom Anon
@Napoleon: Yep. My dentist has 5 full time employees who do nothing but deal with insurance companies and collecting the money that the insurance companies don’t pay. 4 of the women in these jobs are scared shitless of a public option or single payer because they think they’ll lose their jobs. They may be right about that,I have no idea. But this is a single dentist practice with a staff this large. They’re dealing with over 50 different dental plans. (and could we get dental and mental health thrown in as part of Health Care? Please? Dental “insurance”is a joke,it’s more like a coupon for 10-20 percent off of anything major)
Tommy
I think it’s a safe bet that the people fighting to protect the status quo in health insurance have one thing in common: they have never been hospitalized or faced major medical bills.
geg6
Tommy: Or they have the federal healthcare insurance exchange, a Cadillac package as a part of their executive compensation, or they are making billions for themselves and their buddies off the current system. Or they are too stupid to understand the issue and easily manipulated by all of the above.
Comrade Jake
One of the points Klein has made recently (and I’m sorry, can’t find the link) is that Baucus’ bill looks A LOT like a bill a moderate Republican would craft. In fact it looks a lot like the one that a Republican had crafted in response to Hillarycare.
And it seems clear that today, in the Senate, it would not receive any GOP votes, perhaps not even for cloture. Pretty fucked up.
Napoleon
@A Mom Anon:
My dentist practices with his wife and the numbers you give pretty much describe his office and what single payer would mean to an office like that.
A PS to my original post, when you hear how much less Canadian doctors “make” compared to American doctors it is in a lot of way apples to oranges because the Canadians have significantly lower overhead (as do French, etc.) and my understanding is the numbers you hear are what the doctors office is reimbursed, not the doctors take home pay (which I understand to still be lower, but not nearly what the reimbursement rate would suggest).
Napoleon
@Napoleon:
PPS, my generalist doctor also is in an office he shares with one other doctor and just eyeballing his staff over the years I would guess that his ratio is even worse.
AemJeff
Be happy. 99% of everything is crap. Punditry is no exception.
kay
@Comrade Jake:
My big complaint is that it doesn’t offer people (or the government, actually) any relief on costs.
Whether or not you’re in the group who are eligible for a subsidy doesn’t change the bottom line, that someone (you, alone, if you’re not eligible for a subsidy, or the government if you are eligible) are still paying too much for health insurance.
Is it written somewhere that we have to spend 17% of individual gross on health insurance? Why are we frantically protecting this percentage? Why doesn’t that percentage of gross come down when they mandate an additional 40 million customers?
We’re satisfied with that? Almost 1/5 of everything we earn in this country is going to go to health insurance? That’s not even including uninsured costs on top of the 17%, and those can easily reach 30% of gross with a serious or chronic illness.
That’s a lot to allocate to health insurance.
General Winfield Stuck
@Sly:
Come on now. Your throwing direct government price controlling into the mix. Of course you can keep premium costs down that way and suppress overall healthcare costs.
The Netherlands is tiny compared with the USA and direct price controls are not politically on the table for this country, and likely wouldn’t work here.
@Martin:
No one says it is. Single payer would be best. And comparing public utilities regulation, in the states, to our health care system is just a bridge too far, imo.
Obama and most economists agree with me, or I with them which is more like it.
jamie
Apparently that was the price of a Wash Post pundit column
kay
@General Winfield Stuck:
But not even single payer addresses why we pay so much and get such poor outcomes.
In terms of the whole country’s economic health, does this cost just keep going up? We’re going to allocate 30% of everything earned or produced to health care?
That’s a huge allocation, no matter who is paying. It doesn’t leave money for anything else.
Bill E Pilgrim
@J. Michael Neal:
Saying that it’s a “plausible” argument that proposing a single-payer health insurance system is necessarily “s0cialism” pretty much makes this invalid right there. Or rather, we certainly do see things differently because I think that’s nonsense.
I live in a country with essentially a single payer system and the s0cialists are very much not in power, and haven’t been for some time. In fact, what’s considered the capitalist right is in power, and entirely supportive of the single payer system.
Also the idea that the Republicans could be somehow more against Obama’s reform effort because “no one would be laughing at them” is a stretch and a half. The Republicans won’t vote for anything Obama wants. It’s politically motivated, it has nothing to do with health care for them. Seeing that, clear eyed, at the start would mean that you bargain with the moderate Democrats, and to do that, starting with what the moderate Democrats already wanted is no way to bargain.
General Winfield Stuck
@kay:
right now we have private industry wasting 30 cents on the dollar for unnecessary admin costs. Part of this is the complexity of a patchwork system, but much or most is makework for padding profit by extracting dollars out of the system that could go to actual health care delivery.
Because health care is not a service that people can refuse cause they will die, which is why a pure private market system leaves open all sorts of un market shenanigans for providers and insurers to push the rate of inflation because demand is exempt from normal reaction to this of going down when the price goes too high.
A PO is just a minimum antidote for this, because it’s non profit and backed by federal payout limitations, ie medicare max. payout for services. On a small scale, it will force the private insurers to tighten up their game and hopefully start to reduce the fluff admin cost waste and other waste to compete. And since medicare payout is mostly set to normal inflation rates, industry will have to adjust it’s rate of 3 times the normal rate of inflation and or wage increases of patients. Everyone will have to take a haircut in the system but it’s the only way to lower costs without direct government price controls. Single payer would just do it more quickly and more completely.
FlipYrWhig
@Lola:
You mean that you don’t like constantly playing a variant of “Quien es mas macho?” called “Quien es mas liberal?”
Brien Jackson
@geg6:
It’s always enjoyable to discuss content with people who don’t actually read things.
Bob
@Xenos:
This dawned on me this morning. I couldn’t decide if it was just me trying to find good in the likely loss of the public option, or was actually a real accomplishment on the verge of implementation.
kay
@General Winfield Stuck:
But why are we assuming that finding dollars = more money allocated to delivering valuable and effective health care?
What if the money found ends up in increased rates of reimbursement, or new fee for service options, or new products billed to Medicare, like the (now infamous) “Rascal”?
I don’t know how you get to costs. The profit motive doesn’t disappear when you make the insurance funding mechanism non-profit.
General Winfield Stuck
@kay:
Right now, the entire HC system is primed for profit, and maximizing it. From Insurers to providers (docs) hospitals, HMO’s etc…/
With a public option, (limited scale), or single payer with reimbursement rates set by a panel or other quasi government entity would change that overnight, at least with single payer, and more slowly with a PO.
Right now the HC industry can charge about what they want because they know demand will remain high and steady regardless of they charge.
From top to bottom the system will need to compete on QUALITY, rather than quantity model because everyone would start at the set reimbursement rates with increases determined on Wages, COL, and national inflation rates.
Theoretically, More docs who have stayed out of medicine because of the racket, would be attracted to the QUALITY model and would likely get into it for the right reasons, and those that are now in it for the wrong reasons (personal enrichment) would maybe stay out and become bankers and such.
Every other western industrialized country has figured this out and has adopted this quality model by different means. We are the last, hopefully for not that much longer.
Nobody has a perfect system because we are dealing with human beings, but taking out, or managing the profit incentive would go a long way in improving HC all around, IMHO>
pseudonymous in nc
The point about private insurers in the rest of the world — and this is where I think that foreign examples are important — is that they’ve generally been kept to heel. They don’t have the Wall Streeters to satisfy, and they haven’t dined on caviar and champagne for decades.
I’m not convinced that the existing pack of insurance behemoths are capable of adapting to that environment, or willing to abide by both the spirit and letter of regulation. I’m certainly not convinced that the regulatory frameworks will have the teeth to deal with the people who decided that rescission and dragging out litigation they knew they were going to lose were good for the bottom line.
Doing that might require a whole new set of insurers.
Sly
Not disagreeing with the political aspect, but price controls could work on a state-by-state level. I wouldn’t advocate for it (at all), and politically it would be a disaster, but that’s sort of the point. The only way to change the for-profit industry is through regulation, a competitive non-profit, or single-payer. The second is more politically sound than the first and third, and has been proven to work.
Which is important. Co-ops are politically sound from the standpoint of more rural states, because they’re small enough to be dispersed. You won’t have to face a Republican challenger claiming that you’ve signed into a law a reform scheme that will create wait times for people who need care, because they’ll have to drive a hundred miles or more to see a specialist. The problem is that Co-ops do nothing in terms of cost containment or influence practices, which is the whole point of the exercise.
Sly
Possibly, but that’s not necessarily a bad thing. When Vermont enacted insurance reform in the 1990s, some of the larger insurance companies left the state completely (a point Howard Dean considered a sign of success and wears as a badge of honor).
You actually don’t want some of these companies if they can’t abide by the rules, and I don’t see a problem if they choose to stop selling insurance rather than not make a gazillion dollars a year. But, under contract, they have to keep providing the insurance policies that they already hold unless they sell them off or declare bankruptcy.
Wall Streeters, its important to note, are not wedded to a single industry to secure their payola. They’ll back whoever gives them the biggest return on their investment, whether that industry makes sneakers or computer chips or orange juice. Case in point: Mortage backed securities. Now that those are dead, there’s a movement to securitize life insurance policies. If health insurance no longer returns the kind of profit on investment that it does now, they’ll move to something else.
Of course they’ll make a stink about it, but at the end of the day a gambler will always find something to gamble on.
jacksmith
ATTENTION!! Congress Has The Votes Needed To Pass A Public Option – TODAY http://bit.ly/TCq7O
Why A Strong Public Option Is Essential – By jacksmith – Working Class
Robert Reich explains the pubic option: http://bit.ly/dDYSJ http://robertreich.blogspot.com/
John Garamendi on the Public Option and the Grassroots: http://bit.ly/TJMty
Howard Dean on the Public Option http://www.youtube.com/watch?v=8SKfW2dUnow&feature=player_embedded
It’s not just because more than two thirds of the American people want a single payer health care system. And if they cant have a single payer system 77% of all Americans want a strong government-run public option on day one (86% of democrats, 75% of independents, and 72% republicans). Basically everyone.
It’s not just because according to a new AARP POLL: 86 percent of seniors want universal healthcare security for All, including 93% of Democrats, 87% of Independents, and 78% of Republicans. With 79% of seniors supporting creating a new strong Government-run public option plan, available immediately. Including 89% of Democrats, 80% of Independents, and 61% of Republicans, STUNNING!!
It’s not just because it will lower cost. Because a strong public option will dramatically lower cost for everyone. And dramatically improved the quality of care everyone receives in America and around the World. Rich, middle class, and poor a like.
It’s not just because it will save trillions of dollars and prevent the needless deaths of millions more of YOU, caused by a rush to profit by the DISGRACEFUL, GREED DRIVEN, PRIVATE FOR PROFIT MEDICAL INDUSTRIAL COMPLEX!
It’s not just because every expert in every field, including economist, and Nobel laureates all agree that free market based healthcare systems don’t work. Never have and never will. The US has the only truly free market based healthcare system in the World. And as you all know now, IT IS A DISASTER!
It’s not just because providing or denying medically necessary care for profit motivations is wrong. Because it is WRONG! It’s professionally, ethically, and morally REPUGNANT!, Animalistic, VILE and EVIL.
THE REASON THE PUBLIC OPTION IS ESSENTIAL:
The public option is ESSENTIAL because over 200 million of you are trapped in the forest of the wolves. Which is the forest of the DISGRACEFUL, GREED DRIVEN, PRIVATE FOR PROFIT MEDICAL INDUSTRIAL COMPLEX! With no way out except through needless inhumane suffering, and DEATH. While the wolves tear at your flesh, and rip you limb from lib. Then feast on your lifeless bodies like a dead carcase for transplant parts.
At the most vulnerable times of your lives (when you were sick and hurting), millions of you have had to fight and loose cruel, but heroic battles. Fighting against the big guns of the DISGRACEFUL, GREED DRIVEN, PRIVATE FOR PROFIT MEDICAL INDUSTRIAL COMPLEX! in the forest of the wolves. All because you have no place else to go. You have no other CHOICE!
But the PUBLIC OPTION will give you someplace safe to go. And it will give us someplace safe to take you. The public option will be your refugium (your refuge). Where the wolves cannot get at you when your down, hurting, and vulnerable. Where everyone who needs it can find rest, security, comfort and the care they need. Protected by the BIG GUNS of We The People Of The United States. THE MOST POWERFUL PEOPLE AND COUNTRY ON EARTH.
This is why it is so critical that we do not lead another 50 million vulnerable, uninsured Americans into the forest of the wolves, without the protections of a Strong Government-run public option. We The People Of The United States MUST NOT LET THAT HAPPEN to any more of our fellow Americans. If healthcare reform does not contain a strong public option on day one. YOU MUST! KILL IT. Or you will do far more harm than good. And millions more will die needlessly. Rich, middle class, and poor a like.
To those who would continue to obstruct good and true healthcare reform for the American people, and who seek to trap millions more vulnerable Americans in the forest of the wolves. We will continue to fight you. We are prepared to wage all out war against you, and will eagerly DESTROY! you. Time…is…UP! YOU HAVE BEEN WARNED! No Co-op’s! No Triggers! NO INDIVIDUAL MANDATES! without a Strong public option on day one.
Healthcare reform can be the GREATEST! Accomplishment of our time and century. A time when future generations may say of us, that we were all, AMERICAS GREATEST GENERATIONS.
BUT WE MUST ACT!
I therefore call on all my fellow Americans and the peoples of the World. To join us in this fight so that we may finish becoming the better America that we aspire to be for everyone.
SPREAD THE WORD!
I have been privileged to be witness as many of you fought, and struggled to take your first breath, and your last breath on this earth. Rich, middle class, and poor a like. Life is precious.
Whatever the cost. WE! MUST SUCCEED.
God Bless You My Fellow Human Beings
jacksmith – Working Class
Things You Can Do To Help NOW! http://www.everydaycitizen.com/2009/09/tired_of_watching_people_die_n.html
No Triggers! http://www.huffingtonpost.com/jason-rosenbaum/a-trigger-for-the-public_b_277910.html
Triggers http://www.huffingtonpost.com/david-sirota/weve-seen-these-triggers_b_283583.html
Krugman on heathcare (http://krugman.blogs.nytimes.com/2009/07/25/why-markets-cant-cure-healthcare/)
Senator Bernie Sanders on healthcare (http://www.youtube.com/watch?v=RSM8t_cLZgk&feature=player_embedded)
Ken J.
Going back to Ezra’s original piece:
“If Americans felt the full burden of health-care costs,…”
Americans have two guiding principles for health care:
1) I shouldn’t have to pay anything for your care.
2) I shouldn’t have to pay anything for my care either.
What do you expect after 60+ years of socializing medicine by tying health care to a person’s employer, similar to the way the Soviets ran things?