Sen. Klobuchar just made a great point on MSNBC- using the logic of those wanting to kill the bill because it isn’t good enough, we would never have passed the Civil Rights Act of 1960 because it didn’t have the reforms of 1964, 68, and 91 included.
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bobbyl
Um yeah, given the mandate to BUY insurance I’m wondering if Mr. Cole will be willing to cover my premiums, cause you see I can’t afford it.
freelancer
@bobbyl:
maye
Just pass the damn bill and have the rest of this fight in conference.
And, btw, having Howard Dean against it will ensure the DINO contingent will vote for it.
KCinDC
John, can you explain why you feel that now is the time to give up on making the bill better? The fight isn’t over, so asking our side to surrender immediately and leave the demands to Lieberman and Nelson is going to result in the bill sliding even further to the right. I want people on the left standing up and making threats to provide some balance.
Besides, having lefties screaming gives Lieberman something to be happy about, so we can hope he won’t demand further concessions.
JenJen
But… but… Arianna said this morning that nobody is saying that the bill should be killed, they’re saying that… well… what they’re really saying is something… else?
I swear, that’s what she said this morning.
Comrade Dread
I don’t think that you can blame people for being understandably cynical about all of this slow progression talk.
There are a lot of conditions that must fall into place in order to get subsequent changes to the law, and I suspect that the mindset of many legislators (especially ones already reluctant to sign on to the current bill) will be that they’ve already addressed health care, and it’s time to move on to other issues.
Jamey
Or, for that matter, ratified the Constitution because Amendments 11-27 were missing…
But, still, a mandate? There had better be some SERIOUS constraints on margins.
eastriver
It’s not just that the bill is flawed, it’s actually bad. It does the reverse of what it was. The Civil Rights Act of ’60 didn’t actually restrict rights.
That’s the point.
Da Bomb
Very good point John.
As it has been stated time and time again, The Civil Rights Act, Social Security, and Medicare have all been worked on constantly. None of these bills had sweeping reforms from their first inception.
But at least we had a foundation to start building on.
@bobbyl: And yet again this is not the final bill, we still have to see how this bill and the House bill will merge.
gwangung
I got the impression he was talking more about the “torpedo the bill now” folks, but I could be mistaken.
Given that details matter, we should still work to make this better. There are some launching points that can make even bigger differences, if we fight for them.
Darius
I’d buy that, if I had any faith that the Dems had the political will to improve the bill later on. Right now, I don’t.
danimal
@bobbyl: There are a hell of a lot of subsidies in the bill covering your policy if you can’t afford it. Jeez.
Da Bomb
@JenJen: She just makes my head pound with a thousand tons of stupid when she talks.
It’s like to listening to Zsa Zsa Gabor on acid.
Jim Crozier
It’s an imperfect bill based on a series of complete fuck-ups along the way tactically. We SHOULD have a better bill right now.
We don’t.
Killing this bill now would just be cutting off our noses to spite our faces.
I agree. Pass this thing. Try and improve it in conference. Try and improve it even more over the next few years. Incremental improvement is better than no improvement at all.
Da Bomb
@eastriver: But it sure as hell didn’t correct all of the aftereffects of Jim Crow either.
wilfred
Given the choice between the time-honored:
And:
I think the latter is a more accurate bromide.
bobbyl
Freelancer, sorry-hate to throw about invective but get your head out of your @ss. I can’t afford it plain and simple. Oh, and comparing HCR to the CRA is completely inane, if the insurance industry gets their profits institutionalized they are NEVER EVER going to give that up.
John Cole
@KCinDC: Killing the bill is making it better?
Hunter Gathers
@bobbyl: If your premiums exceed 8% of your income, there is no penalty.
JenJen
@Da Bomb:
This!!
Jim
In 1996 Arianna told me to vote for Pheel Graahm, because he would cut taxes for the rich and wealth would trickle down.
In 2000, Arianna told me Al Gore was just like George W Bush.
I’ll find my wisdom elsewhere.
Tom Hilton
It’s the classic battle between those who have the courage to compromise, and those who cling to the cowardice of their convictions.
The Logic Escapes Me...
By that reasoning…
Many were increasingly of the opinion that they’d all made a big mistake in coming down from the trees in the first place. And some said that even the trees had been a bad move, and that no one should ever have left the oceans.
Hitch Hiker’s Guide to the Galaxy
Z
Amy has to be happy about this one. Her silence during the HC debate was deafening, especially on the public option. She’s a budding career politician of the worst sort, and she has lost the support of this native Minnesotan. I wouldn’t be lining up behind her opinion, she is in the ranks of the bought and sold.
Robin G.
Holy crap, Klobuchar spoke? I’m stunned!
Let’s just say I’ve been unimpressed with her as a Senator so far, always hiding in the back, trying to wait things out to see who the winner is.
Luckily Franken picks up the slack by being made of Pure Awesome.
J. Michael Neal
Once again, for those opposed to the mandate, it’s essential. Nothing else in the bill works without it. If you allow young, healthy people to opt out, then community rating is a joke and you have effectively prevented the coverage of pre-existing conditions.
Yes, bobbyl, you are going to have to be insurance. Just like you would if you were in Canada, or France, or the Netherlands, or Japan, or anywhere else. If you like, you can think of it as a tax. Of course, there are also some pretty substantial subsidies involved. Every study I’ve seen that actually crunches the numbers shows that premiums go down under this plan. I’ll take some actual analysis over your armchair hypothesizing any day.
KCinDC
@gwangung, John has attacked Bernie Sanders for saying he won’t vote for the bill without modifications. How on earth can anyone expect to get improvements made without saying that the current bill is unacceptable? Attacking anyone on the left who opposes the current bill is a recipe for moving it further and further right, because the people on the other side sure as hell aren’t going to be timid about expressing their opposition.
Brien Jackson
Don’t forget the politics, it was definitely terrible politics. Senators from anti-legislation states that voted their moral compass over their constituents’ bigotry lost their seats in their next re-election bid, and Nixon, Reagan, and Poppy used that motherfucker like a club for the next generation. If it were up today Kos would be letting everyone know they should oppose it because it was electoral suicide.
JenJen
@KCinDC: I am trying so hard to not be cynical about this, but how can we make the bill better? We’ve been at this a year now, and we don’t have the votes.
What do we have… maybe 57, maybe 58 solid votes? The other two aren’t going to materialize out of thin air. The road to 60 is going to have to go through a few asshats, and I don’t see them coming around on any progressive measures to make the bill better. Am I missing something?
General Winfield Stuck
@Comrade Dread:
This is how it works. There will be problems. People will fall through cracks and done wrong in some other ways with ANY bill that is passed, even one that is left wingnut approved.
Stories of these problems will reach senators and congressmen/women, it will be in papers. letters emails and other ways letting congress know something needs changing. These people in congress, dems for their issues and wingers for theirs are largely vessels who patch their electoral boats by responding to input from their voters. If they don’t they don’t get reelected, and that is always a list topper for stuff to do.
It is how medicare improved over time and SS as well. It is democracy. You get the best bill you possibly can, under the political realities of the day, and progress, Progress, PROGRESS, to something better.
But if the opponents in the nutroots are going to accuse me of being an Iraq war supporter or sympathizer, they can go straight to hell, and not pass go. Done with them, gloves are off and all that.
danimal
Folks, the conservadem opposition to the bill is based on optics–“piss off the liberals…” When the bill passes, there will be subsequent bills in this Congress and the next to close loopholes, increase funding, expand programs, etc. It will be infuriating to those in the know, but Nelson, Lieberman and the Blue Dogs will soak up camera time supporting provisions that they have been killing this time around. It’s how they roll. Stop acting like all future health care legislation ceases once this bill passes (if y’all don’t succeed in doing the Republicans dirty work by killing the bill in the next few days).
Zifnab
@John Cole: Killing the bill leaves the problem on the table. You don’t get to walk away saying you “fixed it”.
We’ve heard a few Senators claim that this is a once in a decade opportunity, but that’s only true when you successfully pass the buck once every ten years.
The current bill won’t reduce anyone’s premiums, and they leave loopholes a truck could drive through on rescission and max caps. With the public option cut, the ONLY thing people see in this bill is an insurance mandate coupled with massive government subsidies.
KCinDC
No, John, threatening to kill the bill is the only way to get changes made, as Nelson and Lieberman have been demonstrating. But you want the left to unilaterally disarm.
John Cole
@KCinDC: That was an attack? Seriously? Could you point to the part of the post that was an attack?
jeffreyw
@Tom Hilton: very nicely put, reminds me of Emerson’s “…small minds.”
jenniebee
The Civil Rights bill lost the Dems the solid south – good riddance, but still, it had an effect.
If 20-somethings who can’t afford private insurance get put in a position where they still can’t afford it and get fined for not buying it anyway, the Dems will lose the solid youth vote. Losing the South for a generation is peanuts besides losing an entire fucking generation for a generation.
And the mandate doesn’t make any sense anyway without a public insurance program. If insurance is public with means-tested premiums, then it makes sense to mandate coverage because keeping the cost of care consumed per person covered down keeps the cost of the premiums per patient down as well. If insurance is private and for profit, then lowering the cost of care per person doesn’t lower premiums, it raises profits.
Dean is doing the right thing. If Dems take the position that there’s no such thing as a dealbreaker for us on this bill, we might as well just tack on an amendment that strikes the entire text of the bill and substitutes in its place “We suck Joe Lieberman’s dick like it’s made of cookie dough.”
Zifnab
@JenJen:
Gut the insurance mandate. Pass the internal regulatory reforms as the bill stands. Then come back through with the budget bill and pass the Public Option, the Medicare Buy-In, and the rest under reconciliation rules. Then you need 50 votes plus Biden.
KCinDC
John, we’re not going to get a public option or Medicare buy-in, but we might be able to get better regulations (including eliminating the insane antitrust exemption) or bigger subsidies or other things. The bill is not set in stone, as you’ll see when Lieberman makes his next demand.
J. Michael Neal
@bobbyl:
Yeah, strange. Companies that exist for the purpose of making money need to make money. I doubt that the mandate does more to increase their margins than other parts of the bill do to lower them. If the health insurance companies think this is such a fantastic gift to them, why are they setting up operations to try to get the bill declared unconstitutional?
Look, I think we’d be better off if we restructured the health care system such that we eliminated private health insurance companies altogether. That was never, ever a possibility in this debate. Not now. They were going to exist, and they were going to be key players in the system. Ergo, they were going to make profits. You can’t leave them in and then insist that they lose money.
KCinDC
@John Cole, you’re saying that you were supporting Sanders in that post?
Brien Jackson
@KCinDC:
Well that’s a function of basic reality. Consider a situation where we establish Bernie Sanders as the most liberal Senator, Lieberman as the 60th most liberal Senator, and stipulate that they will not vote for the same bill (a bill Sanders will support is a bill Lieberman will oppose and vice-versa). The problem here is that to get to 60 votes without both of these Senators, you have to slide the bill along the left-right spectrum. But of course, Sanders is the most liberal Senator, so there’s no one to the left of him to pick up by moving the bill to the left. In theory, at least, you can replace Sanders by moving the bill far enough to the right to pick up the 61st most liberal Senator to compensate for losing Sanders. Bt if you lose the 60th most liberal member, there’s no one on the left of the most liberal member to replace him. So it goes back to what rational people have been saying all along; the nature of the Congress is such that liberals just don’t have any leverage. That’s not Obama’s fault, or Reid’s fault, or Sanders’s fault; it’s just what happens when the last vote you need is a sociopath.
bobbyl
There are a hell of a lot of subsidies in the bill covering your policy if you can’t afford it. Jeez.
First of all I believe that these so-called subsidies only apply if you’re at or under the poverty line. Hell even if the premiums are “only” 5 grand a year that’s still to much for me, and most people I suspect.
Wek
I didn’t bang on doors for Obama’s campaign to have HCR reform completed in 2032.
Shawn in ShowMe
@KCinDC
Bernie Sanders trying to make some last-minute changes and the Poutrage Lobby trying to kill the bill altogether and craft a Magical Pony from scratch are two different things.
freelancer
@bobbyl:
I’m not offended bobby, and while I was flip, don’t think I don’t know what it’s like to feel that kind of panic.
I started my current job November 1 of last year. My health insurance kicked in on December 9th, and on December 17th, I slipped in my driveway and absolutely shattered my tibia at the ankle. I had surgery on the 23rd, and spent 3 months hobbling around on crutches. My health insurance still screwed me in terms of paying more than my deductible, but it still unnerves me that that could have happened while I had no coverage.
There aren’t the votes for single-payer, there aren’t the votes for a public option, and there aren’t the votes for even the Medicare buy-in. This bill will expand coverage, and will subsidize coverage to those who cannot afford it (presumably you). It is a step in the right direction.
gbear
@Z:
@Robin G.:
Do you guys ever listen to MPR? Klobuchar is an absolute motormouth when you get her in front of a mike on the lunchtime call-in shows, and she appears often. She also makes sense in a very practical way on most issues. I don’t see reasons for the hate fest.
What’s happening in the senate sucks right now but I don’t see her as part of the problem. She’s almost always on the right side. Not perfect but as good as we can expect from one person.
J. Michael Neal
@jenniebee:
Yes, it does. Anyone who thinks that the mandate doesn’t make sense needs to study the concept of adverse selection. The mandate would work better with a (strong and useful) public option, but that’s because the whole thing would work better with one, not because of anything that has to do with the mandate itself.
If you don’t want a mandate, then you don’t want health care reform. Period. End of story.
Brien Jackson
@Zifnab:
I’m pretty sure those 50 votes don’t exist. And those regulations don’t work without a strong mandate.
On the up side, the netroots has definitely shown greater efficacy than the right in creating their own alternate reality. It took the wingnuts a decade to do what the netroots hs managed in 9 months.
J. Michael Neal
@gbear:
Besides, she’s hot, though that probably means less to you than it does to me.
AngusTheGodOfMeat
@Wek:
Hm. The Concierge model of politics. I worked, I contributed, where is the pony I ordered?
This attitude just makes me homicidal. I did as much as anyone could be expected to do to get Obama elected, and the only thing I have a right to expect is that he does the best he can. On election day in 2012 we will all get to decide if he gets another four years of free rent in the White House. That’s it, that’s what you get.
scudbucket
@John Cole:
Killing the bill is making it better?
Sanders is gone – it (the current construction) is already dead.
Bruce (formerly Steve S.)
John, threatening to kill the bill is a tactic. I don’t know if Jane Hamsher is right in the literal sense of the “current bill” being worse than nothing, and I don’t know if she is ultimately holding any cards in this game, but she sure is one hell of a better poker player than you are. She and Dean are getting invited on the talking head shows. Rahm is in his office having a conniption, and that’s a good thing regardless of what bill finally ends up getting passed.
jenniebee
@Zifnab:
Curious about this, John, Doug & everybody else who’s saying pass anything: if the “Kill the Bill” position was expressed as “kill the individual private insurance mandate or we walk,” would you think that was as all-or-nothing insane? Because that’s where 99% of the objection to this bill lies.
J. Michael Neal
@bobbyl:
If the premiums are $5,000 a year, then you have to be making more than $60,000 a year to face the penalty.
It’s also the case that, if you go without insurance, you are a free rider on the system. You have guaranteed access to emergency care*, but you aren’t paying for that access; the rest of us are. Given the income threshold before the penalties kick in, I consider those who are objecting to this to be a bunch of freeloaders, and I’m not overwhelmed with sympathy.
KCinDC
@Brien Jackson, the various possible provisions that could be added, removed, or modified in the bill don’t map onto a one-dimensional line in which each senator absolutely refuses to vote on a bill with anything to one side of a point and absolutely refuses to vote on a bill without anything to the other side. Sanders can’t get things that Lieberman absolutely opposes, but that doesn’t mean he can’t get anything.
jenniebee
@J. Michael Neal: That’s assuming that the benefit of the mandate is passed on to anybody but the private insurance co. executives and shareholders. You’re asking us to look no further than adverse selection and believe in trickle-down reform. I don’t buy it.
J. Michael Neal
@scudbucket:
No, it isn’t. Look carefully at what Sanders said, and then remember how much he loathes the filibuster. I’m actually fine with Sanders in this instance, though I disagree with him. He hasn’t gone far enough to actually kill the bill until he commits to voting against cloture, rather than the bill itself.
Tom Hilton
@jenniebee: I would, because none of the reforms are possible without the individual mandate. And this has been explained so many times by so many people that I’m not going to bother here–just look it up, ferchrissake.
Shawn in ShowMe
Yes, because I find that even more retarded than include the public option or we walk. You’re going to offer reasonable rates for pre-existing conditions by insuring only sick people. Right.
QDC
I have a lot of trouble believing that all the people running around in comments threads in the last couple of days claiming not to have health insurance and claiming to be against the bill based on the mandate with no public option are actually uninsured. When the public option went away all these supposedly uninsured came out of the woodwork as being against the bill.
The exchanges are going to make it a lot easier to buy health insurance on the individual market. And they will make it possible for people with preexisting conditions. And, of course, there are subsidies.
So, if you claim that you are uninsured now, imagine that you will still be uninsured when the mandate kicks in, and you claim to be against this bill because you think it is worse to be required to buy health insurance than to be uninsured, then I don’t believe you.
JenJen
@Zifnab: From where I’m sitting, I don’t see how real cost reform works without some kind of insurance coverage mandate, though.
I like your plan, but I don’t think it’s gonna happen that way.
danimal
@jenniebee: I think 99% of the opposition comes from “I can’t support any type of bill that the smarmy bastard Lieberman eventually votes for.” The mandates have been in the bill from the beginning and have little to no substantive (as opposed to political) relationship to the public option.
AngusTheGodOfMeat
@JenJen:
Next they’ll be requiring people to have car insurance.
Absurd.
scudbucket
@J. Michael Neal:
He hasn’t gone far enough to actually kill the bill until he commits to voting against cloture, rather than the bill itself.
Good point.
gbear
@J. Michael Neal:
Yeah, hotness is in the eye (and orientation) of the beholder. OTOH I can’t think of any politicians that qualify as hot right now.
gwangung
@JenJen: Yeah, well that’s where the Repubs won a real victory, taking away the carrot that makes the stick go down easily. The mandates need to be there, but to sell them, you needed an equally strong benefit…and those were kneecapped by the Repubs and the Blue Dogs.
jwb
@eastriver: You don’t even know what’s in the bill. None of us will until it comes out of conference.
jenniebee
@J. Michael Neal:
Bullshit. You have guaranteed access to be temporarily stabilized if you’re dying without being asked for cash up front. I assure you, hospitals have excellent billing and collections departments. Until they figure that you’re dead, you’ve declared bankruptcy, or that you’re a transient, if you try to get some of that “free care” they will come after you for their money.
Da Bomb
@J. Michael Neal: Can you site some sources of where you read this:
I am interested in learning more about that.
J. Michael Neal
@jenniebee: No, I’m asking you to understand what adverse selection *is*. There is no trickle down effect related to it. Without a mandate, it is impossible for insurance companies to keep premiums low enough for anything else to matter. If the healthy opt out, then they have to be high enough to cover the expected costs of the sickest patients without the healthier patients paying into the system. You accomplish absolutely nothing if there is no mandate. You don’t lower costs. You don’t increase affordability. You don’t expand coverage.
The point is that, with a mandate, aggregate premiums may be higher, but average premiums are substantially lower. The healthy subsidize the sick. Yes, it means that there are some people, primarily *healthy* individuals who currently do not buy insurance, that pay more. That’s actually the *intent* of health care reform. If those people don’t buy in, then it isn’t possible to cover the sick at reasonable rates.
Besides, the argument that there are no limits in the bill on what insurance companies can charge is patently false.
kommrade reproductive vigor
Waaah! Playin’ the race card!
Bet you $50.
neil
This comparison would only be true if the Civil Rights bill in 1960 contained a provision that made it mandatory for black citizens to pay a poll tax.
Only then would the comparison be at all analogous.
Mnemosyne
@bobbyl:
150% of the poverty line.
Where are you getting $5,000 a year? Premiums can’t exceed 8% of your income. I make about $40,000 a year — 8% of that is $3,200, or $267 a month. Are you making $63,000 a year and can’t swing $400 a month for insurance? Or, once again, are you one of those people complaining about the bill without actually knowing what’s in it, like the 8% of income limit?
TaosJohn
There isn’t anything in the Senate bill to put downward pressure on premium costs. Between now and when any supposed “reforms” go into effect, your premiums will skyrocket. That means those of you who have insurance now will be screwed just like the rest of us. What part of having a bill written by health insurance lobbyists don’t people understand?
You have to put the screws to the insurance industry. This bill doesn’t do that. It will make them stronger. They will buy more senators. This is fundamentally immoral.
Jack
Civil Rights legislation didn’t hand away the commons to private companies. It increased participation in the commons, and legitimized the public sphere – increasing the scope and extent of those commons in the process.
It certainly didn’t give it away on the cheap so we can have “Obama Gets Healthcare Done!”
*
FWIW – we cannot have a globe bestriding proconsul run military behemoth and universal health care.
That’s why it dies this way, as bloggers bitching and Democrats rehashing Hamiltonian bleck.
Most everything else is window dressing.
The holders of authority aren’t going to dismantle the superstructure (and the military/milcomplex is now vital to our economic viability, as a guarantor of markets and the lynchpin of our solvency) for health care.
Brien Jackson
@jenniebee:
Yes, it would be insane, because it would destroy the policy aspect of the bill completely.
As someone pointed out yesterday, I love how the same activists who were bragging about being the “reality based community” a year ago are just as eager as wingnuts now to ignore policy implications when it’s not what they want to hear.
Brien Jackson
Yes there is;
danimal
@bobbyl: The “so-called subsidies” are the most progressive part of the freaking legislation. It’s real money to the tune of hundreds of billions of dollars. Stop using conservative talking points, if the cost is burdensome, push for more subsidies. Killing the bill will guarantee a bad end result.
I’m in favor of single-payer, but the reality is that the votes aren’t there for the type of bill that most progressives really want. I doubt there are even 50 solid votes if we went for reconciliation. This is the bill that can pass congress. If it passes, the discussion turns to finding ways to improve the bill, including subsidy levels.
If it doesn’t pass, health care reform goes the way of gun control as Democratic issue and will not be revived for years.
Mnemosyne
@jenniebee:
Sure, they’ll come after you, but they’ll usually settle for a lot less. And those of us with insurance pick up the rest of the tab.
That’s a big part of what people aren’t understanding: insurance companies are only part of the problem, and probably not even the largest part. Provider charges are also a huge problem, partly because hospitals and doctors have to guess if and when they’re going to be reimbursed for each patient, and partly because provider contracts negotiate a certain amount off a “list” price that almost no one ever has to pay.
Z
@GBear
I have met her, multiple times. I voted for her. And I have seen nothing but oppurtunism since her election. She CAN be a motormouth, just not on any issues of importance. Franken has had a much stronger showing. I don’t see any principled stands IMHO on the most important issues of this election cycle coming from her. Just posturing and baited breath. I know she is a centrist, and she represents her generation, and for me that is the problem. She won’t get my vote again. It is obvious to me right now that we need to raise the bar, not lower it. Amy will be fine either way I am afraid, she has her district locked down and her generation isn’t expecting any results. That is painfully obvious. But you gotta draw a line in the sand somewhere.
@Robin G
I second that emotion. Nice to see Amy DOES have an opinion after what, a year of HC debate? Too bad its all but too late, and NOT better late than never. Good riddance to bad rubbish.
Brien Jackson
@Mnemosyne:
The subsidies apply up to 400% of FPL. The 150% number was one of the original proposals to expand Medicaid.
JenJen
@gwangung: Bingo. Disheartening, isn’t it?
@Brien Jackson: Yep.
J. Michael Neal
@jenniebee:
This is exactly what I said you have. The asterisk was supposed to go to a comment that it’s not great coverage, but it also isn’t nothing. As for hospitals still billing you, sure. However, a very high percentage of those bills never get paid. That means that lots of people received treatment for which they never paid. That treatment wasn’t free to provide, and the hospitals need to cover those costs somewhere. The rest of us who have insurance are subsidizing those who do not, receive emergency care, and then don’t pay the bill. That remains true whether the recipient has to declare bankruptcy or not. They got someone else to pay for their health care.
If you are going to try to cover pre-existing conditions and institute community rating, that can’t happen. Without dealing with the free rider problem, everything breaks down. This is difficult, since, by definition, with community rating, younger and healthier people will be getting a bad deal if they buy insurance. Their expected health care costs, at least while they are young and healthy, are much less than the population mean. Therefore, it is *impossible* to provide them as much benefit as they pay in. A mandate is the only way to do that.
Brien Jackson
@KCinDC:
Actually, it kind of does, because at the end of the day Joe Lieberman is a sociopath who isn’t going to vote for anything that makes Bernie Sanders happy for the simple reason that it makes Bernie Sanders happy. It’s up to Sanders whether he wants to deal with that and limit the damage, or stamp his feet and force everyone to go crawling to Olympia Snowe to put the vote over the top.
Mnemosyne
@Jack:
Civil rights legislation also didn’t require anyone to spend a dime. The more realistic comparison is to Social Security and Medicare, both of which left out huge swaths of people and pandered to industry by exempting low-wage workers. Not to mention that Social Security in particular was structured to pretty much only go to white people.
Will
Just stop it with the historical context, and the legislative realities, and the general sense-making. That’s quite enough, Mr. Cole.
Robin G.
@AngusTheGodOfMeat: That’s not fair. People can choose not to own cars.
TaosJohn
Eliminate the damn MANDATE, and I don’t give a fart if this bill passes, because then I won’t have to buy the shitty product.
Yes, the Dutch and the Swiss have mandates. But their companies are non-profit and rates are regulated by the state. The Senate bill is a monstrosity that forces people who can’t afford it to buy insurance with no guarantee of cost control and nothing to prevent the benevolent insurers from screwing you to the wall. There are also plenty of loopholes to get around the alleged reforms. Nothing will change, except that you will HAVE to pay money to a private corporation that can charge as much as it wants, forever.
Mnemosyne
@Brien Jackson:
Ah, good, thank you. That’s what I mean about people mixing up the details of the bills — I didn’t remember that part. :-)
Catsy
No, it’s a fucking idiotic point, and I don’t understand why you keep making analogies like this when time and time again people have pointed out: IT’S THE MANDATE.
Read that slowly. Again. All three words.
Without the mandate, you would not see anywhere near the desire to kill this bill as you are now. If it consisted solely of insurance reform and the PO or Medicare buy-in were still dead, you and Klobuchar might have a point. Then I could get behind the idea of incremental change.
A better analogy here is if the CRA of 1960 had included a clause that, while implementing penalties of obstructing access to voting, also implemented steep fines for anyone who /failed/ to vote–with no guarantee that any subsequent legislation would address the burden.
silentbeep
@ QDC re comment #60:
Exactly. Couldn’t agree more.
Look: I think a lot of the progressive anger around this bill is justified. I don’t think anyone should just “shut up” and pretend that we should be happy with it. But as each day passes, it feels that some people who want this bill dropped, are more interested in indulging in their feelings of betrayal, bitterness and outrage over the way things are. I would like things to be different to. But they aren’t: this is the reality we are saddled with.
Also there have been instances in the past where Democrats’ have caved when they shouldn’t have, been bad negotiators, been too wimpy- sure, I get that. I think they were wimpy for not stripping Lieberman’s chairmanship back then, and I know it’s not gonna happen now, it sucks. I hear a lot of “I’m tired of having Democrats capitulate” and I get that too. But I don’t believe that just because I’m tired of it too, doesn’t man I should support getting rid of this bill, because it would emotionally make me feel better – people’s health and quality of life are my overriding concerns, not how I feel,and how stupid I think the Dems are (which I think they are in many way). This bill should be better, of course. I’m not happy with it either. I just don’t think $100 million dollars in subsidies is nothing, and I just can’t ignore the 30 million people that would be able to get insurance, when they couldn’t before.
I will quote Robert Reich from a Salon.com article today – this seems particularly apt for me:
“Is the effort worth still worth it? Yes, but just. Private insurers will have to take anyone, regardless of preconditions. And some 30 million people who don’t now have health insurance will get it…..We are slouching toward healthcare reform that’s better than nothing but far worse than we had imagined it would be.”
Mnemosyne
@TaosJohn:
No cost control except the requirement that premiums can’t exceed 8% of income. It’s interesting how people keep ignoring that little fact so they can keep up their righteous rant.
J. Michael Neal
@TaosJohn:
Yes, but the rest of us will still have to subsidize your sorry ass if you have a serious health problem that you can’t pay for out of pocket.
Except, of course, for the parts of the bill that are different than this, some of which have been cited in this thread.
danimal
Once more, with feeling. If progressives kill this bill with the expectation that an improved bill can be developed, they’re right.
Every year, Rep Dingell introduces a single payer bill and every year it is summarily dismissed and ignored. EVERYONE outside of the liberal blogosphere will ignore the purified health care reform bill that progressives champion. If that is your goal, go for it.
Thousands of lives will be lost, hundreds of thousands of bankruptcies will occur and millions will continue to live in anxiety while progressives feel better about not giving in to Joe Lieberman.
Da Bomb
@Mnemosyne: THIS.
RickDFL
Liberals who compromised on the 1960 Civil Rights Bill also engaged in a decades long public fight to weaken the fillibuster. Instead of simply accepting the 1960 CRB as the best they could do, they loudly used the weakness of that bill as evidence that Senate rules must change.
It would be easier to swallow the healthcare bill, if Senate Democrats would mount a similar public challange to the rules of the Senate. Instead, we are cementing the moral legitimacy of a 60 vote Senate. That may be worse than all the healthcare reform in the world.
Mnemosyne
@Catsy:
And as JMN has patiently pointed out again and again, reform doesn’t work without a mandate. If people don’t buy insurance until they’re sick enough to need it, healthcare costs skyrocket.
Every healthcare system depends on healthy people supporting the unhealthy ones. If your healthcare system only consists of unhealthy people, the whole thing collapses.
Now we’re starting to sound like conservatives who don’t want to pay their taxes because Those People will benefit — OMG, I’m paying in money but sick people will get more benefits than I will! Why can’t I just wait to get insurance until I get sick?
J. Michael Neal
@Catsy:
I doubt it. I bet that, just like Lieberman, the base would just find something else to throw a fit about. There is a lot of immaturity on both sides here. One example is on display in the same paragraph of your post:
Great. You could get behind insurance reform if only the linchpin to making it work were removed from the bill. Without a mandate, none of the things you support can exist. Thanks a lot.
KCinDC
@Mnemosyne, I thought it was just that you didn’t have to pay a penalty for not buying if premiums exceeded 8% of income. In other words, when the premiums get too high, more people just don’t have coverage. While that could produce political pressure for coming back and fixing things, it’s not actually price controls.
I’m also worried about what exactly these cheapest available plans are going to look like.
mo
Couldn’t agree more on this. Also, somewhat related is this post by Yglesias, which basically says that politics is really messy and tends to get corrupted by special interests and you can work to highlight and fight it BUT STILL work with the political system you got and keep working for whatever steps forward you can get. OR you can agree with the right-wing perspective that says: “the corrupt nature of the political process means that any effort to seriously remediate social problems through public action is doomed. Therefore, the best thing one can do politically is nothing. “
Jack
@Mnemosyne:
You keep ignoring that the premium is not the only damned price point. Convenient.
Mnemosyne
@silentbeep:
Yep. The fact that people who piss us off will also benefit from this bill is not an excuse for letting down the 30 million people without insurance. If you self-righteously want to let yourself die because you don’t want insurance for yourself, that’s one thing, but insisting that someone else has to die — about 45,000 someone elses every year — because you don’t want Joe Lieberman to get a victory is despicable.
Jack
@Mnemosyne:
CRA wasn’t my example. I was countering it, as a stupid example.
And SS and Medicare/Caid still don’t give away the commons. They expand it.
JenJen
@J. Michael Neal:
You betcha.
@KCinDC:
I’m with you on this point. If those plans end up looking anything like COBRA, which is an unaffordable joke, then even with the best possible intentions we’re really getting nowhere. After getting laid off in October 2008, if I’d have been forced to stick with COBRA, I’d have lost my house.
Mnemosyne
@Jack:
Since what everyone is screaming about is mandatory premiums, I didn’t realize that I would have to give a full breakdown of every possible charge in order to point out that the people screaming about mandatory premiums don’t know what the fuck they’re talking about since they don’t seem to realize that there are limits on those premiums.
Also, you didn’t discuss that premiums are not the only damned price point in everyone’s insurance right now. Convenient.
scudbucket
@J. Michael Neal: I doubt it. I bet that, just like Lieberman, the base would just find something else to throw a fit about.
I’m not sure this is correct. The progressive argument against leaving the mandate in is that it’s original purpose was to provide political leverage to get a PO, or some other goody. For some others, you may be right: they would resist the bill in any form.
Mnemosyne
@Jack:
Getting health insurance for 30 million people who don’t have it now is not expanding the commons?
J. Michael Neal
One important distinction that’s being missed here @KCinDC:
It is a price control, albeit not a direct one. It produces a price ceiling above which an insurance company starts to lose customers. If they want to take advantage of the mandate, then the premiums have to be under that cap.
Jack
@Mnemosyne:
Not when it involves transferring the wealth of the commons to private companies, while labeling it reform. Civil Rights legislation, SS and Medicare don’t do that.
Jolene
I am sick and tired of all the straw-man arguments: Civil Rights, Medicare, Social Security. I, for one, was never expecting a “perfect bill” — that would have been single-payer and was taken “off the table” immediately. Why is is so hard to imagine that some of us can read what is in the bill and decide it is not worth passing? Not because “it isn’t perfect” but because people should not be forced to buy a product from a private company protected by an anti-trust exemption. And why is so hard to understand that some of us can read what is in the bill and decide that it will not move us forward towards anything better? We are discussing the health care reform bill, as it is today, not Civil Rights or anything else.
AngusTheGodOfMeat
@Robin G.:
That made me laugh out loud. Sure, they can choose not to own cars … and totally rearrange and restructure their lives to do so. The whole model of cities today requires efficient transportation over 5-10-15 mile distances just in order to function and have the city fucntion at a basic level, getting to and from work and school and basic services.
Sure we can get rid of cars. We can also get rid of all the things that degrade health, and save more on healthcare than reform will get us, in total dollars. We can stop smoking and overeating, start exercising, reform our lives totally in the interest of health.
Or we could do all our driving at 3:30 am when there is little traffic and avoid most accident risks.
But this is the real world. We are not going to get rid of cars, and we are not going to start living dramatically healthier lives all of a sudden.
In the real world, we insist on car insurance, and can insist on health insurance. We insist on participation in Social Security for most workers. Government control of your basic old age pension has been in effect for a long time. Welcome to progressive government in the modern Western world. It works.
Jack
@Mnemosyne:
It’s not my fault you’re responding to imaginary arguments in defense of barely defensible positions.
You keep treating with the mandate premiums as cost controls. This is your very argument. Ignoring all the other loopholes and cost add ons which make these alleged controls laughably non-existent.
But, now, at least you have DFH to blame if or when the corporate stooges make this worse…
Jack
@Jolene:
Thank you.
J. Michael Neal
@scudbucket:
That may be what progressives think that the original purpose of the mandate was, but making that argument indicates that they have no idea what they are talking about. It also demonstrates that my cats have a longer memory about political debate than progressives do.
All you have to do is go back to the 2008 Democratic presidential primaries to see that this argument is wrong. Remember when Clinton and Edwards were arguing with Obama about the subject of an individual mandate in their various health care proposals? Remember when Paul Krugman wrote his op-ed about Obama’s position on the matter? This was a debate in which Obama was, at the time, wrong.
Edwards, Clinton, and Krugman weren’t arguing in favor of an individual mandate because they were interested in political leverage with the insurance companies. They were in favor of it because reform doesn’t make sense without it.
Please, better arguments.
Brien Jackson
@Catsy:
Well look, we get that, and great. Watever.
Now you need to understand that the mandate makes those reforms work, think about it honestly, and decide which is more important to you.
Mnemosyne
@Jolene:
At this point, it’s because most of the people screaming the loudest clearly haven’t read the bill because they’re complaining about phantom things that aren’t even in it.
Mnemosyne
@Jack:
I’m sorry, someone complaining that the insurance companies will be allowed to jack up his premiums to any level they want with no recourse and me pointing out that no, they can’t, they’re limited to 8% of income, is an “imaginary argument”? Which part of that is imaginary?
Jack
@J. Michael Neal:
Even those of us who understand, on the explicit terms being employed, that this legislation requires mandates (to distribute liability) still have every right to object to the outcomes and consequences, intended or otherwise, in politics and policy.
Knowing that the mandates are essential to this draft legislation doesn’t mean the outcome is laudable, or that the positives outweigh the negatives.
Jack
@Mnemosyne:
You. Are. Again. Responding. To. An. Argument. I. Did. Not. Make.
Jack
@Mnemosyne:
That’s what you want to believe. It’s not the actual case.
Brien Jackson
@Mnemosyne:
This.
Truth be told, the last couple of months have really exposed how shallow “progressivism” of people like Kos and Hamsher really is.
J. Michael Neal
@Jack:
If this is your argument, it’s not only non-sensical, but it means that you should have opposed this health care reform package since June. None of the public options that ever had a chance of passage would have prevented this, even the ones that couldn’t get passed in the *House* that would have used Medicare pricing. The eligibility for the public option wasn’t wide enough in any of them.
What you are arguing for is legislation that can not pass now, could not pass then, and which no amount of pressure from the administration could have passed. It’s chances were zero. It’s unfortunate, but the health insurance companies are, at least for the moment, not going anywhere. They will be a part of the system. *Any* health care reform that can pass would involve them charging for their products.
If you want to argue that just leaving the system as it is is preferable to passing any health care reform that could conceivably get through Congress, fine, but make sure you understand that that is what you are doing. There is no difference between your position and saying that we are just going to leave the system as it is for the foreseeable future.
scudbucket
@J. Michael Neal:
That may be what progressives think that the original purpose of the mandate was…
And so it is….
Edit: Look, I agree that a mandate is essential for any of this to work. But saying (as you did above) that progressives are reflexively opposed to this bill, rather than opposed in principle (even if you disagree with the principle), is incorrect.
Mnemosyne
@Jack:
No, I was responding to bobbyl and you inserted yourself into that argument by claiming I was wrong and bobbyl was right. Now you’re trying to change the subject because you know he was wrong.
Jack
@J. Michael Neal:
It’s neat how you’re arguing with a position I should have had without taking the time to find out what my position is, or might be.
jenniebee
@JenJen:
If the problem was that there are 30 million people in this country who could totally afford to pay for insurance but they don’t because they’re young and healthy Randoids going naked and playing FYIGM then it would make sense that the uninsured themselves are the source of the cost problem. And if the reforms were being set up so that it incentivized people to behave exactly that way and go naked until they got sick because the day they get diagnosed they can buy insurance that covers their pre-existing condition without a substantial penalty, then I could see the argument that without a mandate, we’re just trading one older and sickly uninsured population for a younger and healthier uninsured population, which is bad news for everybody. But neither is the case for several reasons.
First, anybody in this country who doesn’t have insurance – and more who do than you’d like to think – are one car accident away from half a million dollars of medical debt. And these reforms won’t change that. So even if you’re young and healthy, there’s a strong financial incentive to stay covered.
Second, insurance companies provide a lot of savings to their customers by negotiating rates. If you’ve never tried to get health care without having insurance, you’re probably not aware of how big a benefit this is. If you have had the pleasure of needing care without having health insurance, then you know that in addition to whatever else is wrong with you, you may need treatment for sticker shock.
Third, for young singletons who get insurance through work, between employer subsidies and tax incentives, it’s relatively cheap. I’m sure the last time you went through open enrollment and checked the box for the $600 a month family coverage you noticed that the employee-only option was more in the neighborhood of $90 a month. So a cost-benefit analysis for the average employed young healthy single person is to go ahead and shell out the $90 bucks rather than take a chance. Besides, if they don’t and their parents find out… hissy fits will ensue.
My point is, I’m not arguing that health care can work and be cost contained without young healthy people also paying into the system, I’m arguing that young healthy people are already heavily incentivized to pay into the system if they possibly can. So we’re insisting on measures to coerce behavior that was already largely being performed – because of risk aversion, financial incentives and interest in conforming with norms – whenever possible. The only people who really think it makes sense for people to go without health insurance are insured libertarians and my Uncle Larry (who is trying to find a publisher for his novel-length diatribes against modernity and also thinks it makes sense to go without bathing for decades, to give you some kind of clue about the intellectual company libertarians are keeping these days).
Human nature being what it is, however, once a behavior that was being performed willingly is compelled, it incites rebellion against the person who compelled it. And in the case of a person who is only not buying insurance because they are unable to afford it, the compulsion is adding insult to injury.
Mnemosyne
@Jack:
Oh, please. Half the stuff people are complaining about isn’t in the goddamned bill. Am I supposed to let people continue to believe things that aren’t true because they really feel like they’re true?
That’s asking me to become a teabagger and take up the liberal version of “death panels” by claiming that scary stuff is in the bill that is not. Sorry, but not. gonna. happen.
J. Michael Neal
@Jack:
You have every right to do a lot of things that are really stupid. This is one of them. It isn’t that a mandate is essential for *this* legislation. It’s that a mandate is essential for *any* legislation. Quite aside from the question of what could pass this Congress, *all* decent health care systems have a mandate, even the British NHS. They write the mandate differently, by calling it, “paying your taxes,” but it’s still a mandate.
Your argument that this legislation is different, since it allows private companies to draw profit from the commons is idiotic. All sorts of legislation does that, including the health care systems of most other Western countries. They may regulate it tighter, but that’s still what they are doing. There is no bright line here like the one you are trying to draw. Private companies make profit from legislation. Live with it.
Jack
@Mnemosyne:
Use your scroll function better. Seriously.
I don’t have to agree with bobbyl’s assertion to point out that your’s make no sense. You have, in this thread and in others, argued that the mandates are necessary. I agree, for this draft of legislation to work (towards what end is curiously left undefined), liability must be spread.
You have also argued, though, that the capped premiums limit costs. This is crap. Because these premiums are not the only price points. Not remotely. Not even tangentially. The actual draft legislation has loopholes (I linked the pdf yesterday) so large as to be insulting. And it simply does not address out of pocket costs, annual limits, services tiers, co-pays. It does, though, embed explicit rate increases, over the next five years.
Jack
@Mnemosyne:
I don’t care what other people are arguing. You’re disputing points I have not made.
J. Michael Neal
@scudbucket:
I haven’t seen any evidence that indicates that I am incorrect. The fact that you are reduced to a thoroughly incorrect argument about why the mandate was originally included tells me that you don’t have any interest in what’s in the bill, why it’s there, or what it’s consequences are. You just want to whine. If it wasn’t this, it would be something else.
Jack
@J. Michael Neal:
I have distinguished between mandate-for-payment to private insurers, and other sorts now used in other countries. But, please, do continue to aim that lance at a position I have not taken.
scudbucket
@Jack: Yeah, he does that alot.
J. Michael Neal
@Jack:
You have drawn a distinction that doesn’t make any sense. There is no bright line there.
jenniebee
@AngusTheGodOfMeat:
Last I checked, you’re only required, at least in this state, to buy indemnity insurance if you own the car outright, full insurance while you’re making payments. There’s a requirement for you to cover the damage you might do to others – your lender, other drivers – but not to cover yourself.
How that analogizes to health insurance is beyond me.
Hunter Gathers
@Mnemosyne:
Speaking of teabaggers, they have a +18 fav/unfav rating in yesterday’s NBC poll
http://msnbcmedia.msn.com/i/MSNBC/Sections/NEWS/A_Politics/___Politics_Today_Stories_Teases/091215_NBC_WSJ_Poll.pdf
scroll to page 11
We. Are. Doomed.
Jack
@J. Michael Neal:
Well there it is. Caught out on the fact that you (along with Mnemno) have been jousting with a position that your opponent doesn’t actually haven’t, you depart the argument entirely, to mouth a vague generality.
Maybe I should just clap louder and write bad things about Howard Dean or Bernie Sanders. Then you’ll like me. You really will…
Jack
@scudbucket:
I’m starting to notice. It was the same yesterday, with some of the others in the “STFU and eat it” crowd.
scudbucket
@J. Michael Neal:
No, J., it’s that you consistently refuse to hear what people are saying. I think the mechanisms of the mandate are crystal clear to everyone reading this thread, but you consistently miss that point in your paragraph-length explanations of ….. what everyone already knows.!!! You somehow believe that your superior intellectual analyses will answer people’s objections – to you and the current bill – without understanding that some people simply disagree with you, and not for a lack of intelligence. There is condescension in your tone, a hint of arrogance, and a reliance on brow-beating (remember your clam that Krugman thinks he knows more than he really does?). That you refuse to take the time to understand what people are actually objecting to, or the positions they are advancing, indicates that these monotonous nut-and-bolts based comments you enjoy so much are serving your own purposes more than they advance the debate of the issues under discussion.
Jack
@scudbucket:
Bravo.
Catsy
@J. Michael Neal:
Really? Without a mandate, we can’t have bans on preexisting conditions, recission, or any other regulation of the way insurance companies behave? Somehow, automagically, those critical reforms and many others cease to exist?
The order is think first, then post. Try it next time before trying to bust someone’s chops. Also, try an argument that isn’t bereft of factual basis.
The mandate is not the “linchpin” to anything in the current bill. You and others are fetishizing it to the same extent you accuse others of fetishizing the PO. Without a public option and/or draconian industry regulations, a mandate does nothing except hurt families who can’t afford it and drive costs up as insurance companies raise their rates to account for suddenly having to absorb a millions of previously-uninsurable people who are higher-risk and more expensive to cover.
A mandate is only an essential part of reform if you have a strong, well-subsidized public option of some kind, because the mandate is what helps ensure that the risk pool is large enough for the PO to function. Without that competition, the mandate does nothing but hand the insurance industry a massive bloc of captive customers who are faced with the choice of paying the insurance industry’s jacked-up rates, or getting fined.
Progressives who have been pushing a public option–which we consider essential to reform–are somehow supposed to sit down and play nice when anything even remotely resembling it is stripped, yet people like you are perfectly comfortable whining that insurance reform is impossible without your mandate. Somehow that absolutism becomes okay when it’s your policy preference in question.
KCinDC
@J. Michael Neal:
Yes. I saw countless blogosphere arguments about this during the primaries, and the repeated message had nothing to do with a public option, which was rarely mentioned. The message was that Obama’s plan was not actually universal because it didn’t include mandates.
It’s maddening to see people who supported Edwards or Clinton during the primaries now reinforcing Republican anti-reform messages by trashing the very idea of mandates. The other damaging, anti-progressive message from the kill-bill folks is that cost control is the most important part of reform.
J. Michael Neal
@Jack:
It might help if you actually explained what you meant. So far, all you have done is make a big deal over a distinction that doesn’t mean very much. You said:
All of these governments, except those like Britain with complete single *provider* systems mandate that their citizens to hand money over to private corporations, usually insurers. The methods of payment collection may differ, and the existing regulatory structure may differ, but that principle is true all over. The countries that you are arguing don’t do this do, in fact, do exactly that.
Saying that you oppose the idea of government mandated enrichment of private parties implies that you are opposed to conceivable health care reform altogether.
Either explain why you mean something other than that distinction when you say:
or:
or explain how you think reform is possible without doing just that.
Mnemosyne
@Jack:
I argued that capped premiums limit premium costs. You then tried to take my very narrow argument and insist that I spread it out to every other possible cost of insurance even though all of those possible costs already exist in the real world. It’s not like co-pays and benefit limits are some brand-new innovation being introduced by this bill.
If you really want to get into a point-by-point comparison of all of the possible costs to the consumer in the bill as compared to what those consumers are currently paying in the same costs, I can make you a chart, but I can’t do it until the weekend.
TOMC
This is not a valid comparison. The Civil rights bill had no financial implications like HCR does. This HCR bill will arguably make things worse without addressing cost. As premium inflation speeds up less people will be able to afford coverage exacerbating the one thing HCR does currently address: uninsured.
jenniebee
@J. Michael Neal:
It isn’t coverage. And it isn’t care. It is stabilizing someone who is actually at that moment dying and shipping them elsewhere as soon as they stop actually dying and go back to only dying in a purely philosophical sense. This isn’t how young and healthy people are bucking the system, and the ones that try don’t generally survive to buck it a second time.
This idea that people are avoiding buying health insurance because the actuarial tables are in their favor is like arguing that nobody actually plays the lottery because the odds are so low of winning. Yes the odds are low, but people play because the payoff is huge. And yes, the odds of a young healthy person becoming suddenly unhealthy are also low, but young healthy people still buy insurance because if their number comes up, the costs of being uninsured are literally catastrophic.
Did you know that the single biggest controlable factor, when you get taken into an emergency room, in whether you leave the hospital alive is whether or not you have health insurance? Drat those lucky duckies who don’t pay for insurance and get emergency room care anyway! They’re laughing at the rest of us suckers all the way to the morgue!
Mnemosyne
@Jack:
Again, if you’re going to take up someone else’s argument, you don’t then get to claim that we should have known that their argument is not your argument. I am not actually psychic and can’t tell what your position is by what position you take one someone else’s argument.
If you want to make an argument, make it. Don’t use other people’s arguments and then complain that we didn’t address points that you didn’t bother to make.
J. Michael Neal
@scudbucket:
No. I am not missing that some people simply disagree with me. What I am pointing out is that some, though not all, of the people that disagree with me have no idea what they are talking about. That includes everyone who says that they’d be perfectly happy to support a bill with just the reforms so long as it had no mandate; they don’t know what they are talking about, because they do not realize that you can’t have the others reforms without the mandate. If they would simply recognize that their position of no mandate inherently means that there will be no other reforms, I wouldn’t respond the way I do. I’d simply say that I disagree.
It also includes someone who insists that the original purpose of the mandate was to get the insurers on board for passing a bill, when nothing of the sort is true. The original purpose of the mandate was something completely different, as should be apparent not only from the arguments that were made, but also that they were being made before the legislative strategy was created. Hell, Obama was opposed to a mandate at the time, and he is the guy who is supposedly responsible for the legislative strategies.
Oppose the bill. Fine. But understand that the objections you are making to the bill mean that you oppose the insurance reforms, too. You don’t get to claim that you are in favor of them while also arguing that the only thing that makes them possible should be killed. I am not going to treat seriously someone who tries to make that argument.
Jack
@J. Michael Neal:
Again – you are responding to an argument I didn’t make. I was originally criticizing the comparison between HCR and the CRA, because the processes and the structures involved are not related.
That is all.
I was not making a point that all health care reform must of necessity involve some prevention of expenditure outside the commons, or that NHS somehow lacked mandates.
Jay B.
Hmmm…What happened that turned the small measures of Civil Right Acts of 1957 and 1960 into the Civil Rights and Voting Rights acts of ’64 and ’65…Thinking….Thinking.
I’m sure it was just political incrementalism playing out and not some kind of galvanizing tragedy.
What a fucking stupid analogy.
Brian J
@J. Michael Neal:
This.
jenniebee
@Catsy:
What she said. Monopolistic insurance companies paying 72 cents on every premium dollar are not suffering from having too small a pool.
Jack
@Mnemosyne:
Heh. I’m not sure you’re arguing with anyone but yourself at this point. Loyal onward, then.
Jack
@Jay B.:
Thank you.
Mnemosyne
@Catsy:
No, they become pointless, because costs spiral out of control when the majority of the people in the healthcare system need a lot of healthcare and there’s not enough money coming in to pay for it. That’s why every healthcare system that progressives tout has a mandate that everyone pay into it.
If you take away the mandate, the whole house of cards collapses.
fasteddie9318
Really? They’re setting up operations to try to get a Lieberman-approved, Medicare buy-in AND public option-free, subsidy-rich, mandate-centered bill (which doesn’t even exist at this point because Senate leadership hasn’t had a chance to capitulate to Ben Nelson yet) declared unconstitutional? And the Lieberman appeasement happened, what, two or three days ago? They can move that fast? Wow; if they approved their customers’ health care as quickly as that, we probably wouldn’t be worrying about HCR in the first place.
Brian J
@TOMC:
But the bill is supposed to bring down premiums to a point where they’d be lower than they would otherwise be. I doubt it’s going to stop inflation entirely, but I don’t think anyone has claimed it would.
Mnemosyne
@Jack:
If you don’t care to present an actual argument, that’s your privilege, but don’t then complain that we’re not magically understanding the argument that you never bothered to make.
dadanarchist
You are making a huge assumption John that the bill is going to get better in the future. Based on what?
You cite the civil rights bill but it is a totally different piece of legislation.
Medicare improvement would be much more analogous, but most of the improvements to Medicare were accomplished by the same Great Society politicians who passed it in the first place. Meanwhile, our politicians are widely discussing Medicare’s dismemberment. Why should we believe that the same politicians now discussing reducing benefits and raising the retirement age, who passed the bullshit bankruptcy bill and the toothless credit card reform bill, are going to suddenly see the light and make this shitty bill better?
What magic is going to accomplish that other than progressives raising holy hell?
Most of our politicians are wholly owned corporate subsidiaries and should be forced to wear their logos like NASCAR drivers. At least we’d have some transparency.
J. Michael Neal
@Catsy:
Yes, that’s *exactly* what happens. It’s not magic. It’s adverse selection. If you don’t get the healthy on board, then none of the rest of it works. Community rating becomes the rating only for the sick. Pre-existing conditions can’t get covered at premiums that sick people can afford to pay, because they have to be based on the expected costs of the sick people only.
@Catsy:
This isn’t that hard to understand. In fact, it’s one of the most basic principles of insurance that there is. Insurance works on an actuarial basis, and the insurance payouts have to be covered by the premiums paid. (Roughly. There are some investment elements, but there’s also a present value question.) If the people who are paying in more than they are taking out leave, then the people who are taking out more, like the sick, have to pay more in.
I really suggest taking some time to find out how insurance works. The mandate is the linchpin of the rest of it. It does a lot more than you are saying here.
No. The mandate is what makes *any* risk pool large enough to function. It doesn’t matter whether it is the public option or a private company. The mathematics of the risk pooling doesn’t care who is running the pool.
Yeah. Math is funny that way. It doesn’t really care what outcome you would like to see.
Brian J
@jenniebee:
I don’t think that’s correct.
You can’t have the regulation that insurers are unable to refuse customers without ensuring that there is a pool of healthy people who won’t be collecting paying into the system. That’s why there is a mandate. While the insurance companies could probably do things a little differently, right now they are doing things without such people.
Brien Jackson
@jenniebee:
The problem with the lottery analogy is that the risk-reward factor is reversed. With the lottery, people are paying for the potential of a huge reward. In your construction of insurance incentives, people are paying to mitigate risk. Not saying you’re wrong, per se, but people respond differently to risk than they do to potential reward.
Mnemosyne
@fasteddie9318:
Yes, because — and this may be a shock to you — they don’t want any bill to pass. Even one that Kos keeps insisting is a total giveaway to them, because they know it’s not and they don’t want the government stepping in and regulating them.
I know it’s become an article of faith that the insurance companies just loooove this bill, but it’s just not true. They’re still fighting it with everything they’ve got, because they don’t want to be subject to government regulation.
Tax Analyst
AngusTheGodOfMeat said:
Well, that’s just fine, coming from a cow. You can’t fool us, though, EVERYONE knows cows can’t have ponies.
But other than that I guess I have to agree with you.
kay
@TOMC:
The Civil Rights Bill had no financial implications? Civil rights has no financial implications?
Amazing. You better tell the Supreme Court. We’re going to have to reverse a lot of case law.
dadanarchist
J. Michael Neal: I agree with you that the mandates cannot come out, but since many of the other aggressive cost containment measures and regulations have been gutted by the corporatists, what is to prevent premiums from going up and causing the mandate to become a huge burden to those forced to purchase insurance?
I agree with you on one aspect of the policy, but what about the (holding back vomit that I’m saying this) the politics?
jenniebee
@TOMC:
I think this is what the zomg dun kill! incrementalists don’t get. It isn’t that people who are saying “not this” are saying it because they don’t think it’s good enough, it’s because we think it’s actually bad. This isn’t the Civil Rights Act or Medicare, this is No Child Left Behind. It started out as a good idea, but was implemented as an intrusive, underfunded mandate that nearly everybody who has to deal with it hates and which won’t go away.
TOMC
@ kay
Oh yeah – I forgot about the civil rights tax that was part of that bill.
dadanarchist
The point TOMC was trying to make – similar to one I was trying to make last night – is that corporations, once they restructured their HR departments and rejiggered their hiring policies, which initially required them to spend some money, did not find civil rights law to be onerous or to in any way impinge on their bottom line.
Civil rights for minorities threaten many entrenched power interests, but civil rights expansion poses no substantial threat to the moneyed interests.
In fact, expanded civil rights seem to be good for business; look at all the corporations that stridently supported marriage equality.
TOMC
@jenniebee
Exactly. And it’ll cost the Dems control of congress.
Brian J
@dadanarchist:
Because a lot of social insurance gets better as legislators identify flaws and locate solutions to fix such flaws. Social Security has been amended over the years.
This sounds incredibly vague, and it is, but we don’t know exactly what is going to happen with this legislation. We have very educated guesses, but as a lot of people have been saying, this is an experiment. What works will hopefully be cemented and expanded and what doesn’t will be changed. This is how virtually every country that has a universal system has approached the problem. Why should we expect anything different? (And no, I don’t want to hear about how we already know what to do. We don’t. If we did, there wouldn’t be such drastic disagreement about the solutions among the people willing to admit there is a big problem.)
I’m not trying to make excuses here, because I do imagine some things could have been handled better, but it’s unrealistic to expect a grand solution to a problem of this magnitude, particularly when the interests involved are as entrenched as the insurance companies.
CalD
Klobuchar’s kung fu is good.
kay
@TOMC:
That’s okay. We’ll revisit all that, I suppose.
When liberals bring their “state’s rights” challenge to health care reform.
I see you’re using “unfunded mandate” too. Catchy.
J. Michael Neal
@jenniebee:
No, really, it is care. It isn’t optimal care. It sure as hell isn’t the way that I’d like to see the system run, but it is care. The only thing that constitutes not providing car is just leaving the accident victim in the street to die. If an ambulance shows up and they put a band-aid on him, that’s care. If they actually put him into the ambulance and take him to the hospital, that’s care. It’s pretty expensive care, and someone has to pay for it.
Not true. Most of the ones that try it get away with it just fine. They are correct in their analysis that, on average, they are unlikely to need serious medical care, and never end up with a crisis trip to the emergency room. They simply live their life with that put option available to them were they to need it.
You also have an inaccurate view of the survival rates in American emergency rooms. By a large margin, most of the people that end up there survive and prosper.
This is not the way that human beings tend to evaluate risk. Your example of the lottery actually works the other way around. People are terrible at evaluating the expected value of very unlikely outcomes. In practice, they tend to overestimate the expected benefit of unlikely events that would be in their favor, while underestimating the expected costs when the outcome would go against them. Thus, they are more likely to buy lottery tickets than they should be, while less likely to buy insurance than they should be.
However, that’s not the only effect. Yes, while the costs of a catastrophic health event on someone who doesn’t have insurance would be high, the chances of it happening are remote. This is true to an extent that the expected value of health insurance to younger, healthier people is *negative*. When they think that they are going to pay more than it’s worth to them, they are generally correct. It *doesn’t* make rational sense for them to buy into a community rated health insurance scheme where they pay a premium based upon the expected costs for people who are much sicker than they are.
It also doesn’t take all of them opting out to crash the system. Only some of them. That’s because this isn’t a binary distinction, with one group of healthy people and one group of sick people. It’s a continuum, with some people who are much, much healthier than average. Those are the ones you are going to lose first. Then the slide starts.
@jenniebee:
I’m not ignoring any of that, though a lot hinges on the definition of “controllable” there. That doesn’t eliminate the problem of trying to pay for the care that the uninsured receive. You seem to think that I’m arguing that people will refuse to buy health insurance even if they know that they’re going to end up in the hospital, but that’s not it. The key is that they have to buy insurance before they know whether they will have a health crisis, and that any attempt to enforce community rating means that there will be a large chunk of the population for whom the probability that that’s going to happen is so low that it doesn’t make sense for them to buy insurance.
TOMC
@ kay –
that was jenniebee and it was “UNDERfunded mandate”
dadanarchist
I understand the concept, and I understand the history, but that is my entire point: we are living with a different set of historical and political circumstances. The “ideological capture” of American politicians by Wall Street and corporate interests is much more advanced now then it was even 20 years ago.
We probably have more true-blue *cultural* progressives now then we have had at any time in the history of the Republic, but where are the *economic and social* progressives?
Look at Barney Frank or Chris Dodd, for instance: solid voting records on “cultural” matters, but both are stooges for the banks and investment houses.
So my question remains: what politicians are going to vote against their corporate paymasters to improve this bill? Why would they ever do so unless the left-wing of the party starts actually flexing their muscle?
scudbucket
@J. Michael Neal:
What I am pointing out is that some, though not all, of the people that disagree with me have no idea what they are talking about.
That’s because you view things through a very narrow lens. So, for example, you say that some people ‘do not realize that you can’t have the others reforms without the mandate.’ But this is just non-sensical. You may not get premium caps, but you could get anti-monopoly protections; you may not get guarantee issue, but you could still have government subsidies for the poor. This is just ordinary legislative wrangling.
Regarding the mandate, since it is included, people want to see that they are actually getting something in return, not just promises of incrementalism. Yet you fail to appreciate that some people’s skepticism on incrementalism is warranted simply by the crappiness of the bill currently under discussion.
I could go on and on in the ways you refuse to account for the levels and breadth of people’s complaints.
Comrade Scrutinizer
__
I said that yesterday. Just sayin’.
J. Michael Neal
@scudbucket:
People are focusing on community rating and covering pre-existing conditions. You can’t have those without a mandate. Anti-monopoly protection would be a good thing, but it doesn’t accomplish those things. You could have subsidies for the poor, but that’s not going to solve the underlying problem of adverse selection.
gwangung
Yet incremental improvement still occurs, even under these times. I think the problem is more of finding the ways to get those increments done, as the situation evolves, rather than trying to suss them out ahead of time.
dadanarchist
Over the last 30 years, I’ve found the opposite to be true on almost everything having to do with socio-economic issues. We’ve made great progress on cultural matters and on racial issues, but over the past 30 years, life has gotten harder for working people. Part of that is the globalization of the economy and the decline of the industrial economy, but part has been the shitty bills that have come out of Washington, ranging from Welfare “reform” to the Bankruptcy Bill.
I agree with you that our task is to find ways to make improvements, and it is for that reason that I support what David Sirota calls “progressive federalism,” which is essentially focusing on local and regional problems.
But then again, I’m a Cascadian nationalist. ;)
Cat
@J. Michael Neal:
Because they have no idea what the final bill is going to be and they need to plan ahead in case something they missed gets through and jeopardizes their wealth?
Because they are worried this maybe a first step to doing away with them and want to nip the legislation in the bud to prevent medicare for everyone.
There are many reasons to get a legal challenge of the bill rolling other then they dont like it. They could be happy with how it stand now, but it would be irresponsible of them to not plan for the worst.
Jack
@jenniebee:
A thousandfold, yes.
chris
The Civil Rights Bill of 1960 didn’t hand a permanent majority to its opponents. A bill with mandates and no public option will. So, if you want to usher in President Palin and a Tea Party Congress in 2013, by all means, support the current version of the Senate bill.
J. Michael Neal
@Cat:
Doesn’t this undercut the argument against passing what we have? It’s an implicit endorsement of the possibility of the incremental change approach.
sparky
@J. Michael Neal: let me try a different angle here–
no one is disputing your insurance model.* what people are disputing is its applicability in this context. why? because without any competition from the public sector it presupposes a regulator who is not captive to the industry. there is no evidence to support that proposition, and none in the current legislative proposals to change that. as an example, look at the exchanges–by state, just as they are now.
so, no existing regulation, destruction of the possibility of tighter state regulation, and … what?
all you are doing is proposing handing over immense power and revenue in the hope that maybe someone will regulate the people you just gave that money and power to.
in other words, you believe that the people who cannot curb any other rent-seekers can somehow, this time, get it right.
it’s not those of us who are opposed to this that are hoping for ponies.
*there is an argument that health insurance isn’t like other kinds of insurance but i’ll leave that aside
jenniebee
@Brien Jackson:
Yes, this is why very few people spend as much on lottery tickets as they do on health insurance premiums. If your number comes up in the lottery and you didn’t play, you aren’t any further ahead but you aren’t any further behind, either. If you’re uninsured and your number comes up, you and your family are facing financial ruin – that’s if you don’t die fast enough to avoid the really exorbitant medical bills.
The only rational reason for not getting insurance if at all possible is if you believe the fiction being propagated on this thread that free care is always available in the emergency room. I can’t stress enough how misguided a notion this is. The idea that anybody with the wherewithal to get insurance could get around the system that way is ludicrous. To get out of paying for that “free” care you have to declare bankruptcy, or be actually bankrupt – literally no assets and no income of any kind (plus no medicaid coverage, so we’re talking transients), or be dead. And there are people in this country today who are choosing to die and take their bills with them rather than seek continued treatment. That’s the risk.
Cat
@J. Michael Neal:
Luckily people are more idealistic then you give them credit for and many would be willing to pay into a system knowing that their parents, aunts and uncles, grandparents, or the poor people whom they have never met will get to have health insurance even if it means they don’t get the full benefit of their premiums
Tax Analyst
@Mnemosyne – #102
“If you self-righteously want to let yourself die because you don’t want insurance for yourself…”
My far-right wing older brother did this and boy, he sure showed everybody, didn’t he? FYI – just passed away this June at 66.
But nonetheless I found it very unsatisfying, emotion-wise.
Jack
@sparky:
Precisely. It’s entirely a faith position, argued by the “incrementalists.” And not just one they hold, but one they’re trying hard to evangelize.
We are being asked to believe that the exact same people who are, right now, negotiating away every provision we fought for will, at some undetermined future date, put them all back in and fix the mess they created.
It’s obscene, really.
Cat
@J. Michael Neal:
Just because they are worried about it doesn’t guarantee its going to happen.
I carry a spare tire even though I haven’t had a flat tire, ever. Should I take out my spare tire to realize the fuel savings or should I continue to carry the spare tire because the cost of having a flat tire outweighs the savings in fuel? If the cost of not carrying a spare tire is the loss of the entire car I’d be foolish to not carry a spare tire.
They only risk they run in fighting against their own bill is the legal costs which are meaningless compared to the loss they’d suffer to a single payer system. Thats just assuming a rational governance. If you factor in the personal wealth of health industry CEO’s any threat of real reform will have many of them scared out of their minds.
Bruce (formerly Steve S.)
Re: incremental change. One thing I think we can agree on is that the “current bill” further entrenches the private insurance industry as the main provider of health insurance in our country. Is there any reason to think that any future incremental change will not be in that direction? The steady erosion of financial regulation in recent decades immediately comes to mind.
scudbucket
@Cat: Cat, don’t even try, it’s like arguing with tree bark.
J. Michael Neal
@jenniebee:
This is only true for certain definitions of “rational” that depend upon putting a very high price on uncertainty. The rational reason for not buying health insurance is that the value of the expected benefits you will receive plus the value of eliminating uncertainty is less to the potential purchaser than the costs of the premiums.
The costs of the premiums is fairly easy to establish. The expected benefits are harder, if not impossible, to calculate for an individual, given all of the unknowns of actual health condition and risk factors in life, but can be pretty conclusively established for population sub-segments in general, providing a pretty good estimate. For a large chunk of the population, the latter is going to be *much* smaller than the former (unless you prevent them from buying in at a later date, and they have to calculate the value of the benefits they might need as a senior citizen). Your argument thus depends upon the value assigned to the uncertainty. That’s pretty difficult to calculate. All of the estimates done indicate that most young people don’t put a high enough value on it to cover the difference.
*You* don’t think that it’s a rational choice based upon the value you place on that uncertainty. Fine. That’s a perfectly rational choice, but only by a definition of “rational” that isn’t much use in this sort of discussion.
Further, you are misstating my argument about emergency room health care. I am not claiming that it is universally available, only that it is generally available and gets used a lot. I am also not claiming that it is “free” care in any meaningful sense. Quite the opposite. The reason that this is such a problem is that such care is very expensive. The problem is in trying to get someone to pay for it.
You can argue that it is a bad idea to go without health insurance and rely upon the emergency room all you want. You can point to bankruptcies all you want. So what? In the context of my point, those are completely irrelevant arguments. A lot of people *do* rely upon the emergency room, and a lot of people *do* leave those bills unpaid, and someone else *does* have to cover those costs. Those are empirical facts, and they do some severe damage to your hypothesis.
There is a large free rider problem if you don’t have an individual mandate. That’s just a fact.
The reason that very few people spend as much money on lottery tickets as they do health insurance is because, while human beings are bad at estimating the probabilities of unlikely events, they do have some ability to do so. The chances of winning the Powerball are around 250 million to one. There’s a drawing twice a week. There are about 325 million people in the United States; I’m going to take a complete guess and say that 25% of them, or about 80 million, live in Powerball states. If the odds of winning the lottery were the same as having a health care crisis, then there would be about 12 people a week in those states that need hospitalization or serious treatment. I think that it’s pretty clear to everyone that there are a lot more people than that have have health care problems. People spend more on health insurance because the differences in probabilities are so great that even if we are bad at calculating them, we can see that it’s of a completely different magnitude. For example, I can name, off the top of my head, about a dozen people who have been hospitalized for one thing or another. I don’t know anyone who has ever one more than $100 at a time on a lottery ticket, and only one of those.
Your assessments of whether or not people should buy health insurance don’t get us very far. The simple fact is that, based upon objective measures, health insurance is not a good buy for most young, healthy people, and that there are a lot of people who, for one reason or another, would not buy insurance in an individual market. They just won’t. You have to have a system that deals with that. Your personal assessment of subjective factors of risk really don’t matter.
sparky
@Jack: well, obscene is a bit condemnatory for those who may actually be arguing in good faith. that said, i find it really quite odd and don’t have a good explanation for this leap of blind faith by people who have otherwise unimpaired reasoning. the more you back up and look at it, the crazier this current proposition looks.
perhaps it is being accepted uncritically because this is coming from the D side, or maybe it is some kind of strange battered citizen syndrome.
the only other thing i keep coming back to is the Shultz classic of Charley Brown, Lucy, and a football.
or maybe it’s just what I believe Johnson said about second marriages: “The triumph of hope over experience.”
NB to the proprietor–THANKS for restoring edit to us!
Kilks
edit: I am not accusing anyone here of arguing that the federal government can not regulate insurance companies, but I have seen it elsewhere.
The federal government can definitely regulate the insurance industry. Assuming that the federal government is unable to is simply not credible.
Massachusetts for example under its universal health care plan mandated that insurers had to keep children on until they turn 26 or two years past the child’s loss of dependent status, whichever comes first. Since I’m still on my parents insurance, the insurance company appears to have listened.
One of the arguments against the mandate as compared to the Swiss version has been our own governments inability to regulate the insurance industry.
I’m not arguing that the current regulations will be strong enough. Just please stop assuming the health insurance companies will be able to ignore the regulations.
Also, health insurance actually is not that profitable a business. Insurance companies are only 3.3% profitable.
Jack
@Bruce (formerly Steve S.):
Your lack of faith in future reward is disheartening. More faith, less questions!
Also, please clap louder.
frankdawg81
fuck Amy Kloucher! She is my Senator, I busted my ass making calls & knocking on doors for her. She supported every damn thing Boy George ever asked for – FISA, Rendition, War Funding. She was worse than the empty suit (Dayton) she replaced & about the same as the ass-kissing empty suit (Coleman) she shared MN with.
That she now makes the same lame ass excuses for supporting a very bad bill that will hurt her constituents & enrich large companies that she made for the same affect before is no surprise.
Fuck her & the horse she rode in on.
J. Michael Neal
@Cat:
Unfortunately, the behavior of people as we can actually measure it does not support your evaluation. Like it or not, people tend to be pretty self-interested. Not entirely so, but it’s a large part of human nature. We have data on the rate at which individuals buy health insurance on the individual market. That’s real, empirical evidence. Unfortunately, it doesn’t support your claim. As a general rule, I think that theory should give way to evidence, not the other way around.
jenniebee
@J. Michael Neal:
I don’t know what to say except that you seriously don’t know what you’re talking about, but you have absorbed all the talking points.
This bill, if it passes with the mandate and no public insurance, will enhance insurance industry profits, do little to contain costs, and do more to usher in that fabled Permanent Republican Majority than Karl Rove ever could. This was intended to be a great expansion of civil rights, but in practice it is an extension of civil obligation to the very people who are at this moment the future base of a generation of Democratic hegemony.
kay
@TOMC:
All you’re doing is convincing people there shouldn’t be universal coverage.
The big progress we made in this debate was that we finally admitted that everyone should probably be covered.
That progressives are now arguing against that is insane.
Keep talking about government “forcing” you to do something, too. An anti-government argument is always helpful when we’re trying to re-regulate.
J. Michael Neal
@sparky:
I can’t speak for others, but this isn’t an article of faith with me. I don’t know for sure that it’s going to happen. Given what has happened with other such reforms, such as Social Security and Medicare, in the past, my guess is that it will, but I can’t guarantee it.
What I am pretty damned certain of is that, if this bill gets killed, the whole project is dead for a long time. No one is going to go through this again in the next couple of years, even if the Democrats hold on to enough seats to even try.
If there is a *chance* that we can continue incremental reform, it must start with this bill. No matter how much we hate Joe Lieberman and Ben Nelson, it’s this or nothing. Reconciliation is a pipe dream; between the parliamentarian and clowns like Evan Bayh, it’s not a realistic hope for getting the whole bill through.* We need 60 votes.
Realistically, we have two choices: pass what can get 60 votes and try to improve it in the future, or let it die and hope to get back to it in 15 years. If you really think that the status quo is better than the result of this bill, go ahead and try to kill it. I disagree with you, but that happens. Just recognize the obvious consequences of doing so: you get the system we have now into the indefinite future, and no chance of incremental reform building on what has passed.
*I could see reconciliation being useful in the future, to pass bills that make this stronger. I just don’t see it being useful right now. You can’t even break it into two parts, passing the one the parliamentarian would allow through reconciliation and then doing the rest through the normal process. That approach assumes that the clowns like Lieberman can’t recognize what is happening, and will happily vote for the regulatory reforms after having been outmaneuvered through reconciliation. I just don’t see it.
sparky
@kay: this is where i must part company with you. IIRC you have told us that you work within(?) the medical-industrial complex (MIC), so you probably know this better than most of us–the only way the MIC went along with this was by guaranteeing their profits. structurally, ideologically, legally, whatever way you want to call it, that is NOT the same thing as agreeing on universal health care.and this thing will come at a terrible institutional cost. and cost the US money that it will probably not have in the future.
if this bill did establish that proposition i’d certainly be more inclined to go along with it.
but it doesn’t, so i don’t.
Jack
@sparky:
I was perhaps hasty in my choice of terms, since “obscene” has a host of meanings. I favored the archaic, but that was, in near hindsight, akin to favoring the ancient meaning of “truth” (what a man pledged) to the modern (“universal fact”).
J. Michael Neal
@jenniebee:
Can you provide any backing for your assertions? Do you have any reason to think that basic actuarial math no longer applies to this situation? What I’m arguing isn’t even at all controversial among people who study this. You are, pretty much, in the same position as the global warming denialists. Sure, all of the people who have taken the time to learn the subject and research it have a unified view, but that’s no reason to think that they know what they’re talking about, right?
If you want community rating and coverage of pre-existing conditions, you have to take a mandate. If you don’t want those things enough to pass a bill, fine, but you can’t take only half of that package. It’s all or nothing.
Jack
@sparky:
FWIW, I think that core of all faith is desire.
Oddly and maybe just predictably enough, most of us on opposite sides of this argument share a similar overriding desire.
A revolutionary one, even (in the States).
Universal health care.
It’s just that, at the present moment, the argument has broken down broadly into two camps, one arguing from a position of faith, the other from a position of doubt.
Stance and temperament overriding politics and ideology?
Something else?
I’m not sure.
Jack
@kay:
Doubt about the uses and abuses of power does not necessarily indicate disavowal of public commonweal.
J. Michael Neal
@sparky:
Well, uhm, yeah. Entities that exist for the sole purpose of making profits are notoriously unlikely to support legislation that would force them to operate at a loss. Funny, that.
The alternative to doing it this way was to pass a reform package that either eliminated the role of health insurance companies (true single payer), or that left health insurers enough profit to continue to operate but that they opposed. The first of these was never even close to a realistic possibility. Sure, all of us here know that it is, policy wise, the best option, but that doesn’t mean squat in terms of getting it through Congress. Bot a chance.
The second might have been a possibility if the Republicans were a serious opposition party rather than a bunch of crazy nutters. Without any of them, it became necessary to keep every single Democrat and not-really-Democrat-though-he-caucuses-with-them on board. There’s no way to do that if we also have to fight all of the interest groups, or even just a few of them. Co-optation was the only way to go. It was either that, or nothing. So, the insurance companies get something they want.
Cat
@J. Michael Neal:
ROFL. Your as bad as BoB using polar ice cap extent to claim the polar ice cap rebounded after 2007 when thickness measurements show the total amount of ice has decreased from 2004-2009.
Your ‘data’ doesn’t refute my claim as its data from a system that in no way reflects the proposed system. If the data from the past system is still valid for the proposed system its an argument for killing the bill as the old system was filled with insurer fraud, cancellations, and refused treatments all things proposed bill was supposed to do away with.
scudbucket
@J. Michael Neal:
If you want community rating and coverage of pre-existing conditions, you have to take a mandate. If you don’t want those things enough to pass a bill, fine, but you can’t take only half of that package. It’s all or nothing.
There you go again, not hearing what the other person is actually saying. And what the hell does actuarial math have to do with her objections? I think you need to stamp your foot louder, so that she knows your serious about this.
dadanarchist
Exactly – I have no faith in our bought and paid for “representatives” to revisit or revise these statutes for the better in the future. Incrementalism works but only when you have politicians dedicated to crafting policy, rather than protecting special interests.
I hope to be proven wrong, but the insistence that this is guaranteed to happen is magical thinking.
Jack
@dadanarchist:
Especially since it’s a declared faith that policy will unfold just thus, without any politics.
As if the Republicans cannot also possibly manage to cook up a campaign theme about this clusterfuck that might just resonate with Americans.
sparky
@J. Michael Neal: two things–
1. for the nth time, this is NOT medicare/medicaid/SS. this is a handover to the private sector. given your remarks about insurance above it is borderline disingenuous of you to pretend that they are akin. do you really believe that once these allocations are set they will be able to be renegotiated?
2. your argument that if it doesn’t pass now reform will not happen for another 15 years is an argument. you say that is “realistic”, but i say that is just your belief. other than that happens to be the magic number since the Clinton experiment, you have no evidence for that assertion. could you be correct? yes, though i think you are wrong. what’s my evidence? Medicare part D was passed by the GOP. what i infer from that is that there is an incredible potential for passing real change–not because they did it, but because even the GOP sees the wisdom of getting something that is seen as a boon passed. all this demonstrates is that Clinton wasn’t such a great president not that health care reform has some magic 15 year increment attached to it. all that really has to happen is someone has to be an actual leader.
so in sum, so far as i understand it, your position boils down to, “i believe.” no offense intended, but i am no more willing to cede control to the insurers on that belief than i am to hand over science teaching to creationists.
Mnemosyne
@chris:
Actually, it kinda did — backlash against the civil rights bills fueled Richard Nixon’s presidential ambitions and exploiting that backlash got him elected in 1968. I’m about a third of the way through Nixonland right now. People are really, really underestimating how angry people were about civil rights, especially the 1968 act that did away with housing discrimination. It was a major factor in strengthening the Republican Party, especially when the Dixiecrats started turning Republican.
sparky
@Jack: usage is a harsh mistress. ;)
Mnemosyne
@sparky:
The massive clusterfuck that is Medicare Part D is your proof that good healthcare legislation will be passed in the near future? Srsly?
Mnemosyne
@Cat:
If JMN’s data can’t be used because the system doesn’t exist yet, what data are you using to come to your conclusion that a system that doesn’t exist yet is going to suck?
kay
@Jack:
Okay, Jack. Whining that you’re going to have to pay into a pool to cover the uninsurable, without admitting that’s what your doing, will absolutely get you closer to the “commonweal”.
Government mandates spell electoral disaster? This is the liberal position?
Are you familiar with the work of Grover Norquist? Why are you carrying water for him?
J. Michael Neal
@sparky:
Yes, they will be able to be renegotiated. That doesn’t mean that they necessarily will be renegotiated, but it is certainly a possibility. While this is not Medicare or Social Security, those are the best examples we have. I also disagree that Medicare was not a giveaway to private industry. It wasn’t a giveaway to private *health insurers*, but it was definitely a giveaway to health care providers. That hasn’t stopped rates from being negotiated downwards over time.
Your assumption is that, because this bill is not exactly like Social Security or Medicare, that we can’t use any of the evidence provided by those examples to predict what will happen. Further, after assuming away all of the evidence, you assume your conclusion. The argument that your opponents are just operating on faith that something will happen is pretty silly, since faith is all you have to support your own argument.
Sure I do. Based upon the past evidence, 15 years is the low end of the likely wait. Clinton was 15 years ago. That was 22 years after the Kennedy/Nixon attempt at universal health care. That was 22 years after the Truman attempt to provide universal health care. Before that, it had been even longer. All of the evidence we have suggests that this push gets made only once every couple of decades. Again, you want to argue that we should discard all of the evidence that we have and just operate on an assertion.
Equating an attempt to provide a limited form of service (prescriptions) to a limited portion of the population that is disproportionately likely to vote (the elderly) with an attempt to provide coverage for everyone pretty much misses the point.
The problem here is that the *first* stage to universal coverage can’t be done incrementally. There are too many moving parts to community rating/mandates/pre-existing conditions/exchanges/subsidies/etc. You have to have a huge package in order to get anywhere. Once you have those, *then* incremental change becomes possible.
Which is kind of amusing, since you want to discard all of the available empirical evidence and go with your gut.
sparky
@Jack: good point about both “sides” seeking the same goal. speaking as someone who until fairly recently thought an adequate world could be reached through the right process i have some sympathy for that view though i no longer subscribe to it.
scepticism is Sisyphisan; conventional wisdom is a Siren riding atop a steamroller.
Bruce (formerly Steve S.)
I haven’t made up my mind yet on whether the “current bill” is on balance a yea or a nay, but I am concerned about the foundation upon which change will be built. The “current bill” doesn’t establish some tepid little public option to build on, rather, it further entrenches the private insurance industry, though it makes them a little less bad than they are now. And it’s true that some social programs have been improved in our country — mostly we’re talking about several decades ago. In recent years it seem that all the incremental change goes in the wrong direction.
So again I’ll pose my question to the incrementalists: is there a reason to think that any future change won’t be in the direction of further entrenching private insurance? That the “looming fiscal crisis” won’t be used as an excuse to erode the subsidies in the “current bill”?
kay
@Jack:
What’s next?
Big gubmint forcing you to contract with a private trash removal service?
scudbucket
@Mnemosyne:
Interesting philosophical point you’re making here. Points!!
Cat said: the old system was filled with insurer fraud, cancellations, and refused treatments. The current bill contains the same language regarding ‘fraud’ by which deniability is justified, plus there seems to be no constraints on insurcos unilaterally increasing deductibles, co-pays, and out-of-pocket expenses, or reducing lifetime caps. I think the burden here is on the reformists to show explicitly how the system will get better with regards to these factors.
Not that I think there is anything wrong with the current bill.
jenniebee
@J. Michael Neal:
Honestly, you don’t know what you’re talking about. By law, emergency rooms are required to stabilize patients who are dying without regard to their ability to pay. That’s not how they lose money on uncompensated care. Hospitals and doctors lose the vast majority of the money they lose on uncompensated care taking care of people who have insurance. You aren’t subsidizing people who could get insurance and could pay for it but don’t, you’re subsidizing a system… let me explain this to you:
First, every year in America, about a million people declare bankruptcy because of medical bills. 80% of those people are insured. That’s a mid sized city full of people every year. And those bankruptcies – some of the money written off is on credit cards and second mortgages and other debt incurred to pay medical bills, but a lot of it is defaulting on the medical bills themselves. The glibertarian who decided to take his chances and lost might be part of that 20% who were uninsured, or he might be on a payment plan for his $20K broken leg or what have you, but he and his ilk hardly make up the majority of that 20% and that 20% hardly makes a majority of that 80% because of, you know, math.
All of this drives up the prices that doctors charge (and what they charge insurance companies is peanuts to what they charge people who aren’t covered – a tremendous amount of what you pay for when you buy insurance to keep your costs down isn’t for the insurance company to pay on your behalf, it’s for them to negotiate rates on your behalf). This state of affairs, with insurance companies getting charged higher rates due largely to their own denial of coverage, exists because the incentives line up for the insurance companies to work this way. Insurers could cover more and bring rates down, but the rates would only fall if all insurers covered more. Individual gain at a socialized cost has such a predictable outcome that I’m sure nobody could have seen this one coming. Besides, not all the cost gets recirculated back to the insurer through defaults and higher prices because the insured people going bankrupt (let’s not forget about them) tend to empty their bank accounts and pass some of the costs on to BOA and Citi on their way to a lifetime of ruined credit and viewing the words “retirement planning” as a cruel joke.
You are not paying through the nose because of dippy hippy artists or calculating yuppies who are uninsured out of choice. If you want to see the people who you think will be ruining it for everyone if they aren’t forced to pay up, take a drive down to your local auto parts store sometime. The clerk behind the counter, that’s the guy who isn’t paying what you think is his fair share. He makes less than $9/hr, the company he works for has an employee turnover rate of 200% a year and likes it that way, and the insurance he could get through his employer would cost him more than his rent. He has not had a checkup since he graduated high school. Before he’s thirty, he will have started losing his teeth.
One guy like that I know, he was bitten by a dog and spent the next two years paying off the “free care” stitches he got in the emergency room. I’m sure if you explained to him that his irresponsibility is costing you a higher copay and that’s why you think he should be fined for his obstinacy in refusing to think about how his choices affect you, he’d be intrigued by your ideas and ask to subscribe to your newsletter.
Mnemosyne
By the way, I have to say I absolutely love the people who say in one breath that the don’t trust Congress to improve the bill in the future and say in the next that they absolutely won’t vote for Democrats in 2010.
Gee, guys, maybe if you would work to get better Democrats into Congress you could trust them to fix things? Nah, better to act like there really is a permanent Republican majority that’s going to be back any minute now, so we’d better rush through any legislation we can get.
Jack
@kay:
Huh?
[double take]
Again, huh?
You don’t honestly think I have a problem with assuming liability in an insurance pool, do you?
Mnemosyne
@jenniebee:
Everything you posted is an argument in favor of a mandate that spreads the cost through the whole population instead of allowing insurance companies to restrict coverage to a select few and hospitals to charge those few through the nose for it to cover everyone who doesn’t have insurance. I’m a little confused why you posted it as your explanation for why we shouldn’t have a mandate.
Jack
@kay:
Do you always make wild assumptions like this?
scudbucket
@Mnemosyne: Yes, (if I understand you here), the manic-progressive thing. Personally, I think all the heated debate is a good thing, and good for the Democratic party. I think this bill sucks, and I think the progressive wing is certainly justified in being pissed off and vocal. But I will certainly support Democrats in the future against the GOP. Against the Teabaggers? I can’t say.
J. Michael Neal
@scudbucket:
No, it does not. It contains the same language that *basic contract law* contains about fraud. It will *always* be the case that fraud leads to the ability to rescind a contract, such as an insurance policy. Not only will it always be that way, it should always be that way. Fraud makes contracts voidable, end of story.
The question is whether or not non-fraudulent errors should allow a policy to be rescindable. On this matter, the bill does quite a lot. Much of what changes isn’t even explicitly about recission, but rather in changing the environment as to what constitutes materiality on errors.
scudbucket
@Mnemosyne: So much confusion. She’s not arguing against the mandate simpliciter.
Jack
@jenniebee:
Yours is a voice of reason. It may not break through the faith assertions of those asking us to STFU and eat this last, worst concession, or their faith assertions that the very people making these deals will at some point in the future change their temperaments, ideologies and (most importantly) patrons and fix the mess they made.
But, it gives me pause to contemplate that not everyone this side of Bill Clinton is willing to settle for awful.
scudbucket
@J. Michael Neal: You. Are. A. Dolt.
That ‘same’ contract law language is what the insurcos exploit to justify deniability based on false accusation of fraud. Can’t you see anything that’s not printed in you business school text-books?
Jack
@scudbucket:
Again and again with this.
I guess we need to start every reply with “I’m not against the concept of universal health care mandates within a reform package that isn’t also a package of shit sandwiches being sold to us as strawberry shortcake…”
scudbucket
@J. Michael Neal:
Again, you fail to understand what I am saying. Of course contract law requires protections from fraud. But insurcos use what is a requirement for establishing a contract to unjustly violate that contract by claiming fraud with respect to pre-existing conditions. Don’t you get out in the world at all?
scudbucket
@Jack: Yeah, it is somewhat intriguing how anything we say gets processed through a vary narrow filter.
J. Michael Neal
@jenniebee:
Yes, jenniebee, I do know what I am talking about. That is care. You can argue all you want, but the moment a health care professional touches a patient with the intention of preventing them from dying, that constitutes care. It also costs money.
Further, while you may be right as to what emergency rooms are required by law to provide, the fact is that most of them do more than that. They don’t simply stabilize a patient and toss them out, unless you have a very broad definition of “stabilize.” Keep in mind that this applies not only to chronic conditions, where that is a problematic concept, but also acute care, such as a car accident, where it really means something.
So? Again, you can say this all you want, but every study of the matter shows that young, healthy people get back much less than they pay in. Sure, a million people declare bankruptcy every year, but how many of them fall into the category of being young and healthy at the time the decision as to whether to buy health insurance is made? There are conditional probabilities at work here.
Again, so? This has nothing to do with whether or not it is rational for someone who is young and healthy to buy insurance at rates that are set based upon the expected cost of all of the insured, whether they are healthy or not. All you are looking at is the sell-side incentive. Sure, insurers would be able to sell more policies if they lowered prices. What doesn’t happen is that the healthy are as likely to buy a policy as the sick. That’s a problem at any price point.
From the perspective of trying to put together a functional insurance market, *all* of these people are the problem. I’m not saying that all of them are freeloaders in a moral sense; I think that I said things above that could lead to that impression, but that was poor phrasing on my part. The artists and yuppies are, but not so much the guy at AutoZone. However, all of them *are* free riders in the economic sense. Regardless of their motivations or ethics, they create a problem that is very difficult to solve so long as individuals have the choice as to whether or not to buy into the health insurance system. You can’t make community rating or the other things work with such a large free rider problem.
Frankly, I don’t care whether he wants to subscribe to my newsletter. Worth noting is that, if he is actually paying those bills, then he’s not a part of the problem I’m talking about. It’s the people that hospitals provide care to and don’t pay the bills that cause rates for everyone else to go up.
jenniebee
@J. Michael Neal:
Apart from working in health care for over a decade, some of that in insurance (a BC/BS), currently in medicaid, and all of it as an analyst/custodian of company data and developer of payment rules engines, plus having family with even more decades working in the actual delivery of health care in both hospitals and private practice… nope, I got nothin’.
Look, what’s in the public discourse is the boiled down blurbs that become conventional wisdom, like the emergency room schtick. It’s convenient to blame the uninsured, and there’s a grain of truth there. There are costs for performing CPR on bums, but those same experts will tell you that what’s really expensive is managing chronic diseases and paying for CCU and ICU time, none of which gets delivered to people who hospitals don’t think will be able to pay for it one way or another, unless we’re talking about a non-profit hospital and those have been closing lately because they tend to get all the people who can’t pay dumped on them. That’s why the survival rates for accident victims and other people who are admitted to the ER are so much higher for people with insurance (of course, survival rates only affect those for which survival is in some doubt). Somebody who has insurance is going to be stabilized in the ER and then admitted to the CCU or ICU; a person with no insurance is going to be stabilized and then, if they can’t be discharged outright, transported to a public hospital. That’s how it works.
Jack
@kay:
And for what’s it worth – I am obligated to dispose of my trash properly. I am obligated to contribute my share towards the funding of city highway, which collects the trash should I choose not to transport it to the landfill myself. I am not required to contract with a private company to do so.
J. Michael Neal
@scudbucket:
Maybe, maybe not. However, THERE WILL ALWAYS BE PROVISIONS THAT ALLOW FOR RESCISSION IN THE CASE OF FRAUD. That’s basic contract law. Congress probably couldn’t change it even if it wanted to; the courts would throw it out. Simply pointing to the language doesn’t mean anything, because it’s not going anywhere.
Sure, that’s the language that they point to when they rescind a policy. That’s because that’s how you get a contract rescinded. That language is going to remain. The way to change it is to change the environment in which such decisions get made. Such a claim only has merit if it meets the definition of fraud. There are several things that can be done there, including defining what constitutes scienter in such a case, as well as changing the environment in which materiality is determined.
Yes, I do. That doesn’t mean that it is either desirable or possible to say that fraud shouldn’t make a contract voidable.
If you are simply making an argument that our current legal system is designed in a way that allows rich companies to bully poor individuals by making it too expensive to pursue even meritorious claims, great. I agree with you. It’s a very real and a very serious problem. However, it has absolutely nothing to do with the question of whether fraud makes an insurance policy rescindable. That’s just a fact.
Jack
@jenniebee:
My wife works for a not-for-profit OB/GYN office (within a larger non-profit medical facility).
They get every single patient refused by the other practices, every recent immigrant (this is not to be interpreted as a rant against immigrants, natch) on public assistance, almost 80% of the state medicaid recipients for a population pool of nearly 750k, and the overflow and non-routine cases from the city contracted charity clinic.
The organizational endowment is Ivy League affiliated, so there are resources to be had, but they’ve been operating under a wage freeze for nearly two years (chosen by the staff and providers) in order to continue operating at status quo, because the money is drying up and none of the other practices are willing to take these patients.
They absorb untold socialized costs.
J. Michael Neal
@Jack:
As I have repeatedly said, if that were all you were arguing, I wouldn’t have a problem. It’s when you can argue that we can have all sorts of things that depend upon having a mandate while getting rid of the mandate that I respond.
I suppose that I need to start every post with, “If you want to ditch the health care bill altogether, fine. I disagree with you, but you can’t have some parts of it without other parts.”
If you want to kill health care reform altogether, go ahead. I think you are making a huge fucking mistake, and I don’t want to listen to you complain in three years that you can’t get anything even started in Congress, but that’s your call. But don’t try to sell me a pony by saying that we can have strong regulatory reform without a mandate.
J. Michael Neal
@jenniebee:
Uhm, yeah. Thank you for making my point. You just admitted that it is impossible to provide universal care without a mandate, because it’s impossible to pay for the people who need treatment if those who don’t opt out of the system. That’s exactly what I’ve been trying to say.
Jack
@J. Michael Neal:
And which one of us has argued “ditch everything and start again,” please?
Jack
@J. Michael Neal:
At what point did jennie argue “no mandates,” please?
scudbucket
@J. Michael Neal:
If you are simply making an argument that our current legal system is designed in a way that allows rich companies to bully poor individuals by making it too expensive to pursue even meritorious claims, great. I agree with you.
Finally, a concession to a valid argument. Followed by
However, it has absolutely nothing to do with the question of whether fraud makes an insurance policy rescindable. That’s just a fact.
more condescension. What would make you presume that I am so ignorant of the purpose and value of contract law that I would deny the function of necessary penalties for committing fraud with respect to that contract? Where do you get this stuff from?
However, I would add that it is not primarily the fault of the legal system that insurcos rescind policies and deny coverage: it’s built into their business model (not the one you learn in B School!), as evidence by its systematic use to curtail large and continuous payments to clients.
Cat
@Mnemosyne:
I never said I had data that empirically proved the proposed system was going to suck. I have said I don’t believe the bill has enough reform in it to actually extend affordable healthcare to enough people to be worth the increased costs to everyone else.
Their past behavior of health insurance companies shows they will allow you to die if it costs them to much to keep you alive.
The cheapest plan at my company, which still pays for a portion of the costs, will cost around 500 a year for a family and has enough of a deductible that it would cause a median income household to forgo eating or worse if they had to pay for any kind of serious illness. Bought on the open market I’d imagine it would cost 2k under the proposed plan and they don’t qualify for subsidies unless they added subsidies for Median income households while I wasn’t looking.
This is how I know its a crap bill, the median household can barely afford insurance without subsidies, which they arent getting, and they can’t afford to actually get sick even if they had insurance because any insurance they could afford would bankrupt then with out of pocket expenses in the case of an illness.
We receive the bills for my wife’s Chemo and hospitalizations and we thank FSM we opted for the gold package and we are lucky enough to have access to it. If we were some median income household working at some small business some where we’d be bankrupt as it costs well over $100k to get treated for cancer not to mention the forbearance of your employers.
Will
@J. Michael Neal:
Yes, that.
sparky
@J. Michael Neal: i am at a loss as to why you felt the urge to take a fragment of mine out of its context (a reply to someone else) and then rebut your out of context construction. whatever.
@Mnemosyne: no, that’s not what i meant but the fault is mine for not elaborating my point a bit more. on a bit of reflection i think it’s a bad example not because it’s wrong but because it has too many other interpretations attached to it, as your comment rightly shows. sorry about that.
jenniebee
@J. Michael Neal:
Which ones do you want to go after first, the ones who have declared bankruptcy, the homeless, or the dead? Because those are your options. Other than the illegals who give a fake address, but I’m guessing you don’t think they’re part of the problem because a mandate wouldn’t affect them anyway. Doctors and hospitals have collection agencies and they know how to use them. Why you think that there’s this low-hanging fruit of uninsured people with money who just won’t spend it to pay their medical bills and for-profit hospitals who just let them go, I don’t understand.
I am right, and yes, they do. It’s on video. And there is absolutely zero, no, nada, zip, zilch requirement for a hospital to treat a chronic condition for a person who can’t pay.
Maybe an example will help explain this to you. Let’s say that I’m uninsured (been there, done that, and my god is it expensive) and I have an asthma attack. If I go to an ER, they are required by law to do what they can to stop the attack without asking whether or not I can pay. They put a breathing mask on me and let the Epinephrine or Atrovent do its thing. Afterward, the doc writes me a prescription for a $280 inhaler. I spend the next couple of years paying off the $5000 that visit cost. If I don’t pay for my visit, the hospital goes after me until I either pay or am bankrupt or dead. When my inhaler runs out, I’m going to have to find another doc who will write me a prescription for another one.
Is that care? You’ve got a broad definition, you’d say yes. But I’m not going to the doctor to manage or improve my chronic condition, I’m only going to the doctor to get something to stabilize me when the condition becomes life threatening. If I had a heart condition, it would be the same as not having my cholesterol and blood pressure monitored, just showing up when I have chest pains. When people talk about the ER being the expensive way to treat things, that’s what they mean: instead of getting care, monitoring and treating a chronic condition, people without insurance tend to wait until things get really bad and expensive. The location of the treatment isn’t the determinative cost factor, it’s all about that the whole point of an ER is to stabilize patients and then either release them or admit them. A 20 minute office visit and bloodwork every three months costs a lot less than a crash cart, IV drip, massive amounts of drugs, and the rest.
It has nothing to do with selling more policies, it has to do with the source of defaults on payments for medical services. What you don’t acknowledge and can’t answer is the fact that hospitals have collections departments and go after everybody, insured or un, who they believe they can get money from for services rendered. You are not paying to subsidize people who have money. You are paying more to cover the costs of people who have declared bankruptcy, the homeless, and the dead. The reason that those funds aren’t getting recovered by hospitals is that there is no more money that can be legally had that way.
If the mandate came coupled with a public option and means-based rates, I’d be behind it. But the problem we’re having isn’t that the private insurance industry is going bankrupt and is in danger of collapse without more healthy people paying premiums. The BC/BS I used to work for, their annual bonuses for skilled but non-managerial schlubs like me was enough a few years ago that a friend of mine who stayed after I left bought a new boat with hers. That’s for the folks at the bottom end of the org chart. I just don’t know how to say it any more clearly, you are talking about getting money out of a place that there is just no more money to get, for the sake of an industry that’s rolling in it.
J. Michael Neal
@scudbucket:
I get it from you. You said:
Well, yeah. Either you think that it’s a problem that it contains this language, in which case I have to assume that you don’t know that all contract law contains the same language, or you don’t think that it’s a problem, in which case, I have no idea what your point is, because you are arguing like you do. Note that this is not the first thread in which you’ve made this argument.
jenniebee
@Cat:
This this and more this.
The end of my career in private health insurance came when I was gathering requirements to build a reporting database for a managed care program. The idea was that the insurance co would call its customers with chronic conditions and check on them and advise them to manage their conditions better – all good stuff, right? But the data, the metrics, they were all financial. Never once did we check to see if we were saving money because our customers got healthier or if it was because they were dying faster. There’s an adage that whatever you measure automatically improves by 10%. The most frequent outcome we measured was trending premiums vs medical loss.
Thess
Because an incredibly devisive rights expansion that most of the country was shivering-in-the-cellar-with-a-shotgun terrified of is exactly the same as an unprecedentedly popular, desperately needed health care expansion.
Civil rights are exactly the sort of thing that, speaking purely pragmatically, should be done incrementally. I see no evidence that suggests this is a good path for health care reform, and common sense tells me the opposite. You’re worried about the wingnuts taking over? They only get that chance if a shitty bill passes. They get no chance to take over if either a good bill passes or no bill passes.
sparky
@J. Michael Neal:
Um, ok. So you’re with me so far, that this is a possibility. Would you care to assign a numerical value to that possibility?
uh, no, that’s not what i said. the analogy is yours not mine. all i said is that the analogy is dubious at best and gave what i believe is a good reason for doubting its validity. as you are propounding it as a reason for action, it is incumbent upon YOU to explain why it is a useful analogy. i have provided a reason why it is not; you have provided, what, exactly?
and if you want to call my skepticism about your incrementalist idea assuming the conclusion, well, fine. i still say, show me an example of the federal government regulating a sizeable segment of the economy that is not captive to that segment and i will say you at least have a possible argument. without that, it’s just wishing. i at least have a pretty good mountain of capture evidence. again, you have, what?
as for the year claims, i will grant you that the efforts have occurred at intervals. as i said above, that is an argument, but as you know, i could offer up some facts that contradict that notion pretty easily, so there is no “proof” on this point one way or the other, and of course there can’t be. it certainly could be used as a talking point, though it seems a bit strange to make something that is incapable of being proven the basis for passing legislation now. that said, i do not think legislation should be enacted on the basis of what amounts to a scare talking point, and i especially don’t think bad legislation should be enacted on the basis of a scare talking point. i would have thought the Bush years would have conclusively demonstrated the pernicious consequences of enacting legislation using scary talking points but apparently i was wrong.
i already agreed that Part D was a bad example, again, because people can read too many other things into it, as you, validly, did.
as for your last point, it seems to be raised as a rebuttal to something i didn’t say. as far as i can tell you seem to be convinced that everyone who disagrees with you has a particular construction in their head that is independent of whatever it is we type here, and it is that construction with which you seem to want to engage with, endlessly. in my case it’s not necessary.
J. Michael Neal
@jenniebee:
None of them. I want everyone to buy into the system *before* they get sick. That way, all of these people get covered by the premiums paid by the people who don’t need large scale health care. This is the very basic concept of insurance. Arguing about who should pay *after* they get sick is a completely different argument.
In order to get the sick and the homeless covered, the people who are not sick and not homeless must be required to buy into the system, both to cover the sick and to cover the unlikely occurrence that they might get sick. You keep skipping right past the point at which discussing risk pooling, or the entire concept of risk, makes sense. It can’t be discussed within the frame of things that have happened, or that will happen, only things that might happen. Your use of the past tense in the instances in the above paragraph negate the entire point.
No, believe it or not, I understand all of that. That’s why I’m pushing INSURANCE. If everyone has to buy in, then the people who do get sick don’t have to cover the entire cost of their treatment. The people who have insurance but don’t get sick subsidize them. However, if the people who are unlikely to need the insurance, and for whom the expected value of benefits received is lower than the premiums don’t have to buy insurance, a lot of them won’t. That simultaneously does two things:
1) It means that, the small subset of that population that does have a catastrophic problem will be forced to declare bankruptcy, AND everyone else that does buy insurance will see their premiums go up in order to cover the cost of the catastrophic care that person receives. Meanwhile, the ones that don’t need serious medical care BUT MIGHT HAVE GIVEN THE KNOWLEDGE POSSESSED AT THE TIME OF THE DECISION NOT TO BUY lived their lives in a situation where they had a fallback position of universal emergency care without ever paying for it. Sure, it’s really crappy care that they get, but it’s better than nothing. It is, in effect, a really bad health insurance policy that doesn’t charge a premium. That’s free riding.
2) Without that set of people that would produce fewer costs to the system, the premiums have to be set based upon the expected costs of those that do buy policies. You lose premium revenue faster than you lose health care expenses as healthier people opt out. That means that you have to charge higher premiums to those left in the system. That means that there’s an even larger group of people for whom it doesn’t make sense to buy insurance in the first place. It creates a vicious cycle in which more and more people opt out. Fortunately, since some of the people for whom it is an irrational (in the economic, not the psychological, sense) buy it anyway, you eventually converge to a market-clearing price for an insurance policy at which the market works. However, this is at a point where premiums are much higher, and the number of people insured is much lower, than they would be in a system in which everyone is required to buy insurance.
I know I’m repeating myself, but you seem to be ignoring the most basic elements of my point. As soon as you start arguing about who should have to pay for coverage after it is delivered, you’re on the wrong track. That’s exactly what I want to avoid.
J. Michael Neal
@Cat:
Well, yeah. And? As I’ve said repeatedly, I agree with the argument that we would be better off if we came up with a system that eliminated private health insurance companies role in providing basic coverage. (I have no problem with allowing them to continue to sell supplemental policies above what we determine should be available to all.) The problem is that this is a complete impossibility at the moment. No conceivably passable legislation would do this.
We’re stuck with the fact that insurance companies are going to be involved, and that they are profit motivated. That means that they will prefer to let you die if it saves them enough money. The question is what environment we want them to be making those decisions in. Simply saying that a profit motivated company is motivated by profit doesn’t answer that question.
My preference is that they have to use community ratings and accept people with pre-existing conditions. Given that I want those, I accept that we have to require that everyone purchase insurance. I think that those things are important enough that I’m in favor of the bill even without a public option. That’s particularly true since a public option that would actually serve the purposes people want it to died months ago. If that was your big objection, the events of the last week have meant nothing; Holy Joe didn’t actually kill the bill in any meaningful way, since it died in the House.
scudbucket
@J. Michael Neal:
I get it from you.
Touche, though frankly I thought you could do a little more here.
I have no idea what your point is…
Well, of course not, because I explicitly stated it in the comment you referred to:
it is not primarily the fault of the legal system that insurcos rescind policies and deny coverage: it’s built into their business model (not the one you learn in B School!), as evidence by its systematic use to curtail large and continuous payments to clients
I really don’t know how to make that point any clearer. Now, I know you will go on about ‘materiality’ and what not, but those legal constraints on rescission already exist in case law or by legislation and the insurcos fail to act in good faith regarding them.
That, in a nutshell, is the point!!
Edit: I leave it as an exercise for you to determine a) how this point has no bearing on the discussion upthread, and b) fail to infer from this point to a broader point, which also has no bearing on comments made upthread.
jenniebee
@J. Michael Neal:
Said it before and I’ll say it again, you really have no clue what you’re talking about, but you have a firm grasp of the talking points.
There’s no one here that I’ve seen on this thread who has objected to mandates in conjunction with a public plan because a public plan just like a public hospital has to take all comers regardless of their health or their ability to pay. A private plan just like a private hospital can, and does, find ways to ditch anybody who isn’t profitable. What this bill does is to shift the method they’ll use to do that from denying people outright to denying them by making coverage unaffordable. A mandate with that just punishes people for not being healthy, wealthy and young enough for Humana’s taste.
J. Michael Neal
@sparky:
Not really. My whole area of interest in academic research is on the subject of *not* assigning quantitative values to things that we can’t provide more than a vague guess on.
Not really. There’s no natural state here. If the question was whether or not the health care system would be better if we changed it, you might have a point, though it’s undercut by the fact that the current situation is so bad. When we are in an environment that is so evidently suboptimal as the current one, the Burkean (Hah! Used it in its proper context!) argument that you are making, that we should be inherently skeptical of change loses a lot of its power. We’re in a situation where a high level of variance is a good thing, since there is so little about the current system to mourn if it cracks.
However, that’s not the question at hand. You are arguing that there is no compelling evidence that letting this bill die means that there will be no health care reform in the near future. In this instance, the burden of proof is on you, because you are the one arguing that it is different this time. In every previous instance, the death of an attempt to provide universal health care was followed by, at the absolute minimum, 15 years of inactivity on the subject. Every. Single. Time. Why is it different now? I don’t find your position any more compelling than the 2005 argument that it was different this time and house prices really would just keep going up. If you want me to believe that there really will be serious attempts at reform in the near future after killing this bill, tell me why history is no guide here.
I’m not sure what you are getting at here. If you want to argue that regulatory capture is, in general, a problem, I’m with you. It is. However, what does this have to do with the question of whether this particular attempt at regulatory reform is better or worse than some unknown attempt in the future? Your argument applies equally as much to this hypothetical as it does to the current bill. Regulatory capture will still be a problem. It doesn’t seem to me that the next try will be any less subject to it. It seems that you are arguing that health care reform is an impossibility, but I don’t think that’s what you mean.
Until you offer up these facts, I don’t know that you could do so very easily. Please, what are they?
Well, we disagree that this legislation is actually *bad*. I agree that it is far from perfect. I agree that it delivers a lot less than I had hoped. I agree that we need to keep working to make improvements in the system after it passes. I disagree that it is not an improvement on what we have right now. Every study I’ve looked at indicates that it would increase the number of people who have insurance, lower average premiums, slow the growth rate of health care costs, allow people with pre-existing conditions to get access to individual health care, provides subsidies for people up to 400% of the poverty line (a lot of people in this thread seem to be forgetting this one), and establishes the basic principle that everyone should have access to health care.
Howard Dean was less ambitious than this in 2004. The people who object to this so much would have been thrilled to get it in the recent past. Yes, it allows the insurance companies to continue to make money. I can live with that.
Jack
@jenniebee:
In support of this, a reasoned argument from elsewhere:
http://sideshow.me.uk/sdec09.htm#12171438
Shorter that:
“Here’s a clue: One reason commercial insurance mandates work in the few countries that have them (although at far greater expense than the other countries that don’t have them) is that in all of those countries, health insurance is non-profit. It has to be. That’s the law. Oh, and they have to deliver, too.”
J. Michael Neal
@scudbucket: All that’s nice. What I don’t get is how you go from the point that the insurance companies’ business model includes doing some thoroughly immoral things (agreed) to the conclusion that it’s a problem that the bill recognizes basic contract law.
Yes, they do, which is what makes your continued complaining about the language of the bill so dumb. Whether that language is in the bill has nothing to do with whether the insurers behave in good faith. That exact language is going to exist regardless of that. If you want to argue that insurance companies behave immorally, and therefore we would be better off without them, go ahead. However, given that we have them, focusing on the language of the bill in this case isn’t any sort of argument at all. It’s basic boilerplate.
So, I guess your point is perfectly clear. I just think that it'[s stupid.
scudbucket
@J. Michael Neal:
I get it from you.
Touche, though frankly I thought you could do a little more here.
I have no idea what your point is…
Well, of course not, because I explicitly stated it in the comment you referred to:
it is not primarily the fault of the legal system that insurcos rescind policies and deny coverage: it’s built into their business model (not the one you learn in B School!), as evidence by its systematic use to curtail large and continuous payments to clients
I really don’t know how to make that point any clearer. Now, I know you will go on about ‘materiality’ and what not, but those legal constraints on rescission already exist in case law or by legislation and the insurcos fail to act in good faith regarding them.
That, in a nutshell, is the point!!
Now I leave it as an exercise for you to a) determine why this point has no bearing on what was commented on upthread, and b) to fail to infer from this point to a broader point which also has no bearing on comments made upthread. But one thing is certain: you will not actually address the point.
jenniebee
@J. Michael Neal:
I’ll give you the numbers again:
1 million people will declare bankruptcy this year because of their medical bills
80% of them will have medical insurance.
Average medical expenses of those with insurance filing for bankruptcy is around $20K
For those of you playing at home, that’s US$16B in medical bankruptcies for the insured.
For the uninsured, it’s about $27K in expenses for those filing for bankruptcy, which comes to about US$5.4B
Meanwhile, insurance companies collect what is it now, 16% of our $14.2T GDP in premiums, of which 27% is redirected to “administrative costs” and profits. For those folks playing at home, that’s US$613.4B in salaries and profits. The total medical bills of all those bankruptcies amounts to 3.5% of the insurance industry’s non-medical costs. The total for just the uninsured is only 0.88%.
That’s the money that the uninsured are holding out on us by getting their “free” health care. Basically, in 2008, somebody in America went bankrupt because BC/BS wouldn’t pay $20K of their medical expenses, and instead they gave just about exactly that much as a bonus to my friend who was a dba for them, and she used that money to buy a boat.
And here you are, arguing that the real problem is that more people aren’t forced to give their money to the insurance companies, whether they have money to give or not. All I can say is that, if this thing passes, the next round of bonuses at insurance co’s should land heavily in the PR departments, because those guys will have earned it.
J. Michael Neal
@jenniebee:
To reach this conclusion, you have to ignore what is actually in the bill. How many times do people have to point out that the penalty for not buying insurance only applies up to 8% of income? They can’t both keep raising rates *and* take advantage of the mandate. Further, with community rating, they can’t deny coverage just to those who are sickest, which is what they want to do. Once they set the premium price, they have to take all comers.
No. This sentence means that you don’t understand what a mandate does. It “punishes” people who *are* young and healthy, not those who aren’t. It’s the young and healthy who will be getting less for their money. They will face higher premiums than they would without community ratings, while the people who are chronically sick will get lower premiums.
As for those who aren’t wealthy enough to meet Humana’s tastes, if they charge too much, then those people are in exactly the same position they are in right now: they don’t have any health insurance. They aren’t any worse off.
scudbucket
@J. Michael Neal:
I just think that it’[s stupid.
So, just to be clear here: you’re saying that, in light of the mandate requiring US citizens to purchase private insurance, additional provisions to guard against the immoral and illegal practices of insurance companies with regard to rescission and denial of claims … is stupid?
J. Michael Neal
@jenniebee: You still aren’t making any relevant arguments. You are also making factually inaccurate ones. Health insurance companies don’t collect anything like 16% of GDP in premiums. That’s the figure for total health care spending. It includes things like Medicare, Medicaid, and the VA system, as well as all care paid for by something other than insurance. That includes co-pays. If you are going to provide numbers, try to provide accurate ones.
You can’t even keep up with your own posts. Your lengthy calculations omit the costs that you pointed out that are borne by non-profit hospitals. There are plenty of other sources of these costs. However, let’s just unpack the numbers you did give, adjusted for what private health insurance actually collects.
In 2008, private health care insurers paid about $600 billion in health care expenditures. This implies that they kept a little more than $200 billion in revenues for their services. Much of this goes, not to shareholders or executives, but rather to your average employee who isn’t getting $20,000 bonuses. Private health insurers employ about 450,000 people, who all need to be paid. Based upon figures from Fortune, I’d guess that total health insurance profits were less than $15 billion in 2006. The figures you are giving as estimates for the deadweight losses associated with unpaid medical bills, once adjusted both down for the percentage of the market that private health insurance covers as well as up for all of the losses that you miss, constitute a very large percentage, possibly more than 100%, of this figure.
This is not to say that the insurance companies are efficient, because they are not. Again, if we could get them out of the business of basic coverage, I’d be all for it, but I don’t see any prospects of that. Given the relative numbers and running them through ROI calculations, it looks to me like those deadweight losses probably have a very substantial effect on the premiums the companies need to charge.
jenniebee
@J. Michael Neal:
I hope you’re right and I know you’re wrong. “Insurance” can be watered down to mean as little as you mean by “care.”
Honestly, this attitude is why liberals get the bad rap they have. Conservatives don’t think that anything can go wrong with a well-intentioned war and God help us, liberals don’t think anything can go wrong with a well-intentioned program. That’s your theory of who will be affected, but it isn’t too hard to anticipate insurance companies getting sick customers off their books by pricing plans out of their reach, at which point, the people who need insurance most won’t only not be able to get it, they’ll be charged a fine for not getting it.
A mandate to buy public insurance is a mandate that runs both ways, because the state is also mandated to provide care that’s affordable. A mandate to buy private insurance in a system that is mathematically, demonstratably, already turning a profit for private insurance companies is bordering on sadistic.
They’re 8% of their income in fines worse off with nothing to show for it.
J. Michael Neal
@scudbucket:
No. I think that, given basic contract law, the specific argument you are making to demonstrate the lack of provisions to protect us from insurance companies is stupid. Really, really stupid. Your continued pointing at the language that allows rescission in the case of fraud has absolutely *nothing* to do with whether or not sufficient protections exist. That language is going to be exactly the same whether the protections are sufficient or not. Fraud will always be grounds for rescission. That the bill allows this is a big, “Duh.” If you want to demonstrate that there aren’t sufficient protections, you need to dig into the conditions under which fraud would be a valid claim, not that it is allowed as a claim.
jenniebee
@J. Michael Neal:
ROFL. Yeah, because County hospital is a charity that never charges for all that free care everybody else is ruining things by getting. You really don’t have a grasp of this beyond regurgitating talking points and scapegoating the uninsured. Just you keep on chasing those mythical rich 20-somethings who are holding out on us and keep passing blanket punitive measures trying to get at them. Ignore the facts and keep sticking to theories no matter how many times people explain to you that the circumstances in which those theories apply don’t actually exist here. Just keep clapping your hands and believing in mandates.
Enjoy your permanent Republican majority, you’ll have earned it.
J. Michael Neal
@jenniebee:
That may or may not be true in practice, but it has nothing to do with the mandate. The mandate absolutely, positively makes insurance more expensive for the healthy relative to the sick. You seem to be looking at other problems, and blaming them on the mandate when they are the result of something else. I think that you understate the protections for the less healthy, but you are certainly focusing your ire on the wrong part of the bill. The mandate puts pressure in the other direction. The problems that you are looking at would be worse without it.
No, it isn’t. Profit is not, in and of itself, evil. The government mandates that people pay into the profits of private companies all the time. It usually does so by collecting taxes and then buying stuff from the private companies itself, but this isn’t really any different than that. In this case, the government is just cutting itself out as the middleman on the purchase, and telling you to pay the company directly. This is a tax, just like any other tax. Given the subsidies, it isn’t even a regressive one.
No. For God’s sake, could you please take the time to figure out what is actually being proposed? No one is charging fines of 8% of anyone’s income. As shown in a link back in post 19, the fine for an individual without insurance in 2014 is $95. That goes up to a maximum of $750 in 2016. For a family, the maximum fine that can be assessed under the bill is $2,250.
The 8% cap is that the cost of the cheapest plan can’t exceed 8% of your income. If it does, then the maximum fine you can pay is $0. No one is going to go bankrupt by being fined nothing.
J. Michael Neal
@jenniebee:
You were the one who said that all of these hospitals are going bankrupt from trying to cover the poor. I’m curious as to how an organization that charges enough to cover its expenses is going bankrupt.
I give up. You keep making blatantly incorrect arguments and contradicting yourself.