The morality of waiting for a pony

My  last post was a fairly technical dive  into Wyden waivers, subsidy bundling and actuarial value calculations.  It was an effort to explore a plausible future possibility space that in my opinion would lead to more people who are in the bottom half of our society to be made better off than they are today. It is,  as a commenter pointed out , a convoluted kludge to work within the context of our current political reality instead of an advocacy for maximal efficiency or effectiveness that can not be passed within the next decade.  I think that is a fair description of how I am trying to use my minuscule amount of influence to nudge policy in a better direction.

So when I see  arguments like the following , my moral sense is highly offended:

Health is not just another commodity for Wall Street to bleed to death. I am tired of these posts that attempt to make the writer appear to cheerlead for improving the system, rather than dealing directly with the con game that health insurance and health care has become. No wonder Trump’s ridiculous braggabully talk of cutting through the bullshit resonates so strongly.

The implication is single payer or bust and anything else is selling out to the man.  In a world with no political constraints, I would agree with this argument that creating a convoluted, complex system that mostly but not completely solves the stated problem at higher than needed costs is not an ideal solution that should be pursued.  However we don’t live in an ideal world.

We live in a world where vested interests have significant say.  We live in a world where there are numerous veto points that favor conservative interests in the best of circumstances (2009/2010) and reactionary interests in most circumstances.  We live in a world where large liberal majorities are fleeting (1933-1937, 1965-1966, 2009-2010) and even then the liberal majorities are dependent on a significant number of representatives and Senators who represent right of the nation seats.  We live in a world where ideal policy for anyone other than the top 2% or post office naming candidates can not be enacted.  We live in a complex and imperfect world.

Furthermore, I don’t think  American liberals are well positioned to take advantage of “shock doctrine” moments.    Enacting liberal policy plans in a shock moment is tough as liberal policy goals broaden the possibility space while most “shock” moments contract the possibility space.  These shocks are moments of high scariness.  Scariness means people and politics retract inwards and becomes far nastier and less complex.  People as a whole will sign off on inflicting pain on others of  lower status and power if that means they are re-assured that in doing so, they avoid pain that was otherwise hit them.

This is how I view the world.

And from there, my morality dictates that I do what I can to make things slightly better on any given day, especially if that slight improvement benefits people who need more help.  So that means advocating for improvements that continue to entrench a complex, bifurcated health insurance system as I don’t see any action today to smash the machinery of the insurance industry paying off for a generation or two.  I could be wrong, but I will take a bet that the insurance industry is recognizable and prominent in twenty years versus it is a supplemental industry appendage to a single payer (esque) system.  And I will give very good odds.

I can respect people advocating for single payer.  If I can be convinced that there has been  significant policy homework   done on a single payer plan and a plausible pathway to assemble a winning coalition (both electoral and interest group), I’ll hop on board.  However I don’t think holding one’s breath and condemning millions of people to more pain in the hope that the contradictions will be sufficiently heightened in a long shot bid that the entire American employer sponsored health insurance complex will death spiral itself out and from the wreckage, a panacea policy can be implemented is a viable strategy to actually achieve positive policy change.

I could be wrong, but in the mean time, I’ll keep plugging away at making things incrementally better.

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145 replies
  1. 1
    JPL says:

    Bravo!

  2. 2
    BGinCHI says:

    Great post, Richard.

    I agree on the incremental approach, since we have to play with the electorate we have and not the one we wish we had (see elections, KY).

    But I also think incremental politics is a matter of maturity. As I’ve gotten older I see the wisdom in pecking away at hard projects. When I was younger I just wanted to fight about everything. And I mean everything.

    Hell, I’m not even sure I want smart young people in their teens and twenties to believe in the incremental approach. Let them bang away and find out for themselves how things work. Plus some of them might just be successful where we were not.

  3. 3
    Baud says:

    You probably won’t even sit out the next election, you sell out!

  4. 4
    BillinGlendaleCA says:

    @Baud: If he sat out the next election, how could he vote for Baud!!!2016!!!?

  5. 5
    Linnaeus says:

    I can respect people advocating for single payer. If I can be convinced that there has been significant policy homework done on a single payer plan and a plausible pathway to assemble a winning coalition (both electoral and interest group), I’ll hop on board.

    Same here, although I’m skeptical that we’ll ever get single payer in the US.

  6. 6
    LAC says:

    Well said! A bracing bit of reality and maturity to start the new year with on balloon juice

  7. 7
    rikyrah says:

    The implication is single payer or bust and anything else is selling out to the man. In a world with no political constraints, I would agree with this argument that creating a convoluted, complex system that mostly but not completely solves the stated problem at higher than needed costs is not an ideal solution that should be pursued. However we don’t live in an ideal world.

    \

    TELL IT OVER AND OVER AND OVER AGAIN!!

    I’m so tired of these pony and unicorn muthaphuckas I could SCREAM.

    Saw one on facebook this past week, and just wanted to cuss him out…but, life is too short.

    If you can’t see the MILLIONS that Obamacare has helped..

    and the MILLIONS MORE that could be helped if GOP Governors weren’t evil sociopaths…

    We have nothing to talk about, because you don’t live in the real world.

  8. 8

    @LAC: fuck, I am sorry for bringing gallon Juice into repute :)

  9. 9
    FlipYrWhig says:

    @Linnaeus: I can sort of imagine it happening if a coalition of the biggest employers decided they had had it with benefits administration and wanted to throw the whole thing over to the federal government to deal with. But if it’s the government’s responsibility, that means injecting MORE politics into everything. Good luck having abortions covered in a single-payer system paid for and administered by the government, for example.

  10. 10
    Mike J says:

    @Linnaeus:

    Same here, although I’m skeptical that we’ll ever get single payer in the US.

    They couldn’t even make it work in Vermont where they have magical Bernie sprinkles to make everything wonderful.

  11. 11
    FlipYrWhig says:

    @Mike J: They just need a “political revolution,” then.

  12. 12
    Linnaeus says:

    @FlipYrWhig:

    Yeah, in the US context, that’s probably the more likely path to single payer. Although that runs counter to most employers’ preferred option, which is to have all costs borne by the consumer.

  13. 13
    Linnaeus says:

    @Mike J:

    True, although I don’t think that’s proof that it can’t be done. Just that it’s really hard.

  14. 14
    BGinCHI says:

    @Mike J: We all know HRC sabotaged it there so that BS could never be Prezinent.

  15. 15
    MomSense says:

    I’m always hoping the people who advocate all or nothing are just expressing frustration and not actually stating their preference that millions of us go without access to health care while we wait for that magical day to arrive. If you have never been without health insurance, you can’t really know just how stressful it is.

  16. 16
    low-tech cyclist says:

    Kludgy as Obamacare is, it was the best we could do in 2009-2010, and even then, we just barely got this sucker over the line. (Remember spending the first few months of 2010 calling up our Congresscritters and begging them to just Pass The Damn Bill, when it looked as if Scott Brown’s special election win had brought the whole thing to a halt, inches short of the goal line?)

    It’s a long way short of perfect, but that hasn’t stopped it from doing a world of good.

    Maybe there will come a day when the Republican Party is thoroughly discredited, and the Dems have a 75-25 majority in the Senate. And when that day comes, sure, single-payer might be within reach.

    But in the meantime, we’re damn lucky to have Obamacare. And anything that we can do to improve it at the margins is absolutely worth doing.

  17. 17
    MomSense says:

    @FlipYrWhig:

    I always assumed it would be insurance companies wanting to peel off more and more of the 55 and older into Medicare as it becomes more expensive to insure them.

  18. 18
    Satby says:

    I also answered that asshole on that thread:

    @Docg: Trump resonates with idiots. And as one of the people who spent more of my life without health insurance, thus without health care, I am happy to “settle” for being covered against catastrophe. As a “lowly mental health care practitioner”, I assume you’ve enjoyed many of your six decades with health insurance and the ability to get care. About 1/2 of my six decades I have gone without.

    I notice that after dropping his sanctimonious turd he never responded back to Richard, dr. bloor, or me.
    People like that are as sociopathic as the right wingers who would let people die, because none of us are actual individuals whose suffering is real to them. A non-sociopath accepts small improvements that help people as better than nothing; a sociopath committed to his ideology doesn’t care; it’s all or nothing, currently suffering people be damned.

  19. 19
    Roger Moore says:

    I can respect people advocating for single payer. If I can be convinced that there has been significant policy homework done on a single payer plan and a plausible pathway to assemble a winning coalition (both electoral and interest group), I’ll hop on board.

    I would also say that it’s important to continue to advocate for single payer (or NHS!) as long as it doesn’t come at the expense of supporting incremental improvements to the current system when they’re available. We’re never going to get from here to there unless there are far-sighted and/or crazy people advocating for it even when it seems politically impossible. To give an example, Bernie Sanders continues to advocate for single payer, but his vote was still there to pass Obamacare. That’s what a responsible advocate does.

  20. 20
    FlipYrWhig says:

    @MomSense: That’s possible too. I’m just imagining that if big corporations decided they’d had enough they could get old-school Republicans and business-friendly Democrats (think Mark Warner) to forge a win-win solution: help American businesses’ balance sheets and create a wonkish technofix that delivers a baseline level of effective services to a large population. And the sop to culture-war Republicans would be that they get to raise a ruckus over abortion, contraception, gender resassignment surgery, etc.

    The biggest sticking point is always going to be doctors complaining over reimbursement rates. People distrust the government, distrust politicians, distrust insurance companies… and trust doctors all too well.

  21. 21
    Betty Cracker says:

    I’ve also been a realist about health care reform — better half a loaf than none, etc. But I can understand the frustration of the commenter whose remarks inspired this rebuttal. I don’t assume that he or she thinks its okay to condemn millions of people to suffer and die to heighten the contradictions. You seem to believe that’s a self-evident assumption about anyone who calls bullshit on the current situation, but that’s the most uncharitable possible reading of that commenter’s admittedly short and un-detailed contribution to the discussion.

    I find Dr. Bloor’s more nuanced comment on the very real problems with the ACA and the implications of defending it more persuasive.

    In the original fight for ACA passage, I remember urging people who opposed it on “single payer or bust” grounds not to let the perfect be the enemy of the good. We should also be cautious about letting the incremental improvement be the enemy of the transformative.

  22. 22
    MazeDancer says:

    “Incremental change” is the foundation of Mr. Obama’s philosophy. He will always choose movement forward, no matter how small, over holding still. He believes that incremental change creates a solid foundation for continual progress.

    This belief maddens many. Even if “incremental change” is the foundation of reality, and how change happens in institutions, society, and even people’s inner landscape.

    The only broad, instant, yet, lasting changes that come in methods other than increments are via disasters. Hurricanes, floods, fires, wars, bombs. Those all make big shifts overnight. Yet, people will often try to build back exactly what was there without consideration of would new create better.

    Even political revolutions are the result of long festering needs, as Jefferson noted in the Declaration. (Which is an eloquent outline of how change – psychological and physical – really happens.)

    The further people are from the reality of the 3-D, including how the planet, itself, functions – like seasons and how long it takes to grow things – the more they believe in instant perfection. Technology has encouraged this belief.

    Great post, Richard. May we all join you in promoting good change over no change at all.

  23. 23
    Snoopy says:

    my morality dictates that I do what I can to make things slightly better on any given day, especially if that slight improvement benefits people who need more help.

    Amen, brother.

  24. 24
    FlipYrWhig says:

    @Betty Cracker: But that sneery comment was also suggesting that discussing the system was tantamount to endorsing it, implying in turn that the right thing to do is fulminate against it at all times. We all already know that something closer to single payer would be better than the status quo. There’s no point in Richard’s using his platform to wave his fist at clouds and demand of someone unspecific that things in general be better in some way. It’d be like asking a film critic to lament the films that aren’t being made rather than to evaluate the ones that we can actually see.

  25. 25
    WaterGirl says:

    @MazeDancer: There was a great article written before Iowa even voted for Barack Obama in January of 2008.

    I don’t recall the title, but it totally debunked the ‘obama is a radical’ crap and it made a really strong case for Obama as an pragmatic incrementalist.

    What’s the old saying about none so blind as those who will not see?

  26. 26
    The Thin Black Duke says:

    Maybe it’s simplistic, but I think that the loudmouths who advocate this “all or nothing” philosophy are people who have never had to deal with a serious medical issue. Until I was diagnosed with stage III stomach cancer in 2009, I thought I had good medical insurance. I didn’t, but I was glad for what I had. Bottom line, not having access to health care in this country is playing Russian Roulette with a loaded gun, and the well-meaning but foolish people who try to minimize that bleak reality might as well be accessories to murder. Sick people don’t have the luxury to wait for that unicorn to take them to the promised land.

  27. 27
    Betty Cracker says:

    @FlipYrWhig: I agree to a certain extent — it was a drive-by comment. I’m grateful to Richard for shedding light on so many aspects of a byzantine system. But sometimes I think we get so defensive about the ACA that we lose the plot.

  28. 28
    WaterGirl says:

    My sister votes in every election, but she is quite apolitical and not well informed. She feels like she can’t do anything about it anyway, so she ignores all of it and just goes about her daily life.

    But as I said, she does vote. I was with her yesterday when I realized that it was 8 years ago to the day that I left for Iowa to work for obama before the Iowa caucuses. I admit to being a bit tears eyed thinking about that.

    She asked who I was going to vote for this time, and it’s clear that she shares my dislike of Hillary Clinton, just from the way she said her name. I said I don’t like her either but that I will vote for her if she’s the democratic candidate.

    Without really thinking about it, I went for the simplest argument. I told her that I think it’s just wrong that one person gets sick and they get to live because they have money, and another person gets sick and they have to die because they can’t afford treatment. I talked about Kentucky ad how hundr,needs of thousands of people are going to Lise their health care because They voted in a republican governor who vowed to repeal it. She said that can’t happen, someone would stop him.

    I’ll spare you the st of the conversation, but I am hoping the life and death arguement will stick with with her where a more complex arguement would not.

  29. 29
    ruemara says:

    That person, sorry Betty, is a moron. You know how England got an NHS? A massive war that blew the structures of most of the country. We’ve passed the point where a radical restructuring like that could happen easily. And no, I fully hold people who wanted to scrap the system and hold out for single payer or bust are perfectly OK with the tragic losses that would have continued. It’s a type of emotional porn that some love. Every cause needs some good martyrs. Incremental progress isn’t a bold revolutionary act, according to those. But the feeling of health and security that the ACA has given literally millions, even ungrateful Tea Party fools who keep voting for people who’d take it away, that’s fucking revolutionary. You are in the right, Richard. I appreciate your healthwonk posts, even as I have seen and experienced the shortfalls of the ACA itself. But I wouldn’t get rid of it at all.

  30. 30
    The Thin Black Duke says:

    Moderation? What did I do?

  31. 31
    Emma says:

    Even a quick scan of a half-way decent history text will show you that groups under pressure become idiots or monsters, not saints, which is why stories of the few people that swim against the tide become best-sellers. Expecting people to under social and economic stress to embrace exchanging what they have for the unknown is to lose sight of the basic premise.
    Exhibit one: Kentucky.

  32. 32
    BGinCHI says:

    @The Thin Black Duke: Go for a Time Out until you can say you’re sorry.

  33. 33
    WaterGirl says:

    @WaterGirl: Shorter WaterGirl:

    I went for the moral arguement rather than the political one.

  34. 34
    gene108 says:

    After 80 years, incredible success, and reliance and expected reliance by generations of Americans on Social Security, there are conservatives in this country who want to find ways to gut Social Security.

    Until we weed out these people, how can you guarantee Single Payer would not be gutted the second Republicans control government again?

    The incompetence of Bush, Jr., 9/11/01 pushing his disastrous foreign policy agenda to the forefront of his first term, and Hurricane Katrina and its aftermath, coinciding with Bush, Jr.’s attempts to drum up support for privatization helped push off the latest round of seriously gutting Social Security.

    Put a competent Republican President in charge, with a Republican controlled Congress and we can kiss Social Security good bye.

    There’s no way in hell Single Payer would survive in this country. The conservatives in this country are crazy and they are dedicated voters.

    The problem with Single Payer is more than just technical. It is cultural.

  35. 35
    Roger Moore says:

    @WaterGirl:

    I don’t recall the title, but it totally debunked the ‘obama is a radical’ crap and it made a really strong case for Obama as an pragmatic incrementalist.

    I think Obama is and isn’t a radical and an incrementalist. He’s a radical in his goals, but an incrementalist in his methods. It’s a frustrating position for people who share his goals but not his methods to watch, because it looks so much like selling out.

  36. 36
    MomSense says:

    @FlipYrWhig:

    I think the business friendly Democrats are the old school Republicans. I think the reimbursement situation is going to change on the private insurance side, too.

  37. 37
    Betty Cracker says:

    @ruemara: If our goals are the same — and I think they are, i.e., basic coverage as a right for everyone — I guess it boils down to what you think it the more effective way to build a coalition to achieve them. I’m saying that calling people who are disgusted with the status quo morons and would-be murderers isn’t a good strategy for building that coalition, though I can well understand the passion behind those remarks.

    There are very good reasons to be disgusted with the status quo. I’m glad people are continuing to push for single-payer since it is unquestionably a better approach, even though I agree it isn’t politically feasible right now and probably won’t be for many years. Tearing down Obamacare would be a huge mistake, but so would stifling dissent about Obamacare on the left.

  38. 38
    Kay says:

    I do think Democrats have to pay attention to affordability, particularly regarding the group of people who make enough to keep them above Medicaid but don’t get employer-provided insurance. I am getting complaints that the program is too expensive. It worries me because resentment will follow in Medicaid expansion states- people who are barely making it will resent people who have less and get Medicaid and honestly it becomes ludicrous to call the lower middle income people “selfish” when they express this- they are just above being low income. They’re not “selfish”. They’re drowning.

    One of the reasons we make these programs universal (poor AND lower middle class) is political- I think of it as middle class people “standing in front” of poor people, which benefits lower middle but also makes poor people less vulnerable. It’s quite literally a bigger and thus more powerful group of people who benefit when lower middle and poor are combined. Democrats have to make sure lower middle people think this is a “good deal”, partly because that helps poor people.

  39. 39
    MomSense says:

    @Roger Moore:

    It may be frustrating but working hard for incremental change has been the most successful path for change in our history. Social Secutity excluded a lot of people (like my grandmother) when it was first enacted. To get the votes FDR had to compromise with the Southern (racist!) conservadems in the Senate Finance Committee. We have greatly expanded Social Security since then but it was not without consequence. I doubt my grandmother wanted to spend her golden years raising her bratty grandchildren and keeping house for my parents but she didn’t have any money for her retirement.

  40. 40
    Betty Cracker says:

    @Kay: That’s a great point. I’m also concerned about the heftier penalties that are about to kick in for people who don’t qualify for Medicaid and feel that they can’t afford to buy coverage under Obamacare. I understand the rationale behind the penalties and agree that they’re necessary. But I think many people are going to be blindsided by them, and that could create a new anti-Obamacare constituency.

  41. 41
    MomSense says:

    What bothers me more than anything is how little libersls and progressives are talking about the people who fall into the Medicaid Gap. I wish Sanders and Clinton would talk about the millions of working poor people and their families could have health care now if it weren’t for psychopath Reoublican Governors and legislators. The silence in this is cruel.
    ETA I wish every D person running for any kind of office would shout from the rooftops about this.

  42. 42
    Enhanced Voting Techinques says:

    I don’t know, Liberal evolution seems to work well enough. Take gay marriage for example – that was more like a paranoid fantasy of the hard right in 2001 than anything anyone on the left seriously expected to see in their lifetime. The flip side is once a liberal program is in place the numerous veto points keep it from being removed by reactionaries.

  43. 43
    Kay says:

    @Betty Cracker:

    Me too. I cannot overstate the importance of tax refunds for working class/lower middle class people :)

    It is LITERALLY the one and only time they have a bigger chunk of money. They plan to spend it- they buy cars, catch up on mortgage and other debt payments- they buy “big things”- appliances, water heaters- they will notice if they’re fined. If you make 30k and have children, 5k at one time is the biggest payment event” of the year, by far.

    OTOH, child support has been collecting payments for mandatory health insurance for children for a long time- close to a decade, and child support isn’t just for divorced people, it’s for “never married” parents and there are a lot of them. Bush put it in with a federal rule change and states adopted it with “enabling” legislation. In Ohio, if they come in at over 150% of poverty level and don’t have health insurance for their children they pay 5% of gross in medical support payments. There’s precedent for this “mandated” concept- much narrower, obviously, and it’s *technically* state law, but when it went in everyone thought there would be outrage and there wasn’t. People just accepted ti as “fair”.

    People generally put “programs to benefit children” in a different category, though, in my experience, so maybe adult insurance is different.

    It’s why Democrats got so much traction against Bush with his refusal to expand S-CHIP. Nancy Pelosi was outraged every day for months – she took full advantage of the “for the children” thing :)

  44. 44
    amk says:

    It’s 2016 ffs and we’re still having this argument? That pony should have been dead by now.

  45. 45
    Kay says:

    @MomSense:

    The reality is Democrats have to walk a fine line with these programs. The worst thing for the ACA would be for it to become a welfare program, because that makes it instantly vulnerable.

    I really feel as if FDR understood this in a way that LBJ didn’t, which is funny, because one of those two was actually poor growing up and it wasn’t FDR.

    I cringe when Kasich goes into his bullshit “I love the poor routine” on Medicaid because they can’t be culled from the herd like that- set apart- they have to be IN with the lower middle class or they’re screwed.

  46. 46
    tamiasmin says:

    Hardly anybody gets it completely right the first time. Even God had to start over with Noah, or so the story goes, and things are still suboptimal. Maybe the third time?

    Our glorious Constitution, which some people say is the greatest document ever written, gave disproportionate power to small states; left millions of people enslaved; and only suggested eighty years after its first adoption, by reference to ”male inhabitants” in the Fourteenth Amendment, that women may exist. Those terrifying beings could not be mentioned explicitly even in the Nineteenth Amendment, which says that the right to vote shall not be denied or abridged ”on account of sex,” sounding to a modern ear as if voting was previously limited to celibates. But in including a procedure for amending the Constitution, its drafters made clear that it was not the last word on governance, and many substantial and progressive changes have been made. The alternative to odious compromises was not immediate perfection but limping along with the Articles of Confederation or abandoning the very idea of a United States.

    If everything must be perfect from the beginning, it is not just better institutions or better policies that we require, but better humans. Still, with all of our hesitations and equivocations and setbacks, we seem most of the time to be going in the right direction, toward a more inclusive and benign view of other people.

  47. 47
    MomSense says:

    @Kay:

    I know that it is tough to defend welfare and yet I am working with some desperate people. One guy could very well lose his leg because he cut his shin on some metal at the wharf. If he loses his leg, he and his family will lose everything. As it is I don’t know how they will cope with the medical bills and loss of his income. There are a lot of people in rural America who can relate to his situation.
    If I had money I would run ad campaigns showing the people who catch our fish, clean our rooms, serve our meals, watch our kids with the message that we work hard every day, and no matter how tough we are sometimes we have to go to the doctor.

  48. 48
    Kay says:

    @MomSense:

    My son’s school is about 50% lower income. They have a code they punch in for lunches so they (supposedly) don’t know who pays and who doesn’t but I was listening to them talk and they talk about it- not paying or paying for lunches. Some pay, some pay part and some pay nothing. I asked my son is it matters- do people get made fun of, etc. and he said “it wouldn’t because there are a lot of people who say they don’t pay”. That’s a kind of herd immunity. That’s grouping working class and poor in a way that protects the program and the individuals.

  49. 49
    Eric U. says:

    single payer sounds like a really good idea until you realize that you would be dependent on Republicans to fund it. And not only that, but with such a big pot of money, there will be republicans surrounding it trying to steal some.

  50. 50
    Kay says:

    @MomSense:

    This is harsh, but I once had a conversation with Sherrod Brown where he told me rural health care providers are the best advocates for Medicaid expansion. I told him the CEO of our hospital (who is a truly horrible individual and wingnut and makes more than 99% of people IN the county) wrote a dishonest rant to local paper on Obamacare.

    Brown said, smiling, that they all secretly lobby Democrats while denouncing government health care for a really simple reason- they want to get paid. He says that guy lobbies him for Medicaid :)

    So maybe ask them to stop lying and admit they want to get paid and they don’t really care who pays?

  51. 51
    ArchTeryx says:

    For me, I’ve experienced the ups and downs of Obamacare in the starkest of terms, mostly because while the fight was going down, I was still employed…and by the time it concluded, I wasn’t any more.

    When Obamacare passed, I felt a vast sense of relief, because it meant my permanent medical condition would continue to be treated after I lost my job. Then the Supreme Court took it all away by making Medicaid optional. I faced a stark choice: Move from the refusenik state I lived in, or die in slow agony. It really was that simple.

    And I was very, very lucky. I had a friend willing to let me crash in his spare bedroom in New York, which unlike my home state, took the Medicaid expansion part of Obamacare. It took me 6 months of fighting to get them to recognize that I had no income, but once they did, I’ve been on Medicaid ever since.

    And yes, the Medicaid system is seriously screwed up, and prevents me from working jobs I otherwise might be able to work because to lose Medicaid, but not be on employer-sponsored health insurance, is to lose my life. I have no money to spend on $6500 deductibles and 20% co-insurance. I’d go from having care to not having care. Single payer would be the only way I’d ever have true peace of mind.

    But I wasn’t interested being a martyr then and I am less interested in it now. Martyrs don’t move this system, even en masse, so it would be a pointless death, and one that would come with a massive amount of pain. So the Purity Ponies, many of whom are upmarket and have secure insurance, can all bite me – they would condemn me to slow torture and death as surely as the wingnuts would. I hope like hell a D gets elected President this election, because the next choice for me might be to leave the country or die…and I don’t want to do that.

  52. 52
    MomSense says:

    @Kay:

    I think there is a way to do it that involves making the case to lower middle income folks who know how precarious their economic situations are that Medicsid is there for them if something happens. I also think that we should tell people how their local hospitals benefit. Local hospitals are valued employers.
    I think we are at the point where we have to let go of some of the CW and get creative about how we tell this important story.

  53. 53
    NCSteve says:

    @rikyrah: Speaking as a Kentuckian who immigrated to North Carolina, and avoids FB like the clap for that reason, if the worst thing you have to deal with on your FB page is posts by Rainbow Unicorn Purity Pony Lakers, you should count yourself lucky.

  54. 54
    gex says:

    People like that remind me of libertarians. Glibly immune to or ignorant of the complexities of how things got to be the way they are and the political realities. It’s all fun and games to say that if we started with a blank slate, this would be the best system to design. It’s another to believe that we can ever go about this as though we are starting from a blank slate.

  55. 55
    Kay says:

    @MomSense:

    I think they should just slowly expand Medicaid like they did with SCHIP so it covers everyone under 40k.

    This slicing and dicing of people is exhausting. It’s probably deliberate on the part of conservatives. If they keep us all divided they win.

    It’s not what you’re doing, but the reason I’m sort of defensive about this is there is a type of advocate for the poor who make the huge mistake of setting this up as working class versus poor- working/middle class should be more generous, is the implication. I think that’s a big mistake because it’s what labor organizers call “slice and dice”- peel off groups and set them against one another. It ends up as conservatives setting middle class against poor people and liberals setting poor people against middle class. It’s an argument based on scarcity and fear- conservatives insist poor people are taking from middle class and (some, in my view misguided) liberals insist working/middle class are taking from poor.

    99% of politics in the US can be summed up with the word “fair”. It has to be fair :)

  56. 56
    cahuenga says:

    Everyone has ethical/moral limits – When your limits for compromise exceed mine you become a “purist”. “Purity” has been and always will be a non sequitur. It’s what people say when they have no rational arguments left.

    Frankly, the calls for “baby steps” and lowered expectations has been nothing short of a slow downward death-spiral promoted by people who often have one foot in the grave and solidified economic trajectory. Gen X and millennials simply can’t afford baby steps, if they even exist or ever materialize..

  57. 57
    FlipYrWhig says:

    @cahuenga: And the alternative is?

  58. 58
    Kay says:

    Bill Kristol is ‘semi-serious’ about launching a new third party. That’s a bad idea.

    Happy New Year! :)

    I thought this election would be boring but it’s showing real humor potential.

    https://twitter.com/TheFix?lang=en

  59. 59
    Ruckus says:

    @Kay:
    When you think of a drowning man you probably see someone in a large body of water who can not foresee swimming mile after mile in water far too deep to do anything else. That is what being without insurance is about, being so deep in over your head that there is no hope. Now make that ocean into a lake that’s 10 ft deep and 4 miles across. Swimming may be doable but it’s a cross between will you drown or will you die of the exertion. When there is no way for you to afford insurance (pre ACA) that’s the ocean. When there is a possibility but it is still pretty remote and very difficult how is that much different for most?
    Granted for those who it does work the ACA is much better, for those just holding their nose above water (little to no subsidy) it still feels like drowning. And of course the opposition just says, see how bad obamacare is, without of course mentioning that they are the cause of it being shitty.

  60. 60
    Goblue72 says:

    @Kay: Well said.

  61. 61
    J R in WV says:

    Some interesting grains of wisdom in this thread.

    I’m strongly in favor of single-payer, even with the problems noted above of 1) creating such a large pot of funding that Republicans create a feeding frenzy trying to steal from it, which seems inevitable to me given the greed factor of many Rs ( I mean look at the ways they have proposed stealing from Social Security already! ) ; 2) expecting Rs to help fund a health program sufficiently to keep everyone healthy, when they don’t even believe in science based medicine.

    So maybe America as a nation isn’t mature enough to have a responsible approach to medical care coverage.

    In Europe things like mouthwash and skin lotion is what people pay for. If you’re really sick there’s no charge most places. They appear to not even have a method to bill people from “away” when they have an infection or allergic reaction. Now that is mature!!

  62. 62
    OzarkHillbilly says:

    @cahuenga: Having witnessed 57 years of ‘baby steps’ I can say you are wrong. Sometimes it is hard to be patient but the alternative is worse.

  63. 63

    There are a couple of different needles to thread here.

    If you have a broken machine, there is one thing you must do and two things you may do.

    You must acknowledge, at once and continuously, that the machine is broken. It is not okay to pretend that it isn’t broken.

    This is not a piece of ponyism; it is entirely pragmatic, because only once you have done this are you able to do the other things, which are:

    1. Try to fix/replace the machine.
    2. Try to go on using the machine even though it is broken.

    The problem with #1 is that it may be radically infeasible. Hold that thought.
    The problem with #2 is that anything you try to do with a broken machine may have unpredictable/inconsistent/perverse results.

    #2 is where we are. In principle, #1 and #2 might be pursued concurrently. But the radical infeasibility of #1 is also where we are.

    So the unpredictability/inconsistency/perversity of the only results we can get compels us, once again, for pragmatic as well as philosophical reasons, to proclaim, at the top of our voices and at each opportunity, that the machine is, indeed, quite throughly broken. We cannot appear to excuse this or to be unaware of it.

    The implications of the infeasibility of fixing or replacing the machine, however, go much, much farther.

  64. 64
    NCSteve says:

    @Roger Moore: Obama’s politics and policies are, and as best I can tell always have been, rooted in the philosophy of John Dewey. The reason he frustrates so many people are a) lamentably, the only people who learn about Dewey these days are people who took at least a couple of philosophy classes in college and b) people who seek to solve moral or socioeconomic or political problems by resort to dogmatism or simplistic bromides are pretty much the at the core of Dewey’s critique and thus unlikely to find him anything but infuriating.

    And the thing is, this same contest for the mind, if not the soul, of the Democratic Party, which is playing out here in the comments on Richard’s two threads, has been a core struggle in the Democratic, and at one time the Republican, Party for decades.

    That contest was fully and finally resolved in the GOP a couple of decades ago. Dewey lost. Democrats would do well to take heed of the consequences.

  65. 65
    Kay says:

    @Ruckus:

    I think the amount of some of the deductibles and out of pocket are daunting, in a way that doesn’t seem to recognize that for a lot of people saying “5000 dollars” is like saying “a hundred thousand dollars”.

    They don’t have it. They don’t have anywhere near that at one time, ever, except for the 2 weeks after they get their tax refund, which leads us to the next problem, because that’s where the fine is coming from!

  66. 66
    gene108 says:

    @Kay:

    I do think Democrats have to pay attention to affordability, particularly regarding the group of people who make enough to keep them above Medicaid but don’t get employer-provided insurance.

    @ArchTeryx:

    but not be on employer-sponsored health insurance, is to lose my life. I have no money to spend on $6500 deductibles and 20% co-insurance.

    When is the medical profession going to have to account for why they are sucking up more and more of the money from everyone?

    The problem isn’t Democrats, though Democrats will pay the price for other people’s problems.

    Until the medical profession can explain why their costs keep going up year after year, faster than anything else in the country, with the exception of college tuition, there’s not a lot one political party can do to solve the issue.

    More needs to be done to shed light on how screwed up the providers are with regards to where the money goes and hopefully some positive changes changes can come out of it.

  67. 67
    Matt McIrvin says:

    @gene108:

    Until we weed out these people, how can you guarantee Single Payer would not be gutted the second Republicans control government again?

    That’s an argument against any national health-care system with government involvement. They’ll gut the ACA the second they control government again. There will be a strong political incentive against just yanking everyone’s insurance entirely, but they’ll do their best to carve it down around the edges. And the same political dynamics would be involved with a single-payer system.

    (I’ve even seen Republicans use this argument, even though it’s the classic two-step of arguing that government doesn’t work because you’re hellbent on sabotaging it. “Why would you trust your health insurance to the likes of me? I’ll kill you and your family! Vote for me!”)

  68. 68
    Ruckus says:

    @Eric U.:
    I am dependent on a government healthcare program, the VA. And it is constantly underfunded by congress, republicans specifically. I am also in another government program that I depend on, SS.
    Both of these are underfunded by congress, republicans specifically (and sometimes a few democrats!). I’m not getting a cost of living increase in SS for 2016, thanks to congress. 2015 it was less than $8.00/month but every bit helps.

  69. 69
    Sherparick says:

    @Linnaeus: This is where the Sanders acolytes (not Sanders) lose me. Let us look at the history of attempts to get Universal or near Universal Health Care in the United States. http://www.pnhp.org/facts/a-br.....-in-the-us It is a litany of partial reforms and a failures of all the ambitious universal systems until the Affordable Care Act (Obamacare), and consequently has proved a political liability, arousing no enthusiasm on the left (which sees it at best as modest reform of a corrupt system or as some commentators on this blog state ad nausem, a “sell-out” to the insurance companies and drug companies, and fanatical hostility on the right which sees it a socialistic taking from the “producers” to give to the “takers.” The result being two disastrous mid-term elections when the Democratic vote turn-out was not spiked by Obama himself at the top of the ticket. This is not the way to encourage politicians to endorse single payer. A Presidency alone, as the 100 years of failure under TR, Woodrow Wilson, FDR, Harry Truman, John Kennedy, LBJ, Jimmy Carter, and Bill Clinton indicates, is not enough. Nor is that failure explained just by the power of plutocracy. The fact of the matter Americans usually feel much more solidarity along racial, ethnic, and religious identities then they do on a class identity based on shared economic interests. http://digitalcommons.ilr.corn.....t=articles

  70. 70
    Ruckus says:

    @Kay:
    I know/knew that you understand this, I thought that a vivid simile might just point out how dire the situation is for many.

  71. 71
    FlipYrWhig says:

    @gene108:

    Until the medical profession can explain why their costs keep going up year after year, faster than anything else in the country, with the exception of college tuition, there’s not a lot one political party can do to solve the issue.

    This. Add pharmaceutical companies too. And of course this is the sticking point for single-payer: just because the government pays can’t mean that the government reimburses every doctor for every treatment regardless of price or effectiveness. And that’s when doctors start squawking about “rationing” and so forth.

  72. 72
    gene108 says:

    @Frank Wilhoit:

    This is not a piece of ponyism; it is entirely pragmatic, because only once you have done this are you able to do the other things, which are:

    1. Try to fix/replace the machine.

    SNIP

    The problem with #1 is that it may be radically infeasible. Hold that thought.

    #1 is not infeasible to fix.

    Line up every medical service provider executive, who has power over where they money goes and how prices are set, against “the wall” and demand they explain why prices keep going up.

    When the first one can’t answer, bang…go to the second one…and so forth and so on, until they get the message that their bullshit won’t fly…

    Fixing the problem – and single payer won’t fix it all by itself, because we have a Single Payer system in this country already in Medicare/Medicaid – is to figure out how much it actually costs to do medical procedures and then figure out how much extra you need to charge to keep hospitals, doctor’s offices, etc. running.

    Getting $10 from Medicaid, $20 from Medicare, $25 from Private Insurer A and $35 from Private Insurer B for the same procedure is no way to run anything or figure out where the pain points actually are in terms of why costs keep going up and up and up.

    Get the cost end of the equation sorted out, so you know what you are paying for and then you can fix the problems in the system, with regards to affordability.

    As long as we’re throwing more and more money at providers, year after year after year, there’s nothing we can do address affordability.

    @Kay:

    Brown said, smiling, that they all secretly lobby Democrats while denouncing government health care for a really simple reason- they want to get paid. He says that guy lobbies him for Medicaid :)

    He should be first up against the wall, when the revolution comes. His getting paid is killing people.

  73. 73
    MomSense says:

    @Kay:

    Wasn’t the point of the PPACA to slowly expand Medicaid? We are dealing with a particularly ruthless opposition who were willing to forego hundreds of millions of dollars just here in the low population state of Maine for political gain. They were willing to sacrifice the lives and livelihoods of the same people who voted for them in their elections to the state legislature and governor. On our side we didn’t even tell people what was at stake beyond expanding MaineCare. We need to make it clear what that means in human terms because these people think Obamacare left them behind and they use it as a further reason to think that the President and Democrats don’t care about them.

  74. 74

    No wonder Trump’s ridiculous braggabully talk of cutting through the bullshit resonates so strongly.

    Trump’s central plank is racist hate speech, and everyone knows about it before they know about any of his other positions. There are even less crossover voters involved than with Ron Paul. The lie that Trump has uncovered some liberal streak in the GOP must never be allowed to stand.

    EDIT – @Emma:

    Expecting people to under social and economic stress to embrace exchanging what they have for the unknown is to lose sight of the basic premise.
    Exhibit one: Kentucky.

    Kentucky is the exhibit for why you are wrong. In Kentucky, vast numbers of people under economic and social stress voted to destroy what they have, Kynect, and embrace the imagined pony they will get when the Undeserving are crushed.

  75. 75
    Ruckus says:

    @cahuenga:
    Not all of us older generation are “set.” Some/lots of us are in the same boat as the younger generation, we can not work or work well paying jobs anymore, we lost or never had everything in the recession and we have more medical problems and still need to eat and house ourselves while looking at the rest of our lives knowing that it will never be any different.
    And don’t forget that Medicare is absolutely not free. You pay every month out of that huge sum you get for SS for it, and it doesn’t cover the cost of everything.

  76. 76
    gene108 says:

    @Matt McIrvin:

    That’s an argument against any national health-care system with government involvement. They’ll gut the ACA the second they control government again. There will be a strong political incentive against just yanking everyone’s insurance entirely, but they’ll do their best to carve it down around the edges. And the same political dynamics would be involved with a single-payer system.

    Single-Payer is the government paying for everything. It is much more vulnerable to being gutted by an unfriendly government.

    Even, if Republicans try to repeal the ACA, they will probably not be able to carve out everything in one go. There a components to the ACA that some states can still try to maintain on their own, even without the Federal Government, as Massachusetts demonstrated with their health care reform 10 years ago. New York State, California and a few other Democratically controlled states could still keep covering people in some shape or form.

    Other aspects, like not being denied coverage due to pre-existing coverage, can probably remain intact.

    Also, you have powerful corporate interests that have benefited from the ACA and will push business friendly Republicans from utterly destroying a source of steady income.

    I just don’t see single-payer building up or surviving a Republican government in the same way the ACA can. Single Payer advocates are expressly out to stick in a shiv in the side of the private insurance market. They’d love to see private insurance companies cease to exist. That right their is turning a current advocate for the ACA into an enemy.

    There are probably other pro-business groups benefiting from the ACA that would get frozen out, if single payer were enacted.

    There was a lot of coalition building that helped get the ACA off the ground, with regards to corporate interests. I don’t see single payer being able to build a popular enough coalition to outweigh current vested interests and the right-wingers in this country.

  77. 77
    Ruckus says:

    @Frankensteinbeck:
    Trump is the bullshit.

  78. 78
    Emma says:

    @Frankensteinbeck: No. In Kentucky people who had gotten health care for the first time in their lives consciously chose to vote against their best interests. The reason only matters as an illuminating side-effect.

  79. 79

    @Ruckus:
    …yes, actually. Well spotted, and true in exactly the sense that anyone who says he ‘cuts through the bullshit’ claims to mean.

  80. 80
    dr. bloor says:

    @gene108:

    Getting $10 from Medicaid, $20 from Medicare, $25 from Private Insurer A and $35 from Private Insurer B for the same procedure is no way to run anything or figure out where the pain points actually are in terms of why costs keep going up and up and up.

    One of the advantages of single-payer, which you seem to think is a nonstarter, is that one rate gets set for a particular procedure, medication, etc., adjusted regionally. (Think $20 from Medicare” across the board). Add to that a greater degree of control to force providers to use best practices for any given medical problem. A government-run monopoly would have a marvelously salutary effect on prices.

    Certainly more feasible than your charmingly Trumpesque suggestion that we start shooting people.

  81. 81
    boatboy_srq says:

    @Richard Mayhew: Wins the “inadvertent autocorrect truth’ of the day.

    Brilliantly stated, overall. I must confess, though, that the last time I said something like this (about another unrelated Progressive pet rock) in the libprog blogosphere, I was called a PINO (Progressive In Name Only) and nearly booted from the blog for my heresy. It’s as good to have a reasonable audience as it is to present reasonable positions.

  82. 82
    Kay says:

    @gene108:

    Honestly, though, I feel like states will force this issue. You’re already seeing it- they’re expanding licenses for nurses, physicians assistants and even pharmacists to give them a bigger chunk of primary care. One of my sisters is a CPA for medical practices. She says there’s real upheaval in health care. She primarily deals with physicians and they’re absolutely feeling this pressure -they’re almost redefining physicians as “case managers” with more and more direct care going to nurses and assistants. She says it makes “hands on” (general practice) physicians miserable, because the reason they got into it was to do “whole patient” care. They feel as if their profession is being destroyed by managers- “technocrats” which is almost a universal complaint in any field these days, really, so physicians aren’t alone in that- teachers say the same thing and so do lawyers.

  83. 83
    Ruckus says:

    @gene108:
    So many people have no idea of how big the health insurance industry is, nor how convoluted. My last doctor before I got in the VA (and I had no insurance, paid cash and got a discount for it, as well as at the prescription medicine store in the building) had more people doing insurance paperwork than providing medical care. That’s not only a huge cost inflation but it is also jobs for the paperwork people, paperwork welfare if you will.
    Had some friends ask me why the ACA took so long to roll out and I asked them how big did they think that the medical industry/healthcare insurance industry is? And how long do you think it might take to make changes as radical as the ACA is in an industry this big? Rolling out single payer would be even more of a challenge and there would be all those paper pushers out of work. That’s not even counting what you hinted at, the amounts that the medical industry profits or where those profits go.

  84. 84
    Keith says:

    @gene108:

    @Kay:

    Brown said, smiling, that they all secretly lobby Democrats while denouncing government health care for a really simple reason- they want to get paid. He says that guy lobbies him for Medicaid :)

    He should be first up against the wall, when the revolution comes. His getting paid is killing people.

    There is an interesting anecdote about just how it was that Britain got their physicians and surgeons (the BMA) to buy into the NHS – for it was not any sure thing.

    But much as he might mock, Bevan was pragmatic enough to know that he could not run the NHS without consultants, doctors and nurses. Faced with the threat of a BMA strike, he conceded that GPs would retain the freedom to run their practices as small businesses. The consultants were given more money, and allowed to keep their private practices. In Bevan’s own blunt words: “I stuffed their mouths with gold.” Faced with a shortage of nurses, he also pushed up their wages to attract recruits.

    Paying for care is the one universal rule. How you pay for it is the variable recipe – with either beneficial or deleterious consequences.

  85. 85
    Betty Cracker says:

    @gene108: Someone above mentioned what strikes me as the most viable path toward building a coalition for single payer: convince the Chamber of Commerce types that they’ll be better off in the long run extricating themselves from an employer-based system that hampers them economically.

    @Emma: From what I’ve read, the people who benefited most from Kynect didn’t vote at all. There’s the problem.

  86. 86
    Ruckus says:

    @Frankensteinbeck:
    We are of course both correct. tRump is running a campaign based upon two things, first, I think he believes his bullshit, at least to a large degree. He couldn’t keep up this level and keep raising the bar if he didn’t, he isn’t nearly this good at anything. Second he is running to win, and I think this because of the first part and because he thinks he’s better at anything than anyone else. It’s how he can turn 40 million into less than if he had just invested it in a mutual fund but tell everyone that 3 is equal to 9, no, 3 is equal to 10 billion.

    tRump is bullshit and tRump spreads it out thick because he believes it.

  87. 87
    Kay says:

    @Keith:

    He’s just horrible. He got a letter published in the WSJ once and he was just over the moon. There’s probably 20 people in this town who read the WSJ so, you know, he had to tell us.

    His main complaint about the health care law was he would have to offer his vast low wage, part time support staff better health insurance- a “qualifying” plan. The big gallows humor in town was the low-level hospital employees had crap health insurance.

  88. 88
    FlipYrWhig says:

    @dr. bloor:

    One of the advantages of single-payer, which you seem to think is a nonstarter, is that one rate gets set for a particular procedure, medication, etc., adjusted regionally. (Think $20 from Medicare” across the board). Add to that a greater degree of control to force providers to use best practices for any given medical problem. A government-run monopoly would have a marvelously salutary effect on prices.

    Aren’t those also why doctors will never stand for it? How do you prevent doctors from blowing up any attempt to pay them less or otherwise change their ways? Per Keith above, what’s the best way to stuff their mouths with gold, when so many of them already have plenty of mouths full of gold and no reluctance to stop speaking?

  89. 89
    texasdoc says:

    @gene108: I’m seeing a lot of comments that complain about the costs of medical care and use the phrase “medical providers”, with surrounding context that suggests that doctors and the reimbursement they get are the cause of medical inflation. Actually, doctors’ fees are only a very small part of medical costs. You could argue that doctors order too many expensive tests/procedures, and there is some of that. However, I would argue that the cost of care in hospitals and (particularly speaking as an oncologist) the cost of medications, are far more significant. Who can possibly afford a drug that costs $80-100,000/year? Even with good insurance, the copays will be expensive. And the insurance company has to take that into account when setting rates. Some treatments (Harvoni for hepatitis C for example) end up being rationed/not paid for due to cost. New cancer drugs are priced unreasonably, even the ones that are only minimally effective. I think pharmaceutical companies should be regulated like utilities–it’s OK to make a profit, but we’re not going to let you make a killing.

  90. 90
    Ruckus says:

    @FlipYrWhig:
    Maybe because a lot of doctors have costs, like insurance paper pushers, and reimbursement levels that aren’t quite in line with what we are told we pay. Yes many get paid well, some maybe too well but that comment above where I paid cash ($85 for a 5-10 minute visit, that took about 1 1/2 hr from walk in to walk out in 2006 in Marin county CA) how much did the doctor see? I’d bet somewhere about $20-25.
    If I remember correctly dr. bloor is an actual practicing physician and has discussed this before. But it’s like my first business, a machine shop. The shop rate for work was considerably higher than what I made, there are capital costs, the machines/buildings, employee labor costs-about 1/3 of the total, insurance-both workers comp and health, utilities and we used a lot of electricity-nearly 10 times what my home utilities cost………it goes on.
    A doctors office will have similar cost factors, even though the ratios/amounts will change.

  91. 91
    dr. bloor says:

    @FlipYrWhig: Oh, the lobbying against single payer would be intense and driven by more money that you could spend in eleventeen billion lifetimes. But it would be physicians guild organizations (which is an animal apart from “doctors”), insurance organizations, hospital associations (again, not “doctors”), and others working in concert. I really don’t think “doctors” alone have the pull to kill such an initiative.

  92. 92
    gene108 says:

    @FlipYrWhig:

    This. Add pharmaceutical companies too.

    I think people have a better idea on what the mark-up is on pharma and where it’s coming from.

    We’re in a better position to bring down pharma costs because of this, because we have a starting point. Pharma companies know what it costs to produce (R&D, clinical trial, etc.), manufacture, ship, etc. a drug. The publicly traded companies make some level of disclosures on their costs in their public filings.

    What it costs a doctor to see a patient or perform a procedure is a bit less transparent than a black hole.

  93. 93
    gene108 says:

    @Betty Cracker:

    Someone above mentioned what strikes me as the most viable path toward building a coalition for single payer: convince the Chamber of Commerce types that they’ll be better off in the long run extricating themselves from an employer-based system that hampers them economically.

    If the escalation of health care costs, since the failure of “Hillary Care” 20+ years ago hasn’t gotten the business owners of the world to unite in demanding single-payer and/or an end to employer based coverage nothing will.

    Like I said up thread, I think the resistance to single payer is cultural and not just something that’s going to be solved by great legislation and good policy.

    You need an all out effort to educate and inform the public to change its thinking.

    We’ve sort of done this with regards to smoking, seat belts, etc., as well as attitudes towards women working and race relations*.

    I just don’t see how to align media, corporate policy(on paper at least), etc. to the goal of single payer like we have with other social issues.

    * Race relations are not perfect and women aren’t treated the same as men, but things are better than they were a generation or two ago and are generally trending in the right direction.

  94. 94
    FlipYrWhig says:

    @dr. bloor:

    But it would be physicians guild organizations (which is an animal apart from “doctors”), insurance organizations, hospital associations (again, not “doctors”), and others working in concert.

    Fair point, but the public understands all those organizations to be “doctors,” and since they trust doctors, that’s a huge obstacle to reform. (Get a bunch of white-coated doctors doing spots on TV talking about how the Universal Health Act or whatever would put them out of business and jeopardize their patients and the status quo immediately wins.) Seems like there would need to be a loud pro-reform doctors’ organization that tried to negate the pressure those other entities are bound to apply.

  95. 95
    burritoboy says:

    I hate purity ponies more than anyone, but I do think we should also keep this in mind: politics doesn’t only run on incremental progress either. You must be able to communicate big and inspiring goals too. Most of FDR’s New Deal programs were incremental, or small, or had little marginal impact. But he could communicate the hundreds or thousands of small changes by putting them together as a big, inspiring whole that the vast majority of people of the time were proud that the country was working towards, even if most people could never even hope to grasp what the entire program of changes and efforts meant in a detailed or technical way.

    You can’t ignore that emotional level either. People want to, maybe even need to, feel that they’re a part of doing something big and meaningful and important and good and positive, even if their particular benefit or role in that big something is inevitably very small or technical. To take FDR as an example: nobody except for FDR and a comparatively tiny number of his closest policy makers really oversaw the New Deal or WWII on the macro or holistic level. You could (and FDR often did) put them all in one conference room. Heck, at Bretton Woods, FDR did the same for the entire global economic structure. But hundreds of millions of people (and not just in the US, either) were emotionally satisfied by doing their own one small part in those huge efforts.

    Everybody who marched with MLK knew that they were a part of something important, even though their own individual role was, for most, comparatively pretty marginal and fairly humdrum. And even the victories that even FDR or MLK won were sometimes small (being able to ride in the front of the bus in Birmingham Alabama doesn’t turn Birmingham magically into some sort of Edenic Utopia – it’s still Birmingham, Alabama.) But those leaders were able to add those victories together into efforts that changed the world.

  96. 96
    gene108 says:

    @dr. bloor:

    One of the advantages of single-payer, which you seem to think is a nonstarter, is that one rate gets set for a particular procedure, medication, etc., adjusted regionally.

    I don’t think rates getting set is a non-starter, but what is the rational behind setting them?

    In most transactions the rational for setting prices is “my cost is ‘x’ and my price will give me ‘y’ profit”.

    How can a single payer system set prices, without know what the actual cost of a procedure is? Or some such method of calculation that will yield the minimum price a provider needs to receive to stay in business?

    To go from what we have now to single-payer, without addressing the arbitrary pricing of procedures in healthcare will be an issue.

    Medicare and Medicaid manage to set their prices because providers make-up some of the difference through the private insurance market.

    If we had Medicare-for-all, Medicare better set their reimbursement rates correctly or there will be a lot of ripple down effects and without more transparency in the current system,

    And if the current system becomes transparent, I don’t see why some combination of government and private sector, like we have now, cannot bend the cost curve.

    I’m not opposed to single payer.

    I just think the complexities in implementing it are more than the proponents want to admit.

  97. 97
    dogwood says:

    @Kay:
    I’m always a bit baffled by the notion that economic status drives our sense of what is morally acceptable. Three of my friends and I pay for and prepare a meal twice a month at the Salvation Army soup kitchen. When others find out I do this they inevitably say something to the effect that the people there must be so grateful. It makes them uncomfortable, but I tell them the truth. Some of the people are gracious and appreciative and some are complete assholes. No different than my college days when I waited tables at the country club. Some of the regulars were a pleasure to serve and some were jerks. There are plenty spiteful, ignorant wealthy people in the country, many in Congress. And there are plenty of the same among the lower classes. So I’m not surprized by what happened in Kentucky.

  98. 98
    Betty Cracker says:

    @burritoboy: Good points. I think PBO did a good job of communicating the goals of healthcare reform and outlining the rationale behind the incremental approach at the outset, but his voice was largely drowned out by the orchestrated, well-funded campaign opponents waged to inject nonsense into the debate, such as that the cautious, corporate-friendly reform efforts were “socialized medicine.”

  99. 99
    Keith says:

    @FlipYrWhig:

    what’s the best way to stuff their mouths with gold, when so many of them already have plenty of mouths full of gold and no reluctance to stop speaking?

    I’ve long held out hope that this could begin by being done at the edges. And the most available edges are newly graduated Doctors & specialists, and the VA.

    Newly minted doctors almost always carry a massive debt burden – as large or larger than lawyers. What could be more enticing than an offer to pay off that debt? That pay off would come with strings attached, but they are not precisely burdensome strings in this hypothetical scheme.

    — Have the doctors and physicians on an escalating pay-down: for every year at a VA clinic or hospital a portion of the medical debt is paid off..More would be paid off in later years than earlier years. After (say) 10 years all the accumulated debt is paid down.
    — Doctors departing the program early retain the portion of their debt not paid off, plus accrued interest.
    —- I suspect the rate of attrition from such a program would be relatively modest, first because of self-selection, second because those members of their graduating cohort who went into private / commercial practice would regale them with tales of the misery of form-filling and procedural documentation. (Which, in the VA is basically not a worry).
    —- Conversely, I expect the happy campers who self-select into this program would offer them tales of relative bliss, about concentrating on medicine rather than coding for a multitude of insurance providers.

    Perhaps a similar program could be constructed for the endangered community hospitals, before they are entirely bought up by major chains.

    Ultimately, the goal of this piece would be a bifurcation of the medical professional class into two streams: one relentlessly pursuing dollars, dancing as fast as they can; the other happy with their lot and debt-free.

  100. 100
    Ella in NM says:

    A major reason that “Single Payer” or something similar is a “non-starter” in the US is the physics of overcoming the linear momentum of the healthcare industry, which makes it’s living off of the administration of health insurance and healthcare and unfairly squeezes the benefits and profits of that work upwards to the completely resistant top-tier.

    As those of us who took physics instead of econ all know, P, or linear momentum, is a vector quantity, possessing a direction as well as a magnitude, in other words

    P=mv

    where “m” equals the

    total mass of all the lardassed-overpaid-six-figured-salary administrative bloodsuckers in healthcare +

    the mass of their-well-paid-starry-eyed-hopeful-underlings-who-are-convinced-they, too-will be -lardassed-overpaid-six-figured-salary administrative bloodsuckers in healthcare +

    the mass of all the corrupt Congresscritters who vote against any subtantive change to our healthcare system for bribes from the previous

    the velocity, v, of their combined pull on the economic levers of society, which is something like a million miles an hour

    We also know that P is conserved, meaning that if a closed system is not affected by external forces, its total linear momentum cannot change. P will go on forever like this until its mass or velocity changes, whether slowly or rapidly.

    So we’ll not be getting any real change in our healthcare system anytime soon, apparently, because too many people with the knowledge and the power and the opportunity to do so simply won’t do it.

    Well, for what it’s worth, I call bullshit. I for one am someone wants to slam the mother fucker off it’s track with a big, heavy object.

  101. 101
    burritoboy says:

    Ruckus,

    What the worst thing that the Drump does is to create cheap and fake inspiration – easy and simple answers that don’t require any thought or sacrifice (at least, sacrifice from his audience – they don’t mind forcing others to sacrifice for their goals). But we can’t ignore our own need to create the real inspiration to counter that. And you can’t counter the false inspiration with just nothing or a mound of legalese that doesn’t create a big “good” that millions can get behind.

  102. 102
    dr. bloor says:

    @gene108:

    Like I said up thread, I think the resistance to single payer is cultural and not just something that’s going to be solved by great legislation and good policy.

    Great legislation and good policy is precisely what can solve that. You know what else used to fly in the face of American “culture?” Social Security. Which is still here and not going anywhere despite your concerns about the republicans, because it is now a part of our “culture.” You can’t do anything without having a substantial swath of the population pushing back against it–that’s just who we are as a nation. Not doing something because it’s going to get pushback doesn’t make sense.

    I don’t think rates getting set is a non-starter, but what is the rational behind setting them?

    In most transactions the rational for setting prices is “my cost is ‘x’ and my price will give me ‘y’ profit”.

    How can a single payer system set prices, without know what the actual cost of a procedure is? Or some such method of calculation that will yield the minimum price a provider needs to receive to stay in business?

    I’m not sure what you’re questioning here. If you’re asking how the government can determine an appropriate price for a procedure, they already do–it’s called “Medicare,” and however imperfect it might be, it’s better than anything the “free market” has to offer.

    If you’re asking how they can enforce rates, well, they just can. As a psychologist, I can decide to charge one of my Medicare folks $5000 per session, but the gubmint is going to give me about $103, and I’m contractually obliged to accept that as payment in whole. That’s how it works with any insurer, and as a provider in a single-payer system, my option is to accept that rate or open a cash-only practice.

  103. 103
    I'mNotSureWhoIWantToBeYet says:

    @Kay: re: slicing-and-dicing.

    There’s fair, and there’s fair.

    I think the most compelling argument for covering everyone is two-fold: 1) it prevents slicing-and-dicing, and 2) it means that you don’t need people checking the law and the regulations all the exceptions and conditions to see who fits and who doesn’t. It’s cheaper to administer.

    That’s why I think proposals for free college tuition should cover everyone, too. That’s another area where I think Hillary’s wrong. Yes, Donald Trump’s and Martin Shkreli’s kids should get free college tuition too. (Up to some sensible limit like in the New GI Bill.) The benefits of making college education available to everyone who can do the work and wants it, without regard to ability to pay, is compelling to society. It’s not a handout, it helps to build society in a wide variety of ways and makes us all richer and better off. Having kids spend 20-30 years paying off student loans doesn’t help the economy or anyone except the banksters.

    I don’t think that fears about “welfare” should hold as much power over us as they did in the past. We don’t take complaints about people using the sidewalks and roads, libraries, public parks, etc., etc., without overtly paying for them seriously. Being a member of society gives you the ability to use those things that we all have paid for without fear of being called a “moocher”. This Teabagger mania of forcing to show a receipt for your ride in an ambulance or your drive on the highway is going to destroy the USA if it continues.

    Similarly, having a permanent underclass (e.g. 133% of the poverty line) that gets some assistance from the state while another, slightly higher-earning group, doesn’t isn’t fair, isn’t workable long-term, and doesn’t serve society’s goal of lifting everyone up.

    I recognize that Obamacare has lots of issues, many caused (as Richard has documented) by CJ Roberts throwing a monkey-wrench in the gears, but we shouldn’t lose sight of the fact that a Democratic President and a Democratic Congress can fix them relatively easily. We should treat the problems as an opportunity to get voters fired up to elect people who will do the fixing.

    My $0.02.

    Cheers,
    Scott.

  104. 104
    burritoboy says:

    Gene108,

    What you are describing is, within the history of economics, what was called the Socialist Calculation Debate. If you want to think about this issue seriously, that’s the discourse you need to understand pretty thoroughly. The Wikipedia page on socialist calculation debate is a pretty good backgrounder.

  105. 105
    I'mNotSureWhoIWantToBeYet says:

    @Betty Cracker: A year or so before GM declared bankruptcy, there were often comments in the news from their management that the cost of each car included $2000 for their health insurance costs for their current and retired employees. Costs that Honda and Toyota and the other Asian transplants supposedly didn’t have to pay. So they wanted some sort of expanded national health insurance to get those costs off their books (or at least make their competitors pay them, too.). Arguments like that seemed to be gaining some traction (but it was still an uphill battle), until the housing bubble burst and the economy imploded and so forth.

    I don’t hear those complaints any more, or if I do it’s expressed in terms of “… Obamacare destroying our best-in-the-world healthcare system…!!1”

    :-/

    Cheers,
    Scott.

  106. 106
    FlipYrWhig says:

    @Keith: It sounds like a sort of public health corps, a track for medical professionals perhaps more analogous to teachers than what (I understand) happens now. I feel like there would be something appealing in that: maybe the key tradeoff is that you’d expect less income but far more stability, which is how most of the public sector works.

  107. 107
    burritoboy says:

    Dr. Bloor,

    But we do need to remember simultaneously is that FDR didn’t sell Social Security to the people by enumerating one by one the innermost details of what was and is an extraordinarily complex package of programs. Of course, that complex defense of the policy details was readily available to the day’s policy wonks, lobbyists, economists and so on, but that’s not how FDR promoted the program. How he promoted the SS Act were by these great pieces of truly inspiring rhetoric about how the SS Act would ennoble our nation by treating our elderly with the honors they deserve.

  108. 108
    FlipYrWhig says:

    @burritoboy: OK, but there aren’t many classes of people that the general public considers worthy of respect and/or care anymore. Most elderly; most disabled; most children; most soldiers; some poor. Once you’ve got social welfare programs in place for them, what soaring rhetoric is going to get people to be willing to ennoble the nation by taking care of run-of-the-mill assholes like the rest of us? Obama is actually very good at inspiring people to think about the purpose of government, the public good, and collective responsibility. The problem is that it doesn’t work on people who hate him, which is basically half the country. The calculus shifts if the economy strengthens. Until then, broadening the social welfare state isn’t in the cards, sad to say.

  109. 109
    Ruckus says:

    @Keith:
    Not aware of any cost benefits but most of the docs I see at the VA are residents in various specialties, meaning they are still in training. Most of the preventive care people are physicians assistants or nurse practitioners. Now this may be different in parts of the country without a few medical schools in close proximity. The VA system is very cost effective, if somewhat less speedy than the civilian system. But if you need immediate care, it happens. If your situation does not actually require emergency care, you may have to wait for openings. But testing and care is right up to date, it’s just waiting for it, which having been in the military most are used to even if they hate it.

  110. 110
    gene108 says:

    @dr. bloor:

    As a psychologist, I can decide to charge one of my Medicare folks $5000 per session, but the gubmint is going to give me about $103, and I’m contractually obliged to accept that as payment in whole. That’s how it works with any insurer, and as a provider in a single-payer system, my option is to accept that rate or open a cash-only practice.

    Basically what you are saying is the medical profession gets stuck accepting whatever rates they get and they can only make up the difference by increasing the volume of patients seen in the practice, clinic, hospital, etc. and charging for more procedures performed to get additional revenue and make more money.

  111. 111
    Ruckus says:

    @burritoboy:
    What tRump does is bullshit. To everyone else and to himself. It’s what he knows best.

    Having a goal, even a lofty one is good. Taking off to land on the sun really isn’t a good idea. I’m not saying that single payer is wrong, it is the most cost effective and reasonable way to have a fair healthcare system for all. Full stop.
    But. And it’s a full, round, firm but, that works when you have nothing and/or a system that really doesn’t have any rewards. What we have is a system with huge rewards for a relative few, and that works half assed at best. Or as it has been said “Best healthcare in the world. If you can afford it.” Which of course many can not. But we have a system, broken it is but it is a system. Tearing that down and replacing it with some other huge system that can be politically fucked at any odd time is not really progress.
    One of the big things we need to make progress on in this country is that everyone matters, their lives, their health. That we have rampant racism and economic imbalance that needs to be shifted to an understanding that we are all equal, not that some are more equal than others is what really needs to be changed. Our health system, our financial system, our government itself are all geared towards some are more equal than others. Until that changes, the best that we can do is pick at the edges and hope it gets better.

  112. 112
    dr. bloor says:

    @gene108: Yes, and this pretty much describes the state of the “industry” at present, but with eleventeen different insurers to deal with, each with their own reimbursement schedules, guidelines for preauthorization of care, allowable procedures for given clinical problems etc to manage. The added value of the government running the show, in addition to setting fair prices, is the ability to exercise greater oversight as a means of encouraging best practices and minimizing unnecessary procedures for a given medical condition. From the physician side, the reduction in paperwork, having to employ billing specialists and the like, and price/reimbursement certainty are big plusses.

  113. 113
    The Other Chuck says:

    @I’mNotSureWhoIWantToBeYet: Yes, and the takeaway apparently was that we’re being too generous to the unions. Not sure how a nation — or at least electorate — of unrepentant assholes can make any change for the better, incremental or no.

  114. 114
    Elie says:

    Hmmmm.

    I had a comment and it posted, then disappeared….

    Weird

  115. 115
    gene108 says:

    @dr. bloor:

    Great legislation and good policy is precisely what can solve that. You know what else used to fly in the face of American “culture?” Social Security.

    Not to the extent to which you think. There were retirement schemes in place at various levels, but nothing on a national scale.

    Fuck you, grow old and die was never part of anyone’s culture and when it did become part of the culture, usually revolutions followed.

    What did fly in the face of “culture” were the Civil Rights Act of 1964 and Voting Rights Act of 1965, but there was a certain level of pressure being put on Congress to change things from both the Civil Rights movement that had been working for decades to bring about change.

    Even with the New Deal, there was a lot of pressure placed to change things from the existential threat of Communism taking over America to the very real problems people had that they had been organizing to change for decades. There was a decades old labor movement that demanded such things as a minimum wage. FDR didn’t pull a coalition out of thin air. People had been making demands for such things as a minimum wage, end to child labor, etc. for decades.

    Politicians, especially Presidents, in the U.S. rarely spear head movements. They pull together existing groups to build a coalition that changes the status quo.

    Which is still here and not going anywhere despite your concerns about the republicans, because it is now a part of our “culture.” You can’t do anything without having a substantial swath of the population pushing back against it–that’s just who we are as a nation. Not doing something because it’s going to get pushback doesn’t make sense.

    To achieve single payer, you do need a mass movement to change the “culture” of this country that is scared of “socialized medicine”.

    Until this changes, I’m not sure passing laws are going to be a lasting solution.

  116. 116
    burritoboy says:

    FlipYrWhig,

    If being a politician on the level of FDR was easy, everybody would do it. What I would say in response to your comment is at least three-fold:

    1. Even if humanity achieved some sort of fairly universal high economic affluence (say, the entire world was Switzerland writ large or something), that by no means addresses all sorts of other ways humans can collectively do what is ennobling or inspiring or good. High economic affluence is hardly the only goal of humanity (though it’s certainly a critical one.)

    2. Practically, of course, very few places have achieved such levels of universal high economic affluence anyway – and certainly not the the US – so this discussion is at least somewhat academic. Add to this, of course, that even the most affluent places are carried along within the stream of vast global economic injustices and turbulences. Switzerland is equally as affected by Middle Eastern terrorism or the Syrian refugee crisis or climate change or global economic imbalances or a million other things as other nations are.

    3. Looking at it solely through the lens of what has traditionally been social welfare policies is artificially limiting, I think. A lot of what FDR did, for instance, was not strictly social welfare at all but economic policy and economic structuring. (Indeed, I would argue he did much more by his economic restructuring than through his social welfare policies narrowly conceived.) A lot of what FDR did was through his own positive life-story, his leadership qualities and virtues, his own leadership acts, how he educated the nation through his rhetoric and how he helped the people understand themselves. That might sound ludicrous, but: think about America’s experience in WWII as guided by the genius of FDR. Americans were really ennobled by how FDR (along, of course, with so many others through whom he acted) tried to fight WWII in a just, measured and merciful way. Not everything got done correctly (Japanese internment camps, for just the beginning), but still: look at the virtuous and selfless way both the American leadership and people sacrificed to free peoples from the worst evils and even to help nations which had become evil to begin to heal themselves (especially in the cases of Germany, Japan and Italy). FDR (and the USA) could have fought dirty and in evil ways, and probably it would have been easier for us to do so. But FDR didn’t do that. The American leadership helped the American people ennoble itself with positive and just acts all over the world, and rebuilt the people’s self-confidence which had been so damaged by the self-indulgences of the 1920s and the economic frustrations of the Great Depression.

  117. 117
    gene108 says:

    @dr. bloor:

    The added value of the government running the show, in addition to setting fair prices, is the ability to exercise greater oversight as a means of encouraging best practices and minimizing unnecessary procedures for a given medical condition. From the physician side, the reduction in paperwork, having to employ billing specialists and the like, and price/reimbursement certainty are big plusses.

    I agree.

    I just think, if the government sets the “fair price” incorrectly and their is a provider backlash, you may have a bigger mess than just the status quo.

    The opponents will look for any excuse to tear down single payer.

    The advantages to single payer are real and would greatly improve this country.

    Finding a practical way to implement it, which includes making sure it can’t be gutted by our conservatives, includes setting “fair prices” and other controls and getting providers – from hospitals, pharma, device manufacturers, etc. – to take a cut in profits, as well as what to do with all the dislocated billing specialists, insurance company employees, and insurance brokers ( and their employees), is going to be very complicated.

  118. 118
    Kylroy says:

    @dr. bloor: Social Security was implemented after a world-shattering depression that caused suffering on a level no other purely economic crisis did before or has since. And even then it had to be carefully constructed to exclude black people and women.

    Our culture can change when world events point out the foolishness of the American fetish for “rugged individualism”. Barring that…not so much.

  119. 119
    FlipYrWhig says:

    @burritoboy: I don’t have much hope in the arrival of FDR II, though. I think if Republicans had been less unrelenting Obama would have managed it — young, inspiring, the embodiment of hybridity and newness — and that’s precisely why the Republicans did everything in their power to muck it up. They’ll ruin everything that could possibly have the effect you’re describing. So if there can’t be FDR II, I’m OK with splitting the difference between Obama I and Clinton I: aim high, bank small significant gains, preside over mostly positive developments, keep the ship of state steady.

  120. 120
    FlipYrWhig says:

    @dr. bloor:

    The added value of the government running the show, in addition to setting fair prices, is the ability to exercise greater oversight as a means of encouraging best practices and minimizing unnecessary procedures for a given medical condition. From the physician side, the reduction in paperwork, having to employ billing specialists and the like, and price/reimbursement certainty are big plusses.

    If a critical mass that can be identified as “doctors,” per my comments above, can articulate these benefits, then maybe there’s a chance. Because if there’s any possibility that the public can be induced to see that a government-run health care system is bad for doctors in general, or their own doctor or their parent’s doctors in particular, it’ll happen, and poof, there goes any hope for reform.

  121. 121
    chopper says:

    i could understand the argument more if obamacare was old, old news. but it isn’t. the exchanges are only ending their second year. obamacare really isn’t the ‘status quo’ here, at least the main part of it. give it a second!

  122. 122
    cahuenga says:

    @OzarkHillbilly:

    Having witnessed 57 years of ‘baby steps’ I can say you are wrong. Sometimes it is hard to be patient but the alternative is worse.

    If all you know is baby steps then the alternative can only be conjecture on your part.

    And although I think Richard’s heart may be in the right place I do wish he would disclose his interests here for those who don’t know. From his financial perspective single payer is a disruptive policy and baby steps or “no steps” are likely preferable.

  123. 123
    burritoboy says:

    FlipYrWhig,

    I think what we’re discussing is technocratic leadership. And, ultimately, over the long term, I think it will fail (at least, if there is only technocratic leadership but no inspirational leadership) – as certainly useful as keeping the ship of state steady is! Part of politics exists on that emotional level, and people are very much searching for that. Perhaps they even need it on some level. It can be harnessed for good or bad, and if not harnessed for good, it will sometimes curdle and turn actively bad. Or it can be manipulated by demagogic actors.

  124. 124
    Kylroy says:

    @cahuenga: What would you prefer to baby steps? A Great Leap Forward, perhaps? America has not experienced the alternative, but other countries have, and the evidence really does favor baby steps.

    If you’re going to dismiss anyone’s insight because they work for the insurance industry, you’re writing off virtually everyone with expertise in this field. And Richard projects costs and patient behavior for a living – this is a job that would still be needed in a single payer system.

  125. 125
  126. 126
    Brachiator says:

    @cahuenga:

    And although I think Richard’s heart may be in the right place I do wish he would disclose his interests here for those who don’t know. From his financial perspective single payer is a disruptive policy and baby steps or “no steps” are likely preferable.

    But here’s the interesting thing. I have been hearing that single payer is the best and only system for years, and yet people advocating single payer often have no expertise or particular knowledge about the health care industry, or even much in the way of any historical knowledge with respect to how universal health care works in various countries.

    I don’t think that Richard has anything special to disclose. His knowledge and insights speak for themselves. Anyone else with equivalent insight can add to the discussion any time.

  127. 127
    burritoboy says:

    A bunch of people have asked how you do the right thing with a nation of assholes. Well, I guess the greatest leaders try to train the population away from assholishness. There’s usually a great project or undertaking that needs to be done, but, until the right moment arrives, the project is blocked from moving forward. When the right moment arrives, how the project is done is nearly as important as the solution. The truly inspirational leader helps the people overcome their previous assholishness as he structures how they come together to accomplish the goal.

    An example would be Lincoln: the Civil War (or, at least Secession) was probably either inevitable or nearly so. But Lincoln’s goal wasn’t only some simple brutal demolishing of the Confederacy (though the Confederacy did need to be militarily defeated.) Other lesser men might have succeeded in the military goal but failed in the salient goals of trying to rebuild the nation from a collection of selfish assholes. How Lincoln went about doing this – his careful analysis of the Confederacy’s evil foundations, his analysis of the character faults slavery inevitably created in the Confederacy leadership, his understanding of the virtues and faults of the North, how Lincoln restructured the Union’s government, economics, society and army, and so on – were all determined by his re-education of the people away from assholishness.

  128. 128
    FlipYrWhig says:

    @cahuenga:

    From his financial perspective single payer is a disruptive policy and baby steps or “no steps” are likely preferable.

    You do realize that there isn’t really a “Mayhew Insurance,” right?

  129. 129
    jl says:

    I don’t see a big conflict between single payer and moving along private payer programs. People are arguing over a financing system, and either may work well or not well at all depending on design of insurance system, provider behavior, and market environment in which they operate.

    So, insurance system: need to define and implement a risk pool that ensures a socially optimal sharing of health cost risks over life-cycle. No one knows how to do this without either letting people die in the gutter or enforcing a universal health insurance coverage and medical care mandate. High income industrial nations have rejected the former so they need to enforce the latter.
    provider behavior: encourage provision of efficient health care protocols.
    market environment: need price transparency to find market structures that drive observable prices close to average (or where relevant in health care, marginal) cost of provision.

    Single payer or private payer, or mixed systems can work well or not well depending on how well the criteria above are met. IMHO. As I noted in comments in a recent RM health care thread, I think best quickest steps to improving PPACA are also those needed to pave the way towards a high quality single payer system, if society decides it wants to go that financing route.

    Evidence I have read, regarding the quality/cost/patient satisfaction trade-off that a society gets is much more determined by the contrast between the choices of
    lightly regulated mostly private for-profit provision of insurance and care (sub-optimal, except wrt to private profits, and all have abandoned except US)
    highly regulated social insurance system (which may be single payer, or mixed public/private non-profit, or mostly private non-profit, insurance financing system)
    national health care service (and there are a few examples of national health care service with private insurance, I think Greece is the clearest example, and that might be sub-optimal as well as is the US approach, though hard to untangle developments there with broader Greek economic problems)

  130. 130
    dr. bloor says:

    @FlipYrWhig: I confess I’m moving the goalposts here a bit, but I don’t think pro socialized healthcare docs are going to be much help, but they’re certainly out there. As I’ve said in other threads, the tipping point is going to come when the middle class is no longer sheltered by employer provided plans and they have to pay the full hit (which will happen when employers can’t afford to offer it to employees at any level of subsidy). From reading the comments, it’s clear that many commenters in these parts are already there.

    To wit: in RI, if you’re buying a plan from BC/BS, a silver-level “BasicBlue” plan for you, the missus and your two kids, your unsubsidized premium will be $831/month in 2016. For $9972 annually, you get basic office visits with a $20 copay and specialist consultations with a $45 copay. Nothing else is covered–including routine blood work or tests that specialist might want to run- until you’ve killed your $9800 deductible, and even then you’re looking at a 10% copay on everything until you hit the max out of pocket limit of $11000 per year.

    Even with the ideal (and I would say virtually nonexistent) smart shopper that Richard talks about and general good health, you and yours might be able to limit your costs to low five figures. But in any given year, if the ER doc says “we think it’s his appendix” or “we’ll need to admit him overnight,” it’s game over.

    Once enough of us are looking at this scenario, every year without exception, the political will to change will be there. It’s not going to much matter what the doctors think.

  131. 131
    FlipYrWhig says:

    @dr. bloor: That doesn’t bode well. I figure that ACA is a bit like switching from traditional incandescent bulbs to CFLs. It mildly slows the arrival of the day of reckoning. But it’s hard to get people to avert the day of reckoning because doing so is still going to be painful. I figure people will be drowning in Miami and _still_ people will deny that rising water levels are a problem. It’s hard to get people to deal with a coming crisis.

  132. 132
    nihil obstet says:

    I wish I could understand discussions like this one. It seems to be generally accepted that we can’t have a genuinely universal health care system because Americans are such assholes, totally culturally opposed to one. But not only do I not find that in talking to people, but I read poll after poll that shows majority support for expanded Medicare for All. I guess we have to give up on the policy that the majority want because we can’t have democracy? Now obviously accepting oligarchy doesn’t apply to anyone on this list; just all the Americans who don’t agree with us, both on the right (nasty, nasty Republicans) and on the left (totally immoral self-satisfied morons who want ponies).

    When the DNC, DCCC, and DSCC start working to recruit and support candidates who say they believe in what the Democratic Party should stand for rather than supporting Republican-lights, and the party leader talks about what the Democratic Party will deliver rather than saying policy must be trimmed so that it will be bipartisan, bipartisan, bipartisan, then I’ll scream about the nasty Republicans. Otherwise, I won’t conform all my political thinking to not doing anything that I imagine the Republicans want to undo.

    burritoboy is being much more tactful and reasonable than I about what’s needed to enact decent policy.

  133. 133
    cahuenga says:

    @FlipYrWhig:

    I’m just taking his bio at face value:

    About Richard Mayhew
    I am a mid-level bureaucrat at a mid-level full service insurance company with a policy analysis addiction

  134. 134
    FlipYrWhig says:

    @nihil obstet:

    It seems to be generally accepted that we can’t have a genuinely universal health care system because Americans are such assholes, totally culturally opposed to one. But not only do I not find that in talking to people, but I read poll after poll that shows majority support for expanded Medicare for All.

    I don’t think Americans are “culturally opposed to” universal health care. I’m sure they like the idea of having better insurance and paying an affordable rate for it. But what do you think will happen to that level of support when TV spots start to appear showing frowny faced people in white coats saying they don’t think it’s a good idea? Majorities favored “health care reform” but, after millions upon millions of dollars of demagoguery about freedom and eugenics, that number came down a tad. Therein lies the problem.

    @cahuenga: He has a conflict of interest because of his sweet sweet mid-level gig? That’s a bit like being suspicious of all the delicious grant money those global warming scientists get.

  135. 135
    jl says:

    @cahuenga: In early post, Mayhew said he is for single payer. There will be plenty of good paying public and private analysis jobs with single payer. Most of Medicare actuarial and statistical analysis and wonk grunt work done by private contractors who get pay comparable to wonkgrunts at private insurance companies.

    There won’t be a surplus of cost and statistical analysts and actuaries, there will be surplus of marketers, utilization management and collection hatchet people zeroing in on who is using up unneeded resources, and who can be screwed, and armies of drones who sit in vast cubicle farms at insurers and providers fighting and everlasting twilight trench warfare over insurance reimbursements and hospital bills.

  136. 136
    nihil obstet says:

    @FlipYrWhig

    what do you think will happen to [majority] support [for Medicare for All] when TV spots start to appear showing frowny faced people in white coats saying they don’t think it’s a good idea?

    All the deficit hysteria in the world has not shaken American support of Social Security. Nor will it shake longing for a decent healthcare system. (I don’t discount adverse propaganda — I want a National Health Service with the profit motive completely taken out, but I think I am facing too much opposition there). Unfortunately, what I think will happen is that the elites will all go Very Serious about how Americans don’t want it, and the Democratic tribe will wail about how nasty the Republicans are and how unreasonable everybody else is. It seems to work for them.

  137. 137
    Satby says:

    @cahuenga: Being employed in the industry is not per se a conflict. He could conceivably take his analysis skills to a number of industries. And being employed by the industry under discussion allows Richard to share insights that outsiders wouldn’t have.

  138. 138
    The Raven says:

    There’s tons of work been done on a single-payer system. Assembling a coalition? Not until Citizens United is overturned.

    But, man, do you have any idea how awful the ACA system is? Better than what we had before, but that’s like saying having a tent and a place to pitch it is better than sleeping on the streets. It is, but that is no comfort to families that have to care for sick children. Most people would rather have a home with walls. And it’s only going to get worse, as the insurance industry, the pharmaceutical industry, and the hospitals learn how to work the system. Until the power of the right-wing coalition is broken and Citizens United is overturned there will be no improvement, so we’re talking years.

    @MomSense: “What bothers me more than anything is how little libersls and progressives are talking about the people who fall into the Medicaid Gap”

    I’ve been writing about it since Virginia v Sibelius in 2012, and you can read what I wrote then at here. I continue to talk and write about it, since it is certainly the biggest failing of the US health care system. I spent time at a party on Christmas day explaining it. The system as it stands is also exceptionally hard on the working poor who make just enough not to be eligible for Medicaid, and on people 55 and over who do not have employer-funded insurance, and I wrote about that here.

    One of the things I feared that has not materialized: Republicans are not making hay of real and obvious faults of the system — they are too busy making up easily debunked lies.

  139. 139
    different-church-lady says:

    Single Payer is not a pony.

    Single Payer is a long, tough slog.

    The pony part comes in when on-line blow hards progressives start ranting about how it would all be so easy if only the [insert cardboard villain here] would just WILL it into being, and the fact that they won’t means they’ve sold out and we’ll all live in control of the Borg forever unless [insert cardboard hero here] gets elected.

    I hate the insurance industry almost as much as anyone. But I don’t think the fix is going to be the progressive version of the Underwear Gnome’s business plan:

    1. Demand single payer
    2. ?
    3. PROGRESS!

    That second slot is where they think the pony arrives.

  140. 140

    @dr. bloor: Don’t need single payer for that. Maryland has an interesting experiment in single rate healthcare where Big Blue, Purple People Eaters, Medicare, Medicaid and Plucky CHIP kids insurance all pay the same rate to a single hospital.

  141. 141
    The Raven says:

    Two more points:

    1. I remind everyone that with the huge amounts of cash controlling major media, the public is extensively misinformed. The problem isn’t that most people are assholes, it’s that huge amounts of time and effort are spent on misinforming the public. So stop calling the public “stupid.” It’s wrong and it doesn’t help.

    2. I have gotten to hate explaining to people on the right that this is the system they asked for, and debunking right-wing lies. I have gotten to hate explaining to people on the left that, yes, this is a rotten system and it is nonetheless an improvement. And I have gotten tired of explaining to my friends the reasons to sign up, even though it’s a crappy system and an extra expense they do not need.

    I do not believe that this was the best compromise possible. As with the banks, the Obama administration just rolled over. I do not know what hold the financial services industry has on this administration, but it is profound.

  142. 142

    @cahuenga: Thanks for impugning my integrity.

    I freely disclose that I am a mid level bureaucrat at a midlevel insurance company in my Balloon-Juice bio.

    If we went to national single payer, I would most likely be out of a job after a 12 to 18 month data clean-up and transfer. If my state went to single payer, there would be a good chance that my employer would be the hired contractor as the state regulators know that we know our shit, so my job would be secured.

    I’ll worry about my job disappearing when there is a plausible pathway to 218-51-1-5; I don’t see that for another decade at best.

    Until then, I’m going to plug away at the margins of the system as it is to make it better.

  143. 143
    mclaren says:

    THE IMMORALITY OF MISNAMING UNCONTROLLED GREED AND CORRUPTION AS “WE DON’T LIVE IN AN IDEAL WORLD”

    Richard Mayhew is lying to you once again.

    This time, he’s using the old warhorse, that logically fallacy known as “the excluded middle.” The excluded middle goes like this: “Either we must wage immediate nuclear war on the USSR or we will become Soviet slaves.”

    No, there’s a huge range of middle options between those two extremes. This argument dishonestly and fallaciously acts and talks as though there is nothing in between the two extremes.

    In Richard Mayhew’s case, he’s trying to convince us that there’s nothing between the extreme of tinkering at the edges of America’s current broken collapsing medical-industrial system, and a nationalized single-payer health care system.

    But there is.

    Let’s explore some of the most powerful and effective options in the middle, between those two extremes…and in the process we’ll discover that implementing those options in between carries with it a high probability of leading a single-payer nationalized system.

    We begin with the corruption and greed that currently drowns America’s medical-industrial system. In the Slate article “The Hidden Public-Private Cartel That Sets Health Care Prices,” the author talks about how a small clique of doctors arbitrarily set up the “codes” that determine health care costs. This clique of doctors has no oversight, no accountability, no cost-benefit analysis…it’s just a bunch of millionaire specialist doctors sitting around in a smoke-filled room figuring out how to jack up costs for each medical procedure so they can all have a vacation in Maui.

    Unleashing the hounds of antitrust hell against that process would go a long way to reform America’s broken massively corrupt medical-industrial process. Unleashing the DOJ’s antitrust division has nothing to do with “having a pony” or “living in an ideal world.” But Mayhew doesn’t want to you realize that.

    Another example: Big Pharma currently bribes doctors, giving them perks like a new car if they prescribe enough of some new medication. Letting the DOJ loose to prosecute this kind of thinly disguised bribery once again has nothing to do with “living in an ideal world.” But Mayhew would like you to believe it does.

    Yet another example: manufacturers of insulin pumps use the DMCA to jack up the price of their devices from $4,000 to $80,000 by making sure their firmware is copyrighted — then they tell a patient that they need an “upgrade” every couple of years. Which means paying another $80,00. Letting the DOJ prosecute this kind of corrupt abuse wouldn’t involve nationalized single-payer health care. But Mayhew wants you to think it does.

    And yet another example: In 1965 America had more medical schools than it has today. Do you think the U.S. population has grown since 1965? Why, yes, I think it has. So why don’t we have more medical schools? To keep the salaries of U.S. doctors high — U.S. general practitioners are currently paid three times as much on average as European M.D.s, and American medical specialists like oncologists or neurosurgeons or arthroscopic surgeons get stratospheric paydays in the multi millions of dollars that doctors in Europe can’t even imagine. If we used current Antitrust laws to break the AMA’s stranglehold over medical schools and increase the number of U.S. it wouldn’t have a goddamn thing to do with “living in an ideal world.” But Mayhew sure wants you to believe it does.

    The larger point? Making these kinds of reforms removes so much of the filthy lucre from U.S. medicine that it would greatly speed up movement toward a quasi-single-payer system. The only reason for the current Balkanized fractionated system we have now is greed and corrupt profits. Remove those, and the system will quickly move toward a single-payer-type system for reasons of mere efficiency.

  144. 144
    Nathanael says:

    Whatever.

    The fact is that single-payer systems are taking over in every country in the world except the US. Even in Mexico.

    It’s easier to advocate for a single-payer system than for some insane kludge which feeds vast amounts of money to corrupt “health company” executives.

    I mean, if I were in Congress, I wouldn’t vote against incremental improvements. But it’s completely worthless to waste your advocacy time on them.

  145. 145
    cahuenga says:

    @Richard Mayhew:

    Thanks for impugning my integrity.

    Not my intent. Disclosures are a standard practice in journalism and typically not buried in a link. Especially wise if editorial content appears to align with personal self interests.

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