Re: Bird's eye view

1

I've heard others making this argument, and it's true that many government programs are very popular once they're enacted. This is one of my concerns about the timeline of this bill, there are at least two congressional and one presidential election before most of the bill goes into effect. You can be sure that should there be a Republican congress and president in 2013, we'll hear nothing else except how the Democratic minority needs to allow an up or down vote on repeal of the legislation.


Posted by: SP | Link to this comment | 12-20-09 12:39 PM
horizontal rule
2

I'm not a historian, but there's a really big difference between the government extending civil rights or providing retirement benefits and forcing citizens to buy crappy products from an abusive and predatory private cartel.


Posted by: apostropher | Link to this comment | 12-20-09 12:41 PM
horizontal rule
3

Are there counter-examples of what could have been major legislation, but it was so crippled by compromised, and then thoroughly gutted by the next administration?

I'm thinking of Carter -> Reagan, perhaps. Reagan certainly gutted plenty of programs, but I'm trying to think of something that can be blamed on the compromises of the original legislation.


Posted by: heebie-geebie | Link to this comment | 12-20-09 12:44 PM
horizontal rule
4

1) Don't need to be a historian to go cherry-picking

2) Amateurs also can try to understand The Whig Interpretation of History and the related delusions at the bottom of that page.


Posted by: bob mcmanus | Link to this comment | 12-20-09 1:02 PM
horizontal rule
5

From the link in 4, "Its antithesis can be seen in certain kinds of cultural pessimism." Bob, thy name is cultural pessimism.


Posted by: heebie-geebie | Link to this comment | 12-20-09 1:05 PM
horizontal rule
6

Allow me to quote the following short verse by James Thompson, poet and pessimist:

Once in a saintly passion
I cried with desperate grief,
"O Lord, my heart is black with guile,
Of sinners I am chief."
Then stooped my guardian angel
And whispered from behind,
"Vanity, my little man,
You're nothing of the kind."


Posted by: nosflow | Link to this comment | 12-20-09 1:24 PM
horizontal rule
7

Author of The City of Dreadful Night, apparently.


Posted by: nosflow | Link to this comment | 12-20-09 1:34 PM
horizontal rule
8

Thomson, apparently.


Posted by: Jesus McQueen | Link to this comment | 12-20-09 1:38 PM
horizontal rule
9

"To understand the others: this is the historian's aim. It is not easy to have a more difficult task. It is difficult to have a more interesting one."
(Kula 1958,p. 234)

Epigram for Chapter One of Roncaglia's Wealth of Ideas, "The history of economic thought and Its Role" Roncaglia discusses Kuhn, Popper, Lakatos, and Feyerabend but goes nowhere near Foucault and similar froggy ilk.

I think my attempt to start discussion of Obama as a CIA/neo-liberal mole planned before Obama was even born might be more fun. Does DeLong know the secret history?


Posted by: bob mcmanus | Link to this comment | 12-20-09 1:48 PM
horizontal rule
10

Apparently.


Posted by: nosflow | Link to this comment | 12-20-09 1:49 PM
horizontal rule
11

6:You may be wise beyond your years, young neb.


Posted by: bob mcmanus | Link to this comment | 12-20-09 1:51 PM
horizontal rule
12

"Ye sons of Indolence, do what you will,
And wander where you list, through hall or glade;
Be no man's pleasure for another stay'd;
Let each as likes him best his hours employ,
And curs'd be he who minds his neighbour's trade!
Here dwells kind ease and unreproving joy:
He little merits bliss who others can annoy."


Posted by: bob mcmanus | Link to this comment | 12-20-09 2:01 PM
horizontal rule
13

||

No more masturbating 2 Brittany Murphy.

""2day the world lost a little piece of sunshine," Kutcher wrote. "My deepest condolences go out 2 Brittany's family, her husband, & her amazing mother Sharon."

|>


Posted by: Bave Dee | Link to this comment | 12-20-09 2:18 PM
horizontal rule
14

Pwned good buddy. Makes me think of seeing "Elton" at the Baths.


Posted by: A White Bear | Link to this comment | 12-20-09 2:22 PM
horizontal rule
15

I feel like there should be a 24-hour grace period on masturbating in some cases. One needs to grieve.


Posted by: A White Bear | Link to this comment | 12-20-09 2:24 PM
horizontal rule
16

Oh, I did not see that other thread at all.


Posted by: Bave Dee | Link to this comment | 12-20-09 2:27 PM
horizontal rule
17

13:Sad. An artist distinctive enough with a long career that I knew who the name belonged to immediately.

Like Judy Holliday or Marilyn Monroe or Jennifer Tilly, smart & confidant enough to make ditzy fascinating.


Posted by: bob mcmanus | Link to this comment | 12-20-09 2:33 PM
horizontal rule
18

@5

Today's achewood is relevant.


Posted by: F | Link to this comment | 12-20-09 2:50 PM
horizontal rule
19

Okay, I don't actually know how to fix that link. Can someone tell me how to stop it from automatically assuming achewood is in the archives?


Posted by: F | Link to this comment | 12-20-09 2:55 PM
horizontal rule
20

||?

This is the kind of thread that gives Making Light its reputation. Books about Byzantium => Colonialism => Avatar => Privilege => Bujold. Charlie Stross shows up. I was poleaxed by the original post, where Justinian gets into an extemporaneous poetry contest with a fan at a Hippodrome on the subject of the Incorruptibility of Christ's Body while the crowd cheers and jeers the pair

I say:"What Fucking Progress?"

Sean Paul Kelley says Avatar has nothing to do with race or post-colonial guilt, even if Cameron thinks it does. Kelley studies the Silk Road, and has maybe walked it for all I know.

|>


Posted by: bob mcmanus | Link to this comment | 12-20-09 3:05 PM
horizontal rule
21

By the way, the closest analogy is the Medicare catastrophic coverage act of 1988. Proposed by Reagan in 1986, passed in 1988, repealed in 1989 before it ever went into effect.


Posted by: SP | Link to this comment | 12-20-09 3:14 PM
horizontal rule
22

Are there counter-examples of what could have been major legislation, but it was so crippled by compromised, and then thoroughly gutted by the next administration?

He quoted one right there. The Civil Rights Act of 1957. I don't find his interpretation persuasive. (There were a number of civil rights acts. The one that had the effects everyone was after was the Civil Rights Act of '64. The argument was that they tried and opened the door. Or maybe they just tried and fucking failed so eventually they tried again. Note that the Civil Rights of 1875 seems to have been similar to 1964. It was declared unconstitutional.)

I don't find the interpretations of the Social Security Act persuasive. The taxes were there, the system was in place. It wasn't expansive enough, but the system was there. Only if you believe paying money to insurance companies is a system that should endure until the end of this century do you go for that interpretation. Changing over to a single-payer system would mean effective abolition of this law.

I don't find the interpretation of the Emancipation Proclamation persuasive. Lincoln declared right off the bat he wasn't going to do that, trying to forestall the civil war. Eventually he acted. A bit thereafter he extended it. A little bit later, the Radical Republicans really acted. He spent almost his entire administration in a war, while that was going on.

All three of those have the same problem: intense opposition, and severe criticism by supporters. I take that mean the stuff is controversial. Woo woo.

max
['OK, a counter-example...']


Posted by: max | Link to this comment | 12-20-09 3:24 PM
horizontal rule
23

Heebie, Rauchway may be your guy on this. He has a lot of fans, even if I am not one. The thread goes off track, I think.

I should tell my version of the origin of our antagonism someday. I think its funny.


Posted by: bob mcmanus | Link to this comment | 12-20-09 3:26 PM
horizontal rule
24

I am way too tired to think about this topic cogently, but an excellent book that tries to look at both the way inequality is structured in social welfare and the tangled history of compromise is Linda Gordon's Pitied But Not Entitled: Single Mothers and the History of Welfare.


Posted by: Parenthetical | Link to this comment | 12-20-09 4:03 PM
horizontal rule
25

Simultaneously reading Ian Welsh and Mark Ark Leiman, both of whom are people I have trusted for years, I learn that anybody who either opposes or supports the bill is a moral monster who is either too stupid or too gutless to be truly deemed human. A curious game: the only way I can win is to stop reading political commentary.


Posted by: Cryptic ned | Link to this comment | 12-20-09 4:03 PM
horizontal rule
26

Ezra seems to think that having hospitals publish a list of standard charges will somehow lead to price transparency.

That strikes me as nonsense. First, most of the charges you get hit with while in the hospital aren't from the hospital, they're from the radiology group or the blood lab group or the hospitalist - all of whom are distinct from the hospital and don't show up as hospital charges. Second, I expect that the standard charges are the wholly fictional amounts that only poor people pay, like the $900 blood lab charge I got which was marked down to $150 because I got the special Blue Cross rate.

Am I misreading this as usual?

I like the idea that HRC is as good as the emancipation proclamation: all we need is a civil war and a zillion dead people and we'll have made some real change.


Posted by: Michael H Schneider | Link to this comment | 12-20-09 4:14 PM
horizontal rule
27

[Your counter-example. Way too damn long. Sorry. Kill me.]

The National Industrial Recovery Act (NIRA), officially known as the Act of June 16, 1933 (Ch. 90, 48 Stat. 195, formerly codified at 15 U.S.C. sec. 703), was an American statute which authorized the President of the United States to regulate industry and permit cartels and monopolies in an attempt to stimulate economic recovery, and which established a national public works program. [...]
The National Industrial Recovery Act was enacted at the very end of the Hundred Days. Hugh S. Johnson, Raymond Moley, Donald Richberg, Rexford Tugwell, Jerome Frank, and Bernard Baruch--key Roosevelt advisors--believed that unrestrained competition had helped cause the Great Depression and that government had a critical role to play through national planning, limited regulation, the fostering of trade associations, support for "fair" trade practices, and support for "democratization of the workplace" (a standard work week, shorter working hours, better working conditions).[...]
Many leading businessmen--including Gerard Swope (head of General Electric), Charles M. Schwab (chairman of Bethlehem Steel Corporation), E. H. Harriman (chairman of the Union Pacific Railroad), and Henry I. Harriman, president of the U.S. Chamber of Commerce--helped draft the legislation. A two-part bill, the first section promoting cooperative action among business to achieve fair competition and provide for national planning and a second establishing a national public works program, was submitted to Congress on May 15, 1933, after Roosevelt himself reconciled differences between the two competing bills.The House of Representatives easily passed the bill in just seven days. The most contentious issue had been the inclusion of Section 7(a), which protected collective bargaining rights for unions. Section 7(a) had nearly not made it into the bill, but Senator Wagner, Jerome Frank, and Leon Keyserling (another Roosevelt aide) worked to retain the section in order to win the support of the American labor movement.
The bill had a more difficult time in the Senate. The National Association of Manufacturers, Chamber of Commerce, and industrialist Henry Ford all opposed its passage. Senator Bennett Champ Clark introduced an amendment to emasculate Section 7(a), but Wagner and Senator George W. Norris led the successful opposition to the change. The bulk of the Senate debate, however, turned on the bill's suspension of antitrust law. Senators William E. Borah, Burton K. Wheeler, and Hugo Black opposed any relaxation of the Sherman Antitrust Act, arguing that this would exacerbate existing severe economic inequality and concentrate wealth in the hands of the rich (a severe problem which many economists at the time believed was one of the causes of the Great Depression). Wagner defended the bill, arguing that the bill's promotion of codes of fair trade practices would help create progressive standards for wages, hours, and working conditions, and eliminate sweatshops and child labor. [Hrmm. Answer is... ehhhhhhh... NO.] [...]
The heart of the Act was Title I, Section 3, which permitted trade or industrial associations to seek presidential approval of codes of fair competition (so long as such codes did not promote monopolies or provide unfair competition against small businesses) and provided for enforcement of codes. Title I, Section 5 exempted codes from the federal antitrust laws.[...]
NIRA, as implemented by the NRA, became notorious for generating large numbers of regulations. The agency approved 557 basic and 189 supplemental industry codes in two years. Between 4,000 and 5,000 business practices were prohibited, some 3,000 administrative orders running to over 10,000 pages promulgated, and thousands of opinions and guides from national, regional, and local code boards interpreted and enforced the Act. The backlash against the Act was so significant that it generated a large loss of political support for the New Deal and turned a number of Roosevelt's closest aides against him. Roosevelt himself shifted his views on the best way to achieve economic recovery, and began a new legislative program (known as the "Second New Deal") in 1935. [...]
Implementation of Section 7(a) of the NIRA proved immensely problematical as well. The protections of the Act led to a massive wave of union organizing punctuated by employer and union violence, general strikes, and recognition strikes. At the outset, NRA Administrator Hugh Johnson naïvely believed that Section 7(a) would be self-enforcing, but he quickly learned otherwise and the National Labor Board was established under the auspices of the NRA to implement the collective bargaining provisions of the Act. The National Labor Board, too, proved to be ineffective, and on July 5, 1935, a new law--the National Labor Relations Act--superseded the NIRA and established a new, long-lasting federal labor policy. [...]
President Roosevelt sought reauthorization of NIRA on February 20, 1935. But the backlash against the New Deal, coupled with continuing congressional concern over the Act's suspension of antitrust law, left the President's request politically dead.
It is widely agreed that the NIRA was a failure as public policy. As noted above, even by early 1935 there was nearly a consensus in Congress that the industry codes were not working and that the economic effects of the public works provisions would not be felt for many years. But why the NIRA failed is the subject of dispute. A key criticism of the Act at the time as well as more recently is that the NIRA endorsed monopolies, with the attendant economic problems associated with that type of market failure. Even the National Recovery Review Board, established by President Roosevelt in April 1935 to review the performance of the NRA, concluded that the Act hindered economic growth by promoting cartels and monopolies. One of the economic effects of monopoly and cartels is higher prices. Higher prices were an intentional outcome of the Act because deflation was a severe problem at the time. There is anecdotal evidence that these higher prices lead to some stability in industry. But were these prices so high that economic recovery was inhibited? A number of scholars answer in the affirmative. But other economists disagree, pointing to far more important monetary, budgetary, and tax policies as contributors to the continuation of the Great Depression. Others point out that the cartels created by the Act are inherently unstable (as all cartels are), and that the effect on prices was minimal because the codes collapsed so quickly.
A third major criticism of the Act is that it was poorly administered. The Act purposefully brought together competing interests (labor and business, big business and small business, etc.) in a coalition to support passage of the legislation, but these competing interests soon fought one another over the Act's implementation. As a consequence, NRA collapsed due to failure of leadership and confusion about its goals.
On the other hand, the public works part survived:
The leadership of the Public Works Authority was torn over the new agency's mission. PWA could initiate its own construction projects, distribute money to other federal agencies to fund their construction projects, or make loans to states and localities to fund their construction projects. But many in the Roosevelt administration felt PWA should not spend money, for fear of worsening the federal deficit, and so funds flowed slowly. Furthermore, the very nature of construction (planning, specifications, and blueprints) also held up the disbursement of money. Harold Ickes, too, was determined to ensure that graft and corruption did not tarnish the agency's reputation and lead to loss of political support in Congress, and so moved cautiously in spending the agency's money. Although the U.S. Supreme Court would rule Title I of NIRA unconstitutional, the severability clause in the Act enabled the PWA to survive. Among the projects it funded between 1935 and 1939 are: the USS Yorktown; USS Enterprise; the 30th Street railroad station in Philadelphia, Pennsylvania; the Triborough Bridge; the port of Brownsville; Grand Coulee Dam; Boulder Dam; Fort Peck Dam; Bonneville Dam; and the Overseas Highway connecting Key West, Florida, with the mainland. The agency survived until 1943, when the Reorganization Act of 1939 consolidated most federal relief and work relief functions of the federal government into the new Federal Works Agency.
You will have noted that those are the problems with have had with this administration and the stimulus.

Anyways: monopolies and cartels ARE! BAD! It didn't work for the Communists. It didn't work for the Fascists. It didn't work for us, neither.

(And incidently was what earned the 'fascist' epithet for the FDR administration, because the NIRA was um, er, fascist. In the sense that fascist thought was considered the leading wave of the future in the early 30's, and monopolies and cartels (state-directed but not state-owned) were a big feature of fascism. And 'rationalizing industry' was tried out all over the place and more or less went down the toilet.

The only decent summary of fascism as an organizing ideology that I know of: fascists accept Marx's critique of capitalism, but reject his solutions, preferring to 'bring all classes together' to work inside the state. (Thus, fasces.) Mostly what this results in, is class warfare continuing inside the state as part of a highly, intensely corrupt bureaucracy that can't get anything done without constant intervention from above. This also describes large corporations. And the internal guts of the XSSR as well. But neither of those systems make bureaucratic warfare & leader worship their raison d'etre, so other effects come into play. Fascists like vicious bureaucratic power struggles, believing that the strong will survive. And the strong do strong, but the strong at bureaucratic warfare tend to be lousy at anything else. At any rate, I think the effects of bureaucracy trump ideology.

This is also why that DLC 'third wave' shit gives me the fucking hives. This shit does not work. It's invariably crooked, worse when you make it the main point of your action. It's repressive and awful and bad, much like the police, but without being responsive to democratic control. Bureaucrats who work for the state don't get paid enough to buy off legislators, not to mention they aren't primarily interested in profit.)

So, anyways. Not thinking this health care bill will work out so much. Unfortunately, the administration and the D congress have got themselves so far out on the tightrope, that if they fall off, we get nothing else. Screwed. Either you wait for the 'centrists' to kill the bill, you suck it up and accept the hit so you can go on and get something else worthwhile, or you commit to something else. 'Something else' would have to be abandonment of the Democrats and presumably the organization of a third party, unless you just want to sit around with your thumb up your ass for 3-6 years.

I don't like the choices at hand either.

max
['Blech.']


Posted by: max | Link to this comment | 12-20-09 4:18 PM
horizontal rule
28

26:Tyler Cowen liked Ezra's post, but his commenters disagreed, with some very good arguments and suggestions. This will be posting the equivalent of MSRPs.


Posted by: bob mcmanus | Link to this comment | 12-20-09 4:24 PM
horizontal rule
29
Posted by: | Link to this comment | 12-20-09 4:39 PM
horizontal rule
30

28: Thank you. I am reassured to learn that I can still see the obvious within mere days of when everyone else has pointed it out.

Isn't the problem with the argument in the post's link that it's an analogy?


Posted by: Michael H Schneider | Link to this comment | 12-20-09 4:39 PM
horizontal rule
31

Ezra, for all his wonkish knowledge, and it is considerable, seems surprisingly wide-eyed and complacent to me at times. Michael's comment at 26, and the comments at Cowen's, are pretty obviously and immediately correct, and I'm really not sure sometimes why Ezra doesn't cast a more critical eye at some of the provisions he becomes excited about. Enthusiasm over this one seems particularly bone-headed.


Posted by: parsimon | Link to this comment | 12-20-09 4:51 PM
horizontal rule
32
Posted by: | Link to this comment | 12-20-09 5:06 PM
horizontal rule
33

Ezra Klein is amazing. I consider the juggling of personas required to stay acceptable to the WaPo editors and Big Media (Charlie Rose!); his Congressional Sources; and whatever subset of the blogosphere and wonkosphere he remains collegial with to be immensely entertaining.

Hamsher and Bowers are doing well, but as someone I read tonight, Olbermann and Maddow don't really much matter. Good Morning America matters.

Krugman has turned out to be a superb blogger, but I think has burned bridges to the policy establishment, and to some extent the MSM, and is mostly an academic and wonkosphere Active.


Posted by: bob mcmanus | Link to this comment | 12-20-09 5:45 PM
horizontal rule
34

It's not clear to me why the course of legislation enacted during the New Deal-Great Society era should be comparable to legislation passed now. Do we really think that the next thirty years will be an era of unquestioned liberal dominance?

If I did, I would be more sanguine about this. New Deal legislation contained within it the seeds of it's perpetuation. This bill does not.


Posted by: JRoth | Link to this comment | 12-20-09 7:56 PM
horizontal rule
35

28 makes me think I should be more worried about the Supreme Court than I have been.


Posted by: Witt | Link to this comment | 12-20-09 8:22 PM
horizontal rule
36

-'


Posted by: JRoth | Link to this comment | 12-20-09 8:30 PM
horizontal rule
37

That Emancipation Proclamation analogy is such bs. Unless you think the federal government was going to engage in a massive re-enslavement project if it won the war. And if you think thousands of formerly enslaved people fleeing for union lines was a relatively minor occurrence. Of course the abolitionists were disappointed and they were right to be. But their disappointment is not the only measure of the policy.


Posted by: Fake Accent | Link to this comment | 12-20-09 9:33 PM
horizontal rule
38

The thing about potentially major legislation that was watered down by compromise is that some of what would be the most famous cases actually aren't that well remembered because they were at the beginning (legislatively speaking) of longer movements. So the NIRA was a mess, but not long after you get the New Deal legislation that did many of the same things, but better. Plus most of NIRA was struck down, sparing people from having to deal with its problems directly. Or you get the 1957 Civil Rights Act, which wasn't much, followed by the 1960s civil rights and voting rights acts. Most people probably haven't heard of either the NIRA or the 1957 Civil Rights Act because of what came later.

There are some famous failed compromises from before the civil war, with Compromise in the title. It took some time for the 1820 version to prove unworkable. If you want to get deep in the weeds of regulation and the Wilson administration, there's an argument that the act creating the Federal Trade Commission was watered down and confused. I think the FTC was later strengthened, but that act didn't have nearly the impact of some of the other legislation out of the same period like the creation of the federal reserve.

What stands out about health care reform is that it looks pretty small set aside almost all of the analogies people are coming up with. There isn't even an identifiable program to build on. The good provisions are good - pre-existing condition regulation and the like - but you can't say it's like Social Security or Medicare or something like that. Maybe this is minor, but is there anything in that can be named and promoted by name?


Posted by: Fake Accent | Link to this comment | 12-20-09 9:54 PM
horizontal rule
39

(Oh, and since I won't be around most of tomorrow to explain. I'll just note that I'm not a new commenter and leave it at that.)


Posted by: Fake Accent | Link to this comment | 12-20-09 9:56 PM
horizontal rule
40

What with the HCR branding, anyway ? In '92 it was 'Womb to the tomb!'. Reform is such an evasive label.


Posted by: Econolicious cannot spell HCR without HRC | Link to this comment | 12-20-09 10:15 PM
horizontal rule
41

38.last: The Exchanges carry with them almost $500 billion in subsidies over six years (2014-2019) -- at almost $100 billion a year that's a pretty sizable new entitlement program. Then you get all the regulations of insurance offerings within the exchange. It's not hard to imagine the exchanges becoming a recognized part of the social safety net.


Posted by: PGD | Link to this comment | 12-20-09 10:22 PM
horizontal rule
42

So if they make it into existence two years after the next presidential election, we will have an identifiable program? It still sounds somewhat diffuse to me - will people be more aware of the Exchanges than of the private companies they're dealing with?


Posted by: Fake Accent | Link to this comment | 12-20-09 10:26 PM
horizontal rule
43

40: I think one problem is that there is already a healthcare analog to Social Security - it's Medicare. And then kids have S-CHIP. In between, it's hard to name something that should just be the normal course of business for all adults.


Posted by: Fake Accent | Link to this comment | 12-20-09 10:29 PM
horizontal rule
44

41:that's a pretty sizable new entitlement program.

Medicare, Medicaid, SCHIP, VA, Gov't Employee Care, and now subsidized exchanges and mandates,some federally regulated, some state regulated, with a chaos of financing.

Looks kinda complicated to me.

The Village doesn't like Medicare and the States don't like Medicaid.

Where could this possibly be going? Hmmm?


Posted by: bob mcmanus | Link to this comment | 12-20-09 10:35 PM
horizontal rule
45

Answer:Merge everything into the exchange. Without a very robust public option single payer, it will be the privatizing of all the above into profit centers, with subsidies for the neediest.


Posted by: bob mcmanus | Link to this comment | 12-20-09 10:40 PM
horizontal rule
46

Voting happening on CSPAN2 right now...


Posted by: Otto von Bisquick | Link to this comment | 12-20-09 10:48 PM
horizontal rule
47

About the only notable thing about this vote so far seems to be that Reid requested that the Senators follow a 198x rule and vote from their seats. Makes for a somewhat more dramatic scene.

Getting to the holdouts now. Mr. Lieberman, aye.


Posted by: Otto von Bisquick | Link to this comment | 12-20-09 10:52 PM
horizontal rule
48

Mr. Nelson of Nebraska, aye.


Posted by: Otto von Bisquick | Link to this comment | 12-20-09 10:53 PM
horizontal rule
49

But I am watching Oldboy again! I can't switch.

Whatever is thought of the content, the stylistic and cinematic audacity keeps me glued to the screen. This will not be remade well.


Posted by: bob mcmanus | Link to this comment | 12-20-09 11:01 PM
horizontal rule
50

What!? I want Book TV!


Posted by: Fake Accent | Link to this comment | 12-20-09 11:04 PM
horizontal rule
51

48: The first of the vengeance films is the health care reform one. Maybe the third, too, but I haven't seen it.


Posted by: Fake Accent | Link to this comment | 12-20-09 11:06 PM
horizontal rule
52

50: Go firebomb your cable provider.


Posted by: Otto von Bisquick | Link to this comment | 12-20-09 11:06 PM
horizontal rule
53

My cable provider's listings says this is supposed to be when C-SPAN2 shows some guy talk about "Obamanomics." I guess I'm not too disappointed it's not on.

My favorite C-SPAN2 roll call moment was during the FISA debates in 2008 when the mic caught someone advise another Senator to vote with their conscience, or do what they thought in their heart to be right, or something like that.


Posted by: Fake Accent | Link to this comment | 12-20-09 11:09 PM
horizontal rule
54

Final vote Dec 24 7 eastern. Cutting things kind of close.


Posted by: Fake Accent | Link to this comment | 12-20-09 11:12 PM
horizontal rule
55

54: Shit, that means I'm going to get sucked into an HCR argument during Christmas Eve dinner, doesn't it? I kept relative cool during today's argument, given that the guy began the argument by trying to get me to say whether I am an in favor of freedom. (I had resolved to stay out of the discussion I heard brewing on the opposite side of the room, but found myself jumping in when I heard him saying that they needed to publish the bill and let people debate it before it went forward. I mean shit, man, I know there have been some last minute changes, but the outlines have been published on the web for months now. He really didn't seem aware of this.)

He seemed awfully short on specifics but was nonetheless comfortable with accusing me of being unwilling to acknowledge that there were many "nefarious" things in this bill. I may have not given a complete or completely accurate explanation of good and bad things that may come from this bill, but I sure think I was a hell of a lot better informed than he was.

Also, those 30 years older than I am seem to have a hard time talking to me without being condescending. Perhaps this is unsurprising. Perhaps it is to some extent justified

The dad (an MD, and generally fairly conservative) admitted that the bill was not all that bad, and that there's a lot of de facto rationing that goes on under the current system as well. He then told stories of arguing for approval for MRIs and such with aloof insurance bureaucrats.

After further discussion, he said that if they're going to pass an incrementalist, middle-ground bill that he'd rather they'd pass a single-payer bill. This was actually somewhat surprising to me, and is a reminder that my dad is more often than not a rather thoughtful and intellectually honest individual.

I hardly wanted (and want, going forward on this vacation) to be this bill's cheerleader. I just find that I can only listen to so much underinformed nonsense and righteous indignation before I feel the need to bring out some of my slightly-better-informedness and greater dispassion. But it's more fun to just be hysterical and talk in vague generalities about incipient disaster, right?


Posted by: Otto von Bisquick | Link to this comment | 12-20-09 11:48 PM
horizontal rule
56

I guess it could still be delayed, but that was the schedule C-SPAN put up.


Posted by: Fake Accent | Link to this comment | 12-20-09 11:50 PM
horizontal rule
57

I mean, if you want to oppose the bill, go ahead. Just do it for real existing reasons, OK?


Posted by: Otto von Bisquick | Link to this comment | 12-20-09 11:50 PM
horizontal rule
58

56: Nah, I'll be getting in periodic arguments this week and next no matter what the Senate does.


Posted by: Otto von Bisquick | Link to this comment | 12-20-09 11:56 PM
horizontal rule
59

I briefly dated a resident who seemed to think that passage of any healthcare reform would mean that we'd all be sent to VA hospitals for treatment, or perhaps merely that all doctors would immediately become only as competent as the most competent VA doctor. Or something astoundingly bizarre like that. (I refrained from asking her if she thought she would become incompetent.)

This was especially surprising to me because the only other medical professional whose opinions about health care I'm more than superficially familiar with is my father, who's generally pretty conservative in a bush-despising way but who favored Kucinich because he thought he was the only one who was serious about health care reform.


Posted by: nosflow | Link to this comment | 12-21-09 12:02 AM
horizontal rule
60

I just find that I can only listen to so much underinformed nonsense and righteous indignation before I feel the need to bring out some of my slightly-better-informedness and greater dispassion. But it's more fun to just be hysterical and talk in vague generalities about incipient disaster, right?

Not only more fun, but better politics.

Or maybe you really got into the thickets of yellowcake and mobile chemical labs and Colin Powell's presentation.

I think it was a very stupid way to do politics, and didn't work worth a damn. Hysteria and vague generalities do work better

Hey Hey LBJ how many kids did you kill today?

I oppose the bill, and can link cite or argue any number of sane specifics to the self-satisfied Ivy wonks. But "sell you out to insurance companies" and "steal the medicare trust fund" might actually have killed or changed the bill.

And how did Obama talk about it? Politics is not fucking science.


Posted by: bob mcmanus | Link to this comment | 12-21-09 1:06 AM
horizontal rule
61

John Emerson's latest contribution to Open Left

The subject is "Stupid Voters" and how to expand the base

It's stupid to talk about "the stupid voters", and liberals should quit doing it. But my recent internet experience has taught me that this bad habit is deeply ingrained and that many find it very satisfying, and I suspect that many liberals are going to find changing their ways hard or impossible. The educated tend to define their own identity and their relationship to the rest of the human world in terms of their own educational success and their difference from those without it.

Hmmm...


Posted by: bob mcmanus | Link to this comment | 12-21-09 1:13 AM
horizontal rule
62

I do think you're right about how politics works in general.

On a personal level (and thus, probably, not-that-importantly), however, I don't respond well to that sort of politicking. And I think part of my aversion to florid, nuance-free rhetoric comes from my having been raised by fairly conservative parents who I felt gave me a fairly one-sided perspective on the issues of the day. When I later came across other perspectives and found them to be in many cases quite compelling, I grew frustrated with my past unquestioning acceptance of my parents' worldview. And so nowadays I grow mighty suspicious whenever someone says to me: "This is the way the world is. Listen to me and accept it as gospel truth." I want to know some details before I sign on. And if the message is delivered all colorfully, I get doubly suspicious that someone is trying to distract me with those colors so that they can pull the wool over my eyes. Maybe the real issue is that I'm afraid they think I'm stupid?

I'm reading the CBO report about the manager's amendment right now and it's a nice and soothing coda to my evening. All those numbers and descriptions.

So I'm probably the wrong person to lead Emerson's left populist revolution. But I never claimed to be much of a leader. Fortunately, I have a day job.

Every once in awhile I do get all riled up, though, and thus I do understand on some level what it's all about. I'd probably be a better person if I were more pissed more often. Maybe I'd do something.


Posted by: Otto von Bisquick | Link to this comment | 12-21-09 2:01 AM
horizontal rule
63

The perspective in the linked thread is interesting. I continue to doubt that the new profusion of filibustering has really changed that much of how the senate works. Things like this just somehow don't convince me. There was a way for the minority to exert a veto over things, and it was even easier in the past because the majority required was more than 60, and yet senators were just too darn polite to use it? In a world where we are also being reminded of "holds" and other things senators can do to prevent anything from happening, it just sounds a lot more plausible that the "60-vote majority because of threats of filibuster" has appeared because it's easier than whatever other mechanism reactionaries used before to shout "HALT!".


Posted by: Cryptic ned | Link to this comment | 12-21-09 7:08 AM
horizontal rule
64

IOZ spends the week reading Klein and Yggles, with an affectionate shot at Berube.

Strictly speaking, it's true, and yet I note that you could likewise say that the issue with the National Socialist party was that its leaders all shared a world view that was extremely . . . narrow. And that is not to say that the Democrats are Nazis, Dude, far from it. It is merely to point out that the problem with our ruling junta isn't their unwillingness to "look beyond" their pernicious crocodilian cannibalistic blood-worship, but rather the fact that they are, in fact, flesh-eating, blood-drinking, reptilian man-crunchers. Suggesting that they have somehow failed to look beyond the received wisdom of their class presumes mere intellectual failure and thus undercredits their vicious intelligence. The problem is not that they are idiots, although idiots are certainly well-represented in the upper echelons of our lategreat empire, but that they're bastards

"[that which]...Leftwhich Warrior Michael Bérubé in his High Late Early Medieval Postmodern Enlightenment mode semi-coined "deontological war", is plainly completely insane"

The dude can write.


Posted by: bob mcmanus | Link to this comment | 12-21-09 7:14 AM
horizontal rule
65

63:Oh, if ari and eric weren't so terrified of my rapier wit, we could get some actual historians over here with some knowledge of the Senate.

Bills weren't filibustered in the older ages because bastard committee chairman, usually from the Deep South, had the power and sheer pleasure of killing disagreeable ideas before they even could reach a fricking committee vote. "Umm, Ah nid to study on that thang for a few years."

And Nelson and Landrieux are frankly such pathetic midgets at the art of bribery and pork that I worry for our civilization. FDR had to give them TVA and Bonneville Dam. Entire Army bases and Naval Ports were sold for votes on minor bills, hundreds of thousands of jobs at a whack. De facto slavery and foreign wars were bargaining chips. We have become so small.


Posted by: bob mcmanus | Link to this comment | 12-21-09 7:26 AM
horizontal rule
66

63:Oh, if ari and eric weren't so terrified of my rapier wit, we could get some actual historians over here with some knowledge of the Senate.

Bob? This sort of petty shittiness isn't up to your normal standards of expansive lunacy.


Posted by: LizardBreath | Link to this comment | 12-21-09 7:46 AM
horizontal rule
67

The pressure to make new bits of expansive lunacy has got to be enough of a burden on its own without added stress.


Posted by: Moby Hick | Link to this comment | 12-21-09 7:49 AM
horizontal rule
68

We must not allow an expansive lunacy gap!


Posted by: JP Stormcrow | Link to this comment | 12-21-09 7:52 AM
horizontal rule
69

I thought that prior to the adoption of the cloture rule, the Senate was like Mr. Smith: one senator could keep debate going. Wikipedia seems to back that up, and blames Burr. As does the book on Senate practice and procedure cited therein.


Posted by: CharleyCarp | Link to this comment | 12-21-09 7:53 AM
horizontal rule
70

66:It was intended mostly as a self-deprecating joke. I do that a lot.


Posted by: bob mcmanus | Link to this comment | 12-21-09 7:53 AM
horizontal rule
71

and blames Burr.

Yes, a great many people have felt that it is important to have the Secretary of the Treasury be a better pistol shot than the Vice President. Bush didn't abide by this wisdom.


Posted by: Moby Hick | Link to this comment | 12-21-09 7:57 AM
horizontal rule
72

Along this theme, I linked at Thoma's to the Wiki article on the 17th Amendment last night, along with some expansive lunacy of my own as commentary.

That place used to be really crazy corrupt.


Posted by: bob mcmanus | Link to this comment | 12-21-09 7:59 AM
horizontal rule
73

And, it seems, the 1917 rule allowing cloture was a response to a filibuster, led by LaFolette, of Wilson's request to arm ships -- and thus slide into WWI. That was 11 senators, who prevented the matter coming to a vote for the last 3 days of the session. The first invocation of cloture was over the Versailles Treaty.


Posted by: CharleyCarp | Link to this comment | 12-21-09 8:02 AM
horizontal rule
74

My purpose at Thoma's was to provide an example of how institutional change is actually done, as opposed to begging the lions to lay with the lambs.

The Congress had resisted proposing the amendment and so the states pushed to take action into their hands. Usually only the Congress proposes amendments, but two thirds of the states can call for a new constitutional convention to propose amendments (in either case, ratification by three-fourths of the states is required for adoption). By 1910, 31 states had called for such a convention (one short of the then-required number), putting additional pressure on the Congress to propose the amendment.[3]

The Wiki is straightforward and onpoint with little context, but an actual constitutional convention in the progressive populist era would have been...interesting.


Posted by: bob mcmanus | Link to this comment | 12-21-09 8:08 AM
horizontal rule
75

Speaking of the progressive populist era, if you type "Minnesota Farmer-Labor Party" three times, John Emerson appears behind you.


Posted by: Moby Hick | Link to this comment | 12-21-09 8:19 AM
horizontal rule
76

I'm liking the Kyoto Protocol as the best analogy to the current health insurance reform bill. It's got many of the elements: deeply entrenched interests with a lot of money at stack in trying to squelch it, massive misrepressentation, widespread ignorance and misinformation among the electorate, and a cautious incrementalist first step rather than being something big and shiny and new.


Posted by: Michael H Schneider | Link to this comment | 12-21-09 8:39 AM
horizontal rule
77

44-45: that's interesting -- private insurance with subsidies for the neediest was always the responsible Republican health care reform track, back before the whole party went nuts. Bush I proposed something like that. As I mentioned in another thread, once upon a time this was the conservative-economist plan for Medicare too. Converting Medicare into such a structure would be a big win for the right and a bad thing all around. But I'm not so sure that Medicaid in a lot of states wouldn't be improved under such a structure; it's so underfunded that many providers don't take it.

The Exchange structure as currently envisioned would regulate the private insurers much more than the Republicans ever said they would, there are a number of statutory committments to that in the bill. But the long delay before the whole thing comes up is concerning. One early action thing to keep a close eye on is how HHS defines medical loss ratio -- insurers who don't meet a certain level of medical loss ratio will have to make refunds to policy holders.

I'm not as down on the mandate as others here; something like a mandate will always be part of a national health system. For single payer, the mandate is called a tax. Since I don't think it was ever in the cards for the private insurance industry to be wiped out, I'm not too shocked that they are the middlemen here.


Posted by: PGD | Link to this comment | 12-21-09 8:45 AM
horizontal rule
78

The problem with the mandate is that this is not an entitlement program at all, and it appears to the untrained eye to have nothing at all in common with Medicaid and Medicare and Social Security. It appears to be equivalent to the requirement to buy car insurance, except that instead of being required for everyone who owns a car, it is required for everyone who is a human and alive.


Posted by: Cryptic ned | Link to this comment | 12-21-09 8:58 AM
horizontal rule
79

78: It is an entitlement in the sense that it is a right to buy insurance, which is very much not a given now. If you don't mandate that everybody gets insurance, you're basically allowing individuals to do what FDIC insured banks did before the crash, gamble and keep the profits if they win and the public bears the costs if they lose.

People who are healthy won't buy insurance until they get sick. If they don't get sick, they keep what they would have paid in premiums. If they do get sick, everybody else has basically been paying for their coverage (though higher costs of their own insurance) up until they moment the uninsured guy gets sick and seeks coverage.

As PGD said, I don't see anyway to get closer to universal coverage without a mandate.


Posted by: Moby Hick | Link to this comment | 12-21-09 9:07 AM
horizontal rule
80

79

People who are healthy won't buy insurance until they get sick. ...

They would if charged a fair rate.


Posted by: James B. Shearer | Link to this comment | 12-21-09 9:17 AM
horizontal rule
81

80: The fair rate creeps higher for every healthy person who chances not having insurance. There are multiple equilibria in this game and a huge collective action problem in shifting from one to the other.


Posted by: Moby Hick | Link to this comment | 12-21-09 9:19 AM
horizontal rule
82

And if they have guaranteed issue, why would they buy insurance before they're sick? An abstract sense of decency?


Posted by: LizardBreath | Link to this comment | 12-21-09 9:23 AM
horizontal rule
83

A love of paying money and completing forms?


Posted by: Moby Hick | Link to this comment | 12-21-09 9:27 AM
horizontal rule
84

As near as I can tell, that's why people do NCAA basketball pools.


Posted by: Moby Hick | Link to this comment | 12-21-09 9:28 AM
horizontal rule
85

And if they have guaranteed issue, why would they buy insurance before they're sick? An abstract sense of decency?

I would guess that James thinks a fair price to buy insurance when you are already sick is very high so it would make sense to buy coverage before you were sick if it was fairly cheap. Most people don't want the already sick to pay a "fair" price though. Basically this comes back to my opinion that we should stop calling it insurance since we don't actually want medical insurance we want medical coverage.

Also I don't think anyone here with the possible exception of James is against a mandate. They are just against this particular mandate.


Posted by: CJB | Link to this comment | 12-21-09 9:37 AM
horizontal rule
86

To my knowledge there are no universal health care systems without a mandate that everyone pay into the system. I think peoples' real issue is less the mandate then just not trusting the private insurers to be responsible middlemen in the system. For good reason, I would add. But that goes back to the regulatory relationship with the insurers, not the mandate.

In the sense of service to beneficiaries (as opposed to a fair price for taxpayers), I think the Federal government has done an OK job in regulating private insurers that have been made part of the system in Medicare Part D, Medicaid managed care, and even Medicare Advantage plans. On the other hand, the states have done a lousy job regulating private insurance more generally.

One thing I observed in this process was that the Administration did not seem to get behind or push for the tougher regulatory oversight structure in the House bill.


Posted by: PGD | Link to this comment | 12-21-09 9:37 AM
horizontal rule
87

the problem with our ruling junta isn't their unwillingness to "look beyond" their pernicious crocodilian cannibalistic blood-worship, but rather the fact that they are, in fact, flesh-eating, blood-drinking, reptilian man-crunchers.

This needs a "literally" in there somewhere.


Posted by: PGD | Link to this comment | 12-21-09 9:41 AM
horizontal rule
88

re: 86

To my knowledge there are no universal health care systems without a mandate that everyone pay into the system.

It depends what you mean by that. In the UK you just get treated, no matter what. NHS staff aren't in the business of checking anything other than your citizenship.

Funding is by universal taxation, but, of course, lots of people don't pay tax [because they are on low-incomes, or otherwise exempt, or are rich and therefore tax-avoiding bastards].


Posted by: nattarGcM ttaM | Link to this comment | 12-21-09 9:45 AM
horizontal rule
89

The U.K. has a VAT doesn't it? That applies more to low income people that most U.S. federal taxation.


Posted by: Moby Hick | Link to this comment | 12-21-09 9:48 AM
horizontal rule
90

They are just against this particular mandate.

Right. I was okay with a mandate as long as we were moving in whatever small fashion toward breaking the insurance industry's cartel. The bill now moves in exactly the opposite direction. The employer-based system is dying, and the way this bill is structured, it just ensures that Big Insurance can wring as much money out of you and me as it possibly can in the meantime. And props up a particularly unpleasant, inefficient, and unethical industry that any lawmaker with a shred of decency should be seeking to crush.


Posted by: apostropher | Link to this comment | 12-21-09 9:50 AM
horizontal rule
91

re: 89

Yes, but I'm not sure what the relevance of that is? The UK has a tax sytem, that includes a sales tax. And your point is?


Posted by: nattarGcM ttaM | Link to this comment | 12-21-09 9:50 AM
horizontal rule
92

91: I guess my point was that pretty much everybody pays a sales tax, regardless of low income.


Posted by: Moby Hick | Link to this comment | 12-21-09 9:52 AM
horizontal rule
93

91: The point is that health care is paid for through a system of taxation that's pretty much universal. How much you pay in taxes depends on your income and spending habits, but everyone participates in the system that funds health care.


Posted by: LizardBreath | Link to this comment | 12-21-09 9:53 AM
horizontal rule
94

85

I would guess that James thinks a fair price to buy insurance when you are already sick is very high so it would make sense to buy coverage before you were sick if it was fairly cheap. ...

Exactly. Also insured people get better rates for routine care that even healthy people need.


Posted by: James B. Shearer | Link to this comment | 12-21-09 9:56 AM
horizontal rule
95

re: 93

Everyone funds it [in some sense], but one's participation in that funding doesn't form part of the criteria for care, in a way that, for example, a mandated insurance scheme would. Simply being an EU citizen or permanent UK resident qualifies you for care.


Posted by: nattarGcM ttaM | Link to this comment | 12-21-09 9:58 AM
horizontal rule
96

To my knowledge there are no universal health care systems without a mandate that everyone pay into the system. I think peoples' real issue is less the mandate then just not trusting the private insurers to be responsible middlemen in the system.

Yes, that was my problem in 78.

Another problem I foresee is that the legislation will not do anything until Obama has been replaced by a Republican president. But I can't tell if this applies to all the interesting cost-cutting and information-gathering experiments, or just the "insurance exchanges".


Posted by: Cryptic ned | Link to this comment | 12-21-09 9:59 AM
horizontal rule
97

Also, the quality of care one receives is the same, no matter what. That wouldn't be the case with multiple mandated insurance schemes, no?


Posted by: nattarGcM ttaM | Link to this comment | 12-21-09 10:00 AM
horizontal rule
98

we could get some actual historians over here with some knowledge of the Senate.

I was offended for a moment, but then realized that I actually don't count as a historian with a knowledge of the Senate. There wasn't a Senate at all for a good portion of my period.


Posted by: Parenthetical | Link to this comment | 12-21-09 10:03 AM
horizontal rule
99

94: That would require not caring for people who didn't buy insurance. Which does not seem politically possible, for very sound moral and practical reasons. Which is why I used the example of banks getting bailed out. Letting somebody run a risk when the public will have to cover them if it goes bad is just a smaller example of the "privatize gains, socialize losses" shit that means I'm now part of a body politic paying people who really screwed the pooch more money that I make while guaranteeing the mortgages of people who make less money than I do while living in much bigger houses.


Posted by: Moby Hick | Link to this comment | 12-21-09 10:05 AM
horizontal rule
100

94: Even saying that, 80 is demonstrably false, unless you have some concept of 'a fair price' that's never existed in reality. People do, in fact, go uninsured in the absence of a mandate.


Posted by: LizardBreath | Link to this comment | 12-21-09 10:05 AM
horizontal rule
101

Also, Democratic control of everything and instead of overturning the Hyde Amendment, it looks almost certain that anti-abortion forces are actually going to succeed in moving *that* in the other direction as well. Everything about this process is just completely maddening.


Posted by: apostropher | Link to this comment | 12-21-09 10:06 AM
horizontal rule
102

Geez, Moby, type a little slower, could you?


Posted by: LizardBreath | Link to this comment | 12-21-09 10:06 AM
horizontal rule
103

101: Did you notice the last change in the language? Not great, but not as bad as Stupak -- as I understand the status quo is that individual states can prevent insurance companies from offering abortion coverage in subsidized plans, but the ban isn't federal.


Posted by: LizardBreath | Link to this comment | 12-21-09 10:07 AM
horizontal rule
104

95, 97: As was said above, making you pay taxes is part of a mandated payment. As for the variance in the quality of care, I have no idea how that will come out in the end. I don't see how it can vary more than it does now.


Posted by: Moby Hick | Link to this comment | 12-21-09 10:08 AM
horizontal rule
105

102: S--O--R--R--Y.


Posted by: Moby Hick | Link to this comment | 12-21-09 10:09 AM
horizontal rule
106

re: 104

But it really isn't. It's disingenuous to compare universal taxation -- which pays for everything, and where ones contribution to tax plays no role in one's eligibility for health care -- with a specifically mandated health insurance scheme.


Posted by: nattarGcM ttaM | Link to this comment | 12-21-09 10:12 AM
horizontal rule
107

That would require not caring for people who didn't buy insurance. Which does not seem politically possible, for very sound moral and practical reasons.

Why would that suddenly become politically impossible? Isn't it totally acceptable to not care for people who DID buy insurance? That's what the movie "Sicko" was all about.


Posted by: Cryptic ned | Link to this comment | 12-21-09 10:15 AM
horizontal rule
108

Not great, but not as bad as Stupak

Want to place bets on which one is closer to the language that comes out of the conference?

I wholly endorse this post. Best I can tell, Obama isn't willing to fight for anything I care about, and I'm at a loss to say what *he* cares about.


Posted by: apostropher | Link to this comment | 12-21-09 10:17 AM
horizontal rule
109

106: "Disingenuous to compare" seems overly harsh. You're right that mandate isn't the right word for what exists in the UK (and I'd much rather have what you've got than what we're going to get).

But if you go back to 86, and think of the word 'mandate' in it's ordinary language sense, rather than as a defined term meaning 'mandate to purchase coverage, this:

To my knowledge there are no universal health care systems without a mandate that everyone pay into the system.

isn't really wrong. In the UK, just like in every other UHC system of which I'm aware, the universality of the health care benefits is matched by the universality of the funding mechanism. An individual's benefits aren't ever matched up with their payments, but to a pretty good approximation, everyone who benefits from the system pays into it.


Posted by: LizardBreath | Link to this comment | 12-21-09 10:19 AM
horizontal rule
110

106: Assuming a sufficient subsidy for those who can't buy insurance, admittedly a big issue where the outcome isn't known, I don't see a moral difference.


Posted by: Moby Hick | Link to this comment | 12-21-09 10:21 AM
horizontal rule
111

108: Maybe. I don't know what to do at this point except hope for the best.


Posted by: LizardBreath | Link to this comment | 12-21-09 10:22 AM
horizontal rule
112

Obama "repeals ban on federally funding needle exchanges.

FAA issues new rules saying that airlines can only trap passengers in planes on the tarmac for up to three hours.

I'm not even all that whirly-eyed about Obama. I'm super pissed about DOMA and wish he'd fought harder for health care reform. But he is steadily getting good stuff done where he can.


Posted by: Megan | Link to this comment | 12-21-09 10:27 AM
horizontal rule
113

Needle exchange.


Posted by: Megan | Link to this comment | 12-21-09 10:28 AM
horizontal rule
114

113: Hot dog. And inner-city diabetics everywhere thank you.

(Note to UK commenters: Part 736 in the series: Yes, poor people in the US are often unable to get regularly needed medical supplies to treat life-threatening conditions.)


Posted by: Witt | Link to this comment | 12-21-09 10:35 AM
horizontal rule
115

"Obama has sent a mixed message on needle programs. He endorsed federal funding as a presidential candidate, but his proposed 2009-10 budget continued the funding ban, even as his drug czar, Gil Kerlikowske, was supporting needle exchanges at his confirmation hearing."

This is exactly what I'm talking about.


Posted by: apostropher | Link to this comment | 12-21-09 10:40 AM
horizontal rule
116

155: But the outcome (in that limited case) was good.


Posted by: LizardBreath | Link to this comment | 12-21-09 10:41 AM
horizontal rule
117

Yes, poor people in the US are often unable to get regularly needed medical supplies to treat life-threatening conditions.

I just took a diabetes class. The first thing they did was hand out blood glucose monitors and teach us how to test our blood sugar, which you're supposed to do at least three times a day. (Testing blood glucose after meals is about the only thing that will let you maintain tight control of your blood sugars, and tight control is the one thing that will stop the progression of the disease.)

Turns out that the strips you squeeze the little blood droplet onto cost a little more than $1 each; a month's supply will cost you about $120. One of the educators teaching the class specifically went over how to rotate the testing, for the people who couldn't afford to test regularly. Fucking appalling.


Posted by: Josh | Link to this comment | 12-21-09 10:47 AM
horizontal rule
118

98:I apologize to any historians, lawyers or anyone else who was offended. I should have, for instance, taken lurkers into account.

I can't keep track or who and what everybody is around here, and I suppose I don't put enough effort. I am unsure of the gender of many. It took me months to figure out Natilo P.

After half a decade, Standpipe Bridgeplate and his blog remain mysteries to me. And the time I look for the mouseover text...


Posted by: bob mcmanus | Link to this comment | 12-21-09 10:49 AM
horizontal rule
119

20 - He may have studied the Silk Road, but he specifically says that he hasn't seen the big ol' Racist McRacist Avatar.


Posted by: snarkout | Link to this comment | 12-21-09 10:50 AM
horizontal rule
120

Yes, the outcome was good, but best I can tell the credit is Nancy Pelosi's, not Barack Obama's. I suppose it's true that he didn't veto a $164 billion appropriations bill over it.


Posted by: apostropher | Link to this comment | 12-21-09 10:51 AM
horizontal rule
121

Yes! Test strips are RIDICULOUSLY expensive. It's boggling.


Posted by: redfoxtailshrub | Link to this comment | 12-21-09 10:53 AM
horizontal rule
122

Just to leaven my unrelenting negativity with a ray of sunshine, I'd like to state for the record that Pelosi is the best Speaker I've ever seen, and by a really huge margin.


Posted by: apostropher | Link to this comment | 12-21-09 10:54 AM
horizontal rule
123

Yeah, you're right about Pelosi deserving that credit. Needle-exchange isn't really a story about doing-right through the agencies.

Still, my response to stuff like "I don't know what Obama is for anymore", is "Pretty much all of the things I like, although not always forceful enough when it is high-profile and contentious."


Posted by: Megan | Link to this comment | 12-21-09 10:58 AM
horizontal rule
124

It is not over, and this bill is not yet law. I could link to FDL again, or Open Left.

The next very important thing, after the Senate votes, is who Pelosi assigns to conference, if there is a conference. Stupak has renewed confidence, the House Hispanic, Pro-Choice, and Progressive Caucuses are furious about their issues, and many House members are incensed at Senate arrogance.

There may be changes that lead to Senate filibusters, and some Senator may just decide to kill the bill for history and spite. If you read like me, you are thinking all the screaming about the filibuster is about what is to come, not about what already happened. Why would Specter embarrass Nelson & Lieberman now?

I have moved my odds of Obama signing something before SOTU down to 60-40. I should check InTrade.

With Kent Conrad at Rules, reconciliation is very unlikely to be worth a damn.


Posted by: bob mcmanus | Link to this comment | 12-21-09 11:01 AM
horizontal rule
125

Praying for the death or incapacitation of one's political adversaries is a little more old school than I am comfortable with, and by "old school" I mean "twenty times more pagan than the prosperity gospel, which is pagan enough to, I don't know, make the Emperor Julian blush."


Posted by: Flippanter | Link to this comment | 12-21-09 11:06 AM
horizontal rule
126

Pelosi is pretty damn good.

For the crowd, who should Pelosi assign to conference?

Blue Dogs who will play ball, and pass the Nelson-Lieberman bill?

Or progressives who can possibly improve the bill, but also might make it impossible to pass the Senate?

Most likely:a mixture we will not quite understand?


Posted by: bob mcmanus | Link to this comment | 12-21-09 11:06 AM
horizontal rule
127

124, 126: Bob -- is passing this bill (or some recognizable version of it) a good thing that you're hoping for, or a bad thing that you're hoping doesn't happen? I'm getting puzzled about whether you're glad or sorry that you don't think it's going to make it to Obama's desk.


Posted by: LizardBreath | Link to this comment | 12-21-09 11:12 AM
horizontal rule
128

100

Even saying that, 80 is demonstrably false, unless you have some concept of 'a fair price' that's never existed in reality. People do, in fact, go uninsured in the absence of a mandate.

I wasn't claiming all heathy people would buy insurance just that some would. Probably most.


Posted by: James B. Shearer | Link to this comment | 12-21-09 11:12 AM
horizontal rule
129

Praying for the death or incapacitation of one's political adversaries is a little more old school than I am comfortable with, and by "old school" I mean "twenty times more pagan than the prosperity gospel, which is pagan enough to, I don't know, make the Emperor Julian blush."

Indeed.

Coburn is the most admired senator by National Journal's Republican "congressional and political insiders", named by almost twice as many as anyone else.


Posted by: Cryptic ned | Link to this comment | 12-21-09 11:13 AM
horizontal rule
130

128: IOW, everything's fine right now, what's the point of reforming anything.

It's a position, but not really close enough to anything I can recognize as reality to really engage with.


Posted by: LizardBreath | Link to this comment | 12-21-09 11:25 AM
horizontal rule
131

To my knowledge there are no universal health care systems without a mandate that everyone pay into the system.

Paul Starr suggests you could accomplish the same end with carrots rather than sticks, but I'm unconvinced. He cites the German system as an example, but elides the fact that there is a strict mandate in the German system that applies to almost everyone.


Posted by: pain perdu | Link to this comment | 12-21-09 11:36 AM
horizontal rule
132

131: there is a strict mandate in the German system
Quelle surprise.


Posted by: Natilo Paennim | Link to this comment | 12-21-09 11:42 AM
horizontal rule
133

"Vee haf vays uff making you healthy!"


Posted by: Natilo Paennim | Link to this comment | 12-21-09 11:42 AM
horizontal rule
134

re:117

In the UK you pay a flat fee for any and all prescriptions [it's about 10 USD], but diabetics and others who need long-term prescriptions are specifically exempt. So diabetics don't pay for that stuff.


Posted by: nattarGcM ttaM | Link to this comment | 12-21-09 11:46 AM
horizontal rule
135

re: 110

Apart from the legal requirement to pay private profit-making companies? Looks pretty damned immoral to me.

I think that's what Apo has been going on about above.

If I want to be compelled to contribute to something, I damned well want it to be to something that's part of the state. On principle.


Posted by: nattarGcM ttaM | Link to this comment | 12-21-09 11:52 AM
horizontal rule
136

If I want to be compelled to contribute to something, I damned well want it to be to something that's part of the state. On principle.

You won't find too many people in this forum who disagree, in principle, (except for maybe Shearer and Lovecraft). The question is whether fidelity to that that principle is worth killing a bill that will create near universal coverage for the first time.

I'm in the "half a loaf" camp.



Posted by: pain perdu | Link to this comment | 12-21-09 11:58 AM
horizontal rule
137

Well, I'd prefer that it be part of the state, but I don't think I have a principled objection to the Dutch system, which, if I've got it straight, involves mandated payments to private insurance companies.

I don't think what we're going to get will be as good as the Dutch system, but that's not a matter of principle, just realism about the awfulness of our political process.


Posted by: LizardBreath | Link to this comment | 12-21-09 12:01 PM
horizontal rule
138

127:All options and outcomes from here on out are tragic and horrible for most people.

Conference problem:the house bill funds with a 1% tax on millionaires;the Senate with an excise tax on very good plans, mostly unions. A Senator has said the millionaire tax is a dealbreaker. The AFL-CIO and SEIU are very unhappy. Think taxing healthcare for a couple making 100k, who won't get subsidies.

If the deal fails, the Republicans might take the House next year. They might if it passes.

Exactly who and what am I supposed to celebrate here?


Posted by: bob mcmanus | Link to this comment | 12-21-09 12:04 PM
horizontal rule
139

127:All options and outcomes from here on out are tragic and horrible for most people.

Sure does simplify the political analysis: Is it an option or an outcome? Then I'm against it.


Posted by: LizardBreath | Link to this comment | 12-21-09 12:08 PM
horizontal rule
140

Exactly who and what am I supposed to celebrate here?

Santa Claus and Hanukkah?


Posted by: apostropher | Link to this comment | 12-21-09 12:09 PM
horizontal rule
141

Santa's not covered. Obesity on that scale counts as a pre-existing condition.


Posted by: nattarGcM ttaM | Link to this comment | 12-21-09 12:14 PM
horizontal rule
142

It's a position, but not really close enough to anything I can recognize as reality to really engage with.

Can I steal this?

(I'm adding it to my collection of excellent phrases for 2009. Other nominees include "My brains have turned to the cheesewhip of life," per max.)


Posted by: Witt | Link to this comment | 12-21-09 12:16 PM
horizontal rule
143

Santa's a socialist who enters the country illegally. You get hurt here, fat man, you're on your own.


Posted by: Jesus McQueen | Link to this comment | 12-21-09 12:17 PM
horizontal rule
144

Consider it yours. I'd take out one of the 'really's before re-using it, though -- I was regretting the repetition in retrospect.


Posted by: LizardBreath | Link to this comment | 12-21-09 12:18 PM
horizontal rule
145

Also, Santa smokes a pipe.


Posted by: LizardBreath | Link to this comment | 12-21-09 12:18 PM
horizontal rule
146

Back when I was a good citizen, I used to practice opposing things on walk to my neighborhood association meetings. NO! I would shout. Not here! I'm OPPOSED!

Sometimes I would get all subtle and suggest that some other neighborhood would be a slightly better location for whatever that was. But mostly I'd practice cutting off suggestions with an emphatic NO. I wanted to belong.


Posted by: Megan | Link to this comment | 12-21-09 12:19 PM
horizontal rule
147

who enters the country illegally

Nonsense! He enters the country with the full knowledge and consent -- nay, with the connivance -- of the U.S. government!

Santa's a socialist

You say socialist, I say philanthropist. Tomato, tomahto.


Posted by: pain perdu | Link to this comment | 12-21-09 12:21 PM
horizontal rule
148

142: (I'm adding it to my collection of excellent phrases for 2009. Other nominees include "My brains have turned to the cheesewhip of life," per max.)

{snort} {chortle} Did I actually type that in?

max
['One of those days, was it?']


Posted by: max | Link to this comment | 12-21-09 12:24 PM
horizontal rule
149

Oh, and I have to stop using "subsidies" since they are actually tax credits.

Waitress gets sick in June, has to pay out of pocket, and get reimbursed at rebate time. That will work well.

But lucky for us I'll bet a whole industry arises that will loan the waitress the money with a lien on the tax credit.
With interest, of course.

Do I want this bill, in this form, to fail? I have said so, but now let's just say I won't put my name on it, I won't approve or endorse this bill.


Posted by: bob mcmanus | Link to this comment | 12-21-09 12:24 PM
horizontal rule
150

147: I love "NORAD tracks Santa," but I'm convinced they'd shoot him down if he presented a threat. It's what I pay my taxes for.


Posted by: Jesus McQueen | Link to this comment | 12-21-09 12:28 PM
horizontal rule
151

Santa may be a socialist, but what about the working conditions for those elves? Are they unionized? How's their health insurance? Do they have Cadillac plans?


Posted by: Otto von Bisquick | Link to this comment | 12-21-09 12:29 PM
horizontal rule
152

I call everyone's attention to these passages from the official history of the Social Security Act -- this actually might belong on the front page:

The Social Security Act did not quite achieve all the aspirations its supporters had hoped by way of providing a "comprehensive package of protection" against the "hazards and vicissitudes of life."

.... In the original Act benefits were to be paid only to the primary worker when he/she retired at age 65. Benefits were to be based on payroll tax contributions that the worker made during his/her working life. Taxes would first be collected in 1937 and monthly benefits would begin in 1942. (Under amendments passed in 1939, payments were advanced to 1940.)

...The new social insurance system was also a very moderate alternative to the radical calls to action that were so common in the America of the 1930s.


Posted by: PGD | Link to this comment | 12-21-09 12:31 PM
horizontal rule
153

149: Oh, and I have to stop using "subsidies" since they are actually tax credits.

Really? I'd been wondering about that. That's not good. Sucks rather badly, actually.


Posted by: parsimon | Link to this comment | 12-21-09 12:31 PM
horizontal rule
154

They are refundable tax credits that come directly out of the cost of your health premium before you see a single bill. That is a subsidy.


Posted by: PGD | Link to this comment | 12-21-09 12:32 PM
horizontal rule
155

How's their health insurance?

If Burl Ives is a reliable source, they've got dental coverage. Managed care, but what do you expect at the North Pole?


Posted by: pain perdu | Link to this comment | 12-21-09 12:33 PM
horizontal rule
156

Did I actually type that in? ['One of those days, was it?']

Yes, I rather suspect it was. (Unfortunately I can't find the context; I think it was that magical vanishing/reappearing post of taddy's at B's that seems to have lost all kinds of comments when it was reposted.)


Posted by: Witt | Link to this comment | 12-21-09 12:33 PM
horizontal rule
157

153: Yeah, I didn't know that either. That's been underreported, I'd say.


Posted by: Otto von Bisquick | Link to this comment | 12-21-09 12:34 PM
horizontal rule
158

Re the quote in 152 -- the 7 year gap between bill passage and first benefits in the original Social Security Act is much longer than the gap in this bill.


Posted by: PGD | Link to this comment | 12-21-09 12:34 PM
horizontal rule
159

they've got dental coverage

Stands to reason, given that they subsist mostly on sugar plums and candy canes.


Posted by: apostropher | Link to this comment | 12-21-09 12:36 PM
horizontal rule
160

Tax credits? What the hell? Who wants tax credits?


Posted by: Cryptic ned | Link to this comment | 12-21-09 12:36 PM
horizontal rule
161

Semi-comity attack!

77: 44-45: that's interesting -- private insurance with subsidies for the neediest was always the responsible Republican health care reform track, back before the whole party went nuts. Bush I proposed something like that. As I mentioned in another thread, once upon a time this was the conservative-economist plan for Medicare too.

That's what I mean. We're passing a bill appropriate for Bush I. And that amounts to a mild defeat for medicare-style system. Wow.

But I'm not so sure that Medicaid in a lot of states wouldn't be improved under such a structure; it's so underfunded that many providers don't take it.

Well, that's the point: it's underfunded because health care costs so much and most of the money is routed through the insurance companies.

But the long delay before the whole thing comes up is concerning.

I don't see how you translate that as anything other than, 'They think this is a stinky bill and they don't want to run on it.'

I'm not as down on the mandate as others here; something like a mandate will always be part of a national health system. For single payer, the mandate is called a tax.

But a mandate isn't a tax and a tax isn't mandate. They're just similar from the end-users point of view: you have to pay. Tax goes to a government organization presumably under democratic control. A mandate (in this context)(and used as a noun, not a verb) is collected by a private, for-profit entity.

Mandated payments to a for-profit entity has a long, bad track record, much worse than either a wholly private system or a wholly government-owned system.

Since I don't think it was ever in the cards for the private insurance industry to be wiped out, I'm not too shocked that they are the middlemen here.

I didn't think it was in the cards either; I also took Obama at his word that he was anti-mandate. Since, as they say, operating without a mandate and using private insurance companies won't work, I took it he would adjust his plan. He did. Not in a direction I care for.

(I emphasize here: I am NOT opposed to universal health care, nor taxes. I've been entirely non-plussed about the wonders of UHC simply because I doubted they could get anything worth doing through Congress. Not without laying a lot of political and/or financial groundwork first. Or doing it piecemeal, just like LBJ. They may have pulled off a feat, but I really doubt it. REALLY doubt it.)

max
['We shall see.']


Posted by: max | Link to this comment | 12-21-09 12:36 PM
horizontal rule
162

I don't see how you translate that as anything other than, 'They think this is a stinky bill and they don't want to run on it.'

My understanding was that the late start was just screwing around with the CBO -- the ten year cost of the bill is actually calculated over only nine years of spending money.


Posted by: LizardBreath | Link to this comment | 12-21-09 12:38 PM
horizontal rule
163

154: PGD, I'm afraid I don't understand. I mean, I pay my own health insurance premiums, a check written every month. Is this to say that the insurance company will deduct my hypothetical subsidy from my premium bill? I think I'm not understanding "refundable tax credit."

Sorry to be dense.


Posted by: parsimon | Link to this comment | 12-21-09 12:38 PM
horizontal rule
164

This tax credit thing is a red herring -- these tax credits are essentially direct cash subsidies. As I said, they are totally refundable (you don't need any tax liability) and they come directly off the sticker price of your insurance premium without your having to do a thing besides file a tax return.


Posted by: PGD | Link to this comment | 12-21-09 12:38 PM
horizontal rule
165

Mandated payments to a for-profit entity has a long, bad track record,

I'm drawing a blank here -- I'm sure I'll feel like an idiot when you remind me what you're talking about, but I'm not coming up with anything similar other than mandatory auto insurance.


Posted by: LizardBreath | Link to this comment | 12-21-09 12:39 PM
horizontal rule
166

Mandated payments to a for-profit entity has a long, bad track record

Could you list some of those? I have the traditional holiday policy arguments coming up soon.


Posted by: apostropher | Link to this comment | 12-21-09 12:39 PM
horizontal rule
167

Is this to say that the insurance company will deduct my hypothetical subsidy from my premium bill?

once you buy through the new Exchanges established in the bill, yes, that is exactly what will happen.


Posted by: PGD | Link to this comment | 12-21-09 12:40 PM
horizontal rule
168

167: Okay. Now I'll have to remember and/or look into exactly who's eligible to participate in the Exchanges, for I believe it's not everyone.

After lunch, since I'm apparently losing track of these details.


Posted by: parsimon | Link to this comment | 12-21-09 12:44 PM
horizontal rule
169

Mandated payments to a for-profit entity

Energy de-regulation in CA?

I'm only guessing. I don't know what Max meant.


Posted by: Megan | Link to this comment | 12-21-09 12:46 PM
horizontal rule
170

168: I'm pretty sure that it's essentially everyone who can't get employer-based coverage.


Posted by: LizardBreath | Link to this comment | 12-21-09 12:46 PM
horizontal rule
171

Everyone whose employer does not offer insurance, or whose employer-sponsored insurance costs more than 9.8 percent of their income is eligible to participate in the Exchanges -- unless their income is low enough to qualify them for Medicaid. (Or unless their state chooses to establish a "Basic Health Plan" as an Exchange alternative for people 133-200 percent of poverty, but never mind).


Posted by: PGD | Link to this comment | 12-21-09 12:47 PM
horizontal rule
172

167:Are there no subsidies for people not in the exchanges, which are being kept pretty small? I seem to remember that employees covered by inadequate plans can get subsidized. (Employees covered by adequate plans get taxed, along with their employers.)

So why do they call them tax credits? Are the premiums covered by paycheck withdrawal?

This is over-complicated bullshit.


Posted by: bob mcmanus | Link to this comment | 12-21-09 12:47 PM
horizontal rule
173

170: If the exchanges work out, then I can be a consultant. If not, hobo.


Posted by: Moby Hick | Link to this comment | 12-21-09 12:47 PM
horizontal rule
174

PGD knows his shit.


Posted by: Otto von Bisquick | Link to this comment | 12-21-09 12:48 PM
horizontal rule
175


PGD, since you seem to be acting as reluctant salesman for the Senate bill here, maybe you have an answer to my question. My major concern with any UHC bill is that it contain "ratchets" that resist backward slippage and bias toward wider coverage / more generous benefits / tighter consumer protections in the future.

Where do you see the ratchets in this bill? I'm semi-convinced that there is one in the Medicaid eligibility threshold. You can easily imagine a Sherrod Brown weaseling through an expansion to 150 / 175 / 200% of FPL or what have you.

But that's Medicaid. The real action is on eligibility for the exchange. There I'm not seeing it. And how about those out-of-pocket limits? Seems like all the forces of nature are going to push them in the wrong direction. What say you?


Posted by: pain perdu | Link to this comment | 12-21-09 12:49 PM
horizontal rule
176

This could have been simple

2009:Medicare for all...lose
2010:Medicare for all...lose
2010:Run midterms hard on Medicare for all...pink up[ as couple seats, scare a few Blue Dogs.
2011:Medicare for all.

But I am trying to not talk about what I would want, and a pony, which is pretty silly.


Posted by: bob mcmanus | Link to this comment | 12-21-09 12:53 PM
horizontal rule
177

156: Yes, I rather suspect it was. (Unfortunately I can't find the context; I think it was that magical vanishing/reappearing post of taddy's at B's that seems to have lost all kinds of comments when it was reposted.)

Ah. What was that about, anyways? I kept seeing haloscan notices and deleting them since I was preoccupied.

max
['That might have been the night I went to bed for four hours and coughed myself awake, so apparently I wandered around wreaking havoc in comment sections.']


Posted by: max | Link to this comment | 12-21-09 12:53 PM
horizontal rule
178

In the UK you pay a flat fee for any and all prescriptions [it's about 10 USD], but diabetics and others who need long-term prescriptions are specifically exempt. So diabetics don't pay for that stuff.

Yeah, I'm not surprised. I think the deal is the same in France, with the added benefit that either once or twice a year you're scheduled for a full day's checkup at a hospital: eye exam, blood work, foot exam, etc. Basically checking on all of the various complications that can arise.

I pay $10 for most of my prescriptions, but I'm on a couple of medications that don't qualify for that level of coverage: one is $40 a pop, the other is $100. (Although neither one of those is for a life-threatening condition). If I ever lose my health insurance, I'm fucked.


Posted by: Josh | Link to this comment | 12-21-09 12:56 PM
horizontal rule
179

This interview is long, but very much worth your time. Matt Taibbi, Bill Moyers and Robert Kuttner: Why Can't Democrats Do Anything Right?

Really, it's excellent.


Posted by: apostropher | Link to this comment | 12-21-09 12:57 PM
horizontal rule
180

175: One thing that I would guess would put more people on the exchanges is employers dropping health insurance due to the availability of non-employer insurance. Buck pays for insurance for his five employees, but wouldn't if he didn't know they'd be screwed on the individual market. I figure there are a lot of small businesses in that same spot, who'd rather pay more in salary than deal with insurance for employees.


Posted by: LizardBreath | Link to this comment | 12-21-09 12:57 PM
horizontal rule
181

175: sorry, too complicated/conceptual, I have to get back to work.

Short answer: I think this bill will accelerate the decline of employer-sponsored insurance, that may be one of your "ratchets", but it won't do anything to prevent the proliferation of high-deductible HSA-type plans because the lowest offerings in the Exchanges are too similar to those.


Posted by: PGD | Link to this comment | 12-21-09 12:58 PM
horizontal rule
182

LB and I are as one on this thread.


Posted by: PGD | Link to this comment | 12-21-09 12:59 PM
horizontal rule
183
Posted by: | Link to this comment | 12-21-09 1:03 PM
horizontal rule
184

176: You think two years of purpose-driven floundering will help pull against the usual anti-incumbent party tide of a midterm election?


Posted by: Moby Hick | Link to this comment | 12-21-09 1:05 PM
horizontal rule
185

170, 171: Right. I'm self-employed. I offer my own health insurance -- to myself! It's actually a group insurance plan, but it's a Group of One. It's a small group plan, such that I could add people to it were I to hire them. From one perspective, I have employer-based health insurance coverage, then. I guess I could stop offering it to myself.*

I'd love to think that I'm in an extreme minority, and this isn't worth fussing over, but I'm not sure that's true. There are a lot of self-employed people.

The language 170 & 171 use puzzles me, that's all: 'if your employer doesn't offer ...'. I'm going to assume, in accordance with all sense, that if you don't have an employer besides yourself, you can participate in the exchanges.

* Sorry for the snark.


Posted by: parsimon | Link to this comment | 12-21-09 1:07 PM
horizontal rule
186

184: Are you questioning the unsurpassedly refined political instincts of bob mcmanus? Then more the fool you! Had the Democrats only sought his sage advice at various critical junctures in the previous decades, the fortunes of the Republic might have been so different...


Posted by: pain perdu | Link to this comment | 12-21-09 1:09 PM
horizontal rule
187

130

IOW, everything's fine right now, what's the point of reforming anything.

No, everything is not fine. Medical care costs too much in the United States and is over-utilized. The bill will make both of these problems worse.


Posted by: James B. Shearer | Link to this comment | 12-21-09 1:11 PM
horizontal rule
188

It's actually a group insurance plan, but it's a Group of One.

Similarly, I engaged in group sex recently.


Posted by: pp | Link to this comment | 12-21-09 1:13 PM
horizontal rule
189

180

One thing that I would guess would put more people on the exchanges is employers dropping health insurance due to the availability of non-employer insurance. Buck pays for insurance for his five employees, but wouldn't if he didn't know they'd be screwed on the individual market. I figure there are a lot of small businesses in that same spot, who'd rather pay more in salary than deal with insurance for employees.

How are they going to be less screwed? They are going to be forced to buy. And why would their price be less than what Buck pays for them? And will they be able to pay with pretax dollars?


Posted by: James B. Shearer | Link to this comment | 12-21-09 1:15 PM
horizontal rule
190

How are they going to be less screwed? They are going to be forced to buy. And why would their price be less than what Buck pays for them? And will they be able to pay with pretax dollars?

The point is that their price would be less than what they would pay on the individual market now.


Posted by: Cryptic ned | Link to this comment | 12-21-09 1:17 PM
horizontal rule
191

Medical care costs too much in the United States and is over-utilized. The bill will make both of these problems worse.

The bill contains a lot of other things besides the reorganizing of insurance payments.


Posted by: Cryptic ned | Link to this comment | 12-21-09 1:19 PM
horizontal rule
192

184:Yes

2002 Midterms

House 2002

Would have needed a better jobs policy, a little less war, and a partisan President, which is why it is pointless to discuss, but I think it could have worked.


Posted by: bob mcmanus | Link to this comment | 12-21-09 1:20 PM
horizontal rule
193

And why would their price be less than what Buck pays for them?

Community rating and guaranteed issue. Eliminates one of the two major distortions that favor group policies (especially large group policies) over individual policies (the other being, as you say, deductibility).


Posted by: pain perdu | Link to this comment | 12-21-09 1:20 PM
horizontal rule
194

Would have needed a better jobs policy, a little less war, and a partisan President, which is why it is pointless to discuss, but I think it could have worked.

This is indeed the chief lesson of the 2002 midterms.


Posted by: snarkout | Link to this comment | 12-21-09 1:21 PM
horizontal rule
195

Medical care costs too much in the United States and is over-utilized.

I'm curious about the basis for the claim of overutilization. I mean, I'm familiar with concerns about over-prescribing of antibiotics. And I'm familiar with emergency room providers complaining about people who use the ER for basic (flu, colds) health care. But I am not familiar with any argument that Americans in general go to the doctor too much.


Posted by: Di Kotimy | Link to this comment | 12-21-09 1:22 PM
horizontal rule
196

192: The 2002 midterms were the 9/11 midterms. The other exception, during the Clinton administration, came after the high water mark of Newt.


Posted by: Moby Hick | Link to this comment | 12-21-09 1:25 PM
horizontal rule
197

195: The Atul Gawande article in the New Yorker a few months ago about health care in Texas made the argument that we get too many tests and optional medical procedures, for little to no benefit.


Posted by: Josh | Link to this comment | 12-21-09 1:26 PM
horizontal rule
198

Further to 197: This is the article.


Posted by: Josh | Link to this comment | 12-21-09 1:27 PM
horizontal rule
199

194:Bush and Obama obviously have different bases.

Bush's significant difficult issue was the tax cuts, which were passed in 2003.


Posted by: bob mcmanus | Link to this comment | 12-21-09 1:28 PM
horizontal rule
200

195 - My uninformed vague sense is that end-of-life care is over-used. The Death Panels should fix that.


Posted by: Megan | Link to this comment | 12-21-09 1:29 PM
horizontal rule
201

193

Community rating and guaranteed issue. Eliminates one of the two major distortions that favor group policies (especially large group policies) over individual policies (the other being, as you say, deductibility).

Community rating and guaranteed issue raise prices because of adverse selection. I believe New York individual policies are currently community rated and guaranteed issue and the prices are ridiculous.


Posted by: James B. Shearer | Link to this comment | 12-21-09 1:29 PM
horizontal rule
202

195: See here for one version of the argument.

There's two different versions of the claim Shearer makes. The "overtreated" claim as formulated by Brownlee has some merit, but as a matter of medical practice and as a matter of health economics.

The other version, the one you will find touted by the Mitch McConnell's of the world (and, I presume, Shearer) places the blame not on overtreatment but on overconsumption of healthcare by anxious, molly-coddled, overinsured individuals who run to the doctor for every cough and sniffle, and think nothing of it because the bill is paid by someone else. While you can certainly find anecdotes to support the existence of the latter, the empirical evidence that it drives the dramatically higher costs in the U.S. is, to be charitable, weak.

This isn't a meaningless debate: the policy prescriptions are very different depending on which version you believe. In the former, the solution is things like managed care, abundant preventive care, and -- yes -- single payer financing.

If you believe the latter, it's all consumer-directed health care and more price transparency and more high-deductible plans and HSA's, and "hey, look how cheap LASIK surgery has become".


Posted by: pain perdu | Link to this comment | 12-21-09 1:30 PM
horizontal rule
203

188: Amusing, but "Group of One" is a technical term, something that's allowed in certain states, and which permits the self-employed to start a business solely, with room to expand, with health coverage. Good idea. It also makes health insurance a possibility if you have a preexisting condition, where you would be turned down for an individual policy otherwise.


Posted by: parsimon | Link to this comment | 12-21-09 1:31 PM
horizontal rule
204

199: Cutting people's taxes is not a difficult issue, politics wise anyway. The beneficiaries of the policy can figure to the penny how much they save while many of those who will pay for it aren't even old enough to vote. For health care reform, it is the other way around. Nobody knows if the new system will help them, but the CBO is telling everybody how much this will cost.


Posted by: Moby Hick | Link to this comment | 12-21-09 1:31 PM
horizontal rule
205

196:2002 was the Iraq midterm.

Turnout up for Republicans, and down for Democrats.

Bush and the Party fired up the base on Red Meat.


Posted by: bob mcmanus | Link to this comment | 12-21-09 1:33 PM
horizontal rule
206

Community rating and guaranteed issue raise prices because of adverse selection. I believe New York individual policies are currently community rated and guaranteed issue and the prices are ridiculous.

are you being deliberately dense? This is exactly why there is a mandate, and why community rating/guaranteed issue don't go into effect until the mandate does. New York state does not have a mandate, does it?


Posted by: PGD | Link to this comment | 12-21-09 1:34 PM
horizontal rule
207

Community rating and guaranteed issue raise prices because of adverse selection.

Community rating and guaranteed issue raise prices for the healthy. But the healthy not the ones who are fucked in the individual market today.

After netting out the impact of the mandate (i.e. the addition of more healthy premium-payers to the risk pool), CR and GI might or might not cause average premium levels in the individual market to go up (an insurance-industry financed study claims the effect is close to neutral). But that doesn't imply higher overall health care expenditures; merely a more solidaristic form of financing.


Posted by: pain perdu | Link to this comment | 12-21-09 1:37 PM
horizontal rule
208

202 "but as a matter" s/b "both as a matter"


Posted by: pain perdu | Link to this comment | 12-21-09 1:38 PM
horizontal rule
209

197/198: Interesting. I only had time to skim, but the overutilizatio described there seems to arise directly from a context in which doctors' treatment decisions are profit driven, getting a percentage of every lab/test fee. Will have to read more closely tonight.


Posted by: | Link to this comment | 12-21-09 1:40 PM
horizontal rule
210

202 is excellent -- it's something I know, but haven't seen laid out clearly.


Posted by: LizardBreath | Link to this comment | 12-21-09 1:41 PM
horizontal rule
211

209: hence the conceptual distinction between "overtreated" (a position held by many liberals in good standing) and "overinsured" (a belief held mostly by Republicans looking for an excuse not to do anything about our disgraceful health care system).


Posted by: pain perdu | Link to this comment | 12-21-09 1:44 PM
horizontal rule
212

209: Yes, precisely.


Posted by: Josh | Link to this comment | 12-21-09 1:45 PM
horizontal rule
213

211: Right, and the distinction between provider-driven overtreatment, and overtreatment that can plausibly be addressed through piling costs onto patients. For medical expenditures whose value can't reasonably be evaluated by the patient, increasing co-pays and the like isn't going to reduce overtreatment in any remotely sensible way.


Posted by: LizardBreath | Link to this comment | 12-21-09 1:48 PM
horizontal rule
214

206

are you being deliberately dense? This is exactly why there is a mandate, and why community rating/guaranteed issue don't go into effect until the mandate does. New York state does not have a mandate, does it?

I don't believe the mandate will eliminate adverse selection.


Posted by: James B. Shearer | Link to this comment | 12-21-09 1:50 PM
horizontal rule
215

207

Community rating and guaranteed issue raise prices for the healthy. But the healthy not the ones who are fucked in the individual market today.

So healthy people will be worse off if the bill passes? Are Buck's employees all unhealthy?


Posted by: James B. Shearer | Link to this comment | 12-21-09 1:53 PM
horizontal rule
216

For medical expenditures whose value can't reasonably be evaluated by the patient, increasing co-pays and the like isn't going to reduce overtreatment in any remotely sensible way.

...and may very well drive *up* aggregate health care expenditures by discouraging high-benefit interventions like preventive care and ongoing management of chronic diseases.


Posted by: pain perdu | Link to this comment | 12-21-09 1:56 PM
horizontal rule
217

215: Community rating and guaranteed issue raise prices for the healthy in the absence of universality. (I realize you've stated your disbelief that the mandate will effectively eliminate adverse selection, but without some support for that disbelief, I don't really know what to say about it.)

I don't know a blessed thing about the health statuses of Buck's employees -- even in a group that small, though, there's a good shot a couple of them would have trouble buying insurance at a reasonable price.


Posted by: LizardBreath | Link to this comment | 12-21-09 1:58 PM
horizontal rule
218

So healthy people will be worse off if the bill passes?

Not worse off at all. Even if they pay more, they'll have the security of protection against personal financial catastrophe and/or premature death of themselves or a loved one.

Health care to the standards that Americans (and other denizens of rich nations) have come to expect can only be financed solidaristically, either out of general and progressive taxation (my preference) or out of the broadest possible premium pool (the political compromise). That the young and (for now, apparently) healthy may, in certain cases, pay more is a problem only to the extent that it creates political headwinds. From a point of view of public policy and moral good, it's not a problem at all.


Posted by: pain perdu | Link to this comment | 12-21-09 2:02 PM
horizontal rule
219

That the young and (for now, apparently) healthy may, in certain cases, pay more is a problem only to the extent that it creates political headwinds.

I agree. Which is why I think this bill will likely reverse adverse selection. And also why I'm spending so much time telling kids to keep off my lawn.


Posted by: Moby Hick | Link to this comment | 12-21-09 2:13 PM
horizontal rule
220

What's the enforcement mechanism to insure that people comply with the mandate?


Posted by: Criminally Bulgur | Link to this comment | 12-21-09 2:17 PM
horizontal rule
221

Me, swinging a rake.


Posted by: Moby Hick | Link to this comment | 12-21-09 2:18 PM
horizontal rule
222

Wait, that's the enforcement mechanism for the lawn. I believe the mandate is enforced by a fine.


Posted by: Moby Hick | Link to this comment | 12-21-09 2:19 PM
horizontal rule
223

220: Fine on your taxes, I think.


Posted by: LizardBreath | Link to this comment | 12-21-09 2:23 PM
horizontal rule
224

217

Community rating and guaranteed issue raise prices for the healthy in the absence of universality. (I realize you've stated your disbelief that the mandate will effectively eliminate adverse selection, but without some support for that disbelief, I don't really know what to say about it.)

Community rating and guaranteeed issue will raise prices for the healthy even with universality as they will be in a higher risk pool. Adverse selection will make things even worse. There are lots of ways adverse selection can operate and I doubt the bill eliminates them all. For example healthy people are more likely to forgo insurance and just pay the tax.


Posted by: James B. Shearer | Link to this comment | 12-21-09 2:31 PM
horizontal rule
225

220: $750 annual fine, I believe, once the whole shebang goes into effect. That's not much of a deterrent if the alternative is thousands per year.


Posted by: parsimon | Link to this comment | 12-21-09 2:33 PM
horizontal rule
226

218

Not worse off at all. Even if they pay more, they'll have the security of protection against personal financial catastrophe and/or premature death of themselves or a loved one.

How are they better off if they are paying more for the same coverage?


Posted by: James B. Shearer | Link to this comment | 12-21-09 2:34 PM
horizontal rule
227

222, 223: Yeah, now that's what I don't get. If the rationale for HCR has (largely) been to address the problem of people being un-/underinsured because they can't afford coverage, doesn't fining people who still can't (or feel like they can't) afford insurance just add insult to injury?


Posted by: Di kotimy | Link to this comment | 12-21-09 2:36 PM
horizontal rule
228

Because they don't have to worry about losing their status as 'healthy people' in the future. Something that happens to us all eventually.


Posted by: LizardBreath | Link to this comment | 12-21-09 2:36 PM
horizontal rule
229

228 to 226.


Posted by: LizardBreath | Link to this comment | 12-21-09 2:37 PM
horizontal rule
230

How about a Taking's Clause argument -- that forcing people to buy insurance or pay a $750 fine if they don't deprives them of property without Due Process? (And no, I'm not saying that in my capacity as a lawyer who thinkgs things through and has a basis for her positions; I'm am saying it in my capacity as a private citizen shooting her mouth off because there just *has* to be something wrong with that.)


Posted by: Di Kotimy | Link to this comment | 12-21-09 2:40 PM
horizontal rule
231

217

I don't know a blessed thing about the health statuses of Buck's employees -- even in a group that small, though, there's a good shot a couple of them would have trouble buying insurance at a reasonable price.

Is the sort of policy Buck is currently buying for his employees going to be made community rated and guaranteed issue also? If not Buck could keep the policy if all his employees are healthy and drop the policy if some of his employees become unhealthy and the premiums get expensive. And what (besides his moral sense) stops Buck from firing any sickly employees?


Posted by: James B. Shearer | Link to this comment | 12-21-09 2:42 PM
horizontal rule
232

227 - This is a fair argument about the politics of things (and one that I felt Obama was right to make during the primaries when HRC called for a mandate in her better-designed health care plan*), but the overall answer is handled upthread. You can't allow everyone access to insurance without everyone getting insurance; otherwise, nobody pays for insurance who doesn't need it, and the system falls apart.

This system is, of course, much crazier than a Medicare-for-all system, which would have the same effect, but replacing premiums with taxes, but there you have it.

* Which the House plan closely resembles.


Posted by: snarkout | Link to this comment | 12-21-09 2:43 PM
horizontal rule
233

220, 22, 23, etc.: Ezra on the penalty:

2) If you refuse to buy the insurance, you'll have to pay penalties of up to 2% of your annual income to the IRS.

Again, who's "you?" If you don't have employer-based coverage, Medicare, Medicaid, or anything else, and premiums won't cost more than 8 percent of your monthly income, and you refuse to purchase insurance, at that point, you will be assessed a penalty of up to 2 percent of your annual income. In return for that, you get guaranteed treatment at hospitals and an insurance system that allows you to purchase full coverage the moment you decide you actually need it. In the current system, if you don't buy insurance, and then find you need it, you'll likely never be able to buy insurance again. There's a very good case to be made, in fact, that paying the 2 percent penalty is the best deal in the bill.


Posted by: oudemia | Link to this comment | 12-21-09 2:43 PM
horizontal rule
234

228

Because they don't have to worry about losing their status as 'healthy people' in the future. Something that happens to us all eventually.

Not everybody will think this benefit is worth $15000 a year.


Posted by: James B. Shearer | Link to this comment | 12-21-09 2:44 PM
horizontal rule
235

overall answer is handled upthread

You can't possibly expect me to read the whole thread!


Posted by: Di Kotimy | Link to this comment | 12-21-09 2:45 PM
horizontal rule
236

235: Let me sum-up. Prince Humperdink is marrying Buttercup in a little less than half an hour....


Posted by: Moby Hick | Link to this comment | 12-21-09 2:46 PM
horizontal rule
237

231: Guaranteed issue, yes, but I'm not sure about community rating. I don't think so, or if it is the reference community is only the few people in the plan. But I'm not involved with the details, not working for Buck myself.

And what (besides his moral sense) stops Buck from firing any sickly employees?

Not a thing. Damn that inconvenient moral sense.


Posted by: LizardBreath | Link to this comment | 12-21-09 2:46 PM
horizontal rule
238

Inconceivable!


Posted by: Di Kotimy | Link to this comment | 12-21-09 2:46 PM
horizontal rule
239

You know what would be sad? If James B. Shearer lost his job and nobody cared.


Posted by: Standpipe Bridgeplate | Link to this comment | 12-21-09 2:49 PM
horizontal rule
240

237

Not a thing. Damn that inconvenient moral sense.

This will produce adverse selection. Sick people are fired and eliminated from employer based coverage and end up in community rated individual plans.


Posted by: James B. Shearer | Link to this comment | 12-21-09 2:49 PM
horizontal rule
241

238 to most of Bob's offerings.


Posted by: Moby Hick | Link to this comment | 12-21-09 2:50 PM
horizontal rule
242

Have you suggested firing the sickly employees to Buck? Perhaps he just hasn't thought of it yet.


Posted by: Megan | Link to this comment | 12-21-09 2:50 PM
horizontal rule
243

242: We line them up and have the sheepdog herd them through an obstacle course occasionally, to make sure they remain vigorous.

(Actually, we never see them. They're all in California someplace.)


Posted by: LizardBreath | Link to this comment | 12-21-09 2:51 PM
horizontal rule
244

240: Sure, but not nearly as much as we've got now.


Posted by: LizardBreath | Link to this comment | 12-21-09 2:52 PM
horizontal rule
245

230 -- Takings Clause only requires compensation, which is, presumably, the insurance itself.

It's like a tax for services, which does not violate the takings clause.


Posted by: text | Link to this comment | 12-21-09 2:53 PM
horizontal rule
246

239

... If James B. Shearer lost his job ...

I prefer to think of it as going Galt.


Posted by: James B. Shearer | Link to this comment | 12-21-09 2:53 PM
horizontal rule
247

I've come around on this thing; it has the all-important text seal-of-approval.


Posted by: text | Link to this comment | 12-21-09 2:55 PM
horizontal rule
248

244

Sure, but not nearly as much as we've got now.

How about the group of one plans mentioned above? Are they going to be banned?


Posted by: James B. Shearer | Link to this comment | 12-21-09 2:56 PM
horizontal rule
249

247: Please tell me your next comment will be an ASCII seal.


Posted by: Moby Hick | Link to this comment | 12-21-09 2:56 PM
horizontal rule
250

248: I think the idea is they will be undercut on cost.


Posted by: Moby Hick | Link to this comment | 12-21-09 2:56 PM
horizontal rule
251

248: Huh? I don't know either why they would be, or what you think the implications would be.


Posted by: LizardBreath | Link to this comment | 12-21-09 2:57 PM
horizontal rule
252

I am sick, and at work, so forgive me in advance if this comment is as fuzzy as my brain feels right now.

But is Shearer seriously trolling on why healthy people who are employed by a small business owner might not be relieved/happy at the prospect that some insurance could be provided by a new mechanism? Really, the sheer amount of terror (or as the economists call it, "friction") involved in not changing jobs, not taking risks, staying with a job you hate, having your spouse stay with a job they hate, worrying that you are going to get pregnant in the midst of an insurance-switch...it's exhausting for a lot of people. Sure there are folks who are healthy now and think they will be healthy forever and don't want to buy insurance in the meantime. But I bet 5 out of 5 of Buck's employees are not in that situation.

I understand we're not getting a public option in this bill (or maybe we are; this thread is the most I've paid attention to HCR in the last month). But even without a public option, this idea of an "exchange" seems like a tiny tiny backup safety net for those of us who are otherwise just crossing our fingers and praying.

(Yadda yadda, I don't like mandates, yadda yadda, I do think people are overtreated, yadda yadda, I'd prefer single-payer)


Posted by: Witt | Link to this comment | 12-21-09 2:57 PM
horizontal rule
253

I prefer to think of it as going Galt.

But clearly, if you were to lose your job, it would mean you were one of the unproductive shlubs living off the genius and hard work others. That's not very Galt at all.


Posted by: Standpipe Bridgeplate | Link to this comment | 12-21-09 2:58 PM
horizontal rule
254

243 - The employees never look forward to Picnic Day the way the Breath family does.


Posted by: Megan | Link to this comment | 12-21-09 2:58 PM
horizontal rule
255

253: You know Shearer got laid off a while back, right?


Posted by: LizardBreath | Link to this comment | 12-21-09 3:00 PM
horizontal rule
256

Re: the enforcement mechanism on the mandate. It would be really nice if the fee came with a requirement to meet with some local bureaucrat/insurer/exchange official to hash out coverage options. A lot of people I know without insurance just have no idea what their options are, and, in the absence of health problems, choose to go without rather than devote the time/energy to finding something affordable. Many of them would probably even qualify for Medicaid.


Posted by: Criminally Bulgur | Link to this comment | 12-21-09 3:02 PM
horizontal rule
257

How about a Taking's Clause argument -- that forcing people to buy insurance or pay a $750 fine if they don't deprives them of property without Due Process?

Di, I'm going to have to insist -- and I think I speak for the whole community when I say this -- that you politely decline all future dinner invitations from your Limbaugh-listening friends.

I'm afraid next week you're going to be arguing that Security Security should be voluntary because you can get much higher returns by investing in an personal retirement account.


Posted by: pain perdu | Link to this comment | 12-21-09 3:03 PM
horizontal rule
258

253: You know Shearer got laid off a while back, right?

You know what would be sad?


Posted by: Standpipe Bridgeplate | Link to this comment | 12-21-09 3:04 PM
horizontal rule
259

A lot of people I know without insurance just have no idea what their options are, and, in the absence of health problems, choose to go without rather than devote the time/energy to finding something affordable. Many of them would probably even qualify for Medicaid.

I believe this is part of the point of the exchanges, to make comparison shopping easy and transparent.


Posted by: LizardBreath | Link to this comment | 12-21-09 3:05 PM
horizontal rule
260

259: Which is why a great big huge open question to me is how stigmatized they're going to be. If it's like unemployment, great. If it's like Medicaid, disaster.

Seriously, CB is probably right that he knows people who qualify for Medicaid, but when the sign-up process is made as intentionally cumbersome and humiliating as it often is, people get the message. They may be eligible for the benefit, but they're not actually entitled to it.


Posted by: Witt | Link to this comment | 12-21-09 3:07 PM
horizontal rule
261

256.last: My dad was remarking yesterday that most of the people he sees who don't have insurance are Medicaid-eligible.

(That saleslady totally just gave me the "you're not really Nordstrom material, are you?" treatment. Shoulda brushed my hair better, I guess.)


Posted by: Otto von Bisquick | Link to this comment | 12-21-09 3:09 PM
horizontal rule
262

228: Silly AB, only the poor get unhealthy as they age. And they deserve it.


Posted by: | Link to this comment | 12-21-09 3:11 PM
horizontal rule
263

For the last 50 or so comments, I feel like someone should be waving a big flag and shouting "Massachusetts! Massachusetts!" Since an exchange and a mandate with a tax penalty for noncompliance and subsidies for various classes of poor people is exactly what we've had for a couple of years now. Also something sorta kinda like a public option. You can look at the a href="https://www.mahealthconnector.org/">exchange web site.


Posted by: Nathan Williams | Link to this comment | 12-21-09 3:12 PM
horizontal rule
264

262: Huh, I guess I was focused on work for a longer period than I'd thought. Go, Productivity!


Posted by: JRoth | Link to this comment | 12-21-09 3:12 PM
horizontal rule
265

259: Which is why a great big huge open question to me is how stigmatized they're going to be. If it's like unemployment, great. If it's like Medicaid, disaster.

I believe the self-employed can get on the exchanges. (They could in the House version; I'm not sure with the Senate version, but I believe it's still the case.) It's going to be a biggish but not ginormous chunk of the population.


Posted by: snarkout | Link to this comment | 12-21-09 3:14 PM
horizontal rule
266

Gah. Exchange web site (sadly, nigh-impossible to deep-link into things like the lists of plans for various family sizes and zip codes).


Posted by: Nathan Williams | Link to this comment | 12-21-09 3:15 PM
horizontal rule
267

when the sign-up process is made as intentionally cumbersome and humiliating as it often is, people get the message.

Intriguing. Do you think the same principle would apply to, say, having a separate comment box just for unemployed mathematicians?


Posted by: Standpipe Bridgeplate | Link to this comment | 12-21-09 3:15 PM
horizontal rule
268

That saleslady totally just gave me the "you're not really Nordstrom material, are you?" treatment.

I'd wear that like a badge of honor.


Posted by: pain perdu | Link to this comment | 12-21-09 3:15 PM
horizontal rule
269

Takings Clause only requires compensation, which is, presumably, the insurance itself.

But there's no compensation for the $750 fine! (Which, let's face it, could just as easily be a "tax credit" given to everyone who does pay for the insurance, with the same net effect. Seriously, not claiming I was saying anything useful.) Anyway, it still has to be fair compensation.

Di, I'm going to have to insist -- and I think I speak for the whole community when I say this -- that you politely decline all future dinner invitations from your Limbaugh-listening friends.

Limbaugh was so 20 years ago. They watch Glenn Beck these days. (And by "they" I think I only mean the husband of one friend. Whom I am happy to decline dinner invitations from.)

I'm afraid next week you're going to be arguing that Security Security should be voluntary because you can get much higher returns by investing in an personal retirement account.

Apples, oranges. If Social Security were restructured so that I was obligated to invest with a private fund or be fined for failing to do so, I'd be disgruntled.


Posted by: Di Kotimy | Link to this comment | 12-21-09 3:17 PM
horizontal rule
270

267: I was thinking more public up-or-down votes on national television, myself.


Posted by: Witt | Link to this comment | 12-21-09 3:17 PM
horizontal rule
271

That saleslady totally just gave me the "you're not really Nordstrom material, are you?" treatment.

Huh. One of the things I always liked about Nordstrom was that the sales people were always really nice no matter how shabby and unkempt I looked.

Silly AB, only the poor get unhealthy as they age. And they deserve it.

As Rory pointed out to me the other day, if we just ignore poor people, the problem really will go away BECAUSE THEY WILL ALL DIE.


Posted by: | Link to this comment | 12-21-09 3:21 PM
horizontal rule
272

How about the group of one plans mentioned above? Are they going to be banned?

you're just being paranoid and tendentious.

self-employed can get into the exchange.

There is a big chunk of text in the Senate bill aimed at the constitutionality issue, drawing the link between a mandate and the legitimate regulation of business. I'd be surprised if the Supreme Court overruled, given their general deference to Congress in these matters since the New Deal.

At $750 (and much lower during a phase-in period in 2014 and 2015) the mandate penalties might indeed be weak, but I'd be surprised if they stayed that way.


Posted by: PGD | Link to this comment | 12-21-09 3:24 PM
horizontal rule
273

271.1: They can probably smell the lawyer money on you. I emit no such odor.


Posted by: Otto von Bisquick | Link to this comment | 12-21-09 3:35 PM
horizontal rule
274

251

Huh? I don't know either why they would be, or what you think the implications would be.

If they aren't banned and they aren't community rated and guaranteed issue than you can buy one if you are healthy and go into the individual plans if you aren't. More adverse selection.


Posted by: James B. Shearer | Link to this comment | 12-21-09 3:41 PM
horizontal rule
275


273: Pecunia non olet!


Posted by: pain perdu | Link to this comment | 12-21-09 3:42 PM
horizontal rule
276

Healthy individuals ruled the veldt with an iron fist.


Posted by: JP Stormcrow | Link to this comment | 12-21-09 3:55 PM
horizontal rule
277

Healthy individualsPirates ruled the veldtSpanish Main with an iron fisthook.


Posted by: LizardBreath | Link to this comment | 12-21-09 3:57 PM
horizontal rule
278

Wait, did Otto just say I stink?


Posted by: Di Kotimy | Link to this comment | 12-21-09 3:58 PM
horizontal rule
279

Mackenzie Astin ruled the frozen north with an Iron Will.


Posted by: JP Stormcrow | Link to this comment | 12-21-09 4:02 PM
horizontal rule
280

You smell like roses, Di.


Posted by: Otto von Bisquick | Link to this comment | 12-21-09 4:02 PM
horizontal rule
281

I haven't caught up with the thread, but in BC and presumably other provinces, you actually pay monthly premiums to be on the provincial health care plan. And it's only basic coverage - no dental or vision and more limited prescription drug benefits unless you buy supplementary coverage. (I think - student fees get me supplementary coverage and I haven't used any of it yet). It's still cheaper than in the US, but if you're a foreigner, but a type of non-permanent resident, and you don't buy into the plan you pay for care as if you're not insured. Or so I was warned. I don't know what's happens to citizens and permanent residents.


Posted by: Fake Accent | Link to this comment | 12-21-09 4:27 PM
horizontal rule
282

But there's no compensation for the $750 fine!

There's also no compensation when they find out I haven't been paying my income taxes and throw me in jail.


Posted by: text | Link to this comment | 12-21-09 4:33 PM
horizontal rule
283

60

it's more fun to just be hysterical and talk in vague generalities about incipient disaster, right?
Not only more fun, but better politics.
I think it was a very stupid way to do politics, and didn't work worth a damn. Hysteria and vague generalities do work better
Hey Hey LBJ how many kids did you kill today?

Bob, sorry, I'm not much of a historian, but didn't Nixon win that election? I mean, I get your point that hysteria is good politics in a sense, but your own example of it seems to have backfired badly.


Posted by: Cyrus | Link to this comment | 12-21-09 4:34 PM
horizontal rule
284

282: Not paying income taxes gets you a job at Treasury.


Posted by: Moby Hick | Link to this comment | 12-21-09 4:45 PM
horizontal rule
285

This place has just fallen apart in the last couple of hours, I swear.

272: self-employed can get into the exchange.

Hey, thanks for that information, PGD. One would have thought they would be, after all, despite the technicality that they have employer-provided health insurance already. Somehow I found myself in the bizarre position of involuntary alliance with Shearer. You should all try that sometime.


Posted by: parsimon | Link to this comment | 12-21-09 4:47 PM
horizontal rule
286

285: despite the technicality that they have employer-provided health insurance already.

By that standard, masturbation doesn't exist.


Posted by: Moby Hick | Link to this comment | 12-21-09 4:52 PM
horizontal rule
287

Re the quote in 152 -- the 7 year gap between bill passage and first benefits in the original Social Security Act is much longer than the gap in this bill.

But that's monthly benefits, not any benefits. The official history you link says:

From 1937 until 1940, Social Security paid benefits in the form of a single, lump-sum payment. The purpose of these one-time payments was to provide some "payback" to those people who contributed to the program but would not participate long enough to be vested for monthly benefits. Under the 1935 law, monthly benefits were to begin in 1942, with the period 1937-1942 used both to build up the Trust Funds and to provide a minimum period for participation in order to qualify for monthly benefits.

So some people were getting benefits only two years after the act passed. Also, there was a Social Security Board created shortly after the act to start administering the program, people were assigned social security numbers, and taxes started paying into the social security system in 1937. In most measurable ways, social security went into effect not long after the act passed.

Yes, many people didn't get actual benefits until later, but that's still true when you think about the time between when someone starts paying into the system and when their benefits start. Social security was pension reform and people generally don't get pensions until they hit retirement age. So even if they're not getting paid right now, what matter is what they're expecting. Health care isn't like that. The whole point is make it so people aren't toiling away thinking, at least when I hit 65, I'll be able to get that physical I've always wanted.


Posted by: Fake Accent | Link to this comment | 12-21-09 5:00 PM
horizontal rule
288

masturbation doesn't exist

Not since Irving Kristol died.


Posted by: apostropher | Link to this comment | 12-21-09 5:00 PM
horizontal rule
289

286: Yeah, I told you it's weird. Anyway, as I've mentioned before, this bill as I understand it will result in a number of people opting to take the penalty, another number hiding some of their income in order to qualify for subsidies, and, as I think we've determined now, a number of very-small employers dissolving their group plans. That doesn't mean it's a completely shitty bill that shouldn't be passed.


Posted by: parsimon | Link to this comment | 12-21-09 5:12 PM
horizontal rule
290

283:There are obviously many interpretations of 1968 (as shorthand). I have more than one myself.

But the main one is that 66 thru 69 elected one of the most progressive radical Congresses ever, the Congress of Dornan and Abzug, the Congress that passed OSHA and EPA, War Powers Act; continually harassed anf eventually impeached a President, and defunded (and ended by threatening to defund, 1st in 1970) an ongoing war. I could go on for pages. Reforming the Democratic Party. Some expansion of Great Society and New Deal. Nixon did not have a chance in hell of a rollback.

The local, state and municipal politics, were also quite interesting. The people felt empowered. The hippies and far left despaired and some withdrew, but that helped the local politics in many cases.

Obviously there were losses as well as wins, and much weirdness, but in general I consider 1968-76 a pretty glorious win, even better than the previous half-decade.


Posted by: bob mcmanus | Link to this comment | 12-21-09 5:14 PM
horizontal rule
291

you're just being paranoid

But the insurance companies really are out to get me. I know that all these exchanges and regulations and such are going to make shopping for insurance a transparent delight, with nobody trying to game the system or do misleading marketing, but still: if there's no possibility of a consumer making a really dumb choice, where does the opening for obscenely big short term profits and a golden parachute for the insurance company execs come from?


Posted by: Michael H Schneider | Link to this comment | 12-21-09 5:15 PM
horizontal rule
292

I should add that I do think the good things in the bill make it worth passing. I'm just objecting to most of the historical parallels being drawn in its support. (And sometimes ones drawn in its opposition, but there seem to be fewer of those.)


Posted by: Fake Accent | Link to this comment | 12-21-09 5:20 PM
horizontal rule
293

Basically, I'm anti historical parallels. Antiquarians forever!


Posted by: Fake Accent | Link to this comment | 12-21-09 5:20 PM
horizontal rule
294

Much has been made recently of the healthcare plan of Nixon and Wilbur Mills, that it was to the left of the current plan.

For those not consumed by "Great Man" theories of politics, what this should tell you above all is not that Nixon was such a "liberal" but should give you a clue as to what kind of Congress Nixon had to work with.


Posted by: bob mcmanus | Link to this comment | 12-21-09 5:28 PM
horizontal rule
295

287: The whole point is make it so people aren't toiling away thinking, at least when I hit 65, I'll be able to get that physical I've always wanted.

This seems a neglected part of the equation, actually. What we (I speak broadly) really want is for people to take advantage of affordable preventive care, now. People should be having annual physicals starting in their 30s, for heaven's sake. They do not, even when they have health insurance. Members of the commentariat here have admitted that.

There are two parts to health care reform (as opposed to health insurance reform), I suppose: slowly tweaking people's attitudes toward health care so that they do not avoid seeing a doctor for just a routine annual checkup, and making such visits affordable in the first place. This bill attempts to address the latter. It doesn't address the former except insofar as it may be a step toward single-payer, universal coverage, which could, in theory anyway, make going to the doctor a pretty standard thing that everybody does once a year.

I mean, some people go to the dentist for a checkup more often than they go to the doctor for one.


Posted by: parsimon | Link to this comment | 12-21-09 5:38 PM
horizontal rule
296

293:Whoever you were/are

I don't conider this to be about historical parallels so much as basic rules of thumb, like:"No land wars in Asia" and "Don't play poker with someone named Doc"


If you want political change, you radicalize the populace, especially your base. The Howard Jarvis and the 70s tax revolt for instance. Create a mob and start a riot. Then politics begins.

Another rule:"All plans become useless in the first battle."

Longterm organization and strategy are way overrated, mostly by wonks and vanguardists. If you have the mob at your back, well, the mob decides. If you don't have the mob...you lose.


Posted by: bob mcmanus | Link to this comment | 12-21-09 5:47 PM
horizontal rule
297

A hamster with polio trying to ride a bike is sort of funny and sad at the same time.


Posted by: Sifu Tweety | Link to this comment | 12-21-09 5:57 PM
horizontal rule
298

People should be having annual physicals starting in their 30s, for heaven's sake.

Actually, probably not. This page (from the UC Berkeley Wellness Letter says that annual exams aren't worth it:

That head-to-toe physical exam has now been discarded for seemingly healthy people, since it yields too few benefits for its cost. Over the long run, it doesn't pay off in terms of better health and longer life.

They recommend regular screening for certain issues like high blood pressure, but on a longer schedule than once a year.


Posted by: Josh | Link to this comment | 12-21-09 6:00 PM
horizontal rule
299

If you have the mob at your back, well, the mob decides.

O.K. Once the mob starts training medical personnel, we'll all be fine.


Posted by: Moby Hick | Link to this comment | 12-21-09 6:09 PM
horizontal rule
300

298: Okay. If that's what the figures show, that's what they show. People shouldn't bother to have their cholesterol, triglycerides, blood pressure, blood sugar, or any of the additional things that come from a CBC (complete blood count), like sodium, iron level, potassium, checked until they're, um, 40. Waste of time, statistically speaking.

How much does it cost to draw blood and run it through a lab once a year, now?

But okay, if it costs too much to do this for people annually, then it just does, I guess. What's the point of having anything other than catastrophic health insurance coverage in your 30s?


Posted by: parsimon | Link to this comment | 12-21-09 6:14 PM
horizontal rule
301

300: You are making me feel so guilty for not going. I don't even have a co-pay.


Posted by: Moby Hick | Link to this comment | 12-21-09 6:20 PM
horizontal rule
302

Just to be clear, I have lots of co-pays. But I get one freebie physical a year.


Posted by: Moby Hick | Link to this comment | 12-21-09 6:24 PM
horizontal rule
303

301: It takes all of half an hour with waiting room time, being ushered in, chatting for a minute or two, blood draw, maybe urine sample, exeunt. Unless you have trouble parking or something beforehand. If you have a primary care physician, they might want your weight as well as your blood pressure. If you're covered for this, I don't see a reason not to do it.

It's the smart thing to do. Scary, yes, because what if something's wrong, but that's sort of the point, to see it coming. I really do think (sorry for the soapbox, but) that people should establish more of a relationship with a doc as a matter of course -- avoidance is half the problem.


Posted by: parsimon | Link to this comment | 12-21-09 6:31 PM
horizontal rule
304

It's the smart thing to do.

Unless it's a waste of time, statistically speaking, in which case it isn't.


Posted by: Sifu Tweety | Link to this comment | 12-21-09 6:34 PM
horizontal rule
305

Somehow I found myself in the bizarre position of involuntary alliance with Shearer. You should all try that sometime.

Bizarre, I know. Who would have ever guessed that Shearer doesn't hold positions diametrically the opposite of everyone here all of the time?

How much does it cost to draw blood and run it through a lab once a year, now?

Having switched from an HMO to a PPO this year (and thus having acquired a deductible), I learned that labs actually cost a good bit of money. A couple hundred bucks. I should try to dig up some of the bills to be specific. I get thyroid levels checked at least annually and had the lipid profile run this year because it had been more than 5 (and I did, at one point, have a history of high cholesterol).


Posted by: | Link to this comment | 12-21-09 6:35 PM
horizontal rule
306

Oh wait, if we're talking a complete physical, you might need to actually disrobe and be felt up. Sorry. I'm not sure what a physical exam for men is. Still though, it goes toward not being anxious about seeing doctors, which I do think is important.


Posted by: parsimon | Link to this comment | 12-21-09 6:35 PM
horizontal rule
307

303: Yes. It's an industrial strength triple no-shit for me. I work about 2 blocks from my guy's office. I've done it before. My cholesterol comes up "watch this guy", so I should keep at it.


Posted by: Moby Hick | Link to this comment | 12-21-09 6:36 PM
horizontal rule
308

I went to get a physical earlier this year. "I need a physical", I told the doctor. "I need, you know, whatever the standard physical is. You know, since I haven't had one in five years or so."

He didn't suggest that any sort of blood or urine tests would be part of this process. I think he took my blood pressure and weight. He prescribed a pedometer.


Posted by: Cryptic ned | Link to this comment | 12-21-09 6:38 PM
horizontal rule
309

307: who has two thumbs and dangerously high cholesterol?


Posted by: Sifu Tweety | Link to this comment | 12-21-09 6:39 PM
horizontal rule
310

Having switched from an HMO to a PPO this year

Yeah. I tend to assume that I'll be using up my deductible each year in one way or another. If you normally don't, then lab tests (if you have a deductible) will cost. I wonder whether Moby's complimentary annual physical includes lab test costs.


Posted by: parsimon | Link to this comment | 12-21-09 6:39 PM
horizontal rule
311

Oh wait, I forgot! The complete physical for men seems to consist of testing blood pressure, height, weight, and testicular cancer/hernia feeling around. And a long questionnaire.


Posted by: Cryptic ned | Link to this comment | 12-21-09 6:40 PM
horizontal rule
312

It takes all of half an hour with waiting room time, being ushered in, chatting for a minute or two, blood draw, maybe urine sample, exeunt.

YMMV on waiting room time, etc. I used to make a point of getting the first Saturday morning appointment with my primary care doc because I knew he wouldn't be backed up yet. My friend is a P.A., and by the end of the day, it's typical for pretty much everyone in their practice to be up to an hour behind schedule. For awhile, the endocrinologist wasn't set up to draw labs, so I'd have to go off-site to get the blood draw -- another half hour out of the day.


Posted by: Di Kotimy | Link to this comment | 12-21-09 6:40 PM
horizontal rule
313

309: No. Border-line. As in, watch this guy because we shouldn't let it get higher.


Posted by: Moby Hick | Link to this comment | 12-21-09 6:42 PM
horizontal rule
314

Yes well your straight-man comedy index is dangerously low.


Posted by: Sifu Tweety | Link to this comment | 12-21-09 6:44 PM
horizontal rule
315

313: It probably doesn't apply to you, but as my public service announcement for the day:
(1) Make sure you fast prior to a cholesterol test -- apparently eating a bacon, egg, and cheese sandwich on your way to the doctor's office will cause your cholesterol to appear to be off the charts.
(2) If your thyroid is out-of-whack, it will mess up your cholesterol, too. For some people, getting the thyroid under control will miraculously cure high cholesterol whilst still allowing consumption of whole milk, heavy cream, many many cheeses, and ample quantities of red meat. And bacon and eggs.


Posted by: Di Kotimy | Link to this comment | 12-21-09 6:47 PM
horizontal rule
316

The complete physical for men seems to consist of testing blood pressure, height, weight, and testicular cancer/hernia feeling around.

Yeah, well, nobody can divine your cholesterol level by feeling you up, despite the rumors.


Posted by: parsimon | Link to this comment | 12-21-09 6:50 PM
horizontal rule
317

314: Moby's physical also discovered that he has three thumbs, so.


Posted by: snarkout | Link to this comment | 12-21-09 6:52 PM
horizontal rule
318

315: Um. Yeah. Most blood tests should be taken in the morning when fasting (having fasted, nothing after midnight except water). The doctor should say that.


Posted by: parsimon | Link to this comment | 12-21-09 6:54 PM
horizontal rule
319

Turns out the third one is a specially adapted wrist bone, like a panda has.


Posted by: Moby Hick | Link to this comment | 12-21-09 6:54 PM
horizontal rule
320

318: Yeah, I know this *now*. Those weeks of strict OMG I'm going to of a heart attack diet were for naught!


Posted by: Di Kotimy | Link to this comment | 12-21-09 7:06 PM
horizontal rule
321

320: It surprises me sometimes that doctors don't make that kind of thing clear to patients, that's all. It surprises me in general that people don't generally know how blood tests work. I've been plugged in to the medical system for quite a while. Though.


Posted by: parsimon | Link to this comment | 12-21-09 7:18 PM
horizontal rule
322

It surprises me sometimes that doctors don't make that kind of thing clear to patients

Or when they send you to the bathroom with a cup, they just say "Fill this" and don't clarify with what.


Posted by: Moby Hick | Link to this comment | 12-21-09 7:24 PM
horizontal rule
323

Sometimes they don't even tell you that you should wash your pee-pee before you proceed.


Posted by: parsimon | Link to this comment | 12-21-09 7:33 PM
horizontal rule
324

Bring back some toilet water and get it tested some time. As a control.


Posted by: Turgid Jacobian | Link to this comment | 12-21-09 7:38 PM
horizontal rule
325

If you don't have a pee-pee yourself, you should wash the pee-pee nearest you.


Posted by: Standpipe Bridgeplate | Link to this comment | 12-21-09 7:41 PM
horizontal rule
326

How much does it cost to draw blood and run it through a lab once a year, now?

Apparently, $657 cash, not paid by insurance. I haven't done it in 12 years, so I didn't know either.


Posted by: A White Bear | Link to this comment | 12-21-09 8:22 PM
horizontal rule
327

I went three years between physicals, the last two feeling mildly guilty about not doing so (I moved away from my existing PCP, and then moved back). When I got around to it (and when I got around to scheduling it, I had to schedule it for three months in the future), she suggested I come back in about five years; no point in bothering otherwise if nothing is wrong (I'm 33).


Posted by: Nathan Williams | Link to this comment | 12-21-09 8:33 PM
horizontal rule
328

no point in bothering otherwise if nothing is wrong (I'm 33)

One year older than Brittany Murphy!


Posted by: gswift | Link to this comment | 12-21-09 8:48 PM
horizontal rule
329

Apparently, $657 cash, not paid by insurance.

Criminy. That's outrageous. I wonder if you got the special poor person rate.

I do the blood stuff once a year, and the lab usually sends me the bill saying that the poor person rate for the work was $900, but I've got my Blue Cross EOB and so my special rich person's insurance company negotiated rate is only about $150. And that's including the prostate screening antigen thingy, which they probably didn't do for you.


Posted by: Michael H Schneider | Link to this comment | 12-21-09 9:00 PM
horizontal rule
330

he last two feeling mildly guilty about not doing so

You kids.

32 years.


Posted by: bob mcmanus | Link to this comment | 12-21-09 9:02 PM
horizontal rule
331

People shouldn't bother to have their cholesterol, triglycerides, blood pressure, blood sugar, or any of the additional things that come from a CBC (complete blood count), like sodium, iron level, potassium, checked until they're, um, 40. Waste of time, statistically speaking.

Did you even read the rest of 298? They specifically recommend doing all of that shit, but *not yearly*. If you're otherwise healthy, checking it every three years or so will be, statistically speaking, sufficient.


Posted by: Josh | Link to this comment | 12-21-09 9:04 PM
horizontal rule
332

It's really easy to lose track of what the eight zillion oddly-numbered copay bills are for when you're doing all the stuff that goes with being pregnant. This is how we triple paid a goddamn bill last month. We still need to call up the insurance people and straighten that one out. Grr.


Posted by: redfoxtailshrub | Link to this comment | 12-21-09 9:08 PM
horizontal rule
333

God, the coverage I had when I was pregnant! All told, I think I spent less than $100 in copays for the entire pregnancy, delivery, etc.


Posted by: Di Kotimy | Link to this comment | 12-21-09 9:22 PM
horizontal rule
334

I had to beg them to test my cholesterol, and when it came up 250, they said, eh, don't worry about it until you're 40. Statistically, that's probably the right move.


Posted by: F | Link to this comment | 12-21-09 9:33 PM
horizontal rule
335

We were with Kaiser Permanente when my oldest was born in 1997. Ten dollar baby.


Posted by: apostropher | Link to this comment | 12-21-09 10:45 PM
horizontal rule
336

Pride drew him in, as cheats their bubbles catch,
And made him venture to be made a wretch.
His wisdom did his happiness destroy,
Aiming to know that world he should enjoy.
And wit was his vain, frivolous pretence
Of pleasing others at his own expense,
For wits are treated just like common whores:
First they're enjoyed, and then kicked out of doors.
The pleasure past, a threatening doubt remains
That frights th' enjoyer with succeeding pains.
Women and men of wit are dangerous tools,
And ever fatal to admiring fools:
Pleasure allures, and when the fops escape,
'Tis not that they're belov'd, but fortunate,
And therefore what they fear at heart, they hate


Posted by: bob mcmanus | Link to this comment | 12-21-09 10:46 PM
horizontal rule
337

People shouldn't bother to have their cholesterol, triglycerides, blood pressure, blood sugar, or any of the additional things that come from a CBC (complete blood count), like sodium, iron level, potassium, checked until they're, um, 40.

Except that it's good for people to be able to identify early on if their lifestyle is having negative effects. Hell of thing to try and suddenly re-tool all that once you hit 40.


Posted by: gswift | Link to this comment | 12-21-09 10:57 PM
horizontal rule
338

165, 166: I'm drawing a blank here -- I'm sure I'll feel like an idiot when you remind me what you're talking about, but I'm not coming up with anything similar other than mandatory auto insurance.Could you list some of those? I have the traditional holiday policy arguments coming up soon.

Mandated auto insurance also has a long, bad track record. But.... great, now I'm drawing a blank. (I hate winter here, really I do.)

Anytime the government grants a monopoly to a privately-owned entity (that is, a private organization that is owned and controlled by someone not part of the state), you start running into problems. (Even Adam Smith says this.) (Note as well that a cartel is a group monopoly.)

So we are talking about things like the East India Company, states in early America agreeing to grant the sole right to collect tolls to a given ferry company (I was thinking of 'the implied powers of private contracts decision' but the example is from Gibbons v. Ogden.), private toll companies operating (or owning) roads built with public money, and so on. That kind of *explicit* public grant of monopoly is fairly rare now (they don't call it a monopoly, they hide it away from the public, and so on), just because it's so prone to abuse, and then everyone hates the things and makes them go away.

You could compare the situation to the military contractor ecosystem, wherein plenty of corporations exist solely to sell military equipment to the government, and then they lobby like hell to make sure defense spending never goes down, and they charge an arm and a leg for toilet seats. (But at least the government has the power to set prices.)

Or you have the situation like the one we have with the Federal Reserve: the banks own the thing, and have de facto control over it, but de jure control is by Congress and given by the power of the president to appoint people to run it. It's a public-private partnership! (People get confused (or not!) over the distinction between having a central bank, and having a central bank owned BY the banks. We have a central bank AND it's owned by banks, not the government.) Having a central bank owned by the banks tends to result in the central banking powers being abused, as I think everyone saw during the late unpleasantness. Thus we wind up with the situation Ben Bernanke saying he thinks 10% unemployment is just fine, and Alan Greenspan running around saying we should do entitlement reform, all while the banks are feeding at the public trough on the tasty free money. But central banking tends to be uh, *special*.

The closest example I can think that seems similar to this situation is copyright. The Constitution grants copyright for a limited time for the purpose of blah blah blah. It's a grant of monopoly over an abstraction. Words are not property. A physical book is property; the concepts contained therein is not. Nonetheless, people run around bitching about property 'intellectual property' (dig the rhetorical jujitsu) since calling copyright a 'government grant of monopoly' is less likely to convince people that copyright holders should be able to do anything they want. (Public execution of software pirates!) Of course, the grantees want that monopoly extended into eternity and maybe expanded and they'd like some cookies, too. So, using the money they get from that grant of monopoly, the big copyright holders (the RIAA cartel, for instance) band together to lobby Congress to get felony penalties for copying a song for a friend and similar stupid shit. Note that I am not saying that copyright should be eliminated, I am saying that grant of monopoly eventually tends to be abused in various ways. (They all want a bigger, more badass monopoly.)

That example is unlike the insurance thing in one way, because yes, you aren't required to buy any particular book or song or whathaveyou, or in fact, any book at all. Whereas with the insurance mandate, you get no choice. (And songs and stories and poems and movies are socially valuable - paying money to a private company to determine just how lousy your health care is, is not all that valuable.) And nowhere do I see any entity being controlled by the power to appoint personnel, as in the federal reserve. Nor will you have the option to just not drive on the goddamn private toll road.

To go with what PGD said, if we treat the thing like a tax then we can compare to the old school funfest known as tax farming:

Tax farming was originally a Roman practice whereby the burden of tax collection was reassigned by the Roman State to private individuals or groups. In essence, these individuals or groups paid the taxes for a certain area and for a certain period of time and then attempted to cover their outlay by collecting money or salable goods from the people within that area. The system was set up by Gaius Gracchus in 123 BC primarily to increase the efficiency of tax collection within Rome itself but the system quickly spread to the Provinces.[...]
Tax farming was historically an important step in the development of state revenues and economic growth by providing a method for collecting taxes across a large area without the need for a tax-collecting bureaucracy (or during periods when such a bureaucracy is unworkable or impossible to maintain). As such, systems of tax collection more or less similar to Roman tax farming were used in Pharaonic Egypt, various medieval Western European countries, the Ottoman and Mughal Empires, and in Qing Dynasty China. On the other hand, as states become stronger, buoyed up by revenues brought in by tax farming, tax farming was discarded in favour of centralized tax collection systems. In part this was because tax farming systems tended to rely on wealthy individuals outside the state machinery, gangs, and secret societies.
The key flaw in the tax farming system is the tension between the state, which wants a long-term source of taxation revenue, and the tax farmers, interested in making a profit on their investment in as short a time as possible. As a result tax-farmers often abuse the taxpayers in various ways, such as deliberately undervaluing goods paid to them in lieu of taxes, which allows the tax-farmers to re-sell those goods at maximum profit. However, such abuses stifle economic growth, limiting the quantity of taxes generated over the long-term.
Tax farming in modern days
In practice tax farming is not outdated as yet. In many countries, including Bangladesh and India, collection of toll on bridges or other public properties like lakes and forests, is often entrusted to private persons or firms to avoid the problems related to the collection of revenue. In 1999, the National Board of Revenue in Bangladesh (NBR) negotiated with the cigarette producing firms the minimum amount of Value Added Tax (VAT) that should be paid per month, although VAT was an ad valorem tax. NBR took this attempt, since under the self-clearance system, monitoring of production and sales of cigarettes proved to be difficult. It was negotiated that if the cigarette producing firms paid the minimum revenue fixed by NBR, physical monitoring would be withdrawn. NBR resorted to this technique of tax farming to avoid the unbearable costs of monitoring, while gaining more in revenue with certainty.
What the health insurance companies appears to me to be even worse. They get control of the very large revenue stream, and not much in the way of controls in terms of what they pay out, and in turn, they are already in control of the legislative process, so they can come back and 'improve' the situation from their point of view. Fewer controls, higher rates, smaller payouts, etc. In theory the insurance companies are supposed to compete with each other, but it is to laugh about that. Price collusion should be dirt simple for them to pull off since there's only like four companies anyways.

We will get some amount of aggregate health care for some aggregate amount of money; probably less health care for more money with the arrow pointing in the direction of even more of the same.

(And dammit, I will stumble across more examples.)

From my POV, insurance == finance, and finance just won another round. Not surprised; annoyed. We're supposed to get some gains from this and I say rat traps are often baited with tasty cheese.

max
['Unfortunately, Obama has set himself up as Solomon, and I'm not going to try and hang onto the baby.']


Posted by: max | Link to this comment | 12-22-09 8:18 AM
horizontal rule
339

Richard Estes

A little leftism for breakfast.


Posted by: bob mcmanus | Link to this comment | 12-22-09 8:51 AM
horizontal rule
340

Apparently, $657 cash, not paid by insurance. I haven't done it in 12 years, so I didn't know either.

Yeah. I went to my first doctor's appointment in twenty years (since my pediatrician) last summer. I was surprised at how little she did (bloodwork, a pap and feeling me up, basically). My co-pay was low, but my health insurance sent me letters saying that they paid several hundred dollars for that.


Posted by: Megan | Link to this comment | 12-22-09 9:12 AM
horizontal rule
341

THe final word on health care comes from Senator Burris, who delivered the following speech on the floor of the Senate this morning:

Mr. President: It was the night before Christmas, and all through the Senate the right held up our health care bill, no matter what was in it.

The people had voted a mandate for reform
but Republicans blew off the gathering storm.

We'll clog up the senate, they cried with a grin
and in the midterm elections, we'll get voted in.

They knew regular folks needed help right this second
But fund-raisers, lobbyists and politics beckoned.

So try as they might democrats could not win
because the majority was simply too thin.

Then across every state there rose such a clatter,
the whole senate rushed out to see what was the matter.

All sprang up from their desk and ran from the floor,
Straight through the cloakroom and right out the door.

And what in the world would be quite so raucous,
but a mandate for change from the democratic caucus.

The president, the Speaker, of course Leader Reid
had answered the call in our hour of need.

More rapid than eagles, the provisions they came
and they whistled and shouted and called them by name:
Better coverage, cost savings, a strong public plan,
accountable options, we said yes, we can.

No exclusions or changes for pre-existing conditions,
let's pass a bill that restores competition.

The democrats all came together to fight
for the American people that Christmas eve night.

And then in a twinkle, I heard under the dome
the roll call was closed, and it was time to go home.

Despite the obstructionist tactics of some,
the filibuster had broken, the people had won.

And a good bill was ready for President Obama,
ready to sign and end health care drama.

Democrats explained as they drove out of sight,
better coverage for all, even our friends on the right.


Posted by: PGD | Link to this comment | 12-22-09 9:17 AM
horizontal rule
342

See, I read 338 and I'm just paralyzed by how much I don't know, and how one slant on the whole thing reads like a federal version of our local patronage mills.

Then I read this in the newspaper and I don't know what to believe:

[Montgomery County, PA] is self-insuring for the first time in 2010, which [county commissioner] Matthews said was necessary because no outside insurer could be found to take on the risk of paying for county workers' health care. The county used Blue Cross as its insurance provider in 2009, and ended up costing Blue Cross millions more than it paid in premiums. Matthews said that appeared to have made other insurers leery of the potential risk.
But Commissioner Bruce L. Castor Jr. said he had not seen enough evidence that the county's private insurance broker had conducted a thorough search for outside insurers, and voted to reject the budget for that and other reasons.

This is one of the wealthiest counties in a state that itself is fairly wealthy. It has 3,100 employees. No insurance company wants their business? What hope is there for the rest of us?

(Should I just hope Castor is right?)


Posted by: Witt | Link to this comment | 12-22-09 10:18 AM
horizontal rule
343

342

This is one of the wealthiest counties in a state that itself is fairly wealthy. It has 3,100 employees. No insurance company wants their business? ...

More likely the county doesn't like the prices they were quoted. By self-insuring they can lowball the price and pretend their budget is balanced for a while.


Posted by: James B. Shearer | Link to this comment | 12-22-09 10:26 AM
horizontal rule
344

Nordstrom's has consistently given me good service--much better than at the old-fashioned lingerie store. As a result,I probably have spent more than I should have on an item or two. However, it always fits really well. Shopping deep discount sales at Saks is not as pleasant. I get that treatment on Newbury Street. I got it at the BCBG store, and I was wearing a BCBG sundress when they did it. Maybe they recognized that it had come from the outlet, and they knew that it was the last year's style.


Posted by: Bostoniangirl | Link to this comment | 12-22-09 4:59 PM
horizontal rule
345

The MA connector is not that transparent. I had questions about the coverage of group therapy under NHP and Network, and none of this info was provided on the one page sheet.

Network counts it toward your 6 allowed visits. Neighborhood had unlimited for group. I got that on the phone, but in the end my decision was based on asking the person who does billing for the psych department which one was easier for them to deal with. I would have liked more info. There was some word of mouth stuff too.


Posted by: Bostoniangirl | Link to this comment | 12-22-09 5:03 PM
horizontal rule
346

281: In Ontario, you're not eligible for coverage for 3 months, so before that you buy BCBS. Students get supplementary coverage, but it usually won't cover vision. You're more likely to get that through an employer.


Posted by: Bostoniangirl | Link to this comment | 12-22-09 5:08 PM
horizontal rule
347

Aren't small employers going to be allowed into the exchanges pretty much right away?


Posted by: Bostoniangirl | Link to this comment | 12-22-09 5:11 PM
horizontal rule
348

338: If you're worried about tax farming, the tobacco settlement from a few years back is what got me worried about it. The state could have gotten the money directly by increased taxes, but decided it was politically easier to make several dozen multi-millionaires in the private sector.

That said, I don't see how it is certain that this health care reform will lead in that direction.


Posted by: Moby Hick | Link to this comment | 12-22-09 5:16 PM
horizontal rule
349

298: What do you mean by that, though? I've had enough good pap smears that my doctor is going to wait a while before she does another one, and last year we didn't do any blood work. But, she still scheduled me for a long visit, and I don't have any major physical medical problems.


Posted by: Bostoniangirl | Link to this comment | 12-22-09 5:20 PM
horizontal rule
350

I've had enough good pap smears

I've had all good Pap smears
Turn their heads each day
So satisfied, I'm on my way.


Posted by: apostropher | Link to this comment | 12-22-09 5:51 PM
horizontal rule
351

How much does it cost to draw blood and run it through a lab once a year, now?

$250 @ tstd.org



Posted by: Joycelyn Elders | Link to this comment | 12-22-09 9:39 PM
horizontal rule
352

labs cost an especially large amount of money if you don't have insurance. i got a bill for $1400 a few months ago, for testing that was only slightly more in depth than the 'basic' package. i looked online and could have purchased the same thing (but not doc approved!) for less than a third that. Once i used my insolvency to play hardball, they let me pay half that.


What's the point of having anything other than catastrophic health insurance coverage in your 30s?
well the issue often is, you'll be told the same advice no matter the results: stop smoking, eat your vegetables, do something that makes you sweat instead of watching tv. though once every 5yrs or so, a better check up seems like it could be useful, for things like the thyroid problems mentioned.

Though, isn't there some benefit to being able to mention 2-3 things that seem off about one's health, so a doctor can verify that you aren't seeing the first signs of cancer/other bad thing? Just to differentiate between 'getting older' and 'oh, that could be bad'. other than extreme pain/dropping over unconscious, how to most diseases first manifest?


Posted by: yoyo | Link to this comment | 12-23-09 11:52 AM
horizontal rule