Five Angry Men

Well, today your hearty blogger is moderately depressed as he hears reports of the Affordable Care Act before the Supreme Court.  Previous to this week supporters were pretty optimistic, as already some Republican-appointed lower court judges had ruled in favor of the ACA.  And then of course there's the actual legal issue, which was never raised in any way when this was done at the state level in Massachusetts and which was never mentioned as an issue when Republicans were inventing the idea of the Individual Mandate in the 1990s. 

But listening to the questioning of the judges, along with the startlingly incompetent Obama-appointed lawyer arguing for the government, commentators I'm reading are saying that it doesn't look good for the Individual Mandate to pass.

It seems hope is pinned on John Roberts, who is very conservative but who also reportedly values solid decisions with splits other than 5-4.  Certainly one could worry about the perceived legitimacy of the court as a neutral arbiter after Bush vs. Gore.  This is the highest profile case since then, and if it's decided by everyone voting strictly along party lines, people are going to call into question whether the court is really any different from the Congress- just reverse-engineering their legal opinions with partisan-colored glasses.

I'm not optimistic.  Not because of the legal merits of the case- I think it's a slam dunk constitutionally- but because I fear that SCOTUS has become nothing more than a repository for partisan hacks.  Depressing.

UPDATE: Put well here by Jon Chait.

...In Which I Try to be Fair to Conservatives on Health Care

I was thinking about the health care debate this week, in light of this article someone sent me about the failures of ObamaCare and the private sector improvements that are coming about (in spite of health care reform presumably) to make insurance more affordable.

I'm certainly ready to agree that ObamaCare is imperfect in a lot of ways, but I'd frame it in the sense that the problem is that it doesn't solve enough of the current problems our system has, rather than that it creates new problems.

But here's what it boils down to: liberals have a goal of universal coverage for health care. To reach that goal (or get close to it- ObamaCare gets close), it is necessary to make some sort of major change involving increased government involvement. ObamaCare changes the health care system as minimally as possible within the frame of reaching its goal.

Conservatives are aghast at the increased role of government- which is fair enough. But of course Conservatives also don't share the goal of universal, affordable health care for everyone. They feel that the downside of increased government isn't worth the upside of insuring everyone.

So there's a stalemate, but it's not really an argument about the technocratic outcomes or unintended consequences of legislation. It's not about a secret Democratic party plan to turn the whole country into a socialist dystopia. It's not about a secret Republican plan to ensure poor people die off faster. It's just about priorities. I care about all Americans having access to health insurance more than I care about government control of my life.  It seems that Conservatives feel the opposite.

 

Yet when I suggest such a formulation, in which I think I'm being fair to Conservatives and their sincere urge to keep government as small as possible, I get pushback- "what do you mean, we don't want universal coverage? Of course we do!"

 

But that's ridiculous- many of the ideas that Conservatives throw out there to improve the health care system in America are fine, good thoughts, which really might improve things- increased competition, less opaque payment systems, making sure consumers see prices, malpractice reform, etc.  These proposals are just fine, and would probably lead to more efficiency and lower prices for many of us.  But none of these ideas would do anything to ensure universal coverage.  People who work in low paying jobs for companies that don't offer health insurance would still be out in the cold.  People with pre-existing conditions would still have nowhere to turn for affordable coverage.  Remember there are 50 million uninsured people in the US.  Go with these Conservative ideas and maybe some small percentage of them would be able to afford it, but the vast majority still wouldn't.

 

We should at least have honest debates.  There's no way to make health insurance accessible to everyone without lots of government action.  It's still perfectly legitimate to oppose universal health care- government doesn't provide universal automobiles for everyone, for example, so maybe health care shouldn't be provided either- but let's dispense with the pretension that Conservative plans would produce health care for all. 

Choices, Choices...... and Dilemnas

I was talking this week with a young woman I know who is a political neophyte.  She knows she is a Conservative, as her father is conservative and she senses he is right about stuff, but she's just contemplating getting more educated and figuring out why she feels the way she does (I hope that doesn't seem mocking at all, because it's not intended to be- we all start someplace politically, for no better reasons than what she has). 

Anyway, we were talking about entitlements, and she talked about how we "can't afford" the Social Security and Medicare benefits that we are promising right now.  This got me to thinking again about the different categories of government spending; there are some things that governments legitimately can't afford, and there are other things that governments and societies decide not to pay for.  And there's a difference between those two.

Greece, for example, is screwed.  They mismanaged their debt so badly, along with a dash of fraud to keep creditors coming a few years too long, and now they're in a hole so deep and wide that there's just no way out.  They can't keep spending what they were spending.  They have to raise much more in taxes than they have been raising.  And the austerity measures needed to get the budget in line are so crushing that they're destroying the entire economy in the country and pushing unemployment to record levels.  They're in a vicious circle in which further austerity just makes the economy worse, which in turn depresses tax receipts and continues the cycle further.  And they're so far in the hole that even Keynesian deficits are totally unsustainable because creditors (rightly) won't fund the deficits.  There's no way out it seems, except for Germany and others to just give them money.  This is an example of stuff "we can't afford".

Back home, on the other hand, we have a looming Medicare and Medicaid crisis.  Health care costs are rising much faster than inflation, and there seems no end in sight to this.  Overall health care spending as a percentage of GDP is rising.  Something has to change.  This is a really hard problem to solve, in that we can raise Medicare and other taxes in the short term, but in the longer term we just have to find a way to stop the explosion of health care costs.  ObamaCare has a commission that is tasked with doing that, though it's hard to predict whether that will work.  Conservatives want to do it by unleashing the free market, but Liberals point out that health care is already a free market in the US, one that seems to work differently from, say, the auto market. (Picture you're going for a knee replacement, and you get a marketing call from another hospital offering to do the same surgery for 25% less money.  Would you do it?  Most people wouldn't take those sorts of risks when it comes to their health, so they trust doctors to decide- it just doesn't work the same).  So this crisis is really hard to solve, but not impossible.

Then you have the problems that are easy to solve- we just have to decide how to do it.  Social Security is my favorite example.  Baby Boomers are retiring, the population is getting older, the ratio of workers to retirees is getting worse, and the math no longer works for making Social Security solvent in the long term.  This isn't because of bad government or poor administration- it's just demographics.  But the good news is that we have a huge buffet full of possible solutions!  We can:

1. Cut benefits to retirees by a modest amount
2. Raise SS taxes in all our paychecks
3. Raise the ceiling so that rich people pay more SS taxes while leaving the rest of us unchanged
4. Increase the retirement age
5. Make SS means-tested so rich people don't get benefits
6. Some combination of any of these

There are probably more solutions I haven't thought of too.  And I hate some of these solutions (4, 5) and would fight hard against them.  But Social Security fits clearly in the category of stuff that has a solution.  We just have to pick one of the plans and implement it.

A Bipartisan Health Care Bill

Congressman Paul Ryan and Senator Ron Wyden have released a blueprint for Medicare reform, which has raised a little stir since it's bipartisan.  It's also not as extreme as Ryan's earlier plan which would have destroyed Medicare and replaced it with a voucher system.  In the liberal blogosphere people are upset with Wyden for giving Republicans some cover and making it harder to hit them with the details of the earlier plan in next year's election.

The plan is essentially to privatize Medicare, while still allowing the use of the old-fashioned system for those who want it.  There are still vouchers, but they would grow at a more realistic rate, and there would be safeguards to make sure insurance wasn't unaffordable for low-income seniors.  People would be allowed to choose more expensive plans, but would pay the difference.

Liberal wonks say this won't save any money.  Conservatives say that the free market will work its magic and generate innovation and efficiencies that will lower costs and increase value.

The issue comes down to what level of free market influence is most efficient in health care. But here I think that conservatives suffer from basing their belief in the free market for health insurance on Faith rather than evidence. Medicare Advantage has been an experiment in privatizing Medicare, and its costs are higher than traditional Medicare. In fact, Medicare's per patient costs are much lower than private insurance. The fact is that we already have a private health insurance system in the US, and it has led to much higher health care costs than you see anywhere else in the world, where government is more involved in every case.

This isn't because conservatives are wrong about the free market being more innovative- it certainly is- it's because the unusual nature of the health care industry seems to have caused the innovation to go into new and high tech treatments that are probably more effective but clearly not increasing efficiency. How many people will be willing to pay much less money for treatment that is a little less efficacious? I'll buy a Dell computer that costs half as much as a Mac even though it's only 75% as good a product, but I wouldn't do the equivalent transaction with my heart surgery.

The burden of proof that a market solution will save us money really rests with conservatives, and so far there's just not much evidence in their favor.

Competition in Health Care

A friend sent me this short blog post from Mark Perry, which points to a company that performs blood tests on the cheap, with a transparent pricing plan, and is succeeding well thanks to its successful attempt to use a market-based approach in the industry.  The quite reasonable argument is that more market-based solutions can bring down health care costs.

But then Perry ends with this:

At the same time that Obamacare is planning a complete government takeover of health care and medicine in America that will stifle competition and raise prices, the market continues to offer many new, innovative, alternative solutions to health care that are competitive, affordable and convenient.

It's unfortunate that the writer would follow up a perfectly legitimate point about a way to decrease health care costs with this kind of polemic and fact-free sentence. ObamaCare is not "a complete government takeover of health care and medicine in America". It's the creation of health care exchanges, mandates to get health insurance, subsidies to help the uninsured afford it, taxation to pay for it, and a panel to reduce Medicare expenditures (a program that was already a "government takeover") through refusing to pay for treatments that aren't effective. A complete government takeover would be the UK system. A partial government takeover would be the Canadian system. This is neither of those.


And I have to point out that the evidence in terms of costs is pretty striking- the US currently has the system with the lowest amount of government involvement in the Western world, and the US also is #1 in health care costs in the Western world. The next-most privately-dominated system is Switzerland's, and it is #2 in health care costs per capita. All the evidence in the health care field points to the sad fact that the free market does not produce cost-effective results due to the unusual nature of medicine.  In fact, administrative overhead inherent in a competitive system is a primary driver of higher costs.

The market has completely failed to produce cost-effective outcomes over the past 50 years in the US. I don't see how that's even debatable. Where our system produces the most satisfaction is in Medicare- the Single Payer part of the system, and also one in which government-run spending is more cost-effective than the privately run alternatives.
I think that conservatives could have had more competition (and could still have it), as well as tort reform, if they would just compromise with Democrats and agree to universal coverage. Democrats were dying for some Republican cover on this bill. We can have the best of both worlds if Republicans would take yes for an anwer.

Budget Plans

I'm tyring to formulate different ways to think about the Ryan budget plan.  As I've said, I think it's silly to call it "courageous", but at the same time it is a stark example of what Republicans are trying to do.  What the plan should be is suicidal for conservatives, as it lays bare what they actually want to do.  The best thing to say about it is that they're no longer focused on lying about Democratic plans, but rather are telling Americans straight out what they stand for: the end of the Welfare State.

Not just "don't grow it any more".  Not "cut it back to 1970s levels".  They want to undo Lyndon Johnson's Great Society program of the 1960s, which created Medicare and Medicaid.  Basically the Right has decided that the answer to the problem of rising health care costs is to get government out of it even for the elderly and leave Seniors on their own to pay for insurance.  Of course, that's the way it was before 1965 so I guess it makes some sense.  I wasn't alive back then, but my understanding is that seniors had a pretty tough time with medical bills- and that was before many years of medical inflation outpacing GDP growth.

So this should be great for Democrats.  Polls show that Medicare is very popular.  Republicans used fear of Obamacare destroying Medicare to help them win the House in 2010, but now they've put out a plan that actually says it will destroy Medicare.  Even the Democratic party ought to be able to hit this batting practice fastball in 2012.

I'm in my 40s.  Under the Ryan plan, when I hit 65 (or a little later- they might push back the age too), I'll get a voucher to purchase health insurance, and the voucher won't be enough so I'll have to pay a lot out of pocket to round out my insurance.  That doesn't sound too reassuring.  And where are the savings going?  Tax cuts for the wealthy.  It's the Scrooge McDuck plan.

In many recent cases I've marveled at how Americans can be continuously fooled by Republican lies.  But this time they're saying what they want, unvarnished.  They're not even trying to fool people.  I think it's a Republican tactical error.  Well, hoping anyway....

Health Care Guest Post

An interesting thought from a relative of mine regarding health care reform and how we're all talking around each other:

often both the left and the right are "right". The problem is they're right about different things. So when the right is attacking health care it's because we can't afford it and it doesn't do anything to fix "the problem". The left says we'll find a way to afford it and it's a step toward fixing the problem of having thousands of people uninsured. If the left sees the #1 problem of health care as the uninsured and the right sees the #1 problem as the rising costs and the model of distribution then you can see how they both might be right. So what gets me is that the left and the right sometimes act like they're talking about the same thing when really they're not.

Well said.  Looking at things this way, I stand proudly on the left of course- the #1 problem is the fact that 30 million plus Americans don't have health insurance.  And of course the Affordable Care Act also addresses rising costs, though not as much as it needs to.

Why is Bipartisanship Dead? (posted by DT)

So the Health Care Reform bill is now behind us, barring an unlikely bit of judicial activism from the Supreme Court. One more post-mortem (maybe not the last- there's a lot rattling around in my brain):

Can serious people please dispense with the "Obama hasn't delivered on his bipartisanship promise" and even the "pox on both your houses" argument about why Democrats and Republicans can't get along in Washington? I get why Republican politicians put out that spin, but it would be nice if the rest of the media would leave Fox News pundits alone and stop repeating their talking points.

What do you mean, DT? The Dems passed a Health Care Reform bill without a single Republican vote? What could be more partisan? True enough, but we have to look with some depth at the facts of the policy before we slice up the Blame Pie for this. The HCR bill is a moderate bill; it's nearly identical to the Massachusetts bill that was passed with the enthusiastic support of Mitt Romney, with the help of Scott Brown's affirmative vote. (When Brown was asked about this in the recent Senatorial campaign he said he opposed Obamacare not because it was different from the MA bill, but because MA already has a good system and he didn't want to subsidize other states doing it). Olympia Snowe voted in favor of almost exactly the same bill in committee. The individual mandate, which Republicans are now calling unconstitutional, has been in numerous past Health Care plans proposed by them. HCR ended up much closer to past Republican plans than liberals wanted- there's no single payor, there's no public option, there's no socialization of anything- if you look at the actual bill, it's just not that radical.

So what happened? The Republican leadership made a decision to refuse any compromise whatsoever. They decided that if the Dems want it, then we'll oppose it. Democrats reportedly offered during the negotiations to put in Malpractice Reform, a provision that conservatives have been agitating for, but when they asked Republicans they were reportedly told that they wanted it, but still would have to vote against the full bill. So there's an idea that liberals have no big problem with, but which results in loss of support of trial lawyers. Democrats were willing to forgo that support to gain some Republicans, but found it wouldn't deliver any votes!

So I know I'm a partisan; I plead guilty there. But let's face it; in this case Republicans have decided to fight instead of compromise. Maybe there will be change on future issues (banking reform? Can't wait for that one), but the blame for partisanship in HCR has to be put on the GOP.

Financial Ruin! (posted by DT)

Well the Wall Street Journal crowd, which includes most of the conservatives I know, has been predicting economic catastrophe if the Health Care Bill passes. OK, that's a little strong, but a common argument I've heard is that it will slow productivity in the US economy. So I would expect that the week when HCR finally passes, we would see that the Smart People who follow stocks for a living and whose livelihood depends on accuracy, selling off stocks since the economy is about to decline.

But lo and behold, the stock market is holding steady this week! The Dow Jones is higher at the end of today than it was on Monday morning!

Now I'm not saying that this proves HCR will help the economy. I know that tons of factors feed into stock market performance. I'm just saying that while conservative politicians and pundits and radio talk show hosts predict terrible things for the economy with the socialists in charge, the people whose livelihood depends on being right about the future seem to have at least a little confidence.

Health Care Reform Truths & Lies (posted by DT)

As I watch congress voting for HCR:

Last night I was at a wonderful party with neighbors talking politics. In discussing Health Care Reform I was surprised once again by the misconceptions out there about this bill. In fact the Right Wing Noise Machine is so great at what it does, that more myth is known about the bill than fact.

So here's a little myth vs. fact:

• Myth: The HCR bill is a government takeover of health care. Fact: the health care system in the US is not being taken over by the government. It is still insurance-based, and those who are getting insurance through their employer will continue to do so.
• Myth: The bill will increase the deficit. Fact: The non-partisan Congressional Budget Office has scored the bill and says that it will reduce the deficit.
• Myth: The Democrats rammed this bill down the throats of the American people through unusual and unprecedented parliamentary maneuvers. Fact: None of the parliamentary tactics used were unusual or unprecedented. Republicans and Democrats have been using all of these tactics for years.

I may have more in a while. Anyway, I predict that this law will not destroy the system of health care in our country, and will not lead to a socialist dictatorship.

Health Care Finale (posted by DT)

Well it looks like the Health Care Reform bill is going to be passed by the House along with a "sidecar" bill improving the Senate version, which will go through Reconciliation in the Senate. Yesterday we saw that Dennis Kucinich, the most left-wing member of congress and an opponent of the bill because it doesn't go far enough, has been convinced to vote in favor. At the same time, some Catholic organizations have come out in opposition to the Conference of Catholic Bishops and announced that they support the bill because it promotes social justice while still allowing no government funds to be available for abortions. This presumably gives cover to some pro-life Catholics who have voted no because the bill doesn't restrict abortion enough more than current policy.

So now Republican opposition has stopped talking about the facts of the bill (perhaps their fiction department has stopped working on new lies about the legislation) and has moved on to bogus process arguments. To be fair, the party out of power always resorts to this crap when they're about to lose, and many examples of Democratic party hypocrisy are out there to be found too. Still, at the end of the day, the Democrats have a large majority in Congress, and to argue that this is somehow anti-democratic is patently absurd.

It's hard to encapsulate such a complex political and policy issue into a pithy statement, but I think it's clear what the difference between the parties is: Democrats want to cover all Americans with health care, like the rest of the civilized world. Republicans don't want taxes to go up one dime in any area for any purpose whatsoever, lest we become like the rest of the (socialist) world.

Keep in mind that the Congressional Budget Office came out today saying that this legislation will reduce the deficit, in both the short and long run. If that sounds surprising to you, it's because the conservative noise machine has cleverly framed the issue: How could something that costs money reduce the deficit? There must be funny business going on! Well the answer is simple: it reduces the deficit because it raises revenue to pay for the extra costs, and then has cost controls to reduce health care expenditures later. This is apparently difficult to understand for Republicans, who are accustomed to doing things that cost money (the Medicare drug benefit for example) but refusing to pay for it.

The fiscal choice is pretty clear to me: Democrats may tax and spend, but Republicans will borrow and spend. Pretty easy choice for me- I'd rather pay now than make my grandkids pay later.

Health Care prediction (posted by DT)

So while I'm predicting things, I'll do one with a little more importance to us all. I predict that the House will indeed pass the Senate Health Care Bill, and then pass a patch of minor changes through reconciliation in the Senate. I predict this will be done by the end of March.

I wish I were really confident about this, but I'm not. The Democrats are fully capable of screwing it up even this close to the finish line.

Abortion, Health Care, & the Christian Right (posted by DT)

Here's something that's been bugging me for a while: the positions of those who identify with the Christian Right.

Now I'm not a Christian, and I don't know much about Christian theology or religious practice. It seems to me, though, that Jesus was a pretty righteous religious figure whose teachings of peace, brotherhood, caring for the downtrodden ("The meek shall inherit the Earth"), etc are in concert with the way I see the world and what is moral behavior.

So there seems to be no question that the Christian position would be that medical care should be accessible to the poor and near-poor. But there's been a hangup in passing this legislation; some pro-life Democrats inserted the "Stupak Amendment" into the House legislation that is very restrictive of abortion, and which would essentially make it impossible for any health plan to cover abortions, even if the government is not subsidizing it. This is clearly an attempt to make abortions more difficult to obtain for middle class women. Stupak and his colleagues are making a stand to get their language put back in the bill somehow. Liberals contend that the Senate language is also plenty restrictive on abortion, and if anything makes abortion more restricted, though not as much as in the House bill. But Stupak & friends are threatening to blow up the whole thing if they don't get what they want.

Now maybe they're bluffing- it actually seems possible that these so-called moderates are just driving a hard bargain but won't let the whole bill go down. But if they're not bluffing, then what does that say about their Christian values? In order to slow abortions they're willing to blithely let living people continue to die without health insurance? The Catholic church too seems to share these priorities- I can understand the maximalist position on abortion, but it would be nice to hear some sort of moral argument from such a powerful institution in favor of legislation that would undoubtedly aid the poor.

Which brings me to what really bugs me about the positions I hear from Christians: what about the torture debate? Is there anything more antithetical to Christian values than the use of torture on our enemies? Why is there no outcry from the churches about waterboarding or about the fact that more than 100 people have been killed in US custody in the War on Terror?

It's not that I think it's wrong for churches to fight with all their power against abortion- it's an important theological issue for them, and they have every right to whip up support for their position- it's just that we hear nothing but crickets chirping from the churches on a similarly huge moral issue. Why don't they care? Wasn't Jesus himself a victim of torture?

Elephant Hunting (posted by DT)

I don't spend much time on Sarah Pailin, as criticizing her is like shooting fish in a barrel, but this is hard to pass up. During a speech in Alberta, Pailin is quoted saying:

We used to hustle over the border for health care we received in
Canada...and I think now, isn't that ironic.

Irony is when one says something, but actually means the opposite. Of course, Pailin is unintentionally ironic here, praising the Single Payor health care in Canada she used as a youngster while decrying a much less liberal plan being proposed for the US.

It just leads me to remember again that the health care plan being discussed now is essentially the same as the Massachusetts plan enthusiastically signed by Mitt Romney, with the addition of cost controls, and it is similar to the Republican alternative to Clintoncare in 1993. It's just not that radical, and if Republican party discipline was just a little less awesome there'd be plenty of Republicans voting for it. [Sigh]

Health Care Reform may pass! (posted by DT)

Sorry to my legions of fans out there for not posting for a few days, but I have a large Event coming up in my family this Saturday so I'm not spending much time writing.

I'm trying not to get too jacked up about the prospects of Health Care Reform, but I can't seem to stop the optimism from creeping in (we liberals are optimistic about human nature and the good government can do, after all). News reports indicate that the House may pass the Senate Health Care Bill as early as next week, which would be a huge win. Then the plan would be for some relatively minor "fixes" to the Senate bill would be passed, taking some of the best from the House bill that is out of the Senate one, and putting it back in. This would have to be passed through Reconciliation, so that only 50 votes (with Joe Biden casting a tie-breaker) would be needed in the Senate.

Republicans are stomping their feet about using Reconciliation, which is absurd given that it's been used often over the years, was in fact used to pass the Bush tax cuts in 2001, and is the only way to pass anything at this point given that Republicans have decided to use the filibuster to an unprecedented degree this term.

But this post isn't about the Republicans- they should be dismissed as irrelevant to passing health care. As I've noted earlier, the Republican party doesn't really want universal health care, in which case they're quite right to vote against it.

Democrats just have to be tough, which is unfortunately not in their nature. Nancy Pelosi and Barack Obama need to tell wavering congressmen that if they don't vote for health care they'll be relegated to miserable, leaky basement offices, they'll face primary opponents from the Left, they'll lose whatever committee assignments they care about, etc. It's hardball, and it's how you get things done in the Big Leagues.

So here's hoping they can stick with it. I can't say I'll be shocked if it all falls apart, but I'm feeling good tonight- don't spoil it!

Health Care Clarity (posted by DT)

Well, this week's "Health Care Summit" again helped clarify where we're at politically with respect to health care reform, and I can only dream that it will move us away from dreary platitudes about how we need bipartisan reform. We shouldn't have bipartisan reform because liberals and conservatives have different goals. President Obama ran for president arguing for Universal Health Care, in which all Americans would be able to get health insurance no matter what. That's what Democratic leaders are trying to deliver.

Republicans clearly don't share this goal. They might support some form of cost controls, plans to cut the growth of health care costs, and certainly want to increase free market influence on health care. They want malpractice reform. All of that is fine; it just doesn't accomplish the goal of universal health care.

Now some conservatives feel this way because they don't think that poor people deserve to get health coverage if they can't afford it- I guess the argument is that we're a capitalist country and it's every man for himself- only the strong can survive. Other conservatives would like to make health care universal, as they see the injustice for those with pre-existing conditions out of their control who can't get coverage, but they just don't want to raise any tax revenue to pay for it. Low taxes are just seen as more important.

So the answer is for Democrats to finish health care and pass a bill. I wish I had more confidence in their ability to do it. As I've said before, I'm struck by the gutlessness of congressional Democrats, and wish they had half the courage displayed by Republicans when they were in power.

I'm trying to be fair to people on the Right, here. Did I miss something?

Reader Response to National Health Care post

Posted by DT
A reader responded:

What if, however, I don't agree that the #1 problem that needs to be fixed
is insuring everyone? Maybe I believe that the #1 problem that needs to be fixed
is to make it more affordable. Once that's accomplished, maybe we can increase
coverage. But to pile more people onto a sinking ship is counter-productive --
first the ship needs to be fixed or a new one built that can hold
everyone...

What do you think, has the Mass. plan been successful? Do
you think mandatory coverage has contributed to Mass. debt which is causing the
government to lay people off and force furlow and limit money paid out to the
towns for services? Obviously the economy is in the dumps so it's hard to
pin down all the factors, but is it reasonable to believe that this might be one
factor?

If you don't agree that a goal in the US should be to insure everyone, I'm not sure we have much common ground. One way to make health insurance more affordable to to cover everyone. Why? Because you increase the risk pool, capturing many young and healthy people whom you need in order to balance out the older, sicker people who cost so much money. But to expand this to a moral argument: isn't the task of government to solve problems? Every other First World country has figured out how to insure everyone, and it's working to varying degrees in each place. There is no movement anywhere to go back to a "you're on your own" system. It's just better for the citizenry. There's a current of thought running through the US polity that we government is completely unable to solve any problems, but it's just not true- our government may not be able to produce consumer goods efficiently, but there are lots of things it can and should be doing.

As to the second point, I'm not aware of any evidence that Massachusetts' insurance plan has been a major factor in its budget problems. For one thing the problems there are no worse than in other states. Financing was unproblematic until the economic crash. In fact the health care industry is one of the relative bright spots in the state. Like any program run by the government, health care subsidization for the poor is going to lead to budget challenges- like other challenges, it can be handled.

The Health Care Debate: Just the Facts (posted by DT)

In recent correspondence, some of my commenters have complained that my tone is too dismissive, too one-sided, and therefore can not succeed in winning anyone over, or that it doesn’t focus on “solving problems”, just bashing the opposition. So in that spirit I want to lay out my understanding of the health care debate in Washington, with a goal of swaying those of you who are against “Obamacare”.

Problem: The health care system in the US is broken. It is estimated that 40 million people (15% of the country) don’t have health insurance. A Harvard School of Public Health study says that 45,000 people die each year because of lack of access to health care services. That’s way more people than have died in all terrorist attacks against the US- ever. For those of us who do have health insurance, we are at risk to lose it at any time if we lose our job or if our insurance company decides to cancel it due to an expensive medical condition. If you own a small business and buy your own health insurance, and a family member gets cancer, your insurance carrier can cancel your policy before they have to pay for all the treatments. At the same time, the US spends more money than anyone else on health care for no better results. Business Week compares the US to France:

France also demonstrates that you can deliver stellar results with this mix
of public and private financing. In a recent World Health Organization
health-careranking, France came in first, while the U.S. scored 37th, slightly
better than Cuba and one notch above Slovenia. France's infant death rate is 3.9
per 1,000 live births, compared with 7 in the U.S., and average life expectancy
is 79.4 years, two years more than in the U.S. The country has far more hospital
beds and doctors per capita than America, and far lower rates of death from
diabetes and heart disease. The difference in deaths from respiratory disease, an
often preventable form of mortality, is particularly striking: 31.2 per 100,000
people in France, vs. 61.5 per 100,000 in the U.S.…And France spends just 10.7%
of its gross domestic product on health care, while the U.S. lays out 16%, more
than any other nation.

So we’re paying more and getting less, and the uninsured are getting WAY less. So what’s the solution? There are many possible solutions to the health care dilemma. I’ll lay them out from the Left of the political spectrum to the Right:

Socialized Medicine: This is the system in the UK. The government is in charge of the whole system. They pay the doctors and own the hospitals. Basically the health system is treated like we treat the post office in the US. The VA health system in the US is socialized. This is not being considered by anyone in the more general US health care debate. Any reference to “socialized medicine” by critics of Obamacare is hyperbole and should be treated as such.

Single Payor: This is the system in Canada. Doctors and hospitals can be private, but payment all comes from one source- the government. Medicare in the US is single payor, for Senior citizens and the Disabled only. This is the solution favored by the American Left. It is deemed “radical” in the media, though I would point out that our closest neighbor already has it. My Canadian-born friends tell me that this system stinks, by the way, and they prefer the current US system (they all have health insurance). Single Payor is not under consideration in the current debate in the US, though there was a brief hope for the Left when the Senate proposed allowing people over 50 to join Medicare if they paid in. This was scuttled at the last minute in the Senate bill when Joe Lieberman changed his earlier position of support for reasons that are unclear.

“Obamacare”: This term is a misnomer, in that the plans passed by the House and Senate were led by Congress. Obama’s lack of leadership has been striking; I think he feared that the debacle of the Clinton initiative was due to Congress being left out of the process and so he has overcompensated in the other direction. The bills passed by the House and Senate are similar, and I won’t go through the differences here. The legislation rests on three connected concepts:

1. Insurance companies can not be permitted to deny insurance to anyone based on their pre-existing condition, and must cover all people who apply.
2. Given #1, everyone must be mandated to have health insurance, just as people in most states are mandated to have auto insurance to drive a car. If this principle is left out, healthy/young people would just stay out of the health insurance market and join only after they get sick. Insurance would cover too many sick people and would become unaffordable.
3. Given #2 and the high cost of health insurance, the government must subsidize poor people so that they can afford insurance. We can’t mandate insurance to people who can’t afford it.

Alternative plans that want to do #1 only won’t work for the reason denoted in #2. This plan does not change the insurance market, and does not require any change for those who currently have insurance. #3 will cost money and must be funded by taxes somewhere- plans to do this differ in the House and Senate bills. Cost savings are also part of this bill, through mandating efficiencies in Medicare by pushing harder to fund scientifically-based medicine and de-fund treatments that are not proven to work. Both bills are scored by the CBO as deficit-neutral, in that they pay for themselves through the Medicare efficiencies and tax revenues. The bills would in fact decrease the federal deficit (remember that Medicare & Medicaid are the biggest budget-busters at the federal level).

Market-Based Solutions: The Right has been working on ideas making the health care field more market-based, in order to increase efficiency and control costs. It has been suggested that tax breaks for employer-paid insurance has tilted the market and led to a situation in which consumers are too separated from the cost of the products. Since we don’t know or care how much an MRI costs, and our doctor doesn’t know or care, the doctor suggests using it and we say “sure” when we may not really need it. Or we might take a really expensive medication when a cheaper, older one would be just as good, but since we don’t consider cost we don’t make the efficient choice. There’s no question in my mind that making costs less opaque would help cut costs and increase efficiency. What it wouldn’t do is cover the uninsured. That can’t be done without revenue from somewhere or bigger deficits, both of which are seen as unacceptable on the Right at this time. So market-based solutions would be an improvement over the current situation but would not solve the problem as defined at the top of this post.

Tort Reform: There’s always talk of putting caps on jury findings so that doctors would practice less “defensive medicine” and be less afraid of lawsuits. This would have a miniscule effect on health costs and would do nothing to cover the uninsured. It may not be a bad idea, mind you, but it won’t solve the problem.

The New Republican Plan: Representative Paul Ryan of Wisconsin has put forward a plan for health insurance reform that finally gets specific about what a Republican plan would look like. I think it’s fair to criticize the Right in the US of carping from the sidelines without offering their own plan, but Rep. Ryan has now filled the void. He proposes taxing employer health plans, issuing tax credits, and expanding health savings accounts. The proposal encourages states to establish exchanges to purchase health insurance and also proposes that states regulate insurers to make sure they are not dropping people who get sick. The plan would still allow insurers to charge higher rates to sicker people, and along with much lower subsidies for the poor than in Democratic plans, millions of people would remain uninsured (there’s no individual mandate). Rep. Ryan also has a recent proposal to slow the growth of Medicare by giving Seniors vouchers toward their health insurance instead- these vouchers would grow at a slower rate than past medical inflation. This would indeed lower the costs of Medicare, but would also ration care for Seniors- poor people would eventually be unable to afford to purchase insurance even with their vouchers.

I think it’s clear that the plans of the Right would not solve the problems of our health insurance system. That’s not to say they have no value, just that they make change around the edges while continuing to allow tens of thousands of Americans to needlessly die every year due to lack of affordable health care.

The most common criticism of liberal health care reform is that “we can’t afford it”. Every other country in the developed world ensures full medical coverage for their citizens. None of them has fallen apart and citizens in them are not clamoring for US-style health care. The employer-based coverage system is itself inefficient and is a drag on economic innovation- I might want to stop working for my big company and start a business on my own, but I would be discouraged by inability to get health care for my family. If the reason we can’t afford it is because increased taxes are never acceptable, then I guess, yeah, we can’t afford it. But you don’t get something for nothing- my town voted to raise taxes last month to fund a new Middle School, because it’s a worthy use of our money. So is health care.

Look, I believe that the free market is the best way to produce a better flat screen TV. I don’t want any government meddling in that market, except to inspect enough to make sure that it won’t explode in my living room and burn down my house. Some things, however, are better provided by non-profit or government forces. We want government providing police and fire departments, fixing roads, running our military, inspecting food, educating our children, running child protective services, managing our money supply, etc. etc. etc. One of the things government should be doing in the 21st century is making sure that everyone has basic medical care.