Missing Ted Kennedy: Health Care Reform Package Would Have Been So Different

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kennedy obama shake.jpg
Had Ted Kennedy been alive today, either Ben Nelson would not have been able to undermine women’s health care equities and move his anti-abortion beliefs into national consequence or Joe Lieberman would not have been able to get included in the health care bill nearly whatever the big insurers wanted — no matter how much these positions conflicted with earlier Lieberman positions.
Barack Obama’s victory ahead in signing major health care legislation would have been cleaner, stronger, better with Ted Kennedy at his side.
The “public option” would have survived.
I’m not a health care expert, though I have been following the debate closely for years, largely through the excellent work of my colleagues who run the New America Foundation Health Policy Program. Len Nichols and his team have been equipping proponents of health care reform in the White House and the Congress about the importance of expanding access and neutralizing the many weapons health care insurers use to undermine or exclude American citizens who have significant health care needs.
Nichols’ predecessor at the New America Foundation was my good friend, Laurie Rubiner, who helped craft for the late Senator John Chafee (R-RI) one of the first pieces of health care legislation calling for a mandate that health care cover all Americans. Rubiner’s work later appeared in test programs that Mitt Romney ran in Massachusetts while Governor and also in California where Arnold Schwarzenegger gave it a very good try. She also crafted Hillary Clinton’s second health care proposal which was pitched during her presidential campaign.
Rubiner and Nichols are both two of the vital, key intellectual architects behind an expanded health care mandate — and Len Nichols has been a passionate, tireless, practically Messianic force in moving behind the scenes this legislation forward.
On one hand, I am pleased that President Obama is going to have a major success he can point to that does address some of the nearly unbelievable practices of health insurers in blocking access and support for Americans. Obama needed this success to be able to succeed in other things.
Losing in health care would have meant calling it a day on nearly every other major policy issue. And the world is in too dire a mess for Obama to be made impotent this early in his tenure. So, I’m glad we are moving forward, passing something, and will hopefully get into other major national security and domestic challenges facing the country.
But I am very saddened that in order to succeed, Obama had to undermine the rights of women in the process. Laurie Rubiner who now heads government affairs for Planned Parenthood, must be very conflicted right now — on one hand seeing a massive expansion of health care that nonetheless erodes the rights of women in ways unacceptable to her organization and to many liberals and progressives around the nation.
Ben Nelson has probably made himself a target now for liberals and progressives who greatly resent the portal he forced all Americans to go through to get to a greater social need.
When George W. Bush achieved his most important domestic priority — tax cuts — he did so after winning a conflicted presidential contest and with very thin margins of support. But there was no sense that the glass was half full or half empty in Bush’s crowning policy achievement.
It is awkward and strange that Barack Obama who one his keys to the White House with the greatest political landslide since LBJ’s victory barely squeaked by in this health care gambit and was undermined by alleged allies in his own party.
But a victory is a victory and Obama will be able to claim it. I’m glad Americans will not be able to be told that they have no health care insurance options and can’t be excluded from coverage because of pre-existing conditions.
I think that the entire nation — Republicans, Democrats, and Independents — need this President to succeed. It’s vital because the challenges ahead are so massive.
I hope that Joe Lieberman and Ben Nelson understand the importance of this too — and again, I think we all miss Ted Kennedy.
— Steve Clemons

Comments

43 comments on “Missing Ted Kennedy: Health Care Reform Package Would Have Been So Different

  1. questions says:

    http://www.nytimes.com/2009/12/30/business/economy/30leonhardt.html?_r=1&hp
    The Times on Richmond, VA’s system for limiting capacity in health care as a way of limiting costs. It’s pretty interesting.

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  2. questions says:

    You don’t quite have my position right. I have no idea if it will raise money (and i said as much earlier in the thread), I kind of doubt it. I’m not sure that it will bend the cost curve much either. The number I saw was pretty small.
    But, if a 25,000 dollar a year premium policy encourages people to use that much care, then it seems that maybe there are some incentive issues with 25,000 dollar a year policies.
    I don’t know who has such policies, how many people need anything like that and so on. So I can’t say much more than I have. I don’t think it will have a huge effect, though given that this is 20% of the market, I guess it must have some effect. The question is really whether or not those premiums go to actually needed and otherwise unaffordable care, of if they go to things that really don’t need the coverage.
    I think that rather than placating Republicans, the tax was put in to make the bottom line work a little better, and to start doing some not super painful cost curve bending. But like you, I am not an expert, just a reader.

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  3. MarkL says:

    There are a ton of articles on overutilization in health care. I certainly don’t have the time or expertise to sift through that literature.
    Granting that there are many procedures and tests which are overused, at great cost, I would like to know that the cause lies with the “cadillac” plans. The only evidence I saw points the opposite direction. As many people know, there are some expensive procedures which are used at very different rates in different regions of the country: for example, C-sections, stents, back surgery, to name three that I saw mentioned in several articles.
    Excess procedures (defined to be above the evidence-based best praxis) are said to cost up to $600 billion per year.
    I don’t see how the examples cited above, where geography is main factor in variance, can be pinned on the fact that some patients have too good insurance.
    Like I said, I’m not an expert, and I’m not going to pretend to be one by putting in a lot of links, but out of many articles I’ve read and browsed, I didn’t see “luxury” level insurance as a cause.
    The excise tax is clearly regressive. I’d like to see a justification beyond helping out the struggling rich.
    Questions, you are holding two contradictory positions. One, you are saying that the excise tax will raise significant money and lower costs. Two, you are saying it won’t be a burden on the middle class.. or not much. You can’t have it both ways, unless you believe in a 1:1 ratio between insurance cuts and resulting wage increases, which is ludicrous in the current job market.
    Personally, I think the excise tax was put in the bill for political reasons—to make the bill more palatable to Republicans—rather than policy reasons.

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  4. questions says:

    I don’t know that I’d say that if we get rid of “Cadillac” plans we get crap leftover. My plan is far far below the Caddie level, but I have quite manageable annual out of pocket maximums, broad coverage, no denials ever, only one time did a doctor have to resubmit a form, really no problems at all. And the cost is far far below the Caddie levels.
    Apparently, 20% of people or businesses or plans (not sure which) have this kind of “Caddie” plan. I honestly don’t know what else could be covered beyond what I get for a whole lot less money. No out of pocket expenses at all? Health clubs memberships for free? I don’t really know.
    My understanding is that actuarially, some kind of out of pocket expense is good, but of course anything that drives people into bankruptcy needs to be done away with. There’s a whole lot of middle ground there to help encourage people to make reasonable care decisions, without causing huge health or financial problems along the way.
    And note that it’s only the amount of the premium OVER the 23k, and it’s a tax levied on the insurance company, not on the policy holder, and so we don’t entirely know how this would play out.
    If someone goes to a 22k plan, loses the health club benefit, is that really junk insurance? Or if someone keep the 24k plan, and there’s the 40% tax on the extra thousand and that tax is split between the insured and the employer, is this junk?
    There might be some limits on the growth of premiums, there might be some limits on the use of medical care, and there might be some revenue. A little bit of each, given that there are apparently a lot of plans that cost this much.
    Remember, health care is expensive no matter what, and we’re all going to pay something into the pot to deal with it. We all have to pay more, somehow. I don’t know the best way to structure it, but we do all have to pay in.

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  5. David says:

    Money as we understand it exists only because of governments. It is not a private thing. In the best of worlds, we are given maximum private discetion over the use of that medium of exchange, a government-established abstraction whose value rests on the full faith and credit of the government issuing it. An economy can prosper if there is a healthy relationship between the private sector and the government under whose umbrella it exists.
    The other part of a powerful economy, the part I really abhor, is the part that requires ruthless exploitation of the earth’s natural resources and callous indifference to any populations in the way of that exploitation.
    Yeah, Nadine, I do have a clue – several, in fact.

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  6. MarkL says:

    The WaPo link lays out the theory of the excise tax quite well. Take away the flowery praise, and you get that the Senate wants to eliminate quality insurance coverage for the middle class and replace it with crap—crap with no regulatory muscle to keep the quality up.
    The next part of the theory is that businesses which pay less in insurance will make it back up to the workers with increased wages.
    Again, a theory, and not supported by surveys of business owners.
    The only sure thing is that the excise tax finances the plan by taking away from the hard-working middle class.
    As for Gruber’s explanation that the “cadillac” plan beneficiaries were getting a tax break before, he reminds me of the WSJ editorialists who used to speak of the “lucky duckies” who made so little money that they didn’t have to pay any income tax.
    The excise tax is a regressive way to finance HCR.
    Soaking the rich is the proper route; furthermore, it makes up for the decade of largesse the Bush administration showed the rich.
    Finally, questions keeps on saying that health care spending will go down because of the reduction in coverage to the “lucky duckies” who actually have good insurance plans.
    I’ve never seen any evidence offered on this point—anywhere.
    It’s another theory, as far as I can tell.
    Look, this plan is probably a step forward, but don’t tell me the excise tax is part of the bill’s wonderfulness. It’s not.
    Subsidies and expansion of Medicaid (if that is in the final bill) will get coverage to more people—not the excise tax.

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  7. nadine says:

    David, you haven’t the slightest comprehension of an economy – any economy, works, or has ever worked, or ever could work, or how wealth is ever created.
    Only the private sector can create wealth, which arises from production and trade. Government produces nothing. Government, by design, leeches off the private sector by taking tax money away from productive individuals.
    If government functions well, it creates structures that allow the private sector to flourish, such as police and national defense and infrastructure. If government functions badly, it takes lots of tax money and throws it away on corruption and boondoggles. But government itself doesn’t make money; it consumes money.

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  8. David says:

    What if the private sector simply chooses to
    be a leech? And what if the President and Congress
    operate as agents of the leech? What then?
    This is where we find ourselves, and it is what has to change before we drown as the ice caps melt, or reality will change us, and in ways we won’t like. The private sector has become more than just a leech, and the polity has, on balance, sided with those in Congress who represent the narrow interests of the private sector. There are safe-seat decent folk in Congress, but they are in the minority. And the polity is too fickle and too limited in both their range of knowledge and their degree of actual insight to have the backs of those in government who would right the ship of state, and this includes the President. Conservative Democrats are the best indicator of the general public mindset, at least as far as what people will stand behind for the long haul.
    Nadine,
    The free market is a myth, plain and simple, and it was government intervention that saved capitalism’s ass post-Depression. And it is Obama who is currently saving capitalism’s ass. The biggest problem is what the bigtime player$ are able to demand/extract from government because they are too big to fail. They know, and Obama knows, that if they go down, taking the world economy with them. We are passengers on a ship I don’t much like or respect at the moment, but like it or not, we are on that ship.
    Your either/or on capitalism/communism is a tired argument that does not provide any insight. The failures of the fascist states in WWII and our ally against the fascist states, the Soviet Union, during the Cold War, can teach us much. So can our own failures. You seem to me to suffer from the delusion that we live in a Manichean world in which we are strictly the good guys, capitalism is a worthy secular religion with a shining track record, and government is inherently a mistake, and certainly never to be trusted or allowed to plan anything, because the private sector gets it right and government gets it wrong. Not likely we are going to see anything in the same light.

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  9. nadine says:

    All right David, I give up. Surveying the history of the 20th century, all you can do is set the glorious successes of fascism and communism, which were planned by government planners, against the abject failures of free market economies, which which “gamed” by free market “privateers.”
    The USSR (under Stalin)
    The Third Reich!
    The People’s Republic of China (under Mao)
    Communist Romania
    Communist Albania
    North Korea
    No privateers! The workers control the means of production! A worker’s paradise!
    Just one question: What planet have you been living on?
    What was it Saki said? “Those who do not remember the past are doomed to repeat it.”

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  10. DavidT says:

    “When George W. Bush achieved his most important
    domestic priority — tax cuts — he did so after winning a
    conflicted presidential contest and with very thin margins of
    support. But there was no sense that the glass was half full or
    half empty in Bush’s crowning policy achievement.
    It is awkward and strange that Barack Obama who one his
    keys to the White House with the greatest political landslide
    since LBJ’s victory barely squeaked by in this health care
    gambit and was undermined by alleged allies in his own
    party.”
    Let’s see. How much sacrifice and asking of the American
    people do sizable tax cuts require? This passage was not
    easy but to compare the two just because they were high
    priorities of each president is to me, silly. As for the Obama
    “landslide,” was it really the biggest since LBJ? What about
    Reagan in 1980 and 1984?
    Criticism of the president is fine by me. I would have
    preferred the “public option” or even better, the Medicare buy-
    in. But were they ever all that realistic given the need for 60
    votes for cloture?
    You criticize Obama for not “fighting” but he is fighting and in
    spite of all the obstacles 31 million more people will be
    insured, insurance companies will be forbidden to make
    recissions, and they will be unable to deny coverage for pre-
    existing conditions. This is not to mention a myriad of other
    improvements and experiments to move our system in a more
    sensible direction. I think this is remarkable particularly
    without Republican support.
    One other thing. Should you not accept some responsibility
    for the Lieberman anti-public option efforts? I am no fan of
    his but don’t you think if he had been reelected as a
    Democrat he wouldn’t have risked further alienating his party
    and his Democratic constituents by rejecting the public
    option?
    Hope you are well and happy holidays.
    DavidT

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  11. JohnH says:

    “The private sector must operate within the context
    of a government whose primary obligation is to
    society as a whole, not government operating within
    the context of the private sector, whose primary
    obligation is to itself.”
    And what if the private sector choses not to? (Like
    today) What if the private sector simply chooses to
    be a leech? And what if the President and Congress
    operate as agents of the leech? What then?

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  12. David says:

    Really smart government planners can, and at times do, ameliorate this rambling journey we are all on. Really smart privateers can, and at times do, game this rambling journey in quite disastrous ways for the rest of us.
    All -isms fail. Of course they do. They require adherence to a particular mindset, a particular set of conclusions, and the exclusion of other perspectives. And every conclusion not based on a fully insightful integration of all of reality will be flawed. Some are just more so than others, and some lead us in a more positive direction, others farther from a valid understanding of reality.
    And there most certainly is no such thing as a free market. It is a myth, and a rather unhelpful one at that. Government represents the only potentially constructive mechanism for a society as a whole, and that government which least harms community and all the private endeavors of its citizenry, while at the same time providing the most coherent, constructive context in which all those private endeavors can occur, is best.
    I cannot imagine anyone but a diehard Rand fan praising the private sector writ large while writing off government intervening on behalf of society as a whole as futile and against the interests of the citizenry.
    Of course government can get it wrong, but there is nothing in history to suggest that the private sector will serve anything but its own narrow interests, and government’s worst offenses against humankind occur because of either sectarian ideology or actions on behalf of the private sector’s narrow, self-serving interests.
    The private sector must operate within the context of a government whose primary obligation is to society as a whole, not government operating within the context of the private sector, whose primary obligation is to itself.

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  13. nadine says:

    questions, you remain under the eternal delusion of the liberal: that because reality is so imperfect and is even prone to occasional failure, really smart government planners can fix it all up and prevent the failures.
    They can’t. Look at every socialist experiment that’s ever been tried. They make things worse, not better.

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  14. David says:

    “I think that the entire nation — Republicans, Democrats, and Independents — need this President to succeed. It’s vital because the challenges ahead are so massive.” This is precisely progressives cannot turn their backs on Obama, no matter the level of frustration and/or disagreement with some of his policies, and I do have some very, very serious disagreements. But I remember when LBJ went down, HHH lost, and we had to endure Richard Nixon. We paid a far more horrible price than we would have had LBJ run again and won.

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  15. questions says:

    Time for some concept work….
    Central planning, ummm, okay, so it’s central planning for the medical boards or the FDA or whatever to say to doctors, sorry, but infusions of lead are not going to be allowed as a cancer treatment. What an outrage it would be to interfere with a doctor’s autonomy. Why, what if the doctor decided on his or her own that lead infusions work?
    Do you get it? I can spell it out better. There’s all sorts of stuff in medicine that COULD be called “central planning” already. There are treatment protocols that nearly every doctor uses absent independent judgment. You start cheap and move up the cost range. You hear hoofbeats and first you look for the horses, then you start working on the zebras, and finally you get to the martians if necessary. Protocol. It’s followed for a very good reason. Research points the way towards somewhat more effective treatments and it makes a whole lot of sense to follow the research and the protocols that come out of it. So that’s what doctors generally do.
    You start with the least toxic drugs, you tell the patient to cope with the side effects, you bargain back and forth, move up the drug list as needed. And you wait to see how the patient copes with the cheaper and older treatments unless the new and improved stuff really is improved.
    There are patterns that vary by region, by culture, and by incentive. Some of these patterns are problematic — like higher rates of c-sections in some places where there seems to be no medical reason for the number. It’s possible that the hospital where many of the doctors did their training pushed c-sections and so that’s the protocol that the doctors got. If the higher number of c-sections leads to adverse results then probably the procedure needs to be rethought in that region. This isn’t your father’s death panel. This is an attempt to use data on procedures and adverse events to guide protocol.
    If this stuff is done right, then the guidelines will be built with a realization that sometimes a c-section is just a c-section, BUT sometimes it’s a stupid risk. When we can tell them apart, we opt for the good risks and do away with the bad ones and we try to set up incentives to help us in this task.
    Doctor autonomy is not necessarily the best thing there is, but there needs to be room for appeals. Medicine often requires judgment, bodies vary in how they respond to drugs, it’s now coming out that generic drugs don’t always work the way the name brand ones do. Eventually we’ll have to deal with this problem as well.
    So the goal is to encourage a reasonable protocol, make it possible to bend the protocol when an individual patient needs the change, and make sure that doctors aren’t doing things just because that’s how they were taught, but rather are doing things because those are the right things to do.
    It is complicated, no doubt. But leaving it all to autonomous individuals denies the existence of already existing protocol, and further gives us huge space for quackery.
    What do you think med schools do, anyway? Teach doctors to do whatever they feel like? Or give basic information about protocols to follow in huge huge huge numbers of situations?
    What do you think diagnosis is all about? Guessing and then prescribing what occurs to your free spirit? Or running through a whole long list of causes and then looking up the protocol for the response?
    Autonomy isn’t really the goal here. Getting the right list of symptoms put together with the right list of drugs or other options is.
    Oh, and what do you think all those nurse practitioners are going to be FORCED to do given that they have very limited medical training? Umm, enter the symptoms into a computer and print up the diagnosis. Talk about autonomy of medical practitioners!
    Nadine, the contradictions are everywhere. Please understand that what it seems you’re really worried about is your own loss of money, and the possibility that your own doctors, whom you clearly trust deeply to operate with no guidance, might do less than what they freely want to do with/to you.
    But maybe that less would be better for your health anyway. It’s all fear of death in the end. You feel YOU might die sooner should your doctors have to follow protocol set by a panel of, umm, doctors. But since they already often do things like that, maybe you should worry less about your own situation and start to worry about all the people who can’t even get to a nurse practitioner.

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  16. nadine says:

    “Thanks for the vote of confidence in my ability to shape policy for the masses!
    Seriously, though, I answered the rhetorical questions by noting that procedures carry a range of difficulty and risk that varies so greatly that picking an average time price is probably a less honest way to price than is doing a procedure price.”
    It’s your delusion, not mine, questions. If you don’t have the delusion that you have the ability to centrally-plan how doctors should be paid and which medical procedures they should be allowed to perform, you don’t get into this difficulty in the first place.
    If you had a modicum more self-awareness, the difficulties you are encountering in trying to think through a single page of examples should indicate to you what an absolute catastrophe Obamacare will be if anyone tries to put it into practice.

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  17. questions says:

    Thanks for the vote of confidence in my ability to shape policy for the masses!
    Seriously, though, I answered the rhetorical questions by noting that procedures carry a range of difficulty and risk that varies so greatly that picking an average time price is probably a less honest way to price than is doing a procedure price.
    (Think salad bar — lettuce is super cheap, potato salad is pricey, and some of the really fancy pasta salads are even pricier. So the price is set at 6 or 7 dollars a pound. Well, lettuce doesn’t normally cost that much, so if you’re a lettuce eater you feel ripped off. But it has to be set there because of the potato salad. The prices are off kilter because they have to average a whole lot of stuff together in order to make a profit. Some people subsidize others. But if you avoid the salad bar, you don’t die. So those who dislike the pricing system can exit. But the pricing makes sense for the store given the labor intensive nature of the fancy salads.)
    Were doctors to use a time price scheme and average their costs over time and patients, we’d be paying a whole lot more for basic care like throat swabs. The basic stuff would subsidize the more time intensive things like putting in a few stitches or figuring our just which rash that is. There’d still be subsidy, and there’d be all the more incentive to rush judgment instead of being careful. This is already something of a problem when doctors jam their work days with patients to keep their incomes up.
    Fact is, any pricing system will set up some dysfunctional incentives. There’s no perfect solution that will miraculously arise as soon as the government is gone from the scene.
    HMOs tried other pricing schemes and failed. Really really failed.
    What it really would take to keep costs down is to limit practitioner pay and use of care. Practitioners aren’t going to practice if the pay is too limited. They’ll walk. And those who enter the field will end up being more like, maybe, teachers — some of the lowest SAT scores are earned by people who go into education. So the salaries are probably in a reasonable range given the schooling needed and the risk undertaken and the hours and demands on people in medicine.
    You could limit pay by limiting expertise and responsibility. But then you end up in the multi-tier system — fine for you and your great insurance. Not so fine for others.
    And you could limit access to procedures. But who’s gonna let a doctor say, well, we should do this scan to be sure your brain is still between your ears, but since the society is limiting procedures, we’ll just wait to see if you die.
    The central problem is that 13k is a reasonable rate for now for reasonable insurance. Where there’s waste in treatments like prostate and breast cancer screening or with HRT or anti-depressants in children, or osteopenia which may or may not predict osteoporosis which may or may not predict an actual fracture, we have the collision between money makers and healers and when both are pushing for the treatment we go for it. When the healers push back, we cut down on the treatment, but only after we no longer have to reason from induction because we have experience of the failure. The screening stuff looked good til the data came in. The bone density stuff looked good til the data came in. HRT looked good til the data came in.
    It’s expensive to keep us going. And failure to pay means in many instances failure to keep us alive and vertical.

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  18. nadine says:

    “Mechanics charge by the hour, not by the procedure. Maybe that would be better. Professors charge by the year, not by the number of students. Maybe that would be better. Lawyers charge by the second. Maybe that would be better. But since each procedure requires significant specialization and significant care and risk, maybe it just will cost a lot of money to keep us all vertical, and maybe we need to pay.” (questions)
    Maybe it all would be better, questions. So which is it to be, a) millions of individuals trying out which way suits their needs best, or b) questions sitting in a chair thinking through the possibilities for them in advance?
    As long as you keep opting for b) over a) you’ll never get anywhere.
    Yet that is exactly what Obamacare sets itself up to do. Of course they would up listening to the highest bidders above all.

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  19. questions says:

    Ahh, the wonders of the market would bring us, umm, wonders.
    I’m not going to go point by point, because doing so would drive me insane. But I’ll touch on a couple of things.
    First, that 55 year old guy who’s paying 131 a month for 3k deductible, 7 mil lifetime — I get the feeling there are a few pieces of information missing. Pre-existing conditions? History of heart disease in the family? Weight/smoking/blood test results…. In other words, is there really any 55 year old who would actually get this policy? Or is this equivalent to bait and switch? And further, what happens when he turns 56, when he actually has a heart attack and, OOPS, forgot to note that he had seen a doctor for acne? Rescission city, is my guess.
    Next, the dox in a box thing — so you take your kid or your body over to the mall to get checked out by a nurse practitioner and for routine things, gee it’s great. As long as you’re really routine, but are we ever really routine? Did you know strep can complicate dangerously, did you know that many medications are contra-indicated in all sorts of situations, did you know that nurses are amazing people, but that they don’t have anywhere near the training that doctors do and that anyone with money is going to prefer the better training — which means that what this is really proposing is a 2-tiered system — doctors for rich people and dox-in-a-box for the Joe Schmoes of the world. Gee, we already have multi-tiered nutrition, multi-tiered justice, let’s definitely institute multi-tiered medical access.
    So that’s a couple of things.
    As for pricing, yes indeed it’s irrational. BUT, the likely cause of the irrationality of pricing is the irrationality of having some people insured, some not, insurance company negotiation on pricing, varying office costs, varying levels of service, varying success rates at different offices, and probably lots more.
    Mechanics charge by the hour, not by the procedure. Maybe that would be better. Professors charge by the year, not by the number of students. Maybe that would be better. Lawyers charge by the second. Maybe that would be better. But since each procedure requires significant specialization and significant care and risk, maybe it just will cost a lot of money to keep us all vertical, and maybe we need to pay.
    Even judging a kid’s ear infection turns out to be really difficult. I have a cousin who’s a doctor and he said it can actually be really hard to know if an ear is infected. There’s judgment even in the most mundane of medical procedures. And that judgment costs money, takes experience, and should be available to all the ears of all the kids.

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  20. questions says:

    The Suderman piece is not convincing near as I can tell. I would guess that it’s leaving out all sorts of issues like: the 13k family plan cost is the nationwide average and seems pretty standard, the basic tenet of health insurance reform seems to be that we need the broadest possible swath of people in the pool to get the cheapest rates coupled with the widest coverage — not state-based, then, but nationwide, and so already the analogy fails. The goal of the leftier dems is not what the Senate passed, and yet it is more the Senate’s version that is being described.
    Also, since 13k per family per year is standard at this point, why be shocked that a community rated family plan is 13k? Subsidies will be needed to make up the difference — as they are for anyone who has employer-based subsidies anyway.
    So this one doesn’t do it for me, but thanks for the link. I generally avoid Reason, and you’ve given me one more, umm, reason to avoid it!
    I’ll get to the next one now….

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  21. questions says:

    You know, Nadine, prompted by a thing in today’s times on econ books of the year, I was just reading Amazon reviews of How Markets Fail by John Cassidy. Cassidy is far from an economic illiterate. It’s worth a read probably. It’s now on my list of things to get.
    (There’s also The Myth of the Rational Market by Justin Fox to look at!)
    The reviews are pretty good, actually. Informative even. Some people think like you do, and some people think like I do. My guess is that you are so deeply committed to your worldview, as am I to mine, that there’s not going to be a lot of movement here….
    Near as I can tell, “market failure” is a concept you need to take on and make peace with. You will, of course argue just what one of the reviewers does: there’s is no free market because the wicked government always gets in the way and distorts natural preferences. If only we could get back to nature, as it were, the markets would save us from everything.
    I don’t actually believe in the concept of ‘nature’ or ‘authenticity’ so I’m not all hung up on what we’d do if the nefarious deeds of the wicked and interfering government could just be undone. I don’t think there’s a market outside of human forces, I don’t think there’s perfect information, I don’t think people rank preferences well, I don’t think the problem of induction has been solved so the chances that anyone can really get things right bumps up against a major epistemic limit from the get go. So there’s no ‘there’ to get to, and therefore, we’re ok here with government regulation.
    But my guess is that you really feel deeply that there is an authentic human experience that we could get to, a sort of golden age or whatever, that the government blocks whenever it (we, collectively) chooses one thing over another. (awk. grammar, sorry!) That very choice seems to be the distortion. But if the government is really “we, the people” then what’s distorting the market is the very choices we the people have made. Taken to the extreme, it would seem that making choices is a distortion of…um, choice-making.
    What this boils down to, near as I can tell, is that there’s really a fundamental contradiction in your position. The government doesn’t distort the market because there really isn’t a market aside from the organized choices people make. So then you’re stuck arguing that choice making distorts choice making.
    Fundamental contradictions are always fun to find, are generally hard to get out of, and usually force people to rethink their positions.
    Work on Jamie Galbraith’s book on markets (I’m part of the way in, but economic illiterate that I am, I struggled a bit even with a popular tale, and I put it down. I need to get back to that. Perhaps 2010 will be the year of the economist….) I think Galbraith’s basic point is that there’s no such thing as the free market. Makes a lot of sense to me. But then, I utterly dislike the notion of authenticity. Really really dislike it.

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  22. nadine says:

    questions, you’re under the delusion that you can shepherd people into behaving just as they should, but are too stupid or lazy to do for themselves. The unintended consequences tend to outweigh the intended consequences. Here are two good articles from Reason explaining a) what has really happened when the states have tried plans like Obamacare and b) what a market-oriented solution would look like:
    The States’ Failed Experiments
    The major provisions of ObamaCare have already been tried. And they don’t look good
    Peter Suderman
    Supreme Court Justice Louis Brandeis famously envisioned the states serving as laboratories, trying “novel social and economic experiments without risk to the rest of the country.” On health care, that’s just what they’ve done. Like participants in a national science fair, state governments have tested variants on most of the major health care reforms Congress is considering. The results include dramatically higher premiums in the individual market, spiraling public costs, and reduced access to care. In other words, the reforms have failed
    rest at http://reason.com/archives/2009/12/22/the-states-failed-experiments
    Markets, Not Mandates
    What would real health care reform look like?
    Ronald Bailey
    While congressional reform efforts screech and shudder along, let’s take a moment to dream about real health care reform. Imagine a system that is genuinely transparent, competitive, and driven by consumers.
    Right now, thanks to incentives built into the tax code, patients are locked into the health plans their employers choose. Consequently, most of us don’t have a clue what our health insurance and health care cost. We have no way to reduce those costs and no incentive to do so even if we could. Worse yet, it’s precisely when you need the system the most that it fails you. In the words of the Princeton economist Uwe Reinhardt, “when you’re down on your luck, you’re unemployed, you lose your insurance.…Only the devil could ever have invented such a system.”
    So the first step toward real reform is to give consumers responsibility for procuring their own insurance. The laws undergirding the third-party payment system must be dismantled, allowing the money employers spend for insurance to be converted into additional income for the employee. This would immediately inject cost consciousness into insurance decisions.
    What would the results look like? It’s impossible to predict all the specifics, but here’s one partial vision of what markets might bring us.
    rest at http://reason.com/archives/2009/12/23/markets-not-mandates

    Reply

  23. pauline says:

    imo, Teddy couldn’t have changed a thing on healthcare reform even if he remained in perfect health. The large forces against true healthcare reform would have knocked him out cold.
    US health care reforms change little, critics say
    By Agence France-Presse
    Thursday, December 24th, 2009 — 4:59 pm
    US health care reforms change little, critics say
    WASHINGTON — The health care reform bill passed by US senators Thursday tramples on women’s abortion rights and leeches off working Americans while enriching the insurance industry and changing little, critics said.
    The National Organization for Women (NOW) blasted the measure as a “disappointing move that sets women’s reproductive rights back” after Democratic senators included compromise language on abortion coverage to muster the 60 votes needed to overcome parliamentary delaying tactics.
    “When a small group of men sets out to determine what rights women can exercise over their own bodies, it’s sexism, not health care,” NOW said in a statement.
    The American Federation of Labor and Congress of Industrial Organizations (AFL-CIO), which groups 57 national and international labor unions, said the Senate bill “doesn’t live up to the kind of reform we need.”
    more at —
    http://rawstory.com/2009/12/health-care-reforms-change-critics/

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  24. questions says:

    Nadine,
    Get some sleep!
    Second, don’t you get statements from you ins. co. that tell you what the doctor charges, what the insurance co. will pay, what’s disallowed by negotiation, and what your portion is?
    Third, don’t you have co-pays and/or deductibles and or out of pocket expenses every year?
    These patient costs are designed to do just what you are arguing for — make people aware of what they are spending, not cover first dollar stuff so that insurers aren’t just paying every cent, but guaranteeing that people have some skin in the game as well.
    For some policies, the out of pocket and co-pay and deductible costs are so high that people simply can’t use their policies for anything. If you have no out of pocket max. for the year, you don’t have real catastrophic coverage. For many people the difference between 40% of 200,000 and 100% of 200,000 is pretty meaningless. So much for open hear surgery that doesn’t result in bankruptcy.
    HSAs only work for really rich people who can “s” — save. If you don’t have extra income, you don’t save. It’s a tax benefit for rich people, not a health care benefit for people who need help. And when you add HSAs to generous health benefits, you get all the more insulated from health costs — and it’s the wealthy who seem to have this, not low wage workers. Oh, and since HSAs are a tax code provision, the benefits are worth far more to a high earner than to a low earner — 15% vs. 33% or 38% or whatever the top bracket is now. HSAs are not health care.
    What we should probably think about is some kind of refundable doughnut hole. You have a little first dollar preventive care, you pick up the tab for the next chunk of money, and if you go catastrophic, you get that doughnut hole money back at the end of a year. Catastrophe should be income-determined and perhaps much of this could be dealt with through the tax code with refundability — so it pays regardless of the presences of income. And the refundability levels can be set via income.
    With some kind of refundability, you have both the patient awareness of cost things medical and the benefit of covering catastrophe.
    Health care works differently from other consumer goods though. Do without it and you die. It’s a much more inelastic service than say, getting your oven repaired. People live without ovens. The use a toaster oven, the cooktop, eat cold food, whatever.
    Live without getting that lump checked out, and you die. So the higher price to dampen the use of the service actually will kill some people.
    We need to be careful about how we set incentives. This is the reason for first dollar coverage in insurance. The premiums act more like the spreading out of costs for heat bills over the course of a year — the winter spike is paid for in larger summer bills so you can predict costs. Built in to the premium structure then is an incentive to get the lump checked early. We don’t really want disincentives for a lot of care. We want disincentives for stupid, unnecessary, redundant, or wasteful care.
    It’s hard to thread this needle since no one has solved the problem of induction yet. ‘In the past, this has not been the sort of thing that’s cancerous in my experience….OOPS. Sorry, I didn’t order a biopsy because I didn’t think…. You die.’
    Talk about letting someone else deal with your mistake. A doctor messes up and the patient dies. That seems worse than letting patients off the money hook. Doctors are off the death hook.

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  25. nadine says:

    P.S. Having totally missed his chance to write a centrist bill that would gather a broad base of support, it’s ironic that Obama has wound up pissing off progressives so badly by being unwilling to fight for the public option. He’ll get the worst of both worlds now.

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  26. nadine says:

    “At bottom, the problem is that Americans just want lots and lots and lots of health care. And why not? Staying alive and staying active is more important to people then just about anything else. And as long as medical technology keeps providing elaborate means for extending our lifespans, people will keep substituting health care expenditures for other expenditures, and pay higher proportions of their income on their health” (Dan Kervick)
    Dan, how much did YOU spend on your last doctor visit? Your last lab test? Do you have any idea?
    I don’t know how much I spent on mine because all I know is the co-pay. Of course Americans want an infinite amount of medical technology, when it’s set up to feel ‘free’, something they are entitled to. If you want people to be frugal and to choose their priorities carefully, then they have to spend THEIR OWN money.
    That’s common sense. Who spends at a restaurant more frugally, the guy on the expense account or the guy spending his own money? Everybody knows the answer to that.
    Yet the vast proportion of medical spending is set up so that the doctor doesn’t know the price, the patient doesn’t know the price, it’s all the hospital and the insurer arguing over some price, leading to ever-inflated ‘list’ prices and cost-shifting. And NO market incentive to reward efficiency.
    People may say that want a public option (esp. when it’s phrased as part of a competitive choice, since Americans like that idea), but give them a realistic idea of what it will do to their taxes and the federal deficit and they’ll think again. Mention that the people who support the public option want it to be “the camel’s nose under the tent” to move to single-payer health care, and they will be against it by 2 to 1, as they are against single-payer.
    People have no good way to estimate medical costs because unlike, say, housing, the medical market doesn’t function and nobody knows the prices. Most people don’t even know their insurance cost, just their co-pays. When they do see a price, it’s usually a hugely inflated ‘list’ price. So very few people are giving informed answers. It leads people to feel that the government MUST provide health insurance because NOBODY can pay for it themselves, when they don’t feel that way even about other big-ticket items such as houses. But people know what houses cost.
    In short, the setup you want to encourage is good catastrophic insurance with HSAs and high deductible policies, just what this new bill makes illegal. That and tort reform, also not in the bill. Those reforms would lower costs naturally without rationing; Obamacare will both ration AND have exploding costs.
    If Obama had been willing to consider tort rerform and HSAs he could easily have gotten true bipartisan support for measures that introduced more insurance regulation to prevent wrongful terminations of coverage and community ratings to protect pre-existing conditions and Medicaid expansion. He could have gotten a lot of Republicans to support a centrist bill like that. But Obama is totally unwilling to govern from the center.

    Reply

  27. Linda says:

    Dan Kervick,
    There is indeed a medical-industrial-complex–and like the military-industrial complex, it is appropriate to add Congressional-academic to both.
    Unfortunately to date we haven’t had a President warn us about the dangers of the medical-industrial complex,as Ike did about the military one.
    However, Ike did that in his Farewell Address.

    Reply

  28. JamesL says:

    And now I finally know that Captcha is really a trojan because this last set of letters, unlike those where I need to find my magnifying glass, was so clear Ray Charles and Stevie Wonder could have agreed on them, and the damned thing still claimed I screwed up. Hey world, Captcha is all about second tries. Doesn’t have anything to do with the letters.

    Reply

  29. JamesL says:

    DanK, thanks for giving what Nadine left out. She he they like to do that.
    Also, thanks for the “flight of the progressives” line. But I don’t think emotions will subside, nor the flight of those who elected Obama. They won’t for me (Obama COULD change that) because I know friends who will die waiting for the promise of “people over corporations” that Obama was glad to implicitly ride to power on. And it won’t be enough for millions of Americans who are on the ragged edge of belief right now, who will see this situation as the campaign promise to progressives having been broken. If Obama did not wish to go to bat in the ninth inning (sorry, baseball ref, and Obama must use basketball) for health care, then in the words of Cheney, he “had other priorities”. And they weren’t mine.
    Obama’s real enemies, and mine, are the military/industrial/medical/big pharma/big agro/media/financial organisms that have gotten themselves defined as people, but who are in the end driven by greed and therefore for all practical intents, sociopathic. There aren’t enough slashes in my computer to define the corporate world that has taken over America, but that is the new world order that, if not defended against, will permanently and by law substitute the well being of profit-based entities over that of the citizens whom they seek to feed on.
    Another milestone passed. Another nail in the coffin. Americans used to make fun of Russians for not having the guts to stand up to their government, and Italians for being so inept. Now we are them.

    Reply

  30. Dan Kervick says:

    The Quinnipiac poll Nadine cites also found that voters strongly back two options that were cut from the Senate bill: they support the public option by 56 – 38, and support allowing younger people to buy into Medicare 64 – 30 percent.
    Given numbers like those, it seems plausible that the falling public support in the last few weeks is in good part due to the dramatic flight of progressives who don’t think the bill goes nearly far enough, as is apparent to anyone who has been reading the progressive and left-wing blogs lately. Once the bill passes and emotions subside, some of that political support will return.
    However, one prediction I will make is that Obama hasn’t succeeded by a long shot in being the “last” president to deal with major health care reform. Neither Democrats nor Republicans have shown the stomach to take on the systemic causes of rapidly-rising health care costs, which would involve taking on an the many parasitical feeders on an extremely wasteful, lucrative and profit-hungry industry, an industry that now comprises a nearly unchallengeable behemoth analogous to the military-industrial complex. Some Americans are going to be helped by this bill, but many others are going to see their health care costs continue to rise. And when that sinks in, we will be back at this issue once again.
    Perhaps some day, some Congress will muster the courage and popular support needed to impose some serious discipline on our health care delivery system, and squeeze out the waste, go after the extravagant salaries, end the collusive game between payers and providers, and rationalize and socialize more of the many redundancies and inefficiencies.
    At bottom, the problem is that Americans just want lots and lots and lots of health care. And why not? Staying alive and staying active is more important to people then just about anything else. And as long as medical technology keeps providing elaborate means for extending our lifespans, people will keep substituting health care expenditures for other expenditures, and pay higher proportions of their income on their health. Health care is a huge part of our lives and our economy. So tweaking and/or overhauling health care delivery is just going to one of those things we have to address repeatedly.

    Reply

  31. MarkL says:

    Isn’t the 14th amendment protection of corporations the root of the campaign finance problem? The absurd notion that corporations are people has got to go.

    Reply

  32. Maw of America says:

    Linda nails it. It is painful to consider all the stalled legislation and bad law that results from lobbyists and special-interests.
    I would posit that healthcare, foreign policy, banking regulation, etc. would be vastly improved if Congress and the President were not lured by the need to raise huge sums of money for their campaign warchests every 2, 4, or 6 years.
    I pine for the day when my lonely voice (and vote) will stand on equal footing with every big money industry that can dangle a campaign contribution before a lawmaker to gain access and obtain a law that goes against my interests.
    Our system is broken, and once we fix the financing of campaigns, we will start to get legislation that works better and truly serves the people.

    Reply

  33. JohnH says:

    JamesL is right: “what is the consensual will and
    decision-making process to limit medical care, and
    what is the limit?” However, I disagree that it is
    “new technology” or true medical need that is the
    main culprit.
    What is happening is that health providers have
    gotten into the business of creating demand for
    their products and services. Nowhere is this more
    evident than the boom in prostate cancer, which
    affects male longevity in no more than a small
    percentage of cases. Yet providers have identified
    a problem they can “solve,” so they are marketing
    themselves aggressively. And who is to deny “care”
    to men spooked by the cancer scare? No one. So the
    service gets provided, and the bill is mostly paid
    by insurers, who are happy to take their piece of
    the action and pass along the costs with a markup.
    There are plenty of other examples of demand
    creation as well. If it’s a medical problem
    advertised on TV, it’s probably demand creation in
    action.
    Likewise, Medicare is riddled with providers who
    have found ways to bilk the system. For example,
    hospital beds are leased to the elderly at
    exorbitant rates. We tried to buy one for a parent
    and save the system money. We were told they were
    not for sale. When attempts are made to reel such
    costs in, Congress predictably balks, as it did
    with the idea of an independent Medicare Cost
    Commission, which died stillborn.
    Sadly, the sick “health care system” is only one
    example. Wall Street and the merchants of death
    are equally parasitic, You have to wonder how long
    this can go on before these parasites succeed in
    killing their host.

    Reply

  34. nadine says:

    After a year of campaigning for health care, the latest Quinnipiac poll shows Americans oppose this legislation by a 17% margin. And that’s before they have figured out how much it’s going to cost them in tax hikes, premium hikes, and fines! There’s a trillion dollar tax hike in this bill, and during a severe recession, too.

    Reply

  35. JamesL says:

    To be fair, Obama’s health care failures have been wastage of the power of the Presidency in this crucial question, and in then selling a potato as an apple. The people who grew and forced the potato on Obama bear a much heavier guilt, and I particularly mean the Republicans who, once more, very clearly, are not merely willing to sell the bodies and souls of human Americans for another acre of lucre, but enthusiastic about the process, and willing to encourage anyone who is manipulable into voting toward their own personal extinction or economic slavery, take your pick. The Dems certainly helped here, most of all the execrable Leiberman, but many of the rest showing themselves to be completely inadequate to the task of hanging this very real millstone of future human suffering and grief around the necks of the Republicans where it belongs. And having not managed to hang the millstone where it belongs, it now becomes their own.

    Reply

  36. JamesL says:

    John and Linda are right. Profit based monopolies will still control costs. People will still be excluded from any coverage. The first commandment of the insurance industry will remain Externalize and Evade Costs. The poor will remain poor, without adequate care, and the minimum blowback from that will be generations thick and as wide as the nation. Hundreds of thousands of Americans–many many times more than died Sept 11, for whom we have and will continue to waste two or three trillion dollars killing people not involved in Sept 11, will die needlessly before all provisions of even this weak bill are enacted. Their epitaph should read: Allowed to Die For The Love of War.
    But the most fundamental questions continue to be ignored in the debate: what is the consensual will and decision-making process to limit medical care, and what is the limit? There is not enough money in the universe to pay for the the most advanced care for all persons. This deficit equation is built into technological health care advances (and EVERY technology). Every new year will bring more advances, more tests, more expensive techniques, and every year the number of people who can afford these advances will decline. You can project this ahead one, five, or twenty years— whatever number works for you personally so that the situation for your loved one or their loved one becomes clear, and the answer is the same. The poor, and the unlucky, will continue to drop farther and farther behind, creating strife. The rich will continue to demonstrate to the poor that the acquisition of money, no matter the means, is the most important thing in life.
    Passage of this bill, and Obama’s congratulatory sales job, obscure those issues. Even when this bill is thoroughly enacted, America will trail other industrialized countrys, satisfied by constant lines of bullshit that it has the best care system, even as the ranking is actually 34 and falling. Just because Obama says this is a good bill, a 95% bill, doesn’t mean it is so. Bush the Miniscule was at least right up front about his job being to constantly repeat the propaganda. I don’t see much difference here. Selling something that is less by saying it is more doesn’t make it more. It’s still less.

    Reply

  37. DCWatcher says:

    Steve,
    Thanks for this interesting take on the health care political
    arena. You are so refreshingly unpredictable. So many pundits
    fail to think and are knee jerk reactionaries. Some are fascists,
    on the right and the left.
    Both myself and a number of friends read this blog every single
    day, and some days, we are in complete disagreement with you.
    Others you describe beautifully our own views in a way that is
    eery sometimes.
    You are fair and are the best commentator in Washington. You
    are educating many people, and I wanted to wish the very best
    to you and your family and dogs Steve.
    Thanks for all you do.
    Some of Your DC Fans

    Reply

  38. JohnH says:

    Amidst all the hoopla and mutual back slapping, I
    would like the experts on health care to answer
    one simple question: how does this mammoth bill
    make these shared monopolies stop behaving like
    monopolists? How does it prevent the price gouging
    and service cuts so characteristics of monopolies?
    As I understand it, the bill contains nothing to
    restrain price gouging. Yes, everyone is ordered
    to get coverage, but at what price? Personally, my
    family will be paying 25% of its income for health
    insurance next year, 33% when you include
    deductibles, out of pocket, dental, etc. And we’re
    relatively healthy! Our premiums go up 30% with
    the new year. What is to stop more of this?
    On the other side of the monopolists’ equation,
    what is to stop them from refusing to pay for
    services they promised to cover? Nothing is the
    most likely answer.
    Sadly, unless something has changed, a year’s
    worth of legislative effort has been wasted. By
    refusing to address the real problem–a parasitic
    industry intent on consuming its host–it has only
    postponed the true crisis for a couple more years.

    Reply

  39. Bill says:

    Steve, I totally disagree that Obama failed to try to get the whole thing, and failed.
    The GOP strategy to exploit the 60 vote closure really dictated the whole process. They made that decision, and it applies to everything, in the first weeks of the presidency. They have become a small and ideologically pure party in the Senate, with 40 members. They can hold them together, and the base likes it.
    This meant that the President and Dem leadership had to go for a plan that would get 60 votes, from the Democrats+Independents in the Senate. It turned out to be more centerest than the Democrats wanted. It was still wonderful!
    The majority of voters are moderates, independents, with no affiliation in the center. They have grown skeptical as this spectacle has dragged on for a year. Fortunately, the centerest bill that is likely to result, will probably bring them back to Obama. It will also show that he is effective, which is what the GOP tries to counter.
    Had Kennedy been alive and well to lead a bipartisan effort, he might have caged some GOP votes (though there are almost no possibilities any more–the GOP defeated them). However, that bill would also have been a centerest bill, after all he was a realist too, that did not have a public option. Mox nix.
    I love Ted Kennedy, and the way he turned around his life to great service, through hard work. And I do miss him.

    Reply

  40. questions says:

    The competing demands of cost control and access to procedures undermine each other long before anyone tries to balance them. For now, there’s lots of access for those with money (which is to say limited access for the population) and lots of procedures. Under the new system, there will be more access and probably fewer procedures. The reduction in procedures might not compromise health, but it does compromise choice. Choice is a deeply embedded value that sometimes conflicts with reason, but is still felt deeply. People want their choice of practitioner, their choice of procedure and they want it to be covered by first dollar insurance. So much for cost control!
    The bill, in my limited understanding of it all, takes an occasional stab at cost control, but can’t do a lot until we expect less from our health care system.
    It’s a first step on a long path towards our accepting that doctors can’t actually fix much that ails us, but that everyone should have a right to get the treatments we know actually work.

    Reply

  41. Linda says:

    Aside from immediately doing away with exclusion of children for pre-existing conditions that would take place immediately, the provisions to do that for adults and to provide more options will not take effect until 2013 in the House bill and 2014 in the Senate bill.
    The bill that passes will be deeply flawed because it is not single payer (and that could well be single payer with private insurers as a number of European countries have). Everyone is not covered by the same program; therefore, there is lots of room to divide people. It is not, as Democrats claim, establishing a universal right to health care in the country.
    Republicans are going to use the above and many other provisions of the bill to ensure that 2010 will be even more divided and politicallly polarized than 2009 was.
    Furthermore, neither bill really controls costs or health care inudstry enough.
    Campaign finance reform, more control of lobbyists, less arcane procedural rules in the Senate, and bipartisanship, there won’t be much needed progress in this country.

    Reply

  42. PissedOffAmerican says:

    “I think that the entire nation — Republicans, Democrats, and Independents — need this President to succeed. It’s vital because the challenges ahead are so massive”
    Extending trhe Patriot Act, attacking Yememi insurgents to aid a despots desperate grasp on power, having his State Department lie to us about the Yemeni operation, behind the scenes escalation of military cooperation with Isreal as he postures an insincere and contrived “hard line” with Netanyahu, expanding covert operations in central and south America. Looks to me like he’s just as “successful” as the last fascist prick, Bush, was. Obama is just faster at screwing us over than Bush was.
    And now he stands before us and makes statements like “I didn’t campaign on the public option”
    He’s a piece of shit liar just like the last piece of shit liar.
    And ya gotta love his “we’ll pull out of Afghanistan in 2011”. How stupid does he think we are?

    Reply

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