It’s time to evaluate where health care reform stands at this point.
Guaranteed Issue: The best thing about the bill is unquestionably the fact that insurers have to issue policies to anyone who can pay. No one can be denied coverage, no matter what pre-existing conditions they have. This is a big deal. While it can help people of any age, it is most important to older people, who are more likely to have pre-existing conditions. This also helps people who are stuck with very expensive insurance because they have pre-existing conditions and if they cancel their insurance wouldn’t be able to get new insurance.
Individual Mandates and cost sharing: An individual mandate forces people to buy insurance whether they want to or not. Insurance works better when everyone is covered and in the same risk pool. It also shares costs throughout the population. Individual mandates seem unfair, but they are generally instituted as part of changes to the system which reduce overall costs significantly. For example, relatively speaking, Canadian GDP/capita costs were reduced by one third compared to what they would have risen to otherwise during the ten years after changing from a US style system to single payer.
If there is no cost reduction due to systematic changes in the system, however, all that an individual mandate does is share costs through the entire population and direct profits to private insurers and medical providers of various kinds by giving them a captive consumer based, forced by government mandate to buy their services.
People who don’t have insurance right now are primarily younger people or those who feel they can’t afford it. What individual mandates will do, then, is subsidize older people’s insurance costs and the price of guaranteed issue, which is very costly since it forces insurers to cover people who are very likely to get sick. The people who subsidize this are, generally speaking younger and poorer.
If subsidies were adequate, then in fact, it would be the government subsidizing the costs, through progressive income tax and corporate taxes. However, since the subsidies in the various bills do not cover the full cost, poorer and younger people will subsidize older people. Since many of those people didn’t buy insurance because they are right on the edge financially already it means that some of them will go without food, not be able to pay tuition, or lose their homes as a result. Many people are already on the edge already, this is one more burden for them.
No Robust Public Option: A robust public option is one that is large enough and with enough pricing power to force down costs, and one which is available to everyone. At this point, the public option will likely have between 5 to 9 million enrollees (the CBO says 6 million, but we’ll be generous). As such it will be smaller than most private insurers and will not have pricing power. If it were linked to Medicare and could use Medicare’s clout, it could reduce costs, but the Medicare +5 amendment, which would have had it paying providers at Medicare rates +5% was defeated.
The Congressional Budget Office has stated that the public option insurance plan premiums will be higher than equicalent private plans. This is likely because of denial of care issues, insurer cherry-picking and lack of clout mean it won’t be able keep reimbursement rates low relative to private insurers who have more customers and thus more pricing clout with doctors, hospitals and other providers. If the public option costs more than equivalent private plans, it goes without saying that it will not reduce costs.
Reduces Practical Access to Abortion: The Stupak amendment, passed Saturday evening, makes it illegal for any plan offered on the exchanges to finance abortions. Any woman who wants abortion access, after being forced to buy insurance that doesn’t include it, will have to buy it elsewhere. The practical result of this is a reduction in access to abortions. This, of course, primarily affects young, childbearing age women though their family members, boyfriends and so on will likewise be effected.
The Bottom Line: Who’s Getting What, and Who’s Paying
This bill does not contain a robust public option which will contain costs. It will give guaranteed issue and force cost sharing through an individual mandate. Older people will disproportionately benefit, and the people who will disproportionately pay are younger poorer people, and especially younger women, the poorer ones of whom will lose practical access to abortions.
For a long time I’ve read that the bright red line for many progressives was a robust public option. None of the bills, including the House bill, have a robust public option. In addition, the Stupak amendment removes practical access to abortions for many women.
It appears that the bright red line was not a robust public option. The bright red line was, and is, guaranteed issue. As long as a bill has guaranteed issue (in exchange for which insurance companies insist on an indvidual mandate, aka, cost sharing and forced customers) any other sacrifice is acceptable.
This health care “reform”, if passed in this form or worse, which it will be if it is passed at all, will blow apart eventually, because it will not contain costs or ‘bend the cost curve” and the US economy simply cannot indefinitely afford health care costs wich rise faster than inflation or wages. But for as long as it lasts, it will help some people at the cost of other, generally younger and poorer people.
If progressives really meant that a robust public option was their minimum requirement, when Medicare +5 failed they would have gone into opposition. They didn’t, therefore it wasn’t their minimum requirement. It remains to be seen if enough progressives really will vote against a final bill which still contains the Stupak amendment. Given progressives failure to live up to their threats to pull support if no robust public option was in the bill, I am forced to suspect that if Stupak is in the final bill, the final bill will pass.
The last couple weeks have been very revealing as to what various people, including politicians, progressive bloggers and activists, are really willing to fight for, and what their bottom line really is.
I would suggest that if progressives ever want their threats to be taken seriously by anyone again they go into opposition against this bill until such a time as it both has a robust public option and the Stupak amendment is out. Failure to do so will show that their threats were always hollow, that they are willing to sell out child-bearing age women, and that they prioritize the interests of older people over younger and poorer people.
In negotiation against a good negotiator, you get the minimum you are willing to settle for. Progressives have shown that their minimum is not a robust public option. It may not even be practical abortion access. They will not get a robust public option if they will not oppose the bill over it, and if they won’t oppose the final bill over the Stupak amendment, that too will most likely remain.
Obama and the Democratic leadership’s bottom line is they must pass some bill called “health care reform”. Unless you threaten to take away their bottom line, they will take away anything that isn’t progressives bottom line – and that includes practical abortion access, and a robust public option.
DWCG
I just want to remind all the young and women P.O.ers (first and primarily those idiots at MoveOn and in the unions) who sold out what has been a core constituency in Democratic politics for over 20 years (the single payer movement) of a prophetic poem that begins with:
First they came for the communist; and I didn’t say anything because I was not a communist…
It should be a lesson to the entire so-called progressive movement, but I doubt it will be learned.
Maybe it’s just now hitting me, but these guys just screwed up the best opportunity for true health care reform in 45 years and with it enacted the greatest evisceration of a woman’s right to choose in our country’s history. Wow. I mean frickin’ WOW!
How many ways can you spell: “FAIL!”
selise
DWCG, would you please consider posting that comment as a diary at fdl?
selise
no shit. over $400,000 raised to support congressmembers who promised to votes against a bill without a “robust” public option, 57 of them unquestionably, according to their own definition, should have voted “no.” and it all goes down the memory hole? no whipping to demand the 57 live up to their pledge? (actually, i did ask my rep directly and got blown off — but i’m a single payer extremist, NOT a po supporter). where did all the po boosters go?
Formerly T-Bear
The Democrats have just gone and sewn the wind on this issue, I quail to think of the horrendous political whirlwind that will ensue.
I expect nearly all partisans of the issue to be cognitively blind to the fact: the political process is broken, it does not work anymore, the traditional tool of political decisions is useless and go about bashing all about them about the ears for failing to support the issue. Everybody does need to take a breath or two then go back and read their Federalist Papers, this is exactly how the federalist system was designed to work, to keep the powers of government from the “madness of the crowds”, then, when the passion is passed, the task of reconstituting the issue needs be faced.
The Republic has become myth. The choice becomes recognizing that fact or not. If recognized, finding a structure to replace the myth that functions to meet the requirements of political congress, decision, and administration of and for the body politic. Hint: find where it is written that democracy cannot be exercised at large scale, by a competent population, then give governance to that population.
Formerly T-Bear
error: SOWN not sewn, my bad edit
lambert strether
Maybe all the PO boosters were too busy figuring out how to whip for the Kucinich Amendment that they didn’t have time for anything else?
jbaspen
– you have done the best of anyone/anywhere (and that includes FireDogLake) of reducing this 1990(??) pages of legal-eze to common-sense, salient issues! Well done, Ian!!
I’ve suffered from Multiple Myeloma for > 8 years. Many scientists opine that the seminal cause is a very clever virus, much like AIDS (their “Ts” are attacked, with me the “B” cells). It’s funny, but you almost have a (very) grudging respect for these devil-ish protiens. I’ve managed to beat them back, but not eliminate them entirely. Of course, often some unknown “tripwire(s)” set them off on a powerful dynamic.
And, while on the subject of “tripwires” and “dynamics”, does the initial weak public option have the legal conditions and monetary means to “morph” into something resembling a “Robust” option and formible competitor to the Private Insurers (aka, the “Squeegee Men”)??
Thanks, Ian – JB
b.
“In negotiation against a good negotiator, you get the minimum you are willing to settle for. Progressives have shown that their minimum is not a robust public option. It may not even be practical abortion access.”
The so-called “progressives” have no minimum. They are like Obama, without the power – they just want to play at the table.
But the incumbents are of no importance – the past year has amply demonstrated that, no matter how the election turned, nothing has changed. Nothing will change, unless we change the players.
The only action that matters is ending incumbency.
I would suggest that if progressives ever want their threats to be taken seriously by anyone again they go into opposition – no money, no support for anybody who does not deliver, money and support against any incumbent that did not deliver.
Jane Hamsher has been right on the money [sic] with her points about NARAL and Planned Plarenthood on the Democratic Sepsis Coalition, specifically, and on the “veal pen” in general.
I argue that Jane’s “veal pen” frame is off only in that it is the Democratic base that is in the pen, and the handmaidens of the incumbishment are the vets draining the blood and injecting the sedatives. You need to care about power, and only power – who are the prime movers behind a given turn for the worse, what gives them their power, and how to take it away. The money that NARAL et.al. are draining from their base and divert to prop up themselves first, their establishment second is the lifeblood of the cause draining away.
Follow the money, then work to stop the flow.
The “progressive” base simply does not seem to grasp that the only way to sustain strategy is to stop accepting strategic losses for tactical wins, and to stop endorsing tactical losses that appear to “prevent worse”. If the numb-nuts behind the “2nd Amendment At All Cost” movement that the NRA draws on can muster this resolution for a cause this flawed, it does not bode well that “progressives” seem to be unable to learn from history.
End Incumbency. *That* is the only lever, that is the only only tool that disrupts networks, derails careers, removes seniority. That is the great leveller. If you want to have political influence, keep elected representative sweak and vulnerable – keep them first term.
No doubt, the elites will adjust to that – so pay attention to Known Associates. Obama’s rise to power was, at crucial points, facilitated by Tom Daschle and Joe Lieberman. By their sponsors know them – vote against their sponsors. Vote against their network.
Mandos
This is where I think your analysis is mistaken: as I said on the other thread, it’s not actually a negotiation.
In any case, what keeps the e.g. Canadian system popular more than anything else is the buy-in by the Canadian middle class and the concomitant awareness that many of them couldn’t afford the cost of care if they weren’t in the system. As we appear to see in MA (so far) is that large-scale buy-in creates support for further reforms.
I’m not saying that it isn’t a bad bill: it’s a terrible bill, as described. But who here thinks that any reform that drove down premiums in a serious manner would ever have passed in this Congress (yes, a (D) Congress)?
Mandos
But all this may be completely academic. It may not pass in any form any time soon.
Bolo
Question:
“The best thing about the bill is unquestionably the fact that insurers have to issue policies to anyone who can pay. No one can be denied coverage, no matter what pre-existing conditions they have. This is a big deal. ”
But does this mean that those of us with pre-existing conditions will still be paying through the nose for insurance? And that all that has changed is that we cannot be denied insurance? If whatever plan I’m offered costs me a couple thousand per month then it may as well not be offered. But then, will I have to purchase it anyway because of this bill and be forced to pay ridiculously high rates?
nihil obstet
Since many of those people didn’t buy insurance because they are right on the edge financially already it means that some of them will go without food, not be able to pay tuition, or lose their homes as a result.
I don’t think so. I think most of them will simply not buy insurance. The fine is less than the price of insurance. If you get sick, you can buy the insurance next year.
I remain fascinated by the enforcement mechanisms necessary when you adopt the uniquely American practice of using the legal penalties system to address social issues. Here, of course, the first issue is making people buy insurance. IRS is supposed to handle that. I wonder if the government will continue to divert IRS priorities from enforcing compliance by the rich to beating up of the poor, in the same manner that finding fraud among EITC recipients became the major goal of the agency. Why go after a guy who may owe the government millions, when you can get a single mother in poverty for the low three digits?
And of course, exactly how will the IRS work? Say you buy an insurance policy. Pay a month’s premiums. Drop the policy. Show the IRS the completed purchase contract. Will this become an audit issue, with the use of IRS time to determine whether there was a good reason for dropping the policy? Lots of this legal stuff assumes middle-class comfort with forms. Remember that about 10 million Americans don’t file taxes, and a third of those are owed refunds. People pay tax preparers to do their EZ 1040! So you’ve got a complicated program involving everybody to be enforced by an agency that hasn’t done too well recently.
And then there’s the incentive to minimize declared income. The large underground economy is likely to get a lot larger. If you work off the books to avoid FICA, you avoid some income tax and you’ll eventually collect less SS. If you work off the books with the health insurance mandate in place, you get to collect a subsidy for the insurance.
The whole control system is based on everyone being employed by large corporations that pay documented salaries. I don’t think our lawmakers understand how many people are outside that system.
And then there’s the other side. I buy the insurance. I use it in accordance with the contract, but the insurance company keeps rejecting the claim. The medical business sends a collection agency after me for the bill. Does this wonderful “health care reform” have any mechanism to see that the insurance company and/or the medical services providers comply with their contracts? Without such help, a lot of people will continue to be ripped off.
It strikes me as a very bad idea to pass laws which require action on everybody’s part which either require massive enforcement actions or allow blatant flauting.
tjfxh
The good:
1. A health care bill that passes in the House and Senate and is signed by POTUS would be an enormous symbolic victory in the quest for universal health care that Teddy Roosevelt began. A defeat of health care yet again would be an enormous victory for the opposition, which unfortunately includes both Republicans and Democrats.
2. Some people will be helped by this bill, if the final bill truly eliminates exclusion for pre-existing conditions.
The bad:
1. Everything else about it.
2. By swallowing this bill, progressives in the House signaled that they will accept just about anything that comes out of the reconciliation process, effectively destroying their negotiating power.
Do we even need to bring in a scale here?
But it really comes down to how much weight one assesses a symbolic victory versus an ignominious defeat. This is what the argument will be about among progressives.
Mandos
Yes, exactly. The big question is, what would have happened if the progressives in Congress (such as they are) had called the administration’s bluff? Would a better bill have even passed?
If no bill passed (ignominious defeat), then I’m still at a loss as to what would happen next.
nihil obstet
But it really comes down to how much weight one assesses a symbolic victory versus an ignominious defeat. This is what the argument will be about among progressives.
Any group whose argument is about symbolic victories and defeats richly deserves the marginalization that it’s assuring itself. Should the bill pass on the grounds that it does more good than harm and does not incur an opportunity cost for better policy. I’ve stated repeatedly in various places that the answer is no twice. Yes, it will help some people, but it will harm others. If you are one of the ones it will help, by all means support the bill. That’s what politics is all about. Otherwise, along with those who will be harmed, Kucinich lays out the reasons to oppose this bill.
If the bill is passed, I foresee cash-laden lobbyists will swarm the regulations process, making sure that it is even richer for the corporations. I don’t understand how progressive supporters of the bill think we can compete with the money, time, bodies, personal relationships and all the rest to get improvements made for us, yet I keep hearing about getting something, anything, passed so we can improve it. If the expense and deadliness of the current system can produce only this bill, what in the name of god do they think will lead to improvements?
If no bill is passed, I’m not at a loss as to what will happen next. Some people will curl up in the corner and say, “See, the failure of a bad bill means we can’t get anything, so let’s wait another 2o years.” For some of us, demonstrations and sit-ins continue. HR 676 or something like it is re-introduced. I think we can count on Kucinich for that. And then we fight for what we all should have been fighting for all along.
Bolo
“2. Some people will be helped by this bill, if the final bill truly eliminates exclusion for pre-existing conditions.”
But my question still remains: I had cancer in 2005 and, if I lose my insurance for more than 30 – 60 days, it will become a pre-existing condition. I understand that this legislation changes that and tells insurance companies that they must offer me a plan–no more pre-existing conditions. But will that plan be extremely expensive? And, due to other provisions in this bill, will I be forced to buy that plan?
Mandos
It didn’t happen the last time around, and even under the best conditions/policy, the Democrats are going to lose seats in the House. I mean, time will tell/would have told.
tjfxh
Pelosi was crazy to get herself in this box. The Democratic Party is now in the process of tearing itself apart, and soon the thing could start looking look like the Republican fiasco if the leadership doesn’t get a handle on it.
Ian Welsh
Jane has been good on NARAL, but FDL has been unwilling to admit that their bottom line, a robust public option, is no longer in any of the bills.
Cujo359
and a robust public option
I hadn’t really thought about this until very recently, but whenever I discussed the public option, I always used a word like “viable” to describe the version that would work. In retrospect, I think it was a mistake to try to use words like “strong” or “robust” to describe it, because that implies there’s an acceptable, but weaker or less fault-tolerant, version of it. “Viable” implies that anything less won’t work. I hadn’t even considered this before, but the reasons behind my word choice versus the commonly used one actually have some importance.
Anyway, one of those lessons for next time.
Jeff W
The symbolic victory might be more like a pyrrhic victory.
Kip Sullivan (of PNHP) makes the argument that roughly a trillion dollars per decade will go to the insurance industry (as subsidies designed to help people under a certain level pay for the insurance), if the public option is weak enough; “[a]n insurance industry strengthened by a trillion dollars per decade of new tax dollars will not only be in a better position to oppose single-payer legislation,” or, presumably, a stronger public option later.
Aside from that, I’ve thought that guaranteed issue, while definitely “the best thing about the bill,” as Ian says, will act as a ceiling, rather than a floor, to further reform efforts. (It’ll become a more sophisticated, less disingenuous version of “everyone can go to the emergency room.”) Any plan that purports to “cover everyone” (or 96%, say)-whether it, in fact, does or doesn’t and no matter how costly, byzantine, unfair or ineffective-acts as an impediment to further health care reform, in my view at least. (I hope I’m wrong.)
gtash
Just exactly where are those promises Obama claimed to have secured from corporate healthcare in the legislation? When folks upstairs ask “how much is my policy going to cost” , I wondered whether these so-called promises to reduce health care costs were written into the legislation or merely some kind of gentlemen’s agreement.
Anybody know?
tjfxh
gstash, the agreements were specific giveaways privately negotiated by the administration with the industry, and which the industry expected the administration to be able to deliver on. When those apparently didn’t materialize to the industry’s satisfaction, or were watered down in the final bills, then the agreement was considered broken and they went on the attack. If you want to see the bill the industry wanted, you need look no further than the GOP’s recent proposal.
tjfxh
The shit storm has already begun big time with women over the extension of abortion restrictions by the Stupid amendment. Claire McCaskill had to back down from a tweet about her position almost immediately, and over forty House Dems signed a statement that they would not vote for a reconciliation bill which extends abortion restrictions.
Lines are finally being drawn in the sand, it seems, and the establishment has added women to its opposition in addition to LGTB’s.
Ian Welsh
Robust and viable are two different things. At this point, however, it may not even be viable.
Jeff W
Ian is perhaps too modest to link back to his own post so I will: this one talks about what a public option needs to be viable.
Cujo359
I think his article was one of the things I had in mind when I was using the term “viable”. If the plan isn’t viable, it’s not worth doing. Calling it a “strong” or “robust” plan implies one can have a weaker one.
If it can’t make private insurers keep prices down and deal honestly with their customers, it’s not worth doing.
At this point it’s pretty clear there won’t be a viable plan. Based on that, I’d say the rest of the plan is in a similar state. Trusting this government to regulate the health insurance industry will be as hazardous as trusting it to regulate the banks and securities industries.
BDBlue
An interesting theory that one of the main goals of the “reform” is to stop poor people from seeking ER attention (even if they need it). Get out of my emergency room!
John J Sears
It’s also far too expensive for individuals. The subsidies in the House bill allow the cost of premiums alone to take up to 11% of your income, at the top of the income range for receiving any subsidy at all. The cap on out of pocket costs is 5k/10k for a family on top of THAT. The actuarial value is 70% for House plans I believe, and something like 60 for the Baucus bill.
So what you’re getting is an incredibly lousy piece of insurance at a very high price. 30% copay, effectively, though it might be a lot more or less for an individual depending on how the insuranace company structures costs.
11% of income plus a 10k annual fine if someone actually uses it for anything much more than the sniffles. The insurance companies get all THAT money plus the federal money for the subsidies, and the CBO says they’ll further optimize their profits by dumping sicker people onto the flimsy PO. It’s a mess.
DWCG
Umm, what is this Groundhog Day? Same song different dance.
And 1990 pages. Amazing. Why does it take so many words to produce something that is so simple.
If this big FAIL! had not passed I think someone sane would have stood up and said, “How about we let everyone who likes living under the thumb of parasitic mercenaries stay there, and allow open enrollment into Medicare for the rest of the people with a brain.”
By the way, can Medicare negotiate prescription drug prices or re-import Canadian drugs yet? Seems like everyone has totally forgotten about how Barry sold us down the river on something Democrats started from the fricking minority, but couldn’t get past the goal line with both houses of Congress and the White House.
Whole damn this is a cruel fucking joke. (Sorry Ian).
quixote
Brilliant post, great comments. Learned quite a bit from nihil obstet’s. Do you have a blog?
I notice that Bolo’s question about how much this guaranteed coverage will actually cost hasn’t been addressed (unless I missed it). As I understand it, the House (?) version allows insurance companies to raise their rates to 125% of current. I’m not sure of the time frame on that. I.e. whether that’s just for the first year and open-ended thereafter, or fixed at 125% of current forever.
Since the latter might eventually do people some good, I kind of suspect it’s the former.
And anyone who thinks handing Obama a symbolic victory is more important than ignominous defeat needs to think about how long the symbol will last. My guess is to Nov 2010. So for one year of fulsome bloviating we’re going to give a trillion dollars to the insurance industry?
That reminds me of the fairy story about the idiot son who goes to the market and trades the family ox for three sticks of firewood.
Mandos
And we’re back at square one. If it does anything approaching this, it won’t happen in this Congress. I’d like to see what the people who think HR676 had any chance were smoking. Can I have some of that?
Mandos
I don’t care about the symbolic victory. I for one would support the “No bill better than bad bill” position if I thought it were the case that no bill now would lead to a much better bill later.
Right now, here are the three future scenarios as I see it:
1. No bill: interpreted as defeat for Obama and Congress. Nothing happens on the health care front for another 20 years. System runs into the ground (who even knows what this looks like?).
2a. Bad bill: symbolic victory for Obama and Congress, but the system it generates really sucks, (R) president in 2012, even worse “reforms” implemented. System runs into the ground.
2b. Bad bill: symbolic victory for Obama and Congress, creates push for further reforms to close some of the gaps over the medium term. (ie, “small” parametric tweaks later on that make more people eligible for the public option, etc, etc)
In this arrangement, “no bill” has no upside. “Bad bill” has a big downside just as “no bill” does. But it has an upside. I’d personally rate the downside (2a) as being much more likely than (2b), but (2b) exists within the universe of political discourse in which we live (in that tiny parametric optimizations are still possible and susceptible to liberal lobbying—such as widening PO eligibility later on).
What liberal opponents of the reform are postulating is a scenario 1b:
1b. No bill: Obama and Congress learn big lesson, go back to drawing board, present something closer to single payer. The people rejoice!
I find it extremely difficult to believe that anyone actually thinks that this pollyannaish scenario could come to pass in the USA of today. But maybe someone has some evidence other than wishing really hard and can point me to it.
tjfxh
I’d say that Mandos has summed it up. Obama and the Congressional leadership allowed the Democrats to be backed into a corner by failing to lead. Now they’re all afraid of “failure,” and will contrive anything that that can pass reconciliation and still get the president’s signature. I”d say that’s just about anything entitled Health Care Reform unless progressives draw a line and are willing to kill a really bad bill. But they already caved on this one, so that’s unlikely. Only the opposition has the guts to kill health care reform outright when the public wants it.
In the meanwhile, they’ve punked the base and torn apart the party is the idiotic search for “bipartisanship” when the GOP signaled from the get-go that cooperation was off the table except on their terms. Good strategy, that.
Ian Welsh
I’d say 12 to 16 years, 8 if we’re really lucky.
They are? I’m not. And you’re commenting on my post. I expect nothing from Obama. What I am saying is that if you are willing to defeat the bill, Obama may compromise somewhat to get something, anything, through. He may not, I’m willing to live with that, since I don’t believe that screwing over the young and poor is acceptable because it will help another demographic group. Me, I live by the rule which says you don’t sell out one large part of your coalition to help another part of the coalition. (If it was a stable solution set for any length of time it would at least be understandable.)
I really don’t think people understand the economic situation the US is in. This is a giant corporate giveaway, not a health care plan, yet people keep treating it like it is health care. The US cannot afford this.
The stupid is tiresome, but apparently stupid done wrong is what most Americans, including far too many liberals, want.
They will enjoy the fruits of their stupidity, and their betrayal of their fellows will only save those lucky enough to die. Soon.
Badtux
Two words: Conference committee.
Once the bill comes back from the conference committee it gets one more up-or-down vote with no debate. We’ll have to see what comes out of the conference committee, and whether it is DOA.
As far as the basic construction of the plan is concerned, it is similar to the various European plans that we know work. On the other hand, those European nations also heavily regulate their health insurance sectors and prohibit profit-making on the basic issue plans, only allowing profit-making on supplemental care plans (those that provide coverage beyond the minimum required under the mandates). I haven’t looked at the final bill yet to see whether it still has the mandated minimum Medical Loss Ratio (i.e., maximum profit allowed to insurer) that the draft had, but in that respect it would turn health insurers into a regulated utility. Regulated utilities tend to be less efficient than government providers since they tend to view the allowed profit as a guaranteed profit and thus not worry about efficiency (they’re a monopoly, after all, why worry about efficiency?) but it’s still a preferable situation to the regulated utility being able to charge whatever they wished without any limit at all.
Mandos
They are? I’m not. And you’re commenting on my post.
I am also commenting at the tail-end of a comment thread with all kinds of people writing, and specifically responding to quixote. Please inform me if it is not appropriate to address the comments of others on the post.
I took quixote’s post as questioning the value of passing this particular variety of bills that you mention in your post. If quixote is doing so, I can only assume that s/he has some other path to reform in mind. I was outlining what liberal opposition to the bill as it stands actually implies. Which is that no bill now will lead to a better bill in due course.
This would make perfect sense if it were the case that there was a path to doing anything that didn’t involve this tradeoff. The reason is that the ceiling of reform is the profits of insurance companies. Insofar as that is considered to be at minimum invariant, any change is necessarily shuffling money from one constituency to another, by definition.
Then the argument becomes, once again, about the political value of systemic change in itself, as opposed to policy outcome improvements as none are presently possible.
But it’s clear on which side you come down. You would rather have no bill and wait for another political cycle entirely than have a bad bill. ie, I can only infer that you believe in scenario (1a). I would ordinarily agree with you if I were confident that at systemic breakdown, better policy options would emerge. I am not presently so confident, so I have to bet on scenario (2b). Some commenters on this thread seem to believe in scenario (1b), or so it seems to me: do we at least agree that this is misguided?
Mandos
The root of this is the mainstream economic consensus. Insofar as few opinion leaders in the world of economic policy are willing to discuss what is a crisis of overproduction in which the US worker is on the receiving end, it will remain very easy to convince middle-class America that prosperity is just around the corner, and only small changes are required.
I feel a little optimistic because I do see that some mainstream economists are lately willing to reconsider things that were once absolute iron-clad received wisdom, even though some of us have been yelling about this since way back when.
nihil obstet
quixote, thanks for your kind words. No blog — a lot of people do it better than I can, but it’s nice to know I’ve added something to the considerations.
Mandos, anybody who thinks that any bill has a better upside than no bill hasn’t paid attention to NAFTA (we can add labor and environmental protections later), welfare reform (we can add health care and child care later), credit card reform (we’ll cap usury rates at usurious levels), and TARP (we’ll get lending going again). I think the bad-bills-can-be-improved crew are the pollyannas.
Mandos
Badtux: At this point I am expecting DOA, because Lieberman has effectively declared it to be so in advance, and it’s very difficult to see what could be done to placate him except for he himself backing down. But then, who knows?
It’s interesting to hear of the Medical Loss Ratio. Is this truly the case? If insurance company profits are strictly capped, then we are approaching something similar to Switzerland. Hmm.
Mandos
nihil obstet: As a Canadian then living in Canada, I opposed NAFTA in principle way back when, for exactly that reason. The difference between NAFTA and health care was that there was very little downside to having no NAFTA at all at the time—at least as compared to the economy at the time, which was in (by comparison to now) in a small recession IIRC. The NAFTA argument at the time was simply based on the promise of MUCH greater prosperity than then extant.
On the other hand, there’s a big downside to the US health care status quo.
So the big question is actually the expected value of the size of that downside vs the probability of reform. After one sets appropriate thresholds, one comes up with the four scenarios I described above. I wish I had the time to draw a handy graphic.
Naturally I think that the most appropriate system for the USA is a single-payer health care system mandated by the federal government, and the complete extinction of Aetna, Cigna, KP, BCBS, etc, etc.
tjfxh
Hey, maybe the libertarians are right. So should we just give the industry its way, instead of giving it it its way and a trillion dollars too.
Just kidding, But, seriously, nothing much is going to happen without a huge populist revolt as long as bribery is legal and the revolving door is open. And there’s no telling which way a populist revolt would go.
Get the money out of politics and close the revolving door.
Obama said from the get-go that single payer was the best way to go. Why aren’t we doing it? $$$$ talks.
Scott R.
Stimulus in Disguise…,
I’ll give you two guarantees:
1. A “health care” bill will get passed.
2. It will include “mandatory coverage”.
Beyond that…, all bets are off. Many people asked why The Big O was intent on taking on health care reform when the nation was on the brink of economic collapse? Because…, it’s the only way he can pump another trillion stimulus dollars into the economy. The vast majority of that money will filter straight to Wall Street and The Banksters. And they won’t let it fail.
One more guarantee…, it won’t reduce health care costs. Mandatory auto insurance didn’t reduce auto insurance premiums…, and mandatory health care insurance won’t either.
This is economic stimulus in a very thin disguise.
joy
”’Since many of those people didn’t buy insurance because they are right on the edge financially already it means that some of them will go without food, not be able to pay tuition, or lose their homes as a result.’
I don’t think so. I think most of them will simply not buy insurance. The fine is less than the price of insurance. If you get sick, you can buy the insurance next year.”
Methinks you have never been poor, or even had to feel hungry.
When you cannot pay for both food AND rent, much less food AND rent AND medical care for even serious conditions, it’s not like you can either fork over five grand or ”just start paying for it next year.”
No. You’re just going to keep walking around with death inside of you, with cancer eating you alive, with a goiter the size of a baseball on your neck, with legs swollen to unrecognizable dimensions, with crippling pain from broken bones that were improperly reset by your family or by yourself, because you couldn’t afford to seek medical help.
Because it’s not like welfare is that easy to get — trust me, I know, I well qualify for almost every kind of public assistance and I’m still not getting any of it because so. many. others are in the same shape if not worse — and besides, think about it. If you CANNOT AFFORD HEALTH INSURANCE, it’s not like you’re going to just have a spare FIVE GRAND sitting around your house or in your possibly nonexistent bank account. And if it’s like that this year, it’s not like it’s going to be magically better next year. ESPECIALLY if you get sick.
Please, folks. It’s not a terribly hard concept to grasp.
nihil obstet
joy, it’s my impression that a person as poor as you describe will get Medicaid or subsidies. I was talking about the people who don’t quite qualify for serious subsidies but who currently have to juggle priorities, which will affect the food and housing budget but not leave you hungry or homeless. The concept of who gets the subsidies, who is denied care under the current bill, and the interaction of assistance is kind of a hard concept for me.