Elizabeth Drew on the state of US health care reform
February 16, 2010 8:03 AM   Subscribe

Is There Life in Health Care Reform? Elizabeth Drew analyzes the current prospects for US health care reform, in the New York Review of Books. Logically, there should still be a way to get a bill passed. But logic went out the window on January 19. The situation was as much psychodrama as legislative stalemate. The perfectly reasonable argument was made to Democrats in Congress, mainly by the administration, that, having voted for the bill already, it would be worse for them to fail to pass it than to pass it, but this seemed not to be heard.
posted by russilwvong (213 comments total) 5 users marked this as a favorite
 
The perfectly reasonable argument was made to Democrats in Congress, mainly by the administration, that, having voted for the bill already, it would be worse for them to fail to pass it than to pass it, but this seemed not to be heard.

Well, you know, they might lose out in the Midterm Musical Chairs game.
posted by Halloween Jack at 8:16 AM on February 16, 2010 [1 favorite]


To Democrats in Congress, "perfectly reasonable" is a synonym for "never going to happen".
posted by DU at 8:17 AM on February 16, 2010 [3 favorites]


The problem is, if they pass it then they might miss out on all those shiny mountains of newly-legalized corporate bribe money that the health care industry will be waving around.
posted by mullingitover at 8:20 AM on February 16, 2010 [5 favorites]


I don't think I've ever been as disheartened and disillusioned about (at least two branches of) our Government as I am right now.

destination: expatriation
posted by JeffK at 8:25 AM on February 16, 2010 [3 favorites]


As someone who is currently seriously studying the notion of leaving the U.S. in order to remain alive, because of the lack of affordable, reasonable health insurance coverage, I say take away the healthcare plans of ALL elected politicians. Let these scumbags know how it feels, to have to consider leaving my country in order to survive.
posted by dbiedny at 8:26 AM on February 16, 2010 [16 favorites]


Hey, the Republicans have a 41 vote majority in the Senate now. There's no possible way the Democratic minority of 59 can possibly stand up that sort of overwhelming Republican power. And anyway, Massachusetts failed to elect a truly awful Democratic candidate, so that means America hates health care reform.

Of course, when the Democrats were in a minority somehow, like magic, the filibuster just plain didn't count and somehow, like magic, none of Bush's priority policies could ever be stopped. But that's because there's different rules for Democrats and Republicans, I mean we can't expect our elected Democrats to actually get anything done. The only party that is ever allowed a victory is the Republicans, and every Democrat out there is dedicated to that shining principle.

Less sarcastically, I don't see any point in passing the abomination that the Senate shat out. It mandates that we give our private dollars to the insurance industry, it gives away a crapload of tax dollars to the insurance industry, yet it has no meaningful protections for us, no guarantee of actual coverage for anything. It's the biggest gift the government could possibly give to the insurance industry, as illustrated by the surge in insurance stock prices following the Senate's passage of their version.

I see no reason why the government should decree that the insurance industry is so sacred, holy, special, and all around great, that it must be guaranteed customers, profits, and success via force of law. We shouldn't be in the business of granting what amount to fiefdoms.

Let it die. The filibuster, Reid's cowardice, and Obama's lack of will to fight for it, killed anything worth passing a long time ago. The shambling zombie that is left is worse than the status quo.

If Reid had any balls he'd swear to end the filibuster for the next Congress and pass real reform then. But he doesn't, so he won't. Honestly, I don't think any of them actually want reform, Obama included. From the very outset this was intended to fail, and it has done its job well.
posted by sotonohito at 8:27 AM on February 16, 2010 [27 favorites]


to have to consider leaving my country in order to survive.

AMERICA: DIE FROM IT OR LEAVE IT!

BOO--YEAH!
posted by DU at 8:28 AM on February 16, 2010 [8 favorites]


Why is this in the Review of Books?
posted by graventy at 8:29 AM on February 16, 2010


Shouldn't the question be "was there ever life in healthcare reform?"
posted by Pollomacho at 8:30 AM on February 16, 2010 [2 favorites]


Next week. It'll happen. The whole purpose of the Health Care Summit is to show that the GOP has nothing. Which is true. Then "Plan C" as it is called here, will go into effect. First, the Senate will pass by reconciliation a set of of budgetary changes to put the bill closer to the House version. Then the House will pass the rest of the Senate bill entire. There has been an agreement in principle on this for some time now.

This has all been on TPM for weeks.
posted by Ironmouth at 8:36 AM on February 16, 2010 [7 favorites]


Why is this in the Review of Books?

Because they also publish reportage and extended essays, and Elizabeth Drew writes for them.
posted by OmieWise at 8:38 AM on February 16, 2010


Ironmouth, I'm confused, what do the bills that will actually make it through, perhaps next week even, have to do with actually reforming healthcare?
posted by Pollomacho at 8:40 AM on February 16, 2010


god i hope you're right ironmouth
posted by Kwine at 8:40 AM on February 16, 2010


DU : To Democrats in Congress, "perfectly reasonable" is a synonym for "never going to happen".

FTFY.
posted by pla at 8:42 AM on February 16, 2010


Hey, the Republicans have a 41 vote majority in the Senate now.

I'm constantly amused by how many people are blaming the Democrats for this mess.
posted by Brandon Blatcher at 8:48 AM on February 16, 2010 [1 favorite]


Ironmouth, I'm confused, what do the bills that will actually make it through, perhaps next week even, have to do with actually reforming healthcare?

By increasing cuts to medicare and by using excise taxes to reduce spending/coverage on private insurance, they will "bend the curve" and set the political stage for further cuts to medicare and social security in the name of deficit reduction, while preserving a "private" model of health-care for those who can still afford it and a subsidy to those on the low end which will get passed right through the health insurance industry as a broker.

also, there will be as of yet unspecified new laws regulating insurance which, because they will not change the basic business model of the industry, will either be either circumventable (by design) or window dressing.

there won't be any changes because to change the health care system would require an investment of money into what would be public health care infrastructure, and we don't invest in people in this country. i.e. it would cost money up front, not promise savings.

so, in short, better make friends with your parents because they're moving in and you'll be working to pay their doctor bills.
posted by ennui.bz at 8:51 AM on February 16, 2010 [4 favorites]


Ironmouth It'll be interesting to see if you are right. If so it demonstrates more spine than I thought the Democrats had.

I don't like the bill, and unless either the mandate goes away or something serious teeth in regulation are implemented I don't think I will like the bill. But it would be interesting to see the Democrats play hardball for a change.

I don't think it will happen, but I'll be pleasantly surprised if it does.

Of course, then we'll have to kill the monster of guaranteed business for the health insurance industry, and given the invulnerability of the military industry, the prisons industry, etc I don't see that ever happening. I don't think I'll be dancing in the streets if the Democrats do pass eternal profits for the health insurance industry. Still, anything but the constant stream of Republican victories with a minority would be nice.

Mind, it doesn't change the fact that on every other bill the Republicans will use their all powerful 41% majority in the Senate to kill any Democratic proposed bill. Nor the fact that I really don't expect any reform on the filibuster to pass come the next Congressional session.

Brandon Blatcher Reid was specifically instructed by Obama to give Lieberman everything he wanted, and not to try even mild arm twisting; basically it was Obama's giant upraised middle finger to the bulk of the Democrats, and especially to those of us who voted for him. Nelson, a nominal Democrat, did his absolute best to kill the bill. Then there's Stupak in the House, etc. The Republican bloc and its filibuster empowered those people, but in large part the reason this bill never passed and is so dreadful is because of the Democrats.
posted by sotonohito at 8:51 AM on February 16, 2010 [3 favorites]


Next week. It'll happen.

You do realize they've been saying that for six months now?
posted by enn at 8:52 AM on February 16, 2010 [4 favorites]


I'm constantly amused by how many people are blaming the Democrats for this mess.

This is largely because their whole response seems to be "But they'll filibuster! Waaahh!" Both parties are to blame here, for sure, but it really doesn't seem like the Dems are trying too hard.
posted by graventy at 8:53 AM on February 16, 2010 [2 favorites]


Shouldn't the question be "was there ever healthcare reform?"
posted by stormpooper at 8:53 AM on February 16, 2010


This congress is a joke, who whilst having the power to get things done just decided to remain stagnant. I sincerely wish that the majority would have said screw bipartisanship, we're going to get this done.

But they didn't. Senator Evan Bayh has the right idea:
"There is too much partisanship and not enough progress – too much narrow ideology and not enough practical problem-solving. Even at a time of enormous challenge, the peoples' business is not being done."
posted by deacon_blues at 8:57 AM on February 16, 2010


Democrats: Even when they win, they lose.
posted by dirigibleman at 8:57 AM on February 16, 2010 [3 favorites]


sotonohito : Less sarcastically, I don't see any point in passing the abomination that the Senate shat out.

This.

I firmly believe that we need some form of healthcare reform, whether going totally socialized, or outright banning health insurance, or simply exempting nonpalliative EOL care, or some other drastic change we haven't yet heard. But the crap Congress has suggested (and the House version doesn't look all that much better) amounts to a great big unlubed pitchfork up all our asses.

Now, I have no problem with the rich getting preferential treatment (and I say that as anything but) - Capitalism just works that way, he who can afford the best, gets the best. But medical technology has advanced to the point where we have no excuse as a society for failing to provide basic health care for everyone.

It doesn't take a genius to figure out that we have a problem when I (a fairly typical middle class American) pay over $4k/year for health insurance and haven't even seen a doctor in a decade, except one trip to the ER for an injury - A trip which I had to pay for out of pocket (and no, I didn't get reimbursed, but they "kindly" counted it toward my deductible). $40k thrown in the garbage, and then an extra $800 for a few inches of thread? Hey, I understand the idea of spreading the cost around, but c'mon guys, can we at least get something back for our input?
posted by pla at 8:58 AM on February 16, 2010 [1 favorite]


I'm constantly amused by how many people are blaming the Democrats for this mess.

It's like being bullied by a six year old. If the Democrats had even the barest functionality as a party, the Republicans would be powerless. The Congressional Democrats, however, are weak of constitution and have leadership; whereas the GOP members of Congress are afraid of their own party's whips and leadership and constituency, the Democrats are afraid of... the Republican Party. And so the GOP has remarkable power- not due to their numbers, or even due to their tactics, but simply due to the fact that the Democrats lack the will and the courage (and have been lacking these for many years) to act effectively.
posted by Pope Guilty at 9:01 AM on February 16, 2010 [9 favorites]


Responses like sotonohito's are the most frustrating of this whole process. When you say something like, "it has no meaningful protections for us, no guarantee of actual coverage for anything", it is clear that you don't know what you are talking about...but you insist on opining about it.

wtf?

Let me spell out what you get
1. You get to keep your insurance (protection)
2. You can't be denied coverage for pre-existing conditions (guarantee of coverage)
3. Your coverage won't be dropped if you get sick (guarantee of coverage)
4. No cap on coverage you can receive in any given year/lifetime (guarantee of coverage)
5. A cap on how much you can be charged (protection)
6. Required coverage for preventative care (guarantee of coverage)
7. Open/transparent market for those with no insurance (protection)
8. Tax credits to pay for #7 (guarantee of coverage)

There is more. What I don't get is what compels a person to try influence others when they are obviously unaware of that which they speak.
posted by Hypnotic Chick at 9:01 AM on February 16, 2010 [27 favorites]


Reid was specifically instructed by Obama to give Lieberman everything he wanted, and not to try even mild arm twisting; basically it was Obama's giant upraised middle finger to the bulk of the Democrats, and especially to those of us who voted for him.

So, the Republicans act like jackasses en masse and yet somehow Obama is giving you the middle finger? Ooook then.
posted by Brandon Blatcher at 9:03 AM on February 16, 2010


Incidentally, in case you missed it last week, Durbin (who stands an even chance of taking Reid's job when Reid loses this fall) is supporting filibuster reform.
posted by enn at 9:04 AM on February 16, 2010


I wrote to my congressman, Peter DeFazio (D-OR) imploring him to work on passing the Senate bill in the house.

The reply I got back seemed like pie-in-the-sky thinking. . .that the Senate bill was too flawed and let's start over and pass something better:

I believe we should begin to reclaim the healthcare debate by passing a smarter and more effective health reform plan. No more 2,000 page bills that are hard to explain to people in simple terms. We should put forward a series of proposals that will go at the heart of the abuses of the insurance industry. We should start with my provision, included in the original House health care bill, to end the antitrust exemptions of the health insurance industry. It would stop them from colluding to drive up prices and exclude people from coverage, and save people billions in premiums. It is simple to understand, effective, and it fits on one page. The next bill should prohibit insurance companies from refusing to insurance people with preexisting conditions. After that, we legislate a ban on dropping sick people off their plans because they are no longer "profitable". Finally, we should eliminate the annual and lifetime caps on coverage that are hidden in the fine print of many plans. I dare any Republican to vote against these common sense reforms.



After we pass these common sense reforms, we then need to return to a bill that includes a strong public option and a nationally regulated exchange. This will ensure that the uninsured and small businesses can choose, in an open and transparent way, affordable health insurance, whether it be a private plan, or the newly created public option.



The problem, of course, being that in this political climate, what he's talking about is impossible, and that he gets to hang on to his progressive cred and when nothing gets passed, he's noble and blameless.

I'll have a hard time voting for him ever again.
posted by Danf at 9:05 AM on February 16, 2010 [2 favorites]


I basically have two part-time jobs right now. The proceeds from one of them goes entirely into paying Blue Cross/Blue Shield for a shitty health insurance policy for me and my wife. BCBS paid out exactly $0 on us last year. They just raised my rates by 10%.

But I guess I should thank my lucky stars I'm not in California, where Wellpoint just raised the ransoms on their hostages' bodies by three times that much.
posted by vibrotronica at 9:05 AM on February 16, 2010 [1 favorite]


Senator Evan Bayh has the right idea

Bayh's idea is sound. His spouting that idea while on the way out the door because he was too much of a sniveling baby to stay and deal with the problems that he was elected to help solve was a massive fail. He could've said the same thing six or nine months ago and perhaps sparked a genuine and meaningful discussion. Instead he sat on his ass and said nothing.
posted by blucevalo at 9:06 AM on February 16, 2010 [3 favorites]


I'm constantly amused by how many people are blaming the Democrats for this mess.

I understand what you're getting at. On the other hand, when I look back over the history of this current, ongoing, trainwreck, I honestly DO come down to blaming the Dems for this mess. They had an unassailable majority. They had an extremely popular President. They had a public eager for affordable healthcare.

And yet, they successfully lost the initiative, lost the lead, let a couple of their more conservative members hold the process up to ransom, and simply lived-up to every damned stereotype of "Democratic leadership" you can imagine. It's almost as if the party leadership got together over drinks and drew-up a plan for utterly screwing-up every advantage they had in January '09.

As for the Republicans...They're just being Republicans. I'm pretty sure many of us predicted exactly how they were going to conduct themselves as soon as Obama took office, so you can't really put much of them blame for this mess on them. They're as predictable as clockwork and the Dems should have planned accordingly. Instead, at the first sign of Republican push-back, the Dems caved. Obama included. Predictably, the Republicans simply kept pushing-back. It's what they do. No one should be surprised. Certainly not the Dems.

No, I'm afraid the Democrats have only themselves to blame for their failure to enact meaningful healthcare reform. They had every possible advantage going-in and utterly failed to convert.
posted by Thorzdad at 9:11 AM on February 16, 2010 [12 favorites]


Next week. It'll happen

Okay, I'll trust you on this one, only because you work in d.c. and have a confident voice. If you're wrong, you owe me one huge-ass beer.
posted by Think_Long at 9:13 AM on February 16, 2010


But I guess I should thank my lucky stars I'm not in California, where Wellpoint just raised the ransoms on their hostages' bodies by three times that much.

Actually, it's 4 times as much. I say that not to be pedantic but to underline that 39% hikes on individual policies are nothing short of corporate power at its worst.
posted by blucevalo at 9:17 AM on February 16, 2010 [2 favorites]


The health insurance industry needs to diaf already. And please don't mandate my uninsured ass to pay for shitty insurance or face a fine--that doesn't help anyone except the insurance companies.

Single payer or gtfo!
posted by mandymanwasregistered at 9:17 AM on February 16, 2010


Thorzdad,

Why do you blame "the Democrats" instead of blaming Ben Nelson, Blanche Lincoln, Mary Landrieu, Joe Lieberman, Claire McCaskill, Kent Conrad, and Max Baucus? What leverage does an Al Franken (or even Obama) have in convincing these sniveling cowards to vote for/against anything?

By finding fault in the whole party, we give a pass to the real perpetrators here. By blaming the whole party, we set the stage for blanket cynicism instead of recognizing that this is falling apart because a few people with relatively little accountability decided that actually doing something might make them look bad in the news for a couple of days (the horror).
posted by Hypnotic Chick at 9:22 AM on February 16, 2010 [1 favorite]


As for the Republicans...They're just being Republicans.

That's exactly the attitude I'm talking about. People expect this sort of shit from Republicans and shrug their shoulders when they get it.

I'm not saying the Democrats are blameless, far from, but it's astonishing how much crap people get from the Republicans, to the point where they're arguing against reforms they championed, just for political points and yet Democrats are the problem? Sheesh.
posted by Brandon Blatcher at 9:25 AM on February 16, 2010


Why do you blame "the Democrats" instead of blaming Ben Nelson, Blanche Lincoln, Mary Landrieu, Joe Lieberman, Claire McCaskill, Kent Conrad, and Max Baucus? What leverage does an Al Franken (or even Obama) have in convincing these sniveling cowards to vote for/against anything?

What leverage does Obama have? Are you kidding? What leverage did Bush have to push through his tax cuts and every other large, small, and/or incoherent thing he wanted passed or implemented in his eight years in office?
posted by blucevalo at 9:26 AM on February 16, 2010 [2 favorites]


Why do you blame "the Democrats" instead of blaming Ben Nelson, Blanche Lincoln, Mary Landrieu, Joe Lieberman, Claire McCaskill, Kent Conrad, and Max Baucus? What leverage does an Al Franken (or even Obama) have in convincing these sniveling cowards to vote for/against anything?

I'm starting to feel like a bit of a broken record, but: eliminate the filibuster on the first day of a session of Congress with a simple majority vote and they can vote for whatever the hell they want and we'll still have healthcare.

Also, what leverage does Obama have? The ability to finance and promote primary opponents. The fact that neither he nor any other party head will ever, ever do this doesn't mean it's not an available option.
posted by enn at 9:28 AM on February 16, 2010


Hypnotic Chick : 1. You get to keep your insurance (protection)

...Which would have happened even in the complete absence of Congressional action, as long as I kept paying - A "choice" the current legislation would take away.


2. You can't be denied coverage for pre-existing conditions (guarantee of coverage)

Well, jolly good of them to include a nice-sounding clause made totally redundant by the individual mandate aspect of it (even today, as long as you have continuous coverage, preexisting conditions exemptions don't apply).


5. A cap on how much you can be charged (protection)
3. Your coverage won't be dropped if you get sick (guarantee of coverage)
4. No cap on coverage you can receive in any given year/lifetime (guarantee of coverage)


...At least, directly. They manage this by subsidizing the insurance companies through our taxes.


8. Tax credits to pay for #7 (guarantee of coverage)

AKA "give back a fraction of what they plan to take from us"


7. Open/transparent market for those with no insurance (protection)

Even the House version (the arguably better of the two) will leave an estimated 17M Americans without insurance. Unless that number drops to zero, all your "protections" and "guarantees" amount to nothing more than feelgood but unsubstantiated fluff.


What I don't get is what compels a person to try influence others when they are obviously unaware of that which they speak.

Who wants to convince anyone? Just calling a turd, a turd. I have no motivation to "convince" anyone on this matter, because our Congresscritters have made it blatantly obvious that that don't give two shakes of a rat's ass about what We The People think.
posted by pla at 9:31 AM on February 16, 2010 [1 favorite]


Why do you blame "the Democrats" instead of blaming Ben Nelson, Blanche Lincoln...

You're kidding, right? By laying the blame entirely on the small handful of cowards, you give a pass to the party leadership for not doing their jobs and slap the cowards down in order to get reform passed. Leadership could have dealt with the people you mention. But, once again, caved and let them bully the process into submission. Yes, the "party" is to blame for not acting as a unified group to marginalize/eliminate Nelson, Leiberman, et.al.
posted by Thorzdad at 9:32 AM on February 16, 2010


But, you know what, forget all the nitpicking about filibuster-proof majorities and who has leverage and the rest of it. You know why we blame the Democrats? Because they are in charge of everything and nothing is getting done. If that failure is due to forces beyond their control then there is really absolutely no point in doing anything political of any kind and the system is irredeemably fucked. So naturally politically-minded people are going to operate under the assumption that the Dems are doing something wrong because the alternative is there is no alternative.
posted by enn at 9:33 AM on February 16, 2010 [6 favorites]


By blaming the whole party, we set the stage for blanket cynicism instead of recognizing that this is falling apart because a few people with relatively little accountability decided that actually doing something might make them look bad in the news for a couple of days (the horror).

The people who should have held them accountable—Reid and Obama—failed to do so. You don't think they had any leverage over them? Why is Leiberman still the chairman of the Homeland Security Committee? He's not even a Democrat any more! Reid is incompetent, has been incompetent for years, and I will be happy when he loses.

That's exactly the attitude I'm talking about. People expect this sort of shit from Republicans and shrug their shoulders when they get it.

How much more can I hate Republicans? No more. How many more tools can the voters give the Democrats to fight the Republicans? None.
posted by vibrotronica at 9:33 AM on February 16, 2010 [1 favorite]


blucevalo

The leverage he had is the decades-long campaign to convince American that all taxes are evil. Furthermore, he didn't have the Democrats filibustering everything, not that it would have mattered because those tax cuts were done through reconciliation.
posted by Hypnotic Chick at 9:33 AM on February 16, 2010


Senator Evan Bayh has the right idea

Fuck Evan Bayh. He is just another DINO corporate whore who urges Democrats to "move to the center" so he and his wife can skim from both sides. His dad was ten times the man he'll ever be.

Partisanship is NOT the issue here. If you have a particular letter after your name, doesn't that indicate that you ARE a partisan? Supposedly, Democratics have one core set of government philosophies and Republicans have another. There is absolutely nothing wrong with that; in fact, the concept is that one side defends from the left, one side defends from the right, and compromise is hammered out. Compromise is the issue. Congressional adults have been gradually replaced with congressional children. This is the logical result of Newt Gingrich's "take no prisoners" philosophy - the "other side" has no legitimacy, so "we" aren't even going to play ball.

From a strategy standpoint: Republicans, as a group, understand that they are partisans - but they've willfully forgotten the "compromise at the end" part. Democrats, on the other hand, can't get the partisan idea down and insist on compromising before making their case. Either way, the citizens get the short end of the stick.
posted by Benny Andajetz at 9:33 AM on February 16, 2010 [9 favorites]


Yeah, blucevalo, look what Bush did to Social Security!

US Presidents have a lot of latitude in foreign policy (until it's time to ratify treaties); and a lot of freedom of movement when managing executive departments. They have less leverage pushing big domestic policy initiatives through Congress. The named Senators feel more pressure from their constituents (voters, contributors), than they feel from the President.

So. How might a President put more pressure on those reluctant Senators?
posted by notyou at 9:34 AM on February 16, 2010


Thorzdad and vibtronica,

"Leadership could have dealt with the people you mention"...How? By stripping them of their leadership positions? Once you do that, why would they vote for your agenda?

Actually, I'm serious about the question. I might be missing something here, but in my reading of this, there is no practical leverage Reid or Obama have.
posted by Hypnotic Chick at 9:37 AM on February 16, 2010


By stripping them of their leadership positions? Once you do that, why would they vote for your agenda?

They aren't going to vote for your agenda anyway, as they have proved over, and over, and over, and over again. But the next guy who walks by their metaphorical heads on spikes on his way into the office every morning might.
posted by enn at 9:39 AM on February 16, 2010


What leverage did Bush have to push through his tax cuts and every other large, small, and/or incoherent thing he wanted passed or implemented in his eight years in office?

This is the RINO effect: by pushing out of the party anybody who is not ideologically pure, the Republicans made for themselves a Congress which could easily be pushed to act because every member fundamentally agreed, save the odd Arlen Spector who was too popular with his district for DeLay, etc, to fuck him out of his seat. This worked remarkably well for awhile; Bush had a Republican Congress that agreed with him on every major issue, and so he was able to push through whatever he wanted not because he was pushing (although the Rove/Cheney White House did do a bit of that) but because most of the Republican majority agreed with him. Long term it's fucked the GOP pretty badly, as it's engendered massive resentment of the party among everyone outside of the fringe of the base, but as a short-term strategy, it was astoundingly effective. (Karl Rove's major failing as a political analyst was to underestimate the backlash potential and overestimate the size of his base.)

The Democrats are patently unwilling to respond to heterodoxy within the Democratic Party in any way; the party leadership does nothing to bring members around to party line positions and does nothing to twist arms other than the singularly soft touch of making pork concessions. Obama may have a greater party majority than Bush, but the number of reliable ideological allies that Bush had- a much more useful measure of a president's power in Congress- is tiny by comparison.
posted by Pope Guilty at 9:39 AM on February 16, 2010 [2 favorites]


even today, as long as you have continuous coverage, preexisting conditions exemptions don't apply

That's only true if your coverage is employer-based (or COBRA).

Not that it matters. All the "protections" offered by the healthcare bill require states to enforce. Ask California how well that works out.
posted by dirigibleman at 9:41 AM on February 16, 2010


The Democratic obstructionists are not even being asked to actually vote for the bill, only to vote to break the Republican filibuster.
posted by vibrotronica at 9:46 AM on February 16, 2010 [3 favorites]


Next week. It'll happen.

You do realize they've been saying that for six months now?


Yep. And they had everything in a row to get it done until the Mass. election. Now they are working it again. It will get passed, I'm pretty confident. The agreements in principle are already in place. You just have to follow the congress closely.

The Democrats are patently unwilling to respond to heterodoxy within the Democratic Party in any way; the party leadership does nothing to bring members around to party line positions and does nothing to twist arms other than the singularly soft touch of making pork concessions.

I'm always amazed at how the people who are cursing Obama for not getting things done are the first people to call "sellout" as soon as any concession is made. What exactly is your plan for arm-twisting? How exactly is that you are going to get it done?
posted by Ironmouth at 9:46 AM on February 16, 2010 [1 favorite]


The leverage he had is the decades-long campaign to convince American that all taxes are evil. Furthermore, he didn't have the Democrats filibustering everything

The leverage he had was party unity, the strength of his convictions, and the determination to prevail against heated opposition. Obama has not established that he is able to manage any of those. Blaming the minority party for filibustering and blocking as the source of the failure of your single central domestic priority as president when you have (or had, until the Massachusetts special election) a 60-seat majority is absurd. But that's what Obama and the Democrats have done.

So. How might a President put more pressure on those reluctant Senators?

Good question. But Obama has put almost zero pressure on them, so it's a moot point.
posted by blucevalo at 9:47 AM on February 16, 2010


Yep. And they had everything in a row to get it done until the Mass. election.

They had everything in a row for a long time before the Mass. election with nothing stopping them and they didn't do it. They're far less likely to do it now. They're going to drag it out until the midterms and then use that as their excuse when Scott Brown is too far in the past to be credible.
posted by enn at 9:52 AM on February 16, 2010


Good question. But Obama has put almost zero pressure on them, so it's a moot point.

We don't know what sorts of pressure a President can apply to reluctant Senators, but we do know the current President hasn't applied any.

How can we know the latter if we don't know the former?
posted by notyou at 9:53 AM on February 16, 2010


So then there are known unknowns, known knowns and unknown unknowns?
posted by electroboy at 9:54 AM on February 16, 2010 [1 favorite]


blucevalo,

Uh, dude, I am blaming the people I said I was blaming. In my response to your "but-Bush-did-it" post, I noted that the filibuster was not used as much during his administration but that it didn't matter because the Bush agenda was passed through reconciliation, something that is complicated for HCR.

For what it's worth, how do you know what pressure was put on Senate Democrats? If you know some inside stuff here, I am extremely interested.
posted by Hypnotic Chick at 9:57 AM on February 16, 2010


Hypnotic Chick wrote What leverage does an Al Franken (or even Obama) have in convincing these sniveling cowards to vote for/against anything?

The threat of revoking their chairmanships and memberships in various committees.

When a few liberal House members looked like they might do the right thing and oppose Obama's "let's go kill a lot more people in Afghanistan!" plan, Obama phoned them up and informed them that if they did he'd ensure they didn't get a single cent of DNC money, that he'd arrange primary challenges for them, offer his public support to those primary challengers, and in general do his utmost best to ensure that their political careers ended.

Somehow, when it came to a proposal that didn't enjoy massive right wing support Obama's willingness to play that sort of political hardball vanished. Funny.

4. No cap on coverage you can receive in any given year/lifetime (guarantee of coverage)

To the best of my knowledge this is not true, and the Senate bill (the one up for consideration) allows annual caps. In many ways an annual cap might be worse than a lifetime cap.

I also see nothing requiring that health insurance cover anything. Add in copays and deductibles sufficiently high, and the health insurance is wastepaper. Add in aggressive denials, and it's wastepaper. Unless specifically forbidden by regulations with real teeth, why wouldn't the health insurance industry, empowered by its new mandate, simply start eliminating anything it can get away with from coverage? "I'm sorry, but your insurance plan does not cover appendectomies."

The current plan, in essence, says "here insurance industry, everyone must now buy your product, you've got to sell it to them, but you can make what you sell to them as crappy as you want!"

Brandon Blatcher wrote So, the Republicans act like jackasses en masse and yet somehow Obama is giving you the middle finger? Ooook then.

They're the opposition party. I don't mean that in the parliamentary sense (though that's also what they essentially are), but rather in the sense that their entire reason for existence is to oppose. They don't have any plans of their own, they don't have any proposals of their own, they exist to oppose the Democrats and that's that. Yes, it sucks, yes it's bad that a large percentage of Americans keep going for them, but it's part of the basic structure of our political ecosystem, and has been for decades now.

Obama fought tooth and nail against the liberal members of the House for his escalation in Afghanistan, he gave the conservative members of the Senate everything they asked for when it came to HCR. That, to me, looks like a giant middle finger extended towards us liberals.

Obama has declared, in essence, that when it comes to working for conservative goals he will do everything in his power to get it done, but when it comes to liberal goals he will not only do nothing, but will actively do his best to ensure that the most reactionary and conservative members of the Democratic party get everything they want.

Coming into the current Congressional session the Democrats knew damn well they had 60 votes in the Senate , and that meant not that they could get everything htey wanted, but rather that they could be held hostage by a single Senator, and they knew one of their supposed votes came from Joe Lieberman. The same Joe Lieberman who actively campaigned for the Republican candidate for President. The same Joe Lieberman who has a giant chip on his shoulder following the successful primary challenge he underwent last time he was up for reelection.

The Democrats knew damn well the Republicans would vote as a block, and knowing this, knowing that it meant Joe "the traitor" Lieberman essentially had a veto on anything in the Senate, they didn't even try any reform.

Expecting Republicans not to oppose is simply foolish. Yes it's annoying as all get out, yes we should be doing our best to get rid of them, but they exist, they oppose, and that's that. You might as well expect a scorpion not to sting, or a snake not to bite. That the Democrats did not evolve a strategy to deal with this fact is a monumental failure on their part.

So, yeah, boo Republicans for being dicks, but bigger boo to Democrats for failing to take the known factor of Republican dickatude into consideration in their planning.

More to the point, we gave the Democrats everything we possibly could. We gave them the presidency, a 60 vote supermajority in the Senate, a giant majority in the House, a wildly popular president (in the beginning anyway), a Republican party with popularity in the gutter, and they still can't get shit done.

We gave the Democrats the most power they have enjoyed in a very long time, and they pissed it away. They're in charge, so yes, it is their fault. If a supermajority in the Senate, the presidency, and an overwhelming majority in the House aren't enough to let the Democrats get things done (especially when the Republicans did so much with less), then I think its time we just gave up.
posted by sotonohito at 10:03 AM on February 16, 2010 [7 favorites]


'm always amazed at how the people who are cursing Obama for not getting things done are the first people to call "sellout" as soon as any concession is made.

Hey, I'm not Joe Beese here. I voted for Obama expecting pretty much what we've got so far. You can try and use other peoples' dismay that Obama isn't the second coming of FDR as a rhetorical bludgeon, but you can't swing that thing at me.

What exactly is your plan for arm-twisting? How exactly is that you are going to get it done?

Don't give committees or pork to Democratic Congresscritters who won't play ball. Sponsor primary challengers to them. Remind them, ever so unsubtly, that their party funding is dependent upon them being part of the party. You know, the kind of things a political party does. The Democrats have decided to be a letter after names rather than a political party, and that means that the only real political party in the country- the Republican Party- wields a lot of power even with minority representation in the government.
posted by Pope Guilty at 10:04 AM on February 16, 2010 [4 favorites]


I die a little inside whenever I read a thread like this. There's just enough attention to the parliamentary sausage-making to distract attention from the substance of the bills, but not enough that the average commenter ever has her absurdly farcical preconceptions about the the US legislative process challenged. As a result, no one is forced to confront the ignorance from which her poor judgments extend.

Everybody who talks in generic anthropomorphic terms about the actions, characteristics, and intentions of political parties ought to be forced to take remedial political economy at interment camps for the willfully dumb.

Of course, the solution is to skip these threads, but in this, I am poisoned by optimism. Few people ever confront the endless desperation in that phrase, "Hope springs eternal," but let me tell you, it's a curse.
posted by anotherpanacea at 10:11 AM on February 16, 2010 [3 favorites]


The Democrats knew damn well the Republicans would vote as a block, and knowing this, knowing that it meant Joe "the traitor" Lieberman essentially had a veto on anything in the Senate, they didn't even try any reform.

I don't understand this line of argument. You admit that the Democrats only had 60 votes by making deals with the not quite a devil of Lieberman and the like, yet you still complain they made deals with him. Strange, IMO.
posted by Brandon Blatcher at 10:12 AM on February 16, 2010


>Re: Evan Bayh: His dad was ten times the man he'll ever be.

I don't know much about Birch Bayh but I do know he was in a 1964 plane crash along with Ted Kennedy and pulled Kennedy from the wreckage. That's pretty badass.
posted by ekroh at 10:16 AM on February 16, 2010 [4 favorites]


Brandon Blatcher You seem to be missing the point: they could have reformed the filibuster with 51 votes when the new Congress convened. Instead they chose to allow Joe Lieberman the veto over everything, knowing perfectly well that the Republicans would filibuster everything they could.

The current political situation was well known, the filibuster as the standard Republican tool for everything was well known, and if Lieberman's tendency towards betrayal and petty vengence isn't well known by the Democratic party leaders then they're brain dead. Yet knowing all this they did nothing coming into this Congressional session, and they had the ability to at least try.

If they'd tried filibuster reform and failed I'd be grumpy, but not as pissed off at the Democratic party as I am. I'd also have a list of people to work against, namely those who opposed the reform. But they didn't even try, which implies that they like the situation as it is and wanted to give Lieberman the veto.

More to the point: they've got a giant majority. We can't give them any more, pretty much literally we can't give them any more. Other than Brown, pretty much every other Republican in the Senate comes from a state where Jesus is thought of as the first coming of Sarah Palin. I don't see how it is physically possible for the Democrats to do better than 60 votes.

You tell me that somehow this is insufficient, that unless they have no opposition, unless they have 70, or maybe 80 votes, it just isn't reasonable to blame them for their failures. I'm not seeing the logic in that position.

If the Democrats can't get stuff done with a 60 vote majority, yet the Republicans could get their agenda rammed through with a 55 vote majority, I think it seems pretty damn safe to blame the Democrats for their own failures.

Question: when, in your opinion, do the Democrats become responsible for their own failures? How big a majority in the Senate does it take before you will agree that the Democrats have failed and that it isn't the fault of the Republicans?
posted by sotonohito at 10:22 AM on February 16, 2010 [1 favorite]


Rates were raised this time around to pay for lobbying efforts and research that proved what would happen if health reform went through as is.
posted by stormpooper at 10:26 AM on February 16, 2010


Yep. And they had everything in a row to get it done until the Mass. election. Now they are working it again. It will get passed, I'm pretty confident. The agreements in principle are already in place. You just have to follow the congress closely.

Calling bullshit on this one. I don't care what Talking Points or any other blog on the internet says about it. The healthcare reform proposals are radioactively unpopular outside of this thread and blogs like the one where you heard about the "agreement in principle." (Also, agreement in principle. In the House and Senate. That didn't give away the joke?)

If the Democrats adopt the legislation that required the Cornhusker Kickback and the Louisiana Purchase, and they decide to push it through by means of an arcane legislative procedure like reconciliation, then the Republicans will take back both houses this year. The Democrats understand that, even if Elizabeth Drew doesn't get it. That is why healthcare reform is done for now.

We'll see next week, though. The thread will still be open. Maybe I'll come back to eat my words. Be sure to call me out if I don't.
posted by Slap Factory at 10:35 AM on February 16, 2010


they could have reformed the filibuster with 51 votes when the new Congress convened.

I always see this trotted out, but the sentiment seems to ignore that political cost of doing so. Yes, they could have changed the rules, but all hell would have broken out, it's debatable whether the Senate had the will to do this.

As to the Democrats, they certainly could have done things better and much of this mess is their fault. I'm just saying that it's hard to get much done when you're in a three legged race and 1 or 2 of your legs is refusing to budge.

The Democrats have tried to get some health reform done and they get points for that, IMO. So at this point, I'm looking less at the leg that wants to move forward and more at the leg that doesn't.
posted by Brandon Blatcher at 10:36 AM on February 16, 2010


Since it's basically equivalent to giving up and never talking of the matter again does anyone arguing for starting over seriously believe in starting over?
posted by Artw at 10:43 AM on February 16, 2010


Of course, the solution is to skip these threads, but in this, I am poisoned by optimism. Few people ever confront the endless desperation in that phrase, "Hope springs eternal," but let me tell you, it's a curse.
posted by anotherpanacea at 1:11 PM on February 16 [+] [!]


Kind of eponysterical.
posted by Slap Factory at 10:50 AM on February 16, 2010


Sotonohito,

Pushing around House members (who run for office every two years!!!) is a lot easier than pushing around electorally-insulated Senators. The reality is, the holdup is in the Senate and citing House strong-arming tactics doesn't resolve the main problem I have with the comments here...HCR isn't failing because of "the Democrats", it is failing because a number of key Senators are willing it to fail.

To echo Ironmouth here, what would your plan be to extract votes from Nelson, Lincoln, etc.? If you threaten them with the loss of their leadership positions, do you really think they will fold? If they lose their positions, will they then have any inclination to vote for HCR?

What, in detail, is the arm-twisting tactic and how would it play out?
posted by Hypnotic Chick at 10:52 AM on February 16, 2010


Hypnotic Chick, how many times do we have to answer the same question until you stop ignoring our answers?
posted by vibrotronica at 10:55 AM on February 16, 2010 [2 favorites]


I apologize for shooting my mouth off and asserting that Bush had an uncontested path to victory on all (or even most) of his domestic priorities. One article on the subject states that he had a lot of success in his first year and diminishing returns throughout his first and second terms, with an overall success rate of 44.6% (contrast this with Clinton's 66% and Reagan's 52%).
posted by blucevalo at 10:58 AM on February 16, 2010


is a lot easier than pushing around electorally-insulated Senators.... To echo Ironmouth here, what would your plan be to extract votes from Nelson, Lincoln, etc.?

Nelson is up for re-election in two years. Lincoln is up for re-election this fall. Both of them are looking shaky and neither of them is remotely "electorally-insulated."
posted by enn at 11:02 AM on February 16, 2010


Hypnotic Chick I've got no idea, I'm not an expert on the Senate, its rules, nor on the Democratic party's specific rules in the Senate.

I do know that Bush rammed through stuff that was unpopular with many of his Senators.

I do know that Lieberman, after repeatedly stabbing us in the back, is still the chair of the Committee on Homeland Security and Governmental Affairs. I don't know if revoking his chairs, and kicking him off other committees would change his mind or not. I do know that no one has tried, and that Obama specifically instructed Reid not to try any strongarm tactics on Lieberman but rather to give him anything he asked for.

I don't demand success, but it would be really nice to see someone at least try something. But no, they don't even try. Frankly, now, with 41 real Republican votes you'd think it'd be time and past to give Lieberman the boot, to screw him ten ways from Sunday in vengeance for his multiple betrayals, to twist every Senate rule they can to abuse him. But no, the Democrats just keep right on pretending that Lieberman is their best buddy, leave him in a powerful committee chair (isn't there a real Democrat somewhere who is a little miffed that they're being fucked over on the Committee on Homeland Security and Governmental Affairs chair for Lieberman?) etc.

This tells me that they like losing, that they don't want to win, that they won't even try to win.

Brandon Blatcher wrote I always see this trotted out, but the sentiment seems to ignore that political cost of doing so. Yes, they could have changed the rules, but all hell would have broken out, it's debatable whether the Senate had the will to do this.

No, it isn't debatable, the Senate didn't have the will to do it, otherwise they would have.

A political cost for doing so? Bigger than the political cost of putting all the power in the hands of Lieberman and his ilk? Or are you arguing that the Democratic leadership is stupid that it was unable to recognize that Lieberman would betray them again?

Please though, do tell me when you will deign to permit us annoyed liberals to blame the Democratic party for its own failures. How many votes in the Senate does it take before you will admit that the Democratic party is failing? I'd like a hard number if you can provide one.

I'm just saying that it's hard to get much done when you're in a three legged race and 1 or 2 of your legs is refusing to budge.

Bush managed with a 55 vote majority in the Senate, why do you keep making excuses for the failure of the Democrats to accomplish things with a greater majority?
posted by sotonohito at 11:06 AM on February 16, 2010


If the Democrats adopt the legislation that required the Cornhusker Kickback and the Louisiana Purchase, and they decide to push it through by means of an arcane legislative procedure like reconciliation, then the Republicans will take back both houses this year. The Democrats understand that, even if Elizabeth Drew doesn't get it. That is why healthcare reform is done for now.

that's totally wrong. first off, this isn't 1994. Look at the way the GOP is acting. They don't want to lead. Usually when one party is going to take over, it starts controlling the agenda ahead of time. That's not happening here.

Instead the latest polling indicates the GOP is more hated than Dems.

The poll found that 51 percent of Americans now view the Democratic Party unfavorably, nearly matching the highest in the history of the Times/CBS News poll. At the same time, 57 percent have an unfavorable view of the Republican Party.

They are being torn apart by what they are going to be. Currently their right wing is trying to take over everything, despite being the cause for their decline. I think this is going to make them really weak.

Literally, Obama's focus has caused them to come out with their budget plan. It involves saving the tax cuts for those making over $250,000 a year by gutting social security and medicare. This ain't going to fly with Americans.

Have hope. This is a long, tough struggle and we need to be strong.
posted by Ironmouth at 11:07 AM on February 16, 2010


is a lot easier than pushing around electorally-insulated Senators.... To echo Ironmouth here, what would your plan be to extract votes from Nelson, Lincoln, etc.?

Nelson is up for re-election in two years. Lincoln is up for re-election this fall. Both of them are looking shaky and neither of them is remotely "electorally-insulated."


We are asking for the plan.
posted by Ironmouth at 11:08 AM on February 16, 2010


Currently their right wing is trying to take over everything, despite being the cause for their decline.

Citation for this statement.
posted by Pollomacho at 11:18 AM on February 16, 2010


vibro,

Let me be clear about what I mean. The main levers described above are the stripping of leadership positions and the removal of Democratic campaign support.

I contend that knocking these Senators from their positions is a non-starter. I don't feel as though a Democratic Senator would actually fear this because to actually follow through on this would all but ensure losing that Senator's support for HCR. To threaten and not follow through would reinforce the idea that Reid/Obama are not in a position of power.

In terms of campaign funds, I think that pulling away DSCC funds would have a minimal impact on someone intransigent like Lincoln.

What I am asking for is a point-by-point approach: Step 1. Reid does X. Step 2. Reid does Y. The reason is that as long as we keep talking about this vaguely, we never truly understand what is going on and I think that this breeds cynicism.

I am prepared to admit that I am not as knowledgeable as many on MeFi, and I open the question to anyone...what is the plan (in detail) to extract votes from these Democrats and how do they think it would play out?

enn,
I wasn't clear, I am sorry. The insulation I meant came from the amount of time that these Senators have to build up a war chest. I apologize for the misunderstanding.
posted by Hypnotic Chick at 11:26 AM on February 16, 2010


Well, jolly good of them to include a nice-sounding clause made totally redundant by the individual mandate aspect of it (even today, as long as you have continuous coverage, preexisting conditions exemptions don't apply).

Continuous group coverage. These portability protections don't apply to all plans, particularly individual plans. That means what you're talking about doesn't apply for the increasing number of Americans who aren't offered insurance by their employer, don't currently have an employer, or for most among the ranks of the self-employed. Which is to say that the clause you marked as redundant isn't.

They manage this by subsidizing the insurance companies through our taxes.

Among other things. It's important to understand that while the subsidies are a real part of the plan, they're not an end in themselves, they're a consequence of guaranteeing participation in "the" risk pool by mandate; the subsidies are for the portion of the population that would be financially unable to participate.

AKA "give back a fraction of what they plan to take from us"

The funny thing is that the existing private system would take what "they" plan to take from "us" eventually anyway. There's weak if any actual market forces operating on the consumer side in the insurance industry (much less health care) right now; insurers and providers are more or less price makers. And you think it's a bad idea to subsidize care for those who can't afford it? You'll pay for it anyway. You pay for it now when they don't pay the medical bills they can't afford and providers raise their prices to compensate. You pay for it increased costs across the entire economy in lost productivity from individuals that might otherwise make who knows what kinds of contributions. You'd pay for it in critical public health issues, but we still do a half-decent job of addressing those apart from insurance.

Exchanges, though, have the prospect of introducing some market power for consumers and some degree of further regulatory and possibly all-payer style pricing power for states/regions. Those kinds of changes alone have the possibility of curbing cost increases that are inevitable under the current private system.

Even the House version (the arguably better of the two) will leave an estimated 17M Americans without insurance.

I believe you're talking about the Baucus bill; I haven't seen specific figures like that attached to anything else, though you're welcome to cite.

Unless that number drops to zero, all your "protections" and "guarantees" amount to nothing more than feelgood but unsubstantiated fluff.

You're correct that unless that number drops to zero, our work isn't done, but in the context of a 50+% drop in the number of uninsured, saying this amounts to "nothing" is clearly nonsense.

What I don't get is what compels a person to try influence others when they are obviously unaware of that which they speak.

Perhaps you were making the rather human error of mistaking your own experience for the boundaries of reality when, for example, you incorrectly spoke up about the current irrelevancy of pre-existing conditions, but that mistake sure seems like a sign that you're only marginally familiar with the current state of affairs and the legislation under discussion yourself.
posted by weston at 11:39 AM on February 16, 2010


The main levers described above are the stripping of leadership positions and the removal of Democratic campaign support.

These levers work great for the Republicans when they're trying to enforce discipline in their party. Once again, we're not asking the obstructionist Democratic Senators to vote for the bill, we're just asking them to vote for cloture so we can have an up-or-down vote. How many times have you heard Harry Reid use the phrase "up-or-down vote"? How many times have you heard Obama use the phrase "up-or-down vote"?

I contend that knocking these Senators from their positions is a non-starter. I don't feel as though a Democratic Senator would actually fear this because to actually follow through on this would all but ensure losing that Senator's support for HCR.

That's because they know they have nothing to fear because they know that neither Obama nor Reid would even threaten them. There is no stick, only a carrot, and every time they're given a carrot, it's not big enough. You say you are afraid of losing these Senators' support on health care. Guess what? Your worst fear has already come to pass! Your approach has already produced failure.
posted by vibrotronica at 11:45 AM on February 16, 2010


I also see nothing requiring that health insurance cover anything. Add in copays and deductibles sufficiently high, and the health insurance is wastepaper. Add in aggressive denials, and it's wastepaper. Unless specifically forbidden by regulations with real teeth, why wouldn't the health insurance industry, empowered by its new mandate, simply start eliminating anything it can get away with from coverage? "I'm sorry, but your insurance plan does not cover appendectomies."

I think you're confusing the idea that the industry as a whole will be guaranteed customers with the idea that any individual company will be guaranteed customers. In fact, if we don't screw it up, under an exchange system, any individual company has less of a guarantee of customers than they do now. With no restrictions on pre-existing conditions, it'd actually be easier than for a consumer to switch from one insurer to another if the former drops coverage for something important. The individual consumer actually gains some power to vote with their wallet/feet without screwing themselves, and we might see something like an insurance market where if an insurer turns out to be crappy, people don't just stick it out because going somewhere else is difficult if not impossible.

Under that setup, the only way you're going to see insurers dropping appendectomies is if the entire industry colludes to do it all at once, and AFAIK, that's already illegal.

This isn't to say I think it's impossible for private industry to find some way to work the system. But it's far from a forgone conclusion that this amounts to a blank check to insurers to do whatever they like.
posted by weston at 12:01 PM on February 16, 2010


The main levers described above are the stripping of leadership positions and the removal of Democratic campaign support.

These levers work great for the Republicans when they're trying to enforce discipline in their party.


Could you cite a time when the Republicans threatened to strip a senator of their committee chair for not following something? Because I've never seen it. Ever.

What keeps them in line is the rabid, nut job GOP primary voters. If we play our cards right we can make them pay for that. The secret here is to push the GOP on unpopular votes. Because the more we show the GOP as the obstructionist fools they are, the easier it is for right wing dems to vote with the party.

Here's the other thing, Dems are tactically at somewhat of a disadvantage becasue they have seats in red and purple areas. Today's GOP is a southern, white, christian party. This means that we have more asses to cover, so to speak.

p.s. the Nelson buyoff is going to be cut in a separate amendment that the GOP can't filibuster. Because they complained about it, they aren't in a position to do that.
posted by Ironmouth at 12:04 PM on February 16, 2010


Here's the deal, we can't give up on this and the Dems aren't going to do it, because Obama isn't the type to fold.

We ought to follow the lead of General Grant. On the first day of the Battle of Shiloh, his forces were almost completely whipped when poor front line leadership nearly wiped them out. He had a conversation with General Sherman that night.

Sherman: "Well, Grant, we've had the devil's own day, haven't we?"
Grant: "Yes, Yes. Lick 'em tomorrow, though."

The GOP is wrong. The people do not support the policies they espouse. What's needed now is a little backbone and a little less complaining.
posted by Ironmouth at 12:11 PM on February 16, 2010 [2 favorites]


Could you cite a time when the Republicans threatened to strip a senator of their committee chair for not following something? Because I've never seen it. Ever.

From the article linked in the FPP:

"The Democrats believed that they had a deal with Thad Cochran of Mississippi, the senior Republican on the Defense Appropriations Committee and widely admired as a courtly and honorable man, to adopt some amendments he wanted to the defense bill; in return he would provide the sixtieth vote to shut off the filibuster on defense appropriations. (One Democrat was holding out on this vote.) But then the Senate Republican leaders, in particular the dour whip John Kyl of Arizona, leaned heavily on Cochran, telling him that the Republicans had to stick together and make the Democrats come up with their own sixty votes. "It was kind of an agonizing ordeal for me," Cochran told me later.

In some instances, Republicans who might shun the leaders' demands are given indications that their future committee assignments might be affected; and they can be made to feel very lonely in conference meetings. Cochran's Democratic colleagues watched in amazement as the last man they thought wouldn't keep his word quietly raised his hand to cast his vote (he couldn't even say it) against shutting off the filibuster on the defense bill, and quickly left the Senate floor. If the Republican leadership is willing to treat Cochran—who is third in seniority among Senate Republicans and would be chairman of the Appropriations Committee if the Republicans were in the majority—in this way, it's not hard to imagine how more junior members are treated."
posted by vibrotronica at 12:13 PM on February 16, 2010




Ironmouth wrote Here's the deal, we can't give up on this and the Dems aren't going to do it, because Obama isn't the type to fold.

Yeah, he just compromises everything away so the end result isn't worth supporting. There's a time to admit it was a miserable failure from the get go, and that time is now. The bill is simply not worth supporting.

It burns to let the Republicans win again, but the alternative is far worse. Maybe next time they'll get a real bill out there instead of a giant giveaway to the evil insurance companies like we got this time.

The plan from the very beginning was simply bad. Forcing Americans to purchase private insurance is simply a terrible idea. The US government should not be in the business of guaranteeing business for private enterprise. More to the point health insurance != health care. Right this second 80% of people declaring bankruptcy due to medical reasons have health insurance.

We've already seen Obama's "resolve" when it comes to regulating industry. It's nonexistent. Look at the banksters, they get their bailout, they get their bonuses, and they get no new regulations of any sort at all. We'll see the same thing here, the health insurance industry will get it's tax dollars, they'll get their government guaranteed victims, and the promised regulations will be ignored with impunity.

weston wrote This isn't to say I think it's impossible for private industry to find some way to work the system. But it's far from a forgone conclusion that this amounts to a blank check to insurers to do whatever they like.

Isn't it?

They already do pretty much whatever they like right now. Denials for care are routine, getting seriously sick is a virtual guarantee of bankruptcy, premiums are high, deductibles and copays are so high that even for us lucky enough to be insured going to the doctor is economically harmful, and even in a catastrophe you'll still have to bankrupt yourself.

That is the system you think it's OK to force all Americans to buy into? That's the system you think it's OK to shower with tax dollars?

They already screw us, how is forcing everyone to buy their worthless products going to fix anything?
posted by sotonohito at 12:39 PM on February 16, 2010 [1 favorite]


I also see nothing requiring that health insurance cover anything. Add in copays and deductibles sufficiently high, and the health insurance is wastepaper. Add in aggressive denials, and it's wastepaper. Unless specifically forbidden by regulations with real teeth, why wouldn't the health insurance industry, empowered by its new mandate, simply start eliminating anything it can get away with from coverage? "I'm sorry, but your insurance plan does not cover appendectomies."

I don't know where you're looking to get your information about the content of the bills, but this is really wrong. One really good source of information about what the House and Senate bills actually cover can be found using this KFF comparison tool. If you select a comparison of the "Senate bill" and "House bill" for "benefit design" and "changes to the private market," you can see exactly what each bill will do. Not surprisingly, the Senate bill is less progressive than the House on this front, but it's just wrong to say that there won't be any standards for what qualifies as health insurance. Namely:

*The Secretary of Health and Human Services will define a minimum benefits package that has an actuarial value of at least 60% (Senate) or 70% (House), and every insurance plan will be required to cover those services at a minimum. Past experience shows us that when states and the federal government define "minimum benefits," it has 100% of the time included inpatient surgery when medically necessary. It's literally inconceivable that the Secretary would create a minimum benefits package that didn't cover appendectomies.

*Health insurance products will be required to maintain a medical loss ratio of at least 85%; if the amount paid out to actual medical costs dips below 85%, the company will be required to refund the excess back to policyholders. (Note that this really creates an incentive for insurance companies to cover more, not less, as profits can only rise when the amount paid out in medical benefits also rises.)

*In order to participate in the exchange, products will have to conform to certain benefit packages. (Note that all of these will, by definition, provide equal or more coverage than the minimum benefits package.)


None of this is perfect but it's such an incredible improvement over the total lack of consumer protections that currently exist. I'm literally dumbfounded every time I make the mistake of coming into another metafilter thread on health care reform and see people flaunt their cynicism about how the whole thing is a waste of time and won't change anything (and then bitch about how the elected leaders of the Democratic party are tentative about passing the bill and blah blah blah "snatch defeat from the jaws of victory" and how does your brain not explode from cognitive dissonance here?)
posted by iminurmefi at 12:41 PM on February 16, 2010 [1 favorite]


Isn't it?

Yes. It isn't. In support of my assertion, I offered an argument as to why. Perhaps you have one in support of your rhetorical question.
posted by weston at 12:45 PM on February 16, 2010


The individual consumer actually gains some power to vote with their wallet/feet without screwing themselves

This isn't really true, though, for people who either (a) get insurance through their jobs, or (b) live in one of the many states in which one insurer has a de facto monopoly on individually-purchased insurance that is actually accepted anywhere in the state. One or both of these conditions is true of a huge majority in this country.

Under that setup, the only way you're going to see insurers dropping appendectomies is if the entire industry colludes to do it all at once, and AFAIK, that's already illegal.

My understanding is that the health insurance industry is exempted from antitrust law. Some versions of the current bill were going to eliminate that exemption but I think that elimination was amended away.
posted by enn at 12:49 PM on February 16, 2010 [1 favorite]


While these fuckwads (excuse me - honorable, distinguished, esteemed fuckwads) are fiddling - insurance companies are running around with torches setting fire to everything they can:

In California, Exhibit A in Debate on Insurance

An excerpt:

With health care negotiations stalled in Washington, the Obama administration is seizing on the seething fury felt by Mr. Punzet and nearly 700,000 other Anthem customers in California who have received notices of increases that average 25 percent. About a quarter of them are seeing leaps of 35 percent to 39 percent, the company said, at least four times the rate of medical inflation.[emphasis mine]
posted by Benny Andajetz at 1:02 PM on February 16, 2010


Could you cite a time when the Republicans threatened to strip a senator of their committee chair for not following something? Because I've never seen it. Ever.

I don't get this. Do you think that back-room armtwisting, dealmaking, etc. normally make it into public view? I have to ask because you seem like an insider or at least politically savvy, so it's weird to see you demand a cite to... what exactly? Some Senator's blog? "Boehner threatened to screw me if I don't fall in line on Bill XYZ and I told him to stuff that committee chair up his ass and I don't need the party's money. More after the jump"
posted by r_nebblesworthII at 1:06 PM on February 16, 2010 [2 favorites]


Could you cite a time when the Republicans threatened to strip a senator of their committee chair for not following something? Because I've never seen it. Ever.

OK, how about Chris Smith from New Jersey for example. In 2004 he voted against the Republican budget resolution and for the Democratic one because the Democrats' included more veterans' spending. He was rewarded by the GOP leadership by being pulled not just from his Chairmenship, but from the whole Veterans' Affairs Committee.
posted by Pollomacho at 1:50 PM on February 16, 2010


iminurmefi I'm willing to be convinced that I'm wrong. I do think that when the Senate passed its bill health industry stocks skyrocketed tends to indicate that we're going to get screwed.

I also have an ideological opposition to entrenching the health insurance industry with guaranteed customers. The government simply should not be guaranteeing customers to any private industry.

The Secretary of Health and Human Services will define a minimum benefits package that has an actuarial value of at least 60% (Senate) or 70% (House), and every insurance plan will be required to cover those services at a minimum.

I'm afraid I don't understand what that means. I googled "actuarial value", and after reading the first three entries I still don't really understand what it means.

"In other words, the actuarial value (using that definition) represents the portion of the total cost of covered benefits that are paid by a health insurance plan." - Townhall.

If I'm understanding this properly, that means the insurance would be required to pay for 60% of medically incurred expenses? So if I go to the hospital and the bill comes to $10,000 dollars the insurance would pay for $6,000 and I'd have to pay $4,000 out of pocket? Or am I misunderstanding?

If my understanding is correct, that sounds like a very bad deal indeed. Certainly not worth giving the insurance industry government guaranteed profits and customers.

Right this second 80% of people declaring bankruptcy for medical expenses have insurance. Under the Senate plan will people still be declaring bankruptcy because they get sick? If so, why should we be bothering with it?

Health insurance products will be required to maintain a medical loss ratio of at least 85%

Any amount of government guaranteed profit is too much. The government is not supposed to be giving private individuals guarantees of profits. I don't care if the plan decrees that insurance profits can never exceed half a percent, that's too much. It's a matter of principle.

Looking at your link it appears that the Senate plan does include a medicaid expansion, I'm pretty sure I'd heard that was eliminated as a favor to Nelson or Lieberman, apparently I was misinformed.

However, I do see (on page 8 of this PDF) that the "bronze" plan allows insurers to demand that the insured pay $5,950 (individual) or $11,900 (family) out of pocket before coverage actually kicks in. That's a little over 1/3 of the annual pre-tax income of a person working full time at minimum wage. This doesn't seem any better than being uninsured.

Even using the 400% of FPL discount (page 9), and bringing the out of pocket expense down to $1,983 doesn't seem much better for the poor. That's 7.6% of a minimum wage earner's pre-tax annual income. At minimum wage there isn't any cushion, an extra 7.6% taken out of your income means you starve.

I also don't see much of anything on what a plan must cover. Page 10 says that someone is to define a minimum benefits package, but what that package is, who that someone is, etc all seems quite vague. Will the person in charge of creating the package be able to receive "campaign contributions" from the insurance industry, or be appointed by people who receive such money? The latter, at least, seems incredibly likely, and I hope you'll excuse me if I say I don't hold out much hope that the minimum benefits package will cover much?

And, of course, it prohibits abortion coverage from being offered through the Exchange, even to people who want to pay extra. Joy.

I'm still not seeing anything worth granting the insurance industry eternal profits and a guaranteed customer base for.

As I said, I'm willing to be convinced, but looking at the link you provided, I can understand why insurance industry stocks went up when the Senate passed it. This looks like a great deal for them, and a raw deal for us.
posted by sotonohito at 1:54 PM on February 16, 2010


This isn't really true, though, for people who either (a) get insurance through their jobs

Yeah, I really dislike provisions that stipulate you're required to take what your employer offers, and I sometimes think I would prefer to see group plans disappear altogether if we're going to go with community rating. But I think this problem is somewhat mitigated by the fact that employers can and do switch insurers (this is one of the few ways in which the insurance market functions as such at all right now), and while employee and employer interests can diverge, they also coincide enough while the employee's useful to the employer that I think I can accept this, at least for a while, particularly if we're going to take steps that solve the biggest current problem of employer-related insurance, which is that you can lose coverage and even eligibility for coverage when you lose your job.

or (b) live in one of the many states in which one insurer has a de facto monopoly on individually-purchased insurance

If there are there really states in which there's essentially only one viable choice (not my experience, but I've only shopped in two states so my experience is limited), then yes, that's a problem. And in fact, it's a bigger problem than just introducing a lot of competition. Because on one hand, you want insurers with enough market power to negotiate prices with providers. Absent state involvement, they are one of the few significant downward pressures on prices. But on the other hand, you don't want insurers with enough market power to dictate premiums with consumers.

From what I understand, though, there is some state involvement in terms of price ranges and services as a condition of selling on the exchange, and I think that it's possible that some of the insurers who now only do group will be operating on the individual market with the policy changes, which should increase competition... if the market power on the provider side isn't so entrenched that only 1-2 powerful insurers can even negotiate effectively.

My understanding is that the health insurance industry is exempted from antitrust law.

This is a good point; it would mean that legal protections against collusion would be greatly reduced unless the exchange regulation somehow fixes that.
posted by weston at 1:59 PM on February 16, 2010


sotonohito: I also have an ideological opposition to entrenching the health insurance industry with guaranteed customers.

Paul Krugman explains how the components of the health care bill depend on each other:
... let me explain at fuller length, because this is one of the great misunderstood keys to the whole health care debate.

Start with the proposition that we don’t want our fellow citizens denied coverage because of preexisting conditions — which is a very popular position, so much so that even conservatives generally share it, or at least pretend to.

So why not just impose community rating — no discrimination based on medical history?

Well, the answer, backed up by lots of real-world experience, is that this leads to an adverse-selection death spiral: healthy people choose to go uninsured until they get sick, leading to a poor risk pool, leading to high premiums, leading even more healthy people dropping out.

So you have to back community rating up with an individual mandate: people must be required to purchase insurance even if they don’t currently think they need it.

But what if they can’t afford insurance? Well, you have to have subsidies that cover part of premiums for lower-income Americans.

In short, you end up with the health care bill that’s about to get enacted. There’s hardly anything arbitrary about the structure: once the decision was made to rely on private insurers rather than a single-payer system — and look, single-payer wasn’t going to happen — it had to be more or less what we’re getting. It wasn’t about ideology, or greediness, it was about making the thing work.
posted by russilwvong at 2:20 PM on February 16, 2010 [1 favorite]


I actually cut my little explanation of "actuarial value" from my comment because I was afraid it was a bit TMI and wandering. Guess I should have left it in! Actuarial value is basically a way to standardize health benefit packages, by measuring how much of an "average" person's health expenses would be covered. If you had gold-plated insurance that covered everything--basic check-ups, vision, dental, all prescription drugs--it would be rated at 100%. Nothing meets that standard, not even Medicare, nor any other country's universal health care that I'm aware of. Really great insurance through your employer will typically have an actuarial value of around 90% if you're with an HMO and around 80% if you're with a PPO.

60% is a really low standard. However, I think that people who are calling this bill "worthless" are not really aware of just how bad things are in terms of consumer protection right now. There are absolutely health "insurance" plans being sold now--including one that is hawked on my local channels at 5am, that I'm sure is eventually going to be shut down by the state insurance department once someone photogenic enough dies in a spectacular enough fashion to merit a newspaper story--that don't even come close to 60%, that don't really cover anything. Against the backdrop of the system as it exists now, a 60% (or, God willing, 70%) minimum actuarial value for anything sold as insurance is a huge, huge victory in terms of protecting consumers. Same with the caps on out-of-pocket expenses; yes, $10K for a family is well north of what I think is ideal, but it's infinitely better than the current situation, where many people with individual insurance have no cap at all.

Right this second 80% of people declaring bankruptcy for medical expenses have insurance. Under the Senate plan will people still be declaring bankruptcy because they get sick? If so, why should we be bothering with it?

Because suffering a catastrophic medical problem and ending up bankrupt is not the worst thing that happens in the current system. The reason that most people who end up in medical bankruptcy have insurance is because those who don't have insurance generally don't get treated at all. If you get cancer and don't have insurance, and you're not lucky enough to be poor AND in a category eligible for Medicaid (that's *only* pregnant women, children, parents of young children, and the disabled) then you're screwed. Nobody is going to be giving you chemotherapy and sending you the bill; they'll just wait until you're sick enough to cycle through the ER on your way to die. That's the worst case scenario, that's what happens now to those who can't buy insurance (either because they get turned down or because they don't have enough money), and that's what this bill is going to fix.

This legislation not only vastly expands Medicaid to cover a huge swath of very poor people who don't currently qualify (namely, poor adults who are not disabled nor pregnant)--which by itself makes it one of the most progressive pieces of health legislation passed in DECADES--but also makes sure that everyone at least has a decent enough policy to at least get in the door to get treated. I understand people being frustrated that it doesn't go far enough (I agree, I'd prefer something more generous for subsidies and smaller out-of-pocket limits for low-income people), I understand being pissed at insurance companies and not wanting them to do well, but opposing claiming to be progressive yet opposing this bill feels like a whole lot of letting-the-perfect-be-the-enemy-of-the-good (it doesn't include the public option!) mixed with cutting-off-nose-to-spite-your-face (screw insurers!).
posted by iminurmefi at 2:23 PM on February 16, 2010 [2 favorites]


russilwvong Then it shouldn't be undertaken.

I do not think the government should be mandating that people do business with any private organization, period. If that means the insane plan of getting everyone health insurance, as opposed to health care, can't be implemented, well, I never was keen on giving everyone insurance instead of care.

I like and respect Krugman as an economist. He knows his stuff, and I'm sure he is correct in that the mandate is critical to the very bad plan. But the critical part is "once the decision was made to rely on private insurers rather than a single-payer system", that decision was the wrong decision.

We've already got a couple of industries that have unofficial guarantees of profits, prisons and military contractors. Those unofficial guarantees of profits and customers are causing both economic and social harm. Do you think it is a coincidence that the USA has both private, for profit, prisons and one of the highest incarceration rates on the planet? Do you think that will ever change?

The last thing we need is to add a third industry with guaranteed profits and customers and make it official.

Guaranteeing profits and customers for any industry both a terrible idea and morally wrong. If that means we don't get a full package of health care reform, so be it. Some things are not worth the price.

iminurmefi wrote letting-the-perfect-be-the-enemy-of-the-good (it doesn't include the public option!)

The public option was, from my POV, not a nice little feelgood progressive measure, but the only thing that made the mandates even remotely tolerable. It provided an out, a way for people to not be forced by the government to buy services from private enterprise by allowing them to buy from the government instead.

Without that this bill is nothing but a way to establish, by force of law, that the health insurance industry has guaranteed profits and customers. Even if I didn't dislike the health insurance industry, even if they were nice and kind and everything a liberal type like me wants to see in a corporation, I'd still be opposed. Without some sort of out that allows us to not be forced to give money to private enterprise, the plan is simply unacceptable.

The USA has already granted far too much power to corporations. Giving them guaranteed profits and customers is so wrong I have a hard time coming up with ways to describe how wrong it is. It's eating kittens level wrong.

Nobody is going to be giving you chemotherapy and sending you the bill; they'll just wait until you're sick enough to cycle through the ER on your way to die.

And how does having worthless insurance change that? You can't pay the copay, or whatever they want to call it, isn't that the same as not being able to pay without insurance?

Even if, and I think it sounds unlikely given past performance of the health insurance industry, a failure to meet the copy doesn't mean you get rejected for treatment, we still see every major illness resulting in economic ruin for the victim.

For that you want me to give up one of my core principles and give my support to granting eternal profits and customers to an industry? It isn't worth it.

Not to go into hyperbole, but this is the path to fascism. "Fascism should more properly be called corporatism because it is the merger of state and corporate power." - Benito Mussolini. Merging state and corporate power is so dangerous to my way of thinking that there must be overwhelming need to do so, or overwhelming benefits from doing so. I see neither overwhelming need nor overwhelming benefits here. If this plan gave everyone health care that doesn't result in bankruptcy or financial hardship I could, with extreme reluctance, go along. But it doesn't, so I can't.
posted by sotonohito at 2:51 PM on February 16, 2010 [1 favorite]


As for the Republicans...They're just being Republicans.

No. They're not the republicans of the eighties and nineties before.
The 60 vote majority on EVERY SINGLE FUCKING PIECE OF LEGISLATION INCLUDING LAST WEEKS JOBS BILL is a new thing.

They're not the Lee Atwater Republicans of yore that me and other leftists despised. They are something worse. They are something evil.

I've concluded that health care is dead, mostly because I don't think I can stand to get my hopes again.

However, on climate change -- boy. Now there is something I think could justify the second revolution, to borrow the language of the crazies.

Because if legislation to control emissions is torn about by these evil fuckers, I will be ready to go to war.
posted by angrycat at 2:52 PM on February 16, 2010 [2 favorites]


Without that this bill is nothing but a way to establish, by force of law, that the health insurance industry has guaranteed profits and customers.

I understand your distaste at this, but the alternative is the current system, where people are literally dying for lack of care. Do you believe that if this bill goes down, we're going to see a successful push for a single-payer system? If your answer is no (and much as I might wish the answer was yes, I can't see any path by which this would occur), then hoping this bill doesn't pass is basically saying your ideological principles are more important than ameliorating the real pain and suffering that happens, and will continue to happen, under the current system.

I dunno. I'm pretty close to this, because I study the health care system and its failures as my job, and maybe seeing all the ways that safety net doesn't exist for such a huge portion of the population makes me view this legislation with more hope than is warranted. But I sort of think that too many people on metafilter have good jobs (whether freelancing or working for the health-insurance-providing-man) and decent insurance or at least what they believe to be good insurance, having never suffered the sort of catastrophe that would test it, and that makes them too willing to hold tight to ideals at the expense of making real, concrete improvements in millions of people's lives.
posted by iminurmefi at 3:15 PM on February 16, 2010 [1 favorite]


No. They're not the republicans of the eighties and nineties before.

Yeah, we get it, but the nineties were, you know, ten years ago. For how long is this fact going to continue to take the Democrats by surprise every single time?
posted by enn at 3:16 PM on February 16, 2010 [1 favorite]


Would it be possible for Democrats to give money to a Republican candidate in an election and not put a Democrat in that election?

I still see Republicans as the major problem, since most Democrats are ready and willing to vote for the bill. But the Republicans seem tied together, so I wonder if there's any way to peel off several of them to get them to vote.

Or is the GOP just so far gone, that its members actually believe the crap they're spouting?
posted by Brandon Blatcher at 3:42 PM on February 16, 2010


Guaranteeing profits and customers for any industry both a terrible idea and morally wrong.

Why?
posted by weston at 3:42 PM on February 16, 2010


I stand by what I said. It seems like the very people pissed that this bill isn't done yet are the same people opposed to any dealmaking or compromise to get it done. I don't understand how people think things in Congress get done.
posted by Ironmouth at 5:04 PM on February 16, 2010


I understand your distaste at this, but the alternative is the current system, where people are literally dying for lack of care.

sotonohito's point is that this bill will not change that, that unless the terms of policies sold by insurance companies are dictated to those companies by the government, they're just going to create the same shitty, worthless policies that Wal-Mart employees get- high copay, heavy restrictions on where you can go and who you can see- which give the illusion of coverage but are no better than the current system of not getting care until you end up in the ER with something horrible that could've been prevented- and treated much more cheaply- by the regular checkups and treatment afforded by good insurance.

This is not a flaw of this health care reform- this is a problem caused by the very existence of corporate health insurance firms. Being forced to purchase worthless coverage from them by the government so that we can dishonestly claim that everybody has coverage is an act of war on the lower class, and is made monstrous by the fact that it will be used to argue that health coverage is no longer a problem.
posted by Pope Guilty at 5:14 PM on February 16, 2010


Why?
posted by weston at 3:42 PM on February 16

Because it excuses both illegal and unethical conduct, and it ensures that the benefit to the society and the captive audience of "customers" will be quickly be nothing.
posted by Optimus Chyme at 5:16 PM on February 16, 2010


I stand by what I said. It seems like the very people pissed that this bill isn't done yet are the same people opposed to any dealmaking or compromise to get it done. I don't understand how people think things in Congress get done.

I agree with you in principle, but once you're done cutting the white stuff off the edge of a steak, you're cutting meat. What these guys are left with at this point is nothing but the bone.
posted by Pollomacho at 5:41 PM on February 16, 2010


sotonohito's point is that this bill will not change that, that unless the terms of policies sold by insurance companies are dictated to those companies by the government, they're just going to create the same shitty, worthless policies that Wal-Mart employees get

With all due respect to sotonohito, who strikes me as a generally smart guy, it appears that people who hold this view (that the current bill doesn't change the status quo) are all the same people who are making factually incorrect statements about what the legislation actually does. I find that really depressing, because mefites are generally an intelligent and well-read bunch, and but it seems like every thread about health care reform has become a fact-free zone where people can show off their cynicism.

As weston pointed out, as I've pointed out, as many of the excellent sources that are covering the nitty-gritty details of health reform legislation have pointed out, "the terms of the policies sold by insurance companies [being] dictated to those companies by the government" is exactly what will happen. That's not something that's tangential to the legislation, it's one of the major functions of the health insurance exchanges. You could easily have an individual mandate and guaranteed issue without an exchange; the only reason to implement an exchange is to standardize the benefit package (i.e., dictate the terms of the policies sold) and regulate the companies that sell it. That handy-dandy link I provided above is a good place to start if you're interested in what those regulations will entail and how those standardized benefit packages will be decided.
posted by iminurmefi at 6:28 PM on February 16, 2010 [1 favorite]


> Hey, the Republicans have a 41 vote majority in the Senate now. There's no possible
> way the Democratic minority of 59 can possibly stand up that sort of overwhelming
> Republican power.

So many people seem to be confused about the real exsistence of of an entity called "the Democrats." Tip O'Neill, who knew more about Democratic politics than any other sentient being in the universe, said "In any other country the Democrats would be five parties."

The true state of things is easier to imagine if you think of the Republicans having 41 Senators and the other 59 divvied up five ways (11.8 Senators per party) And those five parties arrayed along a spectrum from moderately right of center to moderately left without anything in particular to bind them together. If the US had a parliamentary-style system, the current government would be a very rickety coalition on the point of imploding whenever any major player in the coalition has a bad hair day.
posted by jfuller at 7:22 PM on February 16, 2010 [2 favorites]


PS I can see by the misspellings and garbled syntax that it's 'way past bedtime. Good night all. (But the point stands.)
posted by jfuller at 7:33 PM on February 16, 2010


i wonder how many of those leftists who argue that the bill at hand is a bunch of crap are in a situation where they have no health care and really need it (i.e., they are sick).

this is sorta an asshole rhetorical question, but i really am curious.
posted by angrycat at 7:36 PM on February 16, 2010


I'm no American, but here are a few things that stand out to me:

a) HCR as a principle is popular, but HCR in its details is quite unpopular. Whether this is justified or not is a different question altogether; the fact is, of all Americans who have insurance, a majority apparently like the plans they get from their employer-sponsored policies.

b) HCR has always been tough. There was a New Yorker article that pointed out that stories of HCR being "round the corner" were being published way back in 1910's.

c) Republican obstructionism aside, there's a significant opposition within the Democrats as well for HCR. Again, whether it's justified or not is a different question (I do believe it is unjustified, self-serving and lazy), but that's the reality here.

d) Team Obama's main problem isn't intent or implementation; I mean, let's face it, they've based their whole plank of governance and deficit-reduction for the next 10 or so years on healthcare. Without reforming healthcare, Obama's agenda (climate change, financial reform, jobs growth) simply can't move forward.

Obama's main problem is much more delicate, it's legitimacy; unlike JFK or Johnson, people simply don't equate his stances with "liberalism" as such. In the long run, no policy-position or ideology is ever stagnant; that is to say, values ("caring for the poor", "personal responsibility" etc) may be immutable, but how you interpret those in specific scenarios keeps changing from generation to generation. Obama's interpretation of liberal values simply doesn't carry the weight of legitimacy that previous Democratic presidents had; this is where the whole question of "experience" etc comes into play.

Why is this important? Basically, if he had that legitimacy, senators / congresspeople, you really wouldn't need all this arm-twisting/pork nonsense; no Democrat would want to be seen as opposing the Big Man himself.

It's a bit of a chicken-and-egg thing for Obama now; to get that legitimacy, he needs big victories. To get those big victories though, he needs legitimacy. Which is why you'll see him doing splashy things like a HCR summit, high-speed rail and nuclear plants in the immediate short-term.

And oh, finally, any good-faith attempt at HCR is a net good thing now. I don't think non-Americans realize how bad it is in the US; a friend's visit to the doctor for stomachache, where she got prescribed paracetamol, costed her $300. It'd be less S$20 or less in these parts; and mind you, that in itself is considered expensive compared to other middle-income Asian countries like Malaysia or Thailand.
posted by the cydonian at 7:45 PM on February 16, 2010


i wonder how many of those leftists who argue that the bill at hand is a bunch of crap are in a situation where they have no health care and really need it (i.e., they are sick).

this is sorta an asshole rhetorical question, but i really am curious.


I can't afford to visit a doctor and have pretty much gotten used to putting up with illnesses, aches, and pains. There's a bunch of little things that really should get looked at, because I'm afraid they're going to get nasty over time, and my strategy on those occasions when I get really sick... well, all I can do is drink fluids and hope it goes away. It's probably going to be another couple of years until I can get health insurance, so anything that's wrong now has that much time to get worse before I'll be able to have it dealt with.

Sorry for not giving you the answer you wanted to take as read.
posted by Pope Guilty at 7:51 PM on February 16, 2010


PG, the "really am curious" meant I really was curious. Maybe I should have said, "I know this may come off as assholish, but"

And so NOW I'll say, "I know this may come off as assholish, but:
When I say sick, wasn't talkin' about "little things that really should get looked at," unless one of those little things is a malignant, soon to be gigantic tumor.
posted by angrycat at 8:09 PM on February 16, 2010


(PG, and here's hoping that none of your little things become serious things. really).
posted by angrycat at 8:17 PM on February 16, 2010


Angrycat, both of my parents are currently being treated for cancer.
posted by vibrotronica at 8:20 PM on February 16, 2010


When I say sick, wasn't talkin' about "little things that really should get looked at," unless one of those little things is a malignant, soon to be gigantic tumor.

How about a broken finger?
posted by fuq at 8:27 PM on February 16, 2010


How much medical care does a person have to be in need of and unable to acquire before their opposition to this bill is valid?
posted by Pope Guilty at 8:38 PM on February 16, 2010 [1 favorite]


But then again, even though I totally, 100% believe it is wrong to force people to buy a private corporation's products, especially an industry as odious as the health insurance industry, at this point, I'll take what I can get.
posted by vibrotronica at 8:47 PM on February 16, 2010


PG: I'm not trying to impose standards. I'm just saying, I don't think that a person either in good health, or a person with good or poor health that has health insurance, will understand the horrors of being in poor health and without health insurance.

So you know where I"m coming from on this. I have a few chronic and severe conditions that eliminate mobility and bring about sometimes quite severe pain.

I'm also a hardcore leftist. I worked legal aid before I broke my back, and saw a lot of poor and sick people in that practice. I don't know, had I not broken my back, if I would have know just how horrifying it is to be pretty sick (for the sake of argument, let's say the standard for that means chronic with severe symptoms and or life threatening, offer your own if you'd like) and w/o insurance.

At one time I was sick, as defined above, had left my legal aid job, and because I was stupid I didn't apply for SSD right away, and when my benefits from my job ran out, I had no coverage until Medicare kicked in.

as a former legal aid attorney i knew how bad hospitals that take Medicaid can be (as opposed to N.Y.U., say -- in the NYC region. I also knew it through personal experience that hospitals differ largely in quality -- Cabrini sucked balls, while NYU was pretty good. I had to be hospitalized without delay, and my condition was life threatening. I was admitted to NYU, as my mom paid the COBRA (that I couldn't afford, cause this was a thousand a month. This was four years ago, remember. It was a sweet policy I had; it allowed me to stay in NYU and have my surgery done by one of the finest plastic surgeons in Manhattan.

Now I have Medicare. HCR affects me in two ways 1) It would allow me to get off of SSD and work for a greater pay/apply for higher positions. Which I really would like to do, although my current gig is a fun one 2) If it in fact somehow destroys Medicare, then I'll be proper fucked.
The second is Betsie McCaughy's arugment, and for that reason alone I'm pretty not too sure.

PG, I'm not really fuckin with you. I just think that we all have a dog in this fight, all of us, and if we don't acknowledge it, I think that's wrong. That's all I'm sayin.
posted by angrycat at 9:26 PM on February 16, 2010


I'm absolutely sympathetic to you angrycat. I just don't expect it to allow anybody who can't already afford healthcare to acquire it. What about the bill do you expect to help you?
posted by Pope Guilty at 2:14 AM on February 17, 2010


Ironmouth wrote I stand by what I said. It seems like the very people pissed that this bill isn't done yet are the same people opposed to any dealmaking or compromise to get it done. I don't understand how people think things in Congress get done.

If that's what you think, I don't think you've been paying much attention.

We started from a bad position. Even if single payer was never a realistic possibility (and I'll agree it wasn't), we should have started there simply to shift the Overton window. Republicans do this all the time, they stake out a position that is impossible to achieve and much further to the right than is generally acceptable simply to start pushing things their way. But nevermind the metapolitics, I think everyone understands that Joe Lieberman and his evil cronies won't let us have real reform and I don't think anyone is bewailing the fact that this isn't single payer.

Point is that we've been compromising from the beginning. The public option was a compromise, the medicare buyin was a compromise, the exchanges, the co ops, every single thing that has been stripped out of the bill was a compromise.

The problem, Ironmouth, is not that us on the left don't understand compromise or dealmaking, the problem is that eventually all that compromise reaches a point where the end result isn't acceptable.

If this bill contained ANYTHING that let us escape corporate domination I'd accept it, I wouldn't like it but I understand compromise. It doesn't though. Now that all the compromises have been made what is left is a bill that says "the health insurance industry is guaranteed profits and customers until the end of time, it is now criminal to refuse to do business with these people". You've got to have principles and hard lines, or compromise becomes nothing but surrender. And when the bill became a matter of all corporate all the time, it crossed my line. Obviously it didn't cross yours.

But please don't strawman me. The problem is not that I don't understand compromise, but that there comes a time when too much has been given by my side, and nothing has been given by the other side, and I see the result not as a compromise, but as surrender and getting something that just plain isn't worth the price.

I've also got a question, did all that compromise, all that kissing of Republican ass, get us one single Republican vote?
posted by sotonohito at 4:04 AM on February 17, 2010 [2 favorites]


Pope Guilty, I expect the bill to be helpful insofar as I could purchase health insurance with the help of a subsidy. Right now I'm hanging onto SSD/Medicare with gritted teeth -- I'll lose it if I earn over $980 a month. Because the job I want and am qualified to do -- adjunct faculty -- doesn't come with health insurance, I can't apply for those jobs, as I would lose SSD/Medicare but be too poor to buy a policy on my own.
posted by angrycat at 5:18 AM on February 17, 2010


iminurmefi wrote Do you believe that if this bill goes down, we're going to see a successful push for a single-payer system?

Of course not. If the Dems couldn't push it through with 60 theoretical votes there's no way they can do the job with 59 theoretical votes.

But I expect that we won't have taken one more step into a bad future.

At this point I'm pretty much flipping between actual despair and worry, and concern that I'm overreacting and simply not seeing things clearly.

My objections here go beyond any single piece of legislation and more into the general pattern of what has been happening to my nation since I first became politically aware. I am, quite simply, worried about fascism and every indicator I can see warns me that we're moving that direction. I don't mean that in the hippie "the man is fascist!" stupid sense of the word, I mean it in the actual political philosophy sense of the word. Like Sinclair Lewis said, fascism, if it does come to America, will be draped in the flag and carrying a cross.

Corporatism is an integral part of fascism, in fact I'd argue that corporatism is the primary distinguishing characteristic between fascism and communism (other than rhetoric and claimed goals). Ever since Clinton the Democrats have been embracing corporatism as an under the radar way of getting social programs in; it gives them cover against the inevitable right wing shrieks about socialism. It can't be socialism if it makes CEO's happy, right? The problem is that pollutes the government.

Weston asked why I think it is morally wrong to merge the state and the corporate spheres. The answer is that it grants governmental authority to agencies that aren't restrained by governmental bonds. A corporation exists for the sole purpose of producing maximum profit, that isn't necessarily a bad thing, but it is a thing that needs restraint imposed from the outside. By making corporations a de facto part of the government, granting them the power of the state without the restraints that exist on the state, it produces yet another vehicle for authoritarianism. It is this point which is my major break with Libertarianism.

It also produces social problems. Look, for example, at the rise of private prisons and the associated rise in incarceration rates. I do not think it is coincidental that as the profits of a pseudo-governmental corporate group became tied to incarceration rates we started seeing higher incarceration rates. I don't think there are any evil CEO's plotting to increase prison sentences and gleefully rubbing their hands together or any of that cartoon stuff. But more people in prison means more profits for the private prisons, they'd literally be derelict in their duty to their shareholders if they didn't work to maximize the duration of prison sentences and the number of incarcerated individuals.

Prisons and the military industrial complex aren't even officially part of the government, they aren't guaranteed profits and customers, yet they are so deeply embedded that I do wonder if we can ever get them out. This bill proposes to openly and officially give the health insurance industry a guaranteed revenue stream.

The only restraints on the industry will be what few regulations are in place in the bill right this second, I don't see any other regulations ever being implemented so long as the filibuster remains and I don't see the filibuster ever being removed. Lieberman and his ilk won't allow either new regulations or filibuster reform. Worse, regulations are only as good as the agency enforcing them. You think the Republicans, and the industry owned Democrats, will fully fund any regulatory agency? If that isn't already delegated to the states, which all have budget crises, it will be soon. You think Mississippi is going to effectively police the insurance industry?

California gives us an example of how effective the regulation will be. They have a law against rescission, and yet California insurance companies regularly cut people off from their coverage. How do they get away with it? Easy, the agency that is supposed to enforce the law has no funding, the companies have attack lawyers on staff, etc. Result, despite its theoretically illegality rescission is commonplace in California. What makes you think the regulations in the Senate bill will fare any better?

Given the new revenue from all the unwilling "customers" this bill would grant them and all the tax money being given to them as a gift, coupled with the new decision that corporate speech is protected, do you really think the insurance industry can't successfully lobby to prevent themselves from ever being effectively policed?

I'm not just seeing this bill in a vacuum, though I do think it is objectionable purely in its own merits.

All this ties in with other things that make me very nervous. Tazering is on the rise, and other than a few DFH's everyone seems to think it's either hilarious or nothing to worry about. Asset forfeiture is on the rise. The Tea Party is on the rise. Our president has decreed that he won't prosecute anyone for torture. Cheney is on national TV openly admitting to criminal conspiracy, fully secure in the knowledge that he will never face a trial. Obama has declared that he can simply toss anyone he wants to in a cage, for life, without trials, charges, evidence, or anything but his personal whim. Worse, he's declared that he has the authority to order American citizens assassinated by the CIA on nothing more than presidential whim.

Corporate power is more firmly embedded than ever, the bailout went exclusively to the people who caused the problem, there are no new regulations and there won't be. I don't think the outlook for new banking regulations looked good prior to the 41 vote Republican majority, but now I think any banking reform is completely impossible.

I don't know if I'm just bitter at policy losses, or if I have genuine if overblown worries, or if my worries are valid. But I am frightened. I don't know if I'm paranoid, or if I'm right to be frightened, but I am.

I am, among other things, a historian and I've studied the history of fascism. It tends to arise rather quickly, after a longer period of build up and dormancy. Much of what is happening in the USA right now looks very much like the sort of build up period that preceded past successful fascist movements. Especially the growing corporate power.

I don't think Obama is sitting in the Oval Office plotting to help the build up to fascism, heck I'm not even really sure if my worries about fascism are legitimate. I think he's got a bipartisan reflex that is suicidal, I think he's far too enamored of the Clinton era "third way", and I think he just plain doesn't think corporatism is a bad idea. The problem is I can't convince myself that my worries are truly unfounded, and that quite unintentionally Obama isn't helping to lay the groundwork for future fascism.

It sucks that people don't have health care. My father died because it was cheaper to tell him that his back pain was a pulled muscle than to tell him it was bone cancer. He didn't have insurance, and they did exactly what you described, put him off until he cycled through the emergency room to the crematorium.

But I don't see this bill really helping. If a person can't pay the 40% the Senate bill mandates, do you really think any hospital will take them until its time for the ER to cemetary cycle?

What I'm saying is that it looks like the Senate bill that is part of a very troubling pattern, and that I have serious doubts will address any real problems. Yes, I oppose it. If I saw it really helping I could maybe suppress my worries and get on board, but I don't. As it stands, in this bill, the only thing standing between the insurance industry and their customers is regulation we know from prior experience will be toothless, unenforced, and all around worthless. Without some way out of the corporate or nothing trap this bill is just plain not worth it.

If there were a public option, or a medicare buyin, or anything that offered a way out of the corporate dominated health insurance system I could go with the bill. But there isn't, and those things are simply non-negotiable to my way of thinking. Without some way to avoid giving corporations all that power, I see this bill as another step down the road to fascism. I don't know if I'm right to think that way or not, and I'd love to be convinced that I'm not. But I'm coming increasingly to the conclusion that I am right, and that my fears are valid.
posted by sotonohito at 9:09 AM on February 17, 2010 [6 favorites]


sotonohito: If there were a public option, or a medicare buyin, or anything that offered a way out of the corporate dominated health insurance system I could go with the bill. But there isn't, and those things are simply non-negotiable to my way of thinking. Without some way to avoid giving corporations all that power, I see this bill as another step down the road to fascism. I don't know if I'm right to think that way or not, and I'd love to be convinced that I'm not. But I'm coming increasingly to the conclusion that I am right, and that my fears are valid.

Against this, I would argue that the power imbalance between corporations and employees is strongly reinforced by the fact that people worried about losing their jobs are also worried about losing their health insurance (as we frequently see on AskMe). As the cost of health care and health insurance escalates, this factor will become stronger and stronger.

A Canadian-style single-payer health care system would remove this entirely as a factor. The Massachusetts-style community-rating/individual-mandate/subsidies system on the table isn't going to be as effective, but it's far better than the rapidly deteriorating status quo.

If you're concerned about the potential rise of fascism in the US, and if you've studied fascism in other countries, you probably know that it's closely tied to a widespread feeling of personal insecurity and downward mobility (which makes it easier to recruit people into extremist movements; see Eric Hoffer's The True Believer). As health costs continue to rise, this is going to get worse and worse.

My understanding of the US political system (which looks so dysfunctional to outsiders) is that it's deliberately set up to make it difficult to enact major changes. The Senate, with its disproportionate weighting for small states, is particularly difficult to get past. Given this reality, I think the Senate bill is about as good a result as you're going to be able to force through the US political system.

With everything that's at stake, my own guess is that the bill will pass (pretty much as Ironmouth predicts). But it's still possible that it may fail--elected politicians in the US are very reluctant to defy voters, and right now public opinion appears to be leaning against the bill. There probably won't be an opportunity to tackle health care reform again for another 10 or 20 years.

I really think you ought to reconsider your stance on this issue.
posted by russilwvong at 2:07 PM on February 17, 2010


You haven't really made an argument against sotonohito's position, russilwvong.
posted by Pope Guilty at 2:34 PM on February 17, 2010


My argument is that if sotonohito is concerned about fascism, the status quo is encouraging it; the reform on the table would discourage it.
posted by russilwvong at 2:37 PM on February 17, 2010 [1 favorite]


Right, but you haven't actually substantiated that the reform bill would actually done that; you've just said "well this is better than nothing" without actually demonstrating that it is. sotonohito's argument is that for several reasons the reform bill is worse than nothing, and refutation must provide counters to those reasons, not simply handwave them.
posted by Pope Guilty at 2:39 PM on February 17, 2010


Has requiring auto insurance advanced fascism as well?
posted by electroboy at 2:45 PM on February 17, 2010


--you've just said "well this is better than nothing" without actually demonstrating that it is.

In terms of giving people access to health care, it is. I'm not trying to directly counter sotonohito's concern about the bill increasing the power of the insurance companies with respect to the government; I'm pointing out that the bill will increase the power of employees with respect to employers, by giving them better access to health care if they lose their jobs.

But to pick up one thread:

Weston asked why I think it is morally wrong to merge the state and the corporate spheres. The answer is that it grants governmental authority to agencies that aren't restrained by governmental bonds. A corporation exists for the sole purpose of producing maximum profit, that isn't necessarily a bad thing, but it is a thing that needs restraint imposed from the outside. By making corporations a de facto part of the government, granting them the power of the state without the restraints that exist on the state, it produces yet another vehicle for authoritarianism.

That hasn't been our experience in Canada. We have what are called "Crown corporations" that run things like the electrical generation and distribution system (BC Hydro) and auto insurance (ICBC). Our political history here has been exactly the reverse of what sotonohito is describing: the left wing supports the Crown corporations, the right wing tries to privatize them.

I believe it was Hans Morgenthau who pointed out that as corporations have become vastly larger and more powerful over the course of the 20th century, government is the only force that's capable of providing a balance of power. If the regulatory agencies are too weak to be effective (which was certainly the explicit aim of the Bush administration; see Barton Gellman's Angler), the answer is to strengthen them by providing more funding.
posted by russilwvong at 3:16 PM on February 17, 2010


electroboy wrote Has requiring auto insurance advanced fascism as well?

Other than laws declaring a one party state or similar things no single law taken in a vacuum can be said to be advancing fascism. It's the pattern that matters, the effect of many laws taken together.

As for auto insurance specifically, I do object to those laws, and I do think they helped set the stage for the similar very bad idea for health insurance. Now that those laws are considered perfectly acceptable people, like you, can point to them as a justification for mandating that people buy health insurance. I don't think the auto insurance laws were passed with that intention, but they have had that effect.

If the state wishes people to have auto insurance, and an argument can be made that this is a valid thing for the state to want, then from my POV the only legitimate way the state can enact that wish is to provide auto insurance to everyone and raise taxes to cover that expense. Obviously the private auto insurance industry isn't going to be happy about that, and I can understand how they'd object. But I think that's the only legitimate way for the state to insist everyone have auto insurance.

russilwvong wrote If you're concerned about the potential rise of fascism in the US, and if you've studied fascism in other countries, you probably know that it's closely tied to a widespread feeling of personal insecurity and downward mobility (which makes it easier to recruit people into extremist movements; see Eric Hoffer's The True Believer). As health costs continue to rise, this is going to get worse and worse.

You are, of course, quite correct about the influence of economic woes on the rise of fascism. I'm fairly sure that American conservative leaders are deliberately working to eradicate the middle class, not necessarily out of a desire to enact fascism, but out of their dedication to working exclusively to advance the interests of the upper 1%. That this sort of economic problem can give rise to fascist movements is something that seems to disturb many of the conservative leaders.

Still, I don't see the Senate bill helping matters much. The line for subsidies is so low that it will impose a significant financial hardship on many of the working poor, and the mandated minimum insurance covers 60% of medical expenses, which means any significant medical problems will still result in utter economic ruin for most people.

I agree completely that freeing people from dependence on employer provided insurance is an extremely good idea. I agree that medical expenses are a major worry for many Americans and increase economic difficulties.

Where I disagree is with the idea that this bill will do much of anything to solve, or even relieve, either problem.

My argument is that if sotonohito is concerned about fascism, the status quo is encouraging it; the reform on the table would discourage it.

I must disagree with the latter part of that assessment. There is no doubt that the status quo is encouraging the risk of fascism. What I don't agree with is that this bill will help things.

We have what are called "Crown corporations" that run things like the electrical generation and distribution system (BC Hydro) and auto insurance (ICBC).

From a quick look at Wikipedia it appears that those are wholly owned by the government, and thus pretty much de facto non-profit yes? Please correct me if I'm wrong.

If my understanding is correct that's pretty much the polar opposite of my concerns about corporatism. In the case of health insurance, the government would have no ownership, but rather would simply use the full force of law to mandate that individuals purchase goods from a private corporation.

If the regulatory agencies are too weak to be effective (which was certainly the explicit aim of the Bush administration; see Barton Gellman's Angler), the answer is to strengthen them by providing more funding.

Yeah, that's the problem. The Republican party, as explicitly stated in their party platform, is opposed to any and all regulation as a matter of principle. Funding has to get through the Senate, the Republicans have 41 votes and can filibuster anything. Ergo there won't be any funding, nor will there be any tightened regulations when (not if, when) the insurance industry finds lots of fun loopholes in the Senate bill.

Which is why I'm opposed to the bill unless it has an escape clause that allows people out of the world of corporate health insurance. A public option, or the medicare buyin, or any of those would provide for non-regulatory controls on the industry, if they got too bad they'd go out of business because their customers would flee to the government provided services.

As a general rule I prefer non-regulatory controls simply because they're less subject to loopholes, abuse, etc. "I cut, you choose" is the goal we should be seeking, no outside entity has to enforce fairness in that situation.

Given the explicit goal of dismantling any and all regulation expressed by the Republican party, and that party's over representation, and the filibuster, I think it is safe to discount regulation as an effective means of preventing the newly empowered insurance industry from abusing people.

Unlike Crown Corporations this proposes to give governmental power to corporations without any governmental control or restraint. That's a very bad idea, and a big step on the road to fascism.

weston In addition to my long term, and possibly completely unfounded, concerns about fascism, there are other reasons to oppose granting corporations guarantees of eternal profits and customers.

Doing so is essentially the creation of an aristocracy. It says "anyone who owns stock in company X is guaranteed profits", which seems no different from the practice in the bad old days of monarchy of the king granting revenues from various taxes and whatnot to people on his whim. "I like you Bob, you'll get the taxes from whatever by way of illustrating how much I like you. Enjoy your life of guaranteed wealth and no work ever again!"

Why should our government be telling various stockowners that they are so great, so special, so amazing, that they get guaranteed profits and are exempt from risk, labor, or anything but a government guaranteed life of luxury? That's precisely what the aristocracy of old was, and I think you'll agree it is a bad idea to enact a similar system today. Even assuming that my worries about creeping fascism are completely groundless, which they may be and frankly I still don't know how legitimate my concerns are, establishing an aristocracy seems like too high a price to pay for the very minimal reform the Senate bill enacts.
posted by sotonohito at 6:49 AM on February 18, 2010


The other issue is that it is absolutely critical to get this shit right on the first go; given the cowardice of the Democratic party and the open maliciousness of the Republican party, there will not be another bill to fix the inevitable problems with this one for many, many years.
posted by Pope Guilty at 8:39 AM on February 18, 2010


sotonohito: I agree completely that freeing people from dependence on employer provided insurance is an extremely good idea. I agree that medical expenses are a major worry for many Americans and increase economic difficulties.

Where I disagree is with the idea that this bill will do much of anything to solve, or even relieve, either problem.


Paul Krugman's been discussing this at length on his blog. Effects of the Senate bill on health care premiums for a family of four at 175% of the federal poverty line, 275%, 375%, 425%. Subsidies for a family of four at different income levels.
Krugman also notes that the current situation is continuing to get worse.

Massachusetts-style policy isn't as good as single-payer or the public option, but it's still far better than the status quo. In Massachusetts, public support for the health care system is at 79%.

Pope Guilty: This is the US's best shot at improving the affordability of health care. I don't think anything else is going to make it through the Senate for a long time to come. If the White House, the House Democrats, and the Senate Democrats can coordinate their actions, the Republicans can't stop it.
posted by russilwvong at 10:43 AM on February 18, 2010


It says "anyone who owns stock in company X is guaranteed profits"

But it doesn't do anything of the kind. It says "everyone must purchase Y policy, that meets Z requirements". It doesn't guarantee company X anything. It certainly guarantees a market for for Y, but many companies will have to compete to attract customers by competing on price, or offering more services, while still meeting the minimum standards.
posted by electroboy at 1:10 PM on February 18, 2010


electroboy Or simply collude, buy one another up so there's only one seller, etc. Last time I checked health insurance was exempt from antitrust laws. The 41 vote Republican majority in the Senate won't let that be repealed. And you know Lieberman, Nelson, and a few other of our DINO's will filibuster right along with them.

Nope, it's guaranteed profits.

Even if it weren't, guaranteeing a market is just as bad.

russilwvong I'm sorry to sound like a broken record, but the Senate bill doesn't have an escape hatch. It concentrates all power in corporate hands, it forces everyone to buy from the corporate offerings, it is unacceptable on that ground alone. Without something that allows people to escape the corporate health insurance system I cannot support the bill. It's just that simple.

Additionally, I don't see how forcing people to buy wastepaper "insurance" actually solves any problems. The Senate bill requires that the minimum policy cover 60% of medical bills. Leaving anyone with an expensive illness both bankrupt and denied care because they can't cover their copay. The poorest people see their income cut, they're forced to give money to the health insurance billionaires, and in exchange they get worthless policies that don't actually help them if they run into medical trouble.

I can't support it. I just can't. If it had an escape clause I could grit my teeth and eat the giant shit sandwich in the name of not giving the Republicans another win. But this bill is so bad I'm willing to let Limbaugh and the Teabaggers crow about beating the evil liberals rather than let it pass.

Yes, the health insurance situation is going to get worse, I don't see how it could possibly get better. But I still can't see this bill providing any improvement. It'll give yet more yachts to the CEO's, crush the poor under premiums, and it still won't actually get people health care when the need it. What good is that?
posted by sotonohito at 1:35 PM on February 18, 2010


The Senate bill requires that the minimum policy cover 60% of medical bills.

You keep repeating this, and because I'm dispirited enough by the amount of misinformation and false assertions that continue to be thrown around this debate, I feel like I need to clarify. The legislation directs the Secretary of Health and Human Services (currently that is Sebelius) to create a minimum benefit package--that is, to create a set of standards that says "X things must be covered in every health insurance policy in order to qualify as health insurance." Now, Congress could have specified exactly what benefits had to be included in that minimum benefit package, but that's a terrible role for Congress to take for many reasons, so they're leaving it to the more-politically-insulated and hopefully technocratic federal agency to do it instead. Congress didn't want to give DHHS total free rein, though, so they set a standard: the benefits that the Secretary enumerates as necessary to be in each and every insurance policy must cover 60% (or 70%, in the House) of the "average" person's medical expenses. This is the sort of safeguard a forward-thinking aide to some Democratic politician put in the legislation to guard against what would happen if (god forbid) President Palin one day appointed a government-regulation-hating person to the head of DHHS.

Note that this is not the same thing as saying every insurance policy only has to cover 60% of each beneficiary's health costs. It's saying that the Secretary will look at what average medical expenses are for the commercially-insured population, and come up with some package that says (for instance) that all preventative care and cancer screenings have to be covered and all life-saving surgeries have to be covered, but maybe knee-replacement and hip-replacement surgeries aren't on the minimum benefit list. Or maybe all prenatal care and childbirth services must be covered, but treatment for infertility doesn't make the list. I'm guessing that vision and dental services will also probably not end up on that list, except maybe in cases of injury or life-threatening situations. The end result is a list of actual services--and when you take all of these services and run it against actual medical service use nationally, you can say "this would cover 70% of an average person's total medical costs," but that doesn't tell you that every person with that set of benefits would only have 70% of their costs covered. Some people would have 100% of their medical costs covered. Some people--like a hypothetical couple who don't use any medical care other than IVF treatments during the year--would have 0% of their medical costs covered.

Plus, that's the floor. In the exchange, there will be 3-4 levels of insurance (in Massachusetts, they call them bronze, silver, and gold) that include more benefits, and anybody who qualifies for the subsidy can use it towards any of those policies. Currently, it's actually the policies with the richest benefits / highest actuarial values that cost the least--your average Kaiser policy has a much higher actuarial value than a typical PPO, and it's cheaper as well. I would be totally unsurprised if this pattern continues to hold in the exchanges, so you end up with the poorest families enrolled in plans with higher actuarial values (but less choice of provider) and richer families selecting PPO-type plans that cover fewer benefits but allow you to see whoever you want.

Anyway. That's probably more information that you really care about, and I respect that you have your reasons for disagreeing with health care reform (although I disagree with them), but please stop using the argument that poor people will only have 60% of their costs paid for, since that's badly misinterpreting what the legislation actually does.
posted by iminurmefi at 2:09 PM on February 18, 2010


iminurmefi wrote That's probably more information that you really care about, and I respect that you have your reasons for disagreeing with health care reform

No, I'm always interested in new information, and I thank you for correcting my misunderstanding. I'm not an accountant so I assumed that 60% meant coverage of 60% of expenses, not what you described. Not that I think what you describe sounds a whole lot better "oops, sorry it looks like your illness isn't covered so you must pay 100% of costs out of pocket before we treat you." I think I'd rather have what amounts to a 60% discount card than illness roulette.

Plus, that's the floor.

Yes, and that's all the poorest will ever get, it's all the subsidies will cover, so talking about anything but the floor is pretty darn pointless, no?

Congress didn't want to give DHHS total free rein, though, so they set a standard: the benefits that the Secretary enumerates as necessary to be in each and every insurance policy must cover 60% (or 70%, in the House) of the "average" person's medical expenses. This is the sort of safeguard a forward-thinking aide to some Democratic politician put in the legislation to guard against what would happen if (god forbid) President Palin one day appointed a government-regulation-hating person to the head of DHHS

I rather suspect when/if President Palin (shudder) appoints Rush Limbaugh as head of DHHS he will find creative ways to interpret "average" so it covers only the rarest and most unlikely of things. And, of course, there's always enforcement to consider. When XYZ Medical Insurance "our motto: selling you insurance because you have to buy it!" denies people for stuff that is officially mandated, I suspect President Palin's DHHS will have better things to do than bother investigating the complaints, and certainly they won't have the budget to investigate more than a handful.

Maybe I'm overly cynical, but so far I have seen nothing from the government, state or federal, to inspire confidence in their ability, or willingness, to actually enforce regulations.

I don't think I'm likely to convince you that I'm right, or vice versa, and it appears that despite reluctance and opposition from people of my mindset the Democrats will likely push us into the glorious corporate dominated future that Obama seems so enamored of. I'm more registering my official Cassandra-esque prediction of looming disaster than exhibiting any actual hope that we will be able to avoid a legal obligation to buy insurance billionaires a new yacht.

I hope I'm wrong and you're right, and somehow this won't turn into the horrible cash sucking, life destroying, fascism encouraging, mess I think it will. I don't think my opposition will divert the Democrats from forcing the Senate bill through, I'm feeling pretty confident that it will pass and we'll get to see if I'm right or you are.
posted by sotonohito at 7:15 AM on February 19, 2010 [1 favorite]


Paul Krugman's column today: California Death Spiral.
About 800,000 people in California who buy insurance on the individual market — as opposed to getting it through their employers — are covered by Anthem Blue Cross, a WellPoint subsidiary. These are the people who were recently told to expect dramatic rate increases, in some cases as high as 39 percent.

Why the huge increase? It’s not profiteering, says WellPoint, which claims instead (without using the term) that it’s facing a classic insurance death spiral.

Bear in mind that private health insurance only works if insurers can sell policies to both sick and healthy customers. If too many healthy people decide that they’d rather take their chances and remain uninsured, the risk pool deteriorates, forcing insurers to raise premiums. This, in turn, leads more healthy people to drop coverage, worsening the risk pool even further, and so on.

Now, what WellPoint claims is that it has been forced to raise premiums because of “challenging economic times”: cash-strapped Californians have been dropping their policies or shifting into less-comprehensive plans. Those retaining coverage tend to be people with high current medical expenses. And the result, says the company, is a drastically worsening risk pool: in effect, a death spiral. ...

What would work? By all means, let’s ban discrimination on the basis of medical history — but we also have to keep healthy people in the risk pool, which means requiring that people purchase insurance. This, in turn, requires substantial aid to lower-income Americans so that they can afford coverage.

And if you put all of that together, you end up with something very much like the health reform bills that have already passed both the House and the Senate.

What about claims that these bills would force Americans into the clutches of greedy insurance companies? Well, the main answer is stronger regulation; but it would also be a very good idea, politically as well as substantively, for the Senate to use reconciliation to put the public option back into its bill.

But the main point is this: California’s death spiral is a reminder that our health care system is unraveling, and that inaction isn’t an option. Congress and the president need to make reform happen — now.
posted by russilwvong at 8:01 AM on February 19, 2010 [1 favorite]


Has requiring auto insurance advanced fascism as well?

Since when are you requred to own a car?
posted by Pollomacho at 9:01 AM on February 19, 2010


Yes, the health insurance situation is going to get worse, I don't see how it could possibly get better. But I still can't see this bill providing any improvement. It'll give yet more yachts to the CEO's, crush the poor under premiums, and it still won't actually get people health care when the need it. What good is that?

Puh-leeze. The bill will provide health insurance to huge numbers of people who didn't have it before. How any person in their right mind could see this as anything but an improvement, I don't know. I'm sorry that the capitalist expropriators were not destroyed in a single blow by the might of the proletariat, but a bill that removes pre-existing conditions while paying for it makes a whole lot of sense to me. Please do not equate the lack of your pet policies with a bill that won't help anyone. Insisting that your way is the only way to do it may make people feel better about themselves as "true liberals" or whatever, but do not delude yourself into thinking that real people won't be helped by this bill.

Unlike Crown Corporations this proposes to give governmental power to corporations without any governmental control or restraint. That's a very bad idea, and a big step on the road to fascism.

This statement has no basis in reality. This bill is putting tons of governmental control and restraint on the insurance companies. Pre-existing conditions? Check. Coverage floors? Check. Exchanges? Check. Requirements to offer insurance to employees? Check. These are putting government control over peoplel

You are literally distorting the record with such statements. I believe it best that in discourse with fellow citizens regarding political matters the truth should not be told, not blanket statements with no basis in fact.
posted by Ironmouth at 10:17 AM on February 22, 2010


Igor Volsky's breakdown of the house, senate, and White House bills in handy table format.

Sotonohito, I'm not sure where you're getting this from:

I can't support it. I just can't. If it had an escape clause I could grit my teeth and eat the giant shit sandwich in the name of not giving the Republicans another win. But this bill is so bad I'm willing to let Limbaugh and the Teabaggers crow about beating the evil liberals rather than let it pass.


Are you sure that there is literally nothing in this bill to support, or are the corporate gains going to outweigh any of these benefits?
posted by Think_Long at 11:08 AM on February 22, 2010


Since when are you requred to own a car?

Whenever you live outside of a major metropolitan area.
posted by electroboy at 11:35 AM on February 22, 2010


Since when are you requred to own a car?

Whenever you live outside of a major metropolitan area.


By law?
posted by Pollomacho at 12:18 PM on February 22, 2010


There's also no legal requirement to buy food, hold a job or live indoors, but we legislate assuming that most people will.
posted by electroboy at 12:24 PM on February 22, 2010 [1 favorite]


The bill will provide health insurance to huge numbers of people who didn't have it before. How any person in their right mind could see this as anything but an improvement, I don't know.

You are being massively dishonest. The point that has been made over and over and over is that simply having insurance is completely meaningless if that insurance is not good. I brought up earlier the insurance that Wal-Mart provides to its employees- it's massively expensive relative to the amount that Wal-Mart pays its employees, it restricts employees to a small number of providers, and it has a ridiculous copay and deductible. (It may be different now; I can only speak for what I was offered back in 2002; as I recall, the only general practitioner that was covered in the area was a half-hour drive.) The difference between having that insurance and not having that insurance for a Wal-Mart employee is having or not having the premiums in the employee's pocket; it does not provide health care in any meaningful way.

In order to have a mandate for everyone to buy insurance and have it not be an abomination, that insurance has to be meaningful- it must provide access to healthcare. A bill which results in 35 million uninsured buying Wal-Mart-style plans does nothing but impose a financial burden without providing healthcare in any meaningful way. Given that the last 30 years of American history have featured an unbroken chain of governments which are openly hostile to the notion of regulation, I do not see any reason to believe that any bill which passes and relies entirely on private insurance companies will provide anything but awful plans that no more provide health care than a cardboard box provides shelter. Characterizing the goal as getting people health insurance, rather than health care, renders the entire affair a sick joke.
posted by Pope Guilty at 12:42 PM on February 22, 2010 [1 favorite]


There's also no legal requirement to buy food, hold a job or live indoors, but we legislate assuming that most people will.

You compared requiring that people cover their potential liability prior to being allowed to perform the optional activity of operating a motor vehicle on public roads to the requirement that people purchase health insurance.
posted by Pollomacho at 1:01 PM on February 22, 2010 [1 favorite]


The point being that many "optional" things are mandatory for most people.
posted by electroboy at 6:29 AM on February 23, 2010 [1 favorite]


There is a difference between mandatory and necessary. Driving a car is necessary for many, it is never mandatory. In legal terms that is a world of difference. If you want the priviledge of driving a car on government property then you will have to follow the government's rules. This includes purchasing insurance to cover liabilities should you hit someone. In other words, you must cover damage to others' property.

Health insurance is a different matter. You are not asking for permission to use government property when you simply exist yet you would still be mandated to purchase health insurance to cover your own care.
posted by Pollomacho at 6:47 AM on February 23, 2010


The point that has been made over and over and over is that simply having insurance is completely meaningless if that insurance is not good.

Really? Let's examine your language. "Having insurance is completely meaningless if that insurance is not good." Really? So a person who has insurance that is not good, will recieve no medical care whatsoever and receive no benefit whatsoever? And I'm not even putting words in your mouth. You are using the word "meaningless" not me. You are saying there is absolutely no benefit to having such insurance. No wonder you think the bill shouldn't be passed.

But let's look closer, is the government going to make people buy insurance that is no good? Perhaps reference to the bill will help:

Sec. 1302. Essential health benefits requirements. Defines an essential health benefits package that covers essential health benefits, limits cost-sharing, and has a specified actuarial value (pays for a specified percentage of costs), as follows:
1. For the individual and small group markets, requires the Secretary to define essential health benefits, which must be equal in scope to the benefits of a typical employer plan.
2. For all plans in all markets, prohibits out-of-pocket limits that are greater than the limits for Health Savings Accounts. For the small group market, prohibits deductibles that are
greater than $2,000 for individuals and $4,000 for families. Indexes the limits and deductible amounts by the percentage increase in average per capita premiums.
3. For the individual and small group markets, requires one of the following levels of coverage, under which the plan pays for the specified percentage of costs:
Bronze: 60 percent
Silver: 70 percent
Gold: 80 percent
Platinum: 90 percent
In the individual market, a catastrophic plan may be offered to individuals who are under the age of 30 or who are exempt from the individual responsibility requirement because coverage is unaffordable to them or they have a hardship. A catastrophic plan must cover essential health benefits and at least 3 primary care visits, but must require cost-sharing up to the HSA out-of-pocket limits. Also, if an insurer offers a qualified health plan, it must offer a child-only plan at the same level of coverage.

Sec. 2718. Bringing down the cost of health care coverage. Health insurance companies will be required to report publicly the percentage of total premium revenue that is expended on clinical services, and quality rather than administrative costs. Health insurance companies will be required to refund each enrollee by the amount by which premium revenue expended by the health insurer for non-claims costs exceeds 20 percent in the group market and 25 percent in the individual market. The requirement to provide a refund expires on December 31, 2013, but the requirement to report percentages continues.

Sec. 1003. Ensuring that consumers get value for their dollars. For plan years beginning in 2010, the Secretary and States will establish a process for the annual review of increases in premiums for health insurance coverage. Requires States to make recommendations to their Exchanges about whether health insurance issuers should be excluded from participation in the Exchanges based on unjustified premium increases. Provides $250 million in funding to States from 2010 until 2014 to assist States in reviewing and, if appropriate under State law, approving premium increases for health insurance coverage and in providing information and recommendations to the Secretary.

Sec. 1101. Immediate access to insurance for people with a preexisting condition. Enacts a temporary insurance program with financial assistance for those who have been uninsured for several months and have a pre-existing condition. Ensures premium rate limits for the newly insured population. Provides up to $5 billion for this program, which terminates when the American Health Benefit Exchanges are operational in 2014. Also establishes a transition to the Exchanges for eligible individuals.

Sec. 2711. No lifetime or annual limits. Prohibits all plans from establishing lifetime or unreasonable annual limits on the dollar value of benefits.Sec. 2712. Prohibition on rescissions. Prohibits all plans from rescinding coverage except in instances of fraud or misrepresentation.

Sec. 2715. Development and utilization of uniform explanation of coverage documents and standardized definitions. Requires the Secretary to develop standards for use by health insurers in compiling and providing an accurate summary of benefits and explanation of coverage. The standards must be in a uniform format, using language that is easily understood by the average enrollee, and must include uniform definitions of standard insurance and medical terms. The explanation must also describe any cost-sharing, exceptions, reductions, and limitations on coverage, and examples to illustrate common benefits scenarios.

Sec. 2716. Prohibition of discrimination based on salary. Employers that provide health coverage will be prohibited from limiting eligibility for coverage based on the wages or salaries of full-time employees.

Sec. 2719. Appeals process. Health insurers will be required to implement an effective process for appeals of coverage determinations and claims.

Sec. 2701. Fair health insurance premiums. Establishes that premiums in the individual and small group markets may vary only by family structure, geography, the actuarial value of the benefit, age (limited to a ratio of 3 to 1), and tobacco use (limited to a ratio of 1.5 to 1).

Sec. 2702. Guaranteed availability of coverage. Each health insurance issuer must accept every employer and individual in the State that applies for coverage, permitting annual and special open enrollment periods for those with qualifying lifetime events.

Sec. 2703. Guaranteed renewability of coverage. Requires guaranteed renewability of coverage regardless of health status, utilization of health services or any other related factor.

Sec. 2704. Prohibition of preexisting condition exclusions or other discrimination based on health status. No group health plan or insurer offering group or individual coverage may impose any pre-existing condition exclusion or discriminate against those who have been sick in the past.

Sec. 2705. Prohibiting discrimination against individual participants and beneficiaries based on health status. No group health plan or insurer offering group or individual coverage may set eligibility rules based on health status, medical condition, claims experience, receipt of health care, medical history, genetic information, evidence of insurability – including acts of domestic violence or disability. Permits employers to vary insurance premiums by as much as 30 percent for employee participation in certain health promotion and disease prevention programs. Authorizes a 10-State demonstration to apply such a program in the individual market.

Sec. 2706. Non-discrimination in health care. Prohibits discrimination against health care providers acting within the scope of their professional license and applicable State laws.

Sec. 2707. Comprehensive health insurance coverage. Requires health insurance issuers in the small group and individual markets to include coverage which incorporates defined essential benefits, provides a specified actuarial value, and requires all health plans to comply with limitations on allowable cost-sharing.


This is the bill that in your mind does nothing? Because I see a whole lot of good. Do you deny that these are good things in this bill? Please explain how these provisions do nothing and help no one and are "meaningless" as you say.

I'm being massively dishonest? These are facts, not the memory of the health care plan you had one time when you were at Wal-Mart. A little advice. Before you call me massively dishonest, do your homework.
posted by Ironmouth at 9:24 AM on February 23, 2010 [1 favorite]


There is a difference between mandatory and necessary. Driving a car is necessary for many, it is never mandatory. In legal terms that is a world of difference. If you want the priviledge of driving a car on government property then you will have to follow the government's rules. This includes purchasing insurance to cover liabilities should you hit someone. In other words, you must cover damage to others' property.

Health insurance is a different matter. You are not asking for permission to use government property when you simply exist yet you would still be mandated to purchase health insurance to cover your own care.


So you think that Massachusettes health care bill is unfair and should be shut down? Because it has a mandate and penalties.

Believe me I was against mandates at first, until I realized its the only way anything like this works. How else are you to get the pools to have enough healthy people in them to subsidize the less-healthy?
posted by Ironmouth at 9:26 AM on February 23, 2010


In other words, you must cover damage to others' property.

How is this different than mandatory health insurance to cover emergency treatment? Or would you rather that hospitals be allowed to refuse an accident victim if they can't verify coverage?
posted by electroboy at 9:49 AM on February 23, 2010


Ironmouth Does Massachusetts have a public option, or is it a mandate to give your money to the insurance industry?

If public option, than I'm ok with mandates though I still really don't like them.

If no public option, just a legal requirement to purchase something from private enterprise, then I'm not ok with it.

I don't really care what form a "public option" takes, as long as it allows people to escape from the mandated clutches of the insurance industry I'll be happy. Otherwise the law is bad.

As for your above points, they all depend on the government enforcing regulations. That won't work, and I fail to see why you think it will. See: California simply not enforcing its laws against recission for an example. Yeah, the Senate bill provides for toothless and non-enforced regulation. BFD. Without some way for people to get out of corporate insurance the industry will find ways to fuck them over. The only thing that will stop the legally mandated being fucked over is the industry fearing that their involuntary "customers" will flee their abuse and go to a non-corporate solution. Without that, bend over and bring your own lube, the corps will take you for everything and give you nothing.
posted by sotonohito at 9:54 AM on February 23, 2010 [1 favorite]


So, government can't be trusted to enforce regulations, but they can be trusted to develop and run their own health insurance program?
posted by electroboy at 10:01 AM on February 23, 2010


So you think that Massachusettes health care bill is unfair and should be shut down?

I don't understand where you get a value judgement regarding out of that statement of the difference between mandating health insurance and mandating auto insurance. I'm simply stating the differences. Do you disagree that there are differences?

How is this different than mandatory health insurance to cover emergency treatment?

The health insurance is for the insured, the minimum required auto insurance covers the damage to what you hit. If it were the same mandatory auto insurance would require you to cover your own car regardless if you have a car or drive it on public roads.

Or would you rather that hospitals be allowed to refuse an accident victim if they can't verify coverage?

Again, I'm not making a value judgement. I'm just calling the auto insurance vs. health insurance debate apples vs. oranges.

Honestly, my personal opinion is that we should have a two-tier universal socialized healthcare with the option to buy supplemental insurance and pay for add-ons like a private room, elective procedures, or specialized care in a private hospital, but my personal opinion on the matter has nothing to do with the auto vs. health debate being a false equivalence.
posted by Pollomacho at 10:27 AM on February 23, 2010


As for your above points, they all depend on the government enforcing regulations. That won't work, and I fail to see why you think it will.

How can that be any sort of reason to vote against a bill? I don't get it. Assuming, without conceding, that the "regulations won't be enforced," why care about the process at all?

So, government can't be trusted to enforce regulations, but they can be trusted to develop and run their own health insurance program?

Exactly. The thing about the Public Option? It doesn't have the votes. As I always say, in a democracy, you need the votes. And for all the whining we get on the public option, we see nothing on how the votes are going to be gotten. Sure people think you can just arm-twist United States Senators and threaten to cut off commttee chairmanships, but uh, aren't those the people who vote for the leadership? How's the leadership supposed to operate by intimidating its own support? Makes no sense at all. Listen the Public Option is great, but if it doesn't have the votes, is it really worth waiting at least 7 years again to get this done? Because if it doesn't pass now, how is it going to pass later in Obama's term.
posted by Ironmouth at 12:33 PM on February 23, 2010


How can that be any sort of reason to vote against a bill?

Do you want us to believe that you can't see why requiring people to purchase something that nobody has any reason to expect will be regulated at all is a bad thing? Really?

Assuming, without conceding, that the "regulations won't be enforced," why care about the process at all?

Because while industry regulations are generally poorly enforced if at all, the feds are pretty good at catching out private citizens breaking laws. So what I envision if this bill passes is that everybody is required to buy from the insurance companies, with people who don't being punished, while the insurance companies get to keep on keeping on with minimal changes to their obligations at best.

This is the horror of the bill: it imposes a new financial obligation on the populace which will almost certainly be enforced, it imposes obligations on the insurance companies which will almost certainly not be enforced, and its passage will be used to argue that the uninsured no longer exist or are a negligible population of criminals.

We should be focusing on how to get health care to people; health insurance is one (very poor) way of doing that. The obsession with getting people health insurance, regardless of the actual value or quality of care provided by that insurance, is what strikes me (and, I suspect, sotonohito) as so bizarre; it is like insisting that having tickets to the Beatles Reunion Tour is so much more important than going to the Beatles Reunion Tour that you're willing to work during the concert your tickets were for in order to pay off the tickets! It confuses a means with the end, and is willing to sacrifice the end to accomplish the means.
posted by Pope Guilty at 12:53 PM on February 23, 2010


Because while industry regulations are generally poorly enforced if at all,

Cited basis?
posted by Ironmouth at 1:13 PM on February 23, 2010


We should be focusing on how to get health care to people; health insurance is one (very poor) way of doing that. The obsession with getting people health insurance, regardless of the actual value or quality of care provided by that insurance, is what strikes me (and, I suspect, sotonohito) as so bizarre; it is like insisting that having tickets to the Beatles Reunion Tour is so much more important than going to the Beatles Reunion Tour that you're willing to work during the concert your tickets were for in order to pay off the tickets! It confuses a means with the end, and is willing to sacrifice the end to accomplish the means.

This is exactly my problem with the bill as well, and I am positively disturbed at how many people are in support of it. Or the argument, "it's better than nothing!" Sure, I don't have insurance now, but at least I can keep my money for visits to the clinic, as opposed to forking it over to an insurance company that I doubt is interested in my health. Health insurance is a business--trying to use creatures of business to fix a complex and expensive public problem, "regulated" by politicians--the very same people who bend over backwards to any lobbyist with a wad of cash? Ugh. No. I am never supporting this.

It's funny, because I seem to disagree with Pope Guilty on nearly everything politically, except this one. I do believe in universal health care...but as for universal health insurance? I guess people put a whole lot more faith in the ability of politicians to regulate the industry more than I do...what I'm envisioning from this bill are billions of dollars now up for grabs from forced insurance premiums, and the debacle that will ensue from insurance companies looking for the best way to grab that money...

I would not call this a good idea.
posted by thisperon at 2:43 PM on February 23, 2010


sotonohito, your argument seems to have transitioned from "the bill as written is bad" to "the bill as it will be administered is bad." First, that's lame: Ironmouth showed you were wrong, so you moved the target. Second, if the government can't be trusted to regulate the health insurance industry, how can it be trusted to regulate the health care industry?
posted by anotherpanacea at 4:39 PM on February 23, 2010


Better than nothing means better than fucking nothing. True, it's not a happy slogan like "power to the people" but THE BILL WILL HELP PEOPLE.

Thisperson, you can keep your money for visits to the clinic? Fine. Let's say, god forbid, you develop cancer. How much would this clinic charge for chemo/radiation/surgery?

I have a dear friend who is unemployed and thus without health insurance. He needs surgery to correct a problem that is causing him discomfort/pain. The surgery is 10K. He doesn't have the dough because he's fucking unemployed. For him, hell yes, the bill would be "better than nothing." He would be able to have the surgery BEFORE his intestestines start extruding through the hole in his gut.

I get that folks are tired of talking about it. I get that people are cynical. I get that this is not what we hoped for.

But come on. Yes, it's BETTER THAN FUCKING NOTHING. And that's something.

What I'm really angry about though, is the sense of glee that I get from reading some of these arguments about why the bill is bad. What the fuck, some of you people think that single payer is around the corner is this bill fails. No. It's not. And if this bill fails, people who are suffering without health care are going to continue to suffer. Anybody who is dancing with glee about that -- welll, come on out to Philly, and I will gladly beat some sense into you. My wheelchair-ness has given me some powerful arms and a great rage at those fuckers who lack empathy for those who are sick.
posted by angrycat at 4:56 PM on February 23, 2010


I do believe in universal health care...but as for universal health insurance?

Could you explain the distinction a little bit? As I see it, universal health care would mean: Paying a little bit from each pay check in order to support the larger health care system. If you needed the health care you would then be eligible to use as many resources as you needed.

Wouldn't an ideal system of universal health insurance work in the same fashion? Or do you mean 'for profit' insurance schemes in particular?
posted by Think_Long at 5:07 PM on February 23, 2010


BusinessWeek: President Barack Obama may be creating the best chance to push through his stalled health-care plan by summoning his political foes to a summit tomorrow.
posted by russilwvong at 10:17 PM on February 23, 2010


anotherpanacea I'll admit to limited target moving, and yeah it isn't cool. Still, I maintain that I'm not as bad as you claim. The outcome is what I care about, not the intention, and I see nothing to indicate that the outcome would be anything but the insurance industry running amok.

For all that I advocate for more and strengthened regulation, not just in this area but in many others as well, I don't really like regulation. That's not as contradictory as it seems, because my objective isn't regulation but rather corporations not screwing us over. Regulation is merely one possible means to that end.

The problems with regulation are manifold. Regulation is, by necessity, reactive. Prohibit one bad behavior and corporations will find other bad behaviors that aren't prohibited. They have lawyers with nothing better to do than spend all day seeking out loopholes, and they will find loopholes.

In a theoretically normal political environment that wouldn't be quite so horrible. It wouldn't be ideal, but regulations would be enforced, new regulations would be laid down to fill loopholes, etc.

In the extant political environment I just plain don't see how it could work. The Republicans are playing by Westminster rules now, they vote as a bloc and their objective is simply to oppose. Given the existence of the filibuster that means they can shut down any and all new regulations proposed to fill loopholes. And you know they will.

Worse they will filibuster the appointment of anyone with actual intent to enforce regulations vigorously, they will filibuster any funding to the regulatory agencies, etc.

But, more to the point, regulation is a very bad way of dealing with the problem of corporate malfeasance. When it's all we have, I say go for it, but it isn't all we have in this case.

I'm mostly in favor of self-enforcing rules, because those are vastly less susceptible to cheating than rules that require outside enforcement. Remember back when you were a kid and you'd do the "I cut, you choose" bit for dividing cake or whatnot? That's the platonic ideal example of a self enforcing rule. Fairness is assured, not by an outside agency (parents), but by the nature of the transaction.

With health insurance the public option represents a degree of self enforcing regulation. If corporate insurance starts screwing people over too badly, they'll run to the public option. Corporate insurance knows this, therefore they wouldn't screw people over too badly if a public option existed. Which is why they fought so hard against the public option. They knew that if it existed they'd have to be less evil, and they didn't want that. They know they can beat regulation, or at the very least get away with a lot of evil under regulation.

Again, look to California and their complete failure to enforce their anti-rescission law and you'll see what I mean.

It isn't that I don't "trust the government" in one case and I do "trust the government" in another, it's simply that I don't think the government will be allowed the resources necessary to enforce regulations under the current Republican way of doing business.

And, of course, there's still my grave concern about corporate peonage and fascism. Absent a way to escape the mandate to hand the corporate insurance industry my money I can't support the bill regardless of all other considerations. I cannot, I will not, support any bill that grants corporations eternal profits, that gives corporations quasi-governmental power and authority, or that further entrenches our corporate/state intermingling. It is both morally wrong and politically dangerous.

angrycat I think that, under this bill, if a person were unable to make their copay obligations they would be denied care, which makes it about as bad as the status quo, because I doubt your friend has $5,000 for copay.

If anyone can point me to a section of the bill requiring that medical care be given to people who can't make the copay I'll be happy to reassess my position on that particular facet of the bill.

I'm betting that under Obama's proposal if your friend has insurance but can't make his copay there's nothing that guarantees him care.

More to the point, I still can't endorse a bill that enacts further corporatism/fascism. Until last year I didn't have health insurance for my entire life. I understand the situation completely, and I'm not a heartless bastard. But I don't see this bill really helping people, and even if it did I remain morally opposed to laws that further entangle the state and corporate interests, down that road lies very bad things.

russilwvong If Obama gets a single Republican vote for this in the Senate I'll print this comment, record video of me eating it, and post it to the front page.
posted by sotonohito at 7:52 AM on February 24, 2010


Ironmouth wrote Listen the Public Option is great, but if it doesn't have the votes, is it really worth waiting at least 7 years again to get this done?

Yes. Absolutely. No doubt at all.

The necessity of preventing creeping corporatism is sufficient that I'm willing to give this up until later. I don't like that, I'm not happy about that, but given a choice between setting up further domination of our government by corporations, what I still see as a growing risk of fascism as a result, and giving up a not so great bit of health care reform, I will do so.

I'm a bleeding heart, it pains me to see people suffer, and I don't want to increase the suffering in the world. If this bill actually guaranteed health care to all Americans and the price was granting the health insurance industry eternal profits I could grit my teeth and go along. But it doesn't, and given my fears of corporatism and fascism it would take an ironclad "go to any doctor, get treated, end of story" type law for me to support granting the insurance industry a fief.

Maybe I am being paranoid, I don't know. Maybe my fears are groundless, I hope they are. Honestly, even without this bill, I'm fearful for my nation's future. This bill seems like yet another step in a march towards fascism and I must oppose it unless I find evidence that changes my mind about the end result.
posted by sotonohito at 8:00 AM on February 24, 2010


sotonohito: If Obama gets a single Republican vote for this in the Senate I'll print this comment, record video of me eating it, and post it to the front page.

I'm guessing you didn't read the BusinessWeek article! Republicans are pushing back against what they see as a political show designed to paint them as obstructionists so Democrats can score points with the public and move on alone.

Regarding regulation:

Again, look to California and their complete failure to enforce their anti-rescission law and you'll see what I mean.

The article you linked earlier is a bit out of date. February 2009: Anthem Blue Cross agrees to take back clients, pay $1-million fine.

--I'm fearful for my nation's future. This bill seems like yet another step in a march towards fascism--

As I said earlier, I think you have it backward--it's insecurity that breeds fascism.

Ezra Klein:
Democrats should pass health-care reform because it's the right thing to do. They should pass health-care reform because between 18,000 and 45,000 people die each year because they don't have health-care insurance, and this bill will save many of those lives. They should pass health-care reform because it will prevent countless medical bankruptcies and an enormous amount of needless chronic pain and infirmity. They should pass it because it will take important steps towards cost control. They should pass health-care reform, as my friend Chris Hayes says, because it's important for the American people to see their government doing more than starting wars and bailing out banks. They should pass health-care reform because it's the right thing to do, both for the millions of people whom it will directly affect and for the country as a whole.
We'll see what happens today.
posted by russilwvong at 8:55 AM on February 24, 2010


Henry Aaron (Brookings Institution), writing in the New England Journal of Medicine:
The more substantive objection to the use of reconciliation for passing health care reform derives from the fact that, according to polls, more Americans oppose than support what they think is in the reform bills. It is hardly surprising that people are nervous about health care reform. Most Americans are insured and are reasonably satisfied with their coverage. In principle, large-scale reform could upset current arrangements.

If public perceptions of the intended and expected effects of the current bills were accurate, democratically elected representatives might be bound to heed the concerns. Because the perceptions are inaccurate, reform supporters have a duty to do a better job of explaining what health care reform will do. When participants in focus groups are informed about the bills’ actual provisions, their views become much more positive. The prevailing views have clearly been shaped by opponents’ misrepresentations of the reform plans, which supporters have done little to rebut. ...

Meanwhile, supporters have spent most of their time on seemingly endless debates with one another about specific legislative provisions ....

President Barack Obama has announced a bipartisan meeting on moving the reform process forward. It is an opportunity for all sides to present ideas for improving the bills that already have been passed by both houses of Congress. If modifications are identified that will command the support of simple majorities in both houses, they should be adopted through reconciliation. Then the House should pass the Senate bill.

Other strategies, in my view, have no prospect of success. Abandoning the reform effort is the worst strategy of all — not only for reform advocates, but for the nation. Reform advocates are already on record as supporting reform. Voters who oppose reform will not forget that fact come November, and those who support it will find little reason to make campaign contributions to or turn out to vote for lawmakers who were afraid to use large congressional majorities to implement legislation that would begin long-overdue efforts to extend coverage, slow the growth of spending, and improve the quality of care.
Why is it that every other industrialized nation in the world has affordable health care, but the US doesn't?
posted by russilwvong at 9:03 AM on February 24, 2010




russilwvong wrote Why is it that every other industrialized nation in the world has affordable health care, but the US doesn't?

The United States Senate.

Seriously, that's why. Even with the anti-democratic over representation of people from low population states in the House we could still get things done if it weren't for the Senate. The Senate is a deliberately anti-democratic organization, 40% of senators represent less than 20% of the population. Add in the insanity of the filibuster and an already bad body becomes vastly worse.

So, yeah, the answer to your question is "the Senate". The House might have passed universal single payer, they can easily pass the public option. But the Senate exists to empower small minded, rural, conservative voters.
posted by sotonohito at 9:44 AM on February 24, 2010


The United States Senate. Seriously, that's why.

No, no, it's seriously not why. It's hard to take your policy pronouncements seriously if you, yourself, are not serious about policy and history. Sure, votes in the Senate may explain our current situation, but this does not explain the preference for certain forms of public assistance over others in the US. It doesn't even attempt to grapple with public sentiment, or with the structure of our social services.

russilvwong, you might be interested in From Poor Law to Welfare State by Walter Trattner, and Protecting Soldiers and Mothers: The Political Origins of Social Policy in the United States by Theda Skocpol. The first is a more straight history, and is used as a text book in social work schools, the second contains more nuance and analysis. Both argue, in separate ways, that it's the particular origins of social policies in the US that preclude us from having a more robustly protective welfare state. Trattner pretty convincingly argues that it's the religious, and specifically Puritan, origins of "US" charity, which views needing help of a sign of sinfulness, that most heavily influences our national conversation about entitlements. Skocpol argues that the US essentially established social policy based on helplessness (primarily for mother's and children), and that once helplessness becomes the acceptable reason for getting assistance, it's very hard to expand the availability to other classes. (I haven't read her thoughts on the current bills.)
posted by OmieWise at 10:06 AM on February 24, 2010


OmieWise The public option has over 60% support in national polls. It's the Senate.
posted by sotonohito at 10:48 AM on February 24, 2010


The Senate is why this particular piece of legislation is being treated the way it is. "The Senate" is not an answer to this question: Why is it that every other industrialized nation in the world has affordable health care, but the US doesn't? Your explanation mis-characterizes russilvwong's question.
posted by OmieWise at 11:03 AM on February 24, 2010


OmieWise: russilwvong, you might be interested in From Poor Law to Welfare State by Walter Trattner, and Protecting Soldiers and Mothers: The Political Origins of Social Policy in the United States by Theda Skocpol.

Thanks, OmieWise--Skocpol's observation regarding the distinction between "deserving" and "undeserving" is extremely interesting. Personally, I usually look at policy proposals from a technocratic point of view (what are the costs and benefits?); it's helpful to be reminded that people may not be thinking of it that way.

I found a review of Skocpol's book in the New York Review of Books (subscribers only, unfortunately). Paul Starr reviews Skocpol's Boomerang, on the failure of the Clinton health care reform. Jeff Weintraub summarizes Skocpol's thoughts on the current push for affordable health care.

sotonohito, your point that the Senate isn't representative is true, and it's definitely important right now, but then I think--don't people in smaller, more rural states want affordable health care?
posted by russilwvong at 12:06 PM on February 24, 2010


russilwvong Perhaps, but they also don't want to let anyone else get it. Fact is that universal health care is often extremely unpopular when it is first introduced, only later becoming near universally loved.

Look at England, the government that implemented NHS did so over loud shouts of opposition and fell in the next round of elections.

Here in the USA the small minded rural crowd that opposed and hated NHS in England is over represented and can control everything. Thus "the Senate" remains the answer. It isn't that Americans are generally dumber, or what have you, it's that we give our Gumby population control of everything via the Senate. If England and Canada were structured as we are they wouldn't have universal health care either.

In sane polities the small minded rural voters aren't over represented and they get steamrolled on important issues. Since the Senate is defective by design, we have a defective government that doesn't represent that actual will of the people, but rather the will of a tiny minority of rural voters. Most Americans are in favor of some sort of universal health care, but they are overridden by the over represented rural voters.

The existence of such voters isn't uniquely American, giving them full control of the government by systemically over representing them is. Thus I stand by my answer.
posted by sotonohito at 12:37 PM on February 24, 2010




As I said earlier, I think you have it backward--it's insecurity that breeds fascism.

The whole point that sotonohito and I are arguing is that we don't view the current bill as security-creating.
posted by Pope Guilty at 12:49 PM on February 24, 2010


WellPoint Raising Premium Rates By Double Digits In At Least 11 States

One of the main reasons cited for the increases is that as the economy slowed, generally healthy people decided to go without health insurance. If you've only got sick people in your risk pool, costs skyrocket.
posted by electroboy at 12:55 PM on February 24, 2010


electroboy Yup, sounds perfectly reasonable. Just like Krugman said, it's a death spiral.

And exhibit A in why private health insurance is a terrible idea. It requires coercion to get people to pay into health insurance when they're healthy, the state is the only agency capable of that coercion, ergo health care should be run by the state. Using state coercion to get people to support private enterprise is a very bad idea.
posted by sotonohito at 1:11 PM on February 24, 2010


Any healthcare system requires the buy-in of healthy people, whether it's public (via taxes) or private (via premiums). It's not like we can't see what this system looks like. It's basically the Swiss system.
posted by electroboy at 1:31 PM on February 24, 2010


electroboy: Any healthcare system requires the buy-in of healthy people, whether it's public (via taxes) or private (via premiums).

Exactly. We have a single-payer system here in Canada, and there's no provision for opting out.

Jonathan Chait: The Coming Conservative Health Care Freakout.
Ever since Scott Brown beat Martha Coakley, conservatives, with very few exceptions, have been convinced that health care reform is dead.

... there was no rational reason that the Massachusetts election had to kill health care reform. Fundamentally, the main barrier -- getting sixty votes in the Senate -- had already been crossed. The remaining obstacles are puny. All the Democrats needed to do was have the House pass the Senate bill. If they insisted on changes, most of those could easily be made through reconciliation, which only requires a majority vote in the Senate. Most conservatives paid no attention to this basic reality, though they did indulge in some gloating mockery of those of us who pointed it out.

... the mustache-twirling bonhomie has started to give way to the realization that the legislative door to health care reform is wide open, and Democrats simply need to walk through it. By no means is it clear that they'll succeed. But I've been waiting for conservatives, filled with hubris at having swept liberalism into the dustbin of history, to wake up to the fact that health care reform is very far from dead, and start to freak out.
posted by russilwvong at 8:32 PM on February 24, 2010


sonhoito, if you are right about the applicability of the bill (as set forth in the President's plan) to my friend, than i owe you a gigantic apology. since it came out -- yesterday, right? I haven't had much opportunity to figure the ins and outs of the latest iteration. If you have, and I"m wrong, I really am sorry. I was writing in a fighty mood, which I shouldn't have done regardless of whether you're right or not.

If this has been discussed upthread, my apologies, but where in the latest iteration are you finding the stuff that would require my friend to pay a $5000 copay?
posted by angrycat at 8:53 PM on February 24, 2010


What I really hate is the way the left is eating itself right now. It really does remind me of 2000. And look at what the fuck we got.
posted by angrycat at 8:55 PM on February 24, 2010


Why is it that every other industrialized nation in the world has affordable health care, but the US doesn't?

It's not our Puritanism and it's not the Senate. We have expensive health care because of wage controls during World War II. The only way to compete for workers was to offer benefits like free health insurance, housing, and education, and the health insurance part of that system was entrenched by both corporations, unions, and tax advantages after the war. As a result, it exacerbated conflicts between those with good jobs and those without. In this, organized labor is as much to blame as health insurance companies: constantly fighting to preserve benefits for their members at the expense of the lumpenproletariat.

sotonohito, I think you're a smart guy and a wonderful contributor here, but I think your analysis of historical fascism is fundamentally flawed in an ideological way, and that your anxieties are overwhelming your common sense. Your analysis of corporatism is anachronistic in this context, and if you insist on making these claims I think you should try to justify them explicitly using citation and evidence rather than voicing them in terms of your fears and feelings. That way, there's something for other commentators to evaluate: to be persuaded by or to refute.

That said, much of what you say in a positive way about the benefits of a public option are well-put and persuasive: I liked the discussion of self-executing procedures, and the analogy to "I cut, you choose." But without the votes... again, everything rests on your idiosyncratic analysis of fascism. Since this is something I think about, and I know Ironmouth does too, let's talk about that.
posted by anotherpanacea at 4:36 AM on February 25, 2010


anotherpanacea You may well be right. Fascism is not my area of specialty. Still, what I've read does suggest that a massive merger of state and corporate power is a very bad sign, especially when you add in the Teabaggers, the rabidly partisan Republican party, the eliminationist rhetoric that is now commonplace and completely non-controversial on the right, etc.

As for the public option, it'd pass the House with no real difficulty, which bring us back to my answer of "the Senate" when answering the question of why America can't have nice things.

As for votes, 538 had an analysis showing that 43 Senators definitely supported it, and while the analyst there was sure this meant it couldn't be done I do think that if Obama really threw his weight behind it he could find sufficient bribes to buy off 7 extra Senators, then Biden breaks the tie and it's done. Hell he bought off Nelson, a few billion now in bribes to Senators in exchange for the public option sounds like a bargain to me. That tactic is, in large part, how NHS got passed in England.

The more I think about this issue the more I become convinced that we're going to have to try abolishing the Senate one of these days. We can't formally eliminate it or turn it into a properly representative body, not without unanimous consent, but looking over the Constitution I don't see anything there that would prevent a simple Constitutional amendment from turning the Senate into a powerless figurehead with no actual political significance. Let them have the power to name official state birds, with a 3/4 majority, and let that be the only power granted to the Senate.

Even without fascism I still don't like and don't think I can support the mandate with no public option. It's granting what amounts to a fiefdom to the insurance industry, a guarantee of profits for all time to a very bad and destructive private enterprise. Since this bill doesn't even give everyone healthcare, why should we give the industry that great gift? Hell, I don't want to give even industries I like and support a government guarantee of eternal profits and customers coerced by federal law into buying their product; giving that to an industry I hate with a burning passion is going to require one heck of a balancing good.

Without some way for people to opt out of giving their money to the CEO yacht fund I oppose this bill. As I said, if it guaranteed health care, not insurance but no questions asked no money required care, for all Americans I could very grudgingly go along with the eternal riches for the evil health insurance industry plan. But it doesn't, so I can't.

As a purely practical matter, leaving ideology out of it entirely, the entire thing depends on regulations that aren't very strong to begin with, and given the Republican bloc in the Senate those will likely never improve. Worse, we've seen how a government hostile to the very notion of regulation can effectively deregulate things without any formal voting. The regulatory agency gets enough funds to support three field investigators (no travel budget) and a single secretary with a manual typewriter, and shazam, the regulations might as well not exist. You know as well as I do that the Republicans will filibuster any appropriations bill for enforcing health industry regulations.

Right now the bill looks like the biggest gift the government could possibly give the insurance industry: eternal profits, government power coercing people into buying their products regardless of quality, and a government that is hostile to regulation in general and often very bad about enforcing regulation with the promise of Republicans working their butts off to sabotage what little regulation exists. How can I call that an acceptable compromise? What do we the people get out of it? Crappy insurance and giant copays?

angrycat This PDF, originally linked by iminurmefi IIRC, provides a side by side comparison of the plans. Page 13 under "benefit tiers", describes the "bronze plan" of the Senate bill and Obama's proposal, which allows for out of pocket expense of up to $5,950.

I made the assumption that if you can't pay those out of pocket expenses you don't get treatment. That assumption may be completely incorrect, nothing I've read says that this would be or is currently prohibited, so I think it is rational to assume that will be the case if the bill is passed.
posted by sotonohito at 7:09 AM on February 25, 2010


If this has been discussed upthread, my apologies, but where in the latest iteration are you finding the stuff that would require my friend to pay a $5000 copay?

There's nothing like this in the bill. sotonohito is conflating the minimum standard for health insurance with the worst-case scenario (that the maximum out-of-pocket would somehow be all up-front before anyone could receive any care, which as far as I'm aware has never been the case in any plan, anywhere, ever) and asserting that all health insurance in the new exchange will look like that. It's not based on reality--as I pointed out way upthread, in our current market the "cheapest" plans (HMOs) tend to be the one that cover the broadest spectrum of benefits and the lowest amount of consumer cost-sharing--usually a $10 or $20 copay to see a physician, with no other cost-sharing. People hate them (rightly or wrongly) for reducing your choice of physicians and hospitals and for having tighter control over what is considered "medically necessary", but that's a totally separate issue from needing to pay a lot of money up-front to get any medical care.

I think looking at the plans offered in the Massachusetts health care connector is a decent way to predict what sorts of plans would be offered in a national exchange--the current federal legislation is basically the same as what Massachusetts passed a few years ago, in terms of the key provisions. You can see what those plans look like here:

Bronze (cheapest plans with least benefits--note that for the vast majority of these, physician office visits require a $25 - $40 copay only regardless of whether you've hit the deductible for the year)

Silver

Gold
posted by iminurmefi at 7:26 AM on February 25, 2010


There's nothing like this in the bill. sotonohito is conflating the minimum standard for health insurance with the worst-case scenario (that the maximum out-of-pocket would somehow be all up-front before anyone could receive any care, which as far as I'm aware has never been the case in any plan, anywhere, ever) and asserting that all health insurance in the new exchange will look like that.

When I had routine hernia surgery 4 years ago, I was required by the hospital to pay my entire $2,000 deductible up front. The day I showed up for the surgery, they asked me to write a check. Then when the bills were submitted to Blue Cross Blue Shield, they denied, among many other things, the first $2,000 of it, citing the deductible that I had already paid. It took the better part of a year to straighten that mess out, and I still got ripped off, just like BCBS intended. And that was for routine surgery under an employer-provided plan. So while I hope that any adopted health plan will end this practice, this is not something sotonohito is pulling out of his ass.
posted by vibrotronica at 9:16 AM on February 25, 2010


The more I think about this issue the more I become convinced that we're going to have to try abolishing the Senate one of these days.

what
the
fuck
sotonohito?

I said: "Hey, let's try to cite sources and tamp down some of the emotional rhetoric...." and your answer was, "Let's abolish bicameralism!"? Have you even read Article Five? I mean, we're not even close to abolishing the filibuster, and you're talking about getting two-thirds of the states on board for abolishing the Senate?!? And we're supposed to wait to reform health care until this happens?
posted by anotherpanacea at 9:41 AM on February 25, 2010


anotherpanacea Sorry, that was more of a long term thinking ramble than really germane to the topic. I do think we need to eradicate the Senate in the long term, but that's outside the proper scope of the health care discussion.

Whether or not that needs to happen before health care reform can happen depends entirely on the conservative Democrats and Republicans. We had to gut the bill and make it nothing but a giant corporate giveaway to get it past our so-called 60 vote majority, and now we don't even have that.

The current bill is, to my way of thinking, unacceptable. Adding a public option of some sort is the only thing that will get my support for the bill. It's the only way of restraining corporate abuse that doesn't depend on unreliable government regulation. It's the only way to avoid the unacceptably immoral outcome of granting the health insurance industry a guaranteed profit and guaranteed customers.

With a public option of some sort this bill is still a shit sandwich, but I could choke it down. Without a public option of some sort I do not see any benefit in passing this bill. The supposed benefits will vanish as the insufficient and ineffective regulation is circumvented by the health insurance industry, but the mandate will stay and be vigorously enforced. It simply and plainly looks like a very bad deal unless a public option of some sort is attached.

With the filibuster in place, and I really don't think it'll be reformed in the next session, the conservative Democrats like it too much, and the Senate in its current configuration, I agree that nothing better seems possible.

I'll go so far as to say that thanks to the filibuster this bill is likely the best we will ever get absent a major political shift in the USA.

Like I said, I'm a not merely a bleeding heart, and I've lived without health insurance for (just did the calculation) 94% of my life. I could lose my current insurance if I lose my current job, and I've got no real prospects of a job with insurance if I do lose this one. My father died from lack of insurance, the hospital chose to ignore the bone cancer until he could be tossed into the ER and then into the morgue because they knew damn well he couldn't pay if they officially discovered it.

But even given both my empathy for those without insurance, my own history of being uninsured, etc I simply do not see enough benefit in this bill to offset it's harm. If it actually guaranteed every American health care (walk in, get care, no payment asked) I could, with extreme reluctance, go along with enshrining the health insurance stockholders as aristocracy with a guaranteed income. But it doesn't.

iminurmefi Angrycat's example was a friend with a need for surgery to correct discomfort/pain that costs $10,000. Bets that it's covered by the bronze plan? And if it is, there's still the $5,950 out of pocket.

Does this bill mandate that care be given to holders of the bronze plan even if they can't meet the out of pocket expenses? If so I'll retract my comment.
posted by sotonohito at 10:36 AM on February 25, 2010


There are many different ways that insurance companies impose cost-sharing, and I think sotonohito (and you, vibrotronica) are confusing the terms "maximum out of pocket" with "deductible", "copay" and "co-insurance." They're not the same thing.

Both the House and Senate bills limit the maximum out-of-pocket spending to the HSA limits, which are currently a bit under $6,000 for an individual plan or $12,000 for a family plan. (Those who are eligible for subsidies--in other words, people making less than 300% of poverty, which is something like $66,000 for a family of three--have lower limits. Those below 100% of poverty, the truly poor, are covered by the huge Medicaid expansion, and would have a maximum out-of-pocket of $0.) Maximum out-of-pocket represents a ceiling on the amount of cost-sharing anyone covered by a plan would be subject to--when you hit that ceiling, all the other types of cost-sharing you would usually have to pay cease. So, for example, if you're usually required to pay a $25 copay every time you visit your doctor, you wouldn't have to do that any more after you've hit the maximum out-of-pocket for the year: the plan covers 100% of benefit costs from that point forward.

The ways that one might end up reaching that out-of-pocket maximum vary, depending on the plan type. The big three ways are deductibles, copays, and co-insurance.

Deductibles are a set dollar amount that a person has to pay out-of-pocket before the insurance policy will cover anything at all.** It's pretty rare for deductibles to apply to routine care; oftentimes you'll see that a set number of physician office visits per year are exempt from the deductible, and almost always the yearly OB-GYN visits, well-child visits, and an adult physical are also exempt. When a plan does have a deductible, it most frequently connected to inpatient hospital care, outpatient surgeries, mental health benefits, or prescription drugs. For those services, you do have to pay out-of-pocket for the first $X dollars (where $X is the deductible).

Co-insurance is a sliding-scale amount you pay based on the negotiated cost of the service--for instance, 20% co-insurance means that the policyholder pays 20% of the negotiated cost of the service, and the insurance company pays 80%. This type of cost-sharing is often paired with deductibles, so that you have to hit a certain dollar amount (the deductible) and then an insurance policy will start paying for most, but not all, of the remaining cost.

Copays are a small, flat fee (almost always under $50) you pay every time you use a particular service. They're most often used for things like routine doctor office visits, although HMOs often use copays for a much broader range of services. Copays are usually used for services that insurance companies want to encourage (e.g., routine doctor visits), and almost never happen in tandem with a deductible.

Virtually all health insurance in the United States today is what we call "managed care," as opposed to the more straightforward indemnity insurance that you saw in the 1970s (that's the model still used for things like car insurance). This is in large part because medical costs have been inflating so rapidly for so many decades, and managed care (either PPOs or HMOs) are the only policies that have exerted downward pressure on that inflation. At first, managed care organizations tried to keep costs low by directly managing care, doing things like reviewing the recommendations of doctors for clinical or cost effectiveness before deciding whether to cover the service, or requiring step therapy for pharmaceuticals (that is, requiring people to try the cheaper generic version of a drug first, and only covering the more expensive branded version if the generic wasn't working). This went over like a lead balloon for most Americans, HMOs were vilified, and what's grown up instead is an effort to manage care by designing cost-sharing to encourage people to make the cost-effective decisions.

The cheapest plans are still those that more actively manage care, or that have integrated the provider network with the insurance company (the biggies in that vein are Geisenger in Pennsylvania, Kaiser in California/Colorado/DC, and Group Health Cooperative in Seattle). When you actively manage care there's much less reason to use complicated cost-sharing schemes, which is why you see HMOs often only require a copay (no deductible, no coinsurance) for a huge range of services. I would be somewhat surprised if these plans don't end up being the "cheapest" in terms of premiums in the new health care connectors, which is why I think the concern that low-income people will have to pay huge amounts out-of-pocket before getting any care is really unrealistic.

I think it's hard--actually, I think it's impossible--to argue that low-income people are going to be worse off under the reform than they are now. I think your average family making $40,000 would much prefer to face a very low premium (because of big subsidies) and maybe a few hundred dollars for a deductible before going into surgery, compared to the costs of having a policy now (the average family premium is around $1,000 per month) or going uninsured. It's clear that sotonohito has other reasons to oppose this bill, and my impression is that he's throwing out "but what about the POOR" as a rhetorical flourish that doesn't have a whole lot to do with why he actually opposes the bill.



**A deductible will almost never be as high as the maximum out-of-pocket limit on the policy, because all forms of cost-sharing are usually engineered to discourage certain types of health care usage (e.g., charging a big fee for using the E.R. if you're not admitted for whatever ails you) and encourage other types (e.g., routine PAP smears, well-child visits). If a deductible was set equal to the maximum out-of-pocket limit, the policy would cover 0% of costs up to a set dollar amount and 100% afterwards. That type of benefit is generally only attractive to individuals who know they will have high, recurring health costs every year--the chronically ill and disabled--or those who are very healthy and don't do any sort of preventive health care (young men). Insurance companies are leery of covering the first group. The sweet spot is the healthy folks who take care of themselves, and those people generally don't want anything to do with plans that won't cover anything until they hit a very high deductible.
posted by iminurmefi at 11:11 AM on February 25, 2010 [2 favorites]


I think your average family making $40,000 would much prefer to face a very low premium (because of big subsidies) and maybe a few hundred dollars for a deductible before going into surgery, compared to the costs of having a policy now (the average family premium is around $1,000 per month) or going uninsured.

Great. What about the 50% of families below the average?
posted by Pope Guilty at 11:59 AM on February 25, 2010


Uh, they'd get even bigger subsidies (or qualify for Medicaid/CHIP outright where they don't now), so they'd be even better off?

If anyone is getting screwed by this legislation, it's single dudes in their 20s who make decent money freelancing and have dirt-cheap plans in the individual market because they never use health care. Their premiums will probably jump substantially with the advent of community rating (the benefits will be better, but since this group isn't likely to use those benefits anyway it's probably a net loss), and if they make a good salary they probably don't qualify for subsidies that would offset the premium increase.

On balance I think the fact that childless women and men in poverty, low-income people who aren't quite poor enough for Medicaid, the chronically ill, women of childbearing age, and the disabled who are stuck in the 2-year waiting period for Medicare (or not quite disabled enough for Medicare) are getting a huge win from this makes it worth passing. Others may disagree, but it's somewhat misinformed (at best) or dishonest (at worse) to pretend that opposition to this specific bill is somehow rooted in one's deep sympathy with the plight of uninsured people in poverty.
posted by iminurmefi at 12:19 PM on February 25, 2010


Did I miss where the bill subsidizes poor people or are you making shit up?
posted by Pope Guilty at 12:31 PM on February 25, 2010


Here's the section on affordability from the president's proposal. Most of the summaries concentrate on a family of four, so it's not clear what the limits are for individuals.
posted by electroboy at 12:40 PM on February 25, 2010


The House and Senate bills require individuals who have affordable options but who choose to remain uninsured to make a payment to offset the cost of care they will inevitably need. The House bill’s payment is a percentage of income. The Senate sets the payment as a flat dollar amount or percentage of income, whichever is higher (although not higher than the lowest premium in the area). Both the House and Senate bill provide a low-income exemption, for those individuals with incomes below the tax filing threshold (House) or below the poverty threshold (Senate).The Senate also includes a “hardship” exemption for people who cannot afford insurance, included in the President’s Proposal. It protects those who would face premiums of more than 8 percent of their income from having to pay any assessment and they can purchase a low-cost catastrophic plan in the exchange if they choose.

The President’s Proposal adopts the Senate approach but lowers the flat dollar assessments, and raises the percent of income assessment that individuals pay if they choose not to become insured. Specifically, it lowers the flat dollar amounts from $495 to $325 in 2015 and $750 to $695 in 2016. Subsequent years are indexed to $695 rather than $750, so the flat dollar amounts in later years are lower than the Senate bill as well. The President’s Proposal raises the percent of income that is an alternative payment amount from 0.5 to 1.0% in 2014, 1.0 to 2.0% in 2015, and 2.0 to 2.5% for 2016 and subsequent years – the same percent of income as in the House bill, which makes the assessment more progressive. For ease of administration, the President’s Proposal changes the payment exemption from the Senate policy (individuals with income below the poverty threshold) to individuals with income below the tax filing threshold (the House policy). In other words, a married couple with income below $18,700 will not have to pay the assessment. The President’s Proposal also adopts the Senate’s “hardship” exemption.


So in other words if you're poor, your situation doesn't change any, and you'll still only be getting care once your health has already failed catastrophically.
posted by Pope Guilty at 12:47 PM on February 25, 2010


Pope Guilty Its there. See pages 5-6 of this PDF. If you're starvation poor you qualify for the medicare. If you're poor but not starvation poor you'll have to pay some by yourself, the rest covered by federal subsidy.

Of course that's in, how else would the insurance industry feed off tax dollars if there weren't something like that?

iminurmefi But do people who can't pay that get treated? Let's say I'm on the bronze plan and I don't have $50 to give the doctor as a copay when I get sick, do I get treated or shown the door?

Or take angrycat's friend. He has a non-emergency condition that sounds costly to repair. Let's say, for the sake of argument, that his treatment would cost $20,000, which sounds like inpatient hospital work, which you say is likely to fall under the deductible category. If her friend can't make the deductible, does he get treatment? I'm asking honestly, you seem far more knowledgeable about this than I do.
posted by sotonohito at 12:54 PM on February 25, 2010


The subsidies for low-income people are one of the legs of the "three-legged stool" that forms the very heart of the reform:

1. community rating and guaranteed issue (that is, insurance companies not allowed to take pre-existing conditions into account when choosing to cover people or pricing the policy, and insurance companies forced to sell a policy to anyone who asks)

2. individual mandate (to prevent the death spiral that would occur in insurance pools with guaranteed issue + community rating otherwise, see example of NJ health insurance market for what happens when #1 is legislated but #2 isn't)

3. affordability subsidies for individuals up to 300% FPL (Senate) or 400% FPL (House), to ensure that it's possible for everyone to comply with the individual mandate (these subsidies limit both the total amount of income that someone has to pay towards premiums and the total out-of-pocket limit)

These--along with the huge expansion of Medicaid, which will really benefit the extremely poor but not disabled adults who currently don't qualify--are 95% of what the bill does. The last 5% (do you include a public option? can plans that qualify for the subsidy include abortion coverage? can individuals over age 55 buy into Medicare rather than a private plan?) get all the media coverage, but aren't likely to have a huge effect on the day-to-day life of people insured through the exchanges if the reform passes.

If you're interested in playing around with numbers to see how the subsidies would work, you can check out this interactive calculator. As you can see, a 40-year-old with a family of 4 who makes $40,000 per year would qualify for subsidies that cover 74% of the total cost of premiums--that is, on a $786/month plan, they would have to contribute about $188 per month and the federal government would pick up the rest. In terms of out-of-pocket maximums, that family is at 188% of the poverty line, which means they'd face a maximum that is 1/3 of the HSA limit (so $1,983 for an individual or $3,967 for a family).

If that same family was even worse-off and made only $25,000 per year, they'd qualify for Medicaid, which legally cannot require any cost-sharing and has an actuarial value of 100.
posted by iminurmefi at 12:57 PM on February 25, 2010


Insurer handed out bonuses, planned huge rate increase

"While Anthem Blue Cross proposed a 39 percent rate increase on thousands of its California customers, its parent company gave 39 of its executives more than $1 million each and spent more than $27 million on 103 lavish executive retreats, congressional investigators said Wednesday."
posted by homunculus at 1:04 PM on February 25, 2010


sotonohito, whether someone who can't afford a deductible gets surgery depends not at all on the insurance company or the federal government. It depends 100% on the provider (doctors and hospitals, generally) and how those providers choose to do business.

Whether hospitals will perform surgeries if a patient can't pay up front depends on the hospital. Twenty years ago, the vast majority of hospitals probably would; back then, most hospitals were non-profit and the general operating procedure was to do whatever needed to be done, then send the bills to the insurance company, then (weeks or months) later send whatever wasn't covered to the patient. Since they didn't ask for payment up front, ability to pay wasn't relevant--nobody paid (or failed to pay) until well after the procedure was complete.

Starting in the 1990s, we've seen an enormous wave of hospital conversions (from nonprofit to for-profit) and consolidation into chains sweep the country. At the same time, some of the more profit-oriented surgeons have started opening "ambulatory surgery centers" that skim off the healthiest patients with the best insurance (read: highest profit margins), leaving the sickest and least-insured patients to the hospitals, whose margins are now getting squeezed. Given these trends, I'm unsurprised that some hospitals require payments up-front from uninsured patients (or even from insured patients, if they're really paranoid about being paid). I'd hazard a guess that these sorts of policies--pay beforehand or you don't get surgery--are more prevalent among investor-owned for-profit hospital chains. They're probably very common among ambulatory surgery centers, which exist solely to make money. Safety-net and non-profit hospitals, on the other hand, usually have entire staffs devoted to working out payment plans with patient who can't pay a lump sum up front, which implies at least some hospitals would certainly care for people who couldn't pay the deductible right away.

All of which is to say: if you're concerned about corporations capturing the government and unduly influencing policy to the detriment of taxpayers, I think it's weird to be afraid of insurance companies while ignoring the large corporate providers. A public option might be a good idea for a lot of reasons, but unless you're talking about nationalizing every hospital and doctor practice in the country it's not going to end the influence of corporations on health care.
posted by iminurmefi at 1:13 PM on February 25, 2010 [3 favorites]


any good post summit coverage?
posted by angrycat at 5:23 PM on February 25, 2010


(no t.v.)
posted by angrycat at 5:23 PM on February 25, 2010


The summit is broken into parts here, including transcript and video. I haven't seen any expert analysis beyond the huffpo's "republicans were immature, democrats SLAM GOP" type headlines
posted by Think_Long at 5:41 PM on February 25, 2010


Ezra Klein has a number of blog posts on the summit. Most recent: Obama doubles down on health care reform.
The big story out of the summit is not that Republicans and Democrats extended their hands in friendship, but that the White House has dug its heels into the dirt. The Democrats are not taking reconciliation off the table, they are not paring back the bill, and they are not extricating themselves from the issue. They think they're right on this one, and they're going to try and pass this legislation.

Today was a boost for that effort. The Democrats got hours to make their case, at an event they planned, with one of their own controlling the discussion. For that reason, I imagine that this will be the last bipartisan summit we see for awhile. The format is simply too kind to the president, and he takes advantage of it ruthlessly. When the camera panned, you could almost see Republicans wondering why they'd accepted the invitation.
The Health Care Blog has a more diverse range of views.
posted by russilwvong at 4:09 AM on February 26, 2010


anotherpanacea:
It's not our Puritanism and it's not the Senate. We have expensive health care because of wage controls during World War II. The only way to compete for workers was to offer benefits like free health insurance, housing, and education, and the health insurance part of that system was entrenched by both corporations, unions, and tax advantages after the war. As a result, it exacerbated conflicts between those with good jobs and those without. In this, organized labor is as much to blame as health insurance companies: constantly fighting to preserve benefits for their members at the expense of the lumpenproletariat.
I don't think that these are mutually exclusive explanations. Indeed, both Trattner and, with more nuance, Skocpol, argue that providing benefits to people who are worthy because they belong to particular classes (veterans, mothers, workers) while refusing them to others, is precisely why we're in this particular mess. Theirs is a higher level critique, insofar as it explains not just why businesses might offer insurance, but also why this would be a well-received solution from a social perspective. Certainly social mores need to be translated into policy in some fashion.

That Catalyst article was interesting, though. I particularly liked the systems theory breakdown of the difference between flying around the world and seeing a doctor. Do you know of more extensive histories/critiques of the health-care-as-benefit arms race?
posted by OmieWise at 4:51 AM on February 26, 2010


I have a different set of suspicions about the norms that ground 'deservingness' in the United States, rooted in diversity and trust issues. Europeans can have more lavish welfare states because the concept of 'desert' applies to all Frenchmen or all Italians. In the US, we're so large and diverse that we don't think of our countrymen as deserving in the same sense, because we don't trust or identify with people of different races, classes, and religions. If you look at contemporary fascist propaganda in Italy, it's all about how Arabs are standing in front of the your old Italian grandfather in line for social services.... Here in the US, we have the allegations of 'welfare queens' which are always code for non-whites from the inner city, despite the fact that the image itself is based on Reagan's misunderstanding of a California news story around welfare fraud. (I know you know this, I'm just making the point in terms of diversity and trust of the other.)

Do you know of more extensive histories/critiques of the health-care-as-benefit arms race?

A good place to start on some this is in the economic concept of the 'cost disease' which is the basis for that comparison between differing efficiency in doctors and pilots. Here's a good Baumol article. Here's Senator Moynihan explaining how political ideology is reducible to responses to the cost disease:
“You have now explained to me why the Democratic Party is called the party of tax and spend, because we are financing all the things that are affected by the cost disease and Republicans want to short-change them.”
I think we could interestingly complicate that with reference to prisons and the military: I suspect both parties have caught to cost disease at this point.
posted by anotherpanacea at 5:11 AM on February 26, 2010


Also, take a look at the work of James Blumstein. He's generally considered conservative, but I think he's smart and has a handle on a lot of the issues at stake here. Even disagreeing with him is useful, because you can get a handle on the problem in a really interesting way. Obviously, I'm staking out a position here that the problem is institutional and economic, and not, as you've suggested, cultural. But this is something I'd love to talk about, if the promised evidence-based discussion of fascism isn't in the cards.
posted by anotherpanacea at 6:06 AM on February 26, 2010


I have a different set of suspicions about the norms that ground 'deservingness' in the United States, rooted in diversity and trust issues...

Oh, I certainly agree with this, and also that there are all sorts of ridiculous stereotypes built into our ways of discussing these things. (The "welfare queen" to me comes right out of, and is only a bit less absurd than, the "lazy" slave.) But I don't think the explanations are mutually exclusive: how we class those who deserve help and those who don't is still to me largely a social, rather than an economic or institutional, issue. Those classifications change and are differently understood as circumstances change, but still seem to be based first on ingroup/outgroup considerations. (The original colonies weren't all that large, yet still had very punitive poor laws, and institutions set up around who deserves help.) This is particularly true when we look at the entirety of our social services and entitlements, rather than just health care.

I haven't yet had time to dig into your links, but I will.
posted by OmieWise at 7:29 AM on February 26, 2010


Insurer handed out bonuses, planned huge rate increase

State Attorney General Jerry Brown Subpoenas Documents From Health Insurers
posted by electroboy at 8:35 AM on February 26, 2010


Those classifications change and are differently understood as circumstances change, but still seem to be based first on ingroup/outgroup considerations. (The original colonies weren't all that large, yet still had very punitive poor laws, and institutions set up around who deserves help.)

I guess I worry about a kind of genetic fallacy: a few of the early colonies were Puritan, so we'll be forever Puritan. It just doesn't make sense to me that the Puritan 'blood' would dominate more than, say, the Quaker or Catholic tradition.... I understand that it's supposed to be more of Nietzschean/Foucaultian genealogy, but it seems far from verifiable/falsifiable.

Diversity and mistrust solves two birds with one stone: it explains why we haven't managed to respond to collective action problems like health insurance with a legitimate, coercive solution, and it explains why inequality flourishes in the first place. As I understand it, the argument for inequality from diversity assumes we have no shared standards of honor and privilege with which to supply non-financial remuneration to positions like doctors. So doctors have to signal their accomplishments with fancy clothes, homes, and cars. If we lived in a smaller, more like-minded community, there'd be more respect to be had from that profession, so salaries can be cheaper, as they are in much of Europe, but also in places like the Midwest. The problem is that our culture has only consumption/luxury goods to signal success.

This is what Jurgen Habermas calls (confusingly) an entitlement crisis. He doesn't mean entitlements like the welfare state, but rather the system of offices, honors, and prestige that we use to remunerate, signal excellence, and grant some folks the pomp and ceremony to serve as experts on values and norms. Without shared cultural touchstones, we've got nothing but money to give, and the corollary to that is we only recognize the universal sign of authority in wealth and the wealthy.

This might be a bit far afield at this point, but this is one of the problems I've been thinking about these days.
posted by anotherpanacea at 1:42 PM on February 26, 2010 [1 favorite]


Doh! It's not an entitlement crisis, it's a motivation crisis, which happens when the 'entitlement system' breaks down.
posted by anotherpanacea at 1:53 PM on February 26, 2010


Well, you and I have talked about the issues associated with status before, and I agree that diversity and mistrust explain a lot. I wouldn't want to discard the explanation they provide.

While I appreciate the danger of subscribing to a genetic fallacy, even if it's called a genealogy, I'm not sure how else to account for the Puritan/Calvinist strain in American civic life. The issue for me, with the diversity argument alone, is that it transposes the religious strain of American conservativism (small c) into a more secular, frankly modern European, mode. It begs the question for me.

Obviously there's a part of that religious strain that can and should be explained in diversity language, but there are also parts that seem separated from simply diversity and mistrust. I guess I feel as if a diversity argument (and I may be underestimating its depth*) fails to account for the moral condemnation that I see driving US social policy.

*This has come up before. I'm always happy to make pronouncements about something I don't really understand.
posted by OmieWise at 4:45 PM on February 26, 2010


The issue for me, with the diversity argument alone, is that it transposes the religious strain of American conservativism (small c) into a more secular, frankly modern European, mode. It begs the question for me.

Hmmm.... I'll have to think about that. The weird thing is that, though we're obviously a much more religious nation than most of Europe, we're not all the same religion, and it often feels to me that there are many more social justice Christians out there than there are Puritans. But then, how many would it take in a country where 40 Senators representing as little as 1/3 of the population can stop major federal legislation? Hmmm....
posted by anotherpanacea at 5:53 PM on February 26, 2010








Wow. Wouldn't that be awesome?
posted by Artw at 11:23 AM on March 9, 2010


Limbaugh vows to flee the country if health care passes.

Oh please oh please pass! If there is a just and righteous God this will pass! Suddenly I am in full support of this bill as written whatever it may be!

Looks like it's already causing Palin to flee!
posted by Pollomacho at 11:24 AM on March 9, 2010




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