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@bmacs27, my chief point in that comment was that the vast, overwhelming majority of congress is too indebted to big business to pass anything that won't help the existing big businesses either make scads of money short term, or give them a stable business model long term. So, of course the bill helps the bottom line of big business -- the question is, is it simply a gift, or do the American people get something out of it too? I think that this one is a win-win. I would've preferred a win-lose situation (people win, company profits lose), but as long as it seems like there's a fair mutual benefit, I don't begrudge letting the insurance companies make a little more money.

As far as ideology, it only enters into this because one party sees political gain in making it out to be an ideological issue. For proof of that, revisit what republicans proposed in the 90's, and look at what Mitt Romney implemented in Massachusetts. They're arguably less free market than the plan making its way through Congress now. For a real shocker, go back and look at what Nixon wanted to do.

As far as the public at large, I guess what I'm really saying is that I refuse to condone the mistaken idea that free market absolutism is some core tenet of our country's cultural value system. Even amongst conservatives and libertarians, there's certainly no reason to think that government mandated HSA's that abolish a sector of the existing economy should be more acceptable than government mandated insurance, with a new regulatory regime that will improve competition and consumer protection, unless of course people go on TV every day to say the latter is socialism and/or fascism.

I would suggest that existence and popularity of Social Security and Medicare undercuts the idea that Americans are largely conservative ideologues. If Americans really were even remotely the kind of ideologues that you suggest, those programs would already have been dismantled and dismissed as mistakes. Instead, you can't get support for repealing them, even if you call it "privatizing".

The above is my long-winded way of saying that all the talk of ideological resistance is propaganda. When you ask people about the individual provisions of the Democratic plan, everything but the individual mandate is popular, and even the individual mandate has a better net favorability than the bill that contains all of those elements.

The problem isn't that the bill is fundamentally unpalatable to the American people, it's that the American people don't know what's in the bill, and Republicans have filled that void with fear and lies (and Democrats have done little if anything to combat that).

As far as getting Republican voes, Republicans don't actually have an ideological objection to what Democrats are trying to do. They have a political imperative to object to what Democrats are trying to do, no matter what they actually try to do. Republicans aren't suggesting more dramatic, free market reforms, they're proposing minor tweaks that would disproportionately benefit insurance companies rather than people, and wouldn't address any of the shortcomings of the existing system.

>> ^bmacs27:
@gwiz665 : It's funny, because I just got through talking with my lab mate about why this wouldn't work. He just said it wouldn't fly politically. All the vested interests (i.e. insurers, pharma, AMA, etc) all want the Dem's bill. In other words, nothing to do with patients.


Yeah, this is why things like single-payer and replacing traditional insurance with HSA's is a fantasy in today's world. The Democratic bill is pretty much the only special-interest-friendly way to reform health care in a positive way -- big, sweeping changes that put insurance companies out of business just weren't in the cards.

It's why the Republican bill is essentially just tort reform (which limits liability of providers), allowing insurance companies to sell across state lines (which allows them to all relocate to the state with the most lax regulation), and changing the tax incentives so that people are likely to move from the employer/group market to the individual one (which is more profitable for the insurance industries, since you lose collective bargaining power).

In other words, the Democratic bill tries to be win-win for both people and the special interests, while the Republican bill basically just helps the big business interests squeeze more money out of people.

Here in America, it seems that it's contrary to our cultural identity to pass legislation that hurts the bottom line of big business in any way.

@bmacs27, I've got a few concerns about this lump sum idea. One is that you'd replace medicare with it, which seems like a bad idea right off the bat. Second, you push the problems with predictability of cost from government and insurance companies which must only worry about large pools of people and statistical averages, onto individuals who have literally no way of predicting their individual lifetime health costs. Third, any potential savings people make by limiting their spending benefits the US Treasury not themselves. Fourth, you're still leaving people without a safety net, both in the case of severe illness, or simple poor planning.

Those seem like huge issues to me, and the bit about savings benefiting the Treasury seems like a political poison pill to boot.

As for Barasso calling for HSA's, he wasn't actually presenting a policy prescription. He just said he liked HSA+Catastrophic insurance because it makes patients control their own costs. Obama was right to call that a rich man's solution, because you need to have enough disposable income to be able to save enough to cover out-of-pocket medical costs, and currently those are still largely driven by the bad incentive structure of our existing insurance system (in other words, they're ridiculously high).

You said, "If Obama would allow himself some humility here, and pitch a new proposal partially drafted by Republicans, I think he'd win the support he needs." I think this is a deeply misguided statement. The assumption here is that Obama's plan is some radical, left-wing proposal that's antithetical to Republicans, when in truth, Obama basically took previous Republican reform bills as his inspiration.

Since Obama pre-compromised in this way, Republicans just moved the goalposts, and said that Obama's plan is Stalinist health care, and if he wants to be reasonable, he has to drop the public option. So they dropped the public option. Republicans said instead of the House's surtax, they wanted to the tax exemption on employer benefits reduced or eliminated. So the Democrats did that too. The Republicans said they didn't want an employer mandate, so Democrats dropped that too. The Republicans said that they didn't want health insurance subsidies to pay for insurance that covers abortion, so the Democrats added language that did that too. Republicans said that they didn't want insurance companies to be required to cover end of life counseling (DEATH PANELS!!!), so Democrats dropped that too. Republicans said that they didn't want illegal immigrants covered, so Democrats put in strong language forbidding it, and setting up a system for enforcing it.

I could go on like that for quite a while longer. Republicans have been involved in this process from the beginning, and have extracted a ton of concessions from Democrats, in return for absolutely zero votes. The whole time, their rhetoric hasn't softened one iota -- it's still Stalinist, Nazi-ist, Socialist, Fascist Health care that's going to bankrupt our government, bankrupt our citizens, and get everyone killed, grandmas first.

That kind of thing makes it politically impossible for Republicans to turn around and say "well, now it's not so bad".

Obama started with a very moderate, bipartisan bill, especially considering the sizable majorities he still enjoys in both chambers of Congress. The idea that he needs to compromise more with Republicans is ludicrous.

@NetRunner : Yay! An actual conversation.

Yes, the assumption is that medicare is gone, in fact, all other "health insurancey" middlemen are gone. The whole point is that health insurance, aside from catastrophic care, isn't really insurance at all. We aren't transferring risk to anyone (the traditional definition of "insurance"). We are just taking expenses we know we'll encounter, and paying someone to book keep for us. Why not cut out the middleman and pay directly? It's not like we file claims with our car insurance to pay for oil changes. Why should I file a claim to pay for regular service on my body?

To be honest, I don't really care how you pay for it. Republicans probably prefer the underhanded flat tax of the printing presses. If you want to use a progressive tax, whatever, that's fine. In any event, the bills only come due when the "stamps" are converted, so it isn't like you need the government to have the money up front. I mentioned the lump sum just because it gets around the problem of catastrophic situations where the person hasn't paid in enough yet, and the government has to bridge the gap. It removes uncertainty about how much everyone is getting. When it's out, we throw you under a bus (that's smartass for you pay out of pocket). Thus, you still have the incentive to minimize costs. Whereas with the Delong solution you have questions like, when do you roll it over, how do we predict government liability, etc...

Politically speaking I can sympathize quite a bit. However, this IS what conservatives are suggesting we do. You saw it yourself in the video, the guy was calling for HSAs. Obama was the "demagogue," calling it a rich man's solution. If Obama would allow himself some humility here, and pitch a new proposal partially drafted by Republicans, I think he'd win the support he needs. The Republicans are looking for a gracious out to this whole "party of no" nonsense. They know that nobody likes pure obstructionists, they just can't appear to be entirely caving either. They need it to look like they at least contributed something to language of the bill. They need it to look like they have some real ownership, that's all.

>> ^bmacs27:
I'd rather just pick some fixed amount everybody gets for life however, and just hand them the money when they are 18. It doesn't even have to be money right away (to defer the inflation). It could just be stamps that are converted to cash by the doctors when they are reimbursed for services. It's got most of the qualities of the progressive plans. It's egalitarian. It puts money in the pocket of people that need it. Unlike those plans however, it would get the votes from both sides.
Like I said, it isn't that radical. It isn't like the European style systems, but there are models. Like I mentioned, a similar system is quite popular in Singapore (which I wouldn't describe as an entirely backwards society, I could do without the caning, but you know, quit yer litterin'). For whatever reason, however, this debate always gets bogged down in this quagmire of European system or status quo, which I find bunk. I think there are legitimate concerns with the European way of providing health that don't fit neatly with our cultural identity. There would be broad Republican support for a bill that puts consumers in charge of cost control (this video could be cited as evidence). So why not consider that sort of plan? Because it doesn't inch us along the path to single-payer? Political points? What is it? Why isn't it even on the table?


Let me unpack this a bit, and respond separately to policy substance and the politics of the bill.

I'm not sure how a "lump sum" grant would work. Is there a hidden assumption in there that this is to replace their Medicare benefits later in life? Are there new taxes to offset it? Do people get to keep what they don't spend as cash? What happens if you get a serious illness and deplete it before you're 30?

Part of the advantage of the plan DeLong proposes is that most of the cost is borne by the individual themselves. They also have strong incentives to keep themselves healthy, since any money they don't use gets rolled over into their IRA, or if they so choose, returned to them immediately. If they're young and healthy, this means they have a pretty strong push towards saving 15% of their income at all times. If they do get sick, they have an incentive to try to deal with their illness as cheaply as possible, since every dime is out of pocket. If they get seriously ill, and blow through their HSA, they know what they pay is capped at 15% of their yearly income, and everything past that is paid for by the government, so they know they won't go broke.

A lump sum plan seems to lose most of those advantages.

As for politics, what Democrats are proposing now is actually to the right of the bill Republicans offered to Bill Clinton in the 90's. It's more conservative than the Massachusetts Romneycare reforms.

Republican opposition isn't ideological. There isn't a single god damned thing Democrats could do with this bill that would make Republicans vote for it. They win by handing Obama a defeat, period. Any reform that dramatically improves the system that's signed into law by Obama means historically huge credit will be heaped on Democrats in general, and Obama in particular. They will do anything to stop that from happening.

That said, I would have loved to have seen Democrats propose something like what DeLong suggested, just to hear what the Republican anti-reform talking points would've been. Probably they'd just demagogue the mandated 15% contribution to HSA's and call that a "government takeover" of health care. They'd probably still say that all we need to do is tort reform and to "let companies sell insurance across state lines" which would in effect eliminate the states' ability to regulate insurance.

The only bill that would ever get broad Republican support is one introduced by a Republican majority in congress.

Back @gwiz665 : I know you aren't. Like I said, you are arguing for uniform standards of care. We agree that what needs fixing are the perverse incentives in the current system. The question is about how to do it. Correct me if I'm wrong, but under most European systems doctors receive a fixed salary right? That seems fine, as it removes the incentives I'm talking about, but here in 'Merica, we call that pinko hogwash. People should be able to earn more by working harder. The government shouldn't be able to take away that option.

All I'm saying is that another way to prioritize treatment quality, while not having skyrocketing costs is to create HSAs. The idea is that if we took the amount spent on healthcare over the course of the average citizen's life we could just hand everybody half a million dollars in "health care stamps," or whatever you want to call them. That would be what you get to spend, and you get to decide how to spend it (on health related expenses). If you spend it all like an idiot, tough luck, that's how we roll. But it would put you in a position to say, you know, this pimple isn't really bothering me, I'd rather wait and see if I want that hip transplant when I'm older. This puts control of the transaction back in the consumer's hands so we aren't all at the mercy of some fixed income doctor, or government bureaucrat. Doctors obviously still recommend the treatments, but it makes the consumer better able to hold doctors accountable.

@kagenin, I actually disagree. I don't think there's any problem with using markets in medicine -- in fact I think it's preferrable -- the problem is that you need to make sure the market dynamics lead to a cycle of providing better care to more people, and not a cycle of providing more expensive care to fewer people.

For example, the system Anthony Weiner wants is single-payer. All that really does is say that for certain basic types of medical service, there's a single state-based insurance company that covers everyone, and will use a nation-sized customer pool to negotiate set rates common to all providers.

The providers themselves are private, and they profits by attracting more patients with good service, and by driving cost efficiencies. In other words, they get rich by taking better care of people and by eliminating waste.

The problem in our system is that the incentives are all wrong.

The private insurance companies make a profit by only extending insurance to people who're as healthy as possible. Their goal is to collect premiums with the lowest amount of "medical loss" -- in other words, without having to actually cover the cost of any treatment. That leads them to cover fewer people, jack up the rates of people who are older or chronically ill, fight with patients over every expensive claim, and try to rescind coverage retroactively on their sickest customers.

The providers also have bad incentives. They make all their money by performing procedures, and getting reimbursed by the insurance companies. This leading them to have tremendous incentives to give everyone a CAT scan and MRI if they come in with stubbed toe. So, they're always working on new, expensive tests and treatments, and reasons to use them on as many patients as possible, without much regard to efficiency or patient benefit.

There are lots of ways to break us out of those bad incentives. On paper, HSA's might work to reduce costs if that was the only way anyone could pay for medical service. If you eliminate traditional insurance entirely, add in mandatory contributions to HSA's, and a little bit of subsidy to cover people who need to spend more than they can afford, and I might be willing to support it.

But just having HSA's as part of our existing mix has essentially no effect on the system at all. Participation is way too low for it to make any difference at all.

gtjwkq is once again just mindlessly parroting biased studies, getting the numbers wrong, and mixing the results of several bogus "studies" together, and delivering it with his usual heaping dose of rude condescension.

The "study" he wants you to read is this one from the Council for Affordable Health Insurance which describes itself as "a research and advocacy association of insurance carriers active in the individual, small group, HSA and senior markets" (emphasis mine).

It's pretty much the textbook definition of statistical sleight of hand, and more or less declares its own definition of "administrative" costs, which just happens to result in him needing to add costs to Medicare from outside its budget, and subtract things from the private insurance side (such as profit).

Even when he does this, his own biased numbers still show lower costs for Medicare, at which point he switches to the argument that private insurance is giving you a better value for your money, even with the extra administrative costs.

He does not address the liberal argument that the higher administrative costs aren't aimed so much at preventing real fraud, but in trying to uncover any legal pretense for refusing to cover treatment for people who file claims, nor the arguments that government run health insurance is getting some economies of scale by having some of its functions handled by other areas of government, such as policy making being done by Congress, or being able to "acquire capital" at the Government's low interest rates.

Strictly enforcing immigration laws in California, besides being infeasible, would bankrupt the ag industry

I don't share your pessimism. If we built a real wall instead of a flimsy fence, enforced our laws, and tossed out all the illegals then the market would simply adjust itself to the new reality. Worker visas and market innovation would take care of everything by itself.

Oh, and that's okay? But having a similar system which covers everybody is not?

No - just informing you that you ALREADY have options if you are that pathetically down and out. There is no need for a 'new' plan to cover you.

Ah, paycheck, I pay self employment tax, don't have the same options for write offs as you.

HSA medical care is always tax deductible - self employed or not. There are numerous companies who do this either through company payrolls, or by signing on to their plans as an individual citizen where you make personal deposits. If you make income, you can set up a tax-free HSA.

Frugal? Really? please don't mess with me on frugal, I own my house, I have $0 in debt, I spent about $500 a month for living expenses for myself and my GF. Next.

Cool. I also own my house and have zero debt. Good feeling, isn't it? I fail to see how you can own a home, have zero debt, only $500 a month in total living expenses, and yet still claim to be unable to afford a measely $60 a month for medical insurance.

2) auto state min coverage is highly regulated in most states. If you bought up to cover your own car expect to be taken to the cleaners, my whole point is that only highly regulated insurance is worth buying.

Boy - you REALLY don't know much about medical insurance do you? If you are running around operating under the delusion that health insurance is not the most tightly regulated industry in the United States, then this conversation is pretty pointless because you're entire mental frame of reference is in some alternate dimension that only you occupy.

They don't cover nothing, they do systematically not cover things which they claim to provide

This is completely untrue. Are there exceptions? Sure, but they are the exception and not the norm. You have a completely opposite perspective of what really happens. I've had medical insurance for the past 22 years, and in that entire 264 months I have had ONE time when insurance denied a claim. I spent a grand total of about ten minutes on the phone, and bingo it was covered.

And I'm not some singular case. The vast majority of health insurance users are perfectly happy with thier plans. Study after study shows that everyone is getting along just jim-dandy. Your apocalyptic visions of 'routinely denied' care are nothing more than your warped perception of reality. You are focusing on outliers, and calling it the majority. You are cherry-picking the exceptions, and trying to portray them as the rule. What you THINK is happening just isn't true.

You can say I'm wrong if you want, but the statistics prove that I'm correct. All you have is your opinions, and anecdotal stories that you have heard 3rd hand from people that no one has met. What is more, you have personally admitted that you are NOT a member of an insurance policy and you never have been. Your credibility is nil because you quite simply don't know what you're talking about because you AREN'T involved in the system.

You're like a guy who has never built an airplane in his life who thinks airplanes always crash because all you ever see is news stories of crashing planes. How about you stop basing your opinions on rumors, exaggerations and anecdotes and actually try flying the plane for a while?

>> ^Winstonfield_Pennypacker: You really and truly believe that humans are brainless puddings that can't move, think, or live unless some government plan is marching them around, don't you?

The gov really has nothing to do with how our food gets picked, except that they more or less stay out of the way. You are suggesting that they remove the only population willing to do the work at the wages offered by the market. Markets do right themselves, they do this only after the effects hit consumers. Products with long production cycles, such as agriculture, can fall to inaccessibility before the market corrects.

Strictly enforcing immigration laws in California, besides being infeasible, would bankrupt the ag industry, and force a giant federal bailout, massive price increases, and food shortages, that seems a lot more governmentally invasive than what I suggest doing, and leaving them the fuck alone, letting them work, and even collect on some of the services they are paying for.

If you can't afford that, then you qualify for Medicaid.

Oh, and that's okay? But having a similar system which covers everybody is not? Sorry you lost me there. If I am near the line, cycling in and out of Medicaid would put me in a preexisting condition death spiral pretty fast.

If you're SMART (like me) then you'll also have an HSA or cafeteria plan where you set aside a chunk of your income every paycheck for health expenses.

Ah, paycheck, I pay self employment tax, don't have the same options for write offs as you.

a little common sense and frugality.

Frugal? Really? please don't mess with me on frugal, I own my house, I have $0 in debt, I spent about $500 a month for living expenses for myself and my GF. Next.

Your example here falls flat, because auto insurance and life insurance companies do the exact same thing.

1) life insurance is a scam.
2) auto state min coverage is highly regulated in most states. If you bought up to cover your own car expect to be taken to the cleaners, my whole point is that only highly regulated insurance is worth buying.

Not sure why you keep implying that medical insurance companies don't actually cover anything. That's patently untrue.

They don't cover nothing, they do systematically not cover things which they claim to provide, and require arm twisting and lawyers to pay up. It's not that I am sure that they won't pay, that is not my contention, it's just that I'm not sure that they will, and that makes buying their policies seem like a pretty stupid move, even if it were economically feasible.

I'm happy to share risk, but I need to have some assurance that my risk will be mitigated as well, and the current system does not offer that to my satisfaction.

Since I have no interest in starving to death while the agricultural production of California rots in the fields, no, that would be a stupid idea.

The fear-based fantasy that America would starve if we enforce our immigration laws is - as always - an amusing and fascinating delusion when it manifests itself. You really and truly believe that humans are brainless puddings that can't move, think, or live unless some government plan is marching them around, don't you?

So I could pay $720 a year, and have a deductible of what $20k?

$720 a year? If you can't afford that, then you qualify for Medicaid. The most expensive HDHPs on the market have maximum out of pocket limits of $5K for singles and 11K for families. If you're SMART (like me) then you'll also have an HSA or cafeteria plan where you set aside a chunk of your income every paycheck for health expenses. Try it for a while. You'll find that it is neither difficult, nor painful as long as you plan ahead, budget sensibly, and exercise a little common sense and frugality. I know I speak truth, for I speak from experience. I've been doing this for years, and I've never once had to worry despite having a family member who experiences serious medical needs on a regular basis.

My GFs cousins was hired to deny coverage claims, she sits at home, gets folders full of medical records, and without seeing the patient or their physician comes up with an excuse for the company not to pay.

Your example here falls flat, because auto insurance and life insurance companies do the exact same thing.

Why not car insurance is? I am required to carry it, and the gov makes sure it actually covers something

Not sure why you keep implying that medical insurance companies don't actually cover anything. That's patently untrue. When a member of my family got cancer, they were given $250K of medical care and I only paid $5,000 out of my pocket. Everything else was (say it with me) COVERED! Did I have to deal with red tape and the occasional bureaucratic snafu? Sure. It happens. But this insane vision you're trying to peddle of US medical insurance covering NOTHING is just plain bunk. They may deny an OCCASIONAL claim (and often with good reason), but you are trying to say they deny ALL claims. That is absurd, and puts your basic credibility in question.

Kudos for Fran Drescher for being active in any sense and having more civility than Hannity. But, I don't see the problem with tort reform and HSAs. Tax credits for one is a tax on another. "faux new..." blah, blah, blah...very tiring. I don't need to watch Fox news; it runs here constantly. I guess I should be watching Keith Uberass and the rest of the msnbc clowns...where the real truth is.