Just to be clear: Without the mandate, you can just forget about any sort of health care reform

I get sick to my stomach of reading stuff like this:

The Supreme Court struggled Wednesday with a question that looks increasingly significant after conservative justices battered the individual mandate: Should the rest of President Barack Obama’s health care law stand if the requirement to purchase insurance falls?

Most of the justices appeared opposed to throwing out the entire law, but their views on how much to keep in place were murky, and the divisions between conservatives and liberals were not always as clear cut as they were Tuesday….

If you get rid of the mandate that puts everyone into the system, then just scrap the law. Because without everyone in the system, we’re stuck with the same system we have now, which causes us to pay more than other developed nations for some of the worst health outcomes.

Either everybody is in it, or there’s no hope of affordability. And without affordability, nothing you come up with can work in the real world.

Surely the justices are all intelligent enough to understand that.

Wouldn’t it be horrible if our Constitution — the glory of what America is about — proved to be a barrier to our having a rational health care system? Well, that will be the case if the Court holds that you can’t require that everyone be in the system.

The only hope at that point would be if the barrier was simply this requirement of everyone having to buy insurance. Perhaps we could still have the workaround of a single-payer system that covers everybody. That, of course, would be far better than requiring everyone to purchase a hodgepodge of private products. The fact is that you’d still be requiring everyone de facto to buy in (through taxes) to a system that covers everyone, but maybe it would work as a de jure workaround. It sounds possible to this layman.

But then, the political barriers to taking that far more rational approach were (and will probably remain) so great that the Congress passed the cockamamie Obamacare to start with. So the thought doesn’t cheer me up all that much.

123 thoughts on “Just to be clear: Without the mandate, you can just forget about any sort of health care reform

  1. Phillip

    You are correct that severing the mandate in effect kills the law, or any real attempt at health care reform. If the law or even just the mandate portion of it is ruled unconstitutional, don’t hold your breath waiting for the GOP to offer an alternative in terms of serious health care reform. They have failed to at any point in the past, the only efforts at real reform have come from Democratic administrations. The reason is simple: the GOP’s constituency is primarily those for whom health care costs are not a major problem. For those Americans struggling with health care costs, or for the uninsured: they are losers in the American dream, and in the GOP’s Darwinian view of citizenship, they are not a part of our society. Should the law or just the mandate be overturned, you will hear little or nothing from Romney on health care reform (other than the usual platitudes about tort reform). The return to the previous status quo will be just fine.

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  2. SusanG

    They could just expand Medicare to cover everyone — but then wasn’t part of the point of the individual mandate to involve the private insurance companies and not have totally government-insured healthcare?

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  3. SusanG

    Hit enter too soon. The punch line was that means the constitutionally allowable option is the more Socialist one. OMG, does that mean we have a socialist Constitution?! Those godless founding fathers got us again…..

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  4. Steven Davis II

    “which causes us to pay more than other developed nations for some of the worst health outcomes.”

    What are you talking about? People from all around the world come to this country for medical care. Talk to a Canadian who waits in Communist type lines to get medical attention.

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  5. Herb Brasher

    Agreed, Brad. The really frustrating thing about this is that we all pay, one way or the other, when people get sick. Passing up the chance to streamline the payment process, and to provide for many people who otherwise get wiped out by catastrophic illness–this is so disappointing. Not to mention the chance to push insurance companies to do a service, rather than just raking in profits.

    What disappoints me especially is how so many of my evangelical friends will be happy about the injustice done to the less fortunate. In Jesus time there were ingenious ways to practice injustice (Matt 15, the Corban label). One of the modern ways to get out of practicing justice is just to label all such attempts ‘socialism.’

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  6. `Kathryn Fenner

    @ Steven–when you look at the population as a whole, we have vastly poorer outcomes, like on the order of Chile–we’re like 18th, but we spend the most by a long shot.

    All the Canadians I know, and that’s a lot, love their health care and would not trade. The only people who come here for medical care are rich people. Many middle class people go overseas to like Thailand (!) for operations–we even heard about it at Rotary….

    I read somewhere, and cannot find it anymore, that w/o the mandate, you could make it sort of work with like an annual open enrollment period, which would be the only time people could opt in to plans. Not sure how that deals with free riders, but FWIW when people cannot pay their medical bills, it’s not like the providers shrug their shoulders and go away–they take what they can get, which can be most of your stuff.

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  7. Herb Brasher

    Philip, how can we have any serious health care reform at all unless everybody pays into it? Without a mandate, too many people just want to wait until they get sick to buy health coverage. That obviously doesn’t work. So I don’t understand how the Republican party can offer anything at all without the mandate.

    I talked with a retired medical doctor this past week, a good friend and warm evangelical, who cares for the poor (and who did not, while practicing, refuse medicare and medicaid folks). Although he is against having the government administrate healthcare, he agreed that there must be a mandate. He would just want to have a basic plan that all have to have, and private options for those who want more. He named other considerations; I still have to read the materials he has written on the subject.

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  8. Steven Davis II

    Invoking the 8th Amendment, cruel and unusual punishment.

    JUSTICE SCALIA: Mr. Kneedler, what happened to the Eighth Amendment? You really want us to go through these 2,700 pages?

    (Laughter.)

    JUSTICE SCALIA: And do you really expect the Court to do that? Or do you expect us to — to give this function to our law clerks?

    Is this not totally unrealistic? That we are going to go through this enormous bill item by item and decide each one?

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  9. Steven Davis II

    @Phillip – “the GOP’s constituency is primarily those for whom health care costs are not a major problem.”

    This is what I don’t understand about the GOP. Liberals keep using this line, yet most of those country, trailer dwellers living paycheck to paycheck don’t come off as Obama/Pelosi/Clyburn supporters. Just the ones who seem to be comfortable holding out their hand waiting for the government to fill it.

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  10. Steven Davis II

    Rich people – GOP voters
    Poor people – GOP voters
    Most of the middle class people I know – GOP voters

    Just what economic demographic votes for Democrats?

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  11. Juan Caruso

    “Just to be clear: Without the mandate, you can just forget about any sort of [tort] health care reform.”

    We know. Brad! Also, those who served in our military were provided with opportunity to acquaint themselves with our U.S. Constitution.

    Unfortunately, products of public education these days are rarely provided unadulterated opportunities by the same political wing that produced (and vetted?) the incumbent CINC. Just a thought.

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  12. Doug Ross

    It took Congress 2700 pages to say “Everyone should have access to health insurance”. That’s the problem.

    They should have passed a bill with the basics and then fought over how to reward the lobbying groups later. But that’s not how it works.

    And we’re supposed to believe that the government that came up with this bill can implement a healthcare system for the entire country? Fat chance.

    Obama was on record over 100 times during his campaign saying that he would not sign a bill that wasn’t single payer. He punted to get something done. And what he got done was a huge mess (most of which conveniently doesn’t go into effect until AFTER November). The bill itself has had a significant role in causing companies to hold on on hiring employees because they don’t know what it will mean to their expenses going forward.

    But then I still struggle with who can’t get insurance. My son just got a job and I was looking at his options – for a young guy, $26 a month for a high deductible plan seems like a good deal.

    Until you can come up with a plan that doesn’t impact everyone who has insurance they are happy with, it’s a tough sell.

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  13. Bryan Caskey

    The Constitution doesn’t have an exemption for laws that Congress things are good ideas.

    On the issue of severability, there’s no sense in taking the engine out of the car and keeping the rest of the car.

    Scrap it and Congress can start over from a clean piece of paper.

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  14. Jennifer Fitz

    Brad,

    Would it be that bad if we just tried to provide health care for the poor?

    Honestly, I have a hard time worrying about people who can afford insurance and won’t buy it. I’d rather we spent our time and money making sure the people who need help get it.

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  15. Bryan Caskey

    Oh, and on the issue of enacting single-payer if SCOTUS strikes down Obamacare? It’s like this: With Boehner in charge of the House and McConnell about to be in charge of the Senate (or at worst in charge of around 49 solid votes) the chance of a single-payer healthcare scheme getting enacted fall somewhere between the chances of 13 being a winning bet in a craps game and the chances of a sedated mule winning the Belmont Stakes.

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  16. Steve Gordy

    “People from all around the world come to this country for medical care.” Of course they do; in most such cases, their ordinary medical cases are covered in their home nations, so they can afford to spend the extra to avoid waiting in line. Most Canadians (who live within 150 miles of the U.S. border), however, choose to wait in line at home. At least they have a choice.

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  17. Bob Amundson

    Many in the United States are going to other countries to have expensive medical procedures performed. Steven, I’d be more inclined to accept your view when it is backed up by data, rather than anecdotal suggestions such as “Talk to a Canadian who waits in Communist type lines to get medical attention.”

    I do believe there are other solutions to our healthcare problems than a national mandate. I am an advocate of allowing states to develop solutions, as there are State systems working quite well (NO system is ever perfect). Massachusetts is the model for “ObamaCare” and seems to be working well for the majority of people in that State. Utah has an entirely different system, a healthcare exchange mentioned in the Supreme Court hearing.

    Overall, our Healthcare systems need to be efficient, therefore more affordable. The system also needs to be expansive, to cover people universally. ObamaCare tries to do both, with a major efficiency being the mandate (there are others). One big problem with ObamaCare was trying to expand without first being efficient during the “Great Recession.”

    If I’d been advising our President, I would have suggested he use political capital to improve the economy first, with part of that focusing on healthcare efficiencies. Once the economy improved and healthcare became more efficient, more affordable, then concentrate on expansion.

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  18. bud

    Steven, the pay more/worst outcomes debate has long ago been resolved. There really isn’t much point in continuing to debunk that old canard. So let’s move on.

    Sadly this was all predictable. Obama and the Democrats tried to reach a compromise with the Republicans with the mandate approach. Seemed reasonable given that’s exactly the way the GOP talked about reforming healthcare during the Hillarycare debate in the 90s. The Clinton’s proposed a business mandate instead. Ultimately neither was adopted. Plus Mitt Romney’s approach prominately featured an individual mandate.

    Clearly the Republicans don’t want any reform but use whatever strategy is available to continue with the high cost/poor outcome approach. What I don’t get is why. Don’t Republicans want a healthcare system that serves the needs of everyone? Don’t folks understand that if an uninsured person shows up at the emergency room with a heart attack or an accidental injury they WILL be treated and we will all pay?

    Plus, whenever the individual parts of the healthcare law are polled (pre-existing conditions, children parents policy till 26, closing the Part D donut hole, etc.) large majorities are in favor. That includes Republican voters. With the looming likelihood of the Supremes shooting down the mandate the GOP elite will likely get their way. And we will all pay in the end.

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  19. Steven Davis II

    @Kathryn – “Not sure how that deals with free riders, but FWIW when people cannot pay their medical bills, it’s not like the providers shrug their shoulders and go away–they take what they can get, which can be most of your stuff.”

    You’ve obviously not been in a hospital ER waiting room full of people there for colds and headaches. I know several doctors, I don’t know any that are also repo men if they don’t get paid.

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  20. Steven Davis II

    @bud – “Steven, the pay more/worst outcomes debate has long ago been resolved. ”

    Really, did someone forget to send me the memo?

    So how are people who are already getting medical attention for free because they live below the poverty line going to pay for their insurance policy premiums? What’s going to change as far who has coverage?

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  21. bud

    Bob makes some very good points. There was much discussion about efficiency/expansion issues at the time this was debated in 2009. Perhaps going a bit more slowly would have been better. Perhaps not though since this issue has been debated for 100 years the bold approach seemed appropriate. Let’s see what the Supremes say then we can determine whether Obama over-reached.

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  22. bud

    This is a must read, from the Kaiser Foundation.

    http://www.kff.org/insurance/snapshot/oecd042111.cfm

    What is shows is a phenomenal gap in what Americans spend per capita on healthcare vs everyone else in the developed world. We spend $7000+ per capita with Norway and Switzerland coming in way behind at less than $5000. And we have a much shorter life expectancy than most of those countries. So why does this “Canadians hate their healthcare system” nonsense keep croping up. It’s a bogus argument based on anecdotal stories from a friend of a friend that waited a few months for a hip replacement. Yet the Canadians pay far less. If they bumped up what they pay perhaps these long waits would be alleviated. But at least everyone has health coverage.

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  23. Silence

    @ Bob & bud – “Overall, our Healthcare systems need to be efficient, therefore more affordable.” – when did the intervention of the Federal government ever make anything more efficient? I am hard pressed to think of a time. Affordable for whom? For the folks who already don’t pay income taxes? Since they simply skip out on the bill, it sounds like it’s already affordable for them.

    Discussing healthcare outcomes is a case where the “average” is pretty meaningless, like a guy with one hand in boiling water and the other hand in icewater. On average, he’s comfortable. So you have a situation where most folks with insurance get some of the best care in the world, and them that don’t, don’t. It’s a bimodal distribution.

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  24. Silence

    @ bud – re: Kaiser Foundation – I don’t suppose that a managed care organization/health plan provider and health care provider like Kaiser Permanente would possibly benefit from Obamacare…. I’d guess that they aren’t quite a disinterested party… Sort of like taking advice on smoking from Phillip Morris.

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  25. Lynn

    America’s health care problems are access, affordability, and quality. The Affordable Care Act dealt directly with only access by proposing to save private health insurance companies via the mandate with subsidies for the low and middle income.

    For the last 50 years, health care spending has consistently grown 2.5% more than the rate of inflation. This is not sustainable. We currently manage this by throwing uninsured folks out of the boat to live shorter lives in great discomfort. Being uninsured is the 10th leading cause of death in America.

    Other economically developed nations cover all their people with basic and excellent acute care for less spending primarily by spending less on physician care, medical equipment, and prescription drugs. Every health care cost center is someone’s profit center. Americans have yet to learn that sometimes more is not better…more health care kills.

    The objective of health reform should be the right care at the right time in the right place for a fair price.

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  26. bud

    Silence, a bimodal distrubution? Seriously, is that a good approach? Even if it is you’d have to let folks die for it to be truly applicable model. Otherwise you just pay for the slackers in some other way. So let’s just let some 5 year old kid die from a treatable disease. That would certainly fit into this “bimodal” argument.

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  27. bud

    Ok, Silence you don’t like the Kaiser Foundation. Fine. Click on ANY source and you’ll find the same thing.

    We have to decide as a nation what our priorities are. If we decide that we want the following healthcare objectives then we need to move away from what existed pre-Obamacare.

    1. Everyone will be treated for serious illness and injury.
    2. Healthcare spending per capita is reduced to a level commensurate with the rest of the developed world.
    3. Wait times for treatment are not excessive.

    One objective that I would absolutely NOT have is that the system MUST contain some free market component. If that helps us achieve the 3 objectives listed then fine. BUT, that is not a necessary condition.

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  28. Bob Amundson

    Silence, did you read my sentence “I am an advocate of allowing states to develop solutions, as there are State systems working quite well (NO system is ever perfect)?”

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  29. Steven Davis II

    bud – Have you been to Norway or Switzerland? If so you probably noticed they don’t have nearly the number of “burdens on society” that we have in this country. Nor do they have the immigration problems that plague our hospitals and schools.

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  30. Steven Davis II

    bud, it’s not a friend of a friend. I have relatives in Canada and on more than one occasion have come to the US for medical treatment for a number of reasons. One being a better doctor and a second being that they had to wait months for the same treatment or doctor’s appointment. Sure it’s cheaper up there, but you get what you pay for.

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  31. `Kathryn Fenner

    @Silence–You don’t get to just “skip out on the bill.” If you have any assets, they come after them. If you don’t, then you didn’t “Just skip out on the bill.” You can’t get blood out of a turnip, and being poor (or even not wealthy), shouldn’t be a death sentence if you cannot afford care.

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  32. Steven Davis II

    Kathryn – You’re a lawyer, tell us just how long does it take from the time a court says you have to pay until you actually see the money change hands? I know people who are owed money by crooked contractors who have been waiting for years to get court ordered refunds for botched services. I know attorneys who say they can keep you in a house for at least two years after a bank foreclosure. Just because a court says you have to pay, doesn’t mean yo have to pay “right now”… which is a shame.

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  33. Silence

    I think Steven has hit the nail squarely on the head: We’ve got too many people who are “burdens on society” for health care to be effective, ubiquitous and affordable.
    Comparing the US with 9.6% unemployment (official rate, actual is much higher) to Norway with a 3.4% unemployment rate isn’t exactly fair. By my calculation, our labor force participation is about 11 percent lower than Norways. More people working=less burden on them that are.

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  34. bud

    Silence if you’re going to argue a point at least use current data. The US unemployment rate is 8.3% and has been falling for the last year. Not a pretty number but certainly better than 9.6%.

    Not sure what point you’re trying to make. Britain has a higher unemployment rate than we do and healthcare costs are lower. It doesn’t matter what the rest of the economy is doing the point is all countries, 100%, every last one has AT LEAST a 50% lower per capita healthcare cost than does the US. I only mentioned Norway because they were the SECOND highest but still far lower than the USA. And besides if you go back a few years to the time unemployment was low the US had the highest healthcare costs then as well. I think we can throw out this strawman.

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  35. Silence

    @ Brad – agreed. The Germans have the Turks, the French have the North Africans & Levantines, the Brits have the Indians and Pakistanis. Not sure who’s going to Norway, but I do remember that being a motivation of that murderer.

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  36. bud

    If the US was either (1) spending less on healthcare than other countries or (2) living longer then there might be some grounds for defending the pre-Obamacare system. But since neither is true and really not even close then we can categorically say we have a problem. The old adage that if it aint broke don’t fix just doesn’t apply.

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  37. Mark Stewart

    This is where I throw my hands up in exasperation.

    Our system of tying health insurance to the workplace is a dinosaur relic of a bygone century. The idea in an industrialized world was to pool the risk. That was then.

    Eveyone is up in arms about the poor and the lazy. Those people will always be that – in any system. What our healthcare “system” does is force people to make economically irrational choices that are counter-productive to long-term productivity and wealth creation. Too often people take jobs with big (or bigger) businesses, or governmental agencies, for the benefits – healthcare coverage being the primary one – when what they really want is to be entreprenurial and adaptive to an ever-changing economic landscape. That’s not easy to do with families as dependant on health insurance as they are on fire or auto insurance for risk mitigation.

    Our current lack of portability of health insurance is a major, senseless drain on our nation’s inovation and economic growth. Bottom line.

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  38. Bob Amundson

    Lynn, Utah’s Health Exchange system is a free market system that satisfies the consumers in Utah. No surprise for such a conservative state. That system would not work in Massachusetts, just as the Massachusetts system would not be accepted in Utah.

    One size fits all is often an issue with public policy. In areas of Child Protective Services, Child Support Enforcement, Housing, Medicaid and other social programs, the Federal Government sets guidelines and provides funding, but the specifics are left up for the States to decide.

    As a senior public administrator (in all four of the above areas), I sometimes wished the “Feds” would give me more guidance. But that was often due to unclear regulations and expectations from Federal bureaucrats. The key to making any system, or business, work is to hire the best and the brightest.

    The best and the brightest are leaving government employment in droves, leaving “drones” to do the work. To me, that is the problem with the system, not so much as the details of how the system is supposed to work. Bright people MAKE systems work.

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  39. Brad

    Yeah, probably because of those “Stand Your Ground” laws…

    OK, sorry, bad joke. It’s just that Burl’s a newspaperman, and therefore understands newsroom gallows humor.

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  40. Lynn

    Bud Amundson. The last I checked about a month ago, Utah Insurance Exchanged covered between 5000 to 6000 folks employed by small businesses. Individual are not allowed to participate. Its a voluntary plan and it is simply a matter of time before adverse selection sends it into a death spiral. All voluntary exchanges have failed in less than 10 years.

    Review the efforts of NJ to reform individual and small group insurance and you see what happens…on the sick sign up and premiums rise quickly.

    There are about half dozen states that have a re-insurance mechanism to manage unexpected high health care cost patients that have insurance through state programs but these programs are small and their success is limited because the reinsurance is limited.

    The only two states I know having luck are Maryland and Mass. Maryland has an all payer rate review system to pay hospitals and it has been somewhat successful in managing premium increases.

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  41. Herb Brasher

    If we need anecdotal evidence, I can provide plenty of it. I’ve got Canadian friends, British friends, German and Swiss friends, etc. And none of them, absolutely zero, want our system, and they cannot figure out why we do.

    The first problem is not access to health care, but how we pay for it. Sort that one out, and we can provide access. The mandate has to be in there first. If the Supreme Court guts that, then there’s little hope for any progress.

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  42. Tim

    Brad,
    Not sure if that was a personal endorsement, but in any event I will contact an actuary to let them know I am okay.

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  43. Steven Davis II

    Brad, would you say Norway’s immigration problem is greater than the one in the United States? Can children of illegal immigrants enroll in schools or can illegals just walk in and get free government/taxpayer provided medical attention? If you’re going to take the reason of one mass murderer that’s poor investigative journalism.

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  44. Steven Davis II

    If you believe the unemployment rate is currently 8.6%, then you’ll be glad to know that it’ll reduce dramatically when they toss all of those people who’s benefits have expired out of the system. I bet that’ll drop at least a point off the number of unemployed in this country. Obama can brag about how he’s reduced the number of unemployed people by hundreds of thousands.

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  45. Bob Amundson

    Lynn, you’re right that the Exchange is for small businesses. I was oversimplifying and should not have.

    I think you know something about the entire system, and I’m not sure a fair explanation of the entire system is appropriate for this blog. But the fact is, it is a system that is working for the people of Utah. But Utah is unique because of the LDS Church’s welfare system.

    My opinion does not change. One size fits all is problamatic, unless it is universal coverage. That’s not going to happen anytime soon.

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  46. Silence

    @ Bob- Folks out in Utah seem to be pretty industrious, their symbol is even a beehive.
    I think Tenncare nearly bankrupted TN.

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  47. `Kathryn Fenner

    Who said Brad was an investigative journalist? You have him confused with John Monk and Corey Hutchens.

    Brad readily disavows any claims to investigative reporting.

    Now, Steven Davis is quite the Enquiring mind!

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  48. Scout

    I’m going to say something stupid here, I suspect. I’m not a lawyer, but this argument makes about as much sense to me as the broccoli argument that people, including supreme court justices, keep bringing up, so I’m gonna say it. Isn’t it illegal to run around naked? Isn’t there, then, an implied government mandate to purchase a product: clothes. I realize public decency laws would be state or local rather than federal – so it would not be a constitutional question. But still, would this not be, in it’s simplest form, a precedent where a universal human need is correlated with a government mandate to purchase (or at least acquire in some fashion) a product?

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  49. Doug Ross

    As I understand the individual mandate, we need all the people who don’t need to buy insurance to lower the cost for people who really need insurance rather than expect those people who need it to pay their fair share.

    It’s like asking a 120 pound guy to pay for the hamburger that a 300 pound guy wants to eat.

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  50. `Kathryn Fenner

    @Scout–good analogy. Paul Krugman writes today that health care doesn’t work with the broccoli analogy, because you get health care whether you pay for it or not.

    Now, if you have assets, they will come after them, and sooner or later they will get them. The issue is that plenty of people don’t have sufficient assets, and that there is also a lot of frictional inefficiency in collecting bills by seizing assets.

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  51. Brad

    There is no such thing as a person who doesn’t need to buy insurance. There are only people who are too stupid to know they need to buy insurance.

    Yes, there is the occasional miracle person who never needs medical care in the course of his life and dies suddenly in his sleep. That is, I hear there are such people, although I’ve never known one.

    But the other 99.999 percent of the population will need the coverage at some point. Therefore they all need to be in the system so that we’ll have the resources to pay for them when they need it just the same as for everyone else.

    This, of course, is the biggest barrier I have to communicating with you, Doug. You think there are definite different groups of people who have no interests in common. You think that a group of people who will never need medical care, and you get indignant that they have to pay for all those other horrible freeloaders. And the drag on the economy of having sick people who can’t pay for their care is invisible to you.

    I know the world doesn’t work the way you think it does. We have roads and schools and other services because they benefit the entire community, not just specific individuals. And we need universal healthcare for the same reason. Because it makes for a healthier, more functional and more vital economy for all of us to live in.

    But if you think of the world as “me on one side, then everybody else on the other,” then you’ll never accept that obvious truth.

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  52. DixieViking

    We can’t rely on the Federal Government being able to actually operate Obamacare.

    We need to find some means to provide medical help to those who cannot afford it and/or refuse to buy medical insurance.

    Why not open Free Medical Clinics in poorer Urban Areas and in distant rural areas?

    Or use an existing program, such as the VA Hospitals or Medicare, expanding as needed.

    In every instance, financing this would be from Taxes, not Fees or Premiums.

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  53. Brad

    As I’ve written a number of times in the past, our system is lousy for everyone, not just the uninsured poor.

    To take but one aspect of what’s wrong with it — we have millions of people clinging to dead-end jobs because they fear losing the benefits they have. We need to set our economy free — give people the courage to go out on their own and create new businesses — by divorcing health care from employment. Everyone needs good coverage that they cannot lose, no matter what kind of work they do.

    Our system is bad for society as a whole, not just this or that poor person.

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  54. Lynn

    Jeff Morrell: Europe has about the same size population as the US. The English speaking countries: New Zealand, Australia, Canada, Ireland, and Great Britain in total have about the same population as the US. You can find comparative analysis of health care at the Commonwealth Fund website or the OECD website.

    The basic argument is whether you believe health care is a public good that benefits all people or it is a private good that benefits a single or few individuals. Europeans see health care as a collective or public good that all need and therefore all pay for via taxes. In the US health care is a private good. I’ve got mine to heck with yours. To the best of my knowledge broccoli is a private good.

    Excellent discussion thread.

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  55. bud

    It’s a shame we can’t give Obamacare 10 years to see how it works then revisit the issue. If it turns out to be the big disaster the GOP/libertarians say it will then we can change it then or tweek it as necessary. The standard would be to compare cost/outcomes with what we had in the Bush administration.

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  56. Burl Burlingame

    While catastrophic health occasionally comes into play, by far the biggest need is in the small stuff — preventative and minor injuries. Those who get affordable treatment for colds don’t wind up in emergency rooms with pneumonia, nor do they miss work.

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  57. `Kathryn Fenner

    Ah, but Burl–you hit on part of the problem. There is no treatment for colds other than rest and liquids. The cold virus is immune to medical intervention. If people would stop consuming unnecessary medical care, perhaps there’d be more affordable care for those who need it–and fewer antibiotic resistant bugs!

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  58. Silence

    @ Brad – I agree that the current system of employer-linked healthcare is lousy, but I disagree that there is no such thing as a person who doesn’t need to buy insurance.

    You go on to state that “99.999% of the population will need the coverage at some point.” This is also not neccesarily true. 99.999% of people might need health care at some point, but that doesn’t mean that everyone automatically needs to buy insurance. People who are young and healthy tend to consume very little healthcare, and some folks might be better off pocketing the money. People who are very very wealthy can afford to pay for treatment out of pocket, and also don’t need insurance.

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  59. Silence

    @ Burl – what treatment for colds? A portable humidifier and some ‘tussin, vicks vap-o-rub, a salt water gargle, pseudofed if you can get it? Don’t need a doctor for a cold. Colds are viral.

    Reply
  60. Silence

    @bud – Not to pick on you today, but: “It’s a shame we can’t give Obamacare 10 years to see how it works” What non-working federal program EVER went away?
    The answer would always be the same: “It will work, but it just needs more funding!”

    Reply
  61. Bob Amundson

    DixieViking, there are free/sliding fee clinics in urban and rural areas. A good example in Columbia is the Eau Claire Health Cooperative. Most are non-profits that receive much of their money from various government entities, but mostly the Federal Government. But they do rely on private funding; as you can imagine, the better they are capitalized, the better the quality of care.

    Reply
  62. Doug Ross

    “As I’ve written a number of times in the past, our system is lousy for everyone, not just the uninsured poor.”

    By “everyone”, I assume you mean only the minority of people who aren’t happy with the insurance they have or those who don’t have it.

    There are TENS OF MILLIONS of people (government workers, union workers, high tech workers, etc.) like me who are happy with the insurance they have and don’t want to give it up for a system like Medicare which has a horrendous record for monitoring waste and fraud.

    I worked for three companies last year. All had decent insurance and at least 4-5 choices in terms of coverage plans available to all. Two of those companies employ well over 100,000 people.

    Do you seriously think that people working at IBM, Microsoft, etc. want to switch to a government run system?

    So rather than say “everyone” just stick to what you mean: “me”

    Reply
  63. Doug Ross

    ” by far the biggest need is in the small stuff — preventative and minor injuries. ”

    Well, maybe people should allocate their money for dealing with small health issues FIRST before buying TV’s, cellphones, etc. If you can afford a $300 phone and a $75/month plan, you can afford a $300 doctor’s visit if you are sick.

    Insurance should be for emergencies not office visits.

    Reply
  64. Brad

    Doug, I know I’m not going to get anywhere with you about this, but for the sake of those who are susceptible to understanding this.

    It isn’t about you. It isn’t about me. It isn’t about this individual or that individual, or whether they think they have good coverage or not, or (if they are foolish) think they don’t need it at all. It doesn’t matter. This isn’t a consumer matter.

    What it’s about is the best, most affordable way to make sure everyone is covered, not because it’s good for this person or that person, but because the entire society will function better if we have such a system.

    I really couldn’t care less whether you or I or the guy down the street thinks he has great coverage. That’s completely beside the point. This is systemic; it’s about how a complex thing like our modern society works and doesn’t work.

    This reminds me about one of the many moments that I got frustrated with Bill Clinton when he was president. I heard him on C-SPAN one day speaking with a bunch of policy wonks at some symposium or other speaking with great understanding of the need for a national health care system, and he did so in intelligent terms, having to do with the dynamics of a complex modern economy. One of the points he made, for instance, was how important it was for everyone to be prepared to move seamlessly from job to job without having to worry about such peripheral concerns as to whether their families had health coverage. What he had to say was erudite and compelling, and exactly right.

    This was while we were all waiting for his wife to come up with the plan.

    Later, when it was time to present the actual plan, I saw him take the dumbed-down approach, appealing to individuals as self-absorbed individuals: Like a late-night insurance pitchman, he held up a card and said YOU will each get a card like this, and you always be taken care of, and nobody will ever be able to deny YOU coverage. In other words, he pitched it in terms reminiscent of the standard Democratic “I’m going to fight against THEM for YOU” pitch.

    And Harry and Louise knocked it out of the park with their own appeals to self-centeredness.

    Maybe I’m too hard on him. Maybe you do have to explain complex systemic concepts in simplistic “how it affects YOU” terms. But explaining things to people that way leads to trouble — I point to the Bush administration’s overemphasis on WMD (because people understood that as a threat) before the Iraq invasion.

    In any case, Clinton’s stooping to explain didn’t work; Hillarycare died soon after.

    Reply
  65. Brad

    Doug’s a consultant of some sort. He does clever things with computers.

    But it would probably be interesting to do a study of the universe of all people who had three jobs last year, to see how many even had the chance to obtain ANY kind of medical coverage at ANY of the jobs, much less coverage at ALL of them, and much, much less SATISFACTORY coverage at all three of them.

    It would probably work out to be Doug, and one other guy who does the same sort of thing he does for a living.

    OK, I exaggerate a bit. But that subset would be tiny.

    Reply
  66. Silence

    @ Brad – I think there’s a bigger systemic issue than simply creating a national system of paying for health care. It’s that we’ve separated the function of paying (or not paying) for health care from the individual and tied it to work or, increasingly, a government program.

    You need car insurance if you have a car. You need fire insurance if you have a home. You need life insurance if you have dependents.

    The reason you can afford all of these insurances is because the market has built a system that generally people can afford and that provides an acceptable benefit that is in-line with the premiums paid.

    By decoupling the payer from the consumer in the health system, we’ve created a system that is out of sync. It’s a lot like a traditional pension system in that both are unsustainable without a lot of employer subsidy. In very flush times, this can work for a while, but ultimately the load will either break the organization, or get shifted back to the employee/consumer. We’ve already seen this with employers adopting 401(k)’s instead of traditional pensions, and with employees being required to pick up an ever increasing portion of the tab for their health insurance.

    Now granted, there’s a limit to what your auto/home/life insurance might have to pay out. Damages are capped by statute, and a vehicle or structure can always be totalled in favor of a new one. Obviously you can’t do that with a human body. That being said, I think most health insurance plans do have a lifetime maximum.

    Maybe the health care market is already too distorted for private personal insurance to work, but I doubt it. If we wanted to, we could gradually wean the health care system off of the government/employer teat, and usher in a system with more reasonable expenses, which they would be, if more people paid for their own health insurance or care directly.

    People need to realize that on average you can’t take out more than you pay in premiums over your lifetime. That’s what’s going on now with medicare, the premiums are really too low over a working career to cover the high cost of the final years. But the money’s been there for years now, helping to facilitate demand and push up costs.

    Go ahead and give me that extra test doc – it’s covered.

    Reply
  67. `Kathryn Fenner

    An otherwise smart friend of mine who was self-employed went without health insurance for some time. She basically decided she wouldn’t go to the doctor so she wouldn’t be diagnosed with anything (her mother didn’t go to the doctor for more than ten years after the birth of her youngest child and when she did, she was diagnosed with breast cancer, which she beat). I kept trying to get her to see that she could be in a car wreck that was her fault or otherwise un- or under-insured, or in some other kind of accident, and when she woke up in the hospital days or months later, have the kind of medical bills where they take your house (she lives in Heathwood–house poor).

    No one is immune from incurring medical bills. The young may not get diseases as readily, but they do get in accidents with greater frequency, and when you are unconscious, you can’t decline treatment.

    Reply
  68. Silence

    @ Brad & Doug – I know what Doug does, I found him on LinkedIn. I was actually trying to make a joke. Maybe it was not funny, and I apologize to you Doug. It looks like your previous job tenures were rather lengthy.

    Reply
  69. SusanG

    @Silence
    ” 99.999% of people might need health care at some point, but that doesn’t mean that everyone automatically needs to buy insurance. People who are young and healthy tend to consume very little healthcare, and some folks might be better off pocketing the money.”
    But young, healthy people get cancer, brain tumors, have car accidents, etc. Those bills would have to be paid, and it wouldn’t be by that person, as there’s not enough money in their lifetime bank account to pay for it.
    It would be OK by me if the gov’t provided assured major medical coverage (or reqd that I buy it), and I was responsible just for the gap — and could either buy insurance to cover that gap or choose to go it on my own.

    Reply
  70. `Kathryn Fenner

    @ Silence–you hit on one of the more troubling aspects of health care spending:

    I get into a car wreck and I can fairly readily see what needs to be done to repair my car. I can choose to live with a few dents, or not. The law requires some repairs (Windshields?).

    My house burns down. I can see what needs to be done to restore it.

    Say I have abdominal pain (something I actually have fairly frequently). I can scour the interwebs for guidance. I can go to my GP. She sends me to a GI guy. He runs tests, or he tries medicines, or we tinker with my diet….I believe in my case I have figured out what the problem is (after three decades), but what if I’m wrong this time and it is ovarian cancer or appendicitis or …. and what if my doctor is wrong? A lot of medical care is such guess-work. I prefer the kind of doctor who is conservative about ordering tests, but many people HAVE TO KNOW. The rise of the whole body scan industry plays into this. Until we get those jobbies they had on Star Trek, it’s going to be hit-or-miss.

    Reply
  71. Brad

    I reject the idea that the individual is shielded from the cost of health care.

    I last had coverage that had low deductibles and no co-pays sometime in the 1970s.

    Then, the people who run insurance programs — and politicians — said, “People are too insulated from the cost of their health care. We need to do something about it!”

    And did things about it:
    – They raised deductibles, often to more than a person would spend in a year unless he had cancer or major surgery or some other catastrophic occurrence.
    – They introduced co-pays, and within a very short time the co-pays for doctor’s visits and prescription drugs were higher than the total cost, without insurance, of those items in my younger days.
    – They came up with Flex Spending Accounts and Health Savings Accounts to enable us to put money away, in a tax-free way, to pay the increasing out-of-pocket costs that even those of us with “good” insurance routinely have to pay.

    I don’t think any of those were bad things to do. I think it was a good idea for people to have to pay something for their health care, and most of us pay more than just “something.” We pay amounts that generally exceed the total costs of such care a generation ago.

    My point is simply that the “people are insulated from the costs” problem has been addressed, and addressed aggressively.

    Reply
  72. Brad

    That said, the real dynamic to look at is what is happening that’s driving costs up so dramatically that the co-pays (which as I say are often more than we paid for the same service a generation ago) are only a fraction of the total cost. Some of it is indeed the cost of R&D for wonderful new treatments, the cost of truly life-saving technology and the like. But I doubt that all of it is.

    A colleague suggested, years ago, a drastic cure for the problem: eliminate all kinds of medical insurance, whether private or a government program, and let the market find prices it could bear. In other words, the idea wasn’t that we, the patients, weren’t paying enough through our premiums, co-pays and deductibles, but that the additional amounts paid by private and public entities were simply acting as price supports sending the overall cost of health care higher and higher.

    I think there was some truth in that. If all of a sudden NOBODY had coverage, one of the results of the chaos that would ensue would be that providers would accept lower amounts as payment for goods and services. Of course, you’d also see a whole lot of other effects, such as a sudden shortage of anyone out there to provide care at any cost (you’d see doctors out selling real estate or something that paid better), and people would die from lack of care. Doctors and hospitals probably wouldn’t be able to maintain their practices purely on the basis of the few who could fully pay the actual cost of modern care.

    But it was an intriguing idea…

    Reply
  73. Doug Ross

    @Silence

    I left one job for another (promotion). The small company I moved to got bought by another company (promotion). Thanks for asking.

    My son got a job starting this week. He had the choice of three medical plans with varying coverages. The high deductible plan was $26 a month. $3000 out of pocket max.

    All I ask is that you guarantee me and the millions of people like me that your system will be the same but cheaper or better at an incrementally higher cost. Can you do that? Can you tell me it will work better than Medicare? Can you tell me that I won’t see bills any more or that the information systems that support the new model will be as easy to use as what I have now?

    The best solution is to let anyone who wants to do so to enroll in the same insurance plans that government workers have and pay the same rates.

    Then deal with those who can’t afford those rates by giving them vouchers to buy in. Fund those vouchers with direct cuts in the defense budget.

    Reply
  74. Doug Ross

    @Brad

    Do you deny that government employees and many union workers have good to very good insurance?

    Do you deny that there are tens of millions of people working for companies who have insurance that they are happy with?

    Start with IBM, Apple, Oracle, HP, Microsoft, Cisco, Google, and the big four accounting firms. You think they have employees bitching about insurance? How about Coca Cola and Pepsi? IBM employs over 400,000 people.

    Again, go around and ask working people if they are happy with their insurance or not. If they are happy, can you guarantee a better system?

    The transition to single payer would cause so much instability in our economy that I don’t think anyone can comprehend it. You want entire companies to go out of business. You want highly skilled doctors and surgeons to become government employees. THEY WON’T DO IT. How hard is that to understand? They will opt out and work out private arrangements or quit altogether. What are you going to do then? Force them to operate under threat of prosecution?

    Reply
  75. bud

    Maybe I’m too hard on him. Maybe you do have to explain complex systemic concepts in simplistic “how it affects YOU” terms.
    -Brad

    Damn right you’re too hard on him. How could you possibly sell anything if you don’t demonstrate how it will help individuals. The whole systemic argument may be appealing in a debate club but to voters they want to know what’s in it for them. And they should. I would be with Doug if I thought Obamacare would be detrimental to me. But I don’t think it will be. Nor do I think it would be for Doug either.

    Reply
  76. Doug Ross

    @Silence

    Oh, and I guess through you cyber stalking you found out I am who I say I am.

    Go ahead and link to me on linkedin and let me see who you are. Or friend me on Facebook… I don’t have anything to hide. (As Katheryn and Phillip both know).

    Isn’t it amazing that a person can actually say what he believes and not hide behind an alias?

    Reply
  77. `Kathryn Fenner

    In defense of those who would be more anonymous: I can say what I like–my husband has tenure and I work for no one. Others do not have that luxury. I have had some great things happen because I know Doug, Karen McLeod and especially Phillip. People I know and some I don’t have come up and told me they appreciate what I say.

    At the same time, I doubt I could be elected to an office, for example, with some of what I’ve said on the record.

    Reply
  78. Brad

    It is indeed a wonderful thing. And I continue to be proud of Doug for being a trend-setter in this area. Early on, I put out an appeal to my regulars to use their real, full names, and Doug was one of the first to take me up on it.

    That’s why he’s a made guy on this blog.

    Reply
  79. Doug Ross

    “At the same time, I doubt I could be elected to an office, for example, with some of what I’ve said on the record.”

    And I ran for school board in District 2 in 2002 and finished last. So I know where I fit in terms of the general public.

    Reply
  80. Silence

    In deference to my spouse and her career, i need to stay anonymous as a blog commenter. It also lets me troll a bit more than i might otherwise. I’ve met a few of ya’ll at one time or another though, and i dont mind “the regulars” knowing my secret identity, as long as it doesnt interfere with my superhero moonlighting. I just cant be ” out” and still comment like i would want to. Someday, maybe. Other than my name though, ive never misrepresented who i am, and i’d meet any of the regulars here for debate, beers and trivia.

    Reply
  81. Bob Amundson

    I think many, if not all, policy experts believe that IDEALLY the USA would have a single payer system (not necessarily the Federal Government) the covers everyone universally.

    PRACTICALLY, it will never happen. In Germany, sure. However, the German acceptance of collective allowed someone like Hitler to come to power, with incredible support for a very evil man. I believe the American fear of the collective, expressed as individualism, insures we will never have a Hitler lead our country.

    So in the United States, there must be a solution different than in Europe. Quoting Scott Rasmussen, “… it’s the belief held by most Americans that competition will do more than government regulation to reduce the cost of health care. For something as fundamental as medical care, government policy must be consistent with deeply held American values. That’s why an approach that increases consumer choice has solid support and a plan that relies on mandates and trusting the government cannot survive.”

    Reply
  82. Lynn

    How we finance health care drives how we structure delivery of care. Who is allowed to care for you and who is allowed to bill for that care. In the 1950s thru 1970s insurance paid for professional services (Major Medical, Medicare Part B) and hospital inpatient services and some outpatient services such as lab and x-ray. Because insurance didn’t pay for routine outpatient care, Drs would admit patients to the hospital for a 3 to 4 day diagnostic stay. Insurance plans wised up and began to pay for outpatient services. Then Drs began to provide lab, x-rays, MRIs, and outpatient surgery. Compete with hospitals.

    Medicare coverage for seniors allowed hospitals to expand capacity because they could pay for bonds with Medicare revenues. Intensive and critical care boomed.

    Part of what we pay in insurance premiums (either directly or through employers) is prepaying for services we’ll use and part is catastrophic insurance (true insurance) for expensive unexpected events. Insurance is not a reasonable/rational way to pay for expected or planned care but ideal for true catastrophic events. A fragmented financing system has led to a fragmented delivery system that is difficult for patients to navigate.

    Lastly there is excellent research documenting that communities with high levels of uninsured patients have overall lower levels of health care quality. The quality of care your neighbor receives determines the quality of care you receive.

    The objective is to have the right care to the right person in the right setting at the right time for the right price. Why can’t the US figure this out is beyond me.

    Reply
  83. Brad

    Lynn, I’ll explain it: Ideology über alles.

    In this country in the 21st century, ideology trumps reason pretty much all the time.

    The most dramatic, and most harmful, example of this is our refusal even to consider having a rational health care system.

    If I were a Brit or a resident of any of those other countries that are less cursed with such ideology, I would regard us as mad. And on this point, I’d be right.

    Reply
  84. `Kathryn Fenner

    Ha-whoa Bob! Have you any experience with modern Germans? I can think of no people less likely as a group to line up behind a Hitler than modern Germans. They are drilled from an early age in the kinds of ethics and philosophy that does as much as possible to preclude any future Fuehrers.

    Now, southerners–not so much.

    Reply
  85. Bob Amundson

    Kathryn, in no way was I trying to imply modern Germans would allow another Hitler. I was just trying to make the point that Europeans as a whole think differenty than Americans, then and now.

    Reply
  86. bud

    In this country in the 21st century, ideology trumps reason pretty much all the time.
    -Brad

    Now there is a statement I can agree with. That’s why we have this conservative war on contraception and abortion. It’s also why we march to war for no reason at all in places like Iraq, Syria and probably Iran. And let’s not forget the who ideologically based war on Obamacare even though large majorities favor the individual parts of the bill. Yup, 21st century ideology trumps all if you’re a conservative.

    Reply
  87. Brad

    Hate to disagree when you’re trying to agree with me, but first, there is no “war” on contraceptives. There is a current controversy over the subject, and it was started by the left, when the Obama administration tried to force private entities to purchase contraceptives for others through their private insurance plans.

    Just to make sure we’re completely clear on what happened.

    Reply
  88. `Kathryn Fenner

    Actually, Brad, there is a war on contraception, and Santorum is the general and the US Catholic Bishops his troops.

    Reply
  89. Brad

    No, ACTUALLY, there isn’t. Neither Santorum nor the bishops seek to change anything. They are objecting to being forced to do something they don’t believe in, which would constitute a change in the status quo.

    Why is this so difficult to understand?

    Reply
  90. Mark Stewart

    Brad,

    I think you know better than to say “and it was started by the _____”; all of these ideological flashpoints have no beginning or end – they just mutate in the malevolence/mistrust spin cycle.

    Reply
  91. bud

    Bud started it.

    And proudly so. Seriously though there is a bit of war on hormonal contraceptives. The current battle lines are drawn at the church/state divide. But if General Santorum with his bishop minions succeeds there then we move on to the next battlefield. This really is a slippery slope.

    Reply
  92. Scout

    Maybe the bishops don’t want to change anything – but Santorum seems pretty keen to change a lot of things.

    If you follow Santorum’s ideas through to fruition, you get a world where large families are supported by a single working class paycheck (since Dad has not been to college and Mom should stay home with the many kids they have since they don’t use birth control). Probably a few of their kids will have special needs, since older mothers giving birth (which will happen with no birth control) will be more likely to have children with developmental problems. The mother will probably be at a loss as to how to educate her special needs kids since Santorum also wants the federal government out of the public schools, so there goes special education. Sounds like a fun life for everyone.

    Reply
  93. `Kathryn Fenner

    Because you don’t get to say what legally prescribed drugs your employees take, and if you pay for some, you cannot choose not to pay for all. What if ADCO decided it didn’t believe in asthma medication?

    If you don’t believe in using contraceptives, don’t use them. Stay out of other people’s medical business.

    Reply
  94. Brad

    You’re kidding, right? When I had really “good” insurance at the paper, it wouldn’t pay for the one antihistamine that did me any good.

    So what would be new about that? Insurance plans decide all the time not to cover certain things.

    If you want the consequences of elections to decide what gets covered, push for single payer. But no, you don’t get to tell a Catholic institution what it will support and what it will not. That goes to the very core of freedom of conscience.

    And it sets up a clarifying contrast to these people who think their freedom is being threatened by being required to buy health insurance. Sorry, but unless you’re a scientologist or maybe a Christian Scientist (and this is a stab in the dark; I know little about whether either would believe this), you really can’t claim to conscientiously object to health insurance. Freedom of conscience doesn’t come into it.

    Reply
  95. Steven Davis II

    “When I had really “good” insurance at the paper”

    So the insurance at ADCO isn’t worth a damn?

    Reply
  96. Brad

    It’s good for a small business. But you don’t start getting any decent economies of scale until you get over 500 employees or so.

    Which is why I want a single-payer plan, so that I can be in a risk pool — and cost-negotiation pool — with 300 million people. THAT would be good insurance.

    But note that I put “good” in quotations. Even on the McClatchy (and before that, Knight Ridder) benefits, which I knew were better than average, I could see how much better off everyone would be with single-payer.

    As I wrote back at the time, I’ve always thought the emphasis was wrong to keep talking about the uninsured. We would ALL benefit, not just as individuals, but from a much-vitalized economy if we divorced benefits from employment.

    Reply
  97. Steven Davis II

    So what nobody is talking about is how those who don’t have two nickels to rub together are going to be forced to pay insurance premiums or go to jail.

    Would this plan have Warren Buffett paying the same rate as the guy living at Oliver Gospel Mission? Would the two get the same level of care? If not, how is this different than what we have now? Insured and Medicaid.

    Reply
  98. `Kathryn Fenner

    I’m totes down for single-payer and have been forever, at least since I was 21 and got state of the art care in Canterbury, England.

    Reply
  99. Silence

    “Stay out of other people’s medical business.” Kathryn Fenner, April 2, 2012 at 5:22 pm.

    Yup, that’s what this whole Obamacare/Single Payer government run health system is about – and I couldn’t agree with you more, that the Gov’t should stay out of other people’s medical business! I’m glad we agree!

    Reply
  100. Scout

    Steven,

    These are my understandings of the way it is supposed to work in regard to your points. I’m not 100% sure, but I suspect others will help if this is not right.

    First, the choice will not be pay insurance premiums or go to jail, but pay insurance premiums or owe a penalty. Second, the insurance exchanges that will be created are supposed to be able to generate much more affordable policies than is typical right now – so presumably there will be some level of affordable coverage even for the poor. Third, what we have right now is not “insured and medicaid”. What we have right now is insured, UNINSURED, and medicaid. There is a large pool of part time, temporary, self employed, etc. workers, or people who work for employers who can’t/don’t offer benefits for whatever reason who are not insured. Most of them make too much to qualify for medicaid but cannot afford insurance on their own due to the ridiculous prices of individual policies under the system as it is right now.

    This plan would offer a lot of different choices. Warren Buffet and Oliver Gospel Mission guy could choose the same plan or not – it would be up to them, except that I think the exchanges are by state, so unless Warren moves to SC, maybe they wouldn’t have the same exact choices. Warren would probably keep whatever he’s got now, since I imagine it’s pretty good, and that also is an option under the law.

    Reply
  101. bud

    We’ve probably run this topic into the ground but one last comment is in order. Given the great progress the developed world has made in reducing the population growth over the last 50 years doesn’t it make sense to make it as easy as possible to continue providing the best birth control at the lowest price? I just don’t see why we should allow something as out of touch with reality as the Catholic Bishops to thwart this progress. Birth control should be free to all who want it. If we’re not going to do that with single-payer then the next best thing is a requirement for ALL businesses to make it available. If we don’t continue to keep birth rates low then the worlds population will make any decent quality of life unattainable.

    Reply
  102. Scout

    My reasons for being anonymous are probably not really necessary. I’m probably being overly cautious. I suspect that my positions are more liberal than most of the people I work with and I don’t want to do anything that will jeopardize my working relationship with other teachers because how well I can serve my special ed students often comes down to how well I can work with and enlist the cooperation of the reg. ed. teacher who is actually spending more time with the kid, often. Probably most of the people I work with don’t read sites like this anyway and I don’t know how many of them would care or let a difference of opinion affect a professional relationship, if they did (but it doesn’t seem out of the question for some of the people I know). But at any rate, it’s not been something I have wanted to find out, for among other reasons, I tend to have a personality that likes to avoid conflict and confrontation. Except that I have been driving to work with a Sheheen sticker on my car for a year and a half now so I guess anybody that really is paying attention probably knows.

    Reply
  103. Brad

    Yeah, and I DISagree, which makes me consistent, unlike my liberal friends.

    That’s one reason I can’t ever be comfortable with left or right. When you set one group’s positions down side by side, they don’t work together. Not for me, anyway.

    Abortion and related issues (morning-after pills, stem cell research) put liberals in the awkward position of sounding like hyperlibertarians, and all about private over public, when they are that way with very little else.

    Reply
  104. Silence

    @Burl – Good guess, but no! I don’t even like ethnic food, unless it’s Italian

    Although I do like strip clubs, so that would be a similarity between me and the “First Gentleman.” I don’t really ever get to go to them anymore, so that would be a difference.

    Reply
  105. Steven Davis II

    “at least since I was 21 and got state of the art care in Canterbury, England.”

    Just another rich kid who was sent to Europe to “find herself” after college.

    Reply
  106. Silence

    @ bud – we agree again on something.

    I’ve always thought that the reason different religious orders oppose birth control is because they are trying to grow their own flock, overpopulation be damned. Of course, a sect with no sex would cease to exist. I think that’s what happened to the Shakers.

    On the other hand, you have the quiverfull movement (Duggers) and LDS and Catholics who typically have crateloads of crotch-fruit…And they aren’t going to die out anytime soon…

    Reply
  107. Nick Nielsen

    Days late and and dollar short though it may be, I’d like to bring up a point that I didn’t see in the discussion (although I may have missed it).

    One of the reasons for our rapidly escalating medical costs is that, while health insurance is not universally available, health care is. Doctors and hospitals don’t turn patients away because they have no insurance or can’t pay, they treat them and worry about payment afterward. And, in the same way retailers pass the costs of shoplifting and spoilage along in higher prices, medical providers fold their losses (e.g. treatment costs for those who can’t pay) into their billing rates.

    In short, the current American health-care/insurance system is a vast wealth-transfer scheme in which those who have health insurance are forced to pay for the health care of those who don’t. How is this not the “socialism” derided by current self-proclaimed conservatives? Yet those same “conservatives” want this system to remain in place and are fighting to defend it?

    It makes no sense.

    Reply

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