A Realistic Health Care Alternative Going Nowhere

Mark of New Jersey

Mark is a Founding Editor of The League of Ordinary Gentlemen, the predecessor of Ordinary Times.

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72 Responses

  1. willybobo says:

    Really useful thinking about this, Mark. Rather depressing conclusions about the likelihood of developing good policy around an issue both sides — for different reasons — seem to agree is hugely important to our economic and political futures.Report

  2. greginak says:

    The problem is the sausage grinder that is making laws. As you note the R’s are trying everything they can to kill reform. Many of the big stakeholders( AMA, hospital, pharma, insurance companies, etc) all have influence. So we have a situation where many options are off the table due to resistance from to many of the powerful players. If we were starting from scratch I don’t think anybody sane would attach insurance to employment. But as it is the R’s are actively stoking the fear of change even with keeping the link between insurance and employment. How do you go father with all the resistance there is? Getting some reform is a massive balancing act of avoiding pissing off to many of the powerful while still getting something that is an improvement.

    That said I have come to think a mixed system like France and Germany is good so I tend to think a public option is the right direction to head in. It is to obvious and sensible to mention in Serious Discussion but any system we put in will have to be tinkered with for a while.

    Once momentum starts for a plan that is possible to get passed, there is a problem with opening other options. That can turn into a delaying tactic meant at killing the process, which some R’s have openly said they are trying to do. There is also a period to get something passed, which all sides of the debate are aware of.

    “better than an individual-based system because employers have greater negotiating strength against insurance companies. This is simply not true,”

    Any large group has a better negotiating position then an individual in the insurance market. It doesn’t have to be an employer. But that is what we have. The only people who don’t need the bargaining power of a group are those who are healthy, for now, and the insurance company doesn’t think will cost them. It’s not about economies of scale but getting companies to insure people who they don’t want to insure.Report

    • Mark Thompson in reply to greginak says:

      I agree that larger groups have stronger negotiating power in general than smaller groups; it’s just that in the case of health insurance, that negotiating power appears to be relatively small.

      Beyond that, I think I agree with everything that you say here. Where I disagree, presumably, is in the implicit assessment that the option under debate will do more good than harm – I really do think that it will just wind up throwing the baby out without throwing out any of the bathwater.

      I actually have little problem with a mixed system, though – we already have one, to be perfectly frank, and we’re not about to go whole hog to a fully privatized system. The trouble is that until we decouple employment and insurance, I don’t think we can even get a better mixed system. As much as I’m opposed to a single-payer system, believe it or not, I can envision a number of scenarios in which it is an improvement upon our current system, if only because of the fact that a single-payer system would by definition decouple employment and health care. Unfortunately, I don’t see single-payer ever getting the kind of popular support necessary to get passed in the US; Wyden’s proposal strikes me as not only better on the merits, but also far more palatable to most Americans than single-payer….the problem is that it would still probably be unpalatable to too many people.

      I wish I knew how to overcome this dilemma.Report

      • Michael Drew in reply to Mark Thompson says:

        Overcome it by easing up opposition to the kind of incremental measures that are possible. What is the baby that will be thrown out?Report

        • Michael Drew in reply to Michael Drew says:

          Actually, more to the point is to ask whya public plan is the thing in particular that throws out the baby. It seems to me that the employer mandate is the thing that in your (Mark’s) formulation doubles down on bathwater.Report

          • This was bad wording on my part, which I hoped to clarify a bit with my first update.

            Anyways, a public option, of and by itself, doesn’t necessarily throw the baby out with the bathwater – I don’t think it will do very much good, to be sure, and I think it will not justify the cost, but it’s not a dealbreaker for me – I’d be okay with it if it came with a decoupling of employment and insurance.

            You are correct that the double-down in my formulation is the employer mandate. The bottom line for me is that the public option as constituted in HR 3200: 1. Is extremely expensive at a time when the national deficit is getting dangeroulsy high to begin with; 2. Reinforces the existing employer-based system, which is why our system is so messed up in the first place; and 3. Will only marginally increase access to care while ensuring that systemic costs (which are themselves one of the two central problems that result from the current system) continue to rise.Report

  3. Dan Miller says:

    “Yet this proposal, despite bi-partisan support, has exactly zero chance of going forward. It has, so far as I can tell, been largely ignored by grassroots advocates of health care reform, who have largely jumped on the “public option” bandwagon, however flawed that legislation will be if it is to become law. ”

    I don’t think this necessarily rebuts the criticism that the discussion here is irrelevant to the debate as it’s actually happening. Your second sentence in this paragraph follows logically from your first. I think most grassroots advocates of healthcare reform would be happy with the Wyden bill if they thought they could get it passed, but they don’t; so they’ve chosen to concentrate their efforts on an area where they see a hope of success. That’s an arguable position, but not a crazy one by any means (and of course these advocates disagree with you about the degrees to which the legislation currently on the table will make things worse).

    And sadly, I think they’re right about the likelihood of passage. First of all, this bill’s “bipartisan support” is pretty thin; there’s plenty of reason to believe that many cosponsors are using this as a fig leaf and would not actually support the final bill (see the reasoning here). And even if it attracted the support of cosponsors, the bill would prove more disruptive to current coverage–and thus, more open to attacks like the ones that brought down the 1994 bill. Like it or not, liberals took that lesson to heart, and you can hardly blame them for it.

    In short, the biggest efforts to a good reform of health care (which I think we all agree is necessary) are as follows:
    1. Institutional barriers to passage, i.e. the filibuster
    2. Political incentives–Republicans benefit if nothing passes, as it will be a costly defeat for Democrats and electoral politics is to a certain degree zero-sum
    3. The structure of public opinion–fear of change and loss aversion makes people less open to reform than they really ought to be; as a result, any prospective reforms have to either overcome this or work around it

    The best way to improve the likelihood of a good outcome is to attack one of these; other efforts, at this late stage in the game, seem to me to be counterproductive.Report

    • Dan Miller in reply to Dan Miller says:

      Gah. “The biggest obstacles to an effort to reform health care” should precede the numbered list. Sorry.Report

    • I guess the response I have, though, is that this puts us in a position where liberals supporting the public option are at least arguably supporting a plan that could very well do more harm than good while also foreclosing the idea of implementing meaningful reform.

      It may well be that Republicans are just supporting the Wyden bill as a fig leaf, but if the Wyden bill is in fact a better bill and the plan under debate is at least arguably worse than the status quo, why not throw caution to the wind and back the Wyden bill? At a minimum, the Wyden bill is something that won’t be subject to the kinds of increasingly effective attacks that have been made on Obamacare. Plus, it will be very hard for Republicans to demagogue a bill that a good number of them have supported.

      This could even turn into a situation much like, IIRC, the inclusion of women’s rights in Title VII. In that case, opponents of civil rights had, IIRC (my memory may be off on this point) inserted and supported women’s rights in the legislation in the hopes that this would actually kill the legislation as a whole. Instead, the move backfired completely and the result was a far stronger civil rights bill.Report

      • Put another way, pushing the public option over the Wyden bill very much legitimizes arguments against any reform at all, since those arguments would not have much (if any) validity against the Wyden bill.Report

      • Dan Miller in reply to Mark Thompson says:

        Well, I don’t necessarily share your dire assessment of the plans currently under consideration. But even if I did, I think you’re undercounting the effort that’s gone into this so far. Progressives made a strategic judgement that a public plan with an employer mandate was the best deal they could get, and they made it over the course of years–at least a portion of the Obama/Clinton primary was dedicated to hashing this out, for instance. Eventually, most members of a very fractious coalition pulled together enough to win two elections on this and introduce legislation, but the basis for that was built up over a long, LONG time frame. It can’t simply be turned on a dime; it’s more like a supertanker (if you’ll forgive a dip into cliche). To stop and simply switch priorities would blow apart a coalition that was painstakingly assembled with huge degrees of effort, and would start this process over at a moment when time is of the essence due to a limited legislative and political calendar.Report

        • Dan Miller in reply to Dan Miller says:

          I’d also add that part of the reason that any reform bill even has a chance is that it includes significant concessions to the insurance industry (a major flaw, to be sure), and thus there’s been limited business opposition. Want to bet we can’t get the same deal for the Wyden bill? In short, I think it’s mistaken to assume that the Wyden bill is on the table–there’s a lot of forces arrayed against it that haven’t shown themselves yet. I’d love it if we didn’t have to compromise with interest groups and the relatively uninformed public, but I think it’s possible to do better than nothing even with these compromises–especially given that the status quo is untenable.Report

        • Dan:

          I can sympathize with your point, and I understand that liberals don’t share my assessment that this proposal does more harm than good. That said, my point is more that the public option under discussion is, by your own admission, much closer to the line of not being good at all such that it’s subject to some pretty strong arguments that it will do more harm than good. I realize that liberals think that, even independent of the employer-based nature of the system, the private portion of our system is at least a secondary cause of our system’s flaws, but that’s an argument that is open to some pretty strong counterarguments, I think. This puts Republicans in a position where they can win by tackling what is far from the strongest argument for reform by doing little more than shouting “Wolverines!” Meanwhile, they’re still able to raise the spectre of people losing their existing coverage.

          I guess what I’m saying is that although plenty of work went into building a powerful coalition to push the public option, that work will be for naught if, in fact, the public option makes things worse or if it proves to be (as may well be the case) an issue that the Republicans can stop in its tracks.

          It’s a very high risk push at this point that may have very limited rewards at best. Liberals would be better off taking that exact same amount of risk to push for something with potentially very high rewards.Report

          • Dan Miller in reply to Mark Thompson says:

            But even if we concede you’re right for the sake of argument, that ship has sailed (and I am rapidly reaching my quota for nautical metaphors). It’s too late to change options; at this point, the only possible outcomes are a) some version of the House/Senate/Obama plan, however limited it ends up being or b) nothing. And so opposition to a) becomes support for b).

            It would be another thing if we could count on another effort to fix things if this one failed within a reasonable time frame. But we can’t–this really is a once-in-20-years shot. It’s not like the Republicans will try and pass universal coverage if they take over Congress; heck, most of them will oppose any effort to pass it, bitterly and with no quarter. So, with respect, the time for this argument passed in early 2008. At this point, oppostion to the Obama plan is the same as support for the status quo.

            On a semi-related note, I also think you’re underestimating the value of passing universal coverage. Even with significant concessions and poor cost controls, it would be a monumental achievement that would fundamentally reshape the politics of health care. Once we get universal coverage, we can leverage that fear of change in a much better direction, and the next reforms will be easier. It’s certainly got a better track record than failure to pass a bill this year (which would be the inevitable result of suddenly switching to the Wyden plan).Report

            • Well, in my case, if my only choices are what’s on the table and the status quo, then I’ll have to (very reluctantly) take the status quo. (FWIW, I have been writing about this stuff literally since I began blogging two years ago- health care reform was the subject of my very first two posts).

              To me, the employer-based aspect of our system is so far and away the biggest problem with the system that anything that bolsters that element of our system is destined to do more harm than good. I say this even though I’m 100% behind the idea of some form of universal coverage. We’re not talking chump change with this proposal, so it needs to be a pretty effective reform to justify those costs, especially when there are reforms that would be more successful for a lot less money.Report

              • Michael Drew in reply to Mark Thompson says:

                In the political environment we actually exist in, your insistence on decoupling or else the status quo is essentially a poison pill, rendering your arguments not worthy of consideration by those who want reform, even those who want decoupling but not at the cost of the status quo.

                Is your suspicion that what is being considered will do more harm than good grounded in your insistence on decoupling, or have you or someone else made “pretty strong arguments that it will do more harm than good” that are independent of that insistence that we can read and assess? Can you point us to those?Report

              • Michael Drew in reply to Michael Drew says:

                should have said “…even those who want decoupling, but not at the cost of retaining the status quo should it prove not achievable.”Report

              • That’s a fair question. I guess what I would say is that our system has two major but very closely related problems: cost and access, with the high cost dramatically increasing the lack of access. However, the quality of care in our system is top-notch.

                So far as I’m aware, almost everyone who’s looked closely at health care recognizes that the coupling of insurance and employment in our system is the root cause of those two problems. In essence, employer-based health care ==> high costs ==> poor access.

                A public option without decoupling attempts to treat one of those symptoms – access – but does not treat the underlying disease. In fact, the proposal that is likely to pass actively doubles down on that disease by mandating more employer-based coverage. So we may wind up with improved access, but only by increasing the already obscenely high costs, a good chunk of which will get added to the debt (another problem entirely). I suspect (but at the moment lack the time to prove) that some of those costs will inevitably be offset in the form of lower quality of care.

                A closely related problem to all of this is that, once implemented, this program will be essentially permanent. It may well address the access problem in the short run, but the long run unintended consequences and added costs to the system are going to be huge if it does not address the underlying disease (and, in fact, actively exacerbates that disease).Report

              • Michael Drew in reply to Mark Thompson says:

                I hate to sound like a broken record, but this:

                So far as I’m aware, almost everyone who’s looked closely at health care recognizes that the coupling of insurance and employment in our system is the root cause of those two problems. In essence, employer-based health care ==> high costs ==> poor access.

                is an argument by appeal to authority/consensus without any citation of the authorit(ies). That causes this statement:

                A public option without decoupling attempts to treat one of those symptoms – access – but does not treat the underlying disease.

                to beg the question. What I’m looking to do is fully vet for my own understanding the arguments and evidence that have you convinced the employer-based system is the cause or even the primary cause of high costs. It’s plausible, I’ll grant that, but so is the argument that physician and hospital pay structure play a role. That means there’s debate (at least in my mind, but maybe I’m just ill-informed) about what is the greater cause of those two or other explanations. In any case, you make good arguments once you proceed from your basic assumption, but I still haven’t seen the evidence for accepting the assumption.

                As a separate question, it seems to me that cost is an issue that will continue to assert itself until we address it. On the other hand, access (lack thereof to be precise) is in fact a problem that we can choose not to deal with for as long as we as a society see it as not an urgent problem. In my view, addressing cost now while unsatisfactorily dealing with access or not doing so at all, will precipitously lower the chances that we will ever deal with access (in our lifetimes, say). The shock to the system of reform that brings costs to an acceptable level will be so great that I don’t think there will be any energy left to addressing access, especially since doing so will necessitate another round of dealing with the costs associated with it. It’s better in my view to come as close to achieving universality as possible in the short run, after which the full nature of the problem of cost will be better understood. Then the simple limitation of available resources (or resources we wish to allocate to health care) will force us to deal with cost. Hopefully that will mean the end of employer-based insurance as well as changes to the medical pay structure. If we could do all of that now in one fell swoop, I would be for it.Report

              • There’s nothing wrong with challenging me on this. Admittedly, I’m not a professional economist, much less an expert on health care economics, so I’m not going to be able to readily provide hard data. But I would say that the old Ezra Klein piece I link to above includes some similar assertions about the flaws of employer-based insurance, including a statement from David Cutler that “essentially all economists believe that universal coverage should be done outside of employment.”

                Similarly, on the opposite side of the political spectrum, the Arnold Kling piece E.D. linked to on the sidebar this morning includes the statement “We will help the President convert the tax deductibility of health benefits to a refundable tax credit, as supported by economists of all political persuasions. ”

                So between Klein, Cutler (from his pre-Obama campaign days, at least), and Kling, you’ve got a pretty diverse group claiming that just about all economists agree that the employer-based aspect of our system must be addressed for any reform to be meaningful in the long run.

                While I don’t have any good hard data readily available to me, the problems with an employer-based system are fairly intuitive, I think. Separating the consumer and the customer creates a perverse incentive for the denial of treatment, which means that treatment has to be paid for out of pocket on top of the premiums that are already being paid. Additionally, tying insurance to employment exacerbates the preexisting condition problem since someone who changes jobs is going to lose their coverage for that condition; whatever problems may exist in an individual-based market, at the very least someone who develops a condition will be able to maintain their coverage as long as they want without regard to their employment situation. Finally, our employer-based system also divorces patients from directly feeling the pinch of their insurance costs, which has the effect of artificially increasing demand for health care (this last claim may be less agreed-upon, though, I’ll admit).Report

              • Michael Drew in reply to Michael Drew says:

                I’m not an economist or a health care economist either, so I’m basically boning up on this in public like E.D. has said he is.

                But I think a slightly subtle misunderstanding comes through here with your last response. As you say, many if not most people who look at this (liberals like myself and Ezra Klein included) think the employer-based system should be scrapped. We don’t disagree that that is something that should be done. But the argument that it is a desirable reform is not the extent of the claim you have made, nor the part of it I’m asking for a defense of. The claim I’m asking you to defend is that “the coupling of insurance and employment in our system is the root cause of those two problems. In essence, employer-based health care ==> high costs ==> poor access.”[emphasis added] (I’d add that I wouldn’t necessarily admit a one-to-one correlation on the second arrow there either, as there were many uninsured before costs started their upward spiral over the last fifteen years. But for now I’m just asking about your argument for the exclusivity or at least primacy of the first arrow.) That’s a much sharper claim.

                To me it looks above as though you are providing good arguments from experts for decoupling as a general proposition (on which you are absolutely correct there is near-consensus among experts, and this non-expert), but not that decoupling is the singular cause of cost growth to the extent that if it cannot be accomplished because of politics, any other reform would be inferior to the status quo.

                The only other thing I’d say is that we are still basically on your turf. My initial question was whether you had advanced an argument for why the bill being discussed is likely to do more harm than good apart from the fact that it fails to decouple coverage from employment. But we’re still talking about decoupling, partly because I took you up when you stuck with that part of the discussion. I think the one thing you have mentioned that would fill the bill is that far from decoupling, the bill has an employer mandate to couple them more tightly. That’s a fair response, even if it still revolves around the decoupling question. Other than that, I understand you are opposed to the public plan, but because the discussion has been so much about decoupling, I’m not clear exactly why. I don’t see how the public plan enforces the employer-based system, and I’m not sure you’re saying it does.

                So I have two questions if you’re still interested in discussing it in this thread: 1) How does the public plan contribute to the harm the bill will do? and 2) Taking decoupling off the table, and for the moment granting that to expand access without decoupling virtually compels expansion of employer-purchased coverage, is there anything still else that tips the bill into more-harm-than-good territory? I just want to be sure I understand the reasons for your opposition as fully as I can.

                Btw, did you watch the president’s presser last night? The reception was terrible left, right, and center. I didn’t think it was so terribly bad (though man can that guy go on), but then he was defending a policy I’m at least partially behind. But failing to alter the debate significantly with a voluntary prime-time press conference seems like a prima facie failure to me.Report

              • I’m probably not going to have time to respond to all your comments, but I’ll at least try to respond to a couple.

                Here, I think the Klein post I link to above implicitly makes the argument that employer-based health care is the biggest cause of our system’s failures since he writes: “It has arguably been among the most costly and perverse mistakes in the history of American public policy.” I know there are other sources that probably make this point more explicitly, I just can’t remember where to find them.

                As for a generic public option with no strings attached, my main objection is just on cost (not a small objection given the current deficit problems); I don’t think it will do a ton of harm otherwise, but I’m also skeptical that it will have nearly the benefit that is hoped for.

                Of and by itself, with no strings attached, I don’t think the public option would do much, if anything, to reinforce the employer-based system – I just don’t think it would weaken that system, either. Then again, if you take the Obama Campaign/Administration at its word (and I don’t think many wonks do), strengthening employer-based health care is the entire point of the public option.

                So, if decoupling is off the table entirely, my objections are that a public option isn’t going to accomplish much good but will still cost a lot of money that we don’t have, and that the employer mandates (which are unnecessary to a public option if there is decoupling but are at least arguably necessary if there is not) double down on the central problem with the US health care system.

                Beyond that, the compromises that have been made to get the leading legislation this far have both added significantly to the costs of the plan and simultaneously undermined much of the (already limited, in my view) good that the plan could have done, making those compromises a double whammy. (For more on this, see Robert Reich’s July 19 post).Report

              • Michael Drew in reply to Michael Drew says:

                Thanks Mark, that’s all very clear now. I appreciate your taking the time because I’m learning as much about the bill itself from you as I am about your objections, and that’s extremely valuable.

                Do you mean a post on Reich’s own blog? I’ll check that out.

                The only other question I have now is whether the Wyden bill would really move us as far from employer insurance as you think. But it’s probably not a very salient question given the bill’s prospects.Report

  4. Kyle says:

    Great Post, Mark.

    I try not to think of healthcare reform…a harder task than most these days, but this was an interesting and informative read.Report

  5. E.D. Kain says:

    The Wyden proposal is very interesting – and if you click through the Slate article and get to the CBO report – it’s pretty amazing how favorable it starts to look.

    Nice post.Report

  6. Lev says:

    As a liberal, the Wyden plan sounds good to me. I wouldn’t mind having it instead of the bills under consideration. But you all are forgetting one problem–the 80+ percent of Americans that are happy with their current insurance through their employer and don’t want it changed. President Obama made campaign promises to the effect that he wouldn’t change their insurance at all. I tend to think that the Wyden bill would be just as easy to demagogue as what’s actually on the table, and since Republicans aren’t actually committed to health care reform it seems silly to make strategy as though they are.

    In retrospect, the decision to make health reform the key issue of the Obama Administration was questionable. And yet, so it is. Basically, Obama’s task is to enact a complete overhaul of the healthcare system in such a way that nobody loses the insurance they have. Needless to say, this is a contradiction. Wyden’s plan might make sense to wonks, but it won’t play politically. The Democrats’ solution–implementing measures to achieve universality, new regulations to cut costs and allow portability of coverage, a bare-bones public plan to keep down costs–aren’t really the best options, so much as the best individual reforms that can be made without upsetting the applecart.

    Would that we had a functional system of government.Report

  7. Dave Hunter says:

    “Unfortunately, I don’t see single-payer ever getting the kind of popular support necessary to get passed in the US”

    What do you mean? Single payer polls better than anything else.Report

    • It may poll well in surveys, but when it actually got put to a vote in Oregon (not exactly a conservative stronghold), it got absolutely destroyed:

      • Dave Hunter in reply to Mark Thompson says:

        Mark Thompson:
        National single-payer health care, as you concede, polls better than any other option, strongly and consistently. The end. Next to that, your seven-year old referendum on state single-payer, which ran on negligible campaign funds, yet which the insurance industry had to spend a million bucks to keep to 20%, is pretty weak tea.

        It would be far more accurate to admit that single-payer has strong public support, but the game is rigged against that option.

        Dan Miller:
        “B) Even if it is true, mere broad public support is only one component of something being politically viable. It sucks but it’s true.”

        No kidding. But Mark Thompson would prefer not to make that argument. Most of the country wants something that the political system won’t deliver. He’s apathetic to that, because he doesn’t want what most of the country wants.

        Yet, despite not caring that most of the country is being denied their top choice by entrenched special interests, he is deeply, deeply dismayed that the same interest groups have denied him his own pet project, which is like the eleventy-third choice of everybody else.Report

        • Dan Miller in reply to Dave Hunter says:

          I think it’s wrong to accuse Mark of bad faith here. Health care is an extremely complicated topic, and I don’t think you can accurately capture “true” public opinion on something like that (indeed, I would dispute that that concept has any meaning, given the low level of political knowledge of the general public).

          Plus, you’re going to have to account for inconsistencies in the polls if you choose to go this route. If people are so enamored of single payer, for example, what explains their high levels of satisfaction with their current coverage? It’s simply naive to assume that single payer would be just as easy to pass as the current plan.Report

          • Thanks, Dan.

            Just to add to this – look, there’s a reason why Republicans have been shouting “Socialism!” at every turn for the last six months. I think this tactic is childish and, in the long run, self-defeating, but the fact is that there’s not much evidence to suggest that it’s been hurting them either. If, in fact, a complete single-payer system were truly politically feasible, we’d see at least some sort of a serious single-payer proposal floating before Congress right now, rather than having the only alternative (however unlikely to make it through the legislative meat grinder) be the Wyden proposal. Instead, the Republican tactic has been to raise the spectre of socialized medicine as an opposition to the public option; while I don’t think this tactic deserves a lot of credit, it’s worth noting that while they’ve been doing this, support for the public option has been falling.

            As for my personal biases, I’d just point out that I’ve made pretty clear that I, albeit very reluctantly, think single-payer (as opposed to a public option) would in fact be no worse than the current system since it at least addresses the employer-based health care problem. I think it throws the baby out with the bathwater, to be sure, but we’ve got some pretty damn dirty bathwater!Report

            • Dave Hunter in reply to Mark Thompson says:

              You guys are grasping at straws. This essay is founded on the factual claim that single-payer health care has “precious little support from the population at large”. It’s a claim with very little basis in reality.Report

            • Michael Drew in reply to Mark Thompson says:

              If Mark Thompson and Ezra Klein (http://voices.washingtonpost.com/ezra-klein/2009/07/the_idea_that_could_save_healt.htmlare) are for the same thing, it deserves considerable consideration.

              I’m tempted, Mark, to say that if you’re for the Wyden plan, then ‘Wyden’-t ya just say so? (Wokka-wokka.)

              I’d like to find out just exactly what it is that’s preventing this from getting more serious attention. I’ve often wondered. My political sixth sense tells me it’s not just the wonky concern that people will self-sort by risk, with the healthy migrating out of employer plans, leaving employers to cover only sick people at astronomical cost. But maybe that effect, viewed through the eyes of business, is exactly what has killed it so far, via lobbying. It’s worth finding out.

              It’s also possible that it comes too close to forcing change on people who are nominally happy with their coverage, or at least undermines the dominant message that that won’t happen, which has been used to sell the very idea of reform to the majority of consumers.

              Maybe, when all else fails this can be the ace in the hole…Report

    • Dan Miller in reply to Dave Hunter says:

      A) I’m not sure that’s true, and even if it is it’s heavily dependent on question wording and other effects; there’s no way to gauge public opinion on a complicated measure like this completely accurately.

      B) Even if it is true, mere broad public support is only one component of something being politically viable. It sucks but it’s true.Report

    • BCChase in reply to Dave Hunter says:

      Polling numbers are not equal to support on something as complex as health care. You can point to polls that say Americans are happy with what they have, and that they support single payer if the question is worded the right way. Neither of those findings capture what will happen if the government passes a bill that significantly changes things – it may work, it may not. But it’s easier to defend an incremental change.Report

      • Dave Hunter in reply to BCChase says:

        No. This is no longer a fact that can be waved away by whining about “wording.” Polls show support for single-payer even when it’s referred to as “socialized medicine”, and also when it’s explicitly tied to major tax increases. It’s what lots of people want, but it’s not being delivered because of an institutional bias in the government. I think this is so obvious that it’s weird to deny it, but the entire essay is founded on this denial of reality.

        “Neither of those findings capture what will happen if the government passes a bill that significantly changes things – it may work, it may not. ”

        I’m not making any such assertions. I’m just responding to Mark Thompson’s claims that public support for single-payer healthcare is lacking.Report

  8. ChrisWWW says:

    “Americans will be skeptical of attempts to create a single-payer system after having been told that the public option would not be a stepping stone to a single-payer system.”
    That assumes Americans oppose a single payer system. Majorities support the Public Plan and government control of health insurance in general.Report

  9. Kirk says:

    There are at least two problems with the US health care system:
    1. lack of coverage for tens of millions
    2. health care cost inflation

    While the public option may not do number two (which I would dispute), it would do a great deal for the first goal.
    If it isn’t presumptuous of me, I would suggest that the author’s preference for the status quo reflects the fact that he has health insurance.Report

  10. mike farmer says:

    Out of all the assertions being made, the one that no one seems to question is that doing something will be better than doing nothing. As bad as the heavily regulated system is now, there’s no gaurantee that what’s passed will be an improvement, and there’s a good liklihood it will be worse — compromised, convoluted and all cronied up, it will likely be a disaster that they still blame on private enterprise — the left will cry “Government should have taken over completely!” By then it will be years down the road and the players will have milked it. Healthcare is a political bomb the Democrats don’t want complete control over — that’s why they are trying to get Republican support. If it’s a disaster, the Democrats can say they tried, but the Republicans were protecting private interests, when the truth will be the Democrat special interests will have profited, but all of us will have lost.Report

    • Jaybird in reply to mike farmer says:

      But, you see, CHILDREN ARE DYING!!!

      When you open with something like that, you completely change the terms of the debate. I am now, officially, the person who cares that children are dying. You, the person who wants to do nothing, are officially the person who doesn’t mind that children are dying.

      Even if the policies that I want to implement would result in a larger pile of bodies than doing nothing at all, I am still the person that cares deeply, oh-so-very deeply.

      You’re still the person who doesn’t care about The Children.Report

      • mike farmer in reply to Jaybird says:

        Yes, Jaybird — helping The Children will cost their futures before it’s over.

        Actually, the poor and the children are red herrings which assure that the worst plan possible is approved.Report

  11. mike farmer says:

    By “we all” I mean everyone who is not part of the Democrats’ special interest winners.Report

  12. Dave Schuler says:

    I’ve been advocating Wyden-Bennett over at my place for some time now. It’s got most of the advantages of the plans making their way through the Congress now with few of the disadvantages and the plus that it actually takes steps towards solving the dog in the manger problem that we’ve really got to solve: rising costs.

    Despite the pooh-poohing from the progressive wing of the Democratic party, I think there are scenarios under which it could get on to the national agenda.

    It would require Republicans or at least some Republicans abandoning the irrational path they’re on right now. Medicare stops putting funds into the general fund in 2012 and starts taking them out. That’s where the wheel hits the road and it’s not far enough. It’s a problem that must be solved and simple rejection won’t solve it.

    Another piece of the pie is the Blue Dog Democrats. Get some independents and a publicity campaign and you’ve got yourself a working plan.Report

  13. M.Z. says:

    This is simply not true, though – in fact, the differences in per worker premium costs for large and small employers is surprisingly small (see page 5), although the amount of worker contributions varies significantly based on the size of the employer.

    A large employer is defined as one with 200 or more employees. Typically firms under 300 employees have difficulty self insuring. There are significant savings available insuring groups of 1000 versus groups of 18 or 200. Specifically claims automation is a capitalized expense that gets cheaper with the greater number of lives under a given plan. Since groups under 300 generally are fully insured (i.e. just like you and me going to an insurance broker and buying a policy) in pre-existing plans, the automation cost is low with smaller groups, get very high for those entering self insurance and drop off as the groups get larger. Fully insured groups have the very significant sales expenses that can account for over 30% of premium dollars, which is one contributing factor to making self insurance attractive.

    As for the reason why employers are necessary for any solution, class stratisfication has necessitated it. A single policy costs roughly $5000. A family policy is roughly $12,000. If medical insurance (and we are ignoring co-insurance, copays, and deductibles for a second) should not exceed more than 12% of income, then an individual needs to make $42,000 as a single person or $100,000 as a family in order for insurance to be affordable. The median income is around $28,000 in this country. The median household income is around $35,000-$42,000. For insurance to be affordable for the median, it would have to be priced at about $3,000 for an individual and $4,000-$5,000 for a family. That is for the median. For those keeping score at home, $100,000 annual income places you in the top 5% of income in this country. If we attempted to insure that 80% of the people could afford medical insurance, the numbers would just be scary. How you cross that bridge are variations on the conversations being had here over the past week. I’m not sure people in this debate have recognized how many could not and cannot conceivably pay their own way. I’m afraid breaking this illusion is single biggest impediment to social insurance becoming a reality in this country. Piss and moan about the employer health care system – and I’ll join you doing it – the plain truth is that better than 75% of folks in the private market today would be worse off health care-wise without employers in essence forcing workers to divert over 20% of their income-benefit monies to health care.Report

    • mike farmer in reply to M.Z. says:

      If a public option is supposed to lower the price of an insurance policy without putting all the private insurance companies companies, because the public option will cost less and force the private companies to lower their prices, which, obviously, everyone thinks they can, then why wouldn’t the reality of most individuals not being able to pay the high policy prices, if there were no employer-funded policies, force private companies to lower their prices without putting them out of business — plus, with individuals getting a tax break, like the employers get now, wouldn’t it make it likely that individuals buying their own policies, and getting a tax break, make the cost of insurance policies much lower?Report

      • M.Z. in reply to mike farmer says:

        I think it is largely an illusion that private companies have that kind of pricing power, at least the kind to make $12,000 into $4,000. Removing the overhead of the insurance industry (the marketing and what not) might be able to skim 10-15% off the system, might. The insurance companies aren’t driving the price increases though. They just can’t do anything about them. Auto Insurance didn’t make cars safer either; that came about through federal regulation.

        As far as tax breaks go, you have to pay taxes for it to make a difference. If the tax break is refundable, then it is just an expensive way to offer welfare. (See EITC)

        In the end, the dichotomy of lowering prices or going out of business will lead most likely in my opinion to going out of business. The expectation that it will result in lower prices doesn’t seem all that thought out to me at least. The basic assumption rests on believing that health care is a demand driven model with substitute goods and all that jazz. Traditionally health care has been a supply driven model with the best results coming from setting floors. To analogize with food for a moment, the thing that ended the American household’s tie to the land was the price floors set for corn production and other goods. With certain knowledge that farmers would be producing corn since farmers were paid for each acre they grew regardless of productivity, people no longer had to insure that they could independently produce food lest they starve, opening them up to city occupations.Report

        • mike farmer in reply to M.Z. says:

          Costs of tx would also be lowered if individuals had to pay for their own coverage. People would budget their care more carefully, too. The problem now is that no one cares what anything costs because there is the idea that someone else is paying for it. Insurance companies would also offer menu services so that individuals could get the coverage they need and leave off coverage they aren’t likely to use. Hospitals and physicians would be forced to creatively lower prices, and if regulations don’t prevent them from doing so, they will find ways to make healthcare affordable.

          Free market solutions won’t happen, but we need to consider the fact that regulations and employer-funded insurance are the main reasons healthcare costs are so high. Saying that political manuevering is the reality, so it’s useless to consider solutions that won’t be implemented, avoids the intellectual honesty necessary to make decisions, if not now, then in the future, if reformed healthcare is a disaster.

          I believe that if regulations were removed which favor special interests, and if individuals had to buy their own insurance, the whole system would be pressured to come with ways to provide lower cost care. Taxes could lowered to help with the costs — such as giving significant tax breaks to companies who offer coverage of pre-existing illnesses, plus giving the individual with the pre-existing illness a deeper tax cut than the rest. money is now going through the hands of government first — the money should go to individuals, then to coverage and treatment. Individuals should be given a tax break, but, also, without government providing hesalthcare, workers can demand pay raises. There would be plenty of money for individuals to afford insurance policies, and forcing the providers to compete for the business of individuals who have a limited amount to spend on healthcare, rather than large groups, would force down the prices.Report

          • I meant “without employers providing healthcare”, not “government”, but it has become the same thing.Report

          • M.Z. in reply to mike farmer says:

            I’m afraid you are getting close to the idea of perpetual motion machines here. If people can’t afford health insurance, the most likely effect will be for people to go without it. You don’t have to take my word for it though. We had this system in the 19th century, and universally equivalent care was not one of its features unless you mean universally poor care.

            I believe that if regulations were removed which favor special interests, and if individuals had to buy their own insurance, the whole system would be pressured to come with ways to provide lower cost care.
            Yes, but you can’t envision that lower cost being achieved by the closing of facilities and doctors refusing to provide care. For whatever reason, conservatives can accept as gospel that a socialist provision of care will result in doctors leaving and hospitals closing, but the magic health care fairy will preserve a capitalist system stripped of its funding.

            workers can demand pay raises.
            When they are competing against labor from the 3rd World, they cannot demand raises. Workers haven’t been able to get raises for 30 years in this country.Report

            • mike farmer in reply to M.Z. says:

              Well, first of all, I’m not a conservative — secondly, without the regulations, lower cost methods could be provided by physician’s assistants and RN, so I imagine the doctors would be able to preserve their specialty pay, but many more qualified healthcare providers would come into the system and make good money, just not doctor-like money. It would actually improve quality for the general care that be done at levels below MDs. Loosening licensure laws are not a part of any government/socialist plans that I know of.Report

              • Actually, IIRC, they were part of McCain’s initial health care plan during the early part of the primary campaign. I don’t recall if they made it into his plan that was part of his general election campaign.

                Still, as much as I agree with you and think that licensing laws, etc., ought to be in the discussion, the fact is that there’s very little interest in viewing them as part of the cause of the problem, so we’re pretty much talking about an even bigger pipe dream than voucherized health care here.Report

              • I understand it’s pipe dream talk, but I don’t buy the idea that we should simply disregard real solutions just because the political reality is such as it is in Washington DC — I heard that from a recent poster, and it sounds all insiderish and politically sophisticated, but when these schemes blow up and the country is in a bigger mess, there should be rational, reasonable people standing in the ruins ready to lead the way back to sanity. Otherwise we all just follow the pied pipers of political delusion over the cliff, with no idea how to turn things around.

                The worst thing that can happen now is for the country to forget altogether how private enterprise works. If we do, we will think government solutions are all that’s available.Report

              • Oh, I agree with you on all this. I’m just saying that it will be a very long time (if ever) before that issue even gets on the table. Still, someone has to talk about the issue to get it on the table in the first place.Report

              • I’ve placed myself on the fringes yelling in to say — Hey, there’s still a solution over here. I just can’t let all this theoretical talk go by without injecting a little real world into the mix — like MZ giving the theoretical response about employers and workers, no chance of getting a raise, etc. I have worked in management most of my adult life in one form or another– I’ve owned three small businesses. If I know i don’t have to pay for healthcare, I’m going to use that extra money to pay good talent to help me get an edge on the competition — this automatic assumption that businesses are out to screw employees is BS. I know how important good employees are to success — especially in a brain-economy that’s becoming more specialized.Report

              • And, of course, in a very real way, to the extent rising health care costs are absorbed by employers, that absorption is a raise for the employee – just one that the employee doesn’t actually see. Additional expenses borne by an employer that are tied directly to an employee are expenses that the employer considers part of that employee’s wages in a very real sense. Get rid of those expenses, and the employer will pass the savings on in the form of higher wages.Report

              • Yes, that was my point of higher wages.Report

  14. Michael Drew says:

    If Mark Thompson and Ezra Klein (http://voices.washingtonpost.com/ezra-klein/2009/07/the_idea_that_could_save_healt.htmlare) are for the same thing, it deserves considerable consideration.

    I’m tempted, Mark, to say that if you’re for the Wyden plan, then ‘Wyden’-t ya just say so? (Wokka-wokka.)

    I’d like to find out just exactly what it is that’s preventing this from getting more serious attention. I’ve often wondered. My political sixth sense tells me it’s not just the wonky concern that people will self-sort by risk, with the healthy migrating out of employer plans, leaving employers to cover only sick people at astronomical cost. But maybe that effect, viewed through the eyes of business, is exactly what has killed it so far, via lobbying. It’s worth finding out.

    It’s also possible that it comes too close to forcing change on people who are nominally happy with their coverage, or at least undermines the dominant message that that won’t happen, which has been used to sell the very idea of reform to the majority of consumers.

    Maybe, when all else fails this can be the ace in the hole…Report

    • Yeah, it’s pretty weird. Almost all of the liberal wonks I’ve read think that the Wyden legislation would be fantastic, it’s ideologically palatable to conservatives (it’s arguably not politically palatable to Republicans, but that’s a separate issue), and yet it has zero momentum.

      There may also be a sad irony here – the Wyden legislation is really not all that different from the proposal that McCain put forward during his campaign – AFAIK, the primary difference is that Wyden’s proposal would have a more-regulated individual insurance market to turn to (the lack of regulations in the individual market was, IIRC, the central point of liberal criticism of the McCain proposal).

      If McCain had somehow won the election, would we be in a situation where the original Wyden proposal – which wonks of all colors seem to think is preferable to the proposal that will actually pass under Obama – would have all the momentum and would stand a very good chance of becoming law? It seems to me that it may well be that there is more horse-trading and dilution required to pass the bill under a huge Dem majority with a Dem President than there likely would have been to pass a bill under a huge Dem majority with a GOP President. I’m wondering if a similar case could be made on climate change legislation.

      Thinking aloud…is it possible that divided government, while ensuring less legislation is passed, also ensures that the legislation that does pass is, counterintuitively, more far-reaching than legislation in a unified government?Report

      • Michael Drew in reply to Mark Thompson says:

        Hard to say. The fact that the Wyden proposal now envisions a public plan is reason enough for me to be glad things have gone the way they have. That and things like our now having an intention to get out of Iraq and so forth.Report

        • I elaborate on this point about tenfold upblog, so that’s probably the best place for additional comments on this subject.

          In this thread, though, I will just say that the inclusion of a public option in the Wyden proposal doesn’t necessarily refute the theory since it still doesn’t have a snowball’s chance in Hell of going anywhere. The withdrawal from Iraq is more of an executive power issue that doesn’t much implicate the legislature (plus, it’s worth noting that said withdrawal would have been forced on Obama even if he backed down from his pledges since it’s required by the SOFA).Report

          • Michael Drew in reply to Mark Thompson says:

            The case you raised was having a different occupant of the White House and that’s why I raised Iraq, because in my view that difference would be the primary consequence of such an alternate scenario at least more so than the effect on health care bills in Congress. I’ll comment further on that in the thread devoted to it, but I will say this: that a big reason that Obama is expending such political capital on health reform is because that is what he is expected to do by his party — it was a central part of the primary campaign, a major plank in the party platform, and a signature issue for the Democrats, in fact very nearly their sine qua non. (For more on that see here: http://obsidianwings.blogs.com/obsidian_wings/2009/07/why-health-care-is-different.html#comments.) Hence, it became a central promise made personally by candidate Barack Obama.

            Which raises the question of what the state of play for health reform would be with John McCain in the White House and Democrats in control of Congress. I’ll say right now, I wouldn’t put Democrats above holding back on health reform just in order to deny a member of a party that has headed off reform for years and years a historic, Nixon-goes-to-China-style victory. But even if Democrats behaved perfectly according to principle, taking the best deal they could get from President McCain, it’s worth thinking for a moment about what pressures John McCain might be under from his own party. Is there any particular reason to believe that he would not be pressured to follow the party’s traditional approach to the issue, which is that when it comes up for consideration to make it quietly go away? From a rational-actor perspective, I’m not sure that in the scenario you raise incentives would be aligned in a way to bring about reform.Report

          • Michael Drew in reply to Mark Thompson says:

            Last thing — I do think Wyden does in fact have at least a snowball’s chance in Tijuana of getting another look. If things fall through, it could in all seriousness become the fallback if it has the bipartisan support you say it has — if any Republicans are in fact inclined toward helping this president avoid his Waterloo.Report

        • I hope that last comment didn’t come across as snide, by the way – your point is completely reasonable; I was just trying to respond to the comment while also pointing out that this conversation has been significantly expanded in another thread.Report