Predictions about Healthcare


Jason Kuznicki

Jason Kuznicki is a research fellow at the Cato Institute and contributor of Cato Unbound. He's on twitter as JasonKuznicki. His interests include political theory and history.

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179 Responses

  1. Avatar Michael Drew says:

    There is no particular reason for liberals to hate the idea of government and corporations colluding to provide a social safety net. And yes, this is precisely privatized socialized medicine. Which is to say us making a social commitment to each other to provide each other health insurance through existing private entities. I guess if that is socialized medicine, then go ahead and wail away.Report

    • Avatar Jason Kuznicki says:

      So… what social benefit do we get in the big payoffs to an already coddled industry? Would you feel the same way if it were an energy plan, and we were talking about the oil industry?Report

      • Avatar Michael Drew says:

        Expanded coverage (a lot of the uninsured are people with kids who work low-wage jobs or multiple part-time jobs and are not the “young, healthy” types you have in mind), secure coverage, portability, flexibility, mobility, better-supported entrepreneurial opportunity, guaranteed issue, dependable benefits. Just off the top of my head.

        I would love a law that increases competition by nationalizing regulation, but the insurance lobby is too powerful for that. That and a public option would be the best way to control costs. So i agree the cost issue will likely be a problem. I believe over the long run we will make the necessary adjustments, however. Generally I think you absurdly understate the improvements this bill makes.Report

        • Avatar Jason Kuznicki says:

          Again, you’re talking about insurance coverage, not about health outcomes. I have already agreed that insurance coverage will vastly increase, but I do not agree that that’s the right metric to use in judging the bill.

          It is, however, the metric that best suits the insurance companies, because it means that they get a giant new mandatory clientele.

          Now, if it happens that I’m wrong about health outcomes, and if they do substantially improve, I may have to re-evaluate my negative opinion of the bill.Report

          • Avatar Michael Drew says:

            It’s largely the metric on which it is being justified, and that puts you in a bad position to declare another metric the right one on which to judge it. I think we can expect broadened coverage to modestly improve health outcomes especially among the poor, but you seem to be saying anything less than dramatic improvements on overall (which is to say, average) outcomes shows the reform to be inefficacious. That borders on bad faith in my view — as you point out, all in there is not that much room for improvement on average, and in any case this country would never accept that a decrease in stratification of health outcomes that didn’t amount to an improved average would actually constitute an improved overall health outcome situation. Maybe you would. it still wouldn’t be the direct point of the legislation.

            Let me put it to you this way. I am guessing you support a reform that would align consumers’ use of health care with its cost — ie by eliminating the tax subsidy for high-coverage, low-deductible plans that are now the norm. i don’t think there is any way to argue that that doesn’t result in massively climbing numbers of uninsured — people tend to take cash over likely unneeded health coverage. There would be a new equilibrium quantity of plans purchased, and it would be lower than with a subsidy. If you’re for that, then you’re objectively for greater levels of uninsuredness. Liberals view that as intrinsically undesirable, and want to move in the other direction, so they are increasing subsidies and mandating purchase (and regulating the product). They believe that will improve outcomes to some extent, but ultimately the reason for doing it is to allow people to have insurance. You can absolutely be against that on its terms, but saying that it doesn’t achieve something it is only indirectly hoped to achieve isn’t a fair judgement of the bill. I don’t think better outcomes would result from eliminating the tax subsidy (and hence employer coverage) either.

            If you have obvious ways for health outcomes in this country to be dramatically improved, you should let them be known. In the meanwhile, Democrats are busying themselves with the task of making private insurance more accessible and secure for Americans.Report

            • Avatar Kyle says:

              You can see how this looks something like a shell game, right? You’re – in effect – saying (and correctly so) that it’s silly to use health outcomes as a metric in a health insurance reform bill. However, it’s not much of a stretch to connect the reason why liberals and non-liberal supporters of the bill support HCR; they view insurance as tantamount to access to health care. Access to health care is important because presumably it makes you healthier.

              This is why freddie can comment regularly on how the people, “need health care.” Alan Grayson can talk about casualties of the uninsured, etc…

              So even if technically you’re right to make the distinction, in context, why insurance matters or has any value whatsoever – let alone a $940,000,000,000 value, is because it will lead to improved access and improved care, which makes them relevant metrics, even if they aren’t the stated intentions of the bill.

              If insurance has nothing to do with improved outcomes than frankly you (generally, not you, Michael Drew) have no business insinuating that lack of insurance kills.

              Also, when you say, “I think we can expect broadened coverage to modestly improve health outcomes especially among the poor,” isn’t this also not the point of this bill which is overwhelmingly focused on the working/middle class. I mean if we’re talking about expanded coverage to the poor – umm Medicaid?

              As for Jason’s point, I don’t see how one can say it will slow the growth rate of costs, while expanding coverage to more people in an industry that for years has had a critical personnel shortage that – due to licensing and education requirements – can’t respond to increases in demand quickly.Report

              • Avatar Jason Kuznicki says:

                Kyle makes a very good point. If health is not the reason that we’re so desperate to get everyone insured… then why are we so desperate?Report

              • Avatar greginak says:

                Well that would be because health is a major reason why we want HCR. Not having insurance does lead to less, worse or no care.Report

              • Avatar Michael Drew says:

                The formal answer is that this in the long run cements the social benefit of coverage into the social safety net before we embark on the downsizing we will be forced to undertake in coming decades. Without this on the books, mass uninsuredness would get baked into the social contract. This way we are cutting back from a baseline that has a preference for people being covered.

                It also helps us get our fiscal house in order if we follow the plan laid out in the bill — that’s on us going forward.

                Lastly, it helps households better manage this ever-growing part of their budgets (not that I’m claiming it does so in the way you guys would like to see it do.)

                Finally, as greginak says, there are expected health benefits, just not across the board at the level Jason Would count as justifying the bill.Report

              • Avatar Kyle says:

                I’m having a hard time understanding what the “social benefit of coverage” is, if not health?

                Right, the social benefit of unemployment insurance isn’t that the government gives you things to do with your life whilst unemployed, it’s that government gives you money, which is usually earned via employment, that you now don’t have.

                Social security doesn’t provide friends in old age, it provides money.

                Social benefits from the government tend to involve money with some purpose, anti-poverty, anti-bankruptcy, subsidized education loans, etc… So those things can meaningfully be called into question if the money doesn’t accomplish its purpose. If people on Social Security are still poor, maybe we should raise the amount? If people are getting education loans and not actually learning, maybe we should limit them to accredited institutions, not that the accreditation process is particularly great, but you get the idea.

                I really don’t understand how spending $940 billion dollars – over ten years – is justified if it isn’t meant to expand (or prevent a decrease) in coverage, which is itself important because it translates into access, which means improved (or a halted decrease in) health outcomes.

                As for the coverage angle, I turn to exhibit: Nick Kristof who has echoed something said by any number of Democratic analysts, politicians (including the President), and wonks.


                I think there’s a lone voice in the wind but I don’t think it’s Jason’s.

                If we’re going to spend $940 billion on something that can’t be meaningfully measured relative to any goal we have for the program, well then do I have some cloud/robot insurance to sell you…Report

              • Avatar Michael Drew says:

                If you don’t understand the benefit of extending protection against financial ruin due to unanticipated health costs, then I don’t really know what I can say to convince you of it.

                Beyond that, improved health outcomes aren’t irrelevant to the equation, they just can’t be claimed to be the direct aim of this legislation. There are, however, a lot of efforts in the legislation to further research and pilot programs into best practices/value maximization for the health care dollar.

                Whether it’s worth $940B over ten years is of course up to you to determine. I think your suggestion of a trade-off to other public expenditures is insincere – even if you would support $940 billion dollars in transportation and education expansion (of which I am skeptical), you have no way to offer a likely scenario in which these expenditures actually happen instead of this.Report

              • Avatar Kyle says:

                That’s not fair at all, Michael.

                You’re not trying to convince me you’re trying to explain something which is what you meant by “social benefit.” Having done that, I now understand what you mean.

                As for the direct aim, I’m going to go with the words of the people who are voting for the bill and presumably the person(s) who will sign the bill when they insist that it will provide access to health care and improved outcomes for the uninsured. You’ll excuse me if I use the Pelosi-metric and not the Michael Drew – metric.

                I didn’t suggest that it’d be $940 equal swap but it’s hardly insincere for me to point to large government expenditures as having an effect elsewhere. First, that’s what happened post-stimulus, and arguably why the jobs bill was pared down.

                Second, the state level, where expanded Medicaid payments directly impact available funding for education and transportation and until the Medicaid funding changes become law, it’s unclear how much of the increased enrollment the states will be asked to pay.Report

              • Avatar Michael Drew says:

                If Pelosi is contradicting me, then I take it all back. I haven’t seen it.Report

              • Avatar Kyle says:

                I’m watching her on the floor of the House, “This legislation will lead to healthier lives. More liberty to pursue hopes and dreams and happiness for the American people. This is an American proposal that honors the traditions of our country.”

                This is after Democrat after Democrat saying this will make health care affordable and accessible to millions of American…

                Not trying to pick a fight – it’s just hard to miss.Report

              • Avatar Michael Drew says:

                She said that would be a result; that doesn’t necessarily constitute the justification in its entirety. She also talked extensively about the additional flexibility this gives to people in pursuing employment and other opportunities. There are numerous reasons to extend coverage; together they are being advanced as a justification of the act. I did not say that improved health was not part of the justification; I only said it didn’t come down only to that, and disclaimed Jason’s standard of “significant improvement in U.S. health outcomes relative to other countries.” Clearly, they would not be doing this if they didn’t think it would improve health care in this country, but improvements to health outcomes are far from the totality of the justification.Report

              • Avatar Michael Drew says:

                …but that said, by all means judge the effect of the law based on the words used by its elected legislative advocates. She said it would result in healthier Americans — hold her to that. Just don’t protest when she defends it additionally by taking account of the other predictions she made in its justification. We can use the Pelosi metric in its entirety, or else we can move to our respective corners and use our own idiosyncratic standards on which there is not agreement. But using whatever part of the Pelosi standard you feel like using to justify your predisposition about the law and jettisoning the rest is not using the Pelosi metric.Report

              • Avatar Michael Drew says:

                See bottom of thread for a repreint of the actual relevant portion of Pelosi’s actual given justification for passage of this bill. I’d humbly suggest there ought to be MORE than enough there for anyone rightly skeptical about the bill to grab onto to hold her to her words. We don’t need to engage in selective reductionism to get purchase on accountability for the party who put this in place. There is what they’re actually saying in its justification, and there are distorting partial renditions thereof that materially misrepresent the balance of the substantive claims that are made on the bill’s behalf. You will see that finance and opportunity claims are the vast majority of what Pelosi puts forward in favor of this bill; improved health outcomes a vanishing fraction. It is up to everyone individually to decide whether those claims, even if proved true, might successfully justify the measure. What isn’t above board is to make mischaracterize what is being claimed for the legislation by its elected proponents.Report

              • Avatar Kyle says:

                le sigh.

                I don’t think I’m mischaracterizing her to say that this is a justification that has been given repeatedly by any number of proponents. Which is a different argument from it’s the predominant or only justification – which isn’t an argument I’m making.

                The whole point of my response was because you said, “It’s largely the metric on which it is being justified, and that puts you in a bad position to declare another metric the right one on which to judge it.”

                Which – frankly – I think is self-serving goalpost moving. My bottom line is that Jason’s totally fine to use one metric (health outcomes) that’s been alternatively used as a reason for reform and a comparison to demonstrate why reform is needed. You’re the one suggesting that it’s inappropriate because it’s not the main justification.

                I know that in long threads like these, that gets missed but there is a difference between saying “X exists and is fair game for judging the bill” and “X is the only justification/most important justification.” The former is my position, the latter is not.Report

              • Avatar Michael Drew says:

                Unless you also insist that a great number of others also are included, if you insist that a particular measure be included in the assessment, then you are effectively making it central to the assessment. And if you base that on what a particular leading proponent said in a particular speech, but misrepresent the bulk of the claims she made for the legislation in that same speech, then I can fairly say you are misrepresenting her.

                That said, you are absolutely right that Jason can judge the reform absolutely any way he pleases. The question is whether he can legitimately expect me or any other supporter to agree to those standards of judgment. And my position is that because health outcomes were included in, but were far from central to, the justifications laid out for the reform (as represented here by this speech, but other texts can be examined), I believe I can quite legitimately refuse to accept a judgement of the reform that puts them at the center standard of the standard used. But the person who personally still wants to use that standard obviously still can.

                FWIW, I think you now misrepresent your own words above about how important health outcomes must, of necessity, be to any legitimate judgment of this legislation’s performance, but I’m glad you now accept that health outcomes do not have to be central to the standard.Report

              • Avatar Michael Drew says:

                “umm Medicaid”

                –“For adults who are not parents, in 43 states you literally can be penniless and you’re ineligible for Medicare. Period.”

                But not after this.


              • Avatar Kyle says:

                That’s my fault for just throwing that out there but basically, I’m was and still am sick of hearing all about how much this is about the poor. If the poor were a driving focus, the bill/law’d have focused well more on Medicaid reforms (ala the kind in reconciliation) and what not.

                In reality this was a bill overwhelmingly focused on the middle class, after all it’s not the poor who fear medically-induced bankruptcy, and the insinuation that we’re doing this for the havenots is and was a poor rhetorical deflection of criticisms of parts of the bill not actually focused on the poor.Report

              • Avatar Michael Drew says:

                You’re comically wrong. Did you read that? In 43 states you have to have minor dependents in order to be eligible for public insurance, i.e. Medicaid. This law is about Medicaid, Kyle. Is about the poor. It gets pitched to the middle class because they are the swing voters, or are merely voters. But this is the most important measure passed in decades to help underlay some security under those stricken by poverty in our society. You’re just wrong if you think this is not about the poor.Report

              • Avatar Kyle says:

                Unlike justifications which lack explicit rankings, the amounts in the bill actually can decently reflect legislative priorities. This bill could’ve focused more on the poor but didn’t, it expands coverage but does precious little to actually translate expanded coverage into actual quality health care. I don’t suggest that this bill has nothing to do with the poor but I don’t at all believe that health care for the poor has been a driving concern of the development of the law or is reflected in the final composition of the law, not nearly as much as expanding coverage to those with preconditions, limiting rescission, and addressing affordability and cost issues.Report

              • Avatar Michael Drew says:

                Please click on the above ezra klein link. Saying they could have done more says nothing. yes, the bill is also about middle-class health concerns. but it makes major. it seems in your mind the bill can only really be about one thing. but there are many interests that played into its final form. an important group of representatives from urban districts in the house would certainly agree with you the bill could do more to specifically target the poor. but try telling those same reps that the medicaid expansions they did get into in the bill are not enough to make the bill “about” helping the poor.

                the bill claims to be “comprehensive” reform (it obviously falls short of that) — it is going to have to address itself to the interests of many parts of the health care market. if for you the “about”ness of the bill is dependent on having a near-exclusive or predominant focus, well then it just isn’t going to be legitimately “about” anything in your eyes.Report

          • Avatar North says:

            Would a large increase in coverage, a large increase in the portability of insurance and a large decrease in medical bankruptcies not be a positive outcome of this bill Jason? It’s not like HCR is being touted exclusively as something that’ll improve the physical health of the populace (though that’s one of the items that are raised absolutely).

            If the health of the population remains relatively the same and all of the items I listed improve would that not make the bill an overall success?Report

            • Avatar Kyle says:

              But are those things worth $940 billion we’re not borrowing to spend on say education or health care or the environment or transportation?

              More importantly, if “people” who need “health care” don’t have insurance, wouldn’t those $940 billion be better spent on you know health care for those who need it? Is “sleeping better at night because you’re not worried about health care” worth nearly a trillion dollars?Report

              • Avatar North says:

                I’m not a fan of HCR, Kyle, but then again I’m not a fan of single payer either. That said the Dems and the left have been fighting over it and discussing it as policy for decades and I’m willing to give it the benefit the doubt, especially since it’s gotten modest to okay grades from most of the economists I follow. The fact that for all intents and purposes it resembles nothing so much as the proposal that was proffered by the Republicans in 1994 when they were still sane suggests that a lot of the characterizations that have been levied against it are likely false. Especially considering that every objection that was levied against this would have been levied in an equally shrill scream by the Republicans if the money was being spent on say expanding Medicaid.

                Since the Republicans pretty much wrote themselves out of the debate around August (except Snowe of course who eventually ran out of excuses for opposing it except that it was “going too fast [Hah!]”) I consider it a miracle that it’s as centrist as it is. And at least it tries to pay for itself on paper which is a damn sight further than the last attempts did. Given the choice is between this or nothing (with a big scoop of electoral Armageddon added on) I, and most of the left, am willing to accept it.Report

          • Avatar Michael Drew says:

            Kyle an I had an important discussion below regarding this particular part of the exchange that I just wanted to clarify up here: when i said that Jason is in a bad position to “declare” a particular measure the right one by which to judge the bill, I meant that he was not in a position to insist on agreement from supporters (and everyone else) on that point. He is of course completely free to declare that he will judge the bill however he sees fit — and loudly advocate for those judgements unilaterally or with anyone who agrees with them the moment he sees fit to do so. It’s merely question of whether in some way the terms of the debate thus far compel any objective observer of any position on the bill (in particular, supporters) who’s arguing in good faith to accept that that particular measure must be part of any sensible evaluation of the bill. The only claim I know of that even comes within spitting distance of that is the claim about deaths caused by lack of insurance (which is one I never thought should have been used and would disavow if I could, but realize i have to deal with it since it was made). But I think it is entirely conceivable that that claim could be satisfied in a world in which “U.S. health outcomes [have] not substantially improve[d] relative to other countries,” if those are measured in a way consistent with how we would have looked at this question before. it’s better, I think, do deal with that claim directly using the same terms on which it was made.

            I also want to add that, while I do think that to the question of whether there is anything that would get supporters to admit the bill was a mistake (and that was in fact Jaybird’s phrasing), it being so unpopular after, say, three years of full operation is a legitimate answer, at the same time, I didn’t mean to suggest (or if i did i was wrong to) that was the only such outcome either that I could come up with or that I was inclined to. It was just an obvious one that occurred to me at the time that would take into account everything the bill did in the intervening time and give a thumbs up or down on it. because obviously no supporter is simply going to say, “If the law fails to live up to just one of the promises made explicitly or implicitly for it, then I’ll be willing to say it’s a failure.” At the same time it would be equally ridiculous to say, “Sure! I’ll agree it’s a failure but only if it fails to live up to every single promise made for it explicitly and also increases hospital infection deaths by a factor of twelve.” I mean, I could say anything, and then I’ve said something, and we’re nowhere. So then it becomes a matter of saying, well, if it exceeds this explicit HHS-set goal by by this much but misses a reasonable interpretation of the implied promise in that public official’s rhetorical claim of Sept 15, 2009 by that much, do we call that a wash, etc. Times a thousand. So it’s obviously a very complicated question if you want to do it right, and if you’re not interested in doing it right, then it seems likely to me that you might just be asking it in order to be able to sneer at whatever answer comes back. In any case indefinitely should have made that more clear, or less hasty in my initial response.

            That said, as a simple matter of prediction, what really matters here is not so much the standard as the question of who it is we are doing the predicting about. Do we mean every last person who supported the bill in the country? Because yeah, it would take a disaster of truly unthinkable proportions to get the last few to admit it was a bust (the crazies live on both sides). Even just getting every last Democrat who voted for it to say so would take something that just isn’t going to happen. So if that is Jaybird’s standard then no clearly there is not any such scenario worth spending any time worrying about (because if it were worth spending time thinking about that scenario for a political debate, then it would not be worth spending that time on a political debate because it would be time taken away from worrying about how to protect oneself from the coming plague). So short of getting every implicated elected official to eat their crow, how do we draw the line of what level of agreement that it was a bust must be reached under the various scenarios we might contemplate? This is where drawing some line in terms of what happens in Congress starts to seem relevant. If a successful repeal effort isn’t a reasonable standard to look at, then maybe just having a motion for a full repeal come to a vote in the full body of both houses is more reasonable (though I actually think that is rather likely — at least votes on repeal of various sections).

            The problem I’m getting at is that, but for the fact that I piped up and am thereby taken to represent far more people than I actually do, my answers to these questions are no more important that the next guy’s. What we’re dealing with is thousands(?) of standard proposed by millions of people. That’s why I put so much emphasis on the words and actions of our Representatives. However skewed their representation of our views is, they still are the only ones we can all agree to look to as a proxy and hold accountable; the rest of us are all more or less atoms of equal mass in a closed system, no more or less important in our views of these questions than any of the others — except in our numbers.Report

            • Avatar Michael Drew says:

              Damn, another sensitive point I flubbed:

              It’s merely question of whether in some way the terms of the debate thus far compel any objective observer of any position on the bill (in particular, supporters) who’s arguing in good faith to accept that that particular measure must be part of any sensible evaluation of the bill.

              So, yes, you can insist it be *part of* the standard. You can. You can’t insist (prior to a process of debate on the point in which you convince someone or negotiating other points away for it) that it be the central, effectively determining feature of the standard, whereby only if it is met, no matter what else within the realm of plausibility happens, the Act is judged unjustified. IMHO.Report

              • Avatar Kyle says:

                There’s a lot here and I’m short on time but upon first read, I agree with much of this and/or think it’s perfectly fair and reasonable. If I didn’t say this before, I think I overread your earlier point and was arguing that it should be inclusive so generally speaking it seems we agree on the inclusive and rather personal nature of judging a law/policy/bill.

                Considering your disavowal of the “people will die if not for this exact hcr bill” meme, I think you can understand where some of my more indignant responses came from w/r/t the idea that health outcomes aren’t central to – or for that matter the point of – this bill/law.

                I will – for the time being – insist that the benefits you list of this law could’ve been achieved by a cheaper, less complex law but given what politics are, it’s not a vice to take what you want in an inelegant package when the alternative is to likely get nothing you want.Report

              • Avatar Michael Drew says:

                Thanks, Kyle. From my perspective, I actually think much of this debate about impact is pointless. that’s because I regard it on its very terms as arguably unjustifiable, on cost alone. I don’t blame anyone for opposing it on its terms. I only narrowly support it on the substance. Mainly I support it on the basis you mention — that the only alternative was naught. and that its going down would teach all the parties the wrong lessons — Dems that HCR is a good way to get beat up and accomplish nothing (and likely lose the exte elections), and GOPers that HCR is a good thing to beat up Dems with and win elections on opposing. “Nothing” would get deeply entrenched in American politicians’ lizard brains as the right answer on HCR. Because there are certainly better ways we could have done it, but they don’t look fundamentally that much different from this as some might think. I mean, do we think the the GOP was going to run this huge anti-HCR campaign and then turn around and say, hey folks time for HCR? I just don’t see it; it’s not their issue.

                Btw, I was reading some of your blog last night. Very enjoyable. NIce one on UC students protesting their minutely shrinking massive gifted education subsidy.Report

  2. Avatar Francis says:

    And, on the other hand, millions of people brought into the primary care net, no long crushed under health care bills and no longer terrified of losing coverage. not to mention the increase in entrepreneurship because people no longer need to rely on a large employer for health care coverage.Report

    • Avatar Jason Kuznicki says:

      I think you’ve missed my point, Francis. I’m saying that bringing these millions of people into the “primary care net” will do relatively little to affect their health, for the most part.

      As to being terrified of losing coverage, I admit that we mostly won’t have to worry about it now. But there were cheaper and probably better ways of doing this.Report

      • Avatar Francis says:

        JK: But the bill isn’t designed at all to address the quality of care, except at the margins (like improving comparative effectiveness research.) The bill is the best available solution to the problem that the current method of financing health care is not just unsustainable but is actually in the process of collapse. (eg Anthem’s 39% increase.)

        Note also that the bill is not designed to reduce the cost of care, but instead reduce the rate of growth in the cost of the health care system. Given how utterly chaotic are current system is, and looking at every other industrialized nation, do you really believe that there’s little room for improvement? So certain physicians are facing flat salaries for a generation. Boo hoo. They can join the rest of the great middle class that hasn’t seen a raise since the 70s.Report

  3. Avatar Matthew Schmitz says:

    “If I’m right in this hunch, then even single-payer could prove to be a better system than the one we’re on the verge of implementing, which seems to further marry the worst aspects of both the market and socialism, albeit in a spectacularly inefficient way. It seems also to foster more entanglements between big corporations and the government, of exactly the sort that genuine libertarians hate, and that liberals ought to hate as well.”

    My feelings, exactly, Jason.

    I think Michael Drew shares the view of the mainstream Democratic political establishment on this, but I do think you’re right that there’s a substantial chance for libertarians and progressives to work together on this. One group has a high awareness of the problems caused by large corporations. The other has a keen understanding of the problems of big government. I think in the future opposing one is going to mean opposing the other. Every enlargement of government seems to broaden and entrench corporate power, while every act of corporate folly becomes an opportunity for further government expansion.Report

  4. Avatar Bob Cheeks says:

    Will the lawsuits that arise as a result of this bill have the effect of halting implementation until they are settled?
    What will be the result of “nullification” efforts of the sundry states?Report

    • Avatar Jason Kuznicki says:

      Off the cuff:

      (1) I’m not familiar enough with the state lawsuits to know for sure, and my understanding is that not nearly all of them have been filed yet. Too soon to tell.

      (2) I am highly doubtful about the nullification efforts, and I don’t expect they will amount to anything at all.Report

      • Avatar chuck says:

        The nullification efforts will again put the rest the concept of state nullification which was settled at the end of the Civil War.
        That is, if any of these efforts get anywhere when the people in the states become aware of them. Viz. The joker governors who rejected the stimulus funds directed to their states until they discovered that the stimulus funds were wanted by the people in their states.Report

  5. Avatar mw says:

    …even single-payer could prove to be a better system than the one we’re on the verge of implementing, which seems to further marry the worst aspects of both the market and socialism, albeit in a spectacularly inefficient way. It seems also to foster more entanglements between big corporations and the government, of exactly the sort that genuine libertarians hate, and that liberals ought to hate as well. – JK

    Agreed. This is a particular pet peeve – the pretense that corporate statist solutions (or the preferred euphemism – the “public-private partnership”) are somehow more of a “free-market” solution.

    If I were to place this hairball on a scale ranging from free people/free markets at the top, down to the Kim Jong II Korean People’s Collectivist Paradise on the bottom, I’d put this pretty close to the bottom. Corporate statist solutions encapsulate the worst of both worlds. The private sector gets the gain, while public sector takes the risk, accountability is lost in the ether, and to complete the circle – a corrupt money pipeline is laid from the private sector recipients profiting from public funds right back into the pockets of the public servants and elected representatives managing and regulating the abomination. They are worse than a pure public entity/bureaucracy created to address a specific public policy.

    I am sure this will be every bit as successful as Fanny, Freddy, Sallie-Mae, Blackwater – all public private partnerships. Up until now, I’d say the prior administration was the foremost proponent of corporate statism. Looks like the Bush administration will be taking a back seat to the BHO administration in that regard. You can draw a straight line extension of the prescription drug benefit passed under Bush and the public fund windfall it delivered to big pharma to this monstrosity. The first deal cut by the administration was a guarantee of profits for Pharma in exchange for supporting this bill. And just like “Loyal Bushies” during the previous administration who put political loyalty ahead of conservative principles, most progressives have dropped all pretense of principle, proving that Rahm was right all along:

    “In other words, the bill which many progressives were swearing just a couple months ago they could not and would not support (the Senate bill) is materially similar to the bill they’re now vigorously supporting (the Obama/reconciliation bill). The differences are purely “cosmetic,” as Silver says (it’s even worse than that, since one of the few positive changes progressives could point to — the Health Insurance Rate Authority, which would prevent large premium increases — was just removed from the bill). Thus, from a purely strategic perspective, Emanuel was absolutely right not to take progressives seriously because he knew they would do exactly what they did: support the bill even if their demands were ignored.”


      • Avatar Koz says:

        Of course that’s correct, and so is Jason in the original post. But we cannot neglect to mention that the reason that we’re here is the Republican party (probably) lacks the political muscle to stop it. We cannot expect to return to prosperity or limited government in America while repudiating the GOP.Report

        • Health-care isn’t everything. Civil liberties matter. Torture matters. Airport security intrusiveness matters. The War on Drugs matters. NCLB matters. Prescription drug benefits matter. Social issues matter. And yes, military spending matters. I am thoroughly opposed to this health care reform bill, but the notion that the GOP wouldn’t easily make up for the suckitude of this HCR bill with transgressions in other areas is, well, laughable.Report

          • Avatar Koz says:

            “Health-care isn’t everything.”

            No, it’s the only thing.

            I am thoroughly opposed to this health care reform bill, but the notion that the GOP wouldn’t easily make up for the suckitude of this HCR bill with transgressions in other areas is, well, laughable.

            Bullshit, bullshit, bullshit. When you can really come to grips with all the manifold ways this bill hurts America, there is nothing from George W Bush or any other prominent Republican initiative, past present or future, that is remotely in the same ballpark as what’s in play now.Report

            • You are entitled to your opinion. But that’s all it is – opinion. I, likewise, am entitled to mine. And I say that a party that wants to give the President the authority to deprive anyone of habeas rights who he (and by “he,” I mean “DOJ Bureaucrat”) designates a terrorist is every bit as much a threat to liberty as the party that wants to double down on the worst aspects of health care in this country without regard to the best.Report

              • Avatar Koz says:

                “You are entitled to your opinion. But that’s all it is – opinion.”

                Of course it’s an opinion. But it’s also the right one.Report

              • Avatar mw says:

                I am not even sure what the argument is here… “Who was worse when handed single party control? “

                There is no doubt that this would have been a different bill and a better bill if the GOP had not been reduced to a politically impotent irritant yelling from the peanut gallery.

                Looking forward I don’t see any alternative to advocating taking power away from those who have it and are abusing it now – the Democrats. The only rational vote in November is straight GOP. If by some miracle the GOP can get out of the hole they dug for themselves and retake a majority in either house, it’ll be a different discussion for 2012. I’ll vote to re-elect Obama rather than risk another cycle of single party Republican rule.Report

              • Well, as an increasingly committed dividist, you know I’m with you on all that (there’s a reason I voted for the local GOP’er for Congress, after all). It’s the notion that the GOP is inherently a better party than the Donks in the long run to which I object.Report

              • Avatar mw says:

                Our strength is our divided solidarity.Report

            • Avatar 62across says:


              Read through Mark’s list again – slowly this time. OMG.Report

              • Avatar Koz says:


                Yes, really.

                The items on Mark’s list are not the same as the health care bill at all. The partisan division of responsibility is murky. The consequences of them are unclear, our ability to unwind them might be easier, etc., etc.

                Right now, there is nothing on the horizon except the health care bill which has within it the likelihood 1. of destroying the economic foundation of country 2. destroying the republican fabric of our nation and 3. doing such when the government’s ability to borrow money is in the maximum jeopardy of our lifetimes (and probably a good while more than that, both in the past and the future).

                There is nothing on Mark’s list (really, nothing) which combines all those existential-level problems into one ugly omelet. And that is not intending to minimize any of the items on it.Report

              • Avatar agorabum says:

                How is this supposed to do 1 or 2?
                3 is flat out wrong; America is borrowing very cheap right now (in part due to the surplus from China). But it’s still cheap. There is no jeopardy.
                And how does any of that jibe with how the GOP actually governed?
                Medicare Part D was passed with Republicans in control of all levers of government and totally unfunded. Just like the Iraq War. The liabilities of either dwarf HCR. Even assuming the CBO is wrong and it doesn’t save any money, it will at least pay for itself.Report

              • Avatar Koz says:

                “America is borrowing very cheap right now (in part due to the surplus from China). But it’s still cheap. There is no jeopardy.”

                Too much of the analysis on this tends to revolve around bilateral US-China issues (like your comment). That’s only a secondary consideration.

                Nobody is going to invest with or loan to Bernie Madoff or Allen Stanford after the meltdown. Similarly, you can’t arms-length loan to somebody you know can’t pay you back. It doesn’t make any difference if there aren’t any better alternatives. If push comes to shove, the would-be lenders will put their savings under the mattress.

                The US has gotten the benefit of cheap financing for a long time because of the perception that it will be good for its debts. That perception is being is being hurt substantially, like right now. As things stand we are the tallest pygmy in the tribe, so we can be financed at the moment. But it doesn’t have to stay that way forever, or even very long.

                If it ever gets to the point where we can’t borrow for our current spending needs the economy as we know it is over (and life too). Of course that is not entirely the fault of Barack Obama and his overspending Administration, but they are a big contributing factor.Report

              • Avatar North says:

                Koz, I think you should try and stay away from Economics and stick to political prognostication. Politics are murky so codswallop can easily pass as ambrosia. While economics are a dismal science pure partisan hackery still stands out more prominently and visibly.
                The UK’s spending (as a proportion of debt to GDP) makes the US look like pikers and only now are they beginning to see market uncertainty about their debt. As for American debt it’s the only game in town and the Chinese certainly have no motive to stop purchasing American T-bills as Bruce Bartlett (no left winger though he was read out of the Republican movement years ago) explains in simple detail here.

                If Bush minor and his profligate party were able to ram through two wars and a completely unfinanced medicare entitlement without markets even blinking it’s hard to see how a very heavily financed (how cute that the GOP apparatchiks hold the CBO in highest regard except when it issues assessments they don’t like) healthcare expansion is going to break the bank. Maybe if the rest of the world wasn’t up to their ears in deficit spending it’d be a more plausible claim.Report

              • Avatar Cascadian says:

                I’m with Koz on this one.


              • Avatar Koz says:

                “As for American debt it’s the only game in town and the Chinese certainly have no motive to stop purchasing American T-bills as Bruce Bartlett (no left winger though he was read out of the Republican movement years ago) explains in simple detail here.”

                No, no, no. If you’re going to write s**t like this, listen to the f*****g answer already before you turn on the partisan hackery so you might learn something. “The only game in town” business is a highly contingent circumstance of the world economy. It holds for now but it doesn’t have to hold at any time in the future.

                But, we given the path of entitlements and other government spending in the US, we will cease to be creditworthy, we will default or inflate away our debts, the idea of prosperity as we know it will be lost and not be able to be regained.

                We have some amount of time, 2 years, 5 years, 15 years or whatever, before we are the North American equivalent of Italy or Greece. But, it doesn’t make any difference how long it is if we don’t take advantage of the time we have.Report

              • Avatar North says:

                Accusations of partisan hackery are rather rich coming from you Koz me lad. That said; it’s delightful to agree with you on some small subject at least. The countries finances do need to be brought under control.

                That you would assert that this is only possible under Republican leadership borders on the delusional considering the reeking pile of dung that is the Republican party’s record of financial management of the country (which you do the equivalent of clapping your hands over your ears and yelling lalala about whenever it’s brought up).

                Still my support of Obama specifically and the Democratic party in general will be dependant heavily on how they behave with the finances now that they finally have HCR nailed down. Obama, like Bush minor before him, has asserted that he intends to get the finances of the country in order; we shall see whether he is able to take meaningful steps to do so or whether, like the Bush Republicans, his assurances are merely empty vacuous rhetoric.Report

              • Avatar Dave says:

                That perception is being is being hurt substantially, like right now.

                How? I would expect to see rising Treasury rates if that were the case but it’s not. Yes, there are concerns about the long-run nature of deficits but we haven’t seen the interest rate spike one would expect.

                About your opinion being the correct one, let’s just agree to disagree on that one.Report

              • Avatar North says:

                Christ Koz, your numbered points have got to be hyperbole. Dole was trying to destroy the republican fabric of the nation when he pushed a similar plan in 1994? Have you been drinking?Report

              • Avatar Koz says:

                I’m glad you bring that up. I’m assuming this Dole plan is one the Republican alternatives to Hillarycare. I don’t know what happened to that, it probably died in committee or something. That is not what is happening here.

                The citizens are sovereign in a republic and its legitimacy ultimately depends on the consent of the governed. For most people, even if they disapprove of what the government is doing, they are not going to mobilize against it. There are other fish to fry.

                I don’t think there are many liberals, prominent or otherwise, who have really gotten their head around the damage to the republic that will happen when and if a partisan establishment puts something like this into law when it knows there is a substantial majority of citizens opposed to this bill and mobilized against it.

                “Consent of the government, meh, what do I care.”Report

              • Avatar North says:

                Odd Koz that you only discover such passions under a Democratic administration. It’s “Leadership” under Republicans but it’s “a violation of the consent of the government” under Democrats.Report

              • Avatar maraschion says:

                The problem with the right-wing arguments on here is that they are based on ideology, not fact. Amusing as it is to hear the GOP fanboys announcing that the Dems are bound to lose both houses, let’s remember that there is no evidence for the proposition. As for the popularity of the bill, it’s fairly well-known that a good part of the opposition in polls is from the left, because the bill doesn’t go far enough. There are signs in more recent polling that the left-opposition is starting to come home to the Democrats, and that’s why the hot air on here is wishful thinking from the right-wing. It will be enjoyable to hear the hooting and hollering when the bills passes – and even more so as the reality sinks in that the public doesn’t want it repealed. You’ve lost this round, despite peddling lies galore, and you ought to be thoroughly ashamed of yourselves. But then, prudence, integrity and concern for the truth just aren’t right-wing qualities.Report

              • Avatar Koz says:

                “It’s “Leadership” under Republicans but it’s “a violation of the consent of the government” under Democrats.”

                No, because the sort of thing that the D’s are doing here (that is, pushing through a controversial party-line bill like this when the majority of the country is opposed to it and mobilized against it) have never ever ever ever ever been done by the Republicans when they were in power.Report

              • Avatar North says:

                Majority of the country is opposed to it? Pah, a large part of the opposition is from the left. And mobilized against it? It takes more than a small posse in the capitol to qualify as having the majority of the country mobilized against it. The code pink loons mustered up more fuss over Iraq than this.Report

  6. Avatar Freddie says:

    There are people who need health care, desperately, and can’t get it under the current system, and in the new, still deeply troubled and imperfect regime, some of them will get it, and in the course of their lives, the legislation will mean everything, and no empty words will mean anything in the face of the material improvements in those people’s lives.Report

    • Avatar Mike Farmer says:

      This plan will likely be a nightmare of unintended consequences, hidden costs and lack of access to providers for the people you’re talking about. The system will likey go haywire for a period of time, then single payer will be implemented. I think many of the people you are rooting for will be punished by the unintended consequences and might wind up with less access to quality medical care than they had through Medicare, free clinics and emergency room care.Report

      • Avatar Matthew Schmitz says:

        This is one thing I’ve been wondering about — whether or not this system eventually will be rolled into a single-payer model. Care to expand on that? One of the reasons I ask is that, like Jason, I think single-payer may well be better.Report

        • Avatar Mike Farmer says:


          Just one that comes to the top of my mind is the taxes and how they will change business behavior — there’s a very good chance that the pridicted revenue raised by certain taxes will never materialize. We have to have a vibrant economy and we have to create new wealth to pay for things like this. This is not good for businesses no matter how they spin it. Giving a tax break here and there is useless, because at some pont, serious money has to be raised, money that is used for one purpose rather than another — this has economic consequences. It’s why I like free systems where people decide for themselves how money is spent. Technocrats invariably direct money in wasteful directions and create consequences in other parts of the economy which were not intended, thereby frustrating their plans. The economy is not static, whereby government can come in and take from on part to give to another part, the economy is dynamic, moving before government officials act, then adjusting even more after they act.Report

      • Avatar Alex says:

        The last resort of the person with no evidence and no rational argument: jump up and down about unknown “unintended consequences”.Report

    • Avatar Kyle says:

      Now, I just think you’re phoning it in, Freddie.Report

    • Avatar Jaybird says:

      Would this bill have saved Deamonte Driver’s life?Report

      • Avatar greginak says:

        Having the ability to pay for things does actually increase ones ability to get things. So having a health care plan does actually lead to getting health care. I think it has something to do with people exchanging currency for goods and/or services.Report

        • Avatar Jaybird says:

          Does this create more goods and/or services or does it create more currency exchanges?

          If it’s the latter, I think you’re going to be surprise with what happens to prices.Report

          • Avatar greginak says:

            hmmm i think it creates more people who can access health care, less people who will be denied coverage because they have health problems and less people who insurance companies will randomly cut off. So it certainly may save the lives of future D. Drivers.Report

            • Avatar Jaybird says:

              If it creates more demand without creating more supply, there are a number of things that will happen.

              This is not me saying “I wish that they will happen” or “I hope that they will happen” but “they will happen”.

              These things include: long lines, increasingly inefficient rationing of care, and (this is where I go out on a limb):

              A black market for health care.Report

        • Avatar Jason Kuznicki says:

          The problem is that if what you really want is to provide health care to people, giving them health insurance, via private companies, on artificial state-created exchanges, with partial subsidies, and all the rest… is a very inefficient way of doing it. And even if we succeed in giving everyone insurance (which this bill will not do), we will not be able to improve health outcomes all that much. A little, yes. I’ve never denied this. But there’s really not as much room for improvement on the whole as we have been led to believe.Report

  7. Avatar North says:

    Personally I’m no fan of HCR. I’m only reluctantly of the opinion that HCR is better than doing nothing. But couple that with the fact that if the Democrats will face an electoral end of days if they fail on it at this state and since I think they’re still better stewards of the country than the Republicans that pushes me into being a firm but unenthusiastic supporter.Report

  8. Avatar A.R.Yngve says:

    My dad was a physician (the “general practitioner” sort) in Sweden.

    Toward the end of his life, he collaborated on a thick booklet titled “Self-Care” which was sent out for free to I don’t know how many people in his administrative region (Sweden has both regional and municipal administrative regions for public health care).

    I can draw, so he hired me to make lots of illustrations for the booklet. (Weird, I know…)

    The purpose of “Self-Care” was prevention: to educate the public about various common afflictions and infections, how to identify symptoms on your own, and how to prevent ill health, infection and injury.

    I still believe that there are enormous long-term benefits to this strategy. We must teach, not dictate. Imagine how many billions of dollars Americans could save, if they received some basic education about disease prevention, healthy lifestyles and identifying early symptoms! It’s a cheap investment with large payoffs.

    But the focus remains on the “ER” type of treatment — when the patient is already far gone and beyond any self-help. How sad.Report

    • Avatar Matthew Schmitz says:

      A.R., that sounds like a great book. It’s wonderful that you and your father were able to collaborate. My suspicion is that while self-care may be able to produce great benefits for individuals and families, it’s society-wide budgetary impact is going to be insignificant.Report

  9. The biggest effect of the bill, and the most detrimental one, will probably be simply there are going to be a lot more doctors leaving the profession, and a lot less new ones entering the profession. Let’s see someone mandate a law to account for that. Who in their right minds would want to enter the medical profession under these conditions. The only ones to enter it will be those who really have an inner love for the practice of medicine. Unfortunately, not all of the best doctors are so motivated. Some are motivated by the social status and money, believe it or not. You can kiss them goodbye, as it will soon become plain they can do better in another profession. Some of the more hard-core left will, of course, say good riddance. Let them tell that to their diabetes, cancer, and heart disease while they’re waiting months on end for an appointment. Liberal politicians and their supporters never seem to get the law of unintended consequences.Report

    • Avatar greginak says:

      everything has unintended consequences. doing this or doing that or doing nothing all will have unexpected consequences. The “law of untended consequences” is a good observation turned into a simplistic criticism of anything a person does not like. It is a reminder to have humility but this “law” does not offer any guidance how to actually do anything.

      And how exactly is this a law? Answer: it isn’t a “law” but sure is hell sounds good to say call it that.Report

    • Avatar chuck says:

      A lot of doctors will leave? Those guys should leave and become Wall Street Talent. I know so many docs who are jumping for joy now that this has passed. Not all docs are simply out for the buck. You make a pretty penny as a doctor and still be aiming to help your patients and that is not going to change.Report

  10. Avatar Gold Star for Robot Boy says:

    *Liberal politicians and their supporters never seem to get the law of unintended consequences.*

    As opposed to the Bush administration and its enablers, who had gamed out all the possibilities of what could go wrong after invading Iraq.Report

    • Avatar Jason Kuznicki says:

      Good lord, do you imagine that we must side with one or the other? Do you intend to banish all intelligent discourse whatsoever?Report

    • Avatar Jaybird says:

      People who opposed the Bush administration were supporters of Saddam Hussein in the exact same way that people who oppose Health Care Reform want children to die.Report

  11. Avatar North says:

    Word is Obama has cut a deal with Stupak. The President will issue an executive order applying the Hyde agreement to the HCR exchanges. Pro-choice forces are yawning, it doesn’t change the law at all, but it seems to be enough for Stupak. If this is the case with the pro-life Democrats on board HCR is pretty well a done deal.
    I’ll admit it. I was hard on Obama for the run up on this bill but the man really put the lead out for the last stretch. I’m impressed.Report

  12. Avatar Michael Drew says:

    We’ve gone a couple rounds on the policy here, and that’s a good thing. As someone who by no means sees this legislation as the bee’s knees, I have done what i can to respond to the criticisms of opponents, but I will happily concede that there a very strong criticisms of it that I can’t answer — I can only go as far as my intellectual integrity will allow, and I’ve reached that limit.

    So lets return to the important part of all this — the politics! I’m not sure how the politics will work out on, but David Frum thinks he knows: I’d love to what folks think of his predictions.Report

    • Avatar North says:

      Michael, I’d say Frum is right on the money on all points. Obama and the Democratic leaders demonstrated pretty much throughout 2009 that they would be willing to sell their own children to get Republican cover on the HCR. The Republicans made a perfectly reasonable strategic decision to try and cause 1994 to happen all over again. With Scott Browns election it looked for a while like they had won all the marbles. Now (and I must indulge in another moment of gloating, I predicted on Browns victory evening that the senate HCR bill would be whipped through the house and passed into law) they are facing up to the fact that they’ve lost it all.

      They chose to try and destroy Obama with this issue. They almost managed it. They failed. Obama, Pelosi and Reid have managed to hold the Democrats together and get their bill passed (knock on wood), a monumental achievement all by itself. What is more they are passing the bill with 0 read ZERO crooked legislative tricks. No deems and passes or other nonsense; just a 60-vote senate supermajority and a majority house vote.

      Now imagine for a moment that the Republicans had actually had the welfare of the country in mind. Say the Republican leadership had gone to Obama in January and said that they were lined up to support an HCR bill that was based on something like Wyden Bennett. Does anyone honestly think Obama the great goo-goo post partisan wunderkind would have said screw you? No. We’d have ended up with along Wyden-Bennets framework and the left wing of the party wouldn’t have been able to do anything but screech. Memo to the minority party, when you refuse to deal you loose a lot of influence over the final product if it survives. Now instead we get this ugly warty bill that was mangled and distorted by all the buyoffs and tradeoffs that were needed to force it through against unified Republican opposition. From a policy perspective I’m pretty much resigned about HCR passing, it is better than nothing and that’s the best I’ll say about it.

      To be honest though Michael, I don’t see Frum predicting much. Republican rage; loosing does that to a party, especially after the lather they whipped themselves into. Marginalizing their moderates? That happened already too. Bennet of Wyden-Bennet fame was already suffering from a viscous right wing primary challenger for merely deigning to suggest that something needed reforming in health care.

      My own political thoughts; electorally Democrats have given themselves a shot now. If the whole thing collapsed they’d be up shit creek with their base. Now they get to have a –huge- triumphant victory lap (low info moderate voters in America LOVE supporting winners) with news coverage of their historic legislative achievement and remarkable (for Donkeys) party cohesion. Then the issue is out of their hair and Obama and the leadership can play to the center from now till November. Ultimately it entirely depends on the economy (with the Wars playing a secondary but more controllable role). If the economy starts coming to life or even shows really good turn around signs then the Dems have a good shot at keeping their majorities. Even if the economy stays dismal they have a decent chance of holding onto the Senate at least.Report

    • Avatar Koz says:

      I mostly agree with w/ Frum, with some caveats: for America and Americans this bill was a crushing defeat, the worst since the Sixties or maybe even longer. For the GOP and conservatives, it’s a mixed bag.

      This is why you see guys like Tom DeLay cackling on cable shows about Waterloo or 80 seat turnover or whatever. He’s a legislative fixer/infighter, and that’s the way it looks from that pov. For the likes of Tom DeLay, passing HCR is a good thing.

      For the rest of us, this is a horrific disaster. This is a disaster because of the particular policies enacted in the bill, but also because for reasons unrelated to them. Because of the nature of this bill, we can hope that most or all of the policies will be undone before they ever go into effect. But we are going to take the collateral damage in any case, and that will take a long time to heal.Report

      • Avatar ThatPirateGuy says:


      • Avatar Jaybird says:

        This is an excellent point. This bill is great news for Republican Politicians.

        The problem is going over the list of the names the Republicans are most likely to run come 2010, I don’t see a decent top-of-the-ticket name on there and the ones that are there range from “threaten to move to (other country)” to cringeworthy to, at their absolute best, “maybe not an awful choice for VP, maybe”.Report

        • Avatar Jaybird says:

          Argh. 2012.


          • Avatar North says:

            They could pull someone out of the glove compartment. Obama pretty much came out of nowhere in 2008. Then again the Dems weren’t quite as barking crazy as the Republicans are right now so maybe they need to run a Palin or a Huckabee just to vent for a term.Report

  13. Avatar Michael Drew says:

    Nancy Pelosi’s stated justification for health care legislation – House floor speech, Sunday evening March 21, 2010:

    “And this legislation tonight, if I had one word to describe it would be ‘opportunity,’ with its investments in education and health care as a continuation of the President’s budget. We all know, and it has been said over and over again, that our economy needs something new, a jolt. And I believe that this legislation will unleash tremendous entrepreneurial power into our economy. Imagine a society and an economy where a person could change jobs without losing health insurance, where they could be self-employed or start a small business. Imagine an economy where people could follow their passions and their talent without having to worry that their children would not have health insurance, that if they had a child with diabetes who was bipolar or pre-existing medical condition in their family, that they would be job-locked. Under this bill, their entrepreneurial spirit will be unleashed. [Applause]

    “We all know, we all know that the present health care system and insurance system, health insurance system in our country is unsustainable. We simply cannot afford it. It simply does not work for enough people in terms of delivery of service and it is bankrupting the country with the upward spiral of increasing medical costs.

    “The best action that we can take on behalf of America’s family budgets and on behalf of the federal budget, is to pass health care reform. [Applause]

    “The best action we can take to strengthen Medicare and improve care and benefits for our seniors is to pass this legislation tonight, pass health care reform. [Applause]

    “The best action we can do to create jobs and strengthen our economic security is pass health care reform. [Applause]

    “The best action we can take to keep America competitive, ignite innovation, again unleash entrepreneurial spirit is to pass health care reform. [Applause]

    “With this action tonight, with this health care reform, 32 million more Americans will have health care insurance. And those who have insurance now will be spared being at the mercy of the health insurance industry with their obscene increases in premiums, their rescinding of policies at the time of illness, their cutting off of policies even if you have been fully paying but become sick, the list goes on and on about the health care reforms that are in this legislation: insure 32 million more people, make it more affordable for the middle class, end insurance company discrimination based on pre-existing conditions, improve care and benefits under Medicare, and extending Medicare’s solvency for almost a decade, creating a healthier America through prevention, through wellness and innovation, create 4 million jobs in the life of the bill and doing all of that by saving the taxpayer $1.3 trillion dollars. [Applause.]”Report

  14. Avatar chuck says:

    I see this Act, as imperfect as it is, by giving one a chance to buy coverage at a reasonable rate as providing us with a freedom we have not had for a while–to leave an employer that one as stuck to because of coverage. I am old enough to remember when health insurance was not enough to hold people into jobs, yet we have become slaves. Let’s think about some of the unintended consequences in this Act and the value they may bring us.Report

  15. Avatar Jaybird says:

    Speaking of falsifiability, is there any measurement that we might make that will allow us to say “holy crap, this was a bad bill…”

    Anything at all? Like… I dunno… we predict that health care costs for people from age 25-35 will go down 10% and they go up 10%, can we say that we made a bad prediction or will we be able to say “golly, the rates must have been going to go up 20%!”

    If infant mortality goes up instead of down, can we say that maybe something went wrong?

    If a black market is created and people are arrested for practicing medicine without a license (I don’t mean onesy-twosy like now, but something where the news is talking about a bust every week or so), can we say that the market was distorted?

    Is there any falsification test that we might be able to apply to this bill?Report

    • Avatar Michael Drew says:

      Just the test of whether the public (as measured by the actions of their representatives in Congress) wants it repealed or not. I encourage you to seek to make it happen by any means you desire to use.Report

      • Avatar Jaybird says:


        Anyway, I’m appalled to be reading Megan McArdle and to see that she’s making this argument like crazy.Report

        • Avatar North says:

          Megan is pretty exercised. Then again it’s no wonder, considering how much crow she has heaped up in her living room, that she is sputtering and changing the subject. I mean she pretty much spent a week calling poor old Chait insane for saying the HCR had a 70% chance of passing. Or lets not forget her who “one of these sides is delusional” line. I feel for her, she woke up on Monday and discovered that it was her. That had to sting.Report

          • Avatar Jaybird says:

            I like her but… sigh. I don’t see her as much more than a Republican who wants to smoke pot.


            • Avatar North says:

              I like her too honestly. When she’s not poking at politics she can be very sharp and her Christmas gift recommendation lists have often been really helpful. She also has a dry sense of humor that I enjoy.Report

      • Avatar Michael Drew says:

        I get what you’re saying about agreed-upon metrics, but the reason I resist is that it just doesn’t work that way. A repeal debate will proceed along its own path-dependent logic, governed by the politics of that moment. What a couple of guys in a comments thread may agree to the day after passage just couldn’t be less germane to how the actual version of such a debate (which very plausibly could in fact happen) will play out — and it shouldn’t. That debate should focus on the lived experience of the people affected by the legislation, and their unpredictable, contingent political reactions to it. We should listen to its features and take note, not prescribe it for them ahead of time.

        Additionally, the idea that one or a handful of unique indicators should be accepted as constituting a satisfactory measure of the impact of a bill seeking to affect hundreds if not thousands of them (many of which it will obviously fail to reach a given standard on) is fanciful. The answer is that an extremely complex system of analysis of hundreds of indicators ould be the right falsifiability test. If the fact that an amateur proponent like myself is unable to compose that analysis now, or that more sophisticated proponents have not publicly communicated it means to you that this is just further unaccountable advancement of the welfare state by power-mad liberals, well I think from our perspective not much is lost in having you come to believe that from a place of, um, believing that.Report

        • Avatar Jaybird says:

          I have to assume a handful of unique indicators because I assume the following:

          1) My moral intuitions are grounded in stuff that actually happens
          2) If stuff that actually happens goes against my moral intuitions, my moral intuitions (AT THE VERY LEAST) need revising.

          If I am allowed to say “well, we don’t know what would have happened otherwise” under any and all circumstances, then I’m just masturbating.Report

      • Avatar Jason Kuznicki says:

        Jaybird asked about whether there were any conceivable ways we might admit that the bill had failed. To which Michael Drew answered:

        Just the test of whether the public (as measured by the actions of their representatives in Congress) wants it repealed or not. I encourage you to seek to make it happen by any means you desire to use.

        I have to say I’m underwhelmed by this response. Do you mean to say that no policies are ever economically inefficient, unjust, misguided, or ruined by unintended consequences? Do you really mean to say that in your world, there is only popular and unpopular?Report

        • Avatar Michael Drew says:

          You’re right to have that reaction — it was glib. I made a more fulsome response subsequently. The point is that the actual political process of assessment of the bill is more important to pay attention to than our private agreements about how to judge it here. Also that the right answer to the question of our private agreements on that are far too complicated for me to be equal to — it is crazy to think we’d agree on one indicator of success or failure as Jaybird requested. The best I can say is that, yes, we should assess its effect in 2025 or 2030 or another date to be negotiated, but that I see no reason why the areas which we examine to determine those questions can’t be determined closer to that date, after a close,careful review of the claims made on the bill’s behalf, its specific legal and policy mechanisms, etc. The real0time demand for one metric is just grandstanding. No one thinks we’re going to start reviewing this thing for efficacy before such time as a good, thorough discussion of the terms for that review can be devised.Report

          • Avatar Jaybird says:

            I wasn’t demanding just one metric. I was looking for a suite.

            Or, I suppose, an admission that there isn’t anything that would get you to say “yeah, we shouldn’t have done this”.Report

          • Avatar Kyle says:

            I don’t think this is a particularly good response. It seems to me that there are multiple tracks here.

            Is the policy/law popular and/or unpopular to repeal? Is the policy achieving its desired effects? Is the policy worth the cost of maintaining it?

            These are individual questions and policy questions. I suspect that if the bill were amended to include a public option, you would support that but that wouldn’t at all mesh with the suggestion that the law should be let alone for 15-20 years while we agree on how to judge it. Inherent in evaluating policy effects is the presumption that if they are warranted changes might be made, both additive and subtractive.

            It’s glib and not at all untrue that the metric that matters most is the political viability of passage or repeal. However, that doesn’t preclude a separate discussion of what metrics would be appropriate and evaluating how likely a bill is to achieve certain goals and how well its on track to do so.

            I think what the Jason-Jaybird group here is responding to is the detrimental tendency of placing certain laws and policy above examination and reproach because the idea of the law and its success is held as more important than the real world effects. I can’t speak for Jay or Jason but for me, I’m not entirely sure that for a fair number of proponents of the bill there are any metrics singular or plural that might be used to meaningfully measure whether this particular set of reforms will actually accomplish whatever they’re intended to.

            Which is perhaps why your suggestions of ‘it’s all subjective/up to the people’ and “X isn’t a good metric because it isn’t justified whereas Y is because its more of the reason for justification” have produced such responses.Report

            • Avatar Michael Drew says:

              I have admitted that my initial response was glib. On the other hand, I have never claimed the question itself was illegitimate, and when I said that I just had the repeal test, I could argue that i meant that at that juncture, that’s all I had. When I say that we’ll look at the bill again in 2025 (and I did say that date was negotiable), and that that means we have some time to work this out, I don’t mean to say, let’s not talk about it for ten years. I mean like, give us a couple weeks or a couple months to get our heads around the question. The correct answer to the question of accountability is an extremely complex system of analysis, and that, or a decent attempt at it, is what I want to use if I am going to play this game. To do otherwise would surely not do justice to the question.

              Beyond that, it’s also inconclusive, as we occupy but a tiny piece of the public forum. What does it matter what you and I agree to on these questions? There is no finality or authority to our local agreement on it. More important what Pelosi and Boehner would agree to, if they operated that transparently. There is no way “supporters of this legislation” could ever speak with one voice, so it is unfair of you to expect them to.

              It’s also not legitimate for you to expect every citizen to be able to offer up a bill of deliverables for you with respect to every policy preference she has. People are entitled to their opinions, regardless of your feelings about it. Your leaders are the ones who are accountable to you.

              Lastly, the repeated suspicions that people have no idea how to measure the bill, while obviously true for some people since the public is large, is nevertheless baldly insulting here given the size of this forum, and the effort to which at least I am going to engage you on it. If you want to mentally dismiss proponents of this legislation as insincere or unserious or illegitimate or idiotic, fine, but if you do it directly to their face, that amounts to a direct insult.Report

              • Avatar Kyle says:

                I think you should re-read what I wrote, Michael.

                I never tarred all proponents of the bill, I specifically qualified it. Also, I wasn’t saying that’s what you personally were doing. I was saying that this is a phenomenon that’s out there, and fwiw not one that’s unique to any segment of the political/ideological spectrum. I was opining that perhaps the challenges and discussions in this forum are somewhat disproportionate to the specifics of this thread but better explained by a larger context. Which you know might make sense given Jay’s original comment regarding falsifiability – which one would presume would amount to issues of portability, flexibility, etc… for you – so I’m obviously not suggesting you’re one of those people.

                I never demanded a bill of deliverables, never said we had to agree on these questions and never said people had no idea to measure the bill.Report

              • Avatar Michael Drew says:

                Well, you said a lot of things, but I think the part we are discussing is

                I’m not entirely sure that for a fair number of proponents of the bill there are any metrics singular or plural that might be used to meaningfully measure whether this particular set of reforms will actually accomplish whatever they’re intended to.

                Of course there are a fair number of such people. Why is this important? Has anyone claimed that all politically conscious people are conscientious in that way? You’re basically dealing with me here. I am attempting to respond, and I openly admit that at this time, I don’t have the measures specified (and maybe that is all that matters), but in a marginal amount of time compared to the life of the bill I could, and would like to (though I don’t think I am obligated by any civic obligation to you to do so). If it bothers you that there may be a fair number of such people, then how does that not add up to the requirement of a bill of deliverables from basically all supporters?

                I honestly don’t really get what you are saying with this last response, so forgive me if i am missing the point. But is seems to me your point that some people probably don’t know or care what might serve to disprove this bill’s efficacy is either trivial because it refers to the wide world, or insulting because it refers to people here (where I am like one of a few pro-reform commenters). Or else it refers to some group I can’t identify.Report

        • Avatar Michael Drew says:

          But actually, when I think about it, I am willing to say tht the proper forum for determination of the efficacy of laws is in the bod(ies) that pass it. I say ‘determination’ — clearly discourse on the topic is entirely legitimate in the public. The problem with public discourse, however, is that it is eternally that — discourse. There is no mechanism (and shouldn’t be) for bringing debate to a close for decision — other than public electoral ones. Those latter do exist, but they in turn determine the make up of the continuing bodies that passed the laws we want to assess. It all works out pretty good by my lights. Mark Thompson was on this last summer. He rightly decries legislatures’ habit of not revisiting legislation they pass. That’s the issue. I’d support more legislatures doing so much more. I’m also totally fine with ongoing discussion of whether laws are working in public debate. The problem is that public debate will always be as diverse as the American public, so there can never be any claim that consensus or decision has been or can be reached within it as to the efficacy of particular legislation. The mechanisms for that exist in legislatures — that is where such reviews can actually have efficacy themselves.Report

          • Avatar Jaybird says:

            Sunset everything after 5 years. If you can’t pass it a second time, there you go.

            We still have laws on the books outlawing alcohol purchases on Sundays, for God’s sake.Report

            • Avatar Michael Drew says:

              Why is that first sentence phrased in the second person? What are you going to do about it, Jaybird? This is your concern.

              Btw, I’m guessing the teetotaling Sundays thing is local legislation — if you find yourself unduly burdened, take it up at the appropriate levels. Or are you proposing a constitutional amendment binding on all legislatures at every level that they must review laws on the books according to the Jaybird 5-year requirement?Report

              • Avatar Jaybird says:

                What have I done about it? I used to be the crazy guy who called my senators pretty regularly. I stopped after gay marriage pretty much crashed and burned on a national level.

                “Or are you proposing a constitutional amendment binding on all legislatures at every level that they must review laws on the books according to the Jaybird 5-year requirement?”

                Ooooh. Nice. Yes, a Constitutional Amendment would do nicely. State Legislation automatically sunsets after X years (I’m not married to 5… but I wouldn’t want it to be greater than 20ish).

                We could append it to the 10th Amendment.

                I mean, if we’re not going to use it anyway, let’s *REALLY* not use it.

                Given that the alternative seems to be laws that were written by long-dead representatives of long-dead people and presumably interpreted by long dead judges whose precedent we consider stare decisis, I don’t see how laws that have a mechanism for going away without causing legislators any loss of face could be much worse.Report

      • Avatar Koz says:

        “Just the test of whether the public (as measured by the actions of their representatives in Congress) wants it repealed or not. I encourage you to seek to make it happen by any means you desire to use.”

        So it’s already a failure then.Report

    • Avatar North says:

      Jay I’m not getting the connection between the HCR bill and an appearance of a black market in medicine, can you clarify on that part? As far as I recall the bill mostly deals with insurance companies, policies and the like. How’re we getting from a bill regulating the entities doing the rationing to black market doctors? Are there even licensing requirements in the bill? I don’t remember there being any.

      To your initial question, personally I’d suggest watching the medical bankruptcy numbers, the number of uninsured numbers, the performance numbers for healthcare in general, yes the mortality and health stats of course and certainly the cost. Oh and also the public opinion of the reform. If it stays where it’s at now then presumably the Republicans will repeal it next time they get in power yes?Report

      • Avatar Jaybird says:

        Here’s the connection I’m making, let me know if I’m crazy.

        This bill does not create health care as much as it creates health care access and “coverage”. This tells me that it is going to create more demand without doing a darned thing about supply and, as such, the price will go up. As the price goes up, markets will spring up to meet the unmet demand (and there will be unmet demand).

        The cartels in charge of writing this legislation in the first place will create barriers to entry for other providers. Rules, licensing laws, zoning, whatever.

        And a black market will be created to circumvent this.

        That’s what I see happening.

        As for “public opinion”, I don’t really trust public opinion much… and certainly not when it comes to stuff like “entitlements”.

        I’ve no doubt that this monstrosity will be with us until it can no longer be sustained… mostly due to arguments about the number of dead we’ll have in the streets if we go back to the system we had in 2009.Report

        • Avatar Michael Drew says:

          The doctor-shortage issye was raised above as well, and in fact it is one of the more unanswerable criticism I have come across. For my money, Jay, this is an entirely reasonable concern for you to have. Even if we get some or even a good deal of this, however, by no means do I think it alone would be decisively contraindicative of the bill’s efficacy. But it would be one legitimate strike against.Report

          • Avatar North says:

            Agreed. Though that raises the question; from whence comes this shortage of doctors? What is the barrier to entry? What is the barrier to immigration?Report

            • Avatar Jaybird says:

              It’s not that there is a shortage of doctors as much as demand will outstrip supply.

              Hell, we’ve got a price problem now which I assume is caused by demand outstripping supply… this isn’t helping with supply, but it’s creating more demand. Given that the laws were written by companies from which everybody will have buy the product (“coverage”) in question, I see the same thing that always happens when governments collude with corporations happening.Report

              • Avatar North says:

                Well we know that we have access to a lot of supply. If we don’t meet the demand domestically we can also suck doctors in from other countries. Canada and England to a small degree but especially SE Asia and East India. I know I read somewhere about how a lot of doctors trained in other countries aren’t able to work here and so instead have to drive taxis and the like. Why is that? Can this supply not be tapped? We import Philippine nurses by the thousands, can we not do the same with doctors?Report

              • Avatar Jaybird says:

                “I know I read somewhere about how a lot of doctors trained in other countries aren’t able to work here and so instead have to drive taxis and the like. Why is that?”

                Cartels? Barriers to entry?

                What else makes sense?Report

            • Avatar Trumwill says:

              Residency slots, from what I understand. Maybe medical school accreditation for domestic docs, but even if more med schools opened shop, you still have a limited number of residency slots. That’s one of the main throttles with foreign docs. To practice medicine they have to get into a residency program. Preference for residency slots are (understandably) given to Americans and American-educated foreigners.

              This is my understanding of the issue, anyway, from the outside looking in. My wife is a doctor and my former brother-in-law is a foreign immigrant who spent years before being able to get into a residency. Interestingly enough, he made a living those years testifying as an expert witness in court cases even though he was not able to practice as a physician. He’s pretty well set up now, though.

              Anyhow, residency slots is pretty much how it was explained to me.Report

        • Avatar North says:

          Okay I think I follow.
          A) The bill will create demand and remove barriers to access. With heightened demand and lowered barriers more supply will be needed.
          B) But the supply is controlled by cartels.
          C) They have sufficient legal power to constrain supply to inflate prices.
          D) So then a black market in medical services will form to meet the demand.

          Is that about correct? It is a plausible scenario to me. I definitely see the HCR bill in step A. Step B is a statement of the current status so can’t be attributed to HCR directly. C again is dependant on the current state of affairs and of course D follows from B and C. Now by cartels are we talking about professional associations or government accreditation requirements or something like that or is this a corporate thing?Report

          • Avatar Jaybird says:

            I have no idea what cartels will show up. Hell, it might be insurance companies bringing the hammer down on doctors who aren’t part of their (or a company with which they collude’s) network.

            I have *NO* idea how it will happen. None.

            But I see all of the ingredients for a black market. It will require a complete rewriting of my axioms if one doesn’t show up by, oh, 2025.Report

            • Avatar North says:

              Oh okay, my mistake, so you don’t think the cartels exist now but that they will come into existance as a result of the bill?Report

              • Avatar Jaybird says:

                Again: I have no idea. Maybe they’ll evolve their newfound influence in such a way that they’ll become cartels. Maybe it’ll come out that they’ve been the entire time.

                I just see something that I think I’ve seen in the past. The last few times I’ve seen or read about X and Y happening, Z has happened.

                I’m pretty sure that I’ve just seen X happen. I’m waiting for Y.Report

              • Avatar North says:

                Okay well obviously we’ll see in the next couple of years.Report

              • Avatar Jaybird says:

                If I don’t link to this thread in 2025, I hope you do.

                If I say something that begins with “Well, you have to understand,” you have my permission to slap me silly.Report

            • Avatar Trumwill says:

              One issue here is that doctors don’t really get to set their own prices. Not in the normal sense. There are so few people paying them that those that do (the government, insurance companies, etc) have quite a bit of leverage. Particularly when it comes to primary care.

              Where you would likely see the black market (if one were to arise) would be because wait times get too onerous. If you have a virus and by the time you see a (licensed) doctor it will have run its course (either by your white blood cells defeating it or by your dying) you will simply go see someone else.

              This could be some dude in a dark alley with all sorts of medicine he can throw at you for the right price, or it could be (for a virus) seeing a mid-level provider who has more expertise than some guy in an alley but less so than a doctor. For the non-primary stuff, the “black market” may be medical tourism. Canadians come to the US for what they can’t get there. We’ll go to Mexico. Or India. Or at least those of us that can afford to will.Report

    • Avatar Rufus says:

      Also my measurement is going to be the plague metric- I think there’s a 65.4% chance of a frog plague and at least a 23% chance of a locust plague if health care reform passes.Report

      • Avatar Jaybird says:

        “Anyone with a shred of intellectual honesty would have to take into account that these are Chortoicetes terminifera and, as such, ought not be considered particularly remarkable despite their numbers. It’s not like they’re Melanoplus spretus.”Report

  16. Avatar Kyle says:

    Unless you also insist that a great number of others also are included, if you insist that a particular measure be included in the assessment, then you are effectively making it central to the assessment. And if you base that on what a particular leading proponent said in a particular speech, but misrepresent the bulk of the claims she made for the legislation in that same speech, then I can fairly say you are misrepresenting her.

    That said, you are absolutely right that Jason can judge the reform absolutely any way he pleases. The question is whether he can legitimately expect me or any other supporter to agree to those standards of judgment. And my position is that because health outcomes were included in, but were far from central to, the justifications laid out for the reform (as represented here by this speech, but other texts can be examined), I believe I can quite legitimately refuse to accept a judgement of the reform that puts them at the center standard of the standard used. But the person who personally still wants to use that standard obviously still can.

    FWIW, I think you now misrepresent your own words above about how important health outcomes must, of necessity, be to any legitimate judgment of this legislation’s performance, but I’m glad you now accept that health outcomes do not have to be central to the standard.

    I just moved this down here. I’m sorry, I missed the part where Speaker Pelosi said one justification was more important than the other. Which makes it silly to argue which one is the main justification and/or the primary justification.

    You say, “And my position is that because health outcomes were included in, but were far from central to, the justifications laid out for the reform.” But you have no meaningful way of actually deciding what is and is not central besides your own personal ranking.

    Which leads us back to relative-land where everything is subjective. Which makes it fair game for each person to choose a justification and judge the law relative to it, but unfair to say that one justification is more central than another.

    I don’t see how I’m at all contradictory, in my opinion, I think health outcomes are the central justification because that metric alone explains the value of insurance and care in the first place. That is my opinion. It is also my opinion that there is no central – agreed upon by all – standard in the legislation, so arguing over how X is “largely more the justification” than Y is facile.

    Finally, I don’t think I misrepresented the Speaker at all, since my point wasn’t about relative justification, merely that it’s one at all, citing how it’s one at all suffices to prove my point.Report

    • Avatar Michael Drew says:

      If you think you can read that speech and conclude that health outcomes are equal to economic security in the reasons given for the legislation, then okay. In any case, you son’t seem to be claiming anything that I don’t concede — ie that yes, of course anyone can judge this bill for himself any way he pleases. This discussion only matters if it is about what you can rightly claim I should concede is a fair way to judge the reform. If you’re not claiming that, then we’re not talking about anything. If you are claiming that, then you and I will have to come to agreement on what those ways might be, which if we agree they relate in part to what leading proponents climed for the reform, will involve each of us making interpretive claims about what the’ve said.

      And by the way, you’re back to claiming that health outcomes are central to your metric, which is for all intents and purposes equal to them being pretty much exclusive (ie you won’t accept the bill as justified without particular standards having been met). You say it doesn’t matter how much emphasis was put on them in the justification, if it was done at all then you are justified in making it central (and maybe even if it hadn’t been, since you see that as the exclusive point of insurance). But this just goes back to my initial claim, which was that because health outcomes were not the central justification for the reform, then proponents don’t have to accept them as the central standard for judging it. I think that remains a fair claim regarding a universal standard. You, of course, remain free to judge it as you see fit. But you can only vote once per election.Report

      • Avatar Kyle says:

        I didn’t read your initial comments as saying that “proponents don’t have to accept them as the central standard for judging it.” I read them as suggesting that it was inappropriate for anyone to use them because that wasn’t the central justification. So yes, I do think we’ve been going ’round and ’round over nothing, if that’s the case.

        That said, I do appreciate your engagement, and if we can switch somewhat, it strikes me that if health outcomes are secondary to the other problems of portability related concerns and health care induced bankruptcies, then why support reform that entrenches the byzantine system that creates the incentives that resulted in the pre-Tuesday status quo? Won’t natural incentives act as a drag of the efficacy of reforms as they go from proposed to enacted?Report

        • Avatar Michael Drew says:

          Well, I must say that is an odd way to read them, as the context of my remarks was Jaybird’s familiar request/challenge for proponents of legislation to produce measures of efficacy by which they themselves will pronounce on the law’s effectiveness at some future time. But okay.

          As to why support the entrenchment of the system, basically it’s because I believe in the president’s determination that more fundamental, disruptive reform was not politically feasible in this environment, or indeed given his somewhat limited ability to sell the public on fundamental changes. He barely managed to get a reform that essentially doesn’t touch anyone already covered through. I thin it was a perfectly reasonable assessment of the moment and his abilities, frankly. I also happen to find the notion that any politician would be capable of bringing about reform that would bring down the employer-based insurance system through an overt act of commission frankly laughable. We may have a worse system for it, but people fundamentally understand decent insurance as a benefit of having a “good” job (that is in fact the primary social definition of a “good” job.) In my experience, most working people I have met (at least before this debate occurred) had no sense whatsoever that their having insurance through employment was a quirk of historical contingency, or that they in effect receive a massive government subsidy to allow them to have that coverage. I think most would be resentful of the idea that this “subsidy” should be discontinued, and highly skeptical of the claim that id it were, they would receive its value back in cash wages. And all of this so that they can spend copious amounts of time doing tedious comparison shopping in their off hours that their IR office currently does for them? You have got to be kidding!

          Is this system likely to collase under its own weight at some point? Yes! It seems to me the clear soution, from any rational politician’s, or even social planner’s standpoint, would be to let it! This is a reform that will reform itself, it seems to me. Reforms that will not reform themelves, on the other hand, are things like the problem of the uninsured, pre-existing conditions, abusive ins. co. practices, lame Medicaid programs — exactly what this bill puts in place. They set a baseline for coverage and market practices for when real reform comes to the system naturally.

          That said, if a politician were to take a real stab at the employer-coverage system and make the arguments work with the public, I’ll happily eat these words. I’m in no way wedded to the employer system. I just don’t think it’s worth anyone’s time or energy to go after at this point.Report

          • Avatar Michael Drew says:

            ‘…his somewhat limited ability ….’ …was up to the task. I think he assessed that ability astutely, as well. As big as this looks, in fact he went small-ball. This is why I have such a problem with those who don’t support this reform because it is insufficiently radical. A) The more radical reform is still there to be done — it’s not off the table, and B) do you know of a politician that could that at this time? I don’t. Ever before the system collapses? I don’t think I do. If that’s what you’re for, then I really think you’re functionally not for reform at this time. And that’s okay. But that’s what I think.Report

          • Avatar Jaybird says:

            Here’s what I’m looking for:

            We know that this legislation was needed because things were bad.

            This legislation, presumably, was enacted to remedy the bad things.

            Here is my suspicion: No matter what happens (NO MATTER WHAT HAPPENS), proponents of the bill will call it a success. If things don’t get measurably different, they’ll explain how much worse it would have been without it. If things get worse, they’ll explain how it would have been even worse without it and this just demonstrates the need for more funding.

            You know, the way that Drug Warriors explain the necessity of The War On Drugs.

            Is there anything that would get you to say “okay, the war on drugs has failed… it’s time for us to repeal prohibition”?

            Anything at all?

            (Here is my question)

            If so, what is it?Report

            • Avatar Michael Drew says:

              Some certainly will exhibit that behavior, you are right about that. But that certainty is no reason to despair of all accountability in the system.Report

              • Avatar Jaybird says:

                I’m not despairing of all accountability in the system.

                I’m just looking an answer to “If so, what is it?”

                Of course, if I don’t get an answer, I’ll start feeling justified that this bill is to Health Care what the TSA is to the safety of our women and children.

                Why, just look at the absence of piles of bodies in the streets! It’s a success!Report

              • Avatar Michael Drew says:

                I mean, it’s starting sound like what you are reacting to is less a legislative tendency against reviewing major legislation than it is just the general trend toward mindnumbing intellectual laziness in the gen pop.Report

              • Avatar Michael Drew says:

                …and that’s totally fair.Report

              • Avatar Jaybird says:

                Not just the gen pop. It’s when the proponents of major legislation share this tendency to say that it’s a success no matter what happens, I’d prefer less sweeping changes (if not no change at all).

                It’s not like we can’t get away with saying that its not a success, after all.

                Just look at the absence of bodies.Report

              • Avatar Michael Drew says:

                So when you say “proponents” do you in fact mean “the elected officials responsible for its passage”? Because that would clear a lot of things up for me.Report

              • Avatar Jaybird says:

                I generally mean the people who consider me a bad person to the point where they are willing to tell me I am one because I oppose it. Or, of course, to tell me that I must not understand it because I oppose it. Or, of course, that I must support children dying. Or some combination thereof.Report

              • Avatar Michael Drew says:

                That’s a pretty narrow slice of everyone who supported the reform.Report

              • Avatar Michael Drew says:

                …but I take your point (I should have added). Overall I think the “tens of thousands will die for lack of health insurance” meme to have been massively ill-advised, both as an immediate means to pass the bill — you’re entirely reasonable to resent the suggestion you’re responsible for those deaths, even if they were to happen — and from the perspective of accountability to it as a material claim for the bill. I don’t know how to direct the research investigating whether that claim had merit, though I’m guessing it will be done (unless this reform is extremely short-lived whether due to repeal or further reforms in the intervening time that make this one pale in comparison), and that the claim will be borne out in its basic thrust, but not in the specific numbers cited. But that said, the claim was made more in the spirit of demonizing opposition, and I think that should not have been anyone’s tack. I think it had its roots in frustration with the inability to break through the most sensationalized rhetoric of the opposition (and to some extent in resentment over rhetoric used to railroad us into invading Iraq), and to that end (breaking through the endless repetition of the most sensationalized memes, which not for nothing is maybe the most destructive dynamic at play in our media and even broader public domain today), it worked. But two wrongs don’t make a right. And unlike the claim that war opponents would allow Saddam Hussein to continue to kill Iraqis (nevermind who or what else did), this claim cannot be proved accurate or inaccurate for some number of years if not decades going forward. So it is already having its downsides as a tactic revealed.Report