Why the debate over healthcare reform may be just beginning


Elias Isquith

Elias Isquith is a freelance journalist and blogger. He considers Bob Dylan and Walter Sobchak to be the two great Jewish thinkers of our time; he thinks Kafka was half-right when he said there was hope, "but not for us"; and he can be reached through the twitter via @eliasisquith or via email. The opinions he expresses on the blog and throughout the interwebs are exclusively his own.

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149 Responses

  1. Avatar greginak says:

    I think it correct to point out the nature of tribalism and often people just go with what others say. It’s also very easy to overestimate it. Most people aren’t lockstep in line with their tribe and have a mix of beliefs.. We’re less then completely independent decision makers, but most of us are bit more then just following our marching orders.

    At this point the ACA is always going to be a demon for many people. However SS and Medicare were demonized also. Just like there are R’s who are still aching to get rid of SS and Medicare, not at all because of ideological rigidity and general nastiness of course, those programs established things people like. I can easily imagine many people hating the ACA but being just ducky with everybody having coverage and almost all of the parts of the act.Report

    • Avatar Elias Isquith in reply to greginak says:

      Yeah, the Medicare precedent is definitely useful. Ronnie Reagan warning of the Death of Freedom and all that. But that was 40+ years ago and we see with the Ryan budget that the fight goes on. Maybe the squabbling over ACA will go on in perpetuity. Ugh. If that’s the case, it would’ve been nicer for its defenders if the bill was a bit more, well, defensible.Report

      • The first problem with the Obamacare bill was how it was passed/forced: Scott Brown’s election made it impossible to pass the more-properly worked out House bill, which “reconciled” with the original Senate bill. Hence, by manipulation of the legislative process—and it was a technically kosher manipulation—we got stuck with the Senate bill, which was intended as a “first draft.”

        Secondly, “consent of the governed” implies at least some of the “other party” in a 2-party system to go along, esp major changes like this. Although not legally required, consensus lends legitimacy.

        Thirdly, it was 2700 pages afterall, and nobody knows what it says or how it’ll play out even a year later. This is simply bad law. Polls that say we agree with its sentiments and ends mean nothing. We all “want something done” about the rising cost of health care. Duh.

        As for Social Security and Medicare, their opponents were of course correct, as we see as these schemes hit the demographic fan. But they do have consensus and therefore legitimacy. We are keeping them, the only question is how.Report

        • Can’t the problem simply be with the bill and not all this silly ginned-up “process” stuff? And go back and check that Reagan recording on Medicare; the gipper was NOT right.Report

          • Mr. I, perhaps. Reagan is dead. But the Dems manipulating the process denies the bill legitimacy in the eyes of the people and defies the “consent of the governed” as I limned above.

            To force major change down the other party’s throat by the slimmest majority is antithetical to the American system. Per Madison, the Federalist, whatever.

            The Democratic Party has been trying to ram through an American equivalent of Britain’s National Health Service since Harry Truman. And LBJ signed the Medicare bill at the Truman Library in 1965.


            “Charity is indignity when you have to have it,” said Truman at the time.

            Well, actually, it is charity. And upon receiving charity, one should be grateful, not indignant.

            And this is what’s wrong with the current mindset, Elias. It’s charity, let’s not mistake it for something else, like “rights.”

            If I’m going to going to pay for yr healthcare, give you charity, I’d just as soon you eat ribs, drink beer, and be a good and happy fellow instead of some nasty little tofu-eater who begrudges me my ribs and beer because I’m a drag on the “system.”

            You would be the drag in this case. Or as Redd Foxx put it, health nuts are going to feel stupid someday, lying in hospitals dying of nothing.

            This is what’s going on, not policy or bills or any of that political stuff. Once my ribs and beer become a matter of your political concern, you own me. Fish off.Report

            • TvD, I’d ask you to do two things:

              1. Try to stick to the subject, if possible and
              2. Refrain as best you can from non sequitur ad hominem attacks.

              Let’s try to comport ourselves like the refined gentlemen we — or at least some of us — imagine ourselves to be.Report

              • Mr. Isquith, I was on point. This attack on me was expected, since you were obliged to eat shit apologizing for your last attacks on people of good will. I figgered it was my number that was up; you come to fight, not to discuss.

                You have no right or standing to lecture anyone on civility.

                And I was just composing yet another olive branch in your direction, where our minds might meet instead of quarrel. My heart isn’t in it anymore, I hope you understand. Rock on.Report

              • All right, Tom. From my vantage you told me to “fish off” for no apparent reason, and I merely responded by asking you to not do so. But whatever.Report

              • Avatar Koz in reply to Elias Isquith says:

                Contentiousness aside, tvd is right. It’s difficult to overstate the extent to which the Demo majorities repudiated the clear will of the American people. Frankly, the D’s got off cheap in 2010.Report

              • Avatar Murali in reply to Koz says:

                Are you seriously going to go with Roussou’s will of the people stuff??

                Thats leftist talk man!Report

              • Mr. Isquith, you seem to have taken “you” as meaning YOU instead of “one.” I apologize for the imprecision. My wife is just now frying up some tofu at my request—“tofu-eater” was an abstraction.

                [Although we are having ribs tomorrow. Beer, too, most likely.]

                I found debate to be empty at an early age, merely a honing of technique, with winners and losers; quarreling took me far longer to reject, until I realized I’m getting too old for that shit. Sharing and testing ideas is all that colloquy is about. I like colloquy.

                It’s not about YOU; neither is it about ME. I prefer to leave ME out of this, please, por favor, merci. If you want to inject YOU, than you’ve put you on the table.

                If you wish to start over, clean slate, I welcome that, Elias. Ideas, not personalities.Report

              • No prob, Tom. Clean slate it is.Report

            • Avatar Jon in reply to tom van dyke says:

              Yet strangely these evil communist system seems to work in every other non-primitive nation in the world without people getting into death matches about ribs and tofu.Report

              • Avatar Scott in reply to Jon says:


                Really like the Brit NSH that left the guy to die in the hospital hallway then dragged him out by his heels?


                Or when Canadians come to the US for care they can’t get from their wondrous health system? If this is success then count me out.Report

              • Avatar Jesse Ewiak in reply to Scott says:

                The difference is of course, this is big news in Britan. That happens everyday in the US.

                As for Canada, that’s the biggest myth in the history of myths. Do superrich Canadians come here for care? Yeah. Do the other 99% of Canadians? Nope, and even the Harperites act like you just slapped their mother if you even imply they want to get rid of UHC in Canada.Report

              • Avatar DensityDuck in reply to Jesse Ewiak says:

                “The difference is of course, this is big news in Britan. That happens everyday in the US.”

                Cite please, and yes you do have to provide a link, particularly when the person you’re snarking at actually did.

                Besides, if “dragged out dead by the heels” is a bad thing that shouldn’t happen, then doesn’t the fact that it still happens in a UHC country imply that UHC isn’t the solution to all the problems?Report

              • Avatar Simon K in reply to DensityDuck says:

                Yes, I’m pretty sure the NHS has yet to either return to the moon or solve global warming, so transforming human nature might be beyond them. Sad, I know.Report

          • Avatar Koz in reply to Elias Isquith says:

            A lot of libs misunderstood the process business. It was (and is) very important. The procedural corner-cutting could be excused in other circumstances. A large number of Americans, Americans energized by opposition to PPACA and not necessarily politically active otherwise, saw their procedural safeguards bulldozed by the Demo’s.

            If the opposition to PPACA weren’t as strong it wouldn’t have mattered.Report

            • Avatar tom van dyke in reply to Koz says:

              Mr. Koz, I’ve found some of the most impressive lib/left arguments to 2B about “process.” Some in personal correspondence, one Habermas fan in particular. I like Habermas a lot.

              Might be where I’m coming from on this. That and anybody who ever talked about “consent of the governed” understands that it’s not synonymous with majoritarianism, 51% telling the other 49 what’s what. That was the problem with the passage of Obamacare, or neutrally put, the Affordable Healthcare Act.

              It was a 51-49 thing, if that, esp with the election of Scottt Brown to take Ted Kennedy’s seat. That’s no way to run an airline. Or a nation.

              If I were king, I’d ban abortion and tax the bejesus out of the populace to pay for the unwanted kids who were born and sustain the mothers in prenatal comfort. But if I were a president, legislator or even SC justice, I wouldn’t impose my will on America. I’m a republican, not a democrat, if you follow the small “r” and “d,” and I think you do.Report

              • Avatar Jon in reply to tom van dyke says:

                It took 60 votes, not 51, to pass PPACA in the Senate. The HCERA amendments passed 56-43. Neither are “narrow” “slim” or any other sort of adjective you want to throw on it.

                If you want to call that a narrow majority because it undemocratically and artificially takes 60 votes to pass anything through the senate, fine, but it’s still a large supermajority.Report

            • Avatar Koz in reply to Koz says:

              Absolutely. One caveat I’d emphasize is that wasn’t about the numbers as much as the combination of the numbers and the energy. They use to have polls where 70 or 80-some percent were routinely in favor of prayer in public schools and the item veto.

              Whatever can be said about them, the reality is nobody cared enough to do a whole lot about it. That was the key difference in Obamacare. The D’s had to choose between maintaining faith with the American people and pursuing their economically disastrous agenda. We lost a big one there.Report

        • Avatar Zach in reply to tom van dyke says:

          The opponents of Medicare and Social Security warned of massive trust fund debts circa 2050? I’m pretty sure they just argued that the first one was socialism (inaccurately predicting that American healthcare would outpace nationalized care abroad) and that the latter was a raw deal (which makes no sense since Social Security taxes aren’t an investment). This was certainly the gist of Reagan’s complaints, Goldwater’s campaign, etc.Report

        • Avatar Murali in reply to tom van dyke says:


          I’ve found that consent of the governed has always been a sham.

          1. The thief does not consent to laws about private property

          2. Most of us don’t consent to at least some of the laws that govern us.

          3. My quiescence at the current system or administration does not imply my consent to it. For I could do both and not be caught in a contradiction.

          4. Some significant minority does object to the current politicians in power

          5. i.e Always there are some who are governed who do not consent to said governance.

          Yet, some coercive system of laws is legitimate. I am not an anarchist. How do I justufy the state? I will not bring that up here. My point is just this: talking about actual consent of the governed is b******t.

          Now, if we were to move on to hypothetical consent, that would be different already, and that I would understand. But I’m sure that your criticism was not one about hypothetical consent. It was about howactual consent for the bill was passed.Report

          • Avatar tom van dyke in reply to Murali says:

            There is no polity that’s unanimous, Murali, but as a good citizen, yes, I put up with stupid shit that we as a democratic republic have come up with. “Consent” isn’t synonymous with endorsement of a political item.

            If this Obamacare sticks—I hope not—I will consent to go along with it, because I consent to the rights and duties of citizenship. [Note the “duties” part, so often severed from “rights” in this modern age…]

            And I kick about how they passed Obamacare because this here democratic republic was set up for consent and consensus, not brute majoritarianism [again see the Federalist papers: pure democracy scares the shit out of any sane person, as it’s simply mob rule].

            If all our laws were passed like Obamacare, 51% of us against the other 49, well, I think we take the stability of governments a little too much for granted sometimes in the US. At some point, something can pop, whether it’s revolution or simply a society turning scofflaw at its own political system.

            But as it stands, there’s enough consent of the governed that we take the bad with all the good. No, I’m not advocating revolution if Obamacare sticks. This republic has survived far stupider ideas than that.Report

  2. Avatar Trumwill says:

    Agree with Elias on tribalism. I think it’s difficult to really overstate.

    Most people have substantial experience, or have devoted substantial amounts of time researching, in relatively few areas. So say I have researched fruits and I have determined, without a doubt, that Apples are the Best Fruit. I don’t have a real opinion on vegetables. But I enter a conversation, in which one person says “Apples are the best fruit and radishes are the best vegetable” while the other person says “Apples and radishes are junk. Mangos and tomatoes are where it’s at.” Well, as I enter the conversation, I am looking at one person who apparently doesn’t understand what a good fruit is and another with impeccable taste. I don’t really know one vegetable from another, but I am looking at radishes and tomatoes differently.

    And before long, I am a member of the Apple-Radish-Potato-Oliveoil coalition, even though apples are the main thing I care about and I actually prefer butter to olive oil. But those Mango-Tomato-Corn-Butter people are just crazy. And dishonest as hell, because everybody knows a tomato is a fruit!!

    So as Greg says, we’re not automatons all walking a party line. If we feel strongly about something, we’re not going to (necessarily) pretend otherwise, even if it puts us on the “wrong” side of our peers. But given how little knowledge we really have, and how the people who inform our knowledge typically come from a particular direction, we end up taking positions that we wouldn’t if our tribe had come at it from a different angle.Report

    • Avatar trizzlor in reply to Trumwill says:

      I wonder what would happen if the media consisted of “single-issue” pundits. You would have a few people who are experts on, say, global warming and they would come on and debate issues related to that and only that; then you’d have some other group of people, completely distinct, who’d be experts on macro-econ and they would come in and debate tax-policy. The two groups would never intersect and a viewer wouldn’t be able to carry over their support of a pundit in one area of policy to an unrelated one.

      Heck, you could even have some “experts” on optics and framing and such, and they would debate on how an issue resonates with the voter … but no one would listen to them much. I think people would be a lot more likely to say “I don’t know” instead of jumping on one bandwagon.Report

  3. Avatar Zach says:

    Citizens United had a legal rationale. Overturning Obamacare doesn’t. I don’t see how it can get even four votes from the crowd you’d expect on a purely political issue unless they argue some technicality. The conservative block of the court is conservative in many ways, but there’s zero support for some states’ rights interpretation of the constitution. So long as Federal requirements of states come along with Federal funding, has anyone on the court expressed opposition? Let’s take Scalia for instance (in Gonzales v. Raich; the medical marijuana case): “Congress may regulate noneconomic intrastate activities only where the failure to do so “could … undercut” its regulation of interstate commerce.” That’s plainly a rejection of the states’ argument against Obamacare. Scalia makes some tortured arguments (in Heller, see how he explains that handguns are undoubtedly legal while machine guns may be banned since handguns are the 21st century equivalent of muskets and everyone had muskets back in the day), but I can’t imagine him writing the decision comparing “activity” to “inactivity.”

    The real court battle with Obamacare will come when states refuse to implement it and are ordered by state and federal courts to comply. The current cases are expensive wastes of time, and folks living in those states should really point this out. I’m no Chris Cristie fan, but he did the right thing here.

    On fiscal stimulus, I come to the conclusion that it makes sense to borrow money when the interest rate is effectively zero and invest it now. The analogy that, like families, we need to “tighten our belts” is absurd — a smart family offered a massive line of credit at 0.2% would borrow as much as possible, spend what’s needed to stay afloat, and invest the rest to more than pay down the debt going forward. I don’t think tribalism comes into play in this line of thought.Report

    • Avatar Elias Isquith in reply to Zach says:

      I used fiscal policy as my example because it’s not the realm of politics towards which I naturally gravitate or feel necessarily at my most comfortable discussing. There’s *probably* some area of policy where you’ve relied on your prior trust of a certain source to either reach conclusions or simply use as a kind of bibliography as you did your own research.

      And on Scalia, I think it’s most likely that you’re right, but I’ve found him in the past few years to be even less consistent intellectually than usual.Report

      • Avatar Jaybird in reply to Elias Isquith says:

        Scalia is intellectually consistent if you see Applied Catholicism as intellectual consistency.

        From my perspective, Thomas is the only one who *MIGHT* qualify as intellectually consistent but he’s a GIGO machine which results in GO whenever GI happens which makes him significantly less praiseworthy.

        Still more than “none at all” though which makes him somewhat different from the other eight on the court. (Though, to be sure, Kagan recused herself recently from a case that I was pretty sure she wouldn’t recuse herself from and that impressed me.)Report

      • Avatar Zach in reply to Elias Isquith says:

        True. I have some clue what goes on in economic modeling but when I look at the “cost” of some proposal I’ll take the CBO/JCT’s or a centrist think tank’s word over that of partisans and there are obviously other examples. This sort of reliance on authority isn’t specific to policy, though. I suppose policy is different because folks you trust say things and then you go and make political acts in response.Report

      • Avatar Jon in reply to Elias Isquith says:

        Citing Raich as a reason Scalia will do something is ironic. Raich was served up to the Supreme Court the way it was by two very liberal 9th circuit justices (and I say this not believing in the 15 year out of date trope that the 9th circuit is “liberal”) with the specific intent of testing the limits of scalia’s views on federalism.

        He was inconsistent by saying what he said. because it was weed.

        I wouldn’t rely on him sustaining the PPACA on that basis at all.

        5-4, kennedy writes the majority opinion so that he can become the next king of the supremes a la sandra day and leave either side in suspense and do whatever he wants.Report

    • Avatar tom van dyke in reply to Zach says:

      “[Randy] Barnett believes [they] are reading too much into Justice Scalia’s concurrence in Raich. “Two things about that: one, it’s a concurring opinion, so it’s not current doctrine,” Barnett says.

      “Two, if you take that doctrine as it’s enunciated by [Justices] Scalia and Stevens and Rehnquist, it says, ‘If in the course of regulating interstate activity, in order to do that, if it has to reach non-economic intrastate activity,’ it may do so under the Commerce Clause.”

      However, “it’s all about activity,” Barnett emphasizes. “It’s not about inactivity. It’s all about when you can reach interstate non-economic activity.”

      Barnett concludes, “If the people [who] support [the mandate to buy health insurance] are relying on Justice Scalia’s interpretation of his own theory, I think they’re going to be disappointed. I think [Justice] Scalia is more than capable of seeing the limits of the theory that he himself offered. If I were the lawyers for the federal government, I would not feel really confident interpreting” Justice Scalia’s concurrence in the government’s favor.

      “It’ll take him 30 seconds to conclude that it doesn’t apply to an economic inactivity,” Barnett says.Report

      • Avatar Zach in reply to tom van dyke says:

        I can’t see Scalia writing a decision discriminating between activity and inactivity without shooting himself. I don’t know much about the character of the guy, though, so perhaps he’d sign onto someone else’s opinion. There are examples of regulating inactivity going back to when the founders were still holding office. The Federal government has the statutory authority to mandate vaccinations (although it doesn’t exercise this authority in practice since states have been cooperative). Registration with the Selective Service is hardly necessary for the Federal government to raise armies when needed. It’s not necessary to compel everyone to serve on Federal juries when called in order to have trials by jury. Most relevantly, the Federal government mandates that anyone participating in many varieties of commerce (regardless of whether it’s intra- or interstate, and there still is some distinction) pay payroll taxes and participate in pension programs. If you try to avoid this you will be fined for noncompliance, just like Obamacare.

        However, it’s appropriate for this post to admit that I’m biased against Prof. Barnett since this is his pet theory and it’s important for him that it have a chance of being taken seriously.Report

        • Avatar Jon in reply to Zach says:

          obviously, you buy into the myth of scalia. he should have shot himself in the face in raich and bush v. gore then on that standard.

          it’s much easier to explain just about every major controversial court opinion by partisan analysis than it is to waste your time reading old opinions and speeches.Report

      • Avatar Simon K in reply to tom van dyke says:

        If the court rules against on such incredible narrow grounds, there’s no way they’ll strike down the whole bill. It’ll just be the mandate. And the mandate can be brought back without even needing to pass new legislation as a tax. In all probability, the court will conclude that since the mandate is actually indistinguishable from a tax, they may as well treat it as such.Report

    • Avatar Koz in reply to Zach says:

      “Citizens United had a legal rationale. Overturning Obamacare doesn’t.”

      This is a case in point of what I meant below. Maybe Zach is just using a little rhetorical excess, but clearly there is a legal rationale for overturning Obamacare.

      Two federal courts have supported it, Prof. Barnett and others have published law review articles about it. The Volokh Conspirators have circulated it into the blogosphere. And not least, we have gone back and forth over it here more than once.

      I find the case against Obamacare to be persuasive. I don’t expect others to agree but it’s ridiculous to pretend it isn’t there, especially if we try to discuss the legal trajectory of the bill.Report

      • Avatar Jon in reply to Koz says:

        no. you’re making no distinction between having the power to do something and there being a precedent for doing something.

        they clearly can strike down ppaca, and i’m sure they will have extensive research to “back it up.” but trying to say that this is grounded in some kind of long-standing precedent would be incorrect.

        the judges striking down ppaca are moving the “trajectory” where they want it to go, not where it has been.

        the case against obamacare is persuasive because there are usually 5 conservative votes on the supreme court not because it is “correct” or “incorrect.”

        it’s up to kennedy.Report

        • Avatar Koz in reply to Jon says:

          No, what I am saying is much simpler than that. There is obviously a legal rationale for overturning Obamacare, precedent or otherwise.

          As far as precedents go, you probably have me mixed up with somebody else. The key element of the case against Obamacare isn’t precedential, it’s textual. There is no enumerated power for the federal govenment to force Americans to purchase health insurance. End of.

          Our understanding of these things are modified through the development of precedent which leads to the main problem for the DOJ in litigating in favor of the bill. There is no precedent for Obama care. There are a number of precedents which can easily be extended to cover Obamacare, but none that can be directly applied.

          And, why should they be extended? We live in a time where people are overwhelmingly concerned about intrusive government and the reasoning behind some of the precedents looks weak anyway. Therefore we can dial back some of the Commerce Clause overreach and as a bonus we also get to flush Obamacare.Report

    • Avatar Scott in reply to Zach says:


      “Let’s take Scalia for instance (in Gonzales v. Raich; the medical marijuana case): “Congress may regulate noneconomic intrastate activities only where the failure to do so “could … undercut” its regulation of interstate commerce.” That’s plainly a rejection of the states’ argument against Obamacare. ”

      What are you talking about? Barry says that not buying insurance is an economic activity b/c of the special and enormous nature of the health care market and therefore falls under the gov’t ability to regulate it, which in this case means they can penalize you (but not tax you even though this penalty will collected by the IRS) if you don’t buy it. This is, I think, distinguishable from Raich and any other cases I think think of at this late hour as there has never been a suggestion that the gov’t can coerce you to buy something.Report

  4. Scalia is intellectually consistent if you see Applied Catholicism as intellectual consistency.

    Ha! Very true.Report

    • Avatar Baron von Munchausen in reply to Elias Isquith says:

      I would die for Scalia—just love the guy. Have you ever been witness to one of his liberal evisceration’s? Pure, unadulterated, joy. He swats Liberals around like an elephant with a trunk getting slightly annoyed with the liberal mosquitoes. You know how they do it, side to side, swat, swat, swat, and then they’re gone. No offense, but would it be rude to assume from the get-go, that Liberals are organically insane? Their brains somehow got rewired by either Larry, Moe, or Curly. And their free-floating pathological, neurotic misery leads to the land of woebegone death wishes. Do you think maybe God wonders why He had all of this put on His shoulders? He probably wishes the tall straw would have been picked by one of his kindred brethren. I’d say, we need to get to the bottom of this and haul God into the International Court. If the verdict is guilty, good luck trying to find a way to execute Him. Doubt He’d be as kind to the mobs and masses as His Son.Report

  5. Avatar Koz says:

    “I’m of the mind that the “rational” basis for much of our politics is arrived at ex-post facto and that the most influential parts of our decision to self-identify as left-wing, right-wing or moderate are subjective and social. By social, I mean to say that they’re determined by the values we’ve come to hold most dear, and that our ordering of these values is a process largely comprised of experience and emotion. And, yes, it’s very tribal.”

    This is true of course, and in fact a small source frustration for me. In particular, there’s an odd narrowness of alternatives that reasonably intelligent people should be considering. In particular there’s an inability for a lot of people to consider the idea of comprehensively defeating liberals and ignoring their priorities and political maneuvers. Secondarily, there’s also some unwillingness to expect libs to do something for the benefit of the country as a whole as opposed to their narrower agenda.

    Right now, the main case in point is the budget wars, and their impact on growth and unemployment. Somehow, it’s difficult to grok the existence of the main the alternative to our current trajectory. Ie, relative to President Obama’s Feb budget projections, we cut expenditures significantly, (discretionary, entitlements or otherwise) without raising taxes. Doing this will restore credibility that public finance will at some not-too-distant point be on a sustainable course. Then, investors and others will feel secure in participating in the economy. Then employment and growth can be restored and we’ll all have a very merry Christmas. The logic behind this is mildly complicated but not excessively so.

    Obviously not everybody is going to agree with this analysis but we should be that is an alternative to Obama’s budget, in fact the key alternative to Obama’s budget. Unfortunately most of the public discussion around this ends up being more political than substantive. Ie, the Demo’s won’t do this so we’ve got to raise taxes or raise the debt ceiling or whatever.

    We can’t allow ourselves to be boxed this much. Either we should consider repudiating liberals root and branch for the sake of enacting budget reform, or we should be able to engage the liberals and persuade them to cut expenditures for the good of the country even if their desires usually run the other way.

    Optimally both, but at least one or the other. The GOP won 60-some net seats in the House last election. The 2009 stimulus package beat a filibuster no votes to spare in the Senate (or maybe one). PPACA got by with no votes to spare more than once. There is simply no way, in the current political environment, the we have to accept the ever-growing welfare state as a fait accompli. Unfortunately, for many liberals the idea of unwinding the welfare state is literally unthinkable. The herd mentality kicks in before they really understanding what they’re up against, even for the sake of articulating why they’re opposed to it.

    That last part is important. It’s unrealistic to think that the web of political loyalties will dissolve. It’s not unrealistic to hope that partisans can defend the position of the tribe instead of merely asserting allegiance to the tribe.Report

    • Avatar Zach in reply to Koz says:

      “Unfortunately, for many liberals the idea of unwinding the welfare state is literally unthinkable. The herd mentality kicks in before they really understanding what they’re up against, even for the sake of articulating why they’re opposed to it.”

      That’s an odd thing to say since it wasn’t liberals who got in the way of more cost containment in Obamacare (and on other occasions — see Bush-era battles over drug price negotiations). We’re opposed to unwinding the welfare state because we want a country that provides a decent standard of living for everyone, but we don’t mind changing it. Most of us would like to mimic other countries’ health systems that spend half as much to provide better care, more or less instantly fixing most of the long-term deficit crisis. So modifications to welfare/pension programs that cost less without falling below some quality threshold are fine. The recent proposals to privatize Medicare and block grant Medicaid aren’t good primarily because they’ll get less for the same amount of money.

      Also, the GOP had many years of controlling both Houses of Congress and the Presidency. They only had 55 seats in the Senate in the 109th Congress, but had a lot of allies on many issues in the Democratic caucus and a caucus that was much more willing to bend the rules and pass legislation with 50 votes. What did they get done? Well, they changed daylight savings time, dicked around with Terry Schiavo, and built a border fence. I’m not too worried about what we’re up against.

      Have you or anyone you know made major investment decisions (starting a business, etc) based upon the relative likelihood of an American debt crisis? If investors are truly worried about this, the last thing they should do is hold onto their money.Report

      • Avatar tom van dyke in reply to Zach says:

        Mr. Zach, pls don’t douchebag your stats.

        the GOP had many years of controlling both Houses of Congress and the Presidency.


        Unless “many” means “damned few,” like Bush W had 4 years and Ike 2. Otherwise you gotta dig back to before Roosevelt.

        Ronald Reagan? Zero. Nixon, Ford? Zero. Bush 41? Zero.

        What’choo talkin’ ’bout, Willis? What are they teachin’ you kids in school? It ain’t history, and it sure ain’t math.Report

      • Avatar Koz in reply to Zach says:

        “That’s an odd thing to say since it wasn’t liberals who got in the way of more cost containment in Obamacare (and on other occasions — see Bush-era battles over drug price negotiations).”

        Sure it was. It was the liberals who insisted on universal coverage or quasi-universal coverage as you point out yourself. My point is there is no way the GOP or the American people have to accept that as a fait accompli. As it is, the Demo’s, through Obamacare and its exchanges and subsidies and regulations, forced trillions of dollars in new public expenditures.

        The larger point is this: liberals tend to have an odd lacuna in their moral constitution. When a traumatic event happens, a car wreck or somebody gets fired or somebody dies, usually pretty quickly whoever is there asks himself, “Is it my fault?” Sometimes this is self-serving and other times people just want peace of mind, but it’s the natural thing for whatever reason.

        Now, the economic problems we’re facing pretty obviously constitute a traumatic situation by now, and the logic behind the liberals’ culpability for it isn’t necessarily trivial, but it’s pretty clear nonetheless. I don’t necessarily expect to liberals to endorse their own culpability, but I do expect them to offer accountability of some kind for it.Report

    • Avatar Jon in reply to Koz says:

      you can round up all the liberals and put them in freedom camps, but the public still likes it some medicare and social security. unless you are suggesting undoing the “welfare state” by undemocratic means, it won’t be done.

      so, you can either keep painting on your galtian fantasy palette or you can try and find a way to solve the problems in a way that most people can accept.

      most people seemed to like that evil liberal clinton when he left office. and his budget surplus.Report

      • Avatar Scott in reply to Jon says:


        Of course people like the gov’t to give them stuff, who doesn’t like bread and circuses? The Dems learned long ago that wealth transfer via social programs could buy them votes and keep their base voters happy.Report

      • Avatar Jaybird in reply to Jon says:

        The last time we had Freedom Camps in this country, it was the Progressives holding the guns.

        It’s kinda tacky to assume that they won’t be holding the guns next time too without giving *SOME* justification.Report

  6. Avatar tom van dyke says:

    Who’s suggesting killing Medicare and Social Security, sir? Read this damn blog, stop watching MSNBC. The only question is how to save them, not abolish them.Report

    • Avatar Simon K in reply to tom van dyke says:

      Yes, sometime you have to raze the village in order to save it. From communists.Report

      • Avatar tom van dyke in reply to Simon K says:

        Well, there’s some truth in your snark, Simon. But Medicare as presently structured is simply unsustainable. While it’s technically true that Ryan’s plan would “raze” it, the goal, the end, to provide healthcare for our seniors, remains intact. We would have to acknowledge the proposal puts another structure in its place, and not just charge “razing it.”

        Unless we’re satisfied with simply demagoguing the issue, as many of us are. 😉


        • It seems a tad less than completely honest for the author of that piece to cite Ryan’s work with Rivlin without mentioning that Rivlin has repeatedly stated she does not endorse Ryan’s plan nor consider it equivalent to their earlier work together: http://www.washingtonpost.com/blogs/post-partisan/post/the-rivlin-ryan-divorce/2011/05/19/AFhaJH7G_blog.htmlReport

          • Good point, Elias, except the Tanner article is dated April 10 and the disputing Milbank article is May 19.

            In fact, Milbank himself made a similar locution to Tanner’s in his own May 17 column.

            Milbank, May 17: “Ryan came from a similar mind-set. He worked with Alice Rivlin, who had been Bill Clinton’s budget director…”

            Tanner, April 10: “Ryan’s plan is based on a model that he originally worked on with Alice Rivlin, President Bill Clinton’s budget director. ”

            So it doesn’t seem a fair criticism of Tanner here.Report

        • Avatar Simon K in reply to tom van dyke says:

          While demogoging the issue is, of course, fun, the serious question is this: At present, the US healthcare system is extraordinarily ineffective at denying care to patients on the basis of cost. Insurers do it to some small extent, but they’re terrified of doing it and tend to do it for arbitrary trivialities that have nothing to do with cost effectiveness, but can be justified on some absurdly literal reading of the contract and increase their profits.

          Insurers can’t make decisions about cost effectiveness well, partly because they’re legally prevented from doing so in many states, and part because its not really in their interest. If you want to treat your cancer with homeopathic remedies they’d be fine with paying for that – water costs much less than the cost of your premium after all. But if you want to treat it with an expensive course of chemotherapy that might actually work – well, they’ll be looking through your medical records for that undisclosed case of acne from when you were 16 that they can name as a “pre-existing condition” in order to dump you.

          Patients can’t choose treatments on the grounds of cost effectiveness because they don’t know the effectiveness, even when they are exposed to the cost. The only people in a good position to evaluate cost effectiveness are doctors. Right now doctors have every incentive not to do so. Patients don’t like it, but more importantly they’re paid more for prescribing more expensive treatments. Talk about perverse.

          How do we fix this? Essentially there have been two answers proposed thus far. The ObamaCare answer is to have a panel of Very Smart Doctors who tell all the other doctors what is and is not cost-effective. Something similar works reasonably well in the UK, but the peculiarly American attitude to rules and rule-making bodies makes me suspect it won’t work here. The rules will be excessively specific. Everyone will find ways to work around it. The panel will be quietly packed with drug industry hacks. And of course if it does ultimately do anything even remotely useful, congress will neuter it with overwhelming public support.

          But the Ryan plan isn’t any better. In fact its worse. It delegates the task of figuring out what health care is cost effective to consumers, who are the least qualified people in the mix. Not only that, but it delegates that task to them via the obligation to choose an insurance plan. So consumers, who have no idea what health care is cost effective now, are supposed to predict what healthcare will e cost effective in the future, and to evaluate the T&Cs of insurance plans with respect to that? Some chance.

          If the proposal was to give people vouchers to pay for their health care, I would think that was a bit harsh (what happens when you run out?) but I could at least see how it was supposed to work. Patient goes to doctor, doctor recommends heart bypass, patient expresses unwillingess to spend that much money in case he needs cancer surgery later, doctor recommends aspirin instead. Okay.

          But the proposal is to give people vouchers to pay for health insurance, not health care. How is the customer supposed to evaluate the likely cost effectiveness of treatment he’ll receive under different insurance plans? He can’t. All he can evaluate is cost and coverage. The insurer has an incentive to reduce costs, but just as we see currently this doesn’t translate into an incentive to improve cost effectiveness. Instead they refuse to insure potentially expensive patients, and try to dodge paying claims. Actually getting doctors to provide only cost effective treatment isn’t cost effective for insurers.Report

          • Avatar greginak in reply to Simon K says:

            One part you are leaving out is the D’s want some billions for comparative effectiveness research so we would know more about what works and what doesn’t. That would enable people and the gov and the insurance companies to really make better judgments.

            I disagree that insurance companies are terrified of denying treatment. You yourself note they do it when ever they can get away with it. They are just fine with looking at costs and avoiding paying if they can.Report

            • Avatar Simon K in reply to greginak says:

              The trouble is insurers save money the wrong way. By declining to pay their existing customers, or by insuring only people who won’t get sick. Not by paying only for effective treatment. This is understandable because evaluating effectiveness is itself expensive and full of legal hazards they’d rather avoid. That won’t be changed by comparative effectiveness research on its own, and frankly research as such is not the problem. There’s tons of research. The problem is the lack of incentive to make any use of it.Report

              • Avatar tom van dyke in reply to Simon K says:

                Simon, bad faith by an insurer is a lawsuit. But if the gov’t decrees treatment X is ineffective, you can’t sue, you can’t do nothing but die.


              • Avatar BlaiseP in reply to tom van dyke says:

                100% wrong. This is what I do for a living. I’ve done five Blue Crosses and the Association. Insurers routinely do what Simon K alleges. There are no consequences.Report

              • Avatar tom van dyke in reply to BlaiseP says:

                Well, insurance bad faith is a tort, Blaise. You could look it up.

                I actually favor criminal charges as well. That’s doable.Report

              • Avatar BlaiseP in reply to tom van dyke says:

                Dude, I wrote the parts of the messaging system which handles denial of payment and policy termination. It is not a tort. It happens every day. It’s perfectly legal. It is not bad faith. The Blue Crosses have enormous legal teams, one of which completely vetted our part of the system.Report

              • They don’t pay what they’re not legally required to pay? I’m shocked. Such evil bastards.Report

              • Avatar Trumwill in reply to tom van dyke says:

                For most people, the very point of insurance is that when something goes wrong, you are covered. When insurance companies happily accept money based on this premise, then have teams of lawyers going over the contract for uncrossed T’s or undotted I’s when something does go wrong, it represents a rather serious problem.

                A problem, I should add, that single-payer and PPACA are not the only potential solutions to, but a problem nonetheless. And it’s these sorts of bad-faith actions that provoke over-reaching legislation to begin with (just as it’s free-riders that justify non-coverage of PEC’s to begin with).Report

              • Avatar BlaiseP in reply to tom van dyke says:

                It’s an existential question, sorta like “if a tree falls on a French mime in the deep forest, will anyone care?”

                Who says what’s “legally required”? The lawyers do. Look, pay attention for a minute here, the health insurance industry is only interested in providing coverage for people who won’t get sick. Sure, they pay what they can’t avoid paying, and for a good many folks, that’s just great. They don’t want to insure large pools of lives, they want to sell single policies which cost five times as much. Blue Cross of North Carolina tried this stunt, dumping their state government worker contracts so they could circle around and pick up those same people piecemeal at enormous profits. Well, the gummint workers got wind of it and stopped that one cold. That’s where government comes into the picture, when it’s their own policies on the line, and not a minute before.Report

              • Avatar Trumwill in reply to tom van dyke says:

                Out of curiosity, why do you think it is that non-profits behave this way? Or would you say they don’t?

                Our current carrier is non-profit. The first time I’ve had one. Things actually do seem to flow a little more smoothly than previously, but (a) it still doesn’t feel all that different and (b) to the extent that it does, it might be related to my wife’s profession.Report

              • If you shoot a mime do you need a silencer? Anyway, exceptions make for bad rules, and for bad law. Everybody’s got a story, and it’s amazing how many of them don’t hold up upon further inspection.

                Like the one from Texas we looked at in this thread.

                Obamacare was ostensibly about the rising cost of health insurance, or the uninsured, or I don’t know what, but turned into soup-to-nuts, and a bite on every living American with the mandate thing.

                And blowing up the whole country, as was its dastardly intention from the first. 😉

                “At least 30 percent of employers are likely to stop offering health insurance once provisions of the U.S. health care reform law kick in in 2014, according to a study by consultant McKinsey.

                McKinsey, which based its projection on a survey of more than 1,300 employers of various sizes and industries and other proprietary research, found that 30 percent of employers will “definitely” or “probably” stop offering coverage in the years after 2014, when new medical insurance exchanges are supposed to be up and running.

                “The shift away from employer-provided health insurance will be vastly greater than expected and will make sense for many companies and lower-income workers alike,” according to the study, published in McKinsey Quarterly.

                “While the pace and timing are difficult to predict, McKinsey research points to a radical restructuring of employer-sponsored health benefits.”

                Among employers with a high awareness of the health reform law, the number likely to drop health coverage for workers rises to more than 50 percent, the report predicted.

                The numbers compare to a Congressional Budget Office estimate that only about 7 percent of employees currently covered by employer-sponsored plans will have to switch to subsidized-exchange policies in 2014, McKinsey said.Report

              • Avatar BlaiseP in reply to tom van dyke says:

                There’s a difference between nonprofit and not for profit. A nonprofit is a 501c3. A not for profit can like most of the Blue Crosses and routinely do make a ton of money.

                Why do they behave like that? They have AHIP, a powerful lobby, the one that stood up to actual reform of the health care insurers.Report

              • Avatar BlaiseP in reply to tom van dyke says:

                Employer based insurance was largely created by Kaiser Steel as a way to supplement wages during a period of wage and price controls. Of course the employers want to get out from the current system: the health insurance companies screw them with all the vigor and even less kissin’ than the employees. It should therefore surprise nobody, least of all McKinsey, to see the companies rushing away from the Kaiser-era mug’s game.

                As with everything else in life, first someone proposes this dastardly idea of equality, the Conservatives stand up on their hind legs to roar about Goddamn Socialism, then it gets passed as legislation and the next thing you know the Conservatives act like somehow they never opposed it. Seen it over and over again, Tom.Report

              • Actually, the plan is find a problem, and socialize it, Blaise. A look across the Atlantic is all the proof you need.Report

              • Avatar BlaiseP in reply to tom van dyke says:

                Curiously, not only have I looked across the Atlantic, I have actually lived there. Part of the cost of my work visa residency paperwork allowed me to get treated in any hospital in France.

                Now here’s where it gets really curious. You’re telling me to look across the ocean to see how screwed up it all is over there. Dude, I’ve lived there and people over there ask me why we’re such a collection of unscientific dumbasses, allowing sick people to walk around and not get treated for contagious diseases.Report

              • Avatar Simon K in reply to tom van dyke says:

                You’ll note that no government mandated programs are mentioned in that article, Tom. LCP is a framework some NHS hospitals use for what all hospitals everywhere do.

                Prior to PPACA, the only redress to having a policy rescinded was a refund for the premiums. Oddly enough, very few people ever chose to pursue lawsuits. Insurers had departments dedicated to researching expensive patients and trying to find a way to rescind their policies. In some cases, where they could find anything else, they simply claimed the condition was pre-existing and did it anyway. Do you deny any of this?Report

              • Avatar tom van dyke in reply to Simon K says:

                Simon, I’ll stipulate any horror story. The cure is not to kill the baby. Fix what’s broke and not what ain’t. The problem with the Obamacare scheme is overreach, and this is no secret. The rhetorical strategy is that to oppose Obamacare is to excuse the horror stories and want to do nothing about them.Report

              • Avatar Simon K in reply to tom van dyke says:

                On the contrary – there are plenty of possible alternatives. The thing is we have one of them now, and its better than the status quo ante in a number of ways and has the significant advantage of actually being the law. I can’t see how it was particularly overreach – if anything it failed to reach far enough and thereby fell in the mud and got dirty.Report

              • if anything it failed to reach far enough and thereby fell in the mud and got dirty.

                Very nice. I’ll have to steal this.Report

          • Avatar Elias Isquith in reply to Simon K says:

            Wonderful post. When surveying the full gamut of dysfunction that makes up the system, I can’t quite imagine how anyone thinks that single-payer won’t inevitably come (and thus turn this nation into a Soviet hellhole).Report

            • Avatar Simon K in reply to Elias Isquith says:

              I’m not sure about single payer. I see too many cultural obstacles. It works fine for countries where fairness of distribution is important and perfect services is not. That’s not the USA I know.

              The best option is probably a two tier system. Guaranteed, government backed high deductible insurance for catastrophic illness, and forced savings with government vouchers for the very poor for everything else.Report

              • Avatar tom van dyke in reply to Simon K says:

                Now you’re talking, Simon. We have county health systems as well, always ignored in these things. Single payer. Technically, patients are supposed to pay them back. Some, many or most don’t.Report

              • Avatar Trumwill in reply to Simon K says:

                I’m on board here with your two-tiered plan, as well, I think.

                And you make a very, very valuable point about culture. This is why I don’t believe what works elsewhere will work here. We have a specific set of expectations and lack certain sensibilities. I fear that a Canadian single-payer here would result in somewhat better care at monstrously higher prices.

                On the other hand, I look at France’s system (from what I understand of it) and think that it could work here (albeit at higher costs than over there).Report

          • Avatar Trumwill in reply to Simon K says:

            Actually getting doctors to provide only cost effective treatment isn’t cost effective for insurers.

            Could you explain what you mean by this?Report

            • Avatar Simon K in reply to Trumwill says:

              The insurer exists to make money, or at least to break even in the case of non-profits. On average, they break even on any given patient and if they make any money its on the float – lending your premiums to other people while they wait for you to spend them. As such, what they want to avoid is very large claims and very expensive patients. It makes perfect sense that they play silly buggers with recision and randomly denying claims and increasing premiums once they realize you’re going to be expensive. Actuarially they want to get rid of you, and the more you want to not go away, the more they see that as a sign of adverse selection.

              If we’re interested in reducing healthcare costs and increasing coverage, what we want is not what improves insurers profit (or non-profit) margins. What we want is for medical resources – doctors, MRI machines, hospital rooms – to be in less demand. But the people who make up most of the demand are not the very small number of people who cost insurers flabberghasting sums of money if they can’t get rid of them. They’re regular folk who go to the cardiologist when they have indigestion or whose doctors send them for 2 X-rays and an MRI instead of a physical therapy appointment.

              Although this does cost insurers money, it doesn’t cost them enough money for it to be worth getting the medical opinion they need in order to deny the claim on the grounds of medical necessity. Instead they build it into their calculations. Which increases premiums and makes their financial position more precarious. Which makes their willingness to take on risk even smaller. Hence we have the ongoing dynamic of healthcare in the US – a system in which those of us fortunate enough to not be very sick or poor and to have jobs with health plans are very well looked after, but those who fall outside that are not.Report

  7. Avatar Daddy Love says:

    The fight over the ACA is over. Over except for a bit of nibbling about the edges, anyway. Regardless of how a largely uninformed public responds to quesitons about such absurdities as “repeal,” pretty much all of the elements of the ACA are extremely popular. Republicans, want to run on restoring the God-given right of our private insurers to deny our children and elderly medical care based on pre-exiting conditions? Please do.

    I personally think that the individual mandate will pass Constitutional musterunder the “necessary and proper”clause and the commerce powers, but if for some reason it does not, then we will just end up using another funding and risk-pool-populating mechanism, which leads us to single payer, don’tyou think? Especially after the Vermont experiment. Again, a reason why Republicans will let well enough alone and, like abortion, continue to use it as a propaganda scourge without ever doing much of anything about it.Report

    • Avatar Koz in reply to Daddy Love says:

      “Republicans, want to run on restoring the God-given right of our private insurers to deny our children and elderly medical care based on pre-exiting conditions? Please do.”

      Yep. And whatever health care problems are left over after PPACA is repealed are going to be the libs’ fault.Report

      • Avatar Elias Isquith in reply to Koz says:

        I don’t understand this. Are you saying Republicans should run on that? Or not? Also why would it be the Democrats’* fault if Republicans repealed the most popular part of the bill?

        *Liberals wanted a single-payer, so it’s not really accurate to “blame” them for the ACA.Report

        • Avatar Scott in reply to Elias Isquith says:


          Koz is mocking, and rightly so, such a silly statement from someone who is obviously a blue kool aid drinker.Report

          • Avatar Koz in reply to Scott says:

            Actually, I try to dial down mockery and the like as best as I can. I need clarity to get the point across, and clarity is at a premium.Report

            • Avatar Elias Isquith in reply to Koz says:

              So do you or don’t you think the preexisting condition ban should be repealed?Report

              • Avatar Jaybird in reply to Elias Isquith says:

                If one has a pre-existing condition, one no longer requires health care insurance but health care period.

                If you see insurance as people paying pennies on the dollar for health care that they are less likely to need, as a percentage chance, than the number of pennies on the dollar that they are paying, then the pre-existing condition ban makes much more sense.Report

              • Avatar Elias Isquith in reply to Jaybird says:

                I think this is mostly true except we have to keep in mind the expansive definition of “preexisting condition” the insurance companies use. For example, someone could have had cancer at a very young age, but have been utterly healthy throughout her life ever since. Most insurers would likely refuse to cover her, though, due to her “pre-existing condition.”

                But if I understand you’re thinking would this mean you’d be more sympathetic towards arguments in favor of universal or single-payer than the PPACA? (Me too, if so.)Report

              • Avatar Jaybird in reply to Elias Isquith says:

                I’m a fan of a two-tier system of health care.

                Universal up to a certain point, beyond that basic level of health care, you are on the hook.

                The problem with my saying “Everyone should have access to X, but if you want Y, you need to pay for it” is that people tend to respond by asking about poor children who cannot afford Y and whether or not it’s fair to live in a world where Y only goes to Bill Gates and Paris Hilton.Report

              • Avatar Elias Isquith in reply to Jaybird says:

                Besides the framing being profoundly tendentious, the hypothetical response to your proposal doesn’t seem to me to be without merit. It deserves addressing, at least.Report

              • Avatar Jaybird in reply to Jaybird says:

                So we should have nothing health care related in this world that is available to Bill Gates that is not also available to the poorest child in the crappiest ghetto in the most backward state in the nation?

                Or just in this country?Report

              • Avatar Elias Isquith in reply to Jaybird says:

                Well, I’d start with the country; it seems big enough to keep us occupied for at least a while.

                And I wouldn’t say nothing, no. I think we could draw a line. But I’d probably draw the line past “bare minimum,” which is where you’d put it (if I understand you correctly).Report

              • Avatar Jaybird in reply to Jaybird says:

                I get the feeling that wherever I draw the line, if I draw it under Bill Gates, it will be defined as a “bare minimum”.Report

              • Avatar Elias Isquith in reply to Jaybird says:

                Not by me, at least.

                I would hope the line could be drawn by having expensive experimental procedures (generally the costliest stuff), for the most part, be Y. But I’d hope that the boundary between “experimental” and “rudimentary” were drawn by those with a less vested interest in cost-cutting than insurers.Report

              • Avatar Jaybird in reply to Jaybird says:

                I’d draw it here:

                Is there enough X for everybody who is likely to show up? (Sustainably, I mean… we can’t have enough X today but use the X we’d need tomorrow.)

                If there is not, then X shouldn’t be Universally covered. Perhaps we can put some effort into making more X… but that’s where I draw the line.Report

              • Avatar Elias Isquith in reply to Jaybird says:

                Sounds like a good line to me. Now all we need to do is forward this thread to Harry Reid, John Boehner and Barack Obama and we should be able to knock this out by 2014.Report

              • Avatar Jaybird in reply to Jaybird says:

                Let the Republicans come up with it, let the Democrats shoot it down because “poor children deserve health care too”, and then the Democrats can come up with this on their own in 15 years and the Republicans can “lose” the fight over it and the old Republican plan winning can be painted as a Progressive victory over the “evil” Republicans.

                There’s the plan.

                It worked last time.Report

              • Avatar RTod in reply to Elias Isquith says:

                This is not exactly correct, and a bit misleading. You are not denied coverage for a condition you already had but were unaware. You are only denied coverage for conditions that you either knew about, or for which it would not have reasonable for you to have been aware of.

                In the case you suggest, an underwriter might choose to exclude the exact kind of cancer the young girl had that was in remission. But they would only be able to do so if the family chose to forgo paying premium in the years they thought she was healthy.Report

              • Avatar Elias Isquith in reply to RTod says:

                This will be interesting news for the people I know who survived cancer in their early childhood and, until the ACA passed, could not find a single provider who would insure them.Report

              • Avatar RTod in reply to RTod says:

                As I said, if they chose to not be covered for a period of time this would be the case. Portability laws do not allow it otherwise.Report

              • Avatar Elias Isquith in reply to RTod says:

                Indeed, what was this baby thinking?


                Or this child (her father should have known better than to be fired!)


                Or this one (perhaps his family should have simply chosen to go bankrupt)


                Or this one (the baby should have known better than to choose to be born)

                http://www.star-telegram.com/2010/03/25/2068267/crowley-newborn-with-heart-defect.html#tvg [oops — same story as first link]

                Such poor decisions, all around.Report

              • Avatar tom van dyke in reply to RTod says:

                Somebody has to pay for “pre-existing condition” people. The question is who.Report

              • Avatar RTod in reply to RTod says:

                Hope you don’t mind, but i stopped at the first thing you posted:

                “We don’t have health coverage on ourselves because it’s too expensive these days and because of the economy,”

                Again, as I said above, the situation you are describing does not happen to someone with health insurance, do to portability laws – which do indeed extend to new borns.

                You seem to be arguing from a moral standpoint, as if you and I disagree about society’s responsibility to create a healthcare system that works better for people such as this. I don’t. We are on the same page.

                But this is what I do for a living, and before you begin to repair the engine, it is best to know how it works. And the way you describe health insurance working is incorrect.Report

              • Avatar Elias Isquith in reply to RTod says:

                I won’t feign to know more about this than you since you do this for a living — what’s the situation, then, with some of the other links, specifically concerning newborns?

                I was misunderstanding where you were coming from on the issue, though, and was lumping you in with DD, Koz, Scott, etc.Report

              • Avatar tom van dyke in reply to RTod says:

                Aye, RTod. Mainstream media typically buries the truth at the end:

                Doug Tracy said his family has found an alternative route to get his child coverage through the Texas Health Insurance Risk Pool, and the policy will only cost $277 a month — $10 more than the premium on the policy he tried to take out for his son..

                The secret of consuming American media is to always read these sob stories starting at the end instead of the agenda-driven headline and lede. 😉Report

              • Avatar RTod in reply to RTod says:

                No; it is true that I am not a big fan of the current HRC, but mostly because it does not address the underlying issue: it does nothing to control the cost increase line.

                But unlike others here, even if I did not like the idea of universal care (and I am not sure if I do), it’s coming seems inevitable – and I mean for economic reasons, not political ones. The big irony I see is that the mandate probably could have prevented it, but I don’t see it surviving the challenges by those who most fear universal coverage.Report

              • Avatar Elias Isquith in reply to RTod says:

                Isn’t the THIRP the kind of thing the ACA sets up nation-wide?Report

              • Avatar tom van dyke in reply to RTod says:

                Obamacare is a huge Rube Goldberg contraption to fix that problem. And worse:

                Before passage of Obamacare, the law specified that individuals with employer-sponsored insurance cannot be denied new coverage, be subjected to preexisting condition exclusions, or be charged higher premiums because of their health status when switching to different coverage. Thus, in the employer group market, preexisting condition exclusions apply only to those without prior coverage or those who wait until they need medical care to enroll in their employer’s plan.

                Those existing rules represent a fair approach: Individuals who do the right thing (getting and keeping coverage) are rewarded; individuals who do the wrong thing (waiting until they are sick to buy coverage) are penalized.

                The one small, legitimate remaining problem is that the same kinds of rules do not currently apply to the “individual” (non-group) market—about 9.4 percent of the total market for private health insurance. Thus, an individual can have purchased non-group health insurance for many years and still be denied coverage or face preexisting-condition exclusions when he or she needs or wants to pick a different plan.

                The obvious, modest, and sensible reform is to simply apply to the individual health insurance market a set of rules similar to the ones that already govern the employer group market.

                Instead, Obamacare prohibits the application of preexisting-condition exclusions under any circumstances, thus encouraging everyone to wait until they are sick before buying health insurance. That perverse incentive is a recipe for disaster. So, in order to limit the effects of that disaster (of their own making), Congress then included in Obamacare an unpopular individual mandate to buy health insurance.

                And we know the name of that tune.


              • Avatar Trumwill in reply to RTod says:

                Tom, to reiterate The Trumwill Plan:

                (1) If individual coverage lapses, pre-existing conditions (PEC) do not need to be covered for the period of time that the to-be-insured (TBI) was not covered for a period up to 1 year.

                (2) In the event that coverage stopped and started on more than one occasion over the course of the previous year, TBI’s PECs do not need to be covered for sum of the durations of non-coverage over the previous year.

                I think this should apply to group plans, too. The group plans let you forego PEC coverage for far too long for what might be minor lapses in coverage.

                Does anyone know if the Heritage Foundation was in favor or opposed to the group plan model that they are touting here?Report

              • Avatar tom van dyke in reply to RTod says:

                Mr. Trumwill, are you surprised that heartless [GOP] Texas has a previous-condition law and risk pool?

                Because I was. I admit to not being a wonk on all this, but every time I peel the onion [like in the original newspaper sob story], I find that the sick, poor, cancerous and granny have not been permitted to die in the street afterall.

                As for the Trumwill plan, it seems nice. Whoever isn’t covered will be picked up by the taxpayer in some way anyway.

                It occurs to me that each of us “doing our part–” y’know, “paying our fair share”–would include getting ourselves health insurance, yes? A number of these sob stories have the “victim” turning out to have elected to not buy health insurance. Indeed, in the Texas story in question, the parents didn’t have any, but if they had, the newborn would have been “grandfathered” in, if I read the story correctly.

                Are such people bad citizens, unpatriotic? It’s a thought, esp if we use the prog-communitarian view of such things. Can’t be any less worse than not recycling!

                Hey, none of the systems is perfect, including the Euro-style ones. Neither are they all bad, including the Euro-style ones. My trepidation about the Euro-style is that they’re only a half-century or so old, and are not proven to be sustainable either. The NHS nationalized/confiscated the patchwork private health system, including its infrastructure such as hospitals. Now the hospitals and infrastructure are aged to the point of collapse; the NHS has been running on their fumes.Report

              • Avatar Trumwill in reply to RTod says:

                Whoever isn’t covered will be picked up by the taxpayer in some way anyway.

                No moreso than now. It manages to take most of the rationales for a mandate off the table.

                Hey, none of the systems is perfect, including the Euro-style ones. Neither are they all bad, including the Euro-style ones.

                In many ways, though, we have the worst of a lot of systems. The drawbacks but not the benefits of a market system. The drawbacks but not many of the benefits of a socialized one.Report

              • Avatar tom van dyke in reply to RTod says:

                But it’s not a market system because of all the gov’t mandates. Is there a libertarian the house?


                Obamacare builds upon and consolidates some of the worst features of the American health care system from a Hayekian perspective, such as (a) It is more or less illegal to sell actual insurance, and (b) There is at best a grievously hobbled price mechanism in the health care market, if you can call it market.

                If Hayek stood for anything, he stood for the importance of the informational function of freely moving prices for both individual planning and effective social coordination. (a) and (b) screw it up bad.

                The exact set of regulations governing the sale of health “insurance” varies from state the state, but mostly it’s illegal to price insurance policies according to actuarial risk. At the limit, you have states where it is illegal to charge different people different prices and also illegal to refuse to offer coverage to anyone who applies for it. Hayek has a lot to say about price controls and none of it is good.Report

              • Avatar Trumwill in reply to RTod says:

                I know it’s not a market system. It’s not a market system, it’s not a socialist system. And it reaps the benefits of neither.Report

              • Avatar Koz in reply to Elias Isquith says:

                I think all of it should be repealed.

                And this is important: if in the course of repeal, whether PPACA is replaced with something else or not, if people with preexisting conditions do not get access to health care, it’s your fault.Report

              • Avatar Scott in reply to Elias Isquith says:


                Why should a health care corp be forced to accept someone who from the outset of the contractual relationship is going to use services and may never pay enough into the system to pay for themselves much less help to pay for others?Report

              • Avatar Elias Isquith in reply to Scott says:

                What’s your solution for people with preexisting conditions, Scott? What I’m hearing so far from you and Koz sounds to me to be along the lines of “Go die — but not on my lawn.”Report

              • Avatar Baron von Munchausen in reply to Elias Isquith says:

                Elias, if it’s already gotten to this point, can’t you force the patient/client to die on the cemetery lawn? You’re saving lots of funeral $$$ by enacting such a measure.

                Hey, you’re dead. No hurt feelings. Mozart didn’t seem to mind the pauper’s grave and if it’s good enough for him, who are we to complain?Report

              • Avatar Koz in reply to Elias Isquith says:

                I dunno, probably never find out. Too bad we had to do Obamacare instead.Report

              • Avatar Scott in reply to Koz says:


                True, too bad Obamacare had to be passed before we could find out what was in it.Report

              • Avatar Koz in reply to Koz says:

                Yeah, forgot about that one.Report

              • Avatar DensityDuck in reply to Elias Isquith says:

                “What’s your solution for people with preexisting conditions, Scott? ”

                What’s your solution for people whose health issues are due to smoking and overeating, Elias?Report

              • So people born with illness or who contracted cancer through no fault of their own deserve to go without health insurance because other people don’t take care of themselves?Report

              • Avatar Jaybird in reply to DensityDuck says:

                I’d rather ask if there are people who deserve treatment for certain types of cancer and if there are people who deserve to be turned away from certain types of treatment.

                Would you say that “smoking” qualifies as, for lack of a better analogy, “pre-existing condition”?Report

              • Avatar RTod in reply to DensityDuck says:

                I’m not sure I understand the point any of you are making in regards to pre-existing conditions exemptions, but none of them are related to the reason it’s usage is mandatory in a non-universal model. Whether you have cancer as a kid or eat fast food has nothing to do with the pre-ex.

                It exists because if healthcare is not universal and the pre-ex is missing, there is no reason to pay premium until you have a costly diagnosis. There really is nothing else to it – it has nothing to do with whether people smoke or not.Report

              • Avatar DensityDuck in reply to DensityDuck says:

                “So people born with illness or who contracted cancer through no fault of their own deserve to go without health insurance because other people don’t take care of themselves?”

                So people who didn’t take care of themselves deserve to have all their health problems fixed for free just because other people developed cancer through no fault of their own?Report

              • You’re arguing that having to pay for freeloaders is more ethically problematic than letting an innocent suffer/die.

                The whole conversation appears to be moot, but I just wanted to make sure you’re aware of how your statement is likely to be interpreted.Report

              • Avatar Jaybird in reply to DensityDuck says:

                How much money are you willing to take from someone else to ensure that people stop dying?Report

              • “ensure that people stop dying” — that might be a bit of a tendentious oversimplification of my position.Report

              • Avatar Jaybird in reply to DensityDuck says:

                Now we’re haggling.Report

              • OK, well, semantics aside, I’d be willing to “take” a fair amount of money away to keep unnecessary, easily-preventable death from lack of medical attention due to financial constraints. I find it difficult to boil this down into something pithier.Report

              • Avatar DensityDuck in reply to DensityDuck says:

                “I’d be willing to “take” a fair amount of money away to keep unnecessary, easily-preventable death from lack of medical attention due to financial constraints.”

                Keeping an overweight smoker from dying from a heart attack is cheap and easy. Keeping a child with, e.g., ichthyosis congenita alive and healthy is expensive and difficult.

                “You’re arguing that having to pay for freeloaders is more ethically problematic than letting an innocent suffer/die.”

                What I’m arguing is that boiling this down to pithy statements like “why do you hate children and want them to die?” or “the only acceptable number of preventable deaths is zero” doesn’t do anything to move the debate forward, because there’s always an equally-pithy counter-statement, and from there on out it’s just a rap battle.Report

              • It may be expensive, but it’s affordable. Maybe we can stop sending money to agrobusiness or weapons manufacturers — maybe there’s some spare change under the Oval Office’s rug. We’ll find it somewhere.

                I would agree with your condemnation of glib zingers. If I had said either of the things you quoted, I would be deserving of a real finger-waggin’.Report

              • Avatar Jaybird in reply to DensityDuck says:

                What does “deserve” have to do with it, though?

                Should we, as a society, be deciding who “deserves” what and doing what we can to address an imbalance?

                I ask because there is a lot (I mean a lot a lot) packed into questions like So people born with illness or who contracted cancer through no fault of their own deserve to go without health insurance because other people don’t take care of themselves?

                “Deserve” can take you into some ugly, ugly places.Report

              • I think we as a polity have the ability to make choices.Report

              • Avatar Jaybird in reply to DensityDuck says:

                We certainly have the power to impose our will on others.

                To right wrongs, uphold the order of the way things ought to be, and make sure that people get what they deserve.

                It sounds Heavenly.Report

              • Avatar DensityDuck in reply to DensityDuck says:

                “If I had said either of the things you quoted, I would be deserving of a real finger-waggin’.”

                You’ve said all of the things I quoted.

                (not every use of quotation marks is intended to indicate a direct quote from a primary source.)Report

              • My mistake. I forgot the “not intended to be a factual statement” corollary.Report

              • Avatar Scott in reply to Elias Isquith says:


                I would give the states the freedom to solve that problem with insurance exchanges and not saddle companies with the extra costs just b/c it makes liberals feel good.

                Frankly, I would also like to see insurance corps stop covering care for such things like cancer caused by smoking or problems caused by obesity that people can control themselves.Report

              • Avatar RTod in reply to Scott says:

                Would you oppose insurance companies offering coverage to people who are more genetically predisposed to cancer, as this is a greater marker than smoking?

                Also, what is the problem with the current method – that insurers simply are allowed to charge greater premium for smokers due to the increased risk, much in the same way an auto insurer will charge more for a 16 year old boy with a Porshe?Report

              • Avatar Trumwill in reply to Scott says:

                RTod, it’s worth pointing out that even smoking and obesity have genetic components.Report

              • Avatar Jaybird in reply to Scott says:

                How about impulse control? If we find that there are genes that allow for greater impulse control than is likely to be found in folks without this gene, would that be okay?

                Because, let’s face it, someone without impulse control is more likely to smoke, drink, do drugs, or get an STD than someone with a great deal of it.

                (Of course there are exceptions, but they are exceptions.)Report

              • Avatar RTod in reply to Scott says:

                JB & Trumwill –

                I had meant the above point to be a bit of cold water in the face to Scott’s argument. But, since you are diving deeper….

                The truth of the matter is that those things you are mentioning do not, in fact, increase healthcare costs – they decrease them. This is not often noted, because we usually tend to think of healthcare costs in terms of how they affect a singular man/woman on the street. * Take smoking: A forty year old male smoker will, on average, cost more in healthcare expenditures over the next year than a forty year old non-smoker. But we do not spend healthcare dollars on only forty year olds.

                In reality, smokers (or obese people, or people with poor impulse control that contract STD’s or get into bar fights or drive at 120 mph) cost far, far less – they die sooner, and far more efficiently, than people who live healthy lifestyles. If you could make every person in the country smoke 5 packs a day, the healthcare costs would – for a few years – skyrocket compared to where they are now, but later they would plummet to far below, and the cost increase curve – while still going up – would go up far less quickly than it currently does.

                *(The other reason this is not noted is political – it takes away the “there would be no problem if it weren’t for those awful other people” argument that voters so love.)Report

              • Avatar tom van dyke in reply to Scott says:

                RTod, yr point is quite true for Medicare and UHC countries: older or sick citizens are liabilities, not assets.

                Add in how sin taxes [tobacco, booze] feed the tax coffers, and kicking off from them around age 60 or 65 is just damned patriotic!Report

              • Avatar Trumwill in reply to Scott says:

                The truth of the matter is that those things you are mentioning do not, in fact, increase healthcare costs – they decrease them.

                This is a point that needs to be repeated to the high heavens. But that’s when we’re talking about Medicare. When it comes to insurance companies, they don’t reap the rewards. The same applies to the states, which have to pay for Medicaid, but not Medicare (and Social Security), where the savings really come in to play.Report

        • Avatar Koz in reply to Elias Isquith says:

          Sure it is. That gets to the point of what I was trying to get at in a couple of other responses. A large part of the problems is the misunderstanding, deliberate or accidental, of the range of actions available to us, ie what economists call the feasible set.

          The libs forced Obamacare on us. Whatever problems ensue are at least arguably their fault.Report

    • Avatar Baron von Munchausen in reply to Daddy Love says:

      Daddy Love, how are the League Ladies going to throw their panties at you?

      Better check in with Tom Jones–I’m sure he’ll have a solution to such a problem.

      In the meantime, re your comments, “Republicans, want to run on restoring the God-given right of our private insurers to deny our children and elderly medical care based on pre-existing conditions”, you forgot that we all want out mothers to eat dog food. It’s on the House record–just ask Mt. Rushbo. Until the sky falls, be sure to buy lots and lots of Alpo—stocks and cans. You may as well be able to make a few bucks over heartless Republican chicanery.

      When your comments are hit, Barry White should immediately kick in!Report