Choosing Your Own Adventure: Healthcare Edition

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Will Truman

Will Truman is the Editor-in-Chief of Ordinary Times. He is also on Twitter.

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  1. Avatar North
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    I cynically expect that, despite all the fooferaw, the PPACA is going to be the foundation of the reforms going forward. Revising, updating and hammering the dings out of the ACA is simply a much easier legislative lift than trying to implement some entirely new single payer or other system that is expected to spring like Athena fully formed from the left’s collective forehead.
    Ironically enough with the GOP now out of power in congress we have a very dented up version of what could have happened if the Republicans had played ball in 2009 when the ACA was being hammered out in the first place. A couple republican revisions (and a bunch of republican graffiti) have been integrated into the ACA but the underlying superstructure remains sound and is electorally viable now that the GOP have demonstrated definitively that they have nothing at all to offer in its place.

    So I’d not be surprised if a new Dem government wouldn’t be severely tempted to simply amp up the coverage and subsidies, fix the typos and legislativese that let the courts make it less universal and update the regulatory elements to improve on what worked and fix what didn’t.

    It’d be enormously easier and wouldn’t draw anywhere near the public opposition or the ire of the industry players that trying to start from scratch would.Report

    • Avatar Philip H in reply to North
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      says:

      Legislatively I agree. That said, Democrats have already (and for some time) avoided the biggest win on the ACA in the political message sphere – the REASON Republicans have nothing else to offer is the ACA in its initial form codified Republican thinking on how to reform healthcare but keep it in private sector hands. Or rather it did so when Hillary Clinton (as First Lady) began leading conversations about universal health care. Republicans have now spent the better part of a decade trying to take apart their own Idea, instead of doing the happy dance and saying “see, Democrats came around. We should e in power because, in fact, our ideas were better.” But Republicans refused to avail them selves of that elegant and simple argument, and Democrats have refused to hit them over the head with it at every turn.Report

      • Avatar North in reply to Philip H
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        Well sure, but if the GOP had done that they’d have had to have bought into the ACA when it was formulated in 2009, which meant Obama would have achieved his bipartisan goals, Republican states would have signed onto it and the entire partisan clusterfish that spawned the tea party would have been denied a great deal of fuel. The GOP chose to try and win elections on the partisan line instead and they achieved significant success in doing so- it only cost them their souls and their principles.Report

        • Avatar Philip H in reply to North
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          And I argue they could have won elections on the partisan line and sold less of their soul. Its a moot point now for them, but there’s no reason Democrats can’t use the hammer the GOP gift wrapped for them.Report

          • Avatar North in reply to Philip H
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            says:

            Mmmm I can see your point but I don’t think it is realistic. American elections hinge on what the voters think about the executive. Obama campaigned on instituting reforms and doing so on a bipartisan hope’n’change basis. By denying Obama the bipartisan reforms he campaigned on the Republicans denied him a major element of his 2008 electoral platform and that cost him and his party dearly with moderates and centrists in the subsequent elections. I agree the GOP -could- have campaigned the way you’re describing but I submit that it would likely not have worked. They were coming off 8 years of Bush minor and the policies they were identified with were deficit fueled tax cuts and deficit fueled foreign wars. A bipartisan ACA would have been identified as Obama’s policy even though he and the dems basically copied it from the GOP (one part Clinton era triangulating/co-opting strategy and one part Obama era trying to give them what you think they want in advance in hopes they’ll sign on with your agenda).
            Americal would be waaaay better off if the GOP had done that. I don’t know if the GOP would electorally be way better off though. The partisanship, venom and vitriol that gets the older voters in to the polls has been the backbone of their electoral strategies since at least 2010. It’s poison but it’s efficacious poison.Report

        • Avatar Mr.Joe in reply to North
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          says:

          My recollection is a bit hazy. But I think, the GOP was lukewarm but participating and not committing. Where the partisan split happened was over the “public option”/”backstop”. The white house would not drop it and the GOP would not take it. The GOP flipped to full no at that point. It wasn’t until about a month later that blue-dogs forced the white house to drop the public option, but by that point GOP couldn’t turn the rhetoric around and the white house didn’t need GOP votes to PASS the bill.

          Possibly had the public option been dropped sooner, some GOP support could have been had. Also possible is that GOP leadership would have walked anyway for some other reason.Report

    • Avatar Saul Degraw in reply to North
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      says:

      I largely agree but the issue of how to incrementalize is also going to touch on a lot of inter-party debates right now. Brown and Koulbacher seem to be going for the 50 or over buy in to Medicare as a small-incremental reform. I’ve also heard that another idea is a buy in for people like cops and firefighters once they retire. It is true that there are some professions where people generally retire well before 65. However, these incremental reforms are also angering to the younger, more diverse, less likely to have employment-based health insurance because they feel like pleas to Trumpist voters and abandoning the base.Report

    • Avatar Marchmaine in reply to North
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      says:

      I disagree entirely… the ACA is a weird talisman for both the left and right.

      It really doesn’t do all that much… it covers approx 10M people or around 3.5% +/- of the population — and here it is deeply redundant with people who were already buying non-group insurance.

      “Last season, about 12.2 million people signed up for Obamacare plans that were in effect for 2017. The actual number of people who paid their first month’s premiums, which is required for enrollment to be official wasabout 9.9 million as of June.”

      This represents only about 1/2 of the folks who are on Non-Group insurance… which is still just a very small fraction of the health insurance market. Here’s a nice interactive chart to play with people/percent as of 2017. https://www.kff.org/other/state-indicator/total-population/?dataView=1&currentTimeframe=0&selectedRows=%7B%22wrapups%22:%7B%22united-states%22:%7B%7D%7D%7D&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D

      (sorry lost my editing tools)

      The ACA was sold as, and in fact is, purely an uninsured reduction rough draft.

      It would be a HUGE and DIFFICULT lift to make it anything else than that. Time to let the ACA be what it is and stop thinking it is more than that.

      There’s no healthcare “reform” worth more than its weight in piss that doesn’t completely overhaul Employer based insurance… and the ACA isn’t that… not even a blueprint.Report

      • Avatar Trumwill in reply to Marchmaine
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        One of the more substantive parts of PPACA was the Medicaid expansion, which aren’t reflected in marketplace numbers. Sometimes it actually feels like the whole thing was a way to try to make Medicaid expansion more palatable by attaching it to a plan that otherwise didn’t do much.

        That said, we were on the marketplace until late last year when we were informed of a provision that stated that you cannot be in the Marketplace if you are Medicaid-eligible and, through a disastrous series of events, lost our marketplace coverage. (So now we’re pretty bitter towards everybody and everything in our system public private and everything in between.)Report

        • Avatar Marchmaine in reply to Trumwill
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          says:

          Yes, I think it more plausible that the ACA gets absorbed into Medicaid rather than swallowing Employer Healthcare. From the interactive chart I linked to, Medicaid covers 65M folks… and from your story, the ACA is a weird rope bridge from Medicaid to subsidized non-Medicaid.

          Sorry to hear about your coverage… but most everyone is pretty bitter (or in an honest moment, at least nervous) about our system, public private and everything in between.

          As I’ve said before, all you need to do is lose your job once and get the COBRA letter to understand how well and truly F’ed you are.

          But my point – and I realize I didn’t really make it above – is that there are ways to tackle health care that will appeal to the right/left, but its a middle- and upper-middle class project… its not about the poor or the uninsured… its about bourgeoisie concerns. Address those and you’ve got a constituency. Talk about human rights, reducing costs, reducing the number of uninsureds… and then I know you don’t have a plan.Report

          • Avatar InMD in reply to Marchmaine
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            says:

            I think you’re basically right in your last paragraph but maybe overstating the case against the ACA core concept. Yes I know the discussion always focuses on the heartstrings versus the pocket book but slowly cutting the chord between a person’s particular employer and what kind of coverage is available is a core middle class interest.

            So is some level of commodification of the service and we wouldn’t have the growing network of urgent care and similar first come first serve clinics (which now compete with each other to the consumer’s benefit) without nudging up coverage for people at the low end of the economic spectrum. So is putting some real pressure on the payors around transparency and care reimbursement. I doubt I’m the only middle class person who has had a $400 bill show up in the mail after some routine treatment and had to spend hours on the phone trying to figure out what the hell happened.Report

          • Avatar Marchmaine in reply to Marchmaine
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            says:

            “but maybe overstating the case against the ACA core concept.”

            unpossible 🙂

            The only way to cut the cords of Employer insurance is to first make all of the funds used to pay Health Insurance actual employee pay. That is, there’s about $1.5T paid into insurance by Employers… all of those funds have to first go back to the employee… even if we then have to figure out how to re-allocate some/all/more of them for healthcare.

            In many ways, the $1.5T coupled with the $1.25T in Medicaid/care is the bulk of the $3.3T that universal would cost [Personally, I’d assume at least $3.5T++ for a 3- to 5-yr transition – costs will go up, not down].

            The interesting fight is allocating the taxation to recoup the $1.5T once everyone has gotten (on average) a $10k raise.

            The tax fight would be legendary… and cross-cut so many constituencies… those Team Blue DINK stalwarts making $250k/year? Yeah… $42.5k in healthcare taxes (plus all their current taxes… offset by $15k raise).

            But I’m quite sure they will support the project since the $30k/year single mom with the $18k family plan will pay $8k in health taxes *and* take home $10k in additional pay! Win/Win.

            Unless we cap it like Social Security. (Note, Medicare is now already uncapped).

            Employer based Healthcare is so distortionary we can’t even unravel the distortions coherently.Report

          • Avatar InMD in reply to Marchmaine
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            says:

            Of course you couldn’t do that and it would be a disaster to try but I don’t think you have to. You’re assuming that employers are forever going to be offering something better (and cheaper to the individual) than what’s out there on the exchanges. We’re already watching the slow transition to high deductible and employers racing to the bottom because they’re so much cheaper.

            So it isn’t going to be a matter of 42k in premium costs it’s going to be a slow wind down to paying more and more out of pocket on the treatment they actually receive before a deductible kicks in. Once that happens both the politics of the situation and hopefully the economics on the consumer side will start to change.Report

          • Avatar Jaybird in reply to Marchmaine
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            says:

            I think that if a democratic candidate took the attitude toward insurance companies/workers that Clinton took toward coal companies/miners, they’d win 48 states or so.Report

          • Avatar Marchmaine in reply to Marchmaine
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            says:

            No, I really do think we need to do that.

            The $1.5T are actual wages being spent (poorly/inefficiently) on Health Care… suggesting that Employers will simply keep the $1.5T through incremental benefit destruction is a really bad thing… esp if that benefit destruction is transferred to individuals via higher taxes.Report

          • Avatar InMD in reply to Marchmaine
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            says:

            @marchmaine, then consider yourself much braver than me. 🙂Report

        • Avatar Marchmaine in reply to Trumwill
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          says:

          Heh… I don’t know about that.

          I just don’t see any possible path forward that doesn’t start with “repurposing” the $1.5T that’s already funding the healthcare market. Even if you prefer an incremental approach, or decoupled markets… the first thing has to be getting the compensation in the hands of the employees so it can be re-spent in different venues.Report

      • Avatar Dave in reply to Marchmaine
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        says:

        “The ACA was sold as, and in fact is, purely an uninsured reduction rough draft.

        It would be a HUGE and DIFFICULT lift to make it anything else than that. Time to let the ACA be what it is and stop thinking it is more than that..”

        From the patient perspective that’s probably correct. From the provider perspective, I’ve seen three things.

        1. A wholesale change in the way hospitals and health systems, both profit and not-for-profit, are running their businesses. Because the cost of care in the acute care setting is expensive and in some cases more costly than the reimbursements received (i.e. emergency rooms), health systems are shifting to outpatient models where they can.

        2. Because cost control is so important, there’s been a shift towards hospitals partnering with operators in certain kinds of facilities. It’s now commonplace with ambulatory surgical centers and hospital-affiliated in-patient rehab facilities.

        3. One of the reasons M4A is being discussed – further consolidation. The ACA gave health insurers a lot of bargaining power and when five health insurers control almost 85% of the market, it creates an arms race on the provider side. This was going on before the ACA went into effect but is now going all-in on both horizontal (health systems or practices) and vertical consolidation (Aetna-CVS or UnitedHealth and Optum).

        The health systems consolidate so they can wield power over the insurers in order to get higher reimbursements, and they can get them. On the flipside, because the health systems can extract more from the insurers, the insurers raise their premiums.

        It’s perverse. I work in the healthcare real estate business (I acquire commercial property on behalf of a fund). I’m watching the dynamics in real-time and those influence our strategy accordingly. From a real estate perspective, consolidation is good if you’re on the right side of the game (i.e. own a property with a smaller health system about to get acquired by a larger one). My tenants get better reimbursements so the rent gets paid.

        It’s the reason why I don’t touch medical real estate properties with a tenant base of primarily small independent physician practices. That model is dying (Medicare for All would kill it IMO). The insurance companies have them over a barrel to a point where it becomes less enticing to operate a business and more enticing to go to an employed model, hence the reason the rate of physician employment has gone from something like 25% to 40% in the last seven or eight years. Even with the problems from private pay insurers, they still don’t want to deal with Medicare.

        One reason why I like my business so much is that I get to talk to the doctors about the healthcare business. It’s more important to me than the bricks and mortar. I don’t ask about Medicare for All specifically but we do discuss payor mix. Like me, they like as high a percentage as possible from private pay insurers and as low a percentage from Medicare/Medicaid.

        My opinion on Medicare for All is simple – I will take no plan seriously if it doesn’t appropriately address the consequences to health providers. Sure, it’s great for patients if their healthcare costs are tied to Medicare rates in some way by way of lower premiums (or a tax increase that’s less than cost of premiums + out of pocket).

        We have a basic math problem here.

        Average EBITDA margins for health systems are about 6%. The well-accepted assumption on the spread between Medicare reimbursements and private insurance is 40% higher for private insurance.

        Conservatively, assume a payor mix that attributes 40% of total revenues to private pay insurance (as a point of reference, HCA, the largest publicly traded for profit operator is 50% private pay and Ascension Health is 45%).

        Taking a 40% pay cut on 40% of revenue hits the bottom line by 16%. You may have administrative cost offset to some degree but it won’t be close to that in a larger health system.

        Heck, conservatively estimate a 10% net drop in revenues. If anyone is interested in explaining how this is supposed to work, I’m all ears. When that explanation arrives, I not only want an explanation on the business side of healthcare delivery but also the capital markets side.

        Not-for-profit health systems may be not-for-profit and therefore not subject to the Wall Street scrutiny, but they raise debt through the tax exempt markets and have rated debt. Better ratings mean better cost of capital in the form of lower rates. Also, according to the ratings agencies, the reliance on government reimbursements for revenues is credit-negative already (which is why we don’t touch skilled nursing with a 50-foot pole).

        Shift to all government revenue and even hit the numbers with a 10% cut and it’s a ratings disaster. At best, the top investment grade rated systems lose a little but stay investment grade but the other systems are screwed if they can even service their debt.

        The good news for the Medicare for All crowd is that they watch this play out in real time and it’s worth paying attention to how providers respond because 1) payor mixes are going to become more Medicare heavy given our current demographic trends and 2) our current demographic trends point to increased demand for all healthcare services, especially those of higher acuity.

        At the very least, you’ll be able to see how shifts towards more Medicare impact health systems.

        My official position on M4A is that we’re a generation or two away from being able to pull something like this off. The current demographics have to play themselves out and the business of healthcare needs to experience significant disruption in order to drive down costs. That can happen at some point.

        Here’s some fun reading:

        https://www.capitaliq.com/CIQDotNet/CreditResearch/RenderArticle.aspx?articleId=2151274&SctArtId=465221&from=CM&nsl_code=LIME&sourceObjectId=10834664&sourceRevId=1&fee_ind=N&exp_date=20290109-21:50:39Report

        • Avatar Jaybird in reply to Dave
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          says:

          But people *NEED* health care!Report

          • Avatar Dave in reply to Jaybird
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            says:

            Yes and when people that need it and can’t afford it and choose between life and death, they choose life and get treatment in an emergency care setting, which in of itself is very costly. Not for profit health systems can absorb some of that since providing care to people in need is part of the community benefits they have to provide to main a not-for-profit status but that doesn’t happen all the time, which is why the ACA’s main goal was increasing ACCESS.

            If you know the uninsured are going to seek healthcare whether or not they have insurance (as anyone interested in self-preservation would) and you also want to control healthcare costs by keeping people out of high cost healthcare settings (acute care hospitals), they need preventative care.

            I’d even go farther and suggest that a Medicare for All type of plan should be considered in a larger reform of the social safety nets. Not that I have any concrete ideas but if part of having a universal health coverage plan, I would look at other indirect ways to address population health management.

            Yeah, it may sound statist or paternal to the more free market types but in theory, I’m not bothered since I’m approach from a public health perspective.Report

  2. Avatar Saul Degraw
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    says:

    Roughly 160 million Americans receive their insurance from employment. A lot of them really like their employment based insurance from what I understand. There are also a lot of people on the left, right, and libertarian side who think that employment-based health insurance makes no sense and we should get rid of it.

    This is where the problems start:

    1. It is really hard to replace something that benefits around half the population in a democracy;

    2. The left, right, and libertarians all really disagree with what should replace employment-based health insurance. On the left, you have various plans for some kind of government-backed health insurance. On the internet, you can find right-wing and libertarian-types who seem to want to rip off the bandaid, get rid of employment based health insurance, and replace with nothing but “Let the magic of the market work its wonders.”

    3. There is also a debate about how to think of health insurance. I’ve heard libertarians describe it as a “consumer good” and this is something I firmly disagree with as a classification and mindframe.Report

    • Avatar Philip H in reply to Saul Degraw
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      says:

      The more fundamental issue as I see it is we need to decide are we talking about insurance – which is a way to pay for healthcare and thus gain and retain access; or about healthcare itself. Where I think a lot of us on the left are getting fed up is the notion that access to healthcare should be dictated by private market actors who are incentivized to make a profit, whether those actors are tied to employment or not. Where the ACA succeeded (at least early on) was it forced those actors to actually increase access, and do so in ways that were more affirming to individuals as opposed to primarily based on profit impact motives. This is the crux of the drive to get away from employer tied health insurance and to single payer.Report

    • Avatar InMD in reply to Saul Degraw
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      I’m going to do something really stupid and make a prediction. My prediction is that employment based health insurance is going to slowly become less and less attractive due to the proliferation of what would have once been called high deductible plans, driven in no small part by the ACA. My anecdotal experience is that fewer and fewer companies are offering the kind of traditional, copay plans and the ones that still do, more and more only offer it at a much higher price.

      At some point a critical mass of people will already be on the cheapest types of plans associated with the exchanges and the preference for employer coverage will weaken. Then it will be possible to start talking about the kinds of changes that the exchanges really need for viability, including eventual elimination of employer based coverage as anything other than maybe a luxury supplement.Report

      • Avatar North in reply to InMD
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        says:

        Well yes, and that chipping away was one of the ACA’s core intentions. A sloooow gradual off-ramp for employer based plans which is, let’s be real, the only politically feasible way to unwind the existing health care status quos.Report

        • Avatar InMD in reply to North
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          It is the only way and if it works it’ll be to the great historical credit of the Obama administration, battered, and imperfect as the ACA is. My hope is that the Ds in Congress understand this core aspect of the policy and the path dependency we’re on. The worst thing that could happen would be throwing it away in some Quixotic tilt towards the Canadian or UK approaches. They won’t work here.Report

          • Avatar North in reply to InMD
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            says:

            On that you and I are in full agreement. I really do think that once the election season ends and they sit down to actually enact policy the politicians will find the idea of simply polishing the dings and dents out of the ACA damn appealing.Report

          • Avatar Will Truman in reply to InMD
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            One game changing thing PPACA didn’t do that it might have is extended employer tax incentives to subsidizing marketplace plans instead of just offering their own. Would have strengthened the marketplace and weakened exmployee-exclusive coverage.Report

          • Avatar North in reply to InMD
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            says:

            One step at a time Will.Report

          • Avatar DensityDuck in reply to InMD
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            says:

            “One game changing thing PPACA didn’t do that it might have is extended employer tax incentives to subsidizing marketplace plans instead of just offering their own. ”

            This is kind of saying it’s okay for employers to just not offer healthcare to their employees, and that’s bad because reasons.Report

          • Avatar Mr.Joe in reply to InMD
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            I think the PPACA ship has sailed over the horizon. GOP will only accept kill it for a legislative fix. Dem base wants universal care. Tinkering with PPACA is probably easiest logistically and legislatively, but politically it gets the PRO side little to negative political/reelection points. Both bases want revolution. A glass of cool chocolate almond milk is not satisfying when you want rocky road ice cream. Maybe you can get away with a bit of a bait and switch. Esp. if it is on party lines and the other side screams bloody murder. You would have to dress your tinkering up as something “totally new” or “repeal and replace with something better.” I just don’t see much political upside for “I fixed ObamaCare”.Report

    • Avatar JoeSal in reply to Saul Degraw
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      I would argue that is not where the problem starts.

      Somebody correct me if I’m wrong, but the default current liberal position is that welfare and healthcare is a ‘human right’. That ‘human right’ can only be achieved through involuntary taxation. Involuntary taxation when forced upon society is a ‘rule by force’ system. That system requires rule by force enforcement, which requires a rule by force government.

      So the current state of modern liberalism requires a rule by force government, which means that anyone who disagrees with the notion of a rule by force government is pretty much going to have a strong, strong dislike for modern liberalism. Which will likely lead to dismiss all that past loveliness of the old liberalism and its tenets that no longer exist.

      That is where I see the problem starting.

      We will just leave regulatory and guild captures as a first side note.
      What taxation does to an economy (in the name of the liberal ‘human right’ context) as a second side note.Report

      • Avatar North in reply to JoeSal
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        says:

        Mmmm that steals a base I’d say. Health care as a human right is probably a leftist position but I wouldn’t say it’s a universally adopted liberal position. Health care being something that government should be involved in assuring is provided to the entire populace as a matter of good public policy is probably a more accurate blanket statement for liberals as that encompasses the more “it’s a right” position of the left wing side of that spectrum and also the “it’s a humane and good policy” position of the huge centrist cohort of liberals.Report

        • Avatar JoeSal in reply to North
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          If the center, mid-left, and quasi-center that identify themselves as ‘liberal’ do support the policy (that policy being mandatory taxation to provision) then how is the base being stolen? Or is there a problem in associating ‘liberal’ to that large of a political span?Report

        • Avatar InMD in reply to North
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          Cosign. I roll my eyes at a lot of the human right rhetoric. It’s a public policy issue. Getting access and affordability of care right has become a necessary part of the infrastructure for preserving our prosperity and a small-l liberal form of government.Report

          • Avatar JoeSal in reply to InMD
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            Is the small-l form of government you are suggesting a rule by force type? As in producing policy of mandatory taxation?

            What might be refreshing is if there were a small-l liberal sub-faction of the greater faction that would agree to a voluntary taxation instead of a mandatory one. That could at least pull a chunk of liberalism out of a rule by force government and maybe set it back into a self governing framework. I haven’t found much evidence that that exists (or could exist).

            That also might have a useful side effect of getting us out of the battle for the one ring that rules them all.Report

          • Avatar InMD in reply to InMD
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            says:

            JoeSal

            There’s no such thing as a government that can’t use force to enforce laws and compel compliance. Maybe hypothetically such a thing could be done but I don’t see how it could be successful. More importantly, and even if it could, I don’t see how anyone gets there from here.Report

          • Avatar Philip H in reply to InMD
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            I don’t’ see any historical examples where “voluntary taxation” would ever create anything near the resource base needed for provision of healthcare (or any other government service). And frankly the “rule by force” argument regarding government is an over cooked red herring. Even in the most government interference free assortments of human activity, there has to be a mechanism for enforcing basic contract rights and relationships, else commerce can’t actually happen. And if a government rule by force is going to be used to maintain commerce (as it has to in a market economy since profit motive strip actors of any moral willingness to be obliged to anyone else), then the mechanism can and should be extended to secure certain other societal needs and benefits.Report

          • Avatar JoeSal in reply to InMD
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            It takes seeing it in a expanded Cooley Doctrine sense than a Dillon’s Rule sense, I haven’t found a path from her to there that isn’t pretty grim (but no more grimmer than the current path).Report

          • Avatar JoeSal in reply to InMD
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            Philip H-
            There may be something in the American cottage industry during pretty close to the laissez faire era. Wealth was distributed in a manner that the need of social goods was easily afforded on the private side (so social goods by default were affordable private goods.). There is actually more wealth (in a velocity of money sense) in a economic system that doesn’t have taxes. So your argument is somewhat counter factual in the terms of creating a ‘resource base’.

            To your other point, and I think I have seen this argument before in the context of commerce. I would answer that commerce is a social construct that has no innate requirement to be subsidized in any manner by a taxation scheme.Report

          • Avatar Philip H in reply to InMD
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            says:

            @JoeSAL,

            dude, you miss the argument – commerce requires mechanisms to enforce contracts.That mechanism can be Guido and da boys and a baseball bat, or it can be a legal systems supported by taxation with things like courts and sheriffs and tax sales and liens. Once we decide to use the latter – since among other niceties it takes blood of the hands (literally) of those conducting the commerce – we also institute tax supported structures to provide other collective goods – things like clean air, basic education, safe roads. Healthcare falls into that list of public goods as surely as air does. absent a tax supported legal system, however, commerce reverts back to Guido as an enforcement mechanism.

            Which brings me to rebut this:

            “Wealth was distributed in a manner that the need of social goods was easily afforded on the private side (so social goods by default were affordable private goods.). ”

            That’s historical BS. Sure, the wealthy could afford doctors and gift communities with libraries, but most Americans ran without access to modern healthcare, or effective transportation (aside their own two feet) and food insecurity was even greater then it is now since most workers in cities (and we were moving from an agrarian to an industrial society at that point) weren’t paid enough to love.

            but hey, keep dreaming of a world where your neighbor will invest in your well being and social goods as much as you do.Report

          • Avatar JoeSal in reply to InMD
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            says:

            Philip H-
            Social constructs are social constructs. That you prefer the state to Guido doesn’t mean a damn thing in terms of social objectivity. There is nothing to insure the state doesn’t become worse than Guido or Guido doesn’t become worse than the state. Your premise that the state by default leads to a better outcome in social objectivity is unresolved.

            (Commerce can fend for itself)

            I don’t even need to make a case that a non-taxed economy has more wealth to spend on products than a highly taxed economy. After that the only thing at issue is the distribution of wealth, which distributed production produces.Report

      • Avatar Chip Daniels in reply to JoeSal
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        says:

        “That ‘human right’ can only be achieved through involuntary taxation.”

        You see how this same statement can be applied to “property rights”?Report

        • Avatar JoeSal in reply to Chip Daniels
          Ignored
          says:

          Make your claim clear.Report

          • Avatar Chip Daniels in reply to JoeSal
            Ignored
            says:

            Property rights can only be achieved through involuntary taxation. Involuntary taxation when forced upon society is a ‘rule by force’ system. That system requires rule by force enforcement, which requires a rule by force government.

            This isn’t meant as a zinger. I am genuinely unsure of how people reconcile the desire for collective action with the demand for unilateral autonomy.Report

          • Avatar JoeSal in reply to JoeSal
            Ignored
            says:

            That’s a great claim. I don’t support any forced taxation of any kind, even for property rights stuff.

            If people wanted to create a construct of voluntary taxation to produce the property rights provisioning would you have issues with it?Report

          • Avatar Chip Daniels in reply to JoeSal
            Ignored
            says:

            Eh…Didn’t some people already do that?

            They called their construct of voluntary taxation to produce the property rights provisioning the “United States of America”.

            No?Report

          • Avatar JoeSal in reply to JoeSal
            Ignored
            says:

            They sure as hell tried, but they stopped shooting the mandatory taxation bastards……the lesson to be learned is never stop shooting mandatory taxation bastards.Report

          • Avatar Chip Daniels in reply to JoeSal
            Ignored
            says:

            This is the incoherence I am referring to.

            If there can never be any coercive force ever, then the ability to create such things as “rights” seems impossible to me.Report

          • Avatar JoeSal in reply to JoeSal
            Ignored
            says:

            Would you like that I made a stand for ‘rights’?
            To Stillwaters credit I had to resign the ‘rights’ spooks during my year away.

            So now that we are ‘post rights’ where would you like to go?

            I will leave a place marker here that subjective value is still in full effect and individual constructs will remain after passing the ‘post rights’ mile marker.Report

          • Avatar DensityDuck in reply to JoeSal
            Ignored
            says:

            “Property rights can only be achieved through involuntary taxation.”

            Make your claim clear.

            Like, if you’re going to say “property rights can only be enforced by police”, nope. A government could pass laws saying that property owners may take whatever means they consider appropriate to protect their rights, and those owners may use fences and guns, and that doesn’t require any taxation at all.

            Or if you’re coming in with “property rights prevent me from doing what I wilst with whatever I encounter”, then sure, that’s a restriction, but it takes a lot of squinting and playing fast-and-loose with definitions to suggest that a restriction is a tax.Report

          • Avatar Chip Daniels in reply to JoeSal
            Ignored
            says:

            If your rights are only those which you can personally defend then how are they rights, instead of privileges?Report

          • Avatar JoeSal in reply to JoeSal
            Ignored
            says:

            If rights or privileges can only arise through individual constructs of subjective value, then what does it matter?Report

          • Avatar Jaybird in reply to JoeSal
            Ignored
            says:

            I wondered whether there was an interpretation of rights that could not be infringed (and if they could be infringed, they were obviously not rights) but I didn’t get any useful concepts out of the thought experiment.Report

          • Avatar JoeSal in reply to JoeSal
            Ignored
            says:

            From a individual constructs framework, ‘rights’ are kind of a line in the sand where the shooting starts. The line is not a absolute measure, so it’s more like a boundary condition I think.Report

    • Avatar DensityDuck in reply to Saul Degraw
      Ignored
      says:

      “Roughly 160 million Americans receive their insurance from employment. A lot of them really like their employment based insurance from what I understand. ”

      They like the employer-provided insurance, I think, for the same reason they like having taxes collected through paycheck withholding.

      It’s easy.

      The employer says what the premium is but whatever, that comes out before they even cut you a check so as far as you’re concerned it doesn’t exist; you didn’t have to save for it, you didn’t have to keep it in mind when balancing your checkbook. You don’t have to go shop for health plans, you don’t have to figure out how much things will cost and how much you’ll need them, you don’t have to compare HSA versus FSA versus keeping the cash, you don’t have to do any of that. People who are diabetic or have heart disease or cancerous parents might care about this stuff but again, whatever, you aren’t sick and neither are your kids, and if someone breaks their arm it’s gonna cost that plus a leg no matter what plan you’ve got so just pick the cheapest one and get on with your day.

      Like, when someone says “I want to keep my employer-provided health insurance”, what they’re saying is “I don’t want to have to care about health insurance”.Report

      • Avatar Mr.Joe in reply to DensityDuck
        Ignored
        says:

        I would also add that “I want to keep my employer-provided health insurance.” proabably includes an element of “I don’t want to be super shitty like the DMV horror stories”.Report

  3. Avatar JoeSal
    Ignored
    says:

    Republicans don’t have to snipe, just let the inevitable captured-market/overtax turn into the dumpster fire of queues it always ends up in.Report

    • Avatar North in reply to JoeSal
      Ignored
      says:

      Well they have been sniping probably because they’re keenly aware that every time one of those so called “dumpster fire of queues” systems is set up the electorate subsequently will hang any politician who proposes to take it away from them from the lampposts (while grumbling a bit about queues).Report

      • Avatar JoeSal in reply to North
        Ignored
        says:

        The one true grace of conservatism is the dragging of the heels to the crack pipe of socialism. After a few hits there is no real ‘political will’. If liberals want to win by making social program addicts, that’s fine, but it has nothing to do with principle and ends in a despicable manner.

        At that point it’s just waiting to call the time and place where the currency value hit zero.Report

        • Avatar North in reply to JoeSal
          Ignored
          says:

          Man, it’s shocking you don’t identify as conservative considering that this whole bit was like republican cant 101. Those global currency melt downs are like the rapture, always just around the corner, probably hanging out with the United nations black helicopters, the FEMA re-education camps and Obama’s hyperinflation.Report

          • Avatar JoeSal in reply to North
            Ignored
            says:

            Marxism is dragging the conservatism to the left also, so I don’t see any social construct, including liberalism and neo-liberalism surviving.

            I don’t care about any of the ‘global’ melt down stuff. Just draw a line on the purchasing power of the dollar and find the point where it reaches zero.

            I don’t care about Hyperinflation much. A main indicator of that is a exponential function, which is like measuring how far you are from the cliff by the rate at which you are falling.

            I think a better measure from distance to the cliff is something I call ‘fiat rot’ which is just fiat supply doubling to stupid levels without tangible capital formation.

            From 11 Trillion to 20 was a pretty good hit, it will be interesting to see what going from 20 to 40 trillion does.

            Hell, all that doesn’t matter though, by then Alexandria will have went full Pol Pot and have all the peeps pulling plows. Health care will be like what some of the veterans have seen, four months to get in and see a doc.Report

          • Avatar North in reply to North
            Ignored
            says:

            You’re way more bullish on AoC than I am.Report

  4. Avatar Jaybird
    Ignored
    says:

    There is a level of healthcare that is able to be provided to everyone. Vaccines are probably the best example… but I imagine stuff like stitches and plaster casts and other stuff that was mastered by the 1960’s qualifies as stuff easily given to everybody.

    There is a level of healthcare that is a positional good. This stuff will never be able to be given to everybody. Maybe in 100 years we’ll have the tech to do it… but where we are right now? There’s no way.

    And since “the rich” are the ones with the access to the positional good stuff, we think that price is the reason that poor people don’t have it and we think that M4A or Single Payer or similar will resolve the problem of positional goods.

    And it won’t.Report

    • Avatar dragonfrog in reply to Jaybird
      Ignored
      says:

      What are those “positional” health treatments that will never be able to be given to everybody?

      Are they offered to every Canadian?

      At the very least, I think your examples of interventions that can be provided to everyone significantly undersells things. Unless you were trying for an extreme example that will be below the ‘cutoff’ no matter how chintzy and deliberately underfunded the universal care system is.Report

      • Avatar Jaybird in reply to dragonfrog
        Ignored
        says:

        Well, the easiest example would be access to the best (or second best or third best or whatever) specialist in the field for any given ailment.

        Other examples would include the “real” version of a drug rather than the generic version.

        And yet other examples would be whether you’d go to the local hospital for the technique for (whatever) that was perfected in the 1970’s or whether you’d go to the Mayo Clinic for the technique to do (whatever) that was developed back in 2015.Report

        • Avatar dragonfrog in reply to Jaybird
          Ignored
          says:

          Re the first and third examples – they’re kind of the same thing really – I don’t think that’s the case here.

          It’s that old bugbear, “from each according to ability, to each according to need”

          The best specialists in the field see the patients with the most complicated conditions, the ones that really call for the top specialists. The small local hospital does treatments it can easily do in-house, and refers patients to a major urban hospital complex when treatment requires facilities beyond what they have.

          Yes, patients often have to pay for their own transportation, but hospitals also have staff social workers who have the ability to basically prescribe money if, for example, someone needs to travel to the big provincial heart institute or cancer treatment centre, and just doesn’t have the funds to travel there.Report

      • Avatar DensityDuck in reply to dragonfrog
        Ignored
        says:

        “What are those “positional” health treatments that will never be able to be given to everybody?”

        What is the absolute rock-bottom minimum that will keep you from dying right now?

        Anything more than that is positional.Report

        • Avatar dragonfrog in reply to DensityDuck
          Ignored
          says:

          That is perhaps an ideological description of your desired socialized medicine regime, but clearly not a statement of absolute fact given the existence of other countries where the contrary can be observed.

          I’ll just think of some recent non-rock-bottom-survival-maintaining, but quality-of-life-improving medical interventions we’ve had access to in my family recently, all funded through the public health system, none costing us a dime.

          – Just this month I had both my ears flushed of ear wax, returning my hearing to a level I’d forgotten was possible
          – Both fledermaus and Mr T have recently visited physiotherapists for injuries that were in no way life threatening but were impacting their quality and comfort of life
          – Pediatric check-ups for the kids
          – The full course of midwifery care for the birth of both children, with about 15 pre-birth appointments at their office, delivery itself, and several post-partum home visits
          – My parents’ treatments for arthritis and rosaceaReport

          • Avatar DensityDuck in reply to dragonfrog
            Ignored
            says:

            You’re right that quality-of-life matters, but if you start making arguments about “so-and-so will LITERALLY DIE WITHOUT HEALTH INSURANCE” then you’re not making a quality-of-life argument.

            Although it’s going to be hard to convince people that there’s a Fierce Moral Urgency To Nationalise Healthcare if your examples of what healthcare can do is something you could do at home with a q-tip.Report

    • Avatar JoeSal in reply to Jaybird
      Ignored
      says:

      This positional goods thing harshes my melon.

      In the attempts to socialmonkey the pCost-pTime-pQuality thing, there is a artificial tilt to pull the pCost and pQuality to the desired level. This occur I think in both positional goods and non-positional goods. What I think happens is that both positional and non-positional pTime is the only parameter left to stretch, so it stretches in both the positional and the non-positional goods.Report

      • Avatar Jaybird in reply to JoeSal
        Ignored
        says:

        But the fundamental problem with healthcare is that there are a number of cases where when you need it, you need it very, very badly and so pTime is not elastic at all.

        Which corner will you be willing to cut?Report

        • Avatar Jaybird in reply to Jaybird
          Ignored
          says:

          And, of course, the answer for when it’s for me is that I want to make sure that the quality is high, no matter what.

          And when it’s a stranger the answer is that quality ought to be balanced with cost to a reasonable amount.Report

        • Avatar JoeSal in reply to Jaybird
          Ignored
          says:

          Ohh, I agree totally, I am not for social monkeying with any of the three pCost-pTime-pQuality. I don’t restrict any corner of the triangle and let them free float. If you want shorter time, you pay a little more, or expect maybe a little lower quality. That’s how the thing adjusts.

          The problem is the socialmonkeys think that cost can be nailed down, then a minimum quality can be nailed down and they aren’t expecting the pTime to stretch, which it eventually does.Report

  5. Avatar dragonfrog
    Ignored
    says:

    I’m not sure how disbanding private insurance (as anything but the kind of small supplemental health plans that exist in countries with socialized medicine) would require dropping claims that you can “keep your current doctor”.

    Like, here in Soviet Canuckistan, the concept of patients having their own dedicate doctor exists. The kids have a pediatrician, Mr. T has a GP, and I think fledermaus does too. I could have my own GP except I am a notorious medical system avoider – haven’t had a general checkup in about 20 years and I don’t plan on starting soon for all that I know it’s probably a good idea at my age. I’d just need to call some doctors’ offices and find one that’s accepting new patients.

    I don’t see any clear reason why disbanding private insurance would require existing GPs to tear up their patient lists and start over.

    As for legislatively ending employer based coverage – Why would you ever need to do that? Introduce universal coverage, and employer based coverage will self-adjust to focus on whatever your universal coverage excludes. Employers aren’t going to pay for features that aren’t useful. The more complete your universal coverage the more the employer plans will pare back.

    I have an employer plan here, and it’s… nice to have I guess. When I was allocating my benefits options, I think I put a couple hundred bucks a year toward some basic stuff. I could have gone all out on medical (private hospital rooms, massage therapy), dental, and prescription coverage and maybe used four or five thousand dollars of benefit package space. But, like, that’s all it costs to get top of the line supplemental insurance for the whole family, because it’s supplementing something that’s already pretty complete.

    In terms of things keeping me at my job rather than looking for something else, health insurance is not even on my radar. Proximity to a good bakery is more influential. Nobody had to ban anything to accomplish that – just provide good enough universal coverage that the gaps in it don’t threaten anyone’s basic health, and the employer plan is no longer a set of handcuffs keeping you at the job, any more than other minor perks like indoor parking or a good cafeteria.Report

    • Avatar Will Truman in reply to dragonfrog
      Ignored
      says:

      Yeah, I flubbed that sentence and stated things backwards. (Now fixed.)

      If private plans are abolished you get to keep your doctor but not your plan or anything really like your plan. If we keep private insurance you may lose your doctor even if you get to keep a lot of the things you like about your plan.Report

    • Avatar InMD in reply to dragonfrog
      Ignored
      says:

      Two primary issues:

      Path dependency means you can’t just pull the rug out from under what exists now. Trying to do so would be irresponsible on a massive level. Even if you theoretically had the votes there are major obstacles created by federalism and the fact that insurance companies are admitted state by state.

      Second issue is there is no one authority currently capable or competent to administer it. Huge chunks of Medicare (pt C) are already outsourced to private insurers and the states handle administration of Medicaid. Having been in the industry over the last decade it’s pretty clear that looking at the payors and government in the US as entirely separate isn’t accuate. They’re more like semi-symbiotic entities that distrust but also need each other lest the whole precarious structure come crashing down.

      Please don’t take this the wrong way but when Americans say people from countries with other models really don’t get it, it’s because they don’t. Your history is different and as nice as it would be to go back to the 1870s and elect Otto von Bismarck we can’t. Our government has also never owned entire industries as in the UK for example so there’s no soil for something like the NHS to have arisen. Maybe there was a chance during the post war consensus of something different but that opportunity was missed and it isn’t coming back.Report

      • Avatar dragonfrog in reply to InMD
        Ignored
        says:

        Absolutely it would take time to get to fully socialized medicine, and it would have to be done in a way that doesn’t as you say pull the rug out from under the current arrangement.

        But there do exist large organizations that do the kind of thing state health authorities would have to do. If the patient base of the US Veterans Health Administration were a state, for example, it would be the fourth most populous in the USA.Report

  6. Avatar Jaybird
    Ignored
    says:

    I don’t see any clear reason why disbanding private insurance would require existing GPs to tear up their patient lists and start over.

    I think it’s because of the number of doctors that currently aren’t accepting new patients or don’t accept medicare patients.

    Allowing doctors to pull that crap will need to be curtailed come the new glorious system.Report

    • Avatar Will Truman in reply to Jaybird
      Ignored
      says:

      My guess is that most people would get to keep their own doctors (save for retirements and relocations and things like that) but establishing care with a new doc would be even more difficult than it currently is. A lot more people likely get relegated to walk-in clinics. But they probably get to keep seeing their doctor until something happens and/or as long as they are willing to wait.Report

    • Avatar dragonfrog in reply to Jaybird
      Ignored
      says:

      Ah, I see.

      Under the Canada Health Act, medical providers are not allowed to bill patients directly for services listed under the act – if it’s a listed procedure, there is only one payer per province, which pays the same free province-wide. So there is nothing to be gained by preferentially providing, say, a heart bypass, to a patient with private insurance. Heart bypasses are listed under the CHA, so private insurance is unable to bid against the provincial health authorities to pay more for their clients to get them first.

      I suppose the patient with the private insurance might bring in a bit more money to the hospital by paying for the nicer recovery room or something, but I’ve never heard of anyone being denied HCA listed care, or of physicians who are only accepting patients if you have private insurance.Report

  7. Avatar LeeEsq
    Ignored
    says:

    I pay for my own insurance through Kaiser Permanente, which is a famously self-contained private healthcare system based on the idea that doctors are more or less interchangeable. I still have my own GP of my own choosing and if I really want to can convince Kaiser to allow me to see a specific specialist rather than one of their choosing. The entire don’t get to pick your doctor is a scare tactic but if you think about it any economics of scale will have to treat doctors as interchangeable, especially if they aren’t specialists.Report

    • Avatar Saul Degraw in reply to LeeEsq
      Ignored
      says:

      One Medical works on a similar premise. You can get same day appointments or close to it but you don’t get to pick the doctor you see. Though One Medical might also make money on mastering the algorithms of insurance codes/medical billing for top dollar.Report

  8. Avatar j r
    Ignored
    says:

    Recently, I had a conversation with a friend from Australia, who commented that the public hospitals there are quite good. Australia has one of these mixed systems where the public system has universal access, but private care is available for those who want it and can afford it. The key to making this successful is that the public hospitals are not viewed as some kind of absolute last resort. I’ve had some experience with the public hospitals here in Hong Kong, where I presently live, and they are no frills, but seem good.

    Here is my crazy idea: how about the development of a public option that is exactly that, an option. In other words, whenever the left starts talking about a public option in the United States, it always seems like it’s meant as a transition to the single-payer utopia, because the single-payer utopia is the only just/humane/viable/[insert preferred adjective here]. But if the government could actually demonstrate its ability to deliver quality healthcare in a setting that didn’t make people think of a big city bus terminal, that could go a long way to getting people OK with the idea of publicly run healthcare facilities. That is, if we spent more time focusing on the problems of public administration and gave the ideological pillow fights a rest, we might end up with something worth scaling.

    If we had an opposition party that hadn’t devolved into a collection of obstructionist ass-clowns, there might be someone around to make this argument. But I won’t hold my breath.Report

    • Avatar dragonfrog in reply to j r
      Ignored
      says:

      But if the government could actually demonstrate its ability to deliver quality healthcare in a setting that didn’t make people think of a big city bus terminal, that could go a long way to getting people OK with the idea of publicly run healthcare facilities.

      What do you reckon the odds are of that fact being weaponized by Republicans, deliberately making the public option grotesquely, murderously dysfunctional, as the perfect opportunity to demonstrate that the government “can’t” deliver quality healthcare?

      I’d give it about 100%.Report

      • Avatar j r in reply to dragonfrog
        Ignored
        says:

        If you just feel like you want to take a shot at Republicans, go for it. I’m not that interested in defending them. And you’re probably right about a lot of them.

        That said, your comment completely misses the point of my comment in exactly the way that I’m talking about. There are issues related to what we collectively want from an ideological perspective – more or less government, for instance – and there are issues related to our ability to deliver on what we have decided is the right course of action; that’s where the public administration part comes in.

        We can pretend that the only thing standing between us and our Nordic, social-democratic utopia is too many people with the wrong ideology or the wrong motivations, but one of these days we probably ought to fess up to the fact that a big part of the reason that we don’t have great universal public services is simply that we’re not that good at delivering them.Report

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