I agree with Atrios and Bob Herbert that the so-called “Cadillac” tax on health care benefits is a terrible idea. The name itself conjures up images of welfare mothers driving Cadillacs and young bucks buying T-bone steaks with their welfare checks, and that’s no accident — the name was chosen in order to make it sound like a tax on the wealthy and wasteful when in fact it will hit a lot of middle-class people, as Herbert demonstrates in detail.
The thing is, it will be rightly seen as a tax on the middle class no matter what they call it. I know that I mock Chris Matthews and other Villagers when they base their political prognostications on what their cranky, ethnic uncles are saying, but the fact is that I find my own cranky, ethnic uncle to be a pretty good barometer of things. And his biggest objection to the Senate bill is the tax on health care benefits. He said to be, pretty much word for word “They call it a `Cadillac’ tax, but people like me are going to end up paying it too. It’s a big scam.” I don’t think he’ll be the only way saying it.
Update. Ezra Klein completely disagrees, saying that is a legitimate tool for reining in health care costs.
This goes to the one place where I sympathize with the firebaggers — there are things about the politics of the Senate bill that are deeply worrying to me.
J. Michael Neal
Yes, we understand that no one is in favor of taking steps that would actually rein in health care costs, but they still need to be taken. This is one of them. Deal with it.
DougJ
Yes, we understand that no one is in favor of taking steps that would actually rein in health care costs, but they still need to be taken. This is one of them. Deal with it.
I liked you better when you were screaming at me about Niebuhr. ;)
crayz
Yeah. Go read Ezra. I’m all for soaking the rich, but we need to specifically reign in health care costs as well, and if we can’t start by eliminating this regressive subsidy to people with expensive plans, where can we start?
Tappen
Agreed. It may be a tax on the middle class as well as the wealthy, but it also helps the poor. The current system means those without employer insurance pay taxes twice, while the middle class only pays once. It does seem like a fair redistribution.
EdTheRed
She said “Balls to you, daddy!”
She ain’t never coming back.
jenniebee
Well, it’s a terrible idea, but Mary Landrieu has explicitly said that she’ll filibuster if it’s not in the bill.
DonBelacquaDelPurgatorio
I’ve got $5 that says that the Cadillac Tax never makes it out of conference in its present form.
If I lose, I will pay out of the $100 that DougJ owes me.
DougJ
If I lose, I will pay out of the $100 that DougJ owes me.
What do I owe you for?
J. Michael Neal
Take, for example, everyone’s favorite plan, until they figure out what it would actually do: a public option that would be based off of Medicare reimbursement rates. It gets huge raves because people think that it would control costs by slashing insurance profits.
Of course, that’s pure bullshit. It would control costs by slashing the amount of money that goes to doctors and hospitals. The instant it actually got implemented, many of the people who say they love the idea would be up in arms because Doc Farmer down at the clinic tells them he can’t make any money any more and is closing up. Well, that’s the whole point of the policy. It’s supposed to cut doctors’ incomes. Good luck selling that.
If you are in favor of cutting health care costs, then you are in favor of doing things that have a large political cost. If you are unwilling to tell your cranky ethnic uncle to shut the fuck up and live with reform, then you are not serious about cutting costs. End of story. If you are not serious about reining in costs, then you are not serious about health care reform. Again, end of story.
DougJ wants a pony.
Tom Hilton
@J. Michael Neal:
This.
It eliminates a $250 billion subsidy that goes primarily to the upper and upper-middle classes, and encourages inflated health insurance costs. On what planet does that [subsidy] make any sense at all?
[Edited for less incoherence]
DonBelacquaDelPurgatorio
@DougJ:
Well, we made a bet, and after I tried for a year to get you to collect your winnings, they escheat back to me, by rule.
The rule wasn’t well publicized beforehand, I’ll admit that.
Gus
Didn’t McCain propose taxing healthcare benefits?
jenniebee
@J. Michael Neal:
No one is in favor of cutting more than 20% right off the top of the cost of health care by moving to single payer except there actually are quite a few people in favor of it and it needs to be taken but it won’t. I’m afraid we’re too busy dealing with that to add this BS to the pile of deal at the moment, sorry.
DougJ
The instant it actually got implemented, many of the people who say they love the idea would be up in arms because Doc Farmer down at the clinic tells them he can’t make any money any more and is closing up.
I just don’t buy the idea that doctors will go Galt. Sorry.
FormerSwingVoter
Yeah, Bob Herbert lost me at “confiscatory tax”. Anyone who equates taxes with confiscation can be mocked and ignored, because they are stupid.
Mark
Doug,
I must disagree. If my employer doesn’t offer health insurance and I buy it in the individual market, the entire premium that I pay is subject to this “tax.” If I run my own company, or my employer pays for my health insurance, then only a very small portion of the plan is subject to the “tax.”
Let’s say your employer pays $30,000 a year for health insurance. That is a huge, huge amount for someone earning $50,000-$75,000, but it’s possible. The “tax” would repeal the government subsidy for the last $7,000 in premiums. In 2014, this would raise the cost of the plan – if it didn’t change – from approximately $20,000 to $22,333.
But your plan only cost $15,000 in the year 2000, and insurance companies jacked up your rates 100% as you got 10 years older. But the portion your employer paid only went up $10,000, and the other $5,000 came directly from the government subsidy. So the insurance company took 1) $10,000 from raises your company could have given you; and 2) $5,000 of your tax dollars. When the government broadly subsidizes a good like this without controlling the price, it does not impact the consumer at all: the price of the good rises to take advantage of the subsidy. Why you would be in favor of the government subsidizing insurance companies and propping up the employer health insurance system is beyond me.
The protests of union bosses ring as hollow to me as August’s “Keep your Government Hands off My Medicare” protests. At this moment, there are so many working people who receive zero dollars in government subsidies towards their health insurance. Those who have something – be they the rich, the elderly or just people who have a really great deal somewhere – must be willing to support those who have nothing through higher taxes otherwise we are headed to fiscal collapse.
Tom
For the longest time I though the line was “Jesus Christ, where’d you get that kind of lead.” I actually still prefer to hear it that way.
Calvin Jones and the 13th Apostle
Gus:
Yes!!
DougJ
For the longest time I though the line was “Jesus Christ, where’d you get that kind of lead.”
It does kind of sound like that.
Brien Jackson
I think the union framing of the problem gives away the game. You never really hear them say they pushed for the plans, you hear them say they “agreed to accept them.” And that’s rather the point, the tax quirk doesn’t really help workers, it helps employers by letting them write-off compensation in the form of health benefits, and it helps insurance companies by giving employers a reason to buy more insurance. In the long run at least, the policy will benefit workers, on top of lowering cost. Will it be bad short-term policy? Maybe. But that’s something the responsible party is just going to have to live with from time to time.
DougJ
@Mark
I see your point. I still worry a great deal about the political optics here.
Interrobang
If Doc Farmer down at the clinic tells you that he’s closing up shop because he can’t make money anymore because of decreased reimbursements, he’s a greedy bastard and should be replaced. I say this as a citizen of a country where healthcare is non-profit, and doctors still make incomes that put them squarely in the top 1% of income earners. If what they can make from government reimbursements isn’t enough — and here, it’s something on the order of $150 – 300K/a at minimum, not counting teaching gigs or lectures or whatever — they’re asking too much.
I don’t seem to recall that Canada’s healthcare system suddenly suffered from a massive shortage of doctors when Tommy Douglass put through single-payer healthcare, because suddenly all the doctors couldn’t make expenses, but on the other hand, he eliminated the profit-taking middleman by cutting insurance companies out of the loop.
I honestly don’t get what’s so fucking difficult about this, if you’re an American.
FormerSwingVoter
It wouldn’t be a tragedy for Doc Farmer to have to take a salaried position at a hospital. In fact, that’s why the Mayo Clinic works as well as it does – all the doctors are on salary instead of getting paid on a per-service basis, and all the specialists for disparate fields are all in the same place. Why are people acting like every single doctor in America deserves their own private practice?
Mark S.
From the Herbert column:
If the teabaggers weren’t complete idiots, they could have a field day on this. Instead, they’ll just yell “Soshulism!” louder.
Tappen
Do we have to call him Doc Farmer. Some of us have doctor Changs or Wongs or Jones or Singhs. Doc Farmer sounds like a hick in overalls.
jenniebee
@J. Michael Neal:
Insurance companies, in case you hadn’t noticed, also negotiate reimbursal rates for doctors, and nobody pulls your chicken little act about that. Government insurance negotiating or setting rates is no less self-correcting a mechanism as private enterprise doing the exact same thing.
Mike Kay
@FormerSwingVoter:
Sounds like Bob Herbert is mad his taxes are going up.
Brien Jackson
@FormerSwingVoter:
To say nothing of not talking to a single healthcare policy expert/economist.
We are all wingnuts nows.
FlipYrWhig
@Interrobang:
The difficulty is that we’re still rebounding psychologically from the Cold War and have a huge stick up our collective butt about “government control,” even when government control would be better, cheaper, and more effective. Yes, it’s stupid. No, it ain’t changing until a few more generations die off, if that.
Brien Jackson
@jenniebee:
Yes it is. Government programs have larger customer pools, and so have more leverage. That’s why the AMA killed Medicare buy-in.
Ailuridae
@J. Michael Neal:
Err, Doctors accept Medicare at about 97%. Most of those who don’t do not do so because of compensation but because like Drs Ron and Rand Paul they think that government health insurance is the equivalent of slavery. Are you confusing Medicare and Medicaid. Doctors offices, especially if you talk to the administrative staff like Medicare just fine. There is never a refusal to pay, etc etc.
A lot of health care economists have pointed out that long term the only way to control health care costs is to reign in doctor salaries, especially specialists.
The excise tax does a lot to control costs long term and will likely opt in a similar fashion to what Wal Mart does for their customers by squeezing insurance companies who thereby insure provider networks and doctors (the actual source of most of the health care cost issues)
Comrade Luke
@J. Michael Neal: So tell your uncle to STFU so doctors and hospitals can keep their ponies?
Tomlinson
Here are average family plan costs per year. Note that the highest state, Massachusetts, is at around $13K. We’re paying about that, and the plan is very good.
In order for us to hit the cadillac cutoff, we’d have to almost double our costs. That should give you some idea just how rich any plan that will get taxed will be.
Now, is it possible that health care costs are going to about double in the next four years? Sure. But if they do, we all have much bigger worries than that cadillac tax. Like rampant unemployment, extreme under insurance, etc. Stuff like that.
I agree with Ezra, BTW. Taxing the cadillac plans is good policy and it *should not* have a massive impact on the middle class.
Tom Hilton
And I don’t sympathize with them at all on that point, because what the firebaggers are doing actively aids current and future right-wing attacks on healthcare reform. They don’t just say “hey, the optics of this are problematic”; they gin up dishonest wingnut-style attacks on parts of the bill that actually have solid policy justification (individual mandates, e.g.).
Steve Balboni
Ezra responds to Bob Herbert’s column by stating that cost controls are neccesary and the only way to gain those controls is through a punitive tax hike on the middle class. Color me unimpressed.
Cost control is obviously important but, as one of Ezra’s commenters notes, costs are not driven by the consumer. No one signs up for an extra MRI or CT scan just because they have insurance. Sure they may see their general practitioner once more than they otherwise would because the copay is low but that’s not a high cost item in the grand scheme of American healthcare. What drives cost is the fee for service model which encourages doctors to order more tests on the latest equipment. Ezra’s approach to cost control is to punish middle class workers in order to save the medical professionals from themselves. It’s maddening that he somehow views this as a perfectly legitimate means to achieve his desired ends.
In this debate I have, at times, found Ezra to be technocratic to a fault – this is one of those times.
http://steampoweredopinions.blogspot.com/2009/12/ezra-spinning-his-wheels-to-defend.html
C. Gallagher
@Tom Hilton:
The cutoff for the “Cadillac Plan” excise tax will be $8,500 for individuals, starting in 2013. I’m a freelancer making about $50k, and my crummy individual Oxford plan, which cost me $219/month in 1998 and is now almost $1090/month, puts me well over the limit even now — in 2013 the premium will be at least double that, if history is any indicator, and god knows how I’ll pay for it then. It seems I have a “Cadillac Plan” and am one of the “wealthy few” and I didn’t even know it. Look at this page and you’ll see that for someone like me in New York City, they’re ALL Cadillac plans. And you think I’m being subsidized? This is insane, for all the reasons Herbert stipulated and then some.
Ailuridae
@Interrobang:
I don’t seem to recall that Canada’s healthcare system suddenly suffered from a massive shortage of doctors when Tommy Douglass put through single-payer healthcare, because suddenly all the doctors couldn’t make expenses, but on the other hand, he eliminated the profit-taking middleman by cutting insurance companies out of the loop.
You don’t remember that because its a closely guarded secret of history that only Megan McArdle, the Heartland and Cato Institutes and other Koch family beneficiaries are aware of. Also Brett Hart is the greatest Canadian not Tommy Douglass so there.
Tom Hilton
@Steve Balboni:
Ezra isn’t pushing this as the sole or even primary mechanism of cost control; he’s saying it’s one cost control measure. He has also written about the numerous elements in the bill that do attempt to address the fee for service model.
Rick Taylor
Yup. I agree completely. I was thinking they’d clean this up in conference, until another prima-donna centrist in the senate declared that any compromise and they’d filibuster. This is insane.
Zifnab
Gee, it seems like the main problem here isn’t the excise tax or the looming prospect of reduced employee compensation / benefits. Instead, it’s the middle man – the insurance companies collecting that $250 billion in subsidies, ratchet up the premiums, cut the benefits, and increase their profits.
You know what would clot the hemorrhaging flow of cash to the private insurance industry? A public option.
Just say’n.
jenniebee
@Brien Jackson:
I call shenanigans. Leverage gives you a better bargaining position relative to other people who don’t have it, it doesn’t suddenly suspend all the rules of supply and demand. You’re acting as though prices could be set so low that the demand far exceeds supply and… oops! It never corrects.
Same old story, the laws that govern capitalism are fixed and immutable, unless they’re used to the advantage of the person selling their labor or consuming an end product and then – oh noes! You can’t hold out for a better deal! That would break Capitalism!
Ailuridae
@Steve Balboni:
There is a lot in both the Senate and House bill to make a serious dent in the fee for service model.’
Also, your link to your blog is broken
Bruce (formerly Steve S.)
Klein’s tone-deafness is astounding. Note that he agrees with many of the essentials of Herbert’s column, but concludes that cost control not only trumps all else but starts with the middle class. It would be nice if he could point to any tangible benefit that modestly middle class people with decent health care plans would get from this. And no, telling them that their health care costs will only go up $950 a year instead of $1000 is not a “benefit”.
The Republicans will absolutely pummel the Dems with this, mercilessly.
Tom Hilton
@C. Gallagher: as I understand it, individual insurance isn’t being subsidized at all now–so this won’t take away anything from you. (In fact, you may well qualify for new subsidies that the bill introduces.) Individual coverage is (generally) a lot more expensive than group coverage, so using the cost of the former as a benchmark for the impact on the latter makes no sense.
Steve Balboni
@ Tomlinson Health care costs will continue to rise, inflation will factor in and before you know it *bam* we’re at that $23,000 mark. Now, do you think that Congress will then raise that mark? Of course they won’t, just like with AMT.
That’s not even touching on the optics of taxing middle class people to redistribute to the working class. That’s textbook GOP resentment politics.
The other part of this is that in the Senate bill this is the funding mechanism. There’s no effort whatsoever to share the pain a bit and have Paris Hilton kick in her share.
If they can somehow reach a compromise that brings in the House funding mechanism as well it will be a lot more palatable. As it stands now the middle class are bank rolling this entire project and they don’t really care that Ezra Klein is telling them that it’s good for them.
As a policy matter this is a bank shot way of controlling costs, why not address fee for service?
Brien Jackson
@jenniebee:
Why exactly do you think whether or not the public option was tied to Medicare rates was a big issue?
Comrade Luke
The thing that kills me is that, just like financial “reform”, the m.o. has been “Let’s do whatever we can to change things, but whatever we do we need to go out of our way to not disturb the rich from losing any of their money in any way.” And we wonder why we don’t get anywhere.
Doctors in America are among the super-rich, and they constantly complain about paying for liability insurance and fight any proposal that reduces their pay in any way. If you read T.R. Reid’s book you’ll see that doctors everywhere there is “socialized” medicine still make great money, but they’re “only” upper middle class. They don’t seem to be complaining though, because they got into the profession to help people instead of to get rich.
The biggest problem reducing doctor’s pay is that they come out of school with huge financial debts, but that can be more easily addressed than the hoops we’re having to jump through in order to protect today’s doctors from having to live on anything other than lakefront property.
scudbucket
@DougJ: I’m glad your getting on board with how bad this bill is: it’s really bad policy, but it’s politically disastrous for Dems.
Tom Hilton
@Steve Balboni:
For the third time (my second, plus Ailuridae’s comment): the bill does have measures designed to address the fee for service model. Look it up.
Keith G
Why should I get a tax break, in fact a subsidy, on the purchase of health insurance (and actually, several other fringe benefits) when some other poor sucker working for a small local restaurant not only gets no such benefit, but may actually be charged a higher tax rate than necessary over time to make up for my “good fortune.*
*I used to feel that way before I quit my “professional” career and followed my passion. Now I feel that way x 100.
Steve Balboni
Yes, there are other measures addressing fee for service but good luck arguing that with your friends when they are staring at this tax or seeing their benefits cut with no subsequent pay raise. That’s, of course, not how public policy is debated or discussed in the real world.
Terrible politics and questionable policy.
inkadu
@C. Gallagher: From the way people are talking about it, the Caddy tax only applies to employer-based benefits. Or maybe not. Who the fuck knows. I haven’t had a single discussion on HCR that was on firm foundation.
@J. Michael Neal: Doc Farmer at the clinic has a staff of two people just processing insurance claims.
This is turning into a long, dirty war. If we had a functional senate, we could pass simple cost-saving reforms that would quickly squeeze out for-profit medicine (insurance and providers) and lower costs. Unfortunately, we can’t do that, so we have to strangle the political factors that make reform almost impossible. One of those factors is employer-based health care. Since most people have it, they are happy; and since most people don’t pay for it, they have no idea how much it is costing them. It’s the scorched earth path to reform.
Zifnab
@Bruce (formerly Steve S.):
Ultimately, the middle class is the class that is consuming the lion’s share of health care – or at least paying the lion’s share of the premiums.
If you want to impact health care costs without touching the middle class, you’re in a lost cause.
But Erza’s point is that all this extra money being thrown into employer subsidized insurance premiums may not be worth what we pay for it anyway. And if you slash away the supply of tax-free dollars for Cadalliac plans, are you impacting the employees, the employers, or the insurance companies? Erza doesn’t think the employees are going to suffer as much as we would first guess.
jwb
@DougJ: The short-term optics on HCR are just bad; that’s why it’s been so difficult to accomplish.
Zifnab
@Steve Balboni:
Congress regularly raises the AMT. In fact, something like 20% of the stimulus bill was spent raising the AMT and thus pissing all over the Bush budget numbers for ’09 and ’10.
AMT taxes rich people. The last thirty years have been all about cutting taxes on rich people. We always raise the mark on the AMT.
Zach
I have no clue why Democrats insist on calling it a tax on Cadillac plans when, in fact, it isn’t a tax at all.
I can see how unions in already stressed companies are worried about it; cuts in health benefits won’t come hand in hand with increased compensation like they will elsewhere.
Mike Kay
@C. Gallagher:
if you’re paying your premium as a freelancer out of pocket then you wouldn’t be taxed.
Zifnab
@Comrade Luke:
This.
Probably one of the biggest steps towards health care reform would be to attack medical school debt. Hand out a couple billion dollars in Pell grants to med students in exchange for more modest (read: high five to low six figure) salaries down the road.
You’ll have people lining up around the block for the opportunity.
Instead, we pay through the nose for designer pharmaceuticals via Medicare Plan D, because no one wants to upset the Big Drug.
scudbucket
@Zifnab: Erza doesn’t think the employees are going to suffer as much as we would first guess.
Suffer as much? Ezra said? This the best you got?
The cadillac tax is desigto fund the subsidy for the poor. Once the tax is implemented, people will refuse to pay, opting for less expensive plans. That’s lost revenue. Premiums will rise (and coverage will get worse) to compensate for the lost subsidy.
scudbucket
@jwb: Ha ha, that’s good. Wait… you’re serious?
Comrade Luke
I’ll have to add to @this comment, because I ran out of time to add to the original entry.
I went on a date with an OBGYN a couple of weeks ago.
She lives on Lake Washington here in Seattle, which is super-primo real estate. The property includes a boathouse which holds her professional waterski boat, and she goes to Acapulco four times a year for water ski camp.
She’s in a practice with herself and one other doctor, but they have a staff of around 30 because of all the paperwork. Her loans are paid off.
And she said she’d consider closing her practice if we went to “socialized” medicine, because it would be so expensive, even though she didn’t seem to know what was in the current bill or any of the single payer, public option alternatives.
Go figure.
Tomlinson
Yeah, I’m kind of aware of that – been involved in buying health insurance plans for 10 years now.
However, at 10% average annual cost growth (which is high, assuming the rest of the bill passes), we’re 7-8 years away from the point where the average plan hits that $23K limit.
Assuming no cost bending, etc.
inkadu
@Comrade Luke: Doctors are super-rich and I have no sympathy for anyone that feels medicine is the path to infinite wealth.
But when people think “doctor” they are usually thinking of Doc Farmer. And there they would be right to defend doctors. Primary care doctors are moderately well paid, overworked employees who spend most of their time fighting with insurance companies.
And we can also set our sights on private hospital conglomerates who do everything they can to push high cost treatments and also have to compete with all the other hospitals in the area doing the same thing. Since everyone wants the high-end treatments, hospitals spend a ton of money on this equipment, but because those patients are spread around, costs per treatment go up while machinery goes unused. It’s a completely stupid system.
@Keith G: That’s exactly how I feel about the mortgage deduction. Why should someone who rents subsidize someone who owns a home? Tax breaks are a hidden wealth distribution scheme; but you must have money to qualify, so I guess it’s ok.
Zach
Off-topic: A picture of Mao is on the White House Christmas tree!
I’m too disinterested to look into it, but I imagine this is backpedaling after having their initial shock countered with the realization that it’s Warhol’s Mao.
Ana Gama
@Zach:
A lot of unions in stressed companies have already given wage concessions in trade for their enhanced health benefit plans. If they don’t get increased compensation when the health plans are cut, they will have then given from both ends, wages and benefits. That’s part of why the unions are pissed about the Cadillac plan tax.
Tomlinson
@Zifnab:
This is exactly what we should do. Med school should be free. No need to ask them to take lower salaries, though, just flood the market with doctors and nurses.
arguingwithsignposts
@Mark S.:
These people is smoking crack with this:
That’s going to happen real soon, I’m sure. That money will NEVER see workers’ pockets.
Shawn in ShowMe
Here’s another thread where posters we’ve never heard of toss out fabricated numbers about the healthcare bill that are easily refuted by a 15 second Google search.
Zach
@Ana Gama: I know; that’s why I said I understand their opposition. You could always augment it with a wage floor or something… say, the tax isn’t applied to anyone earning less than $75k/year. Or have the tax scale with wages and increase over a few dozen years to be equal across the board. It doesn’t make sense to oppose good long-run policy because of short-term flaws when you can fix the flaws easily.
Brien Jackson
@Steve Balboni:
You can argue that it’s terrible politics, but the idea that it’s terrible policy to not give special treatment in the tax code to employer provided insurance benefits over wages or individual plans is just ridiculous.
comrade scott's agenda of rage
I have a Cadillac plan since I have BCBS’s standard plan with dental and vision coverage thru FEHB (yes I work for Club Fed).
Under a Repup administration, this tax on the middle class would stand because Repup administrations hate the federal work force.
With Dems in control, and more importantly, a shitload of House and Senate members who most likely have the same plan I have, this piece of shit excise tax on the middle class will be killed in conference.
Why?
1) The House and Senate *never* do anything that will cost themselves as individuals money. Never.
2) With Dems in control, they won’t do anything to screw the federal work force. There are some powerful Dem members in both chambers who are big defenders of the federal work force. Steny Hoyer is one.
The federal work force is probably the best cross section of the country’s middle class and if we’re gonna get nailed with this Cadillac plan bullshit, then believe me, it’s a tax on the middle class.
Ezra’s totally full of shit on this one.
Tom Hilton
@scudbucket:
d’Fuh? Because people (employers, actually) will be unwilling to pay for higher-cost plans, insurers will be raising their premiums to levels that employers are…unwilling…to…pay…wait, what?
Will
Has anyone mentioned the fact that discouraging people to visit the doctor through higher costs is a really fucking bad idea? That’s how minor, cheap to treat symptoms balloon into hugely expensive medical problems.
I’d make the point that other nations manage to keep down costs while still expanding other nations, but they are nations without the love of free market Jesus. But I’m tired of snark.
I just note that when you have a problem that is politically impossible to fix, it doesn’t get fixed. And, like those minor symptoms, unfixed problems eventually turn into a terminal fucking disease.
Tonal Crow
@C. Gallagher:
I don’t think that the tax covers anything but otherwise-nontaxable employer-provided plans (including self-employed group coverage if it’s otherwise nontaxable). See s.9001 of the Senate bill by searching for H.R.3590.PP at http://thomas.loc.gov. (Sorry I can’t give a link, since, for some unknown and unjustifiable reason, Thomas links expire).
If I’m correct — and I think I am — I cannot fathom why the Democrats haven’t made this clear.
Beeb
I agree that the tax system should be more progressive. But Obama promised that no one earning under $250k would face a tax hike. Seems to me that one problem here is the definition of “Cadillac.” If the tax were limited to folks whose total compensation, including health insurance, exceeded $250k, that might solve the middle class backlash problem.
There’s an additional problem, though. The fact is that people with good insurance, with low co-pays and deductibles, actually have affordable access to healthcare. People who have it, use it. Surprise, surprise. The point of HCR, at least as it has been sold to the public, is that everyone should have affordable access to healthcare. But if they have it, they will use it. Costs will go up even if some costs, like emergency room utilization, go down. And lots of luck explaining to voters that they shouldn’t have good insurance because, well, it’s good.
Cost containment is really not consistent with universal coverage unless something is done to change provider compensation. But that’s the political bullet no one seems willing to bite.
Zifnab
@scudbucket:
No it isn’t. The “tax” isn’t a tax. It’s a cap on the tax break your employer receives when he pays some portion of your premiums for you. So if you get $10k in benefits, now the $8500 cap will mean $1500 will be taxed like normal income.
The Senate Bill assumes the business will either spend $1500 on the employees in benefits, or just up their salaries to cover the difference on their own. If the money goes into CEO salaries or dividends, it gets taxed there too. If it goes back into business capital, then the guy that gets paid the money will pay it out in salary to his own employees. And at some point, the money will be taxed.
So no, the money doesn’t just go up in a puff of smoke. Right now it’s tax shielded. The Senate Bill caps the shield.
scudbucket
@Tom Hilton: No, nutjob, because the excise tax funding community rating will be disppear.
Zifnab
@Will:
This has nothing to do with doctor’s visits. It has to do with the amount an employer can spend on your premiums tax-free. Since every plan will cover basic doctor visits, you’re talking about the difference between co-pays. If your employer bumps you to a cheaper plan to save money, you’re looking at a $30 co-pay rather than a $20.
If $10 keeps you from going to see the doctor, you are in some serious financial shit.
jlo
I work for a county government. The county pays $820 a month for my insurance. I’ve been to the doctor 3 times in the last four years. So how would a tax on my outrageously expensive health insurance control costs?
scudbucket
@Zifnab:
The Senate Bill assumes the business will either spend $1500 on the employees in benefits, or just up their salaries to cover the difference on their own.
That’s the problem right there – the senate bill assumes. Thanks for clearing that up.
Ailuridae
@Zifnab:
So no, the money doesn’t just go up in a puff of smoke. Right now it’s tax shielded. The Senate Bill caps the shield.
That’s an elegant way to put it.
Ailuridae
@scudbucket:
No, it won’t. Basically every health care economist in the country has looked at this and come to the exact opposite conclusion that you have. In your corner, you have Bob Herbert (and DougJ)
Tom Hilton
@scudbucket: you know, just stringing together a bunch of random healthcare-related words doesn’t actually constitute an argument.
Bruce (formerly Steve S.)
Strawman Alert!
Point being, this bill subsidizes 30 million irregular voters with a “tax” on 30 million regular voters. Providers keep their big fees, insurance execs keep their multimillion dollar bonuses, and Ezra Klein keeps lecturing us on how we don’t understand the political realities inside the Beltway.
Once again, point out one tangible benefit that middle class voters on “cadillac plans” will get out of this. And no, telling them that their health care costs will only go up ridiculously fast instead of ludicrously fast is not a “benefit”. Try convincing them that cost containment will be achieved with sacrifices from all segments of society, including the rich, insurance execs, drug companies, and so on. Go ahead, convince them.
Karl Rove couldn’t create that permanent Republican majority, but the Senate version of HCR just might.
Alex S.
Ah well… that goes to show that all the relevant policy debates are exclusively within the Democratic party.
Martin
@Zifnab: And because employers aren’t going to want to hear crap from employees because their withholding goes up, they’re going to go back to the insurance companies to find a way to get those premiums under the $8500 limit, which is exactly what we want to have happen.
And just to state again for those that still don’t get it, our healthcare spending *is* $2.4T per year. That *is* $8,000 per person. We can knock that number down a good bit, but any family of 4 that doesn’t think that in some way, shape, or form $16,000-$30,000 of what they otherwise could earn shouldn’t go to healthcare needs (either current or future) needs to go have a chat with reality.
What’s so shocking about that number isn’t that it’s so high, it’s that it’s so much higher than what minimum wage is in this country. Remember, we still *are* paying the $2.4T bill while we pay people $15,000 per year to work full time.
scudbucket
@Tom Hilton: But sometimes they sound real good together.
Listen, knowing the corporate/corporate employee world like you do, do you think that a) companies will take the hit on this excise tax, or b) that employees will cough up more dough for the same product? They are both probably really excited about the prospect, but who’s gonna be the lucky-ducky?
Zifnab
@jlo:
$820 / month * 12 months = $9840
The county would only be able to make $8500 tax deductible. You’d pay taxes on the remaining $1340.
When the insurance company comes by in a year and tries to up rates by another 10%, you’ll say you can’t afford it and go to a lower tier plan. All health insurance plans in the Senate Bill have a certain minimum degree of coverage, so you’d still have some degree of coverage.
When this happens to Americans across the country, pretty soon the supply of dollars to health care providers is going to adjust down into the brackets set up by the government regulations simply because people can’t afford to pay $500 for an X-Ray and the insurance company plans are only going to pay out $150.
That is going to hurt. People are going to hit financial walls. Hospitals are going to watch old income streams dry up and need to switch business practices or risk going under.
Cost containment isn’t pleasant and it can get very messy. But subsidizing your $9840 plan so that a hospital can charge you $500 an X-ray isn’t sustainable for the system as a whole.
But, the sad truth of the matter is that you were going to hit that wall anyway. The insurance provider for your county was going to raise it’s rates. The county was going to run out of money to budget for health insurance, and they were going to move you to a shittier plan anyway.
That shittier plan wouldn’t have minimum coverage. And maybe you wouldn’t get any money at all for X-rays. And then we’d see the same ratchet down effect, except the real winners would be the insurance companies that received this virtual subsidy from the tax free dollars your employer was paying in increasingly higher amounts.
Tom Hilton
@Bruce (formerly Steve S.):
So your complaint is that it’s too progressive?
Seriously: I can’t believe how many fucking pseudo-progressives are losing their shit over a transfer from wealthier people to poorer people. What the fuck is wrong with y’all?
arguingwithsignposts
@Zifnab:
Or, it goes to the shareholders, where it’s taxed as capital gains, which is a lower 15 percent rate, right?
les
Christ on a pop tart, a perfect example of the lack of knowledge underlying these endless arguments. Guess what, sport–owners of rental real estate deduct the interest on their loans, reducing rents. Renters aren’t subsidizing shit. On the other hand, not taxing employer provided health insurance is a subsidy; on top of hiding the sink hole where wage increases go to die, reducing the knowledge base of a broad swath of consumers and tkaing them out of the market process, it’s a gift from the treasury to the insurance companies.
Zifnab
@Martin:
Initially, that’ll just mean moving into a lower tier policy, however.
Ultimately – and I know this may sound crazy, but I’m going to say it again – it would be useful to have a public option for employers and employees alike to default to when private firms decided to charge too high a premium for too little service.
Give a guy all the coverage he needs at a $8500 price tag and he doesn’t have to worry about lost income or sacrificed coverage. Let him buy into Medicare at $700 / month. Everybody wins.
Public Option.
Tom Hilton
@scudbucket:
c) the choices laid out here make no sense at all.
Bobby Thomson
Klein is a fucking idiot. Real redistributive politics, in the zero-sum sense, tend to fail politically because the losers organize politically to defeat the policy. This is a classic zero-sum game, taking from those who currently have decent coverage to pay for subsidies for the currently uninsured to buy policies that may or may not provide them with coverage when they need it. Social Security was not zero-sum, because those paying into the system subsidized their own future payments. Although it’s not as stark as Social Security, Medicare also has the beneficial feature that everyone above a certain age qualifies for it.
Not to mention that taxing insurance benefits does virtually nothing to lower health care costs. To do that, you have to either lower demand or increase supply. Adding to the rolls of the insured increases demand, so the only way to lower costs is to increase supply. Bernie Sanders’ amendment to the bill will do far more to lower health care costs than a politically stupid excise tax on union workers and others with employers who aren’t total dicks.
Zifnab
@arguingwithsignposts:
True. But 15% is still more than 0%. And the capital gains tax party ends this year when the Bush Tax Cuts expire. Then it bumps back up to a less insane 20%.
arguingwithsignposts
@Tom Hilton:
I think the point people are making is that it’s lifting people who don’t have insurance by squeezing the next rung up while the higher rungs will be little impacted, thus further widening the income gap.
Martin
@Bruce (formerly Steve S.):
If you cut the salaries of doctors in a single inner-city hospital by 50% (so the average cardiologist there only made $250K) you’d save more money than if you eliminated every health insurance executive bonus across the nation.
The bonuses aren’t going to solve any aspect of the problem. It’ll make you feel better, but the country will still be fucked. Until you figure out where the core of the problem is, you’re about as useful as a toddler hitting a tree with a stick.
Will
Wealthier is what we used to call “weasel words” in the news business. A migrant worker is “wealthier” than a homeless guy.
Look, the Democrats just spent the last election bemoaning how hard things have gotten for the middle class under Republicans and how they intended to help. The middle class debt-to-income ratio is staggering, wages haven’t kept pace with inflation, pensions are gone, 401ks are depleted, people are being evicted and families are going bankrupt paying medical bills at a record rate.
That’s really a great environment to raise taxes on the middle class. This is especially true when the promised Health Care Reform does absolutely nothing to prevent said medical bankruptcies and is starting to look like it’s going to usher in an era of even more limited plans that will drive even more families into bankruptcy.
And I kind of doubt that the magical free market will automatically drive down costs when the providers and insurers still can bill their forced customers into bankruptcy.
inkadu
@Tom Hilton: Progressives put themselves at the center of the universe. Their job is take money from above and pass it down below. If they have to take it out of their own pockets, well, clearly Obama has sold them out.
Res Ipsa Loquitor
@Zifnab:
The problem is when you have to see a doctor frequently such as fora child with a condition that has to be monitored regularly, a cancer treatment that requires many visits for, say, chemo, or visits to a shrink or LISW for therapy on a regular basis.
Multiple visits add up quickly.
OT: Help! How do I get to Amazon from here so I can let some of their loot go to JC?
I couldn’t then I could and now I can’t again – and I’m finally ready to order!
Help, quickly please.
Res Ipsa Loquitor
@Zifnab:
The problem is when you have to see a doctor frequently such as fora child with a condition that has to be monitored regularly, a cancer treatment that requires many visits for, say, chemo, or visits to a shrink or LISW for therapy on a regular basis.
Multiple visits add up quickly.
OT: Help! How do I get to Amazon from here so I can let some of their loot go to JC?
I couldn’t then I could and now I can’t again – and I’m finally ready to order!
Help, quickly please.
Tsulagi
Herbert has it right; Klein in his long-winded, basically fact-free piece doesn’t.
scudbucket
@Tom Hilton: I can’t believe how many fucking pseudo-progressives are losing their shit over a transfer from wealthier people to poorer people. What the fuck is wrong with y’all?
Well, when you say it like that, I do feel like an a-hole. But (thankfully) that’s not my argument: it’s that the subsidy dries up because no one will be willing to pay it. They will choose worse plan, with higher out of pocket costs, to keep under the tax limit.
@Tom Hilton: c) the choices laid out here make no sense at all.
This is just econ 101: who will pay the tax on the cadillac plan, given that neither the employer nor the employee want to incur additional costs. Someone has to, if the cadillac plans – and the resulting subsidy – stay in place. My argument is that neither a) nor b) will want to bear that cost, so cadillac plans – and the subsidy – will go the way of the dinosaur (or more like spotted leopards, very rare).
charlequin
The employer-based healthcare system is fundamentally bad. It ties people to their employers and allows employers to “hide” compensation in the form of tax-free benefits, both of which increase the bargaining power of employers against their employees. It also artificially taxes people who receive healthcare outside the employer system — because they pay full taxes on the income that they pay into their insurance.
The “Cadillac” tax breaks this system down over time: it makes it harder for employers to hide income in extravagant health plans, which first will push them towards shrinking benefits, then towards not providing insurance at all. That’s okay. This reform doesn’t do this in a vacuum; it sets up a system of exchanges that can handle anyone who doesn’t get their insurance through their job. Over time this will kill off the employer system (which is bad) and strengthen the exchanges by filling them with a greater portion of the population (which is good).
Also, it’s really important to understand that this is not a tax on individuals; it’s a reduction of a tax shield on employers. If you have a plan that costs $24k a year right now, you won’t pay anything extra for it, just your employer. And if you have a plan that valuable, it is extremely likely that you are a skilled worker who is sufficiently valuable that you can negotiate additional salary in exchange for any reduction of those benefits.
I don’t want to be mean here, but it really bothers me when progressives flip out on a hair trigger when they hear the words “tax” and “middle class” in the same sentence. This tax is good policy and will not result in a significant loss of income for the vast majority of people in the middle class anyway, so it’s one place where it’s really important for people to hold their noses and not argue solely out of their own personal interests.
Res Ipsa Loquitor
Hoorah! It finally worked. Off to go shopping and I don’t have to get out of my jammies.
KDP
@Zifnab:
As you say. When I saw the comments here, I recalled hearing or reading that this excise tax on high-end insurance plans is applied like the marginal income tax rate. That is, only the value above the cutoff amount is taxed.
Here is an excerpt from the Health Bill Section-by-Section summary on the Senate Web site:
The full summary can be viewed here
I am on Klein’s side of this argument. While I may end up paying a bit more, I am willing to do so to help to fund the availability of health coverage for more people. Is this bill everything I would want? No. On the other hand, having reviewed the summary, it is far better than what we have now.
Will
inkadu,
And moderate/conservative/technocrat Democrats lose elections. Over and over and over and over again. Even sainted Bill Clinton ended up ushering in eight years of complete Republican control.
Democrats haven’t been good at politics since they were progressives. And looking at how people here are defending the dumbest policy I’ve seen in a long time, I don’t see that changing.
Mark
@jlo
The first thing you have to ask is why your county government pays almost $10,000 a year for your health insurance when you are not an actuarial risk.
It’s likely that they’re paying a ton of extra money to prevent even minimal cost-sharing: perhaps a plan with no co-pays and $500 or $1000 maximum out-of-pocket. Switch to $30 co-pays and $2500 or $5000 out-of-pocket and all of a sudden the plan costs $300 a month. Switch to a $10,000 deductible catastrophic plan and it’ll cost $60 a month.
Somewhere along the line, county employees demanded that their insurance have virtually zero out-of-pocket expenses. For this, they saved $250 or $500 a year, but it cost $2000-$4000 a year and it came out of their stagnant salaries.
Most people I know who work for cities or counties have the option of several different plans. The cost difference between the plan they have and the standard plan either goes into an HSA or comes out as extra salary.
General Winfield Stuck
58 senate dems and one soci alist got that memo. One non dem didn’t, and here we are. It really is that simple in the world of passing legislation.
And the calculus is similar with provisions like mandates and taxing “cadillac plans”. it takes 60, and 59 will not get er done.
Welcome to reality. The sausage making one.
But, I know, if Obama had only used his Cat’ a’ Nine Tails, this wouldn’t be happening.
jenniebee
@les:
Why does it necessarily follow that lower costs leads to lower prices instead of channeling into higher profits?
Sorry, but costs set the floor for the supply and demand curve, they aren’t the single greatest determining factor governing it. Rents don’t drop because the owner gets a new tax write-off any more than they suddenly drop to zero just because the owner’s finished paying off the property. They are where they are because that is how much people are willing to pay.
jlo
@Zinfab-
I missed the part where you explained how this contains costs. If I was able to choose a plan that spent my $800 more efficiently and was therefore able to lower premiums I would taxing those who chose to go above and beyond. As it is I pay $9840 year (and my employer does not have a tiered system so I don’t get to choose anything different) for insurance that knock on wood I will continue not to use. If you want to sell this as a tax on the middle class to subsidize those below- I’m totally cool with doing that, but I want real cost containment to go with it.
Bruce (formerly Steve S.)
Can somebody here translate this for me, I don’t speak Strawman.
les
@charlequin:
Fuckin’ a.
Comrade Luke
It is? Employers telling their employees that they will no longer be able to provide them with health insurance because of government taxation, and that they’re on their own to buy their insurance now, is ok? And will be accepted as ok by employees?
Because that’s exactly how it will be explained.
Will
Actually, you have this backwards. Once upon a time, health care coverage for every with a job – which was largely run by (legally mandated) non-profits – was like the government plans.
As for-profit entities figured out ways to squeeze down the cost of health care, this changed. What was normal for everyone a generation ago, became an government-job extravagance today.
One interesting thing about government employees today is that government has become high demand recruiter. The average new state employee has at least a college degree and many jobs that a generation ago hired from among the high school educated now advertise for people with master’s degrees. Because they can.
The old stereotype that government employees were people who couldn’t get a job anywhere else. Now, government work is becoming the last good, stable job in America.
Bruce (formerly Steve S.)
Strawman Alert!
Is there anybody here who can even attempt to argue honestly?
keestadoll
If someone could clarify this for me, I would REALLY appreciate it. Under the “new” Medicare, if a person wants a procedure that is not covered under their plan, can or can they not get said procedure by paying out of pocket?
Sloegin
Basic game theory would tend to indicate that this plan won’t actually garner revenue, it will flatten benefits.
Why would employers offer a plan that would be subject to a tax when they could offer one with fewer bennys *just under* the limit where a tax burden would kick in?
Do the DC swamps emit a stupid gas, or is it just all the Ambien they down every night?
Will
And that, as a great green man once said, is why you fail.
Look, if it politically impossible for Democrats to pass legislation that doesn’t get them slaughtered electorally, let’s just pick the best general the Republicans have and give him the El Jeffe cap and sunglasses. It’ll save everyone a lot of grief.
And Cole can get a job throwing hippies out of planes. It’ll be win-win for everyone.
Martin
@Bobby Thomson: You do realize that insurance directly affects demand, don’t you? Do you think that someone with insurance is more or less likely to go to the doctor with the flu or a rash or anything that is clearly not life-threatening? The more insurance people have, the more comfortable they feel to use it.
What needs to happen is to find a way to regulate people’s use of that insurance by either eliminating coverage for non-critical care items, putting in high copays to discourage constant use of care, or taxing those plans that include all of that stuff.
Let’s draw a little comparison. The lowest deductible I’ve ever seen on auto insurance is $250. If you ding your car, you pay out of pocket since the deductible would just eat that up anyway. All of those low-cost repairs never touch insurance and the costs get driven down because everyone sees the true cost of a chipped windshield or a shopping cart ding. But those low-cost repairs also represent the overwhelming majority of repairs in volume. All that paperwork that doesn’t need to get done, not a penny going to the insurers.
But for health insurance we have a totally different attitude. People think $25 is a high copay. If you have the flu, and you think you’re really sick, are you not willing to pay $50 to get well? Or is it that maybe you don’t think you’re really sick? Or do we just feel entitled?
Health insurance operates completely differently from every other form of insurance, and I think people have really lost the plot. If you yanked out coverage for almost anything under $100 – from minor prescriptions to that sprained wrist it’d eliminate probably 50% of all the claims that are filed, consumers would be outraged at what a wrist splint actually costs (two aluminum strips and some elastic material costs more than an iPod) and put pressure to reduce that cost then we lower the costs of many plans below the tax deduction limit, we directly start to reduce the cost of care because we become consumers again, we reduce the volume of care because we decide to only go in when the fever is over 101, rather than just whenever, and we reduce the overhead of having to process all of that paperwork.
Yeah, it sucks, but we don’t get every nick on our car buffed out for $5 either, do we?
cyntax
@General Winfield Stuck:
Maybe I missed it, but I didn’t notice anyone complaining about Obama or his strategy on this thread. From what I’ve read, the debate’s all about whether the excise tax is good policy or not and what its repurcussions might be. All of which seems pretty substantive and has nothing to do with accusations of sour grapes and whatnot.
How about not flogging that one for just a single thread?
Tom Hilton
@arguingwithsignposts: well, sure–I would love to see the House’s tax on high-income people in addition to a cap on the subsidy for high-end health insurance. I don’t think it should be either/or. I’m just arguing that capping the subsidy is a) good policy, and b) decidedly progressive–and it’s maddening to see the way it has been demonized by people who shouldn’t have any objection to it in principle.
Most maddening of all are the people who see it as a reason to kill the whole bill–and they’re really the ones I consider pseudo-progressives. Killing a $200 billion annual subsidy to lower- and middle-income people in order to preserve a $250 billion annual subsidy that goes overwhelmingly to upper-income people doesn’t strike me as a very progressive move.
Comrade Luke
@General Winfield Stuck: So basically, we’re stuck with accepting literally anything the Senate comes up with because Jane Hamsher pissed off Joe Lieberman.
Bruce (formerly Steve S.)
One more time:
Point out to 30 million middle class voters how the Senate bill looks like a “we’re all in this together” proposition. Do it right here:
Take your time.
Then sell it like a politician would.
Then tell us about how we don’t understand political realities.
General Winfield Stuck
@keestadoll:
Medicare pays for most procedures, at least compared to private insurers and all the denial engine crap they deploy.
And it pays for 80 percent of said procedures, unless you are hospital bound and then pays all of it, but you pay a one time overall per hospitalization, I think, with a deductible of around 800 dollars.
I don;’t know what you mean by “new” medicare.
Will
What needs to happen is to find a way to regulate people’s use of that insurance by either eliminating coverage for non-critical care items, putting in high copays to discourage constant use of care, or taxing those plans that include all of that stuff.
The big realization all the socia list medicine countries made is that people aren’t very good at determining what are and are not “clearly life threatening” illnesses. That’s because they aren’t doctors.
The guy who let’s that bleeding mole go because getting it checked out costs more than he thinks it’s worth to get looked at isn’t saving anyone a dime. He’s costing the system how ever many hundreds of thousands of dollars it will cost to shepherd him and his advanced tumors into the grave.
Ailuridae
@KDP:
Americans broadly don’t understand marginal taxation. If there is a problem with the excise tax its modelling it after marginal taxation as people don’t wrap their heads around it.
les
@jenniebee:
Yes and no. Rental property owners can’t simply charge whatever they want, housing is a market and it’s a shitload more efficient and transparent than health care. If rental owners simply pocketed the tax savings, ownership would be cheaper and people would go there. Or to owners who don’t pocket the difference. The point is, calling the mortgage deduction for home owners a subsidy by renters is fundamentally wrong; it distorts the reality, it obscures the good arguments for capping or eliminating the deduction, it takes the argument away from real policy. Just like ignorant arguments obscure what’s going on in HCR.
In health care, employees really don’t get the cost implications of health care; and the employer doesn’t care much, it’s just a substitute for wages and an excuse to not raise same. All the actual consumer really sees is out of pocket expenses. Among other things, reform ain’t happenin’ unless people get the real cost to them of the current system.
jenniebee
@Bruce (formerly Steve S.):
Not really. The point isn’t to raise money on insurance plans that offer comprehensive coverage, it’s to eliminate those plans alltogether. They’re trying to reduce the amount of money Americans spend on health care not by making health care delivery more efficient or cheaper, but by raising copays and deductibles so that the actual care is priced out of range for more people.
The problem isn’t only the uninsured, it’s also the under-insured, and this adds to the ranks of the under-insured.
Shawn in ShowMe
Assuming there are 100 doctors and you save 150K per doctor that’s 15 million right there. The vast majority of compensation in the healthcare insurance industry is handed out in stock options, not executive bonuses.
Will
I’d just like to reinforce something.
Restricting access is the exact opposite of the steps every other major Western and many Asian nations have taken to control costs. It’s a false saving, as the best and cheapest way to save money is to greatly increase the availability of early detection and treatment.
By discouraging people from getting routine care, we are simply increasing the number of people who will develop serious medical conditions. Beyond the horrid morality of this, it does nothing to solve the underlying problem and instead makes it worse.
Tom Hilton
@Bruce (formerly Steve S.): it’s easy to pretend someone is making a strawman argument when you conveniently leave out the portion of your own comments to which they were responding.
For the record, that would be this:
Sounds like you have a problem with that transfer, doesn’t it?
General Winfield Stuck
@Comrade Luke:
LOL. Nobody is forced to accept anything. Whatever bill that we end up with, is the one we end up with. I am all for constructive complaints and suggestions for improvement until the final bill is voted on. But I tend to think railing on blogs is not all that productive toward that end.
And joe Lieberman likely doesn’t give a rats ass what Jane Hamsher thinks, as per neither do I. He is pissed at the dem party for rejecting his dem primary bid, and generally rejecting his neoconism.
And it is also acceptable to call for killing the bill and retreating to thy corner for some productive thumb sucking, if that is your wont/
C. Gallagher
@Tom Hilton
@Tonal Crow
@inkadu
@Mike Kay
I stand corrected re: self-employed. I still think the cutoffs are low (especially for 4 years from now) and it’s bad politics, but I’m happy I won’t be subject to the excise tax… yet. I remain sad about the lack of public option, no Medicare buy-in, and the fact that we still won’t be even dragging ourselves into the 20th century compared to healthcare coverage in other countries.
General Winfield Stuck
@cyntax:
You got it.
Will
Not as big a problem as the Democrats will have once those 30 million regular voters figure this out.
charlequin
@jenniebee: You’re correct about rents but not correct about how it analogizes with the Cadillac limit.
The mortgage interest deductions don’t reduce rent because they only affect one half of the equation: the cost of owning a rental property. They don’t provide a discount specifically for renting the property (compared to other uses) or decrease the quantity of renters relative to available dwellings so they can be (and are) pocketed directly by the landlords.
The policy under discussion here affects a more complex negotiation — total compensation paid to employees — and has several different effects:
* It reduces the value to an employer of putting compensation money into insurance relative to other forms of compensation, by making each dollar spent on insurance above the cap equivalent to a salary dollar rather than a more efficient deal for the employer.
* It reduces the value to consumers of an employer-provided health plan because someone whose employer does not provide one can now purchase insurance on the exchange at a reasonable cost and even get subsidies to buy it, effectively increasing “supply” of insurance.
* It reduces the “lock-in” effect of insurance because people will now no longer suffer the potential long-term or permanent loss of access to health insurance by leaving a job; this makes all employees with health benefits more likely to switch jobs and thereby improves employees’ bargaining position against their employers.
Employers won’t become more free to just say “whoops, cut your benefits by $5k, nothing’s replacing that” than they are now; if an employer is paying for a $20k plan now, it’s because they weren’t able to negotiate a cheaper deal for themselves with their employees. That means that employers who make cuts like this will find themselves having to renegotiate — with employees who have received one excellent benefit (not having to depend on their employer to provide insurance if they want to have it at all) to help them.
If you want to analogize this back to the rent situation, imagine a situation where you could deduct the cost of paying utilities for a rental apartment but not the mortgage or maintenance; it’d push landlords into raising rents then bundling as many utilities (even those people didn’t necessarily need or want like excessive cable packages) as they could into their rental agreements. Capping this subsidy at a dollar level would mean less people getting forced into paying for Super XL Cable just to rent an apartment rather than people suddenly paying the same rent but getting their utilities turned off.
Martin
Isn’t that the truth. I’ve got 15 years in, and even though I could earn 2x as much elsewhere, I won’t leave because I know that this job will still exist 20 years from now and so long as I keep doing my part, I’ll still have it and the benefits that come from it. Anywhere else and who knows what will happen with my insurance, pension, and so on. A friend of mine is on his 4th job after his previous 3 companies were taken over and his job eliminated. He’s stayed roughly evenly with me because even though he earns a lot more, he spends 6 months unemployed for every 12 months he actually works.
eemom
Terms that need to be banned from political discourse, part 2:
Strawman.
God, I am sick of that one.
Besides, it’s insulting to REAL strawmen, like Scarecrow in The Wizard of Oz.
scudbucket
@Tom Hilton: Most maddening of all are the people who see it as a reason to kill the whole bill
No. This, I think, is incorrect. Let’s not use ‘kill the bill’ terminology. Some people see a) the policy problems with this bill, one of which (but only one) is that there is a 40% tax on 20% of the people which may be odious to those bearing that burden, but more importantly it’s also unsustainable and undermines the subsidy mechanism for the poor; and b) that the bill is really bad politics, since there are far too many clubs and not enough carrots contained in it.
Bruce (formerly Steve S.)
Goddamn this is tedious.
Sell that to the 30 million voters. Go ahead. Take your time.
Tom Hilton
@charlequin: Nice, clear analysis. Well done.
Bruce (formerly Steve S.)
The simplest way to get rid of it is for dishonest people to stop using it.
Will
As I’ve noted before, it’s not just going to be the 30 million haves versus the 30 million have nots. A good number of those have nots won’t qualify for a 100 percent subsidy and aren’t going to be too pleased about losing up to a month’s income to pay for a plan with high deductibles.
Of course, they can take the fine. Voters just love being fined.
scudbucket
@Will: This.
Mary
I’d be careful in saying you find merit in the position of the firebaggers, DougJ, even tangentially. Because by tomorrow, they will have you on the list of people who support them in “killing the bill.” Ten days ago, they were citing John Cole as in their camp. They are profoundly dishonest and they are desperate for support in liberal circles.
Ailuridae
@scudbucket:
There is not a 40% tax on 20% of the people in any substantial way. There is a 40% tax on insurance premiums paid by employers over 23K per family.
I understand and am sympathetic to the argument that this is difficult politics. But as a matter of policy its a very good solution and at some point problems need to be solved.
I would also like to see an increase on top earner marginal tax rates but that has to pass through reconciliation (separately) as there aren’t the requisite 60 votes for it.
General Winfield Stuck
Yep, that’s right. Dems are going to pass a final bill that will destroy them at the ballot box.
If they end up being that dumb, and I am sure they are not, but if they are, then I will say they do not deserve to be the majority in the first place. Consider that circle squared.
The Raven
We are all teabaggers now. (The original quote seems to have been mangled.)
Croak!
Martin
@Will: But we currently deny millions routine care by leaving them without any insurance.
I know the liberal dream is Star Trek where anyone can get whizzed by the tricorder on the way to the bar and have that minor fever diagnosed as Venusian Meningitis and treated just as easily, but no nation can afford unlimited health care.
Somewhere an acceptable middle needs to be reached, and people like me who can walk in and get poked for any reason for $0 out of pocket aren’t worth preserving if others can’t get cancer treatment. My coverage simply has to get worse and perhaps we need to get more educated, or we need to develop more in-home tests, or we have to accept that people that decide to forgo the $100 for the bleeding mole are going to have to live with the consequence of inoperable stage 4 skin cancer. The safety net can’t protect people from making bad decisions. But at the same time we shouldn’t as a society accept that some people are medically disposable simply because they lost their job. An acceptable middle needs to be reached, and yes, we do want early treatment, but there are other ways of doing. And yes, we don’t want $50 copays for every OB visit, but there are other ways of handling that as well without opening the door to free weekly chats with your dermatologist.
What we have now is some people with great health care and some with none. The goal is going to have to be acceptably good health care for everyone, and great for those willing to pay a whole lot for it.
Ailuridae
@C. Gallagher:
I’m in your boat. I would have liked to be able to buy into a public option or Medicare both from the stand point of being economically secure and a responsible citizen.
There’s the separate issue that the self-empoyed, broadly, get fucked by the tax code and health insurance is another example.
The Other Steve
Since when is capping the deductibility a TAX?
Morons.
jwb
@Comrade Luke: Unless you’ve got 60 senators, you’ve got nothing.
Tom Hilton
@scudbucket: There are, in fact, ‘progressives’ who want to see the whole package (absent a bunch of modifications that aren’t going to be made and if they were made would guarantee defeat) voted down. I’m not inventing those people; they actually exist. Sadly, they aren’t even limited to poor idiot Jane “blackface Lieberman” Hamsher–there are actually other people who feel that way.
Anyway–it isn’t “a 40% tax on 20% of the people”; it isn’t a 40% tax on anyone. It isn’t even a 40% tax on anyone’s benefits.
And no, the funding mechanism isn’t unsustainable. As has been explained to you before, it moves money from non-taxable to taxable status; the money is taxable, whether the employers pay it to insurers or keep it or pass it on to their employees.
Tomlinson
@General Winfield Stuck:
This. Exactly this. I fully expect that whatever they pass, it will be politically defensible, if not a huge win.
If it ain’t, as noted, they deserve to go down in flames. And they will.
inkadu
@les: There’s always this awkward moment on Balloon Juice where the conversation has really moved on and I’ve finally gotten around to replying but someone has already made the points I would have made had I a basic command of the facts. So… re: mortgage deduction: @ what Charlequin said.
Will
Every other Western nation does a pretty good job of it. I know we live in Island America, but the rest of the developed world has circled that square. This is why they have much, much cheaper health care.
They do it in a lot of different ways, but some prime methods included emphasizing primary care and early detection, promoting healthy lifestyles, eliminating the profit motive, standardizing the cost of care, standardizing treatment and subsidizing the education of doctors and other medical professionals.
This bill does none of this. It substitutes dishonest accounting for genuine solutions.
Shawn in ShowMe
@Will
Roughly what number of that 30 million will be in this position, based on your calculations?
General Winfield Stuck
@Tom Hilton:
I am fairly certain scudbucket has called for killing the bill on this blog in other threads, as has a number of others. He can correct me if I am wrong, and then I will be corrected.
Will
Who the fuck knows? How many freelancers, construction workers, farm workers, adjunct teachers and other part-timers and self-employed people are there in America? How many make more than the 100 percent subsidy? How many can afford to forego a month’s pay?
I’m guessing it’s not zero. If it’s more than a million, we’ve got a problem.
Dannie22
Let me get this straight. You want healthcare like the French, but you don’t want to pay taxes. Okay. I get it now
Will
I’d love to have health care like the French, and I’d be willing to pay taxes on that. This ain’t that.
inkadu
@Martin: The United States does not have any truly hard choices to make in terms of costs and care. Any of the perfectly competent health care systems in the developed world manage universal care at a fraction of the cost WITH free primary care. Maybe when the United States is really up against the wall financially and medical inflation has risen to a certain point, your concerns will be significant. But right now, the United States has the money, just not the politics.
Bruce (formerly Steve S.)
Which is why I expect that some Dems will work to get a few tiny little goodies thrown into it in conference. Other Dems, like Liebernelson and Rahmbama, don’t give a shit because they aren’t up for election anytime soon. Some Dems are in safe races. Some Dems are in conservative districts. The battle will be between these factions.
Shawn in ShowMe
@Will
Other Western nations also pay their doctors a whole lot less and charge a whole lot less for lab and radiology services. That has diddly squat to do with insurance and everything to do with what healthcare providers charge. Yeah, insurance costs need to be reined in but if you’re looking to make the greatest impact cutting physician/lab/test costs should be first on your list.
jwb
@jenniebee:
Ah, no. The point is to put a brake on health care spending, not to eliminate comprehensive coverage. I see nothing in the bill that requires this solution. I see nothing the requires higher copays or deductibles. The easiest way to achieve those savings might turn out to be eliminating comprehensive coverage and raising copays and deductibles, but that’s quite different thing (and I for one don’t see that solution as inevitable). And if it turns out that actual care is priced out of range for most people, the politicians will get a bloody earful and you can bet your bottom dollar that they’ll find a fix for it.
jenniebee
@charlequin:
Not sure that I was trying to analogize it with health care, but what I suspect will happen is that when employers eliminate health insurance benefits they may raise wages slightly because employees’ perception is that it is expected that they should, but they may not and cite it as a “new industry standard” not to offer benefits. The amount they raise wages will probably be on a curve, as the employer’s annual turnover rate goes up the amount of the raise will approach zero, but nobody’s going to get as much as it would cost the employer to insure them that year.
With the rental question, it’s just a pet peeve of mine when people express the idea that price is directly related to costs and that a drop in costs necessitates a drop in price. That landlord may take the tax savings and use it to become more competitive, if he isn’t already selling all his units at the current price, but if he is already selling to capacity, why should he lower his prices? If you’re lowering your prices because you can’t sell out at the price you were listing then you aren’t lowering them because your costs dropped, you’re lowering them because of supply and demand pressures.
Tomlinson
@inkadu:
Sure, once we (a) break the AMA and drop the standard of living for all doctors by a huge amount (50%?), (b) kill off the health insurance industry, (c) get big pharma to sell at the same rates it sells for elsewhere and (d) enact tort reform.
At least. I’m sure I’ve missed quite a bit in there.
So, while I agree with you and you are probably right, this is magical thinking of a truly awe-inspiring scale.
Will
Just looked it up. The French pay $3,300 per year for pretty much unlimited coverage, with no copays, deductibles or bankruptcy. And the poor pay nothing.
My employer pays $8,000 for much less than that coverage. If I was married, I’d have to pay an additional $500 per month to put my wife on my plan.
I’d take the French system. There would be a cost, but I’d never have to worry about bankruptcy.
Pretending that this bill is anything comparable is just foolish.
Will
This bill does nothing to address this. And, no, backhanded spreadsheet theorizing about the ultimate effects of the bill aren’t the same thing. If economist models were anything near reliable, we’d all be talking about how we’re spending our share of DOW 36,000.
charlequin
And just to follow up before les comes back to disagree with me, the key element distinguishing the mortgage deduction is that buying a house has a huge upfront cost, so huge that the level of this cost dwarfs all other factors in determining the rate of home ownership. If people could freely move from renting to owning then I agree that it would create pressure on landlords to pass portions of their deduction savings back to their renters, but in our current market the vast majority of renters are either permanently (due to low income) or temporarily (due to not yet having acquired the capital) unable to become owners and therefore landlords can effectively keep more of their tax deduction benefit for themselves.
Scott H
@EdTheRed: Many years ago, the word “feckless” showed up on the ACT. I spent the rest of the test humming “Rudy Can’t Fail”.
Will
I’m just old enough to remember the intra-party NAFTA fight among Democrats. This is a mirror of that fight.
The left was up in arms because of the jobs being lost. The moderates and technocrats were patting them on the heads for being naive, while crowing about all the gains that Americans would reap from the free trade and the coming Information Economy.
I believed the technocrats then. I’m a lot more skeptical now.
Shawn in ShowMe
If you don’t qualify for a generous subsidy then you’re probably making over 50K a year. In other words you’re taking home about $3000 a month. What’s this about foregoing a month’s salary again? How much do you think health insurance should cost per year?
Ailuridae
@Will:
A huge portion of those costs you list are because of the very, very high incomes of doctors in America, especially specialists. For some reason, you keep ignoring that.
jwb
@scudbucket: Actually, at this point it’s not clear to me that the optics of killing the bill are any better than the optics of passing the bill. The short-term politics don’t look particularly good for the Dems either way, so I think you have to throw out the argument that the goopers are going to be all over the Dems for mandates or cadillac taxes. If they don’t pass it, we’ll just hear about how incompetent the Dems are, how they aren’t really fit to govern, yadda, yadda, yadda. So at that point it really comes down to the bill itself. Is the status quo on health care better than this bill? Because I think if the bill goes down, you are looking at a minimum of five years before it will be taken up again—only then if there is a serious crisis—and the political environment is really not likely to be any better then than now.
inkadu
@Tomlinson: Hey, I didn’t say it would be easy, but I meant “hard choices” in terms of ethical, the-good-of-the-many, life-and-death nail biters.
“Should we let people die without care, or should we cut the pay of cardiac surgeons to a measly $250,000?” is not a hard choice.
We are the richest nation in the world spending more money than anyone on health care. Life boat ethics are premature.
Ailuridae
@Will:
When did the CBO or any reputable analyst suggest DOW 36000? Of wait, they didn’t.
You should start arguing in good faith as a change of pace.
jenniebee
@jwb:
The first is the end, the second is the means. Is it possible that this is the first you’ve heard of the theory that the reason America’s health care costs are so high is that
peopleunion members with “platinum plans” ruin it for everybody else by using up too much health care for themselves?No, just a 40% tax that penalizes plans that have low copays and deductibles at the expense of higher premiums.
To you it’s a bug, to them it’s a feature.
arguingwithsignposts
@Will:
And that worked out well for us.
Will
Well, I put my old salary and data in the Kaiser engine. The Senate plan would have cost me a month’s take home pay, the House slightly less.
I was making $18,500 a year. Once you subtracted my expenses – rent, bills, food, etc. – I didn’t have that much left over.
J. Michael Neal
@Will:
This is why you need to read the whole fucking bill, and not cherry pick. There are a huge number of moving parts here, and if you pull one out and criticize it by itself, sure, you can make it look ridiculous. Of course, you do that by being ridiculous yourself.
So, let’s say that businesses react rationally to this, and slowly get out of the position of providing health insurance to their employees. That would, in the long run, be a good thing. In addition to getting rid of the gross inefficiency that is employer provided health care, it sends individuals to the exchanges.
This is the part where you have to read about more than your outrage du jour. Once someone is on the exchange, there are certain things that policies must provide. One of them is cheap preventative care. The exact thing that you are screeching about is already covered.
Maybe the people who are policy wonks, like Ezra Klein, who you keep insulting, have actually thought about this. Maybe they have already recognized your objection, and made sure that the bill does something about it. Maybe there is actually some value to developing real expertise on a subject, and maybe, if there is pretty much complete agreement among the people who have done so as to what the effects are likely to be, then folks ought to stop and take note of what they are saying.
Unless, of course, it’s part of your nefarious plan to be just as idiotic as the teabaggers, who don’t stop to listen to consensus opinion among experts, either.
General Winfield Stuck
@Comrade Luke:
And a sorry to Comrade Luke for not qualifying this remark as a general one to those who want to kill the bill, as he didn’t say this in his comment to me.@General Winfield Stuck:
scudbucket
@Tom Hilton: @Tom Hilton: And no, the funding mechanism isn’t unsustainable. As has been explained to you before, it moves money from non-taxable to taxable status; the money is taxable, whether the employers pay it to insurers or keep it or pass it on to their employees.
I seem to get conflicting stories on this, your take and that of the insurance industry : “New Survey: ‘Cadillac Tax’ Would Force Employers To Trim Health Insurance Costs” and PriceWaterhouseCoopers: “We expect employers to respond to the tax by restructuring their benefits to avoid it.”
inkadu
@Will: One thing never brought up about other, more centrally managed systems, is record keeping. You can log onto to a canadian government website and see a breakdown of costs, treatments and outcomes for every province that covers every patient and every medical transaction. If you want to know what works, you need information that is hard to come by in our patchwork jumble.
Tomlinson
@Will:
So would I, in a heartbeat. But that’s not on the menu, nor is it likely to be any time soon. So we have to start somewhere, and expanding coverage, fixing a lot of the obvious abuses, putting mandate in place – all of those are worth starts. Never mind the clinics and the 30 million new people with coverage.
The joke about dotComs was that they all had the same model.
Step1: Do Something
Step2: Poof! A miracle happens!
Step3: Profit!
It seems to me as if a lot of the left thinks HCR happens like this:
Step1: Elect HopeyChangeyGuy
Step2: Poof! A Miracle happens!
Step3: [Insert other country of choice here] healthcare!
Sort of ignoring the MASSIVE constituencies and disruption required somewhere around step 2. Never mind the reps and conservadems.
J. Michael Neal
@Will:
I would, too. If you have the slightest idea how to pass it, please explain. I expect to be waiting a while, because the idea that there is more than a 0% chance of the French system getting through Congress is a fantasy.
In the meantime, what do you propose doing? If your approach is single-payer or nothing, we’re going to get nothing.
If you would like to criticize this bill relative to something that’s actually achievable, go ahead. It would be a much better discussion.
Will
Projections aren’t reality. They are projections.
This is especially true when there is mandated legislative mandate to influence the behavior assumed in those projections. They are assuming a certain set of circumstances will happen – i.e. that the system will respond rationally to market pressures and do the hard work that the political system does not have the will to do.
That might happen. Or the system may put the screws on patients and keep pocketing the cash. Or they may get bankers to create Super Special Financial Instruments to keep the cash flowing. Your guess – and the CBOs – is as good as mine.
Martin
@inkadu: There’s one hard choice that nobody is owning up to. Let’s say that we cut our costs by 50% to bring it inline with France’s. What happens to the $1.2T in domestic spending that we’ve just wiped out? That’s half the GDP of France, to put it in perspective that represents about 1/12th of every dollar that is earned in this country. Just as retail consumption has been propping up our economy, so has health care consumption.
A great deal of those savings are going to come at the cost of jobs. Where do those workers go? Millions of them. And those salary cuts are going to create a new wave of housing and other problems. I’m not saying it shouldn’t be done, but that’s a really big fucking change to the US economy and it needs to be thought out and backstopped by something productive.
And it should also be pointed out that the other side of the equation in these other countries is that they do not possess the income disparity that exist in the US. Even if we got healthcare down to $16,000 for a family of 4, that’s higher than a full time gross salary for someone at the bottom of the income ladder. Corresponding to a proper realignment of how health care gets paid for needs to be a proper realignment of the income distribution itself.
And the French system only reimburses about 2/3 of most health care costs. The rest usually gets picked up from a suplemental policy that people buy out of pocket for the kinds of things I’m describing. I think if you did the math, you’d find that the French are paying more for health care out of their paycheck than most Americans with employer coverage are. For those without employer coverage, the French pay far less. And there’s nothing preventing a similar supplemental insurance system from operating in this country for the people that want to buy it.
But no country has a system as ‘free’ as some are making them out to be. Yes, they’re all better than ours, but they all have various means of controlling costs that either come at a cost or inconvenience to the individual.
scudbucket
@General Winfield Stuck: No, General, you’re right: I’ve said that. I believe this bill is bad policy, and really bad politics. I believe we’re better off without it.
jwb
@Will: Just tell me how you get 60 votes for something that is acceptable to you. What is your alternative if you can’t get 60 votes? Do you really believe the progressive Dems will be in any better position after 2010 if they don’t pass something now? That’s the political calculus staring at you.
Recall
Compare the relative costs of three days of Tamiflu versus two weeks on a respirator in the ICU ward.
It’s this line of thinking that has gotten us in this mess in the first place. The point of a health care system is to deliver health care. People going to the doctor for illness is the whole fucking point.
Will
This American Life did a great show on health care reform that included a segment that examined why the State of Maryland was not having as large a problem as the rest of the nation. A major reason is that the state regulates the cost of every procedure for every patient at every hospital.
I’ve been following the health care debate. Some of the best ideas – primary care centers, computerized records – made it through the legislative grinder, but the majority of the ways that could control costs didn’t.
Instead, we have accounting tricks. Our resident accountants love them, but I’ve learned to have less faith in the wisdom of the market.
scudbucket
@jwb: If they don’t pass it, we’ll just hear about how incompetent the Dems are, how they aren’t really fit to govern, yadda, yadda, yadda. So at that point it really comes down to the bill itself.
Yes, we’re gonna here from the other side no matter what. It’s our side, and independents, that I worry about. And without anything to show other than bad insurance at the other end of the legal gun, there will be a mass exodus from the polls.
Will
Sometimes you fail. I’m coming to the conclusion that the Democrats have just failed. If I’m right, I’ll huddle in my safe state job and try to weather the next Republican decade and hope for something better next time.
geg6
I’ve already stated my case on this numerous times as a person who will be directly affected and who can’t even afford to take advantage of my “Cadillac” plan (haven’t seen a doctor in over 5 years) because I can’t afford the co-pays that everyone thinks are so low and easily payable because apparently I’m so well-paid (and yes, that is deep snark). DougJ and Bob Herbert are exactly right on the politics of this. It will kill the Dems with a large swath of voters. And Ezra lives in the same dream world this bill does if he actually thinks employers will be handing out big raises to the employees who will be getting even crappier health care. Most voters don’t give a rat’s ass if the progressive dreams of the Democratic Party are coming to fruition if they see their health bennies getting shittier and their salaries staying flat. Where many middle income and union workers people live, the real world, this is guaranteed to infuriate them, all your progressive talking points and big picture policy nowithstanding. I know it pisses me off, and I understand the theories underlying it. I’d just like to see all the people explaining how great this is in such wonky fashion come up with a way to make the argument politically palitible. If I’m not buying it, you have no chance whatsoever with my neighbors and co-workers.
Will
Maybe I’m cynical, but my faith in businesses automatically reacting rationally to market pressures has lessened a bit in recent years.
jwb
@jenniebee: “No, just a 40% tax that penalizes plans that have low copays and deductibles at the expense of higher premiums.”
No, there is no 40% tax on “plans that have low copays and deductibles,” only on plans with high premiums. The two things need not go hand in hand (if, for instance, a plan could figure out how to control costs without requiring high copays and deductibles).
J. Michael Neal
@Bruce (formerly Steve S.):
If they’ll give me the time, sure. That’s the problem. There is no solution to this problem that:
1) Would work;
2) Could conceivably pass Congress, and;
3) Can be explained within the average voter’s attention span
On top of that, there aren’t any solutions, even the cherished single-payer systems, that aren’t going to be a net negative for some middle income people relative to what they have now. If it is your demand that no one have to give up anything that they have now, then you are arguing that we shouldn’t have any health care reform of ANY type. Good or bad.
Take the French system that Will keeps pushing. One of the primary reasons that they can do it for so much less money is because they use a lot less health care. It isn’t all about more efficient delivery. They just go to the doctor less often than we do, and demand less from the doctor when they do go.
Some of this is because they demand a lot less end of life care than Americans do. Part of it is because they live overall healthier lifestyles than Americans do, and need less health care. If you do not get Americans to accept those changes, which they would see as taking something away from them, then a French style system wouldn’t work at all like it does for the French. In my view, it would still be the best option for reform, but, even if it could pass Congress, don’t believe for a second that it would mean that we get French quality care for French level prices, and no one has to give up anything they already have.
scudbucket
@Tom Hilton: And no, the funding mechanism isn’t unsustainable. As has been explained to you before, it moves money from non-taxable to taxable status; the money is taxable, whether the employers pay it to insurers or keep it or pass it on to their employees.
I seem to get conflicting stories on this, your take and that of the insurance industry : “New Survey: ‘Cadillac Tax’ Would Force Employers To Trim Health Insurance Costs” and PriceWaterhouseCoopers: “We expect employers to respond to the tax by restructuring their benefits to avoid it.”
(This is a repost, without the links, cuz the other got stuck in moderation.)
Edit: the insurance company quoted is Kaiser.
Ailuridae
@Will:
No, dumbass, your guess isn’t as good as mine or the CBOs. You demonstrate your lack of understanding about the issue by comparing CBO projections to the work of hack authors like Glassman and Hackett. Now, what they wrote was fucking stupid and in that sense you all have a lot in common. But if you want to criticize the CBO projections on this health care bill (or any of the many independent economists also suggesting that the excise tax is very sound policy) you should show a time when they were demonstrably as wrong as DOW 36000. What’s more, you should show thats a trend.
In reality, the CBO does a really good job with their projections and has done an excellent job with their projections on costs for huge ticket health care issues (original S-SCHIP, Medicare Part D). Those are, unfortunately for you, rather inconvenient facts.
jenniebee
@jwb:
Fix’d
Tomlinson
@J. Michael Neal:
I’m really not sure about *any* of those assertions. Got data to back them up?
inkadu
@Martin: Martin, you make very good points, but the post I was replying to was about the hard choices involved in spending extremely limited health-care dollars. Should we let someone’s skin cancer go undiagnosed because we just don’t have the money for instance.
Should we decimate the paper-pushing industry to give people universal access to health care? That’s a different kind of question. I’m inclined to say, “yes,” because people will always need health care, but people handling insurance forms can get different jobs, and if they can’t, they’ll at least still have their health care.
charlequin
@jenniebee:
I think this really takes an overly pessimistic view on the bargaining power of employees, though. People didn’t get Cadillac health plans because employers were feeling generous; they got them because in negotiating for compensation (either together as part of a union, or diffusely through numerous individual salary negotiations) employees were able to extract a certain amount of compensation, and employers and employees both agreed that it was better to get the government to pick up part of the tab by spending a large portion of that compensation on health benefits than to pay it out directly and get taxed.
If the underlying fundamentals for employee compensation negotiation are equivalent or better in 2013 than they were whenever these plans were negotiated originally (and I do think that by making people less dependent on their job for insurance this bill makes them better) then people will just demand more cash salary and saying “well we have to pay you less” isn’t going to actually reduce what people can extract.
If this was a policy change that really affected low-end white collar workers (i.e. people who aren’t personally in demand but don’t have unions to represent them) I’d be more likely to believe that this would be an effective excuse to push through salary cuts, but by definition it’s going to primarily hit either professionals who negotiated effectively for themselves or people represented by unions that will be using records of their last negotiation session as evidence against the “well it’s just standard now” argument.
Yeah, I do sympathize with this peeve. Free market gospel tends to drastically underestimate inelasticities and inefficiencies even though they have a much larger effect on how a market plays out in practice and the mortgage interest deduction strikes me as a good example of a case where they significantly change the effect of a policy.
Recall
Again, this is not a variable that is beyond our control. Easy hassle-free access to healthcare results in a healthier population and lower overall healthcare costs.
General Winfield Stuck
@geg6:
I will try to give you some counterbalance to the pol downside you state, which I do not totally disagree with. There is going to be pain for some and relief for others, and that would be true no matter what the bill is, or could have been.
First, as I understand it, many or most of the new regs will go into effect immediately. Things like ban on rejection for pre-existing conditions, and others.
And it is hard for me to swallow the great windfall of profits from the mandated new customers for the insurance companies with the requirement they use 80 to 90 percent of premiums to go to actual health care services. And also, on the whole, how that is going to cost more while at the same time lowering quality of care.
Will
Ailuridae,
Nothing says “arguing in good faith” like calling people dumbass.
Look, the plan sucks. Everyone except maybe you thinks the plan sucks, which is why we’re at the stage where supporters are demanding critics figure out how to get past the votes for something better.
And, honestly, the CBO score isn’t exactly rosy.
Martin
@Will:
You’re wrong. You need to read more carefully. For people with one of 30 conditions, they get 100% coverage. For everyone else, the system pays about 2/3 of costs and they have copays. So the French pay $3900 (as of last year) for care. That’s much lower than the US, but it’s not free. Most people have supplemental policies that they pay out-of-pocket. They pay copays out-of-pocket which are typically higher than what we see in the U.S.
Further, the insurers in France aren’t the government – they’re corporations little different from Blue Cross/Blue Shield franchises in the U.S. They’re much more heavily regulated, but those that are demanding that not be mandated to pay to a private corporation needs to stop looking at France, because they do precisely that.
And it’s also worth observing that the French health care costs are increasing at a rate not substantially lower than the U.S. They haven’t solved the whole problem, just a big chunk of it.
Will
And I’m not pushing the French system. Some jackass made the comment that we all want the French system without paying taxes, and I responded that this isn’t the French system.
Look, this plan is so wonderful it has Democrats at each other’s throats before the thing is even passed. When the public gets a good look at this thing…
Well, that’s how realignment happens.
The Raven
@Will:
Keep in mind, too, that the Kaiser engine only reflects current prices. There’s every reason to expect insurance companies to raise prices before the plan kicks in.
Shell Goddamnit
EdtheRed & Scott H
Many many years ago I worked at a local big-box chain – imagine my dismay when I found “Lost in the Supermarket” was on the music tape loop.
Until I realized that the Clash probly took the tune from some grocery store tape loop & put their words to it in the first place. Imagine that, “traditional” supermarket music.
I can no longer shop happily
I came in here for a special offer
guaranteed personality
inkadu
@Will: The State of Maryland regulates the cost of procedures? That can’t be right.
@J. Michael Neal: Multiple Choice Question:
– Eye surgery in France costs half what it does in the United States because:
(a) The French have a more efficient delivery system.
(b) The French don’t mind being blind as much as Americans
(c) John Galt can drive my car.
(d) Red wine is good for your heart.
General Winfield Stuck
@Will:
Funny, I don’t see much of that in congress, or from so called progressives in congress. They have some gripes and will try to get changes made in conference, but I have not heard many say unless they get their way, they will vote no. Or try an scuttle the end product. that will be made from the existing two versions we now have.
Now in the senate, the calculus is different with the filibuster and a few blue dog dems have everyone by the short hairs, and they know it.
Most of the uncompromising rhetoric against the bill as it is, which actually isn’t quite yet, is coming from the netroots. Even people like Krugman and Dean aren’t drawing lines in the sand for killing this bill.
Your sphere of dissent or rejection is not what you think it is.
Will
And they, like the Swiss, regulate the shit out of them. We aren’t going to do that.
Look, my point is that there are a whole host of solutions for how we could reduce the cost of medical care, increase access, etc. For political reasons, we can’t actually do any of them.
So, we fail. The Democrats get to score a victory, which will last just as long as people start to see just how much this victory is going to cost them personally. At which point, all the technocrats get a lesson in how democracies actually work.
Seriously, this plan is polling at 40 percent approval before the details get out. I’m not seeing much love for it here. Hell, even a good number of the supporters here don’t like it, but are mandating conformity for the sake of the Party.
Ailuridae
@Will:
I called you a dumbass because you suggested all methods of economic forecasting were equally unpredictable. That’s just fucking stupid.
And, no, I am not the only person who is in favor of the plan. Most everyone on the left thinks its worth passing and improving on and nearly every health economist in the fucking country thinks that the excise tax is a necessary step and it will also help long term wage growth. The excise tax which you have insisted without any basis will suddenly force all collectively bargained contracts to be negotiated by stupid people apparently.
DonBelacquaDelPurgatorio
If this has appeared in quoted or linked form before on the thread, then I will, you know, spend time in Purgatory as required for the sin of laziness. But this fellow at GOS says it pretty well for me, and that same laziness therefore compels me to just quote him and let his words do my work.
____
I’m not either.
Will
inkadu,
Listen to the story at the link. There’s a state board that gets together, sets the price of procedures and every doctor and hospital has to follow. Apparently, it works.
Dannie22
@will.
Spare me. You won’t pony up a few extra dollars to pay for the improvements to our healthcare system, there’s no way on heaven or earth you would pay for a French system. That’s the point. When it’s time to pay, nobody wants their taxes raised, least of all you bub
Tomlinson
@Will:
Yes, it is polling at 40% while under continual attack from the right, much of it completely over the top. I expect that, once it is actually explained, it will poll well. Here’s the core:
– For most of the country (85%+), it doesn’t change what you have now.
– It ends some seriously nasty practices that nobody likes
– It extends coverage to 30 million more people
– It adds a huge number of new community clinics
– And it cuts the deficit
That’s how it sells. And it should sell damn well.
Ailuridae
@inkadu:
(e) A French Opthamologist makes less than 1/2 what a US opthamologist makes.
http://www.businessweek.com/magazine/content/07_28/b4042070.htm
To make all this affordable, France reimburses its doctors at a far lower rate than U.S. physicians would accept. However, French doctors don’t have to pay back their crushing student loans because medical school is paid for by the state, and malpractice insurance premiums are a tiny fraction of the $55,000 a year and up that many U.S. doctors pay. That $55,000 equals the average yearly net income for French doctors, a third of what their American counterparts earn. Then again, the French government pays two-thirds of the social security tax for most French physicians—a tax that’s typically 40% of income.
Martin
@inkadu:
Nobody is proposing leaving conditions undiagnosed, but the U.S. has 50% more doctor consultations per capita than France does (and France is still fee-for-service). And that’s with 47 million uninsured in this country and effectively none in France. Imagine how much higher we would be if all of those people could go to the doctor for $10?
If we’re going to covet the French model, then we need to accept that some deterrence for going to the doctor (by whatever mechanism) is part of the deal. We’re almost 2x as high as the UK. Canada is in between.
Trust me when I say there are a LOT of unnecessary doctor visits in this country. If they come out-of-pocket, that’s fine. That’s the marketplace at work. But if they are coming as part of your insurance policy that others might be subsidizing, I have a problem with that, and I don’t mind taxing those that are going unnecessarily – after all, if you pay out of pocket we’ve already taxed your income, why not tax your benefit if you’re doing precisely the same thing? Or, why don’t we just encourage employers to drop those parts of the policies to avoid the taxation and have people either pay out of pocket for the extra visits or pick up a supplemental policy? Oh, look we’re back in France again yet a lot of people are unhappy with how we got here this time.
Will and some others are refusing to accept that the world is a dynamic place. One of the benefits of the mandate is that millions of people that qualify for Medicaid but either don’t know or are too embarrassed to sign up will now find it and sign up. Problem solved! It was always solved, but we couldn’t get citizens to the solution. One of the benefits of the deduction limit is that insurance policies will become much more uniform. I guarantee that as soon as the bill passes, every insurance company in the nation will in weeks have drawn up a menu of policies that can be had for just pennies below the deduction limit for employers to choose from. Uniformity will help the insurers put pressure on costs. It won’t help a whole lot, but it’ll help some.
Will
The bill is already polling at 40 percent popularity. We’re not a representative sample, I know, but the reactions among Democrats here has not exactly been cheering in the aisles. And as much as people want to pretend that we’re all secret PUMAs who were lying in wait to sabotage Obama all this time, I suspect we’re talking about a schism among people who were all very excited to see a new president and Democratic majority.
When the details of your plan cause widespread dissent among your supporters, that does not bode well for the reception among the public. I can’t predict the future and maybe I’ll look stupid a couple years from now after the public have voted out every Republican up for office.
charlequin
@The Raven:
Well, except that any company who raises prices between now and 2013 is barred from the huge influx of new customers in the exchange.
J. Michael Neal
@inkadu:
e) When I said that part of the reason that French health care is cheaper than it is in the US is because the French have lower demand, I did not say that *all* of the reason that it’s cheaper is because they have lower demand. My apologies for assuming that you aren’t an idiot and could tell the difference between “some” and “all.”
Will
This does not improve our health care system. That’s the problem. It’s a paper fix and mostly serves as a symptom of our political structures inability to honestly tackle hard problems.
inkadu
@Will: 40% of the public is not going to like any big, complicated government plan just on the merits that it’s a complicated government plan. People don’t like change. But I agree with your analysis for the most part (we are increasing access by the most pigheaded way imaginable).
DonBelacquaDelPurgatorio
This may be a repost made necessary by the shittiest website on the intertrons, namely this one, but ….
That 40 percent is purely a Piss On My Leg and Tell Me It’s Raining piece of rehtoric. Probably not even 3 percent of those poll respondents have any idea what they are actually “approving.” No idea of the true nature of the two measures that will go to conference. And like us, no way to predict what final bill will emerge from that conference.
It means not just nothing, but less than nothing. Quit pimping it as if it is important, it’s not. It’s really about the hideous process going on on Capitol Hill, not about the details of any particular bills. It’s about the ugly and scary and dismaying nature of legislation in a contentious political atmosphere.
Tomlinson
@Will:
You know, I see this statement a lot. And I just want to point out that it completely and utterly misses the point.
The problem is not the political structure, it’s the general population. The general population elects these dipshits, out of ignorance (willful or otherwise) and keeps them elected.
Sames goes for the media, BTW.
Will
And this is also true. We have become, as a nation, amazingly resistant to change.
But I honestly do not think that the Democrats are going to be able to sell this plan. And the fact that their plan for 2010 is to run on it really worries me. I do not want the Republicans to come back into power.
DonBelacquaDelPurgatorio
I
Well then, you have certainly found your blog home, and maybe there is hope for you yet.
General Winfield Stuck
@Will:
I was called and rightly so from using these types of rhetorical divisive comments in this fine thread. You ought to do the same. And as far as the polling goes, like Tomlinson said, folks don’t really understand what is going on, and it is the Holiday season and not ideal for polling on wonky debates over health care.
And we do have a electoral reference point for dems failing to live up to efforts and predictions for passing HCR. It was in The Year of Our Lard, nineteen and ninety four.
Will
Or maybe I’m right.
Tom Hilton
@General Winfield Stuck:
It’s almost as if the progressives who are actually responsible for–what is the word?–oh yeah, governing–are willing to accept substantial compromises in order to achieve something.
Shame on them.
DonBelacquaDelPurgatorio
@Will:
I’m so confused. Am I supposed to be cowering in the face of terrorism right now, or cowering in the face of the mighty Republican threat?
Being a Democrat is so scary, I have to wear a double diaper.
jenniebee
@charlequin:
I think this really takes an overly pessimistic view on the bargaining power of employees, though.
At the point at which individuals can get a better deal through the exchanges than a business can get negotiating with insurance companies, and that should happen sooner for small businesses, later for larger ones, I think you’ll see some cases where there’s a wage increase that lets both sides come out ahead. But I don’t think it’s terribly pessimistic that as more and more businesses stop offering employer-based insurance that the win for the employee will get less and less.
But my perception may be skewed – I live in a “right-to-work” state and the culture here is so strongly against employee organization that it’s a major achievement to get any information on what comparable skillsets go for in this market. A few years ago, I was at a job where I made almost 20% more than my immediate supervisor and neither of us knew it until after we’d both moved on to other companies.
Will
If I remember my history correctly, the massive advertising campaign scared the public into opposing health care reform. The Republicans ran, and won big, by running against health care reform.
All of this is speculation until two things happen:
The general public finds out what this bill will do for them and cost them (either honestly or via the distortions of the right wing).
We see the polls on how they feel about it.
Bruce (formerly Steve S.)
Funny how I can say this:
and it still doesn’t sink in with some. There must be a rule against using plain, straightforward language on Balloon Juice.
Go ahead. Tell them about how the public option, Medicare expansion, drug reimportation, a national exchange all got stripped out of the thing, but the “cadillac tax” got left in. See how they like that. Then lecture them about cost control and how they need to suck it up for the sake of the country.
DonBelacquaDelPurgatorio
@Will:
Maybe, but I seriously doubt it. The way you bandy that stupid 40% figure around this thread ……
The fact is, Dems’ fate rests on really one number in 2010 and again in 2012, and that is unemployment. If people are getting back to work and feeling better about the future, we will do well. If not, if it’s 2009 all over again, we won’t. Barring horrendous terrorist attack, a Katrina event, or some really stupid war, nothing else is going to matter that much.
DonBelacquaDelPurgatorio
Go ahead, tell them how the final bill hasn’t been written yet and we won’t know what it looks like until we know what it looks like. Which is going to take a little while.
Just go ahead. Really. Is that plain, straightforward language enough for you?
Recall
It will however, be blamed by employers as the reason for any cutbacks in their healthcare coverage.
The Raven
@Bruce (formerly Steve S.):
Bruce, they can’t hear it. Literally. There are many people who just can’t hear what they can’t imagine. It’s hard to imagine what the response is going to be when the mandates hit, and women start dying because of the abortion restrictions. When reality hits, well, (obscure comics reference alert:) by Odin, people will be Mighty Sore!
Hominids.
Croak!
Will
I’ll say this again and then bow out for the night.
I do not see how a bill that has split a wedge in people with a personal stake in supporting the Democratic Party will play well with the public at large. I may be wrong, but my every instinct screams that this thing is going to piss people off.
General Winfield Stuck
@Will:
The future is not yet written. You do the best you can with the compromise democracy affords, and don’t give up trying to make it better. This bill makes it better, imho, but with much more work to do to correct the shortcomings, which are not few.
I am willing to risk possible downside political consequences, for more people getting treated for health problems. Life is risky and it always will be. But you ought to be able to get the pill you need to stay alive, when you need it.
DonBelacquaDelPurgatorio
Heh. I don’t think there is anything easier in politics than getting Dems into an argument. About 2/3 of the comment inventory on this site is testimony to that fact. If you take out pets and the Steelers, it’s probably 75%.
Okay, take out wine, pets, Steelers, and What’s Your Favorite Breakfast Cereal posts, and it’s 90%.
Okay, I’ll stop.
jwb
@jenniebee: Maybe ponies, maybe not. Really you have no way of knowing.
Ailuridae
@DonBelacquaDelPurgatorio:
And, psst. That 40B Medicaid expansion that starts next year? That’s bascially a miniature stimulus package. And if somehow they jigger the numbers that every state gets the same treatment Nelson negotiated for NE its one of the better policy changes short-term and long-term in a generation. Note: I am not a subscriber to 11-D Chess
J. Michael Neal
@Tomlinson:
Healthy lifestyle:
Obesity Rates – US 30.6%, France 9.4%
Someone is going to point out that obesity has been found to have less impact on health than was thought. That’s true, but only if you control for other factors. Here, as much as anything, lower obesity rate is used as a proxy for a healthier diet and more exercise, which the French get.
I’m not coming up with many end of life care sources in a quick Google search, but there is this, regarding doctors’ approaches to certain situations. Unfortunately, it’s not very comprehensive, and France gets lumped in as a part of Central Europe.
inkadu
@Martin: Maybe the United States has more doctor visits because they can’t see specialists directly. Every trip to a specialist I’ve had had to go through my primary care doc first, instantly doubling the visits. France is also more lenient with what pharmacists can do, so going to the doctor just to get a prescription isn’t always necessary. But the issue isn’t to provide deterrence to doctor visits, but to provide lower cost alternatives.
I don’t really have my fingers on any research here, but the per-capita doctor visits seems to really odd. I know the world is a dynamic place, but going to the doctor sucks and I find it hard to believe anyone would go unless they had a good reason. I find it doubly hard to believe that it is the United States that has the most visits… I’d tend to think it has something to do with the inefficiency of delivery system than actual demand on the part of US health consumers.
@J. Michael Neal: Meh. You say culture plays a large role in controlling costs. But when it comes to procedure-by-procedure cost savings, it’s a hard case to make that the French are less demanding about care. There is an argument to be made that Americans spend money on procedures that give negligibly better outcomes. But that’s because the economics of the medical system is about driving costs UP, not because the patients are satisfied with a lower level of care. You are wrong on the merits.
DonBelacquaDelPurgatorio
@Ailuridae:
I’m not either, and your stim point is well taken.
I am a believer in Rope a Dope politics, though, and I have a funny feeling that we have been watching it all year. I’d bet another Five Spot that “Public Option” might have been a red flag used all year in a baroque play designed to confuse Republicans. And that Joe Lieberman was used as a heat shield, with his permission.
But, that’s just conjecture.
jwb
@Will: There’s a reason HCR hasn’t passed before now, you know. If HCR was easy, it would have been done long before now. People being at each others’ throats was bound to happen since there is a significant faction of the Democratic party who, for whatever reason, don’t want HCR, and among those who do want it there are several competing ideas about what is best. There’s also a huge amount of money involved, which gets everyone’s interest and makes everyone suspicious.
Bruce (formerly Steve S.)
Uh, that’s exactly my position, keep pressuring to improve the thing and don’t just acquiesce to the Senate bill. What made you think otherwise?
DonBelacquaDelPurgatorio
Well, I’m lazy, I don’t read all of long threads, and I like to piss people off. So I might have misread you. If we actually agree on something, all the better.
What’s really perfect is when I can totally piss somebody off and then totally agree with them. That’s what I call a Win-Win.
My public stoning will be held at a location near you very soon, I promise.
jwb
@Will: I can guarantee you that running away from the plan is not going to win the Dems seats—or stem their losses. I see their plan to run on HCR as hopeful—they’re professionals and the see an opportunity in the numbers or they wouldn’t be floating this idea.
Chuck Butcher
Let me see if I’ve got this right, you’re having a big debate about an exicise tax right after you got done celebrating taking a month wage out of the uninsured in order to reward them with a policy that will bankrupt them if they need to use it. What is it you think is left after you’ve yanked another month wage and incur a 10K hosipital bill with a 10K deductible?
Yes, the hospital will get paid for 40K of a 50K bill and the insured will banko, so who is protected? What the fuck benefits from this bill? All the uninsured is horseshit.
On the basis of the policies mandated those people will stay the hell away and incur the same kind of crap that results in them having that higher percentage chance of death. But fuck it, I’m a DFH leftwing nut.
gwangung
Um, I resemble that remark.
scudbucket
@jwb: there is a significant faction of the Democratic party who, for whatever reason, don’t want HCR
I’m not sure this is right: IIRC, initial polling of voters showed pretty overwhelming support for HCR with a robust public option. But it was a ‘significant faction’ in Congress that thought differently.
Ailuridae
@Chuck Butcher:
Chuck, your post is devoid of content. There are massive subsidies up to incomes around 50K, the bill has effectively eliminated any chance an insured person will ever go bankrupt again, community rating creates more intelligent risk pools for the self-employed like myself.
There is a ton of good in this bill. And, again, if the Dems have 50 Senate votes they can pass a Medicare buy-in or public option at any point. Additionally if they have those 50 votes they can repeal the top bracket of the Bush tax cut any time they want.
gwangung
@scudbucket:
Yes, that’s quite correct. Distinctly different statements.
But also something to think about is how red or how blue the districts/states are for those part of the “significant faction.” Dems from red states have significant pressure and significant incentive to be against health care reform; we ignore that to their (and our) peril.
Mr Furious
@Dannie22:
I’m pretty sure I can speak for Will and say that if you could demonstrate actual improvement for those extra dollars like you’d be guaranteed with the French system, he and plenty of others in the thread who disagree with him all agree to pay more in taxes for that.
Chuck Butcher
@Ailuridae:
10K deductible is not going to happen? The subsidy kicks in after 8%? You quibble with 8% being .96 of a month?
Tomlinson
Well, *I* have never seen how the two previously-acceptable forms of this bill made a single bit of sense.
First we had this tiny little public option, that almost nobody could actually get into. But that was good, because it would compete with the insurance companies and control costs.
How? It was so heavily restricted that it couldn’t do jack directly, so the theory was that it would act as some sort of example? And, what, medicaid and medicare cannot?
Then we had the medicare buy in. That was OK, too. Except that was (and is) one of the most stunningly stupid ideas to come out of this whole mess. We already cover the most expensive segment of the population on the public dime, so let’s take the second most expensive chunk and cover them for the insurance companies, too. Eh? Talk about a *gift*.
I’m actually happy with Lieberman for killing that. I think most Americans should be, too.
My take away from all of that mess is that the far left doesn’t really know what the fuck it wants or *most especially* WHY.
It’s hard to imagine what the response is going to be when the mandates hit, and women start dying because of the abortion restrictions
Am I missing something? I just see the same restrictions on federal funding of abortions that we have today, and the option for states to ban abortion funding from the exchanges.
Just like today some do today, with private insurance.
That looks to me a lot like more maintaining the status-quo, not an expansion (or a contraction) of abortion rights.
Tomlinson
@J. Michael Neal:
We’re clearly doing something wrong. The French smoke more than we do, drink more, eat more fat and in general seem to have a hell of a lot more fun in an all-around sort of a way.
Maybe that is the key.
I’m also not at all convinced about the exercise rates, BTW. Or maybe we’re just more visible doing it.
Corner Stone
@Tomlinson: They also beat the shit out of us in vacation days too.
Corner Stone
@Sloegin:
Of course this is the only possible outcome. Anyone who does not see this has not listened to what Landreiu needs or she will veto the bill.
Corner Stone
@Tom Hilton:
Transfer from “wealthier” people.
Ailuridae
@Chuck Butcher:
No, Chuck the subsidy is based on income. It moves gradually from 4% of income at 133% of poverty to 9.8% at 300% of poverty. It doesn’t kick in “after 8% of income” whatever the fuck that means.
J. Michael Neal
@Tomlinson:
A small percentage of Americans are very visible about it. Europeans tend to incorporate exercise, particularly walking and bicycling, into their everyday lives rather than specifically going out specifically to exercise.
I bet they have more sex, too, damn them.
Anne Laurie
@Mike Kay:
Nothing is serious until it affects the well-to-do white guys. Didn’t you get the memo?
inkadu
@J. Michael Neal: And the french smoke less than we do, too.
@Tomlinson: The left is nowhere near as confused as you are. Covering more people under a government program is EXACTLY what the left wants to do. There’s not much confusion on that score.
And the public option was widely regarded as a foundation; eventually the limits would be removed and it could cover more people. That’s why progressives screamed bloody murder when it was stripped out, since it put us on the more difficult political path of regulating private insurance companies instead of the people running their own insurance plan.
Tomlinson
@inkadu:
OK, so it’s OK to use a totally watered down, ineffectual public option, that nobody can really manage to use, as a foundation.
But the current bill cannot be a foundation.
I see.
Chuck Butcher
@Ailuridae:
You do realize that the US measure is $10,300 for one?
Corner Stone
@J. Michael Neal:
So you just pulled these “facts” right out of your ass then?
inkadu
@gwangung: This.
The Raven
@Tomlinson:
National Organization for Women:
Also, David Dayen at FDL.
Ailuridae
@Chuck Butcher:
The individual poverty level is $10,830. Those people and all individuals up to 133% are covered via Medicaid and pay nothing. Here are the maximums that an individual can be charged at various points
http://www.cbpp.org/cms/index.cfm?fa=view&id=3004
Most importantly, for those that demonstrate hardship they don’t have to buy any plan.
The numbers above are actually when the top of the plan was at 9.8%. At that rate (and the 8% rate is more likely to become law) an individual earning between 32.5K and 43.3K would be required to pay on a sliding linear scale 3.2K to 4.2K to have quality health care that they couldn’t lose, the economic security that goes with that. But thats only the case if they can’t demonstrate hardship. At 8% it slides between 2.6K (~220 a month) and 3.4K (~290K a month). Again only if you don’t have health insurance.
So when you say that the subsidy kicks in at 8% you are either mistaken or lying. The current iteration caps premiums up to 400% of poverty at 8% and is only required to be contributed by those who can’t demonstrate hardship.
Ailuridae
@Corner Stone:
As compared to every one else in the thread. I notice nobody responded when I actually pointed out that much of the difference in cost between the US and French systems lies in something nobody has offered even an attempt to address: the obscene compensation in the US of specialists specifically and MDs broadly.
Tomlinson
@The Raven:
Yes, I know the NOW position on this.
I’m trying to compare the current bill to the status quo. Here’s what Nelson seems to have negotiated:
http://theplumline.whorunsgov.com/health-care/nelsons-a-yes-reform-edges-closer-to-reality/
(1) ensure that no public funds will be used for abortion;
That’s where we are today, no?
(2) mandate that every state provide an insurance plan option that does not cover abortion; and
The exchanges are new, so this is a new thing. But it’s hardly coat hanger territory. Seems fair enough, there will be women who want nothing to do with a policy that covers abortion and will not want to pay for it. Are there serious objections to this? What are they?
(3) gives each state the right to pass a law barring insurance coverage for abortion within state borders.
Same thing that happens today on the private market.
Corner Stone
And Atrios says Ezra and all the rest of you are idiots:
And who are you to argue with our Baby Blue Liberal Overlord?
J. Michael Neal
@Corner Stone:
No, but if it makes you feel better to think so, feel free.
jenniebee
@Corner Stone:
So you just pulled these “facts” right out of your ass then?
Hey! “Facts” aka glibertarian talking points pulled out of his ass is all that J. Michael Neal has going for him. By challenging that, you’re impinging on his free speech!
IMPINGING!
FREE SPEECH!
JESUS CAPS!
WOOOOOOLLLLLLLVERIIIIIIIINES!
Ailuridae
@Corner Stone:
DB did that in a whole line of analysis with nothing to back it up, right?
Chuck Butcher
@Ailuridae:
So, at 14,400 you pay 4% or two weeks wage for? A 10K deductible? 70% of your income as a deductible? This will work well for somebody. In case you missed it, the point of insurance is to keep from being crushed by the insured item. In this case the beneficiary isn’t the insured, it is another entity entirely.
gwangung
I’m reminded of the study that the incompetent in an area don’t truly know how incompetent they are, and consistently overestimate their mastery of the material.
Ailuridae
@Chuck Butcher:
The 10K deductible is not flat.
Also, only having to pay 4% for health insurance if you cann’t demonstrate hardship is better than not having a health care option available to you at all that is less than 40% of your pre-tax income (which is where somebody at 134% of poverty is right now)
inkadu
@Tomlinson: The public option could be a foundation for the reasons I listed (similar to the reasons for medicare expansion), even if it is a crappy public option. The current bill can not be a foundation because it does not make the next steps of health care reform any easier; it might be progress (or not, or in the wrong direction), but it hasn’t set us up for any legislative slam dunks in the future.
@J. Michael Neal: I think you may have some statistical arguments to make; I do take issue with you ascribing everything to French culture. The French may have fewer doctor visits en toto because they have more primary care visits, in which problems are taken care of more quickly. They might have reduced end of life care because doctors are free to communicate and treat according to their conscience because they have no profit motive. Maybe all the things you mention as culture are really a response to a radically different medical economic environment.
Whopper jr’s aside, a move toward any real health care system will bring us improved quality and improved cost. Maybe it wont be exactly as cheap as the French system, but even if we get within 1/3 of the cost, we will be way better off.
Corner Stone
@J. Michael Neal: OK, Let’s try this out again:
1)One of the primary reasons that they can do it for so much less money is because they use a lot less health care.
2)It isn’t all about more efficient delivery.
3)They just go to the doctor less often than we do,
4)and demand less from the doctor when they do go.
…
5)Some of this is because they demand a lot less end of life care than Americans do.
6)Part of it is because they live overall healthier lifestyles than Americans do,
7)and need less health care.
Corner Stone
@jenniebee: ATTICA! ATTICA! ATTICA!
J. Michael Neal
@Corner Stone:
Who said:
Maybe. However, if this is true, it has nothing to do with the loss of the deduction on the health plan and everything to do with weakness in the labor market. The same loss of compensation would happen eventually, though adjusted purely through wages, would probably take longer. In the long run, employers are going to pay workers what they’re going to pay them. If it is true that none of the benefit reductions will be converted to wages, as it may very well be, then it is also true wages would be lower by roughly the same amount over time. It would be less visible, but the outcome would be the same.
J. Michael Neal
@inkadu:
Then it’s a really good thing that I didn’t do that, despite you insisting that I did again. Can you read?
J. Michael Neal
@Corner Stone: Feel free to think that the French all got ponies for Christmas, and we could have them, too.
J. Michael Neal
@jenniebee: You clearly don’t know the first thing about what I think, despite my having posted it multiple times in threads that I know you have at least pretended to read. If it makes you feel good to insist that everyone who disagrees with you is a glibertarian, I won’t stand in your way. There’s no reason anyone should take you seriously, though.
Corner Stone
@J. Michael Neal:
Are you insane?
Tomlinson
@inkadu:
A poor public option, one that is setup as the insurer of last resort, could easily be an absolute disaster for future public health reform. See:Maine. So it’s no panacea.
I also disagree that the current bill is lacking as a foundation, or that it will make future reform any harder.
Look, I know we’re insanely backwards here, but the real core battle here is this: “Is healthcare a right or a privilege?” and, so far, we’ve been a lot more on the “privilege” side of the equation. That brooks little reform, since the basic argument then becomes, you have no healthcare, tough, make more money (and yes, I know that argument is some combination of bogus, inhumane, and stupid.)
This bill moves us, if not all the way to health care being a right, then a hell of a long way towards that point.
And that, I would argue, is the real win for future reform.
It’s also important to note that we have a couple of really excellent examples of the benefits of the public option: medicaid and medicare. If we can keep cost growth there well below private healthcare, and if we can establish healthcare as a right, a future public option is virtually guaranteed.
Corner Stone
@J. Michael Neal:
What I will continue to think, and you continue to back up for us all here, is that you are flat fucking off you rocker.
I’m not making any argument re: the French HC plans.
I’m asking you to tell us where your factual statements have any basis in fact.
I’m asking YOU, not making an argument that we can get 60 votes for a French style HC in the US.
I want to know where you diss the French style HC with statements of fact yet don’t actually have any facts to back them up.
So, that’s a nice try to bring ponies up. I mean I for one was temporarily distracted by the idea I could have my own pony.
But then I remembered I was curious where any of your factual statements came from.
inkadu
@J. Michael Neal: Killfile.
jenniebee
@gwangung:
That cuts all ways on this thread ;-)
I’ve mentioned on another thread that I used to work for a BC/BS as a database administrator, building reports for their managed care programs. One thing I can say with some authority, based on that, is that anybody who thinks that insurance companies are trying to improve people’s general health is fooling themselves. They don’t even have metrics for that, not even as a means to control costs. They go straight to cost cutting and any changes in health, positive or otherwise, are a collateral impact.
scudbucket
@Corner Stone: Are you insane?
FTW. I kept thinking it was a delusional sophistic fantasy of argument by word salad.
inkadu
@Tomlinson: You’re talking a philosophical foundation; I’m talking a legislative one.
This current bill makes health care an obligation more than it does a right, so I’m not happy with it.
Just reading a bit on Maine’s public option, and, I gotta admit, it does look pretty bad. But this current bill also looks bad in the short term. The question is really what is the next step with the public option in Maine? Does it become expanded, better funded, is an insurance mandate introduced? All of the things that are politically possible are short-term disasters, a gun to the head to motivate us to take the next steps.
Anne Laurie
@Martin:
I’d be curious to see what percentage of these “unnecessary” visits are already part of the marketplace at work, as in: All those corporations that require a medical note if a worker plans to use the ‘sick days’ said corporation so generously allots. Plenty of situations where only an “unnessary” doctor visit to establish that, yes, Worker A has the flu, and should stay home for a couple days & not share it with the rest of the office, keeps W.A. from losing a days’ pay.
inkadu
@jenniebee: Insurance companies don’t care about your general health; the average stay at a private health insurance company is about six years. If they can keep you from getting a cancer diagnosis until after you leave, all the better for them.
You knew that, of course, but not everyone else does.
How ancient was the software you used?
jenniebee
@J. Michael Neal:
Yes, I know. You want single payer but that’s just so ponies and the only reality-based solution is one that passes all the McArgleBargle tests because that’s what a good reality-based (and easily baited) pompous twit of a pragmatic centrist like you declares is possible. Plus some truly far-right chatter about how the whole problem with American health care is that we want too much of it which we can’t have because it costs too much which is why we wait until our problems send us to the emergency room which we need to stop doing because that costs too much too. Also, the problem isn’t people who aren’t insured and spend years paying off minor treatments, it’s the exact same people who are uninsured and die suddenly before they could pay because they should have known that sudden death was imminent except it isn’t rational to expect that that exact same person might possibly get sick, let alone die, which we know because if it was they’d get insurance which they aren’t which is exactly why it’s necessary that they be forced to buy insurance, QED.
Also America can’t get results as good as every other industrialized country for even as little as two and three times what they pay because we’re culturally different, in other words mcgollum FAT! FAT! You fat fat fatty fat walrus!.
I reckon that covers most of the bases.
J. Michael Neal
@Corner Stone:
Yes. Next question.
Tomlinson
@inkadu:
There is no reasonable formulation for healthcare reform that doesn’t have a mandate. They *all* require it. It’s always going to be an obligation; it already *is* an obligation for the vast majority in this country, who are covered under an employer mandate to buy private insurance.
HCR, any form of it entails risk. The PO is risky (I think even *more* politically risky than the current plan – socialized medicine!) Single payer is risky (same thing). Making the private insurers carry the load is risky, etc.
The only non-politically risky thing to do is…nothing. Works for the GOP, alas. But I think we’re about out of runway for that approach.
inkadu
@Anne Laurie: The marketplace at work leads to unnecessary care because:
– doctors practice defensive medicine;
– there is an oversupply of medical care in some areas;
– doctors get paid more to provide more expensive services;
– nobody takes a good hard look at outcomes/side effects in an economic context. WHo is going to do it? The doctors aren’t. THe insurance companies tried it and failed and now just pass the costs on (or kick the sick off the plan)…
It’s not about hypochondria.
jenniebee
@inkadu:
How ancient was the software you used?
Bleeding edge. We were transitioning from DTS to SSIS while it was still in Beta. Microsoft came out to help us work out the kinks. There were fantastic opportunities there, especially to get experience in data security (you’ll be happy to know that they are fucking serious about security). Plus the money they threw around was astounding. But like I said, you get to the point where you realize that there’s no differentiation when evaluating the efficacy of a new policy between whether it was saving money because it was shifting people into better preventative care and making them healthier, or because it was keeping them away from the doctor when they really needed it and killing them faster. The data to do that evaluation isn’t even being collected. And after that, all those perqs just start eating you.
Corner Stone
@J. Michael Neal:
Actually, that answers all my other questions. Thanks.
J. Michael Neal
@Corner Stone:
Start by telling me where I dissed the French system. Was it where I said that creating something like it would be my preferred way to do health care reform if I thought it had any chance of passing? You know, post #187?
What I said was that one of the reasons that the French get the results that they do for the money that they do (note the “one of,” which, contrary to some readings, is not the same thing as “all of”) is that there are other cultural differences. I didn’t realize that this was such a controversial claim, though I supported it with the obesity figures.
I said that for a couple of reasons. The first is that, even if I got my wish and we implemented the French system tomorrow, the results we would get would not be as good as the ones they get, and it would cost us more than it costs them. Quoting their figures as if they are achievable here is disingenuous.
The second reason, which relates specifically to the point of the original post, is that, if I got my wish, and we implemented the French system tomorrow, it would still involve making some American voters give up things that they have and value right now. There is no way to implement useful health reform without doing that. *Some* Americans, *some* of whom are middle income, and *some* of whom are someone’s cranky ethnic uncle, *will* have to give up something they like. The argument that we need to make sure that we don’t piss anyone off with the bill is exactly equivalent to saying that we shouldn’t do health care reform at all. Quoting how much the French pay for their health care won’t change that.
inkadu
@Tomlinson: I can’t disagree with anything you’ve said there. We’ve got a long frickin’ way to go on this health care thing before either of us are anywhere near close to satisfied.
jenniebee
@J. Michael Neal:
God, I’d hate to have you as a defense attorney. I can see it now: “In an ideal world I’d present evidence of my client’s factual innocence, but what’s realistic here is to forget about that and move straight to negotiating with the prosecution to take the death penalty off the table. Of course, if that’s not possible, we have to remember that the most important thing is that in the end we have a verdict, whatever happens to be in it.”
inkadu
@jenniebee: I’ve really wondered about the social and psychological implications of health insurance. How do people go to sleep knowing they just cut off someone’s health insurance for no good reason? Or knowing they got a fat million-dollar bonus by preventing people from getting on their plan? I know the market demands that behavior, but how does they rationalize it? I people are a lot more blinkered, selfish and stupid than I’d like to think.
@J. Michael Neal: Went back on my pledge… but what specifically are people going to have to give up under the French system? And are they really a significant portion of the population? Nobody in the world has opted for our health care system after switching to a more government managed one. And whatever they had will be replaced by something that is much more stable AND they will — if it is the french system — always have the option to buy whatever they miss. Seriously, what specifically would people miss about their American-system plans under a new Franco-American one?
Why bring up mole hills when we are discussing mountains?
J. Michael Neal
@jenniebee: No. You haven’t read what I write, only selections that allow you to make false statements about what I think. If you prefer to argue with caricatures of what I think, go right ahead. That’s a choice that spells you out as an idiot, though.
On the other hand, you could try reading what I write. I’ll try again.
No. The idea that single payer is some sort of perfect nirvana that we can achieve whenever we want and without imposing costs on anyone is what constitutes wanting a pony. The French system isn’t perfect, and it wouldn’t work AS WELL for us as it does for them. That’s all I said about it’s desirability. As to the possibility that we could pass it, I cop to thinking that that’s an utter pipe dream. If that’s what you hold out for, you will get nothing.
In this case, I’m defining “possible” as what might get 60 votes in the Senate. I have seen *zero* indication that any sort of public option can get to 60 votes. I have seen about the same amount of evidence that a public option that would actually accomplish what its proponents want it to could get through. Given that, I’m taking what we can get.
This is your imagination talking.
This comes from your inability to read. What I said was that any system that has any significant number of people who have no insurance relying upon last minute emergency care imposes costs on the rest of the system that have to be paid by someone. If you don’t mandate that people have insurance, there are going to be free riders, and this introduces a large adverse selection problem. This isn’t even controversial; it’s the basis of how insurance works.
That you continuously insist on misrepresenting what I’m saying short circuits the discussion. You are responding to your imagination, not my argument. Unsurprisingly, I can’t answer your disagreements with imaginary arguments.
Well, yeah. I admit it. I think that a system that puts people in the position where they rely on emergency room care without insurance, whether by need or by choice, is too fucking expensive. I didn’t really think that this was something that many people around here would disagree with, as it seems pretty obvious to me. My point that you should be disagreeing with, if you must, is that an individual mandate is essential to any system that *doesn’t* lead to significant numbers of people doing exactly that. For whatever reason, there are going to be a lot of people that don’t buy insurance if we don’t make them do so.
This is, again, your imagination talking. This is a very serious problem. And, if you don’t make them buy insurance, it is going to continue to be a serious problem. What baffles me is that you recognize that this is a problem, and then demand that we do nothing about it.
This part of your rant doesn’t even make any sense, so I’m not sure quite what your objection is. I’ll try to unpack it, though I’ll offer the opinion that punctuation is your friend.
Yes. It is necessary to force people to buy insurance, or too many of them will avoid doing so. For many of them, it is rational for them to avoid doing so, if we use “rational” in its economic sense, rather than as a placeholder for your opinion of what is wise; the latter definition of “rational” may make sense to you, but it isn’t useful in this sort of discussion.
I’ll try to break out the actuarial basis for this rationality. Again. This is going to be patronizingly basic, but I’ve tried every other approach, and you refuse to get it.
Insurance premiums are based upon expected costs of providing the coverage, plus overhead expenses, plus some profit margin. That profit margin can be negative, in which case, the insurance provider loses money. The key element there is the expected cost of providing coverage. The whole reason insurance companies exist* is that they break the population into groups, with the expected cost of individuals in each group roughly equal to each other.
*Yes, I realize that the rest of this argument is going to mean that the inclusion of insurance companies in our health care system is both irrational in the economic sense, and stupid by anyone’s logic. Once you don’t let them differentiate by risk category, they don’t serve any useful function and become simple parasites. If I thought there was any chance that we could pass reform that eliminated them, I’d be all for it. I don’t see any such chance. We’re stuck with them, either in the current system, or in one that we create with legislative reform. I’ll take the latter, because it’s the only way for us to start moving forwards.
They then offer insurance to individuals in each group at a price (premium) where it makes sense for those individuals to purchase. Note that buying insurance is *always* a negative expected value for anyone buying it, unless the insurance company has underestimated eventual costs. If it weren’t, then the aggregate cost to the insurance company wouldn’t be enough money left over for them to cover expenses and make a profit. If everyone knew that the health care they required was going to cost the average amount, there’d be no point in them buying insurance, because it would be cheaper for them to just pay for the health care out of pocket.
The value added by insurance comes from the variance. Humans are risk averse, and so it is worth it to *most* *of* them to pay some amount above expected cost in order to avoid the risk of paying significantly more than average. However, humans are not infinitely risk averse; they are not willing to pay whatever you want to charge them in order to avoid it. So, there is some limit as to what premiums can be, or they stop buying.
More, not all people are equally risk averse. Some of them are not risk averse. Either because they feel lucky or because they incorrectly evaluate the risk, wouldn’t even pay an insurance premium equal to their expected eventual costs. These people have to be forced to buy insurance under any circumstances if they are going to get it, and the evidence is that there are enough of them alone to skew the system.
The bigger problem is that one of the main purposes of health care reform is to make sure that a variety of riskier individuals can get insurance. The only effective way to do this is to force insurance companies to not break them up into pools. (This is the point where insurance company involvement becomes irrational.) Community rating forces them to put people that they know are healthy into the same risk pool as those that they know are already sick, and that are highly likely to cost more, on average, to cover. This has the beneficial outcome of lowering premiums for people with pre-existing conditions. It has the not-so-beneficial outcome of raising premiums for healthy people. That means that they are even less likely to receive benefits that have the same value as those of the premiums they are paying, and the gap between the two values is going to be bigger.
At that point, the extra cost exceeds the risk aversion of even more of the healthy people. Once it does, it’s no longer economically rational for them to buy the insurance. You make think that it’s stupid of them not to get it, but you are projecting *your* level of risk aversion on to other people. They disagree. That leads to several things:
1) A small number of those people with big risk appetites are going to rack up big health care bills. They bet wrong, and they lose. Unfortunately for them, they face big bills. Unfortunately for the rest of us, a lot of them aren’t going to be able to pay those bills, and we are going to have to. You seem to think that I don’t care about the people who go bankrupt because of this sort of health care crisis, but you are wrong. I do care about them. However, I also recognize that there are other parts of that equation to care about, especially that the rest of us are stuck paying those bills;
2) A large number of those people will remain healthy, and are going to end up with more money in their pocket than if they had bought insurance. They bet right, and win. Great for them. I’d be happy for them, except that;
3) The effect of them having all of that extra money is that the people who did buy insurance had to pay more for it than they would have if the people in group 2 had bought insurance.
If you let the people in the first two groups skip on buying insurance, the costs all flow to the people in group 3 in the form of higher premiums. That’s the cost of not having an individual mandate, and it’s large enough that the reform system collapses. You can’t cover people with pre-existing conditions, and you do nothing to help the people going bankrupt because they didn’t buy insurance.
I suspect that we can’t. That’s no reason not to try to do so, which is what you seem to think that I’m advocating, but my guess is that anyone who thinks that we’re going to succeed is going to end up disappointed.
The problem here is with your reckoning.
J. Michael Neal
@jenniebee:
I agree. I’d make a terrible defense attorney. Then again, that was never my goal in life.
However, your argument as to *why* I’d be a terrible defense attorney should be filed under “When Analogies Fail.”
jenniebee
@inkadu: How often do you talk to the people you work with about how they feel about what their company does? Outside of the non-profit sector it’s not something that is exactly top of mind. I’ve occasionally brought up the subject with co-workers at different places I’ve worked and the reaction is almost always very Werner Von Braun: “Once the rockets go up / Who cares where they come down? / That’s not my department! / Says Werner Von Braun.”
Shoot, I work now for a company that develops Medicaid administration software and half the people in my department oppose government-run health care, including Medicaid. One guy, if you let him get started, will launch a truly epic rant about entitlements and dependency and the rest, and if you ask him how he reconciles that with his job he answers “that’s a good question” and then delivers a twenty minute word salad that can basically be summed up as “FREEDOMS BITCHEZ!”
At that BC/BS job it just wasn’t something that came up in conversation. There were a lot of long lunches, easy deadlines and generous annual bonuses. The technology was current and they didn’t usually fool around with letting amateurs mess everything up. And we weren’t the ones like the poor telephone operators in Sicko who were actually working with the affected people or who were involved in denying coverage or treatment. To notice what was going on you had to notice what the databases and reports didn’t track. And why should you notice that? The whole mission of the managed care division was to lower costs by providing this phone bank of nurses who would call patients and check up on them – how could it be bad? Maybe it wasn’t bad. But we never measured to find out. We just measured costs.
J. Michael Neal
@inkadu:
Believe it or not, there are a lot of Americans that have really, really good health insurance. Much better than what the French have. Smaller co-pays, or none at all. Much greater access to high-tech medical equipment. No need to get prior authorization to see specialists, and a lot more specialists to choose from than the French have. The amenities provided in American hospitals are much better for many, including individual rooms and more frequent testing. They would lose these things under the French system.
The problem with American health care isn’t that there aren’t a lot of people who have the best care in the world; there are a lot of people who have exactly that. The problem is that there are far too many people who have some of the worst care in the world. There really isn’t any way to change the latter while lowering costs that isn’t going to involve some people losing the former. Implementing the French system, as is, would involve less luxury care. If the position is that, out of fear of alienating voters, we are going to make sure that no one loses what they have, then it either won’t cover very many new people, or costs are going to explode even faster.
The determination to make sure that people who like the coverage they have don’t lose it is a large part of why the reform bill got is such an ugly kludge.
Brian Griffin
since a rep from blue Cross blue shield came by my office and implored us all to write congress to oppose the ‘cadillac tax’, I’m inclined to think it would probably cause them to lower their premiums.
don’t know of course, but that’s sure what it sounded like to me.
Martin
@inkadu:
More visits as a precursor to seeing a specialist demands that anywhere from 50% to 80% of our visits are solely for the purpose of getting to a specialist in order to get in line with other nations. And most other nations don’t give direct access to specialists. You don’t have access in the UK and they have half as many visits as us.
Martin
@Anne Laurie:
Oh, probably quite a few of those visits are simply to appease employers, but that practice has also also trained many people to go to the doctor every time they are sick enough to miss work or school.
There’s no simple fix here. Lots of things need to change, and employers not giving employees free access to sick leave is one of them.
jenniebee
@J. Michael Neal:
If – and I know this is a big if – you could expand your mind to consider that I, in fact, do get exactly what you’re drooling across the screen here and that I agree that some of it is true in a system that guarantees access, perhaps you could get down off your insufferably high hobby horse and consider that it actually isn’t true in a system that doesn’t guarantee that coverage. What you’re insisting on is the adoption of a system that forces consumers to support the long-term health of insurance companies without realigning insurance companies’ interests in favor of the long-term health of consumers.
What’s more, you’re doing it based on the specious theory, completely unbacked by demographics, that there’s a substantial pool of healthy twenty-somethings who refuse to buy insurance despite having the means to do so. I’m sure that there are a few true believer subscribers to Reason at any time who think it’s smart to invest what they would be spending on premiums, at least until their parents find out what they’re up to and put a stop to it, but the idea that the number of people behaving that way is statistically significant is silly on its face.
Your complaint, in short, is that the system simply can’t work without getting money out of people who simply haven’t any money to get. We could play this game for hours. The reason that everybody doesn’t have more sweaters is that the people with no sweaters are holding out on the rest of us! The reason we all don’t have more emeralds is that unemployed high-school grads won’t man up and buy them for us! Also, PONIES!
Bobby Thomson
Shaking my head at all y’all chastising the lucky duckies who can wait for hours to see a doctor to get a prescription when they are sick. On the one hand, you call out the death panels lie (and it is a lie), while on the other hand you say that the real problem with American healthcare is that sick people just use too damn much of it.
People don’t go to the doctor anymore unless it’s serious. Even fairly serious cases generally have to wait a minimum of an hour to be seen. Folks aren’t doing this on a lark. Hell, when was the last time a doctor saw you at the scheduled time for a scheduled appointment?
Any health care reform that relies on people not actually using the coverage that you’ve extended to them isn’t reform. At best, it’s an argument for economic rationing, which has already been tried under the status quo and hasn’t done jack shit to bring down health care costs.
Chuck Butcher
I’m struggling with the rationales expressed here, it is a fine thing to lay a 4% tax (mandate) on the bottom of the effective economic scale – wage earners and everybody else is off limits to getting a 4% hit? There certainly are people who measure the risk and don’t buy the ins cos product, but once you hit that 133% of poverty that’s not what you’re talking about. They cannot afford it and they cannot afford the deductible. Fucking period. If they go to the hospital; they’re toast under your Senate bill or without it. You’re insuring the hospitals not them and they will not go unless they cannot possibly avoid it and that’s what exists now.
With the current bankruptcy law, they are doubly fucked. I got out with my credit wrecked, which is bad for somebody who has to bond large amounts and with liability insurance and meant my business was crippled – construction credit. A medical procedure I could barely afford for my wife ballooned into a nightmare and also made her uninsurable.
A 10K deductible means that for over two years other than housing and food; I’ll work for whoever I owe that to and I’m in much better shape that way than the people who have worked for me.
mai naem
Since when did Ezra Klein become the god of healthcare reform policy. Here’s one more FU from the Dems to the average American. You have a country with increasing income inequality and only the Congressional Dems could come up with another way to fuck the average American worker because god forbid the average American worker should get decent health benefits instead of shitty 80/20 or 70/30 plans where you don’t go to the doctor until you get real sick because you can’t afford the copay and hell, you can’t go to the ER because that’s a $500 copay and hey, don’t forget the $5,000 deductible. Meanwhile Steny Hoyer and Joe fucking Lieberprick have a plan that cost them less that $200 for their old fart white asses with their old(literally) women. And, oh yeah, they have a concierge doctor at the Capitol and their medical home at Bethesda Naval. You think LIeberprick or Hoyer have ever been to a sliding scale medical clinic. Bet Ezra Fucking Klein has never been to a sliding scale clinic either. Steny Hoyer can’t figure how to straighten out the Death Tax stuff because only the American worker should be made to beg to their slave masters, never some rich fucking banker who has more money than his great great great grandkid is going to be able to spend.
DougL (frmrly: Conservatively Liberal)
Amid all of the rhetoric in this thread there are some very good discussions about this issue. I have read every single post to this point and I am still in the “I really ain’t going to worry much about anything until there is a bill to vote on” group. I am also a member of the “no matter what I want I am realistic enough to know that what I want really doesn’t matter too much” group. Another one is the “I think that they need to keep the pressure up to try and influence the bill in a positive way” group. One last group I support is the “No matter what happens I am going to vote for the Democrats in the upcoming elections because the Republicans are fucking insane” group.
Groups I am not aligned with are the “I lost my ass on the HRC issue so I am going after (insert name of someone in the Obama administration) and I am willing to embrace the most detestable Republicans out there to do it” group, the “I didn’t get what I want so I am not supporting Democrats in 2010 or 2012” group, the “I want health care for free and all for-profit insurance companies must be destroyed immediately” group, and finally the “I am fighting to improve the bill and I am willing to embrace a detestable Republican hack like Grover Norquist to help me kill it if I am unable to improve it” group.
This is an extremely complex issue and I believe that polling on it is nearly worthless since nobody except the few wonks who have read the bills have any idea what might come out of the compromises between them. The MSM is pretty useless on its reporting of this issue so there is no dissemination of actual bill content to the population at large, thus no informed electorate.
Nope, just lots of hyperventilating that seems to be coming from one side much more than the other.
Ailuridae
@Chuck Butcher:
No, Chuck. If they can’t afford it they apply for a hardship waiver. And frankly a lot of those people would be thrilled to pay 4% of their income for the access to medical care.
Also, you are ignoring that both the Senate and House bills base plans cover preventative care for free and you continue to choose to conflate deductible with maximum out of pocket annual expense. There is a difference, you know that?
Please link a reliable source for your 10K deductible. I might have to start calling people FDL-bots. This is getting absurd.
While I am sorry to hear about your credit problems relatingto previous medical hardships thats exactly what the Senate bill addresses well. Substance not hyperbole, please.
The bill is out there, its in pdf form – cite the 10K deductible number, etc.
Here’s a pretty early CBPP analysis on the bill which I have already linked and you consistently refuse to address. Ill just quote the relevant portion in its entirety
For example, under the Senate bill, a family of three earning $32,000 (175 percent of the poverty line) would have coverage under the “gold plan,” which would have an actuarial value of 80 percent. The Congressional Research Service estimates that such an actuarial value is similar to that of a typical employer-sponsored PPO plan, which typically has an annual family deductible of about $700 and cost-sharing of 20 percent for office visits, labs, and other services.[5] The Senate bill would place an annual out-of-pocket cap on how much a family at this income level would have to pay in deductibles and co-payments at $3,867 if the plan were in effect in 2009. [6] In comparison, this family would receive coverage with an actuarial value of 93 percent under the House bill. A plan with such an actuarial value would likely provide coverage with no deductible, co-pays of $20 for office visits and $250 for inpatient hospitalizations, and no cost-sharing for prescribed lab tests or x-rays. The House bill would also limit cost-sharing for a family at that income level to $2,000 per year, assuming the plan were in effect in 2009.
Link: http://www.cbpp.org/cms/index.cfm?fa=view&id=3004
Mnemosyne
@DougL (frmrly: Conservatively Liberal):
That’s the thing — in those selfsame polls that “prove” that people hate the healthcare bill, the majority of the people polled say that they’re not getting the information they need from the media to figure out what the hell is even in the bill.
I got to spend Christmas listening to my parents natter on about death panels, so I guess that’s not going away anytime soon. They love Medicare (and Medicaid, oddly enough) but not government healthcare. Go figure.
Oh, and my mom is utterly convinced that a doctor’s office can’t ask you for proof of insurance before they treat you. I guess that’s what happens when you’re on Medicare and don’t have to provide that anymore — you become convinced no one else has to do it, either.
J. Michael Neal
@jenniebee:
I recommend checking out the Census Bureau’s breakdown of demographics of the uninsured. You can get cross-tabs by creating tables here. You can condition on age, income, insurance coverage, and health status.
Let’s take people aged 18-30, with family incomes greater than $50,000 and with a health status of excellent. That’s a population of about 11 million. Of those, about 9 million get health insurance through the government or an employer, and so don’t have to make the choice as to whether or not to buy an individual policy. Of the remaining 2 million, about half of them chose not to purchase health insurance.
Your assessment that only a small number of crazed libertarian people would choose not to buy health insurance is dead wrong. Basically, don’t use your own definition of what constitutes a wise choice on purchasing health insurance as a basis for concluding what young, healthy individuals would do. You seem to have a completely different mindset.
J. Michael Neal
@jenniebee:
No, it isn’t. For god’s sake, could you please stop misrepresenting what I say? Either you really don’t understand, or you’re lying.
My point is that the system simply can’t work if there are people not covered by it. Everyone has to buy in. So far, so good. However, you, like a lot of other people, insist on analyzing parts of the bill in isolation, and you just can’t do that. Yes, if you ignore all of the other provisions, the mandate would be every bit as unjust as you claim. There are, however, other portions. There are large subsidies for low income people to buy insurance. There is a cap, such that if the mandatory policy costs more than 8% of someone’s income to purchase, then they are not required to buy it.
So, your claim about what I am saying is not true. I am not asking for money from people who don’t have it. I’m advocating a bill that requires people to pay money into the system, and, if they don’t have it, then it either gives it to them, or doesn’t require them to pay in. If you leave that part out, then you are lying about what I am saying.
Corner Stone
@Ailuridae: Just saw this. I have a friend who’s an anesthesee…anesthesio…she knocks people the fuck out before surgery.
She’s moved hospitals 3 times in the last four years, each time earning more money. She now works about 2 – 3 days a week, never full days, and makes close to what I guess is now $500K per year.
Yes she pays hefty for liability.
But, ummm, I think I’d take that setup.
mai naem
@J. Michael Neal: The people who have good health insurance/benefits are either the old folks who are on old fashioned medicare or government workers,hospital workers and yes, some union workers. Otherwise, if you work in the private sector or you are self employed you are fucked. Yeah, there may be a few high income/high skilled cos. out there which offer decent health benefits but those are few and far. The only private sector non union working people I know who have decent benefits are people who work in hospital groups where you are worked by your hospital group. Hell, most people don’t even know how crappy their insurance because they don’t use it. Most people use it for minor stuff where they consider it a minor inconvenience if the ins. co. refuses to pay for stuff because it’s a one time deal.
Ailuridae
@Corner Stone:
Knock out doctors have a good life. One of my better friends is one and when he isn’t doing that he’s an “anti-aging doctor” for men in their mid 30s to 50s who want to pay a couple of hundred bucks a month to get HGH injections. I do well, but he pays for lunch and drinks as any other arrangement would be criminal.
Oddly, like a lot of doctor’s my age (35) and younger he’s pretty openly in favor of mass government intervention in the health care system and a huge cut in pay as long as his loans are forgiven.
DougL (frmrly: Conservatively Liberal)
@Mnemosyne:
IOW, the polls reflect the narrative the MSM and Repubs are feeding them because the people are so poorly served by the MSM.
Exactly.
I have enjoyed reading this thread and people like Ailuridae and J. Michael Neal are delivering better information than most everyone else on what the bills say and even they couch that with the caveat that we will see what it all really looks like once the sausage making is done and there is a bill to vote on.
Right now it is “let those that froth froth” and I will patiently wait for the sausage to get done. That and be an asshole while I am doing so.
Hey! I have to do something to keep busy! ;)
Martin
@Bobby Thomson:
No, I’m saying that a visit to a $250K per year doctor is overkill for the flu for the majority of people. A visit to an RN would probably still be overkill but would be better. A home diagnostic kit, some public education, and so on would be better yet.
And I’d rather trade mostly well but slightly sick people from going to the doctor for massively sick people getting the ability to go to the doctor.
Shorter version, if you think that we are overpaying to the tune of $4,000 per person, per year simply due to insurance bonuses and paperwork, you’re fucking insane – as in Michelle Bachmann/Sarah Palin insane. We’re overpaying $4,000 largely because we overpay doctors and use them about 1/3 more than we need. Doctors and hospitals are almost 2/3 of our healthcare spending. Even if we outlawed insurance, got drugs and medical equipment absolutely for free (as in nobody pays, it just magically arrives in your home), got free nursing home care (same thing, Jesus takes care of grandma for you), and got free over-the-counter and other care, we’d still be 20% more expensive than any other country per capita.
The only possible way to get healthcare costs in line with any other nation is to go directly at doctors and hospitals and get them to take about half as much money as they are. That’s fewer people using them, fewer people going in via ER, lower salaries, less cutting edge equipment, all of that. That’s the big wedge of the pie. You can’t ignore that wedge. You can say it’s not reform, but it really is. Get otherwise healthy people out of the ER and urgent care and get the actually sick people in there instead.
Martin
@Chuck Butcher:
I agree with you, but the problems you describe aren’t problems vis-a-vis with healthcare. They’re problems with other angles of our social economy. It’s criminal how low minimum wage is and how the bankruptcy laws operate. Those need to change as well. A big part of the healthcare problem actually has to get solved outside of healthcare legislation.
The problem is that the healthcare problem isn’t going away and can’t wait for the other planets to align. I know that’s cruel to those that will suffer under it, but that’s the state that we’ve been put in by the GOP and Democrats that are unwilling to fight the good fight.
J. Michael Neal
@mai naem: On the other hand, as long as we’re trading anecdotes, I know a bunch of people from my former job who have fantastic health insurance. Hell, *I* have damned good health insurance, but that’s only because I live in Minnesota, which actually funds its programs for people like me with pre-existing conditions. They’re out there, trust me.
Martin
@Corner Stone:
Anesthesiologists have it made. Seriously.
Under the Medicare payment schedule (which normally kinda sucks) an anesthesiologist can bill from the moment they start evaluating you until you are done in post-op. Consider an L&D ward where you might have a half dozen women in different stages of labor. As soon as that doctor goes in and start to determine when you are ready for an epidural, they’re billing, and they bill right up to when the epidural has worn off and you’re in the clear. That could be 10 hours – for all 6 women. So they’re often billing for 3,4,5,8 patients at once.
So yeah, we need to deal with the liability issue, but right now that’s mostly stuck in the states, not the fed, and most states are doing fuckall about the problem. But we just can’t afford to be paying people half a million dollars to work half a week.
Ailuridae
@J. Michael Neal:
Minnesota should be the model for a private-public health care hybrid. They have a lot of good regulation, strong competition, that goofy-ass exchange (MNHI?) and it doesn’t hurt to have Mayo in-state.
Martin
@DougL (frmrly: Conservatively Liberal):
No, the polls reflect a public that just doesn’t fucking care. They want the health care system to just magically work, just like they want every other thing to magically work, with Jesus waving his hand of everloving awesomeness over us and solving our problems because we prayed to him and didn’t yank on our peckers during the night.
We live in a country full of people that depend on magical thinking to get through the day. 15% of the public fully believe in evolution. Half of the public thinks that God made us out of Play-Doh and Mindstorms. You think they’re going to be reliable polling on healthcare even if the media was doing their business?
J. Michael Neal
@Ailuridae: I’m in MCHA, but there are a couple of other goofy acronyms for people who don’t have the assets I have.
DougL (frmrly: Conservatively Liberal)
@Martin:
I don’t disagree with you but I do think there would be a healthier discussion of HCR if we had a press that was worth a shit.
But you are right in that we would then need people who gave a shit and we really don’t have many of those. Sometimes I think we need a total meltdown of society before we are going to even start to get back to reality and people will be willing to pay attention.
Short of that all we can do is muddle along until either a miracle or disaster strikes. I’m betting on the latter.
bob h
The politics of taxing the high incomes of the people who have caused so much trouble for the country are right, but Ben Nelson will object to “class warfare”.
Tomlinson
@Martin:
And that is exactly the core problem. It is not the press, it is not our elected representatives, it is not that HopeyChangeyGuy (who, I might add, has been pretty clear about the need to cool it with the magical thinking, if you actually listen to what he’s said), it’s the people who just want this damn thing FIXED but it cannot effect THEM. No, not ME!
Well, it will. Sorry, but it will. It’s going to effect Joe on the street, who maybe won’t be seeing a doctor every time he needs a checkup, he’ll be seeing a nurse practitioner (and a lot more than this.) And yeah, he’s going to have to buy insurance. From someone. It will be effecting the doctor, who won’t be making $250K a year for taking temperatures, it will be effecting med schools (doctors make less, they must charge less), it will be effecting pharma (can’t charge us through the nose), it will be effecting insurance companies (who will have to actually, you know, insure people), it will be effecting lawyers (want to use nurse practitioners? Got to have tort reform.) And who knows who else. A lot of who else.
This is just to get us to the point where we can start talking about setting up a French system or a Swiss system or a Canadian system. This is just the necessary-but-not-sufficient stuff.
It’s a long, bloody slog. And there is no magic wand here. We cannot wave our public option and then go home, mission complete.
So when we hear that meaningful reform, a decent and good first step, is a sellout or is not reform (parrot after me: “it’s not reform without a public option, it’s not reform without a public option!”), it’s a bit frustrating.
We have a long way to go here. We have a hell of a first step right within our grasp, and it is a hell of a first step. It’s not perfect, but *nothing* will be. *Nothing* short of a complete and sweeping overhaul (which is right off the table, see the above list of constituencies) is going to be perfect. So let’s get started.
Tomlinson
Need to add this: For the last 30 years or so, we’ve been sold the notion that the free market will solve all of our problems. That we don’t need to actually do anything, we just need to *not* do stuff. Not regulate. Not tax. Not educate ourselves. And everything will turn out not just OK, but optimally.
This is a hell of a compelling lie. But it is a lie, a con, perhaps the largest con in the history of the world. And like any con, you really want to believe it, because it is so much easier to live in that magical place where cutting taxes balances your budget and deregulating makes companies behave ethically and where a rising tide lifts all boats and where the American worker is just naturally superior. Oh, we want to believe.
Tough. Time to grow up.
The Raven
@Tomlinson: (Defending the Senate bill on abortion.)
Most insurance currently covers induced abortion; the exchange plans will not. In some states, it is likely that no exchange plan will cover abortion; there will be a plan that does not offer the coverage, and no plan that will. The likelihood that some less-well-off women will attempt self-induced abortions is high.
Anyhow, this thread is grown beyond control, so this is my last remark here.
Tomlinson
The way I read it, there is a requirement that there be at least one exchange plan that will not cover abortion AND states *may* ban plans which cover abortions from their exchanges. As I understand it, some states currently ban *private* plans which cover abortions, so – status quo.