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The Perils of High Public Office: II

National Review Online just posted a piece that I did on the Medicare Catastrophic Coverage Act, and its implications for our latest efforts at health (insurance) reform.

Here's the conclusion of the piece:

No one can predict whether the latest effort at health-care reform will meet a similar ignominious defeat. But this story does hold lessons for the current debate.

First, health care is personal. If you mess with people's health coverage, they won't just write a nasty letter to the editor. They will show up at demonstrations with home-made signs, scream at you, chase you down the street, and maybe vote you out of office. So you'd better have a good reason for doing what you're doing, and a compelling explanation of how your plan would personally benefit your constituents.

Second, framing is critical. The Obama administration has shifted ground several times, trying to find a frame that will persuade voters. It remains to be seen whether the latest frame — it's about providing people with insurance; insurers are evil, and the reforms will make them behave — will stick. Update: today's new framing is that health reform is "a core ethical and moral obligation."

Third, don't assume that people who disagree with you are stupid, misinformed, greedy, or evil. They may just have different preferences about health insurance, taxes, income redistribution, or the role of government in health care. If preferences differ, telling people they can't understand the complexities won't help matters. Such condescension just makes aggrieved citizens angrier.

Fourth, be lucky. The administration had better hope that the elderly don't figure out that reform will be paid for, in part, with hundreds of billions in "savings" from cutting Medicare. (In past years, Democrats routinely savaged Republicans for proposing far smaller Medicare cuts.) If seniors figure this one out, support from AARP's national office won't be any more help this time than it was last time — even if AARP stays on board, and there are already indications that it won't.

Finally, embrace your sense of humor and irony. The administration of a former teacher of constitutional law complains about Americans exercising their constitutional right to petition the government for redress of grievances. A party that elected a community organizer president complains about organized communities. One of the architects of the Democrats' current health-care strategy (Rep. Jan Schakowsky) is the very community organizer responsible for the horde of seniors that surrounded Rostenkowski's car. Last year, dissent was the highest form of patriotism. Now, dissent is un-American, and reporting dissent is suddenly patriotic. Who knows what fresh irony tomorrow will bring?

ruuffles (mail) (www):
So ... what? Are you backing of those conservative plans that provides for "tax breaks" to "help" individuals purchase insurance? Would you support a "tax break" that in practice would completely cover more than 90% of insurance plans? Or would you support a Bush-esque $400 once off payment?
8.20.2009 5:23pm
einhverfr (mail) (www):
There is one you missed:

Don't try to pass gargantuan bills that nobody can understand (not even Congressmen). Keep reforms specific to issues, and address one issue at a time. (That also messes with folks coverage a lot less.)
8.20.2009 5:23pm
rick.felt:
Update: today's new framing is that health reform is "a core ethical and moral obligation."

Assuming that this is really today's Official Framing and not just Obama riffing off-Teleprompter, it's a loser.

I don't see how you're going to get people who are already reeling from a recession to pony up money on moral grounds. Moral appeals might work on people with money to burn, but that ain't us.

I don't actually think this is the Official Framing, though. This was just what you say when you're talking to religious leaders. You know, throw terms like "moral obligation" around, quote a little Scripture, and don't worry about being labeled a Christianist by Andrew Sullivan, because it's only wrong to use the Bible to promote conservative ends.
8.20.2009 5:31pm
rj (mail):
It may not be a good idea to assume that your critics are uninformed, but in this case, they really are. Many are simply misinformed on everything from "death panels" (here we go again) to abortion to coverage of illegal immigrants.

It may not be a good idea to question the motives of people who disagree with you on a particular issue, but in this case it's clear that the more spittle-flecked elements tie healthcare in with birtherism, conspiracy theories about reparations and a variety of far-right hobbyhorses.

There isn't any "irony" about complaining about the protests. Neither Obama nor his administration has challenged the first (or second) amendment rights of protesters. It's not hard to believe in the right to assembly while simultaneously believing that those assembled people are generally badly misinformed and create an ugly atmosphere.
8.20.2009 5:32pm
Len:

Third, don't assume that people who disagree with you are stupid, misinformed, greedy, or evil.


Don't forget LIARS!!!!1!1!
8.20.2009 5:33pm
Steve H (mail):

Third, don't assume that people who disagree with you are stupid, misinformed, greedy, or evil. They may just have different preferences about health insurance, taxes, income redistribution, or the role of government in health care. If preferences differ, telling people they can't understand the complexities won't help matters. Such condescension just makes aggrieved citizens angrier.


If they describe a plan to provide all Americans with health insurance as a "Nazi plan," or talk about "death panels," or "keep your government hands off my Medicare," can you then assume that they are stupid, misinformed, greedy, or evil.
8.20.2009 5:33pm
LarryA (mail) (www):
Third, don't assume that people who disagree with you are stupid, misinformed, greedy, or evil. They may just have different preferences about health insurance, taxes, income redistribution, or the role of government in health care. If preferences differ, telling people they can't understand the complexities won't help matters. Such condescension just makes aggrieved citizens angrier.
That should be framed and hung in the office of every politician of every party, and every editor of every news publication in the country.
8.20.2009 5:34pm
rick.felt:
Another one:

"As long as you're quoting Scripture to religious leaders, take a lesson from Matthew 25:14. Prove that the government can manage Medicare without breaking the bank and then maybe we'll let you go to work on other sectors of the health care economy."
8.20.2009 5:35pm
LarryA (mail) (www):
Update: today's new framing is that health reform is "a core ethical and moral obligation."
Or, you could tell the truth.

People, one way or another, sooner or later, the money to fund your health care is going to come out of yor own pocket. If you believe there's a system that will make a visit to your physician cost a third of what you pay to have your hair done, that's being delusional.
8.20.2009 5:44pm
Bruce Hayden (mail):
It may not be a good idea to assume that your critics are uninformed, but in this case, they really are. Many are simply misinformed on everything from "death panels" (here we go again) to abortion to coverage of illegal immigrants.
Let me see if I understand your point. The justification for health care reform is that some 47 million or so are uninsured, and some 1/3 of that number are illegal aliens. So, either the 47 million number being used is bogus, or the "reform" will cover them.

As for your debunking of "death panels", I still have not seen any realistic proposals by the proponents of such "reform" of how they expect to provide additional health care for those 47 million additional people, for less money than we are spending now, without significant rationing. And, both Mr. Obama and Dr. Emanuel, his health care adviser, have repeatedly suggested that the rationing would be on precisely the grounds that has granny so petrified.

As for abortion, it seems to be in the bill one week, and out the next. But there is nothing right now in the legislation that would prevent an unelected panel, commission, etc. of bureaucrats from deciding that all approved insurance policies must cover abortions. (Frankly, I am ambivalent on this subject, since I am middle of the road here, but throw this in for argument's sake).
8.20.2009 5:44pm
ShelbyC:

If they describe a plan to provide all Americans with health insurance as a "Nazi plan," or talk about "death panels," or "keep your government hands off my Medicare," can you then assume that they are stupid, misinformed, greedy, or evil.


Sure, if you think that will help convince them.
8.20.2009 5:46pm
Brian K (mail):
Given the vitriol thrown at anti-war protestors and anti-bush protestors it is amazing to see the lengths that conservatives go to to excuse their protesting.

how's that for irony, david?
8.20.2009 5:48pm
bobh (mail):
"it's about providing people with insurance; insurers are evil, and the reforms will make them behave."

From the very beginning, I've thought that this was how the proponents should have framed the debate -- i.e., that the legislation is about insurance reform, not health-care reform. Under that rubric, there would be no room for discussion of "socialized medicine," because the debate would not be about medicine at all.
8.20.2009 5:49pm
alogos:

Update: today's new framing is that health reform is "a core ethical and moral obligation."


You can't legislate morality.
8.20.2009 5:52pm
rick.felt:
As for abortion, it seems to be in the bill one week, and out the next.

Here's what Obama said to Planned Parenthood in 2007:
Brian Howard: [W]e know that health care
reform is an important part of your agenda. Could you talk—and give us some specifics about how reproductive health care and women's health care is going to fit into and be a part of primary care for women in your health care reform plans and how Planned Parenthood, as a safety net provider, will continue to be a part of the health care safety net for women and families across the country.

Senator Obama: Well, look, in my mind reproductive care is essential care, basic care so it is at the center, the heart of the plan that I propose.... [W]e're going to set
up a public plan that all persons and all women can access if they don't have health insurance. It'll be a plan that will provide all essential services, including reproductive services, as well as mental health services and disease management services.
The only way that this wasn't a promise to pay for abortions through a public plan is if you interpret "reproductive health" as not encompassing abortion. So it's pretty clear that Obama made that promise. And as Bruce Hayden noted, it's in one bill and out of another. Obama hasn't specifically modified his promise to Planned Parenthood. If he's really going to reverse his 2007 stand, he's got to use stronger language, and he's got to make it clear to abortion opponents that paying for abortions is not going to be part of any bill that he signs. The burden is on Obama, having promised that abortion would be part of government health care, to state convincingly that it now will not.
8.20.2009 5:59pm
josil (mail):
It seems clear on the surface of things that the assorted proposals in Congress will cost more in the aggregate than the current system and will result in rationing down the line--as every government controlled system has experienced. If I knew the cost and the rationing rules in advance, I could make an intelligent (i.e., self-serving) decision. But, I don't believe that the political apparatus has any incentive to provide that information...or even search for it. The entire "debate" on health care seems suffused with dishonesty.
8.20.2009 6:00pm
erp:
...former teacher = former part time lecturer of constitutional law ...
8.20.2009 6:11pm
rick.felt:
...former teacher = former part time lecturer of constitutional law ...
...who managed to teach law at Chicago for years without publishing jack squat, or even jumping on someone else's paper as a second author. The academy has a new motto, apparently: "Publish or President."
8.20.2009 6:13pm
Steve H (mail):

As for your debunking of "death panels", I still have not seen any realistic proposals by the proponents of such "reform" of how they expect to provide additional health care for those 47 million additional people, for less money than we are spending now, without significant rationing.


Um, the same way that every other industrialized society on the planet does it?

And this whole "rationing" trope is so misleading. No one says that the school system "rations" language instruction because they teach Spanish but not Portuguese. Instead, people who want Portuguese instruction go out and pay for that on their own.

At *worst*, that is how it would work with government-funded health care (like Medicare -- if you want coverage for the stuff Medicare doesn't pay for, you get supplemental insurance).

Rationing suggests that the government would prevent people from getting health care on their own. That is not on the table, nor will it be.
8.20.2009 6:15pm
ShelbyC:

And this whole "rationing" trope is so misleading. No one says that the school system "rations" language instruction because they teach Spanish but not Portuguese. Instead, people who want Portuguese instruction go out and pay for that on their own.

At *worst*, that is how it would work with government-funded health care (like Medicare -- if you want coverage for the stuff Medicare doesn't pay for, you get supplemental insurance).



Right. If I want Portuguese lessons, I'm forced to pay for both Spanish and Portuguese lessons. And now you're saying that I have to pay for health insurance twice too?
8.20.2009 6:29pm
Steve H (mail):

Right. If I want Portuguese lessons, I'm forced to pay for both Spanish and Portuguese lessons. And now you're saying that I have to pay for health insurance twice too?


I guess.

But the health care example is less unfair than that, because the second payment would be for the extra level of coverage -- you wouldn't pay twice for the same thing.

So it's not exactly like Spanish or Portuguese. Instead, the basic payment would get you instruction in Portuguese vocabulary, grammar, and literature, and you would have the option of paying extra to learn about Portuguese theater.
8.20.2009 6:39pm
The Original TS (mail):
Third, don't assume that people who disagree with you are stupid, misinformed, greedy, or evil.

This has been getting a lot of comments, as it should. It's the biggest blunder the Obama administration has made to date.

The administration and Democrats in general made the classic error of believing their own propaganda. They genuinely believed that all they had to do was go around the country and answer people's questions in order to get buy in. They are genuinely shocked to have run into such a buzz saw of protest and dissent.

This debate has had its share of hysterical silliness but there are also a lot of people who already knew the answers and fundamentally disagreed with the basic premise of the reform: That government control will make health care both better and more efficient.

The thing I find the most ironic -- and humorous -- so far is that far right protests have somehow succeeded in smoking out the far left who are now openly admitting that the "public option" is really a trojan horse for a single payer system. But single payer is a non-starter, even among moderates, let alone conservatives. It is now entirely possible that this Congress will pass no significant health care bill at all.

Sometimes I despair of our political system. There has to be something between the too-often lockstep loyalty of the right and the circular firing squads periodically assembled by the left.
8.20.2009 6:39pm
Spanky von Spankowitz:
Um, the same way that every other industrialized society on the planet does it?

You mean by rationing?

Rationing suggests that the government would prevent people from getting health care on their own. That is not on the table, nor will it be

So it's unfair to look not only at a proposal but the inevitable consequences of such a proposal? The "no-rationing" team have a very basic problem- no one can credibly argue that given the cover everyone and not raise aggregate costs framework advanced by Obama- rationing won't be necessary. Particularly given the statements of Obama and "Dr." Emmanuel. What the no-rationing team can do is pretend that the inevitable consequences of their plan won't come to pass. This would be roughly akin to Bush arguing in March of 2003 that no soldiers will die in Iraq because "that is not on the table, nor will it be." Rationing, like combat deaths, are inevitable given the stated objectives.

More importantly, the continued insistence that a Health Care Perpetual Motion Machine would already be up and running if it weren't for you meddling Republicans (thereby ignoring the current composition of the Congress) is so patently dishonest that it allows all opponents of "health care reform" to be very loose with their own facts. Who associated with the White house can credibly complain about dishonesty when they're knee-deep (to be charitable) in it as well?
8.20.2009 6:40pm
rick.felt:
The administration and Democrats in general made the classic error of believing their own propaganda.

Related: they also overestimated Obama's mandate. Obama ran on a brilliant campaign of (1) Not Being George W. Bush, (2) Being the Opposition Nomineen When the Economy Cratered, and (3) Hopey Changitude. The idea the Obama's election was a mandate to overhaul the health care system in this country is absurd.
8.20.2009 6:51pm
The Original TS (mail):
At *worst*, that is how it would work with government-funded health care (like Medicare -- if you want coverage for the stuff Medicare doesn't pay for, you get supplemental insurance).

This is certainly how some people imagine it would work but it is not how all people imagine it would work.

There is a decent-sized constituency that see this in terms of access and equity rather than in terms of efficiency and cost. They are strongly opposed, on philosophical grounds, to the well-off getting access to better health care than the poor.
8.20.2009 6:54pm
byomtov (mail):
don't assume that people who disagree with you are stupid, misinformed, greedy, or evil.

It's not an assumption. It's a reasonable empirical conclusion from the evidence.
Of course not all thiose who disagree are stupid, etc., but as long as they are willing to follow and endorse those who are there is no practical difference.

And shouting lies and yelling about Obama being a Nazi, while Constitutionally protected, hardly falls under any sensible notion of "petitioning the government for redress of grievances."
8.20.2009 6:56pm
Steve H (mail):

So it's unfair to look not only at a proposal but the inevitable consequences of such a proposal? The "no-rationing" team have a very basic problem- no one can credibly argue that given the cover everyone and not raise aggregate costs framework advanced by Obama- rationing won't be necessary. Particularly given the statements of Obama and "Dr." Emmanuel. What the no-rationing team can do is pretend that the inevitable consequences of their plan won't come to pass.


But if rationing (making it illegal to obtain health care beyond the care funded by the government) is so "inevitable," how come it hasn't happened during the 40+ years Medicare has been around? How come it hasn't happened in the VA system? As far as I know, the supplemental Medicare insurance business is thriving. Is there a movement afoot to ban it?

And how come it hasn't happened in the other Western countries that have had public involvement in health care funding for decades?

(I believe Canada may make it illegal to obtain insurance or health care outside of their Medicare system. But I think they are the only ones who have done this.)
8.20.2009 7:03pm
Steve H (mail):

There is a decent-sized constituency that see this in terms of access and equity rather than in terms of efficiency and cost. They are strongly opposed, on philosophical grounds, to the well-off getting access to better health care than the poor.


Are you aware of any proposals to outlaw Medicare supplemental insurance?

Are you aware of this happening in other countries apart from Canada?
8.20.2009 7:07pm
alogos:
don't assume that people who disagree with you are stupid, misinformed, greedy, or evil.

It's not an assumption. It's a reasonable empirical conclusion from the evidence.
Of course not all those who disagree are stupid, etc., but as long as they are willing to follow and endorse those who are (Pelosi, Reid) there is no practical difference.

And shouting lies and yelling about Bush being a Nazi, while Constitutionally protected, hardly falls under any sensible notion of "petitioning the government for redress of grievances."
8.20.2009 7:20pm
ShelbyC:

But if rationing (making it illegal to obtain health care beyond the care funded by the government) is so "inevitable," how come it hasn't happened during the 40+ years Medicare has been around?


Did Medicare ever promise to increase demand for healthcare without increasing costs?
8.20.2009 7:23pm
Spanky von Spankowitz:
But if rationing (making it illegal to obtain health care beyond the care funded by the government) is so "inevitable," how come it hasn't happened during the 40+ years Medicare has been around? How come it hasn't happened in the VA system?

Both Medicare and the VA are systems designed to apply to sub-sets of the population. When Medicare (or the VA) announces that they won't pay for Cancer Treatment X, there still remains an enormous market for said treatment. Once the public option makes insurance available only to those with a very large stack of chips, when that public option refuses to fund Treatment X- it's effectively unavailable.

Now you can argue that this isn't "rationing" but once again that's a bit like saying Bush didn't actually engage in a War for Oil. As a technical matter "you" may be right, but as a practical matter a good argument can be made that you're being disingenuous- the labels in each instance are well within the bounds of normal political discourse (for better or worse.)

Finally, the fact that it is only happening in Canada, so far, is hardly a comfortable situation. Most importantly, much like education, once the wage-earning guy/gal is forced to pay for the public option through their tax burden- it will be very difficult for that guy/gal to buy the only types of private insurance that will survive. Like education you'll basically end up with three classes of people; those with means who won't even consider the public option, those in the middle who don't want the public option but can't afford to get away from it, and those at the bottom who are stuck with a public option that doesn't have any real incentive to adequately address their needs.

I'll grant that some amount of "reform" would be a good idea- even if I'm not really convinced. What I won't do is pretend that the current system is so bad that we need to create a worse one. To the extent we need something, we need a targeted program that addresses those most vulnerable to health care issues. Forcing 20-somethings who don't want to buy insurance (or simply want catastrophic coverage) to buy insurance isn't at all reasonable given the current situation. Presumably that's why the party in charge, complete with as strong a tail-wind as they could ever hope for, can't even get people to accept "free" health care. If they want to blame that on Glenn beck, they're welcome to do so- but I don't think that's a sound strategy.
8.20.2009 7:42pm
Leo Marvin (mail):
LarryA:

Third, don't assume that people who disagree with you are stupid, misinformed, greedy, or evil.[...]

That should be framed and hung in the office of every politician of every party, and every editor of every news publication in the country.

Update: today's new framing is that health reform is "a core ethical and moral obligation."

Or, you could tell the truth.

Ironies abound.
8.20.2009 8:28pm
santa monica (mail) (www):
It seems logical and almost certain that, if Medicare were to be opened to people of all ages, there would still be plenty of competing programs. No reason to believe that these would not be competitive (based on the heated responses I've seen from some people, they'd stick with a non-govt-run programme, even if the new Medicare was more efficient.)

It also seems that people have grave concerns with rationing that may (or will) occur under Medicare. But what about similar concerns about the rationing that goes on every day under the current private insurance programs? Why are no conservatives screaming about this (now-existing, non-hypothetical) intrusion into medical decisions that we all wish would be made only by a doctor-patient? Is there something about such decisions being made by private businesses that makes it more palatable that if/when it is done by a govt-run programme?

Lastly, if there were a public option, I suspect that there would be a flood of private insurance innovation. Various supplemental plans. Letting the free market figure out plans to provide extra coverage. Since everyone (or most people) would now have a basic plans that covers most stuff, it might even be a result that these insurance companies would get brand new clients, and make healthy profits, while still providing a valuable service. (For example, if my family has a history of cancer, I might go for Medicare, and also buy a supplemental policy that provides extra coverage for cancer, but would not pay anything extra for, say, physical therapy. If I wewe an extreme skier, then I'd do the reverse, and buy a policy that was gold-plated in regards to PT/MRIs/CT scans, etc., but provided nothing extra in re cancer treatments.)

p.s. One or two previous posters have suggested that some people do not want the rich to have the option of obtaining better insurance than the poor. Is that really true? I can't think of a single person who would block a rich person from buying the nicest house, or getting much better insurance, or having 23 cars. It sounds more like a myth, designed to scare the "haves" into keeping the status quo. I want basic affordable insurance, and think it would be a social good to have this available for all citizens and legal residents. You having something much better, due to your income or job? God bless you, and good for you!
8.20.2009 8:37pm
Spanky von Spankowitz:
It seems logical and almost certain that, if Medicare were to be opened to people of all ages, there would still be plenty of competing programs. No reason to believe that these would not be competitive (based on the heated responses I've seen from some people, they'd stick with a non-govt-run programme, even if the new Medicare was more efficient.)

This assumes that any private insurance could compete (both technically and practically) and that the increased tax burden that would come with universal Medicare wouldn't make it difficult for most people to secure private insurance. If you're advocating a universal system (or something like it) to get back to a non-gumint plan, you have to pay twice. We know from the education model that this is virtually impossible for most people.

With respect to your "rationing" point (I'll note here that what you're describing is a great deal less like rationing that what people who claim rationing is coming are being criticized for suggesting is rationing) you certainly make a reasonable point in that health care isn't limitless under the current structure. The difference is that, currently, your ceiling as far as medical care is essentially self-determined- namely, it's what you can afford. That's a very different thing than a gumint board announcing what treatments are permissible and what treatments you can have based on the "errors" of your personal conduct. Or whatever criteria the current stewards of the federal government choose to come up with.

Now, with respect to a preference, I prefer the current scenario as far as "rationing." Of course, that's a value judgment so it's very difficult to really discuss the issue and reach a compromise. I prefer less government involvement (particularly at the fed level) so that the government can set up a targeted effort for those that really need it. You appear to prefer greater government involvement. There's no right or wrong here.

What does frustrate me however, is that a lot of people who agree with your position aren't being particularly honest with respect to the cost of your approach- there will be one, a substantial one IMO. I fully understand that many on my side aren't being completely honest either, but my guys aren't advocating an enormous government action. People who do that should at least be honest about what will be gained and lost. When they fail to do that- and Obama has failed remarkably in this area- it's very difficult to show much trust to the guy who is lying to you. I'd even guess you have some fairly recent experience with this concern.
8.20.2009 9:06pm
teqjack (mail):
Steve H [heavily edited, true:

But if ... making it illegal to obtain health care beyond the care funded by the government... is so "inevitable," how come it hasn't happened ... in the other Western countries that have had public involvement in health care funding for decades? ... (I believe Canada may make it illegal to obtain insurance or health care outside of their Medicare system. But I think they are the only ones who have done this.)


Well, in the UK you can legally buy coverage. But it does not supplement the NHS: it replaces it - if you have private insurance you cannot claim/use NHS coverage.
But yes, in most of Europe insurance supplements are normal.
8.20.2009 9:34pm
santa monica (mail) (www):
I assume that for a true supplemental insurance policy (ie, designed to act in concert with Medicare) would not be that expensive, relative to a full plan. If a full Blue Shield plan costs, say, $550/month (just making up the actual numbers), a more targeted plan that would cover what Medicare does not cover might cost $100. An even more narrowly tailored plan that only would cover PT, CT scans (for one example) might cost $50. (Or, conversely, if you are a thoroughbred jockey or motocross racer, might cost $2000/month)

Somewhat off-point: I completely agree that the Obama administration has handled this quite poorly. (Although, I wonder where we'd be in re health insurance reform if Tom Daschle has been able to be confirmed. I suspect that liberals, pro-health-reformers, et all would be much happier, and those opposed would be much less happy [politically speaking, that is].) For want of a nail, the shoe was lost . . . .
8.20.2009 10:06pm
Mac (mail):

Well, in the UK you can legally buy coverage. But it does not supplement the NHS: it replaces it - if you have private insurance you cannot claim/use NHS coverage.
But yes, in most of Europe insurance supplements are normal.

Good point, teqjack.

Also, I believe Canada just had a Supreme Court case that determined it was unconstitutional to prohibit private insurance. The Canadian Health care folks are convening a conference now to discuss what to do with the Public Health Care System as it can't continue as it is. Europe is looking at privatizing large parts of its health care as it is too expensive and inefficient and, like Canada, they are drowning under the financial burden.

Medicare is going broke and so is Medicaid. You can't have any complete insurance coverage after the age of 65. You can buy a supplement, but your Primary MUST be Medicare. Even at that, it is going broke. There is NO choice!

Given the experience of our neighbors in Canada and friends in Europe, why would anyone who is not "stupid" believe that we won't end up with a single payer system and that it will not break us financially?

There is massive fraud and abuse in the Medicare and Medicaid systems. 290 billion annually, I believe, and it is going broke. And, Obama wants to cut 500 billion from Medicare at a point in time when it is about to grow by 30% as the baby-boomers retire. You believe there will be no change in coverage or benefits with that deadly combination? I might call that stupid.

Why not fix Medicare and Medicaid and start by stopping with the stupid and fallacious statement that their health care administrative costs are less than the private sector? As with the actual cost of health care which the Gov. shifts to the private sector, they shift the administrative costs to the private sector as well and say they, the Gov., is so efficient. Wrong.

Then, Obama hangs with Ezechial Emanuel (his health care advisor) who has his "Complete Life Cycle" and says it's not discrimination to deny health care to an 80 year old for a 30 year old as the 80 year old was 30 once. Huh?
Yeah, people fearing death panels is real dumb.
8.20.2009 10:22pm
Mac (mail):

Brian K (mail):
Given the vitriol thrown at anti-war protestors and anti-bush protestors it is amazing to see the lengths that conservatives go to to excuse their protesting.



But, not by Pres. Bush or even his White House as I recall. Bush steadfastly maintained it was great to live in a country where people could even protest the President. It was a non-issue to him.

i recall many times, especially with Shehan, that the news media would outnumber the protesters by 10 or 20 to 1 or more. Odd that a Constitutional law prof. and a community organizer should have such hateful words for American citizens because they disagree with him. I don't think he quite gets that he is the President. Ditto with the "report your neighbor" e-mail thing and then Axelrod sending unsolicited e-mail.
8.20.2009 10:35pm
santa monica (mail) (www):
Mac, you make some good points. But I am not sure how you think you are helping convince people by saying, in essence, "Either you agree with me, or, you are stupid." Not particularly helpful, and the spirit of such a comment is not in keeping with the rest of your (polemic, but fairly rational) post. Just my opinion. :-)

I have friends in many countries (including, but not limited to, New Zealand, Japan, and Germany) who are very happy with their govt-run health care, and I do not believe that those systems are in danger of financially collapsing. Maybe if our government looked at the systems that are working around the world, we could at least come closer to an objective determination of what is most/least likely to work here in the States.
8.20.2009 10:36pm
Mac (mail):

I have friends in many countries (including, but not limited to, New Zealand, Japan, and Germany) who are very happy with their govt-run health care, and I do not believe that those systems are in danger of financially collapsing.


santa monica

With the current econimic climate, I would not be too sure. Also, there have been a number of articles recently indicating that they are indeed looking to get more "private" and less "public". Ditto, Canada. I will try to find them and post a link.

Not long ago at all, Iceland was rated as the best country to live in by the UN. That was before they went bankrupt, the entire nation went bankrupt. Before that they were so admired for their public, tax-payer funded amenities, including health care.

As to your comment about my saying;


You believe there will be no change in coverage or benefits with that deadly combination? I might call that stupid.


I did not call any person stupid. I said the belief that, given the numbers and facts, there will be no rationing, is stupid. I try to never, ever insult any person. I was partly responding to the White house's accusations and I was calling the belief stupid, given the facts.

I would hope that people who believe that there will be no changes in Medicare even with a cut of 500 billion and adding 30 million baby boomers would explain exactly how their rosey scenarios are going to work.
8.20.2009 10:55pm
Brian K (mail):
But, not by Pres. Bush or even his White House as I recall.

forgive me if i don't trust your recall. you've been wrong too often in the past.
8.20.2009 11:17pm
Steve H (mail):
Spanky, there is absolutely no reason to believe that anything you are predicting would actually happen. None.

You are saying that rationing is inevitable, yet you can't point to any instance in which it has happened, let alone in a situation similar to ours.

It's just the typical faith-based arguments.

Obama is not promoting some radical new approach to health insurance. Western countries have vast experience with this stuff, and the US has experience with Medicare and the VA.
8.20.2009 11:36pm
John Moore (www):

Third, don't assume that people who disagree with you are stupid, misinformed, greedy, or evil.

Those who look at the protesters and seem them as stupid and misinformed (including many in this commentariat) are missing the whole point.

The protesters rightly fear that a government composed of elites who believe they are above the citizenry and who believe the citizenry is indeed stupid, misinformed (or misinformable) or evil is a government that is dangerous.

It is more the tenor of the times than the health care issue in particular that has folks up in arms (although deciding you are going to replace everyone's health care with a new system does take the cake for arrogance and hubris). They have seen the financial elite (with substantial help from the political elite) wreck the economy while waltzing off with tens of millions of bucks apiece; they have seen a "stimulus" bill that doesn't help them, but promises enormous debt; they have seen an administration and their House accomplices try to take over and re-arrange a huge part of the economy in a big rush; they have seen GM become Government Motors; they know the environmentalists are working hard to raise their energy bills; they have seen the government destroying working cars that the poorer of them may have wanted to buy.

They see clearly that this is a government of an arrogant and powerful elite.

They aren't dumb - they are the vanguard. That some have fallen for silly conspiracy ideas is natural - heck, they've been lied to by the Democrats and Obama and their enablers in the main stream media for the last year, and its becoming more and more clear.

The Obama tries to frame the issue differently, the more arrogant and incompetent he appears. Would you buy an insurance plan from someone who is so sure you are dumb that he tries three or four different, contradictory and factually suspicious pitches on you in a few months?
8.20.2009 11:40pm
Guest12345:
Steve H:

You are saying that rationing is inevitable, yet you can't point to any instance in which it has happened, let alone in a situation similar to ours.


I'm not Spanky, but how about this little CBC story. That covers both rationing and a prohibition on private coverage.

Or this one, containing the lovely phrase

"The Western Canada Waiting List Project, a $2.1M Health Transition Fund (HTF) funded project, developed pilot tools to standardize prioritized access to care for select procedures: children's mental health, cataract surgery, general surgery, hip/knee replacements, and MRI scanning, using clinical and research expertise."


Sounds like rationing to me.
8.21.2009 12:00am
Spanky von Spankowitz:
You are saying that rationing is inevitable, yet you can't point to any instance in which it has happened, let alone in a situation similar to ours.

With respect to rationing- you've already conceded that rationing is occurring in the country that is geographically and culturally the most similar to ours. This also obliterates the notion that my concerns are unfounded- they are already occurring. "Faith-based" would be hoping (and praying) that they wouldn't happen here. As I've also mentioned, we have the educational experience from which to draw- and it isn't a pretty picture.

In addition, nowhere is there a situation similar to ours, which is a cause for great concern. No nation on earth has the puritanical traditions (currently found on both the left and right, though they manifest differently) that we have. I've no interest in mixing health care with those traditions. Sin taxes are bad enough, denying health care to certain sinners, or heavily regulating certain sins because they now impact the public treasury is not something I'm excited about, irrespective of which side "thinks" of it first.

Finally, are you suggesting that no other countries (besides Canada which I guess we have to ignore for now) ration health care? That would mean everyone gets what they want, no? Obviously that state of affairs doesn't exist anywhere. What does exist, in all western nations, is a government controlled direction of health resources. Now, I'm willing to concede that a refusal to direct resources to cancer treatment X may not meet the "classical" definition of rationing. As a practical matter however, it's a distinction without a difference. Particularly so if only treatment X is going to save your life and the people who provide it can't stay afloat because the gumint plan doesn't cover it. Now it's possible that the government will make those decisions based on a rational understanding of science and economics, but it's much more likely that other factors will be paramount. See our defense budget for a helpful illustration.
8.21.2009 1:27am
Spanky von Spankowitz:
The word similar in my second paragraph should be identical.

I've got the greatest legal secretary on earth but I can't figure out how to get her to edit my blog comments so as to make them nominally coherent. I suppose I could threaten her health insurance- but what kind of a person would do such a thing?
8.21.2009 1:33am
Ricardo (mail):
This assumes that any private insurance could compete (both technically and practically) and that the increased tax burden that would come with universal Medicare wouldn't make it difficult for most people to secure private insurance. If you're advocating a universal system (or something like it) to get back to a non-gumint plan, you have to pay twice. We know from the education model that this is virtually impossible for most people.

Most people who have health insurance have group health insurance provided by their employers. Individual health insurance winds up excluding many people who have any red flags in their medical history -- these people are then left with the option of either going uninsured and trying their luck or buying into their state's high-risk insurance pool which may or may not have a long waiting list associated with it.

The reality is that there is demand for individual health insurance that is not being met due to the adverse selection problems inherent in insurance and the best efforts of insurers to exclude those who they think are high-risk.

Since the individual health insurance market is less than 10% of the overall insurance market, I wouldn't be too sad at its passing. Politically and practically, it makes sense to let people on group health insurance plans to continue on those plans and there is no reason to think that catastrophic coverage would crowd out these comprehensive health plans.
8.21.2009 2:11am
Anderson (mail):
Third, don't assume that people who disagree with you are stupid, misinformed, greedy, or evil. * * * The administration of a former teacher of constitutional law complains about Americans exercising their constitutional right to petition the government for redress of grievances.

Oh yes, that's what irks the administration -- the mere fact of petition, irrespective of any lies being told by the petitioners and propagated by their media allies.

Mr. Hyman fails to adhere to his own rule. Quelle surprise.
8.21.2009 7:42am
Steve H (mail):

With respect to rationing- you've already conceded that rationing is occurring in the country that is geographically and culturally the most similar to ours. This also obliterates the notion that my concerns are unfounded- they are already occurring.

You're still missing something. I don't believe either Canada or the UK adopted bans on private spending in response to increasing costs, which is what you seem to be suggesting. They adopted a system that way from scratch, out of a strong (and I would say misguided) egalitarianism. Which certainly doesn't exist in this country.

(Actually, I read something posted by a Canadian last night suggesting that they do have supplemental insurance there. So the "most culturally identical" country might not actually ban outside privately-purchased care.)



Finally, are you suggesting that no other countries (besides Canada which I guess we have to ignore for now) ration health care? That would mean everyone gets what they want, no? Obviously that state of affairs doesn't exist anywhere.

This is going back to the misleading use of the term rationing. What I am saying is that I am unaware of any other countries that actively prohibit people from obtaining coverage beyond that funded or provided through the government -- which is the only definition of "rationing" that makes sense in this debate.

Once again, though, you are the one asserting that rationing is inevitable, so certainly you would have no trouble coming up with countless examples.

The fact is, the "government will ration" argument is inherently doomed to failure. If a government plan or coverage refuses to pay for certain necessary coverage, then a market will develop for supplemental insurance. We have actual examples where this has happened: Medicare and most European countries (and maybe Canada, too). We have no examples where this has not happened, except where it was banned from the start (which is not on the table).

The only way a market would *not* develop is if there is a lack of demand, which means that the government plan or coverage would be satisfying the public.

And even if the "government would have to ration" argument had validity, you'd have to show how that rationing would be any worse than what we have now. Right now, private insurers actually do refuse to pay for certain treatments. And in at least one state (and possibly more) Republicans have made it so that if insurance won't pay for continued treatment, a hospital has the right to cut off life support.

There's your death panel.
8.21.2009 11:18am
rarango (mail):
Does anyone know of an unequivocal statement Mr. Obama has made about coverage for illegal aliens? I do not. I think he has words on both sides of the position, but the words are neither "yes" nor "no."
8.21.2009 12:10pm
Guest12345:
Steve H:

(Actually, I read something posted by a Canadian last night suggesting that they do have supplemental insurance there. So the "most culturally identical" country might not actually ban outside privately-purchased care.)


They tried to ban private health care. But then the courts told the bureaucrats that "access to a waiting list isn't access to health care" and struck down the ban on private coverage.
8.21.2009 12:23pm
Anderson (mail):
Does anyone know of an unequivocal statement Mr. Obama has made about coverage for illegal aliens? I do not.

I also do not know of an unequivocal statement Mr. Obama has made about coverage for space aliens.

But unless there's something in the legislative proposals now actually before Congress about space aliens' coverage, I'm not going to worry about it.

(Where's the Weekly World News when you need it? "Space Aliens 'Invade' Earth ... to Enroll in Obamacare!")
8.21.2009 12:36pm
ShelbyC:

The fact is, the "government will ration" argument is inherently doomed to failure. If a government plan or coverage refuses to pay for certain necessary coverage, then a market will develop for supplemental insurance.


And this market increases the cost of said necessary coverage, right?
8.21.2009 1:00pm
The Original TS (mail):
Rationing is inevitable whenever there is a non-market limitation on a resource. If the there is government-run healthcare and the government decides that it can only spend X dollars on it, then rationing there will be.

In fact, there is already a rationing system in U.S. healthcare and it provides an interesting window on how it would operate. Organ transplants are rationed by specific rules. These rules were, thankfully, not developed by government employees -- a class whose rule-making ability I am reminded of every time I fly and am forced to engage in TSA security theater.

But they are rules and they actually do deny care to people who don't meet their standards. Organ donors, as I understand it, are assigned a priority based on a number of factors, only one of which is the time spent on the waiting list. For example, someone who damaged their liver through alcoholism will have a much, much lower priority than someone who's liver got damaged through no fault of their own. A 20 year old will have a much, much higher priority than a 70 year old.

These rules make sense. But they are an unfortunate solution to a problem that cannot readily be addressed through market forces: the shortage of livers. It is another thing entirely for the government to create shortages as a matter of policy, e.g., to cut costs, and then to make up rules to allocate the now-scarce resource.
8.21.2009 1:21pm
Steve H (mail):

And this market increases the cost of said necessary coverage, right?


I'm not sure -- what point are you trying to make?
8.21.2009 1:25pm
Steve H (mail):

Rationing is inevitable whenever there is a non-market limitation on a resource. If the there is government-run healthcare and the government decides that it can only spend X dollars on it, then rationing there will be.


I don't think your second sentence follows from your first. If the government decides it can only spend X dollars on it, that does not prevent others from spending Y dollars on it as well.

Just like the system we have now -- if your private insurer decides it will only spend X dollars on mental health therapy, that doesn't mean you can't have any more, it just means you have to pay for it yourself, or obtain other insurance for that kind of coverage.

The only way this would fail to work is if the government made it illegal for people to pay for mental health therapy on their own. There is no plan to do such a thing, and the history of other systems shows that, at *best*, this is very rare (let alone inevitable).
8.21.2009 1:33pm
Guest14:
Third, don't assume that people who disagree with you are stupid, misinformed, greedy, or evil.
It's less an assumption and more a carefully reasoned conclusion based on a signficiant amount of evidence.
8.21.2009 1:33pm
rarango (mail):
Anderson: cute but totally non-responsive. So in other words you have no idea.
8.21.2009 1:48pm
Steve H (mail):
This is not from Obama, but from the House bill:

SEC. 242. AFFORDABLE CREDIT ELIGIBLE INDIVIDUAL.

(a) DEFINITION.—

(1) IN GENERAL.—For purposes of this division, the term ''affordable credit eligible individual'' means, subject to subsection (b), an individual who is lawfully present in a State in the United States (other than as a nonimmigrant described in a subparagraph (excluding subparagraphs (K), (T), (U), and (V)) of section 101(a)(15) of the Immigration and Nationality Act)—

SEC. 246. NO FEDERAL PAYMENT FOR UNDOCUMENTED ALIENS.

Nothing in this subtitle shall allow Federal payments for affordability credits on behalf of individuals who are not lawfully present in the United States.
8.21.2009 1:57pm
Anderson (mail):
Rarango, it was quite responsive: if you are sincerely worried about whether X is a provision of the bill, then go find out. Feel free to let us know, too.

As it is, idly wondering whether, say, euthanasia of those over 80 years old is a provision -- because you haven't heard the President speak to the issue, so who knows? -- seems a trifle insincere.
8.21.2009 1:58pm
rarango (mail):
Steve H: wasnt the question--what did President Obama say about it
8.21.2009 1:59pm
rarango (mail):
Andeson: I know exactly what President Obama said--which is why I asked the question in the first place.
8.21.2009 2:01pm
zuch (mail) (www):
Prof. Hyman:
Third, don't assume that people who disagree with you are stupid, misinformed, greedy, or evil. They may just have different preferences about health insurance, taxes, income redistribution, or the role of government in health care. If preferences differ, telling people they can't understand the complexities won't help matters. Such condescension just makes aggrieved citizens angrier.
While you may be right that to "assume" such ab initio is not warranted, the implication here is that we should assume and maintain the opposite and afford everyone a polite hearing. That I disagree with. Sometimes you simply have to forget about politeness, and tell them they're stoopid (or at the very least [sometimes intentionally] misinformed). Avoiding that plain truth doesn't help the situation, and pointing it out can't hurt the situation. As Frank says, it's not worth while having a "dialogue" with a dining room table, Stephen Colbert's laudable efforts notwithstanding.

Here's the sad state of our political "discourse" right now.

What needs to be done is for the major networks and leading newspapers to make this fact (of our collective national ignerrence) a prime-time/Page-1 lead story, and state clearly and unequivocally that no "national discussion" on health care (or any other such political question) is possible until the untruths are exposed and left to rot life dead fish on the beach, so that everyone will avoid them, and start talking about the planet we live on.

Cheers,
8.21.2009 2:28pm
zuch (mail) (www):
Mac:
Europe is looking at privatizing large parts of its health care as it is too expensive and inefficient and, like Canada, they are drowning under the financial burden.
The mind boggles. Yes, Europe's just drowning under the burdens of their socialism ... to the tune of $10 trillion or so ... not to mention their moribund economies .... Oh, waidamminit.

And cites for "Europe" rushing to privatize all their health care?!?!? Heard that on Limbot or was it FauxSnooze, eh?

Cheers,
8.21.2009 2:40pm
Steve H (mail):
Heck, isn't most health care in Europe already privatized, i.e., provided by private, non-governmental entities?

(Do any other European countries rely primarily on an NHS-style government-run system to provide health care to the general public?)
8.21.2009 3:15pm
Thorley Winston (mail) (www):
Does anyone know of an unequivocal statement Mr. Obama has made about coverage for illegal aliens? I do not. I think he has words on both sides of the position, but the words are neither "yes" nor "no."


I haven't followed this aspect of the debate this closely but I do know that the bill does provide coverage for legal immigrants and Section 246 says that it doesn't authorize payments for people who are in the country illegally. However AFAIK there is no verification or enforcement mechanism in the bill to prevent an illegal alien from receiving benefits either directly or through their employer. An attempt was made to require that eligibility be determined (the Heller Amendment) but it was defeated on a straight party-line vote.

So basically the supporters of the bill can have it both ways. They can (technically) truthfully say that the bill has language saying that the bill doesn't authorize payments to illegal aliens. At the same time, without any method of verification of citizenship or legal immigration status in the law, this is by design a toothless provision and as a practical matter illegal aliens will likely receive benefits.
8.21.2009 3:47pm

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