Leave The Gun, Take The Cannoli (Leave The Mandates, Take The Subsidies)

Ezra's latest is much better:

How you'll judge Max Baucus's framework depends on how you understand the goal of health-care reform. . . . It really would insure tens of millions of people. . . . It really will expand Medicaid and transform it from a mish-mash of state regulation into a dependable benefit. . . . The main disappointment is that insofar as you see the bill as a vehicle for moving us towards a better, more efficient, less costly system, there are some problems. In particular, this bill seems to block off . . . possible points of expansion. . . . [T]he co-op plan is an interesting policy proposal, but unlike a public insurance option, it's difficult to imagine it growing into anything significantly stronger than what's outlined in the paper.

To follow Ezra's point, if this is where health care legislation is heading, it is no longer reform, but merely providing relief to the poorest among us. And that is an absolute good. That is the cannolis. Let's take that. But let's leave the "reform" (the mandates and the co-ops), or the gun.

If we are giving up on positive incremental structural reform, and to me that means a public option, then let's leave reform out altogether. Let's take the money for Medicaid and other coverage expanding programs, and leave out the mandates. And that makes a reconciliation bill quite doable. Then, maybe, we can do health care reform right later.

Speaking for me only

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    What I want (5.00 / 1) (#13)
    by scribe on Tue Sep 08, 2009 at 04:12:37 PM EST
    is the Canadian system.  Current prices for health insurance:  $50-$100/month for an individual or thereabouts.

    Most of the rest of what I have to say about the debate, and the clowning around which Baucus' lobbyist staff have written as his "deal" wind up being too profane for this site.

    That should have been the "moderate" (5.00 / 2) (#21)
    by andgarden on Tue Sep 08, 2009 at 04:15:35 PM EST
     position. Political framing FAIL.

    Well, I can't help it Obama (5.00 / 2) (#29)
    by scribe on Tue Sep 08, 2009 at 04:22:40 PM EST
    and Rahm have no moral center*.  

    BTW, if we're comparing pricing, in British Columbia, you get your coverage for $54/month for a single person, $96 for a couple, and $108 for a family.

    And below $20k/year, it's free.  Up to $28k/year, there's a sliding scale of subsidy.

    Go look.


    But haven't you seen... (5.00 / 2) (#37)
    by Dadler on Tue Sep 08, 2009 at 04:31:31 PM EST
    ...all coverage of those thousands of Canadians laying dead in the streets with their waiting numbers for non-essential, elective surgery in hand?

    Nope. (5.00 / 2) (#56)
    by scribe on Tue Sep 08, 2009 at 05:04:02 PM EST
    Maybe that's because that doesn't exist.

    When I was in Canada this summer, there were lots of people everywhere, and no dead bodies in sight.

    The one Canadian I ran into who had anything to say about his country's health insurance was a local "First Nations" guy (we'd call them "Native Americans" or "Indians") who was full of praise for the doctors who opened his head and surgically fixed the lesion in his brain that had been giving him seizures.  Of course, he was also the guy talling stories about his making jokes (to the doctors) about "it's finally time you white guys are going to scalp an Indian" that the doctors couldn't laugh at because that might be considered racist or something.

    I could put up with a system like that.


    Wow (5.00 / 2) (#57)
    by nycstray on Tue Sep 08, 2009 at 05:08:01 PM EST
    as a single person, I'd be willing to pay the family rate!

    I may end up in BC after my family obligations are over. I've always thought it looked like a nice place to move . . . and I'd get affordable health CARE ta boot! Since I'll be in Calif  soon, I may also find myself hoping the southern border to Mexico for care in the not so distant future, lol!~


    Hmmm...I would bet that is where we are going. (5.00 / 2) (#23)
    by masslib on Tue Sep 08, 2009 at 04:15:58 PM EST
    That's fine.  The PO isn't a viable policy anyway.  We can do that with the next President by expanding Medicare.  Improving and expanding Medicaid is a must, subsidies for private insurance absolutely suck because it's subsidizing corporate profits, but fine.  Leave it for the next debate.  Politically, I wonder if the Baucus bill has so much bad in it, so Obama can pivot from it, take the good, leave the bad, pass a bill, everyone's happy.  It's not universal health care, obviously, but that was never really Obama's signature issue.

    It is all rearranging the deck chairs on (5.00 / 1) (#32)
    by inclusiveheart on Tue Sep 08, 2009 at 04:25:07 PM EST
    the Titanic as far as I am concerned.  Ten, fifteen years ago some of this mealy-mouthed middle of the road stuff might have had meaning and impact, but the reality is that Americans have lost too much ground at this point between Congressional actions insulating the private insurers' failed business model from failure and an economic collapse just to add insult to injury.  I think they are better off not passing a thing because nothing they are proposing will give them either widespread results or electoral dominance imo.

    But that's what is on the table... (5.00 / 1) (#47)
    by masslib on Tue Sep 08, 2009 at 04:37:30 PM EST
    "mealy-mouthed middle of the road stuff".  The plans on the table in Congress are actually less ambitious than the Clinton plan in the '90's.  If we are going to just throw money at the problem, and kick the can, I'd rather it just provide relief no sticks.  First do no harm, ya know?  Let the states and the next President do something substantial.

    But I am not convinced that we (5.00 / 1) (#50)
    by inclusiveheart on Tue Sep 08, 2009 at 04:43:16 PM EST
    would indeed be providing relief at this point.  Honestly, it is hard for me to imagine defending a lot of this stuff as more "frivolous" spending to add to the GOP's arsenal of cynical complaints about "ineffective and inept government programs".

    That's why I have to say that I believe that this looks like rearranging the deck chairs.  It doesn't even make political sense to me at this point because I really don't see the liberal base being enthusiastic and I don't see whatever enthusiasm that they manage to generate eclipsing the detractors attacks - because the change will not be comprehensive enough to steal them from the criticism they will receive regardless of how good or bad the changes turn out to be.  That's just my opinion though.


    IIRC none of the bills (5.00 / 1) (#36)
    by MO Blue on Tue Sep 08, 2009 at 04:31:07 PM EST
    provide universal health care for all citizens. House H.R 3200, if I am not mistaken, covers the most people.  The Senate HELP bill covers less people than any House bill and probably President Snowe's bill will reduce the number of people even more.

    Yeah, I know. I actually don't support any of tho (none / 0) (#43)
    by masslib on Tue Sep 08, 2009 at 04:33:51 PM EST
    Oopps. (5.00 / 1) (#46)
    by masslib on Tue Sep 08, 2009 at 04:35:13 PM EST
    Any of those bills.  But a band aid of Medicaid improvements, and subsidies, until the states or the next President passes something sensible to provide UHC(Medicare for All), I can live with.

    I could live with that too (5.00 / 3) (#53)
    by MO Blue on Tue Sep 08, 2009 at 04:56:02 PM EST
    If I had to bet, I would bet that the mandates remain no matter what else is taken out of the bills.

    I would also want another caveat. The cuts to the Medicare budget be eliminated as a payment mechanism. After watching this debacle on health care reform, I am very reluctant to have this Congress reform Medicare.


    Agreed completely. I'm all for cutting (5.00 / 2) (#60)
    by masslib on Tue Sep 08, 2009 at 05:12:36 PM EST
    subsidies for private insurance in Medicare but then let's use those funds to stream line Medicare and improve what it covers.  

    not his signature issue (5.00 / 1) (#88)
    by noholib on Tue Sep 08, 2009 at 09:42:18 PM EST
    No, it never was his signature issue.  During the primaries it was his attitude on this particular issue that initially un-enthused me.  I was appalled that he wouldn't even allow single-payer to be discussed, but I wasn't really surprised. What a pity!

    Okay. (5.00 / 1) (#44)
    by Ga6thDem on Tue Sep 08, 2009 at 04:34:17 PM EST
    BTD you win. Simply mentioning his name make me laugh.

    Where I think Ezra goes off the (5.00 / 11) (#49)
    by Anne on Tue Sep 08, 2009 at 04:38:55 PM EST
    rails is in buying into the idea that reform is about everyone having insurance, when, for a lot of us, reform is and always has been about everyone having the ability to get affordable care.

    This isn't just about getting the uninsured a brand-spanking new insurance policy with a little coupon book for their monthly premium payments; it isn't even just about capturing those who currently make too much to qualify for their state's Medicaid program.  

    It's really about all of us being captive to an industry whose focus is not on care, but on making money - that's what businesses do, and just because this is the people's health - physical, mental and financial - that is at stake matters not one whit.

    You are absolutely right that we should be providing relief to the poorest among us, but the state of health care and health insurance is such that any one of us - unless we are multi-millionaires - could be among the poorest with one serious illness or accident - even though we have insurance, have a good job, have some money in the bank.  And it is that essential reality that dictates that we have to truly reform the system.  As soon as you make provisions for those at the bottom of the pile, there will be a new bottom - and the people in it will be just as deserving as the people who came before them.

    Marcy Wheeler has a couple of posts that take the Baucus plan apart in ways that Ezra hasn't; the reality of the numbers in the Baucus plan are eye-poppingly ridiculous, to the point where I wonder what planet he lives on. Oh, yeah - planet DC.

    Is it possible to triage the system, such that it can be fixed in stages?  Maybe, but I don't know that anyone in Congress or the White House has really taken the system apart to the extent that those stages could be identified and planned for.

    Sure, I would be happy to see 10 million people who need help getting that help, but it has not been shown to me that the help will come in the form of actual care.

    And it is care that should be the focus and the goal of any reform effort.

    Good writeup BTD (5.00 / 3) (#54)
    by Militarytracy on Tue Sep 08, 2009 at 05:00:46 PM EST
    But I'm giving up hope that we aren't going to bail out somemore American corporations at the expense of taxpayers and now lives as well.  The existing system of private insurance companies is set to self destruct given the economic corrections taking place right now without government intervention.  I wonder that nobody has talked about that much, and Obama's penchant for saving American corporations first and foremost, then equating that to a modern day FDR saving capitalism.

    Wow. (5.00 / 3) (#58)
    by katiebird on Tue Sep 08, 2009 at 05:08:06 PM EST
    The existing system of private insurance companies is set to self destruct given the economic corrections taking place right now without government intervention.

    This is true.  I bet it's not sustainable after a year or two.... I know my family can't stay insured if we get another premium-hike next year like we did this year.

    So you're saying that this is a bail-out by another name?


    That's what it smells like to me (5.00 / 1) (#61)
    by Militarytracy on Tue Sep 08, 2009 at 05:17:16 PM EST
    Nobody could afford the existing rates and where they were going.  The insurance companies were also gambling on Wall Street too, I don't think they can simply "adjust" with this economic adjustment and the new economic reality we are going into.  People were just going to drop their insurance when it got too nuts, and perhaps in the upcoming near years they will.  But Obama is going to give them a better base to be receiving funds from in a couple of years, one that is mandated to pay them too (they should be able to bank on something longterm to stay afloat on then) as we just now begin to hit more of the grim economic realities we will all face.  I have little faith that anything else will come about.

    Hey katiebird (5.00 / 1) (#62)
    by cawaltz on Tue Sep 08, 2009 at 05:20:02 PM EST
    ((((waving before going back into quietly observing mode)))

    Here's link to a Washington paper (5.00 / 1) (#102)
    by Militarytracy on Wed Sep 09, 2009 at 03:38:04 AM EST
    Seattle PI that has figures on its big three.

    The premium increases follow multi-million-dollar losses in investments suffered by the state's top three insurers, which reported their financial statements earlier this month.

    According to Washington Healthcare News, which summarized the statements, Premera Blue Cross suffered a $111 million drop in capital last year, Group Health Cooperative lost $187 million, and Regence BlueShield lost $128 million.

    Much of the declines were from unrealized losses in the stock market collapse. Some insurers in Washington also suffered a loss in net income. David Peel, publisher and editor of Washington Healthcare News, said it's too soon to tell how the losses will affect customers' premiums.

    Here's a link to a Scientific America (none / 0) (#105)
    by Militarytracy on Wed Sep 09, 2009 at 03:46:53 AM EST
    article about how much insurance companies invested in big tobacco.  Sort of clarifies that they are playing the market and that they also lost big too because nobody won big except for CEOs.

    Why are you convinced health (none / 0) (#68)
    by oculus on Tue Sep 08, 2009 at 05:38:11 PM EST
    Care insurers are on shaky financial ground?  Unemployment?

    They invest our premiums (5.00 / 4) (#87)
    by ruffian on Tue Sep 08, 2009 at 09:08:15 PM EST
    They are not in a "lockbox".  As non-banks, they are not required to disclose their capitalization, are they? Maybe they are in some states. That would be interesting to see. I think the huge premium hikes int he last year or so were more to cover gambling debts than to cover rising health care costs.

    Waxman asked to look at financials (none / 0) (#101)
    by Militarytracy on Wed Sep 09, 2009 at 03:22:08 AM EST
    Last I heard a big fit was had by the insurers he requested it from, never did hear that he got it either.

    Without subsidies from the (5.00 / 2) (#89)
    by MO Blue on Tue Sep 08, 2009 at 10:54:35 PM EST
    government or employee paid insurance, the price for the coverage  and deductibles might well  become more than people will be willing or able to pay. Based on articles I read recently, people are already dropping their insurance because they can not afford to pay the premiums.

    The Minneapolis Star Tribune reported this week, "Americans with employer-sponsored health insurance can expect to pay a bigger share of health care costs this year than ever before -- 41 percent."  For families in Minneapolis, they estimate, that will come to almost $7,000 out of pocket per family. That's the world we live in now.  We also know what the world will look like tomorrow, as the Center for American Progress has put together a projection based on Congressional Budget Office data:  average premiums will rise more than 70% in the next 8 years, even faster than they have the previous 8 years.  Snowe may think employer-based insurance can turn this runaway train around voluntarily, but a Hewlitt Associates survey says  as many as 20% of businesses are contemplating dropping health benefits in the next 3 to 5 years if this trend continues.  So, good luck with that. link

    Once the real cost of health insurance impacts more of the population (3-5 years), it is my opinion that they will demand REAL reform of the system.
 If we didn't have an employer based system,  we would probably had a national health care system by now.

    If we took the health insurance companies (5.00 / 1) (#91)
    by Anne on Tue Sep 08, 2009 at 11:11:44 PM EST
    out of the equation, would we be able to figure out what it actually costs to get and/or provide care?  I would be very curious to know if anyone has tried to quantify that - and I would also be curious to know why someone has not tried to put some hard numbers to it.

    I wonder what would happen if providers said, "If you have health insurance, it will cost you $100 for a 15 minute visit, because I have to pay someone to submit the claim, and possibly argue with your insurance company, but...if you want to pay me directly, it will only cost you $60, because I don't have to deal with an insurance company."

    I think if they wanted to, providers could provide incentives for shutting out the parasitic insurance companies - and we might all be the better for it.


    There was a post a week or so back (5.00 / 1) (#94)
    by MO Blue on Tue Sep 08, 2009 at 11:40:47 PM EST
    that said some doctors in Seattle (I think) have started a practice that does not accept any insurance and charges a flat fee of $50 per visit. One of the doctors interviewed, said that they save 40% by not processing insurance claims.

    Also, read somewhere that processing Medicare claims is substantially less expensive than claims from private insurance.

    One day soon, I'm going to have to organize my insurance related bookmarks so I can find data more easily. Never can find them again by googling for them (skills primitive at best).


    My internist's practice no longer accepts (none / 0) (#95)
    by Anne on Tue Sep 08, 2009 at 11:54:47 PM EST
    any insurance plans; they will submit the claims, but they want to be paid up front for whatever the charge is; whatever one's plan pays is not their concern.  Now, whether what they charge is less or not as a result is questionable, since they are still submitting claims on behalf of their patients, and that means that they still have staff assigned to that task.  But they are closer, I think to cutting out the middleman.

    All I know is that when I go to see my doctor, I do not feel like I am on an assembly line, or that he has to broom me out before we have finished talking because the next person is waiting.


    Some NY Drs tried to do something (none / 0) (#110)
    by nycstray on Wed Sep 09, 2009 at 08:14:48 AM EST
    which was an idea I liked but alas . . .

    Some have (none / 0) (#98)
    by gyrfalcon on Wed Sep 09, 2009 at 12:21:46 AM EST
    The figure I've read is about 30 percent.  That's by no means our entire problem with health care costs in general, but eliminating it would be a darn good start.

    Thie cosmetic surgeions do not (none / 0) (#100)
    by oculus on Wed Sep 09, 2009 at 02:32:14 AM EST
    Accept insurance. Cash.

    But they do have attractive payment plans :) (none / 0) (#104)
    by Militarytracy on Wed Sep 09, 2009 at 03:41:50 AM EST
    Well, it's not like they have a choice, (none / 0) (#108)
    by Anne on Wed Sep 09, 2009 at 07:56:20 AM EST
    since I don't know of any insurance plans that cover cosmetic procedures.  It's okay to be sick, but not to have fun making one's self look better, lol.

    Interesting idea.....n/t (none / 0) (#107)
    by sallywally on Wed Sep 09, 2009 at 07:44:55 AM EST
    I hope that you are right (5.00 / 2) (#103)
    by Militarytracy on Wed Sep 09, 2009 at 03:40:47 AM EST
    that people with mandates are going to get really really angry about the reaity of it all.  I'm so tired of Americans sitting around with that blank expression when they should have been angry years and years ago.

    Paul Krugman (5.00 / 3) (#63)
    by lilburro on Tue Sep 08, 2009 at 05:21:06 PM EST
    has just offered on his blog a pretty good defense of the public option.

    I think at this point anything less than a bill with a public option is a dealbreaker for me.  You just can't throw that much money at insurance companies and expect to be given another opportunity to fix healthcare.

    Krugman leaves out two points (5.00 / 2) (#71)
    by lambert on Tue Sep 08, 2009 at 07:03:20 PM EST
    Both of which make the supposed advantages of public option much less than he thinks:

    1. 10 million enrollees. That's the estimate from CBO, and if public option advocates have a better one, I'd like to see it. (What we do know is that the enrollees will be nothing like the 130 million enrollees in Hacker's Medicare-style academic proposal before the progressives bait-and-switched us into whatever it is we're going to end up with after the Senate gets through with HR3200).

    So, does anybody believe that 10 million enrollees will have enough market power to keep the insurance companies honest? I don't. Krugman may; but if he does, he doesn't say why.

    2. Grandfathering. It simply is not true that if you can always get the "public plan" (or "option"). In fact, if you already have employer based insurance, you can't go out on the health exchange, even if you don't like your plan, at least in HR3200 (See Matt Taibbi for detail.)

    Krugman, and most public option advocates, present public option as competing with the private plans. What they tend not to focus on is how circumscribed that competition actually is.


    Get the PO now, Expand it Later (5.00 / 1) (#72)
    by WS on Tue Sep 08, 2009 at 07:21:00 PM EST
    It'll be easier to expand if and when there is an existing program/public option that people can point to.  

    Yeah (5.00 / 3) (#74)
    by cawaltz on Tue Sep 08, 2009 at 07:31:16 PM EST
    How is that working out for the proponents of expanding Medicare?

    My instincts say taking settling for 10 million just so Obama can say he did something about health care is a bad idea.

    Furthermore, they aren't offering a PO. What they are offering is an expansion of Medicaid and allowing individuals to join a health care co op with their money(which would later be refunded in part or whole in the form of a credit). I'm not sure where they figure folks are going to get the initial money from all things considered.


    Tax credits (5.00 / 1) (#92)
    by MO Blue on Tue Sep 08, 2009 at 11:22:00 PM EST
    Another Republican idea written in the bill to please President Snowe.

    Color me totally disgusted. I didn't vote for a Democratic majority to pass Republican agendas. I wish I could get a refund.


    This is a dead camel (5.00 / 4) (#78)
    by lambert on Tue Sep 08, 2009 at 08:03:53 PM EST
    There's already Medicare to point to,  so what in addition does the public option -- with only 10 million enrollees -- give in terms of "existing programs" that Medicare does not already give?

    Further, given that the 10 million enrollees means that the program won't have the market power to "keep the insurance companies honest" (if that were even possibnle), the program is unlikely to meet its stated objections. That means it's a FAIL.

    So how does passing a FAIL make success more likely? Why won't validate the talking point that government is the problem?

    Then you throw into the mix taxing the insured to pay for the uninsured, and forcing people to pay for junk insurance with the mandate, and having the IRS do the enforcement, and you've got a recipe for a program that people are just going to hate. Like tax resistance hate.

    This is a dead camel.


    I think people on the Left who gave (5.00 / 1) (#86)
    by masslib on Tue Sep 08, 2009 at 08:49:27 PM EST
    up on Medicare for All are just so invested in the PO they can not see the forest through the trees.  It was exactly opposite for me.  I would have settled for the PO IF it was built on Medicare with huge market share.  The minute I saw HR 3200 w/it's best case scenario 10 million enrolled by 2019(never mind HELP with it's ZERO expected enrolled by 2019), I bolted.  It is quite obvious to me that sort of insurance option is not viable.  It's a marketing scheme.  

    How will subsidies work for the self-employed (5.00 / 1) (#70)
    by esmense on Tue Sep 08, 2009 at 06:51:32 PM EST
    & very small business owners whose income can flucuate from one month or one quarter to the next?

    Or for hourly wage earners whose hours may flucuate seasonally, from month to month, or even from week to week?

    How about those who work on commission?

    All of the above are the very people who need some better, more affordable insurance options than those that are readily available now.

    Will they find they have coverage one month, or one quarter, but earn too much to qualify for coverage the next? What will that mean for their ability to secure consistent medical care? And what happens if their earnings for a particular time period do, in retrospect, turn out to exceed the limits for that time period? Will they have to repay their "benefit?" Perhaps having to repay an "undeserved" benefit from a slightly more prosperous month or quarter out of funds earned in a much lower earning month or quarter?

    How much time and energy will they have to devote to determining or proving they qualify for a subsidy? To trying to ensure continuous coverage, etc?

    Subsidies are great for the insurance companies -- but for many of the working poor, small business owners and their employees, the self-employed, commissioned workers, young workers who work less than full time while acquiring training and education, etc., they are a much less than efficient solution. One that many, unless coerced, may decide is more pain than gain in the long run.

    Furthermore, considering the extremely high cost of individual insurance -- even high deductible insurance -- in many parts of the country, will these subsidies really be generous enough to make such insurance affordable?

    Count me as extremely skeptical about subsidies.

    And count people like Ezra as extremely naive about the realities faced by a significant portion of people who work and do business in the modern American economy.

    Baucus plan (5.00 / 1) (#75)
    by cawaltz on Tue Sep 08, 2009 at 07:33:45 PM EST
    doesn't call for subsidies. People would be paying out of pocket that first year and then get reimbursement or partial reimbursement in the form of a credit. It would be similar to the tax credit people get for child care costs.

    I'd imagine that would also answer your hourly wage, and variable income question. It would based on your ANNUAL income.


    That's (5.00 / 1) (#83)
    by Ga6thDem on Tue Sep 08, 2009 at 08:23:08 PM EST
    McCain's plan wasn't it? Or maybe Guiliani's? Man for most of those people if they don't get help up front this is completely worthless.

    A movement should be started to kill this bill because it's simply so bad that it's worse than doing nothing.


    Amen (5.00 / 4) (#80)
    by dissenter on Tue Sep 08, 2009 at 08:08:17 PM EST
    My renewal for next year is $26K a year for me and my husband. Guess what, we can't afford that so we will probably dropping our insurance.

    I don't know on what planet these people live but not only is the health care crisis going to kill Americans it is going to finish off the economy, small business and entrepreneurship in the US.


    Thank you (5.00 / 3) (#81)
    by nycstray on Tue Sep 08, 2009 at 08:13:32 PM EST
    as a self employed person who's dollars vary by month/season/recession, I have those same questions. Whether I qualify for gov help or am paying on my own, the consistency of which I could pay a rate is an issue. When they say "affordable", I ask what is that in their minds. Affordable to me is that I can pay in "poverty" (just above gov help) and also as a self employed person who may have a low month or 3. I'm sure it's the same for many self employed/small businesses. We are looking for insurance we can afford that we can use in good times and bad. I don't know about others, but here in NY, I'd have to be pretty darn poor (not working) to get help, and not having children makes it even worse.

    Reminds me of when we were filling (5.00 / 3) (#85)
    by Anne on Tue Sep 08, 2009 at 08:48:56 PM EST
    out financial aid forms for our older daughter for college, and the end result was "Your expected annual family contribution is $18,000," and I laughed out loud and remarked, "If I had $18,000 lying around I wouldn't be filling out these #$%@&*% forms!"

    I swear, we are just not speaking the same language as the people who come up with these "plans."


    Excellent questions (none / 0) (#99)
    by gyrfalcon on Wed Sep 09, 2009 at 12:24:53 AM EST
    Thanks for raising them.

    Most of us are trapped in a (5.00 / 8) (#84)
    by Anne on Tue Sep 08, 2009 at 08:44:57 PM EST
    system where, by the time we need to see the doctor because we're sick, we have already paid out hundreds, if not thousands of dollars in premiums, and then we are asked for a co-pay of anywhere from $10 to $40, and if we have a deductible, we pay that, and so only if we have a major illness, or have significant prescription charges, do we ever actually cost the insurance company anything close to what we've paid in.  Fifteen minutes with the doctor to diagnose a sore throat just does not cost the insurance company $7K or $10K or $15K - which is what a lot of us are paying on an annual basis.  Throw in an annual physical, a mammogram, a colonoscopy and there still is no way we have gotten care equivalent to what we have already paid.

    If it weren't for the fact that we're all petrified that we're going to get hit with unexpected medical events and end up in bankruptcy, most of us could probably afford to pay to see the doctor for the occasional sore throat, or UTI or sinus infection - and the heck with the parasitical insurance companies.  And the doctor could collect his or her fee knowing it was purely fee-for-service and didn't have to be artificially inflated so he could pay the insurance-processing staff, or so that the reimbursement he got from the insurance company would have some basis in reality.  Silly analogy, but when my kids were in school and would come home with all these fundraisers that involved selling pizza or cookie dough or gift wrap, I would just write a check to the school for $50 because I didn't need pizza or cookie dough (gift wrap I always bought!), and that way all of my contribution went to whatever they were raising money for, and didn't first have to go for the cost of the product that was being sold.

    So, where is all the "extra" money going?  To the same people and the same entities that are going to benefit from whatever reform gets passed.

    And this is how one ends up realizing that as long as there is this middle-man - insurance companies - that stands between us and those who deliver health care, it is ALWAYS going to cost more - a lot more - than it would if we had a way to eliminate that impediment and facilitate the access and delivery of care.

    And nothing that I have seen in any of the proposals on the table suggests that the reform effort will do anything to loosen the stranglehold the insurance companies have on our - and the government's - throats.

    You must have missed (2.00 / 1) (#1)
    by cawaltz on Tue Sep 08, 2009 at 03:44:18 PM EST
    the proposal to fine people $3800 for not buying whatever cr@p insurance that can be got. We've got some seriously twisted representation.

    Read the post (5.00 / 1) (#33)
    by gyrfalcon on Tue Sep 08, 2009 at 04:26:43 PM EST
    he says take mandates and all the rest of the half-assed supposed "structural reform" elements out of it.

    No mandates, no $3,800 fines.


    You must have missed (none / 0) (#2)
    by Big Tent Democrat on Tue Sep 08, 2009 at 03:46:46 PM EST
    my post.

    I suggest you read it again because your comment makes absolutely no sense.


    I've read it again (none / 0) (#20)
    by cawaltz on Tue Sep 08, 2009 at 04:15:30 PM EST
    and I think you are going to be hugely disappointed because if this were truly about the poor then there wouldn't be anything on the table and any talk of fining people for not buying coverage.

    My point is the latest developement is troubling.

    I'm sorry if you missed that.


    Stop discussing this (none / 0) (#24)
    by Big Tent Democrat on Tue Sep 08, 2009 at 04:16:40 PM EST
    in terms of what I EXPECT to happen.

    There is a reason I am not writing about what I think will happen.

    We're in the middle of this right now.


    I'm going to be quiet now (none / 0) (#38)
    by cawaltz on Tue Sep 08, 2009 at 04:32:37 PM EST
    because I wrote what is going on NOW, alongside of this discussion. I think at some point expectations have to be discussed. Evidently you disagree that time is this moment.

    It's your thread so I defer.


    This is sort of on topic (none / 0) (#3)
    by TeresaInSnow2 on Tue Sep 08, 2009 at 03:49:44 PM EST
    because part of the canolis is that the bill will need to help fund the expansion of debters prisons for those who "evade" their tax penalties.

    Do you understand what the (5.00 / 1) (#4)
    by Big Tent Democrat on Tue Sep 08, 2009 at 03:55:07 PM EST
    mandates are?

    I'm curious if you people actually read the posts before commenting.


    ee (none / 0) (#8)
    by TeresaInSnow2 on Tue Sep 08, 2009 at 04:01:36 PM EST
    Of course I know what the mandates are....they mandate that you buy the insurance, if you don't they're proposing that you pay a fee up to $3800.

    CWaltz has a link.

    Okay, so the fees are partly the gun....


    Indeed (none / 0) (#10)
    by Big Tent Democrat on Tue Sep 08, 2009 at 04:02:42 PM EST
    Leave the mandates, take the money.

    But subsidies (5.00 / 1) (#11)
    by TeresaInSnow2 on Tue Sep 08, 2009 at 04:08:05 PM EST
    still aren't much if the insurance companies raise premiums to get their cuts of those.

    Still have to have cost controls.


    Can't raise prices on poor folk (5.00 / 1) (#14)
    by Big Tent Democrat on Tue Sep 08, 2009 at 04:13:13 PM EST
    who can only afford to pay BECAUSE of the subsidies.

    Or you can just expand Medicaid to 250% of the poverty level and dump the subsidy idea with the money.


    Wondering if this will make Medicare (none / 0) (#109)
    by sallywally on Wed Sep 09, 2009 at 07:58:40 AM EST
    look really good to folks who don't have it. I'm getting really grateful I will be on Medicare in six months.

    I can imagine what people out there whose premiums for work-based insurance skyrocket (already have, of course)and people who can't do the mandates because they don't make enough to pay in advance to then get a credit.....will think of us old folks who may be the only ones who can have insurance/ care at all....unless they wreck Medicare too.

    Very scary.


    it isn't subsidies (none / 0) (#41)
    by cawaltz on Tue Sep 08, 2009 at 04:33:35 PM EST
    now it's credits. I'm trying to figure out how that will play into things if at all.

    Credits suck (5.00 / 1) (#96)
    by gyrfalcon on Wed Sep 09, 2009 at 12:12:25 AM EST
    A LOT of the working poor are just above Medicaid rules but don't pay enough in actual taxes for credits to do anything for them.  Same thing happened with the "Cash for clunkers."  If you don't pay $4,500 in actual federal taxes (as opposed to FICA), the tax credit was no use.

    And BTW (none / 0) (#17)
    by TeresaInSnow2 on Tue Sep 08, 2009 at 04:14:47 PM EST
    the $3,800 I was speaking of was the proposed FEE for not opting into mandated insurance...more of the gun.


    ...in case you haven't seen th article yet....


    tThat's my point (5.00 / 1) (#22)
    by Big Tent Democrat on Tue Sep 08, 2009 at 04:15:37 PM EST
    No mandates means no penalties.

    But will Baucus' (none / 0) (#5)
    by lilburro on Tue Sep 08, 2009 at 03:56:18 PM EST
    bill cover as many people as the House bill(s)?  I think not.  So why inflate its importance.

    If you want universal health care (or as close as we can get), get behind the public plan.  It seems pretty simple now.  

    And I'm glad we're not the only ones ripping Ezra -the people in his comments do so quite well too.

    I'll take the money (5.00 / 1) (#9)
    by Big Tent Democrat on Tue Sep 08, 2009 at 04:02:06 PM EST
    and a mandate and a public option.

    We're negotiating.

    Let's pocket the money. That already agreed to.

    Now you want a mandate. Fine. I must have a public option for that.

    What do you say President Snowe?

    See my point?

    Make the money a fait accompli. And let's keep moving.


    Hey if we are leaving out reform (5.00 / 4) (#15)
    by MO Blue on Tue Sep 08, 2009 at 04:13:38 PM EST
    then we have to eliminate the cuts to the Medicare budget. They are according to Obama only reforms to the system.  

    Of course (5.00 / 2) (#18)
    by Big Tent Democrat on Tue Sep 08, 2009 at 04:15:06 PM EST
    Hell give more money to Medicare.

    I like your thinking (5.00 / 3) (#25)
    by MO Blue on Tue Sep 08, 2009 at 04:17:08 PM EST
    I thought this was the (none / 0) (#65)
    by lilburro on Tue Sep 08, 2009 at 05:28:40 PM EST
    negotiation style that worked best:

    This Baucusverse is, I would say, better for me than the current reality. It's also better for CareFirst. CareFirst is basically getting a new customer. So good for them. But I'm also getting a new health insurer, so good for me. Now we could stick it to CareFirst by just enrolling me in a government plan and giving me coverage directly. Bad for CareFirst, but great for me. Alternatively, we could stick it to CareFirst by making it the case that I go uninsured and they lose a customer. That's bad for CareFirst, but also pretty bad for me.

    You can actually make money by showing your hand.  Beltway blogging, they call it.


    Problem is (none / 0) (#6)
    by s5 on Tue Sep 08, 2009 at 03:58:53 PM EST
    Now is the time to pass structural reform, ie. the public option. If it doesn't pass now, then I have no confidence in our broken political system's ability to take it up again later.

    I agree, no mandates without a public option, but then we're essentially left creating a benefit for the poor. Which is both noble and useful, but not popular enough in our broken political system.

    The more I think about this, the more I realize it's all or nothing. "All" has already been defined down to the point where less wouldn't be incrementally better, it would be incrementally worse. Even if it's possible to score some incremental benefits, it would cause extreme harm to the ability to make it better later.

    Sure (none / 0) (#7)
    by Big Tent Democrat on Tue Sep 08, 2009 at 04:00:15 PM EST
    Just answering Ezra.

    Jay Cost (none / 0) (#12)
    by andgarden on Tue Sep 08, 2009 at 04:12:34 PM EST
    made a similar suggestion earlier:

    By demanding comprehensive reform, the President has raised the stakes, perhaps too high. The liberal intractability on the public option is completely understandable. If this is "the moment" for health care reform, then it is imperative that they get their key policy goals accomplished. If that doesn't happen now, they cannot expect that to happen anytime soon (if ever). But what they require is simply too much for moderate Democrats, especially those in McCain- and Bush-voting districts. [ed-This is where the President's political efforts will have failed.] If the President scaled back his ambitions, the final bill would not be as far to the left as the liberals like, but since it is not comprehensive they could at least plan to fight for the public option another day. Then, Obama could pick up enough moderates to pass it, and he could declare victory.

    Not my first option (5.00 / 2) (#16)
    by Big Tent Democrat on Tue Sep 08, 2009 at 04:14:36 PM EST
    But I won't turn down $900 billion for health care for the working poor.

    And the issue is still on the table.

    sort of like S-CHip.


    It will be a real disappointment (5.00 / 1) (#26)
    by andgarden on Tue Sep 08, 2009 at 04:17:29 PM EST
    The takeaway will be that the wave of "change" crested at the ballot box. But it's still worth doing.

    You like Ezra's proposal better? (none / 0) (#27)
    by Big Tent Democrat on Tue Sep 08, 2009 at 04:19:04 PM EST
    Assuming that the public option (5.00 / 3) (#31)
    by andgarden on Tue Sep 08, 2009 at 04:24:47 PM EST
    is genuinely off the table for this discussion. . .I'm actually torn on the policy question. The Baucus plan is similar to the Massachusetts plan, and the jury is still out on it.

    As a political matter, I don't think the Dems should go for Baucus's proposal. The mandate without cost controls will be a killer.


    Mandates (none / 0) (#34)
    by lilburro on Tue Sep 08, 2009 at 04:28:15 PM EST
    to buy private insurance are politically stupid.  But it also seems to me that billions of dollars given to the poor is a politically stupid move and an election loser.  "Handouts."  

    Let's define poor... (none / 0) (#48)
    by masslib on Tue Sep 08, 2009 at 04:38:50 PM EST
    Medicaid would be part of the funding, the other is subs for a family of four making 88k.  That covers middle class families.

    In the age of TARP (5.00 / 2) (#55)
    by lilburro on Tue Sep 08, 2009 at 05:03:11 PM EST
    I think it will be perceived as "here's some more money!!!"

    Dems would be setting themselves up for a cycle of throwing money at poor people (and to a certain degree, the middle class) so they can buy private insurance from a broken system.  It's completely ridiculous that private insurance companies would be so throughly subsidized by the government.


    But that is what the (none / 0) (#59)
    by masslib on Tue Sep 08, 2009 at 05:10:42 PM EST
    plans before Congress call for anyway.  There is no viable public plan before Congress.  

    In both Senate versions (5.00 / 1) (#90)
    by MO Blue on Tue Sep 08, 2009 at 11:02:45 PM EST
    there would not be any subsidies for a family with an income of 88k until the premiums reached 12% to 13% of their income and then it would be very small. Cut off in President Snows bill is 66k.

    Only those families (none / 0) (#66)
    by cawaltz on Tue Sep 08, 2009 at 05:32:18 PM EST
    without access to health care though. Those that had an insurance plan through work would still be stuck getting it through their employer.

    This could potentially help the couple I spoke about paying $600 a month. It doesn't really address the working poor who have access to insurance but can't afford it.

    Are you sure about your numbers? The propasal is for 3 times the poverty level which is $66,000 for a family of four.


    You are correct about the $66,000 (none / 0) (#93)
    by MO Blue on Tue Sep 08, 2009 at 11:27:55 PM EST
    There might and I empathize might, be some small relief for families from $66,00 - $88,000 if their premiums exceed 13% of their income.

    as a general supporter of the MA plan (none / 0) (#35)
    by CST on Tue Sep 08, 2009 at 04:28:43 PM EST
    lets just say I trust the state gov't here to deal with the issues that arise a lot more than I trust the U.S. congress.  And that's the problem with the bill, it's a leap of faith.

    The MA plan sucks... (none / 0) (#39)
    by masslib on Tue Sep 08, 2009 at 04:32:57 PM EST
    I trust the voters here to pass Cape Care relatively soon enough, and then something state-wide.  The MA health reforms were written by Blue Cross.

    We've had this discussion (none / 0) (#45)
    by CST on Tue Sep 08, 2009 at 04:34:35 PM EST
    at length before.  Agree to disagree.

    CST, if the Mass plan` (5.00 / 2) (#97)
    by gyrfalcon on Wed Sep 09, 2009 at 12:16:21 AM EST
    sucks for enough people, even though it works well for you and yours, it's not a success.  I know people on both sides of that divide.

    Not just me and mine (none / 0) (#111)
    by CST on Wed Sep 09, 2009 at 09:18:50 AM EST
    The enrollment has been above and beyond what anyone predicted, and the % insured here is rediculously high.  I get that it doesn't work for everyone and that sucks, I wish it did, and I think it eventually will.  I still say it's a hell of a start.

    That's prob the difference (none / 0) (#28)
    by CST on Tue Sep 08, 2009 at 04:21:41 PM EST
    btwn "still worth doing" and "not worth doing"

    doesn't mean it's not a disappointment


    Better than doing it wrong... (none / 0) (#30)
    by masslib on Tue Sep 08, 2009 at 04:23:43 PM EST
    The Exchange is crappy, though.  Do we still need an Exchange if we take the subs and run?  Exchanges are costly, wasteful bureaucracies.  

    Are they going to allow you (none / 0) (#64)
    by cawaltz on Tue Sep 08, 2009 at 05:24:28 PM EST
    to just take the money and run?

    The 900 billion is going to have to come from somewhere. The suggestion is fees on insurance providers. They have said that they will increase premiums to offset that cost. Who here thinks there will be no political consequences if people's health care goes up to cover those 10 million.


    Either that, or taxing people with insurance... (5.00 / 2) (#69)
    by lambert on Tue Sep 08, 2009 at 06:49:34 PM EST
    ... to pay for the people without it. Yay! Contrast the funding mechanisms for HR676:

    Second, a "Medicare For All Trust Fund" will be created to ensure a dedicated source of funding in addition to annual appropriations. Sources of funding will include:
    • Maintain current federal and state funding for existing health care programs
    • Closing corporate tax loopholes
    • Repealing the Bush tax cuts for the highest income earners
    • Establish employer/employee payroll tax of 4.75% (includes present 1.45% Medicare tax)
    • Establish a 5% health tax on the top 5% of income earners; a 10% tax on top 1% of wage earners
    • One quarter of one percent stock transaction tax

    The stock transation tax is a two-fer, since it will make bubbles harder to inflate...


    I like it (5.00 / 2) (#77)
    by cawaltz on Tue Sep 08, 2009 at 07:43:29 PM EST
    Out of all the proposals being floated out there Medicare for All comes the closest to what I want to accomplish. Unfortunately, I have a blue dog representing me. He won't even go for a public option.


    I am out there pushing though for a system that allows anyone to opt in.


    Sorry to hear about the rep (5.00 / 2) (#79)
    by lambert on Tue Sep 08, 2009 at 08:06:35 PM EST
    There are times when I think that losing a few blue dog seats pour encourager les autres might not be a bad thing. We'd have a tighter and more cohesive party.

    Too much? (none / 0) (#40)
    by katiebird on Tue Sep 08, 2009 at 04:33:00 PM EST
    But what they require is simply too much for moderate Democrats, especially those in McCain- and Bush-voting districts.

    Statements like this make me think that Congressman Dennis Moore (KS-3) must be a REALLY exceptional guy.  He's one of the original Blue Dogs.  He hasn't handled the Health Care issue all that well until this year - for a long time he suggested that a $500 tax credit could help everyone with health insurance....

    But, he's committed to voting for a bill with the Public Option (he hasn't gone so far as to say he won't vote for one without it)

    (sigh) I just realized though -- Obama won the Kansas 3rd district! .... so never mind.


    I think this makes a lot of sense (none / 0) (#19)
    by vicndabx on Tue Sep 08, 2009 at 04:15:28 PM EST
    Gets more people covered, and provides an opportunity to get more folks on board later by giving us all a chance to first, find ways to lower the costs tied to services - instead of an open-ended committment to fork over more tax dollars w/o proven, effective, cost-containment measures.

    Really (none / 0) (#42)
    by Ga6thDem on Tue Sep 08, 2009 at 04:33:35 PM EST
    Ezra should get the message that the less he talks about this subject the better. I can believe that this guy is considered an authority on this subject. He should spend a few years actually working for an insurance company then maybe he can talk about this subject.

    how many people got the (none / 0) (#51)
    by Capt Howdy on Tue Sep 08, 2009 at 04:47:38 PM EST
    godfather reference?

    btw (none / 0) (#52)
    by Capt Howdy on Tue Sep 08, 2009 at 04:51:37 PM EST
    I agree with everything you said.

    Not Blazing Saddles eh (none / 0) (#67)
    by oculus on Tue Sep 08, 2009 at 05:33:24 PM EST
    how do you pay without mandates? (none / 0) (#73)
    by diogenes on Tue Sep 08, 2009 at 07:27:14 PM EST
    A lot of the money comes from mandates--i.e. forcing the young, healthy people who choose to go uninsured to pay full price for policies.

    The suggestion Baucus makes (5.00 / 1) (#76)
    by cawaltz on Tue Sep 08, 2009 at 07:38:48 PM EST
    is that a fee be introduced on the insurance companies, drug companies and other health agencies. Additionally they are floating taxing those of us who have good health insurance. Apparently the fact that my husband was able to get good health care as a result of union negotiations and it was given in leiu of increased income rates means nothing. We must be singled out to pay on a program that will not even be available to us. That way the rich can continue to keep pretending we have the best health care system EVAH(for insurance companies anyway).

    Mandates don't work (5.00 / 2) (#82)
    by nycstray on Tue Sep 08, 2009 at 08:14:52 PM EST
    if the young and healthy and all others who will be mandated can't afford it . .. .

    Ezra is an idiot (none / 0) (#106)
    by Militarytracy on Wed Sep 09, 2009 at 04:12:28 AM EST