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What can we get for giving up the public option?
I really don't want to see universal care with regulation on insurance companies lost to a battle over the public option. Once universal health care is in place the public option can be fought over by itself. It's much smaller as an issue and not as easy to defeat by itself. Once true universal care is in place the real issue shifts to paying for it and controlling health care costs. We are very close to that right now. Is it reasonable to think that the public option could be traded off (for now) to get the rest?
The key is to get universal health coverage and community health pools. Add to that provisions that do not permit insurance companies to reject any applicant, or to increase the premiums for health condition or anything else. Add some effective form of regulation and monitoring that keeps close track of these things.
Once those things are in place they will begin to eliminate a lot of hospital cost-shifting that currently is needed because they provide care to the uninsured. Medically caused bankruptcies should also drop greatly.
A universal standard process for getting reimbursed would lower administrative costs to an amazing degree, both for health care providers and for the insurance companies, and it would aid in monitoring the effectiveness of the system. It would highlight the problems.
I'd also like to see a unified standard procedure and system for appealing denial of coverage. As it is, the insurance companies decide not to cover a procedure, then deal with the appeal themselves. The system for the appeal is different for every company and no one really knows what the decision is based on. That appeal process should be taken away from the insurance companies and standardized. It would fit in with the medical effectiveness studies.
Most of the advantages of size that allows one plan to currently dominate a region would also disappear, especially with a single standard system for getting reimbursed. So competitors could more easily take on the big regional monopolist health care companies.
The Medical effectiveness studies would put pressures on the pharmaceutical companies to sell medications that were more useful, not just me-too drugs that were patented and high priced. The practice recommendations would also quickly become a legal defense for physicians in malpractice claims. How does a lawyer justify a malpractice claim when the medical effectiveness studies suggest the treatment used? And if the physician deviated from the recommended treatment, careful documentation of the reasons for the deviation along with consultation would be a similar defense. Frankly more consultation would improve our health care a lot. Lawyers wouldn't take those cases on contingency, since they would be quite expensive and not likely to pay back anything. Right there the biggest cause of truly frivolous malpractice claims would be eliminated.
I'd like to see the government option as it would lower costs even more and more quickly. But with the above items included in a health care plan we could quickly get to a level of care similar to what the Swiss have.
After getting universal coverage we can focus on lowering cost. Politically that is less important than universal coverage, and probably easier to deal with.
Such a trade off is clearly dissatisfying considering how rotten the Republicans acted when in control of the federal government, but that's what governance is all about. Do the right thing, not the satisfying one. But do something. The Republicans failed when trying to govern because their first choice is always to do nothing, then try to force their agenda on the population, and finally to milk the government for as much money as they can. Health care is a massive and long-term problem both for the population and for the budget. Good governance demands that something be done, and not much has happened for over six decades.
Something has to be done, and I think the core of that something is universal coverage and consolidated risk pools the insurance companies can't manipulate to skim the health individuals and abandon the rest. along with those community risk pools goes a single standard premium for everyone and a government agency to enforce those things and report to the people what is happening.
The key is to get universal health coverage and community health pools. Add to that provisions that do not permit insurance companies to reject any applicant, or to increase the premiums for health condition or anything else. Add some effective form of regulation and monitoring that keeps close track of these things.
Once those things are in place they will begin to eliminate a lot of hospital cost-shifting that currently is needed because they provide care to the uninsured. Medically caused bankruptcies should also drop greatly.
A universal standard process for getting reimbursed would lower administrative costs to an amazing degree, both for health care providers and for the insurance companies, and it would aid in monitoring the effectiveness of the system. It would highlight the problems.
I'd also like to see a unified standard procedure and system for appealing denial of coverage. As it is, the insurance companies decide not to cover a procedure, then deal with the appeal themselves. The system for the appeal is different for every company and no one really knows what the decision is based on. That appeal process should be taken away from the insurance companies and standardized. It would fit in with the medical effectiveness studies.
Most of the advantages of size that allows one plan to currently dominate a region would also disappear, especially with a single standard system for getting reimbursed. So competitors could more easily take on the big regional monopolist health care companies.
The Medical effectiveness studies would put pressures on the pharmaceutical companies to sell medications that were more useful, not just me-too drugs that were patented and high priced. The practice recommendations would also quickly become a legal defense for physicians in malpractice claims. How does a lawyer justify a malpractice claim when the medical effectiveness studies suggest the treatment used? And if the physician deviated from the recommended treatment, careful documentation of the reasons for the deviation along with consultation would be a similar defense. Frankly more consultation would improve our health care a lot. Lawyers wouldn't take those cases on contingency, since they would be quite expensive and not likely to pay back anything. Right there the biggest cause of truly frivolous malpractice claims would be eliminated.
I'd like to see the government option as it would lower costs even more and more quickly. But with the above items included in a health care plan we could quickly get to a level of care similar to what the Swiss have.
After getting universal coverage we can focus on lowering cost. Politically that is less important than universal coverage, and probably easier to deal with.
Such a trade off is clearly dissatisfying considering how rotten the Republicans acted when in control of the federal government, but that's what governance is all about. Do the right thing, not the satisfying one. But do something. The Republicans failed when trying to govern because their first choice is always to do nothing, then try to force their agenda on the population, and finally to milk the government for as much money as they can. Health care is a massive and long-term problem both for the population and for the budget. Good governance demands that something be done, and not much has happened for over six decades.
Something has to be done, and I think the core of that something is universal coverage and consolidated risk pools the insurance companies can't manipulate to skim the health individuals and abandon the rest. along with those community risk pools goes a single standard premium for everyone and a government agency to enforce those things and report to the people what is happening.
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Single payer?
September 6, 2009 4:15 PM | Reply | Permalink
My preference is single payer. Right now, though, universal health care using private insurers is the closest we can get.
I'll take that for now rather than no change in the existing system.
September 6, 2009 4:20 PM | Reply | Permalink
I don't think costs will ever be controlled without public competition at the least, Richard. We have had reform packages, HIPAA 1996 was the last one, that attempted to regulate the industries and enforce efficiency but they have not dented rising costs.
Cost shifting is not just about the uninsured; insureers favor some parties over others and there are regional and local factors. The five or so large insurers seem to have a pluropoly (okay, made that up) or a lock on health care "consumers." We will, in effect, strengthen them by mandating millions more buy their coverage. I also think that if we pass on a PO now, we won't have another chance for decades, if that ("We've already reformed health care").
I don't see how it would be easier to pass a PO as a stand alone program. The interests that have signed on to reform just for universal coverage will not be there to back it. The corporate hold on government is like a boa constrictor. The more we struggle to get free, the tighter it wraps around our necks. MHO.
September 6, 2009 4:36 PM | Reply | Permalink
Part of the problem right now is trying to pass the entire package together. It allows the opponents to pick out one or two elements to oppose and to use them to defeat the whole thing. The anti-abortion movement has switched from passing bans on abortion to small restrictions that are easier to get passed. There were too many inequities in a total ban to get it passed whole.
Right now there is simply no overall system, so there is no way to identify separate problems and correct them one at a time. They interact with each other. Fix one problem and it worsens another problem. HMOs were the great fix, and look at all the ways they failed because other things weren't similarly controlled. The information is locked up in the individual insurance companies, for one thing. Literally nothing can be managed system-wide.
Universal health care with regulation and (hopefully) a standardized system of filing claims, repayments, and appeals is a system that changes that. Such a universal system carefully monitored will surface the most important problems individually. Then each problem can be dealt with separately by publicizing the problem and passing legislation. Do you think that any insurance company could deny 40% of its claims if that were publicly known? Olberman reported that one major California company has that record.
That monitored system is what really frightens the Republicans and the insurance companies, but they can't say so directly and prove it. Set a national system in place, monitor it adequately and all the places the insurers are ripping off the rate payers and failing to provide the services the insured have paid for will come to light.
I think the end result will be single payer, but it might be a generation from now unless there is a major crisis in the overall system before then. If there is such a major crisis and universal health care is in place, it will be politically impossible to take health care away from any one group as is done today. (Keep the individual groups of uncovered clients small,make sure there are a lot of them and just add them piecemeal to the currently uninsured. That is what is presently happening.) It will have to be solved in such a way as to keep everyone getting quality health care.
Every other industrial nation can do it. So can we. Quality health care is not a commodity to be sold. It is a human right. The money is just for planning and preparation purposes to make sure that health care resources are where they need to be when needed and are used efficiently.
September 6, 2009 6:01 PM | Reply | Permalink
Part of the problem right now is trying to pass the entire package together. It allows the opponents to pick out one or two elements to oppose and to use them to defeat the whole thing.
We should see the comprehensive nature of the plan as a political strength, not a drawback. By combining many elements, we make it impossible for the opponents of a single element to vote against that element without voting against the whole package.
How many of these Blue Dogs do you think really want to become known as the guys who killed health care reform in 2009? Call their bluff; turn the tables; put them on the defensive. Let them piss and moan, if they want, about how they are being strong-armed and blackmailed into voting for a plan they regard as imperfect. But let's see how long these prima donnas stand tough when they are out there twisting in the wind all by themselves, with no real friends in either party.
Right now, Obama is giving them political cover. he needs to stop that.
September 6, 2009 9:08 PM | Reply | Permalink
Dan
Fear is stronger than hope, and that shows up in the intensity that drives voters to the polls. If we had mandatory voting then we could expect the majority of voters to look rationally at the situation and vote good sense.
We don't have mandatory voting, and the intensity of the fear drives more voters to the polls than does good judgment. To defeat a big comprehensive bill all you have to do is pull out a bunch of small segments and use each to scare a set of voters so that they all turn out and vote against the overall bill. There is no similar mechanism that creates intensity in unfrightened voters, so the frightened voters are a lot more likely to carry the day.
This is especially true because the American Constitution is designed to favor an intensely driven rural minority that wants to stop change over an urban majority that wants the change to happen.
That's a major reason why getting the overall structure into place first and then dealing with the smaller items one at a time is more likely to get passed through congress. The groups of frightened voters taken one issue at a time are going to be easier to deal with than the whole frightened mob that has many motivators.
It's also easier to fix a structure that is already in place than it is to create a new structure from scratch. Creating a new structure always brings out critics who say it is not needed, and the same people would often look at an existing system with flaws and agree to fixt the flaws.
That's the core of my argument.
September 7, 2009 12:38 PM | Reply | Permalink
To defeat a big comprehensive bill all you have to do is pull out a bunch of small segments and use each to scare a set of voters so that they all turn out and vote against the overall bill.
I don't think standard congressional legislative tactics support your point, Richardxx. At least, not consistently. The usual way people get their initiatives passed is by bundling them together into large packages so that the opponents of the individual initiative cannot vote against them without dumping the whole package. Thus, we get a whole bunch of goodies rolled into a single "stimulus package". Lots of people were forced to vote for individual tidbits they don't like because they were afraid to be seen as obstructionists on the wrong side of economic stimulus.
So progressives say to to the centrists: Go ahead Ben Nelson and Olympia Snowe and Max Baucus: vote against a major, necessary overhaul of the nation's health care system; keep people and their kids on the lists of the uninsured; continue to pad the bank accounts of health insurance CEOs; whine about how the interests of your insurance company backers are threatened by the "unfair" competition that will be provided by the public option. Make our day.
In a couple of years the economy will be taking off again. It will be "morning in America". Health reform and "Obamacare" will be a major legislative success story. A more progressive era will be underway. And Nelson and Snowe and company will be scrambling against some new Democratic challengers, and fighting against the tide to convince their constituents that they were really for health reform all along, even though they voted against it.
September 7, 2009 1:44 PM | Reply | Permalink
HMOs were Nixon’s answer to Kennedy’s national insurance and have obviously made things worse. But that is just what I’m talking about. The more we incrementally reform the private for-profit system instead of starting the process of winding it down (shrinking it down until it's small enough to drown in a bedpan), the worse it gets over time. The HIPAA addressed many of the reforms you’re talking about and just went into effect in 2000, yet we are back to square one. About ten years ago, 60 Minutes did a big expose of a big insurance company that had an army of doctors and accountants who only worked on (illegally) denying claims. It was big news. Has anything changed?
I understand the motivation to take whatever we can get (and opponents are counting on that, as always). As it is, the system is dragging the economy down and many families with it. It will only get worse. Bankruptcies due to medical debts (I think about a million a year now) have gone from 8% of all bankruptcies in 1981 to over 50% today and 75% of those families are insured at the time they file bankruptcy.
But you see, if the health care lobby (spending $millions a day to protect their rackets) can effectively kill a public option, they will also kill any real reforms (or negotiate them down as PHRMA has supposedly done, and then make it up somewhere else). What you’re hoping to get is the change a strong PO would force but without anything to force them to change. Regulations strong enough to effect that change are watered down by the industry lackeys and those that are passed are soon enough ignored.
The country supports national health care. Let's have a show of hands: How many people want "Medicare for all"? Wow, looks like almost everyone! National health insurance has been the holy grail of Democratic politics for decades. We have the numbers, and it is the right time to do this.
The system will only change when the Dems stand up and force it on the corporate interests. If they capitulate, they will lose the support of much of their base and deservedly so. I understand it is playing a game of chicken with people’s lives, but that seems to be the only way entrenched power is overcome and grand reforms enacted. Now is not the time for half measures that will leave us in the same trap. It’s time for the weak and corrupt to sit down and, as the wingnuts say, give us back our country.
September 6, 2009 9:11 PM | Reply | Permalink
Are you only counting democratic hands? The count for independents and republicans and even more fiscally-conservative democrats is not so monolithic on Medicare-for-All as the solution to all our problems.
A robust public option by way of comprehensive Medicare reform was always going to be the extent of the faith most Americans have in the US government to deliver on its promises in a cost-effective fashion.
September 7, 2009 12:11 PM | Reply | Permalink
I certainly wouldn't ask the question at a town hall meeting ("A show of guns, how many...") :)
September 7, 2009 2:11 PM | Reply | Permalink
That would be funny if it wasn't meant to make a mountain out of mole.
September 7, 2009 4:14 PM | Reply | Permalink
It was only meant as a joke, Jason. To tell the truth, I haven't paid much attention to that stuff.
September 7, 2009 4:24 PM | Reply | Permalink
That's cool. I am trying to have a sense of humor most days, but the continued focus on fringe events keeps us from really having a fact-based dialogue.
I used to think poking fun at political rivals was a good time too, until I realized I very rarely got a response I would call positive by anyone but those who already agreed with me. That was when I stopped using politics as a foil for humor. In this particular case, it maintains the fiction that all democrats think all republicans are gun-toting loons.
I will admit it doesn't make me as much fun on the TPM threads sometimes, but I do feel like I have made more progress as a result, making it a worthwhile sacrifice.
September 7, 2009 4:31 PM | Reply | Permalink
You gotta laugh to keep from cryin' they say. The HRC proponent that bit off a guy's finger is ripe for jokes and abuse. I mean, regardless of self-defense or whatever happened, how crazy is that? Anyway, you're right that I was using hyperbole in the first place, and I was just playing with that.
September 7, 2009 4:50 PM | Reply | Permalink
Don,
I don't think we can get this near success in a game stacked against change and walk away empty handed - again.
If we have to settle for half a loaf, then the half we get has to be the structure for a new system that can be improved to something effective. The core of that is universal coverage.
Walking away with nothing leaves a rotten structure in place in which the forces of the status quo have all the power and well-defended turf. A new structure changes every future battleground. The forces of the status quo will be suddenly starting de novo again and will have to develop new tactics, many of which will fail in the development. Each time the forces of the status quo fail the American people win.
The core of any new structure is universal coverage. Once in place, it cannot politically be removed. The public option is not a new overall structure. It is a tactic for lowering costs. Even put into place, it can be tinkered with, made ineffective or removed. As important as lowering costs is, putting a new core structure under the American health care system is the critical issue. That means universal coverage is priority. This is the time to do it.
September 7, 2009 1:01 PM | Reply | Permalink
The half-a-loaf strategy in this case will actually set things back. Without the public option in place, and more vigorous government participation in the marketplace as a big competitive gorilla, the other initiatives might actually raise health care costs, and that will lead to the reform being declared a failure by the majority for whome health care costs and negative wage pressure will continue to increase. The costs of insuring Americans with pre-existing conditions will be passed on to others, and there won't be many forces at work driving aggregate costs down.
The public plan is the key to lowering costs. Unless insurers face strong market pressures to reduce their own costs, and to pressure providers into delivering more and better care, more cheaply and efficiently, they will have trouble competing with the public plan. That's why we want a public plan.
September 7, 2009 1:54 PM | Reply | Permalink
Yes, depending on how it is written, a public plan can be gamed or smothered, which is why most modify the term with strong or robust. As it is, the vast majority of the insured would not have access to a PO anyway. But some of the plans allow that to kick in later, and even if they don't, I think it would eventually be demanded. How can you offer a cheaper more efficient plan to some (e.g. those working for small companies) but not others?
My first comment here was not meant as a snark. I think accepting reform with a robust public plan is accepting half a loaf.
September 7, 2009 2:07 PM | Reply | Permalink
I think the end result will be single payer, but it might be a generation from now unless there is a major crisis in the overall system before then.
Richardxx, the most likely route to single payer is a public option that grows more popular over time as it delivers better and better care, forces providers and suppliers to do more at a lower cost, generates increasing public demand for more effective government influence over the system, and runs insurance companies ragged as they try to compete.
It must be understood that the fear of this possibility by both insurance companies and some providers, and the natural desire of insurers to keep the American public from muscling in on their lucrative stake in the existing market, is the chief source of opposition to the public option.
Let's not be afraid to force our government to stick its nose under the tent.
September 6, 2009 9:16 PM | Reply | Permalink
The problem with your argument is that there is no likely route to a single payer option. Certainly no route from where we are right now.
In another universe ....
Other than that minor detail I agree with you completely.
September 7, 2009 4:48 PM | Reply | Permalink
The problem with your argument is that there is no likely route to a single payer option. Certainly no route from where we are right now.
Really? Earlier you said, "I think the end result will be single payer, but it might be a generation from now unless there is a major crisis in the overall system before then."
I'm just proposing what I think is a more efficient path to that single payer outcome, one that may only take ... oh, let's say half a generation.
September 7, 2009 6:45 PM | Reply | Permalink
Single payer is inevitable if we pass universal health care. Because universal health care will be politically impossible to repeal, excessive costs will have to be constrained in another way.
The most efficient way to constrain costs is government financed single payer. That will be tried sooner or later.
But it won't be tried if we don't put universal health care into practice. As long as there is a pool of uninsured, the most expensive cases can always be sloughed off into that pool of uninsured. That's the money that will pay investors, CEO's and executives.
The insurance companies are playing for time. They collect their money now and as far into the future as possible. If universal health care is not implemented, they will continue to be paid on the backs of the uninsured. And yes, it is blood money.
September 7, 2009 10:02 PM | Reply | Permalink
And the cost you are proposing is very likely to be no change in the current failed health care system while we are so close to getting change enacted. That failure is in exchange for a bet that something better can be implemented later. Maybe.
That is really letting the perfect be the enemy of the good.
Half a generation. Sort of like the time since the Clinton Bill failed and now, isn't it? Things have gotten a lot worse since then as far as I can see. That's just about the best case cost of failure to pass something now.
September 7, 2009 10:14 PM | Reply | Permalink
I really disagree Richard. The "Subsidize now, cut their profits later" approach is just not politically realistic. The reason we're dropping the cost-cutting measures now is because insurers and providers don't like them, and lobby against them. So the bill provides a better insurance product, and does so for more people by subsidizing the insurers. We're giving them the industry a trillion dollars. In exchange we're getting nothing in terms of cost-cutting that actually eat into their bottom line. They retain their current regional quasi-monopolies with unlimited pricing power.
So we're giving them a huge amount of money, with no sacrifice on their part. Because that is too hard. And yet people seem to find it plausible that we can come back and pass cost-cutting measures when we've already given the industry everything they could want - more customers, subsidies, monopolies. The only chance we have to do the cost-cutting, is NOW, in exchange for the subsidies and mandates. Later on it gets harder, not easier.
Sorry if I'm repeating myself across threads on this...
September 6, 2009 4:39 PM | Reply | Permalink
I don't think that the public option can be simply abandoned. It has to be traded for those critical cost cutting measures. The wonks have their jobs cut out for them.
September 6, 2009 6:05 PM | Reply | Permalink
Richard,
1. they don't like the public option BECAUSE it cuts costs -i.e. profits. So it can't be traded for equivalent cost-cutting measures. Moreover, I can't think of any reasonable ways to effect the same cost-cutting without it. Maybe let private plans piggy-back on Medicare rates? I don't know. But nothing like that will fly, for precisely the same reason that the public option won't fly. They don't want to cut costs.
2. And your other idea about transparency creating momentum for change doesn't sound too plausible to me either. We already know enough outrageous facts about how this industry operates NOW. Their profits have increased four-fold over eight years. And what do we do? We propose to subsidize a further increase. Because they already own Congress, and their political power will only grow in line with profits.
3. "How many years do you think that the insurance companies can book high profits without a major political outcry?"
I keep hearing this. But it makes no sense to me. So, like with the banks, we throw a trillion dollars at them now, and wait for people to get so upset they demand change, and then do something about it. But that isn't happening. The banks are stronger than ever, and re-regulating them has become harder, not easier, with the bail-out. Same thing with HCR. We throw a trillion at them, and what? Wait for people to get upset at the profits and their political clout, and then try to force their lackeys in congress to stand up to them?
4. You seem to think it's a question of this universal health care plan OR nothing. But it's not. We can push through the insurance exchanges, the abusive-practices-reform, and an expansion of medicaid. Strip out the subsidies and the mandate if the public option gets killed. And then do that trade-off later. That's a strategy I could go for. But we've got to stop feeding the monster...
September 6, 2009 7:34 PM | Reply | Permalink
What can we get? Another day older, and deeper in debt.
All the talk of insurance reform, i.e. mandating universal coverage, even with pre-existing conditions, raising the caps on out-of-pocket expenses, NOT limiting profit percentages like other countries apparently do, and then mandating we all buy into private plans. It seems that the premiums will be HUGE if there is such coverage required. Can you imagine United Health's board meetings: Say, with these new laws, we're going to have to cut our salaries and bonuses, and tell our shareholders they are SOL, and hoo-boy is our stock gonna tank? I don't get the thinking.
September 6, 2009 5:17 PM | Reply | Permalink
How many years do you think that the insurance companies can book high profits without a major political outcry? That already is public information and available to regulators in detail.
I'd like to see them also have to report all executive remuneration publicly, too. They already have to report CEO pay and pay to a few other top executives in the SEC Proxy statements. It would be nice to see an additional line on the financial statements that shows the percentage by which CEO and executive pay reduces profits or adds to loss. Some of that could be done right now by dedicated groups who monitored the insurance companies. That's how Forbes gets their CEO pay issue every year.
Gather the data and make it into a political issue. Once the overall system is covering everyone, such comparatively minor problems can be dealt with politically one at a time.
And yes, I hate to see them making out like bandits on the deal. But if getting them to permit a system that saves lives in place costs such relatively minor expenses, what it the priority? How much do we spend to save just one life in an emergency situation covered by the media?
September 6, 2009 6:23 PM | Reply | Permalink
I wish I knew the answer to that, richard: how long? I thought many people were trying to explain how the insurance companies are behaving, including the President. And yet so much of what I hear is, "You would put insurance companies out of business!"
Civil; yes.
Reporter: "What do you think of American civilization, Mr. Ghandi?"
Ghandi: "I think it would be a very good idea."
September 6, 2009 6:50 PM | Reply | Permalink
How many years do you think that the insurance companies can book high profits without a major political outcry?
There is a public outcry now ...
... and an overwhelmingly Democratic House,
... and an overwhelmingly Democratic Senate,
... and a Democratic President.
Let's take advantage of this winning hand for the short time that we will hold it.
September 6, 2009 9:19 PM | Reply | Permalink
There I agree completely. Only, I'm not willing to settle for nothing as Clinton did. The Democrats DO have enough power at the moment to seriously consider passage of a bill.
How do we take advantage of the current Democratic strengths if the proposal is defeated by one or two Senators? Because if this goes down to total defeat, that seems to me to be the most likely margin.
What I am trying to explore is how much we can get if dropping the public option is the price of getting something through the Senate.
September 6, 2009 11:17 PM | Reply | Permalink
How do we take advantage of the current Democratic strengths if the proposal is defeated by one or two Senators?
Let's shine a fierce, burning light on those one or two senators who are threatening to defeat health care reform, simply because they don't want private insurance companies to have to compete with a government administered plan.
If the insurers can do better than a government-administered plan, let them prove it in the marketplace. If not, then they are inefficient dinosaurs, and we should want them to die anyway.
September 7, 2009 1:59 PM | Reply | Permalink
Part of this also comes from the conservative mantra that the government is the problem, not the solution. But the health care mess is proof that certain things have to be done by the government.
Another example is Blackwater. They provide an inept military force. Mercenaries don't work well as a military force and even most rational conservatives will generally agree with that. The thirty year's war proved that a professional military almost invariably defeated a mercenary one. The same principle applies to a lot of the delivery of health care to those who need it.
The principle motivation of a health care provider should be to provide health care, not to make a profit off the sick. That is as true for those who finance the delivery of health care as it is for the direct providers.
Besides going after the opposing Senators who might kill the program (and I'm for going after them - especially the Democrats) even if something adequate is passed) we need to ramp up the rhetoric to demonstrate what government does right.
Always remembering, of course, that no human institution is flawless.
September 7, 2009 4:39 PM | Reply | Permalink
Part of this also comes from the conservative mantra that the government is the problem, not the solution.
.
.
Besides going after the opposing Senators who might kill the program (and I'm for going after them - especially the Democrats) even if something adequate is passed) we need to ramp up the rhetoric to demonstrate what government does right.
I agree with you 100%, Richardxx. What I think some are missing in this debate is that one of the reasons progressives are fighting so hard for the public option is that, apart from their belief in the intrinsic merit of the public option as part of the solution to our health care woes, they are also anxious to reestablish the general principle that sometimes government works, a principle that has been undermined by several decades of Reaganism, neoliberalism and market fundamentalism.
And that larger debate is also part of why so many people are so eager to oppose the public option: it is part of their broad agenda of destroying the faith of the American people in the capacities of government - which in a democracy means destroying their faith in self-government.
September 7, 2009 6:56 PM | Reply | Permalink
I will back you today Richard, much to the chagrin of some of my friends here, because we need a piece of legislation. Now
Tomorrow I may just get so mad I retire to the socialist side of things.
Next year, hell we amend.
Assuming 2010 turns out better than what we expected, 2011 and 2012 we go for more.
I get so damn mad and then remember we are in a democracy. With voters who gave Nixon, Reagan and w second terms. For no goooood reason.
Good post Richard.
September 6, 2009 6:11 PM | Reply | Permalink
Thanks for the backing.
I remember when Medicare was passed. I was in college and had voted for LBJ. Since then? Nothing. No movement. No progress. Carter did nothing. No Republican was going to. Clinton tried. Bush 43 was as worthless as any President that has ever occupied the office. His drug plan has few good qualities. Barely better than nothing, and one of the problems that is requiring action now. Now we have another shot at it, and I AM ON MEDICARE!
I stayed in the military for 22 good years and a couple that don't count for retirement in part because I wanted that health care when I retired. (Also because it was damned fun.)
If there is no movement this time, as was true when Clinton's plan went down, then when? And what's the fall-back plan that keeps things moving towards progress?
With a universal health care plan in place and something to monitor, then progress to improve it is possible. The political pressure to improve it can only grow, much as is the case with the Bush drug plan. With no plan in place we are in stasis. Again. The Republican Party Jabba the Hut will have health care frozen in carbonite again.
When does America join the civilized (root word - city) world?
September 6, 2009 6:43 PM | Reply | Permalink
It's been driven home to me that I'm not closer to getting anything from the Democratic Party than I was back in 1968 when I identified with the kids outside the convention being beaten by the Daley machine.
The party can't deliver. I don't want war and I do want healthcare. At least LBJ delivered on the healthcare. Now, we just get the wars.
September 6, 2009 6:57 PM | Reply | Permalink
From what I have read, we got Medicare because LBJ expanded Vietnam.
LBJ wanted Medicare and Westmoreland (who had fought in WW II Europe) thought he could win in Vietnam by fighting a war of attrition. So in 1965 Westy mousetrapped LBJ by demanding a half-a-million troops. If LBJ didn't send them, the anti-Communist conservatives (which included Southern Democrats) were going to shut down all social legislation.
LBJ essentially traded some 50,000 American lives and God only knows how many Vietnamese to get Medicare and the Civil Rights Bill. And I'd a done it, too. Vietnam ended, and Medicare and the Civil Rights bill are chugging along today.
Ike had faced the same issue when the French pulled out of Vietnam in 1954. He had to leave advisers in the Republic of Vietnam because the McCarthyites were already screaming "Who lost China" to great effect. Ike handed the problem off to JFK and JFK was looking to reelection in 1964 so he did not pull the troops out for the same reason. With JFK's assassination, the problem got handed to LBJ.
So it was Medicare AND the Vietnam war in one nasty little package.
By the way, apparently the previous Afghanistan commander, an Armor general, also intended to fight a war of attrition. McChrystal is a special ops general who knows better. He's following the much more complicated plan roughly laid out by John Nagl in Learning to eat soup with a knife. And I think that Obama would have had a much more aggressive exit plan from Iraq if he weren't trying to get health care.
American political conservatives screw up everything they touch, and are responsible for most of the American wars since WW II or for extending them unnecessarily.
September 6, 2009 7:58 PM | Reply | Permalink
Maybe the Democratic Party has simply been lost for 40 years in the wilderness, and now looks out over the promised land.
Only - the city of Jericho is still in the way.
Sorry. Couldn't resist sharing the image. Let's see this Wednesday if Obama can wear the Joshua mantle.
Do not consider this a serous part of my argument. This is just a random thought from my upbringing and I wanted to share it. The imagery intrigues me. It can be a valid motivator to fight, but it is clearly not a rational approach to designing the health care system to meet the needs of a modern people.
September 7, 2009 1:16 PM | Reply | Permalink
I do not know when we join Western Europe. I do not know when.
I mean, can you name me a period when Western Europe was not at war for 65 years?
ha
And Canada. Hell they look down upon us with scornful eyes. Or at least satirical eyes. hahahaha
September 6, 2009 6:59 PM | Reply | Permalink
Yeah, we are in a democracy. It's one that was designed by the rural elites so that the small state Senators could prevent the large urban states from dominating the federal government. Now over half of the population lives in the cities, though many of those think like rural people because they grew up on farms and ranches.
Look at the gang of six. All rural state Senators. The House has passed the bill already. Small state Senators have jobs for life, so they gain seniority over urban state Senators.
The UK has a similar split between the urban bourgeois in the House of Commons and the hereditary and religious lords in the House of lords. I got to wondering what had happened to allow the Commons to keep the Lords from vetoing needed legislation. It's an interesting history. It seems similar to America, just a generation or so ahead of us.
Essentially the UK industrialized and became urban but still had the older traditional leaders in the House of Lords vetoing legislation the Commons and the nation needed. So the Commons (with the help of the King) threatened to pack the Lords with 80 new peers to swamp the troglodytes. The troglodytes surrendered and let the needed Commons legislation pass. 1958 saw the life peerages created which liberalized the Lords further. In 1999 the Labor government expelled all but 92 hereditary peers, and their position is in doubt. Members of the House of Lords may soon be elected.
The point is that the UK has had the same problem with the upper house of Parliament that we are having with the 100 rich men from mostly small rural states. It's time for us to move to restructure the Senate. It's a roadblock, not a useful deliberative body.
September 6, 2009 7:10 PM | Reply | Permalink
Once universal health care is in place the public option can be fought over by itself. It's much smaller as an issue and not as easy to defeat by itself.
I'm afraid I think that is the opposite of the truth, Richardxx. The chief beneficiaries of the public option will be lower income Americans and the uninsured. The program will be heavily subsidized, and the main source of revenue for the public option will be higher-income Americans. If the public option is detached from a comprehensive reform package now, and brought back later as a stand-alone, it will come to be seen and treated like just another redistributive social welfare initiative. (It shouldn't be seen entirely that way, but it will be.) The record of social welfare programs over the past four decades is a steady stream of right wing and neoliberal dismantling of New Deal and Great Society legislation. Republicans will have no trouble at all re-assembling their usual center-right coalition of the affluent and the white middle class to crush an initiative that will easily be portrayed as a handout for blacks, immigrants, the unemployable and the indigent.
The public option can't get through a US Congress if it is the only thing on the table. It has to be part of a comprehensive package. Progressives need to bundle their redistributive, welfare-like initiatives with comprehensive packages that benefit a substantial majority of Americans.
As for your ideas about a trade, it is absolutely impossible to get anything from the Republicans and the Blue Dogs in exchange for giving up the public option if one is signaling to your negotiating opponent that the public option is really not a big deal for you, as David Axelrod continues to do.
I don't see how we get an outcome like the Swiss simply by regulating insurers and establishing the community pools. The Swiss government essentially sets the prices on health care treatments and services each year. Unless we also do something to get the US government into the market as powerful player - and the public option is the chief idea on the table for doing that - then we will not succeed in driving down costs, improving productivity and efficiency, and cutting fat from our system. The new regulations on the insurance plans will then probably result in higher prices on the relatively healthy to pay for those who are expensively ill and have pre-existing conditions. Rather than open the door for the public option later, it is more likely that "Obamacare" will be declared an expensive failure by the affluent mainstream media and the majority of Americans. It will become a great issue for Republicans, and future Congresses will begin work on dismantling it.
September 6, 2009 8:59 PM | Reply | Permalink
We already have a public option for specific groups of people that needs to be reformed to remain viable and can be expanded to include the populations that the new public option is being created to cover and do so at half the additional cost.
It is also a program supported by majorities of Americans on the right and left.
Discounting the comprehensive Medicare reform debate that must happen as the most logical way to gain mass consensus on a robust public option that will actually meet the needs of the nation seems a huge missed opportunity to me, but I tend to take a longer view on things like this.
Most reforms that have lasted in this country have come by way of a series of smaller legislative victories. This whole Super Bill concept is what loses these fights for democrats in the court of public opinion.
September 7, 2009 12:19 PM | Reply | Permalink
I consider mandates without a public option an outrageous insult. Increasing the profits of those who are responsible for the f'd up system we now have is sick, stupid, and disgusting.
I want a single payer system. Having a strong public option is already a compromise in my perception.
And what do we get with 'no' public option. It won't be universal health care. It will be a republican and corporate victory. Republican majority gradually returning to congress and the presidency and more wingnut BS galore from inside and outside DC.
This was always about more than health care and the republicans have always known that. This was about money and power. The wing-nuts and their corporate sponsorship have proven that the democrats are meek, weak, and unable to wield the power of a majority. Based on the 'I'm for a public option as long as it isn't 'public' statement from Senator Harry Reid on Friday and the rhetoric from white house personnel, it looks like the outrageous, insulting results are more likely. That is unless the house is willing to take a stand.
More money in the pockets of the same insurers that have brought more deaths than wars and hundreds of thousands of bankruptcies while raking in massive profits and providing substandard care overall... is moronic.
September 7, 2009 12:32 AM | Reply | Permalink
You make me proud, Sis! It is insane to believe that the people who brought us to where we are will be the people who get us out. Their sole intention is to make profits and any demand that they have to actualy provide a service for the money is intolerable. Am I stretching the truth? Ask someone whose policy was rescinded based on info they provided when they applied. Years later the insurer goes back and states, "we reread your application and we should never have insured you. You policy is cancelled"
What is not written, "Thanks for all those premiums. Yes, we made a mistake, but we're keeping the money anyway."
September 7, 2009 2:07 PM | Reply | Permalink
I seriously doubt that congress can create a regulatory environment that would suffice. That is, they could, but they won't. Not with all the influence from the industry that would come to bear on such legislation. It would end up a lot of meaningless words with holes you can fly a 747 through. I suspect such legislation would end up being tailored exactly as the industry wants it.
September 7, 2009 9:06 AM | Reply | Permalink
I keep finding myself beating this dead horse issue.
David Goldhill has an essay, How American Health Care Killed My Father in The Atlantic Magazine. In it, he tells us exactly where the money will come from without raising the deficit a single penny:
Guess What !!!!
We already earn the money to pay for any god-damn health fucking care option we damn well want!
So let's stop all this nonsense about who's going to pay for what and how much the deficit will go up because it's nothing more than a bunch of right-wing conservative bullshit!
September 7, 2009 9:58 AM | Reply | Permalink
PLEASE ENCOURAGE everyone TO LET CONGRESS and PRESIDENT OBAMA KNOW EXACTLY WHAT THEY WANT IN HEALTH CARE REFORM. ONE EASY WAY THEY CAN DO THIS IS BY USING THE PDF FORM AT GOOGLE DOCUMENTS THAT I CREATED USING THE HOUSE RESOLUTION 3200 OFFICIAL SUMMARY, AS WELL AS PRESIDENT OBAMA'S LIST OF WHAT HE WANTs IN HEALTH CARE REFORM. THIS IS AN EASY CHECKLIST OF FEWER THAN 50 ITEMS. We, the government, of the people, by the people, and for the people must stand up and SPEAK! DO IT TODAY....BE VIRILE...OR VIRAL....BUT USE THE FORM AND SPEAK YOUR MIND. We CAN, we MUST, we WILL!
http://tiny.cc/YH7UH
Thank you.
--
DonnaMarieEllington
http://healthyrickets.blogspot.com
donnamellington@gmail.com
September 7, 2009 10:55 AM | Reply | Permalink
Richard . . .
Your header asked this question:
What can we get for giving up the public option?
If the legislation requires "mandatory coverage" enforced with tax penalties and no "public option" then we pretty much as consumers end up getting sand pounded up our collective wazoos.
And that's why I've pointed out previously in my blog here at the Cafe the following.
No Public Option ... Mandatory Coverage ... GO POUND SAND!
Always remember:
The large print giveth... and... the small print taketh away...
~OGD~
September 7, 2009 11:46 AM | Reply | Permalink
OGD,
I can see a lot of good reasons to agree with you, but I also think that you are making that argument because you have insurance already.
The biggest fear is to not have coverage and not have access to any health care when you need it. It certainly was my fear when I did not have coverage. Try being a midlife graduate student with high blood pressure. The doctors at the University health clinic are not used to such problems. I had to talk one of them (fortunately for me an older MD with a sense of personal responsibility) into removing a skin cancer from my neck even though that was not a function covered by the health clinic. Also fortunately for me it was a slack period.
Tell me. How would a public option have helped me in either situation? I needed access. I needed reliable coverage first.
What the public option does is provide a mechanism for getting quality coverage at lower cost. Yeah, but first someone needs to be allowed in the door, and as long as there is an acceptable pool of people out there with no insurance, it remains legal to shut the door in the face of patients.
The first priority has to be to get everyone in the door. After that is accomplished, the cost of the service becomes important, not before. It's pretty clear now that the Republicans and conservatives will not let us address both issues simultaneously the way a good engineer would do and they can scare enough voters to make their demands effective.
September 7, 2009 12:14 PM | Reply | Permalink
I have to disagree with you Richard.
I agree with OGD.
I am 45. I don't have coverage. I am fortunate to be healthy. But I'll be damned if I think it is good for me personally or others politically or personally to have a mandate that we buy health insurance from the very insurers that have given us again more deaths than wars, hundreds of thousands of bankrupt American families, substandard care all while raking in enormous, outrageous profits. That's just sick and stupid in my opinion. And politically stupid because if the democrats do not do something significant here and merely play into the hands of republicans and corporations when they have the majority and the will of the people behind them we are doomed to have republicans return to power wing-nutier than ever.
I agree mandates without a real public option 'now' is an outrage and an insult as well as political idiocy.
September 7, 2009 1:58 PM | Reply | Permalink
I agree with everything you say about the health insurers. They should be punished for the way they have treated so many people.
But do we punish them by leaving so many people with no access to the health care system?
Sometimes you have to work with bad people to get good results. You might even have to reward them for cooperating because they are so subhuman that they will not work on the project otherwise. That's because if you don't, more innocent people get hurt.
Since we are talking a statistics game, there is no single clear poster child whose face can become a symbol of what needs to be done. That's one of the major drawbacks to attempting to politically create a real system and replace the ad hoc crap that has grown up and built its defenders.
I think that there was one of DickDay's Tao Te Ching readings that addressed this situation. I forget which one, I fear. But I don't think the way of the Tao is to punish the bad man by refusing to help those in need of help.
September 7, 2009 4:07 PM | Reply | Permalink
Richard,
You might find the following essay helpful for some of the points you are trying to make. I'd also recommend it as helpful for the many that seem to be reality-challenged on this issue, I include the excerpt for them.
September 7, 2009 2:19 PM | Reply | Permalink
The fact that the public option will take a few years to be ramped up anyway is one reason not to go along with any "triggers". The trigger option will only add another two years of delay. It will give the industry another two years to throw everything they have into killing the public option; and even if they are unsuccessful, we will have wasted two more years.
The IHI anecdotes are interesting, and certainly suggest options for reform. But we can't wait for doctors and hospitals to produce better quality and efficiency through a haphazard, voluntary process, when they are operating in an overall system where competitive pressures are often ineffective at producing the incentives necessary for aggressive action on costs, redundancies, medical "arms races" and extravagances.
September 7, 2009 3:01 PM | Reply | Permalink
What the hell, dude? You seem way more ideological over this issue than any number of other threads I have seen you on.
I think focusing to narrowly on this particular public option, in addition to the one we already have and can't afford, was always going to be a losing strategy in America today and perhaps for the foreseeable future. I find it surprising that you argue against tactical misdirection as way to go around or over an obstacle rather than through it, which is always more painful in the short and long term.
Much of your commentary on this blog has been speculation at best and much of not supported by the experiences of other countries having gone through the same transition.
September 7, 2009 4:21 PM | Reply | Permalink
I think it is because it has become obvious to most of us the public option is the key to whether we get true health care reform or not Jason.
Without a public option and costs, and correspondingly premiums, continue to rise and when they do the opponents of reform can claim it was a failure. Then we won't get universal coverage and everything that was enacted will be rolled back plus some.
Other countries aren't America. There are so many entrenched interests here that defiantly defend the status quo with their right of free speech, aka corporate money, that if we try to do it incrementally nothing will get done. Any true change on the side of progress has to be a big undertaking, like LBJ and medicare.
September 7, 2009 5:09 PM | Reply | Permalink
"Killing" the public option on this bill would put the debate back where it rightfully belongs - reforming the public option we already have in the form of Medicare/Medicaid and all the various and sundry government-run health care programs.
Only the democratic party could turn a virtual lock on health care reform into a stalemate over a argument based largely in semantics when they had a 70-plus percent approval for systemic reform going into the debate.
Change the discussion into health insurance reform, smack them down hard and declare victory. Then switch gears immediately to Medicare reform as being the most logical home for the public option, not some huge new government program that may or may not work, but is most certainly not going to work any better than Medicare currently does.
Retreat, in this particular case, is the better part of valor and will lead to a much stronger public option as part of a different, more focused effort.
September 8, 2009 8:25 AM | Reply | Permalink
Thank you for that.
I threw this out here because I had a vague idea where the health care debate was and had to go. This is a very capable group, and my views have sharpened a great deal since yesterday. So thank you all of you.
Yes. This is a process, not an event. The legislation will create a milestone along the way of the process, but so did the Clinton effort. Unfortunately, the Clinton milestone was more like one of the roadside markers where someone is killed on the highway.
This one has to be better, but it is still the starting point for another long, hard slog.
Here is a description of one person's view of the newly implemented Massachusetts health care plan. It's clearly a mixed bag that will require a lot of further work, but it is mostly a major improvement in what existed before.
I really, really do not want to see another Clintonesque milestone marker commemorating a death.
September 7, 2009 4:23 PM | Reply | Permalink
Here's an opinion from someone who I think got it right.Passage of a bill that provides universal health care guaranteed by the federal government but without the public option or the cost-cutting features would be a political triumph for the Democrats but a policy monster to administer and budget.
If that's what happens we are in for years of legislation to improve the new system. That's what I've been writing.
I hadn't recognized the likely political advantages of passing such a bill, but they do seem likely. It would be very popular with those who got the advantages, and they would fight to keep it in place. At the same time, it would not threaten those who currently have insurance they think covers them from their employers or from Medicare. Then as the new system begins to phase in and those with employer-subsidized insurance see that there is a safety net available for those who lose the employer-provided insurance, they too would grow to appreciate it.
Josh Marshall's write lays it out more clearly than I have. Go read it. It's short.
September 8, 2009 2:10 PM | Reply | Permalink