Ezra Klein explains why “selling insurance across state lines” actually means letting health insurers write their own regulations. [Bumped to top, yet again. -ed.]
Ezra Klein explains why “selling insurance across state lines” actually means letting health insurers write their own regulations. [Bumped to top, yet again. -ed.]
Stephen Bainbridge responds by explaining why “the automatic assumption that horizontal competitive federalism will automatically lead to a race to the bottom is simply unfounded.”
Thanks for the link. Bainbridge’s perspective is certainly a worthwhile rebuttal to Klein’s, and it’s nice to have a substantive discussion of health-care reform that doesn’t devolve into misrepresentations of the other side’s position, for once.
Having said that, to some extent (with regard to credit cards, at least), Bainbridge is basically denying the existence of a race to the bottom by redefining what is meant by “bottom.” (“So a race to the bottom? Well, only if you think usury laws are pareto optimal.”) In this sense, he isn’t actually presenting an argument that Obama is wrong about the effect horizontal federalism has on the marketplace; rather, he’s disagreeing with the substance of Obama’s underlying values about what is “pareto optimal.” Which is fine, but a bit different than saying Obama’s analysis is structurally incorrect.
Moreover, getting back to health care, the notion that consumer-driven competition will be a sufficiently powerful force to put insurance companies that seek out lax regulation (i.e., that allow them to institute consumer-unfriendly policies) “at a competitive disadvantage” seems rather naive to me. Perhaps I’m wrong; I’m no expert on this topic. But if consumer demand for more consumer-friendly policies had the ability to force (or at least nudge) insurance companies to adopt such policies, wouldn’t that be happening already? Indeed, wouldn’t consumer-protection regulations, whether imposed by states or the federal government or whomever, be essentially irrelevant and vestigial, if that were the case? The whole reason those regulations exist, it seems to me, is that — at least in the distorted, employer- and Medicare-dominated health insurance market we have, not the one conservatives like Bainbridge wish we had, but that we’re never going to get — consumers simply don’t have enough marketplace power (or don’t wield it correctly) to make the desired changes happen. The market pressures on insurance companies to keep costs down are simply much greater than the market pressures to cater to consumer desires will ever be.
It’s a good argument, but I think Klein gets the better of it.
But if consumer demand for more consumer-friendly policies had the ability to force (or at least nudge) insurance companies to adopt such policies, wouldn’t that be happening already?
There are three fundamental problems with health care. One is tort reform, but let’s set that aside right now.
A) Governmental price controls and mandates distort the free market (medicare)
and
B) very few consumers actually pay for their health care.
Take a look at cosmetic surgery. Over the last twenty years cosmetic surgery has improved by leaps and bounds, yet the price for it has dramatically declined. Why?
People pay for it themselves, and the government won’t pay for it.
As long as either employers or the government is paying for the majority of health care prices will continue to rise.
We need to change health insurance to work like all other forms of insurance…the consumer pays his costs and then is re-imbursed by his coverage. When people are forced to pay for $10 aspirin out of pocket, there will no longer be charges for $10 aspirin.
to go back to Brendan’s comment, there is very little consumer demand for consumer friendly policies, because right now most consumers are getting care without having to worry about costs.
I’d like to see insurance change. Basically, why are we getting insurance for routine medicine? I mean, I pay for car insurance for a car crash with damage above what I can afford. But I don’t pay for insurance for my oil changes. This makes it so I have no clue what’s going on price wise, and things have gotten to this point where normal people can’t afford everyday medicine.
“One is tort reform”
Which makes up a minute fraction of the cost of health care now. Tort reform isn’t going to fix the bigger problems. Its not going to stop health care costs from rising because its not whats really causing them to rise.
Health insurance has a fundemental problem, you can’t avoid getting sick, getting old, getting injured, etc. in a reasonable fashion atleast. Its not a luxury item, its a necessity, and therefore free market forces aren’t going to work, because you can’t really forgo it in any meaningful way. Its next to impossible to pay for medical procedures and coverage out of pocket because of the rules and agreements put in place with doctors and hospitals largely by insurance companies. Heck, ask a doctor how much any given procedure costs and they probably won’t have a clue.
Another interesting contradiction that I see conservatives make all the time is that governement is bad at running programs, while simultaneously blaming government programs for preventing free market alternatives to work. You can’t have it both ways. If the government run medical care programs (medicare) was so inefficient and bloated (its not by the way, its actually quite efficient and well run) then wouldn’t that be the PERFECT opportunity for private insurance to step in and demonstrate that they are better? Isn’t the whole argument that government is the problem and privitization is the solution? Of course that argument is wrong, its easy to find examples of well run government programs and poorly run private industries. That doesn’t mean government is always the answer either, but its frustratingly impossible to get conservatives to concede that government can do a better job sometimes or is the right option.
I think its also disingenous to blame medicare for the private sectors failings when medicare doesn’t even compete with most private insurance companies.
Finally, plastic surgery/cosmetic surgery is a flawed example. In most cases such surgery is elective and unnecessary, where as much of the medical treatment that is being talked about as part of health care reform involves non-optional areas. Without the reasonable option to say no to something, the free market model is flawed. I can reasonably say no to paying for a nose job. I can’t reasonably say no to paying for my asthma medication.
Brendan, if the Democratic plan was to pass a federal mandate for insurance that truly covered just the basics, then we wouldn’t have a problem*. The problem is, in every state where Democrats have set insurance policy, the mandated plans must be of “Cadillac” quality and cover things like chiropractic care, birth control, and so on. Now, I understand the “compassionate” liberals want to ensure everyone has access to these wonderful luxuries, but mandating that everyone get a BMW doesn’t make producing a BMW any cheaper.
This is not an “either/or” discussion; it should be a “both/and” solution. You set a truly minimal national standard and include strong disclosure requirements, then you allow insurers to sell across state lines and/or sell the mandatory minimal federal insurance.
At the end of the day though, the deeper problem is the way the whole insurance system is set up, and whether the insurance is run by an HMO or the government, the fundamental problem remains. B Minich is right; routine medical care should be out-of-pocket, and insurance should exist to cover more expensive care. Which is exactly why I have a high-deductible HSA plan.
*The real problem with the federal minimum idea is that, once it exists, the minimum will not be static — lobbying by chiropractors, Planned Parenthood, Livestrong, et al will inevitably vote in favor of “compassion” and add more requirements: funding for state-of-the-art cancer treatments; luxury point-of-service and non-traditional medical care; contraception; and the list goes on. The real choice for voters then becomes, expensive mandatory coverage policies now, or expensive mandatory coverage policies later? The only real solution is to eliminate the federal mandate, which is why the Republican position is more effective in reducing waste and increasing affordability. While Klein is correct in theory about there being a probable race to the bottom, with the winning state becoming the mecca for health insurance corporations, consumer-driven healthcare principles would strongly mitigate that risk by removing the poison pill of third-party payer plans.
The real problem with the federal minimum idea is that, once it exists, the minimum will not be static — lobbying by chiropractors, Planned Parenthood, Livestrong, et al will inevitably vote in favor of “compassion” and add more requirements: funding for state-of-the-art cancer treatments; luxury point-of-service and non-traditional medical care; contraception; and the list goes on. The real choice for voters then becomes, expensive mandatory coverage policies now, or expensive mandatory coverage policies later?
By the way, there’s a named axiom for this phenomenon, although I can’t remember what it is or in where I originally picked it up. But paraphrased, the axiom is that any organization, program, or policy that is not deliberately “conservative” will eventually change and become liberal. That would be true for any federal mandatory insurance mandate — it eventually would mandate unaffordable “Cadillac” plans for everybody even if designed to only be “Smart*” plans.
* I loathe Smart cars. They’re overly expensive for what you’re buying, they’re ugly, and they’re a rolling capitulation to substandard urban and transportation planning.
Andrew, I believe you are alluding to O’Sullivan’s First Law.
Gahrie, I agree with much of what you’re saying about how ridiculously distorted the current market is — NPR has done some excellent reporting on this, which has made me feel generally hopeless about the whole thing — but that’s precisely my point when I say,
“…will ever be” under the existing system, or any remotely plausible system that might result from GOP/conservative reforms currently being considered, that is. Tell me how I’m wrong about that. I recognize that in a perfect world, consumer-driven competition would potentially work to effectively “regulate” insurers and prevent drastically consumer-unfriendly policies (though competition in the health-care context still has some flaws as compared to other types of competitive markets, as David points out), but in the world we live in, it seems to me that it won’t. And no reform proposal currently on the table will structurally change the f***ed-up system significantly enough and quickly enough to change that, and thereby make Bainbridge right and Klein wrong on the race-to-the-bottom concept. So…. point Klein? Or am I missing something?
I thought it was liberals who created policy based on fantasy-world notions of how the world ought to be, rather than how it is…
Brendan, if the Democratic plan was to pass a federal mandate for insurance that truly covered just the basics, then we wouldn’t have a problem. … This is not an “either/or” discussion; it should be a “both/and” solution. You set a truly minimal national standard and include strong disclosure requirements, then you allow insurers to sell across state lines and/or sell the mandatory minimal federal insurance.
Then why aren’t Republicans proposing precisely that, Andrew? For that matter, why didn’t they pass such a thing into law at any point in the last 30 years, during the various times when they controlled most, or all, of the machinery of government? Guaranteed, single-payer catastrophic coverage for all, government hands-off otherwise? That sounds reasonable! I might very well support it! But of course, the Republicans can’t propose any kind of “federal mandate,” no matter how reasonable, because it’s OMG SOCIALISM!!!!1!! (unless it’s Medicare, in which case it’s, uh, socialism to want to cut it, or something).
Don’t misunderstand me: the bad faith of the Right isn’t an excuse for the Left proposing bad ideas. But at the same time, it’s not exactly surprising that a bunch of liberals are trying to pass a bill that’s… liberal. I continue to have zero sympathy for all the carpers on the Right who are shocked, SHOCKED!!! that the Dems are trying to “Rahm” through a liberal health-care reform plan. What the f*** did you guys expect? You do nothing to fix the system for 30 years, and you don’t think the Dems are going to do it their way once they finally have the votes to do so? If Republicans really believed in the sort of reasonable, pragmatic reform you’re suggesting, it’d be law by now, and we wouldn’t be having this discussion. In reality, however, all they really believe in is defeating the Democrats’ plan and then doing nothing for another 30 years. Actions speak louder than words in this instance.
By the way, this is a blatant lie and you know it:
“Brendan, if the Democratic plan was to pass a federal mandate for insurance that truly covered just the basics, then we wouldn’t have a problem.”
Pardon my French, but bull-fucking-shit. If the Democratic plan was to pass a federal mandate for insurance that truly covered just the basics, the GOP would be decrying it as SOCIALISM!!!!!! just as they’re decrying a plan that’s very similar to their (bad-faith) 1993 counterproposal as SOCIALISM!!!!!! Whatever the Dems had proposed, if it had any role for the federal government at all, the Republicans would have decried is as a “government takeover” and played the socialism card for maximum political advantage. You know this to be true.
(And whatever Bush proposed, the Dems would attack… I know, I know. Intellectually dishonest, politically motivated oppositionism runs both ways. I happen to believe it’s at its zenith right now with the GOP, but we can agree to disagree on that detail; in broad outlines, I will concede that the Dems, when in opposition, are very bad with this too. Now don’t you pretend the GOP “wouldn’t have a problem” with a more moderate HCR alternative. What Obama’s proposing is already a relatively moderate proposal, as Democratic health-care ideas go, and they’re acting like it was drafted by the illegitimate gay love child of Lenin and Marx. There is no pleasing these Republicans if you’re Obama, and not a shred of honesty or consistency in their criticisms, except an honest, consistent desire to, as someone once said, “see Obama fail.”)
If conservatives wanted a less liberal health proposal they shouldn’t have defaulted to their current plan of Just Say No from day one. If they had many any sort of effort to be involved in the process and seek some compromises, with a willingness to give on some issues, and THEN they were ignored, they would have valid grounds to complain. Instead they have been merely obstructionist, proposing measures that are either pointless or worse than what we have now, well the ones who aren’t saying we should just stick with our current flawed system.
Also, i’m still waiting for a good explanation on how creating a government run/insuree funded system is a bad thing. If its inefficient and bloated as conservatives claim it would be (the same thing they claim of all government programs) then private companies should easily be able to compete with it. I think the real fear is they know it probably will work quite well (just as Medicare currently does) and the private industry WON’T be able to compete without giving up on dramatically raising rates like they are allready doing and plan to continue doing.
In reading and thinking some more on this, I think I misunderstood what you were saying, Andrew, and clearly shouldn’t have used the term “single payer.” Are you talking about essentially what’s in the Wyden-Bennett bill?
In any case, given Eric Cantor’s comments about the evils of letting “Washington define what essential health benefits are,” it still seems decidedly unlikely that the Republicans would have “no problem” with such a plan if Obama had proposed it. To the extent there is GOP support for Wyden-Bennett and similar measures, it’s because it’s an alternative to “ObamaCare.” Whatever Obama had proposed, the GOP was going to oppose: that much, I think, is abundantly clear.
Brendan, why are you asking me a question which carries the underlying implication that you completely ignored my asterisked point?
The reason the GOP has never supported the both/and reasonable, pragmatic compromise is because legislation is not static and they know that once they compromise, the federal minimum will only be revised on one direction, thus eroding the state competition principle and gradually replacing it with the federal competition principle (see: Bainbridge). It’s truly a slippery-slope condition as explained by O’Sullivan’s First Law (thanks Joe Mama!). In effect, Republicans compromising on federal mandate is inevitabl-izing a socialistic outcome.
As far as “the bad faith of the Right”, as a legislator, you can be judged on one of two things: passing laws; or blocking laws. If you oppose laws that nevertheless get passed, well, you did your best — you can’t be blamed for the outcome, only the majority party can. Still, even this is often mitigated by minority parties having some involvement in the laws being passed so as to lessen their effect. This has been the hallmark of the Right when it comes to healthcare: they’ve been effective at occasionally slowing down the train, but never at getting it to switch tracks. That’s not a sign of “bad faith”, just a combination of ineptitude, internal disagreement, and insufficient power to effect the change. The Left, in contrast, has known which track they’ve wanted to be on since Bismarck, and with the help of FDR and LBJ, the train is on their track, not ours.
The Republican solution is a fundamental, structural change: eliminating the third-party payer system and putting healthcare back in the hands of consumers. (What part of high-deductible HSAs is so difficult for you to comprehend?) But that’s only one rail. The other rail has to be a universal coverage pool for emergency care (ownership and portability of insurance plans are the wooden slats that connect the rails). High-deductible HSA plans are of dubious value to moderately sick or poor people unless you still have access to emergency care once you’ve lost the ability to pay for items under the deductible. Now, in practice, we already have universal access to emergency care, but the problem is, this is done via a legislative mandate and not through an actuarial insurance program that draws income from, and covers risks for, a universal pool. If it was done via the latter, those with more disposable income and inclined to better insure their health could buy luxury add-ons to the basic federal emergency insurance.
David: let me take a stab at the main fear here. The objection to a government run insurance plan is that it would so the following two things:
1. Undercut efficient plans while:
2. Making up for the price differential in a non transparent way.
I’m sympathetic to point 1 myself. But I don’t see any effecient plans! And the word transparent doesn’t describe the current industry anyway.
I fear that short of a complete change of mindset in this country, neither the Democrats solution or the Republicans proposals will do anything. Like I said earlier, we need to change our mindset toward health care, knowing what the costs are ourselves and paying out of pocket for most care. But that would require the industry to have most options be affordable, and I think that train left the station, and proceeded to skip the country long ago.
So basically, my answer to “Is America going to very bad places?” is “Yes”.
In other words, study Greece. Where they are now may just be us in the not too distant future.
Aha, Andrew, so you are a single-payer universalist socialist! 🙂
I didn’t mean to ignore your asterisk, but I confess I’m a bit confused. Is your asterisked point in comment #6 meant to completely obliterate the comment’s first two paragraphs? I thought the asterisk was expressing a reservation/fear, not completely disavowing the very idea you’d just called a reasonable compromise that the Republicans would have “no problem with.” In any case, if we’re going to talk about legislative realities, will you acknowledge that if the Democrats’ big plan fails, we will NOT get large-scale insurance reform, of any type, in this Congress or any Congress in the foreseeable future? That it’s ObamaCare or nothing? That seems to be the political reality. Can you imagine President Romney making health-care reform a major agenda item in 2013 if this fails? I sure can’t.
Meanwhile, you say “the Republican solution is a fundamental, structural change: eliminating the third-party payer system and putting healthcare back in the hands of consumers.” To which I say, where was the effort during the Bush Administration, or under the Gingrich Congress, or the first Bush Administration, or the Reagan Administration, to make this happen? Obama has spent much of his first year-plus in office, and basically all of his political capital, trying to pass his version of comprehensive reform (though I’m not sure liberals would agree with me if I called it “fundamental, structural change”). Where is the Republican leader willing to similarly put his neck on the line for the “fundamental, structural change” you claim is the GOP “solution”? And if no one is going to bother to try to get it through, can you really claim that it’s your proposed “solution,” as opposed to a pie-in-the-sky dream you have no plans of passing? I understand about HSAs, but that’s a hopelessly piecemeal sideshow that will never achieve the kind of “fundamental, structural change” you’re talking about. Incrementalism works in a lot of contexts, but I don’t see how it’s possible to argue that that sort of change can be achieved in baby steps on this issue.
I didn’t mean to ignore your asterisk, but I confess I’m a bit confused. Is your asterisked point in comment #6 meant to completely obliterate the comment’s first two paragraphs? I thought the asterisk was expressing a reservation/fear, not completely disavowing the very idea you’d just called a reasonable compromise that the Republicans would have “no problem with.”
I never said the reasonable compromise was one that the Republicans would have no problem with, I only said the both/and approach was a reasonable compromise. The asterisked comment was to explain the fully defensible reason why the Republicans won’t go for it, regardless.
The rest of your comment misses the point and is incorrect on the supposed intransigent history of Republicans and healthcare. The GOP didn’t have a solution back under Reagan, but nor was it a popular topic for either the Left or the Right — everyone was focused on the Cold War and taxes. Even in the ’90s, only the conservative think tanks were truly pondering this stuff. Politically, in the ’90s, most Republicans hoped the creation of the HMO, a Frankenstein legislative creation of Ted Kennedy which the GOP only lukewarmly supported, would be a permanent stop-gap and make going to universal care insufficiently appealing. But costs continued to spiral, and despite the political collapse of HillaryCare, Republicans rightly feared that as time went by, the public would grow restless for “reform” yet again. So Rove hatched the idea of the Medicare Rx plan as a way to undercut the appeal of healthcare reform as a Democratic issue, and Dubya arm-twisted the GOP Congress into passing it.
This right here is enough to disprove your notion that the Republicans have done “nothing to fix the system for 30 years”. They supported some reforms, but opposed going all the way to a single-payer system.
I don’t give much heroic credit to Obama for pushing Obamacare; Obamacare is just yet another version of the same thing liberals have been pushing since Otto von Bismarck invented the welfare state in the late 1800s. Obama is just the latest in a long line of hardy warriors doing their best to push a rock forward.
In contrast, the Republican solution is ideologically much, much newer, and the party has only recently begun coalescing around it. Newt Gingrich is probably our most powerful spokesman, but he didn’t find religion until many years after exile from Congress. Also, consider Mitt Romney — he was the GOP establishment’s first choice in the 2008 primaries, and I voted for him in spite of what he did with healthcare in Massachusetts.
The Democrats, in turn, aren’t pushing a major structural reform, they’re pushing incremental step after incremental step towards a clear, easily definable goal (one that’s already been reached throughout the world in numerous other countries and political systems by their socialist brethren). The Republicans’ vision of structural reform is truly new and revolutionary, and unlike Chile and many other countries with Social Security privatization, they don’t have an easy precedent to point to — they have to be pioneers and tell a very skeptical voting public traditionally nervous about anything non-incremental, “Trust us — we’ve done the math and this will work!”
The road to a universal healthcare system has been like a train heading down a track at the end of which is a destination to which the train’s occupants deep-down do not want to go. As the train picks up speed, the public freaks out, and Republicans succeed in slowing or halting the train. But then, after a period of stillness or barely moving, the people get restless and want the train moving again, so the Democrats stoke the coals and the train builds momentum. But then, just before the train gets up to full speed, the passengers peak out the window, freak out, and clamor for the brakes again. Republicans again seize control and oblige. On and on this goes, and the story gets quite tiresome. Some passengers eventually come up with the idea of throwing a switch and changing tracks, but since there are so many unknowns, that seems scarier than sticking on the current track and just slowing down. I have a feeling that, eventually, the train will get close enough to the destination that the passengers can see, feel, smell, sense what single-payer will be like, and if Republicans can build and sell a switch fast enough, at that time we might finally change tracks. But the far more likely outcome is that, by then, we’ll be too late, and Americans instead will revert to that Anglo tradition of suffering through.
Your evidence that the GOP, when it had the chance, made good-faith efforts to pursue genuine health-care reform is… the Medicare Prescription Drug Bill?
HAHAHAHAHAHAHAHAHAHAHAHA.
Brendan – the principle thing I have seen the GOP do to try to improve healthcare in this country is Tort Reform … it doesn’t fix everything, yet it is not expected to fix everything … and, as expected, one of the biggest groups supporting a political party are fighting it with everything they can …
Tort Reform would be a good simple start to the process of improving healthcare – so why do the Dems fight it so hard ?
That is not what I said nor claimed. My comments made it explicitly clear that the GOP Medicare Rx bill was a political maneuver to keep healthcare reform from being wind in the Dems’ sails. Your claim was that the GOP did NOTHING on healthcare for thirty years. I disproved your claim with evidence that the GOP did some things and opposed other things. I didn’t say anything about them being good-faith efforts to truly reform anything.
The key to the problem here are your underlying assumptions, which are false and keeping you from accepting the reality of what I am saying. You assume that “healthcare reform” is this easily definable thing backed by some moral imperative.
Well, what specifically is wrong and needs to be reformed, and what is the moral imperative?
Is the real problem the lack of universal coverage — the “right” of healthcare? Well, there are ample philosophical grounds to oppose healthcare as a “right”, for one thing. For another, when you break down who doesn’t have coverage and why, it boils down to A. those who can’t afford it, B. those who are denied it, and C. those who simply don’t want it and refuse to pay for it. We’ll get to A and B later, but C doesn’t really rile people up. Most people understand that there are irresponsible people in this world who will refuse to buy health insurance and may run the risk of one day ending up in the hospital with a gargantuan medical bill. People seem to accept that fact for a couple reasons. One is, hospitals are forced by law to take them in, and another is, forcing people to be responsible goes against the ingrained American qualities of individualism and self-responsibility. The only time people get upset about abuse of the system is when they’re here illegally, because then it’s a risible foreigner mooching off our country.
As for people being unable to afford coverage, that is an effective moral imperatives, with the solution being, “Let’s have a welfare program” — see Medicaid.
Being denied coverage because of pre-existing conditions also angers most people, but the popular approach has always been to find ways to go after insurance companies for doing that. Indeed, codifying this mandate is one of the few aspects of Obamacare that Republicans have signaled a willingness to sign up to.
So what’s left to reform? If we have Medicaid, we fix the problem of people with pre-existing conditions being denied coverage, and we ultimately don’t want to or can’t make people buy coverage if they don’t want to (even Obamacare conceded this point by severely weakening the tax penalty provisions in order to get additional votes), then what’s the clamor for “universal” coverage (which by definition can only be provided by the government)?
Access to prescription drugs for elderly patients? The GOP tackled and took credit for that one.
Maybe the issue is privacy? Well a GOP Congress passed HIPAA, but whatever its flaws are, nobody is clamoring for HIPAA reform. HIPAA will largely be undermined by any major reform to make medical records electronic, anyways.
Maybe the issue is portability? That could be why Congress passed COBRA in 1985, and why members of both parties have occasionally fought to expand healthcare portability and insurance pools/exchanges for the self-employed or individual consumers.
Certainly the issue isn’t the fact that the healthcare system is largely structured around employer-sponsored plans with corporate tax subsidies. The current employer-based system may not be perfect, but most Americans see no moral imperative to change it; in fact, the threat to alter this dynamic was one of the key reasons Obamacare plummeted in popularity. So we can tweak around the edges, but Americans do NOT want to lose their current company-sponsored healthcare plans (and boy does this even go ditto for unions and union members!).
Is the main problem left frivolous lawsuits and skyrocketing malpractice insurance premiums? Last time I checked, the GOP is dead-set on dealing with this issue, and the Dems are in the hip pockets of the trial lawyers and are totally uninterested.
The only remaining issue I can think of is spiraling healthcare costs, but while occasionally alarming, Americans are not motivated by any moral imperative to act on this issue. As a point of comparison, do you see people clamoring for “higher education reform” because college tuition goes up 10% every year? The reality is, since we have a third-party payer system, people mostly just pay co-pays, so the perpetual griping about treatment by HMOs and the occssional horror story of the patient with a $50,000 medical bill that their insurance refuses to cover isn’t enough to scare a steady majority into some sort of major change to the system. Aside from that, the Democrats’ goal of moving from a broad, public-private mix of a third-party payer system to a single-payer system doesn’t solve this problem at all. It merely masks the problem with a mix of monopsony and rationing (anything budgeted is inherently rationed), and has the downside of severely curtailing the drive for medical breakthroughs, technological advances, and newer, more effective drugs (even your Obama-loving buddy Sullivan accepts this as a ground truth).
So what do we have at the end? What we have is the fact that “healthcare reform” is a fuzzy concept, and a dubious, ill-defined problem set whose solution is inevitably more government, more taxes, more regulation, but not actually better healthcare. It’s a political bludgeon used by ideologues to bash Republicans with little attention to the actual details of the issues, how they’ve been addressed throughout the decades by both parties, and most importantly, what the public actually wants. You whine and moan about this “historic” moment of Obamacare being lost, whereas most Americans tell pollsters, “Well, we wanted some changes, sure, but we’re dodging a major bullet if we can make sure this thing fails!”
Frankly, your head is way up your ass on this issue, as attested to how impervious you are to facts and political reality. But if it helps you sleep better at night to make the GOP the healthcare bogeyman, go right ahead. I may fear what Democrats will try to do with healthcare and the negative repercussions, but that fear is easily outweighed by my faith that the American people get the big picture and ultimately don’t want what the Democrats are selling them. So long as a majority of the voting public retain their distinctive American flavor of thought patterns, Republicans have hope that we can roll back the most egregious and damaging “reforms” the Dems end up passing.
Obama and the Obamabots response to way too many things is nicely demonstrated by this cartoon which targets our current President’s fiscal responsibility …
Such an outlook permits folk to claim that the GOP have done nothing, no matter what factual evidence is produced to the contrary …
Alasdair, the adults are having a meaningful intelligent discussion here, you need to go play with your toys. Bye.
Andrew, no time to respond in full, but one point:
Being denied coverage because of pre-existing conditions also angers most people, but the popular approach has always been to find ways to go after insurance companies for doing that. Indeed, codifying this mandate is one of the few aspects of Obamacare that Republicans have signaled a willingness to sign up to.
Yes, and those Republicans are incredibly cynical and irresponsible for “signing up to” a portion of the Dems’ reform that CANNOT stand on its own, given that it will (as everyone who is thinking in terms of policy, not politics, knows) make your “individual irresponsibility / healthy people not buying health care” problem far worse, since people will now have an ironclad incentive to wait till they’re sick buy insurance. This will either: 1) bankrupt the individual insurance industry, 2) cause costs to skyrocket so much that individual insurance will truly be the province of the rich only, or 3) lead to some new clever/devious/consumer-unfriendly cost-cutting tricks by insurance companies (that Congress didn’t think of) to make up the difference, unless it is accompanied either an individual mandate or some other, similar OMG SOCIALIST scheme to get more healthy people into the system. This is not a novel point, or a debatable one. Everyone knows it to be true. Yet the GOP persists in ignoring it for the sake of political expediency, while the Dems are actually trying to craft workable policy, and, y’know, govern the country.
The impossibility of simply waving a magic wand and eliminating pre-existing/uninsurability requirements is precisely why the Dems have proposed an individual mandate: not because they’re a bunch of Marxists who desperately want to force the public to do things, for fun, but because without an individual mandate or something similar, eliminating pre-existing condition and uninsurability rules is a reckless, irresponsible and indefensible policy that sounds good politically, but will have dire unintended-but-totally-foreseeable consequences in the real world. Such policies were, I thought, supposed to be the province of the Left, but in this case it’s the Dems pushing the responsible policy, and the GOP calling them evil socialists for doing so.
The impossibility of simply waving a magic wand and eliminating pre-existing/uninsurability requirements is precisely why the Dems have proposed an individual mandate: not because they’re a bunch of Marxists who desperately want to force the public to do things, for fun, but because without an individual mandate or something similar, eliminating pre-existing condition and uninsurability rules is a reckless, irresponsible and indefensible policy that sounds good politically, but will have dire unintended-but-totally-foreseeable consequences in the real world.
Let’s grant your point for the sake of argument.
Where in the Constitution does it give Congress the power to force American citizens to purchase a product? So now not only does the Constitution give us a newly discovered “Right” to health care, but a mandate to purchase healthcare?
If they can force us to purchase health insurance what else can they force us to buy? Maybe next we will all be forced to buy carbon credits to account for our impact on the earth’s climate.
How about someday a future Congress determines that every American must buy a gun? Or subscribe to a newspaper?
many of us believe that the idea of forcing Americans to purchase health insurance is precisely a “reckless, irresponsible and indefensible policy that sounds good politically, but will have dire unintended-but-totally-foreseeable consequences in the real world”.
Referring back to my first comment above, contra Brendan, I don’t really find Bainbridge’s argument naive at all. It seems to me that the political factors combined with competitive market forces would preserve consumer protections rather than erode them. For example, if South Dakota gutted its consumer protections and began issuing licenses to sketchy insurers in the hope of collecting lots of fees and taxes on premiums, as Klein suggests would be the case, then the following is likely to occur: First, South Dakotans would inevitably be harmed by some of those insurers, and would demand that their politicians restore those consumer protections. Second, competitors would discipline the crap health plans licensed by SD (e.g., higher quality insurers would be sure to advertise the fact that they comply with the stronger consumer protections demanded by other states). Third, courts in other states would deter insurers licensed in SD from bad behavior by enforcing contracts and punishing negligence. And fourth, consumers would discipline the crappy insurers after learning of SD’s reputation through the news, Consumer Reports, etc. Whether SD eliminated consumer protections deliberately or inadvertently, self-correcting mechanisms would likely restore them. It may very well be that states’ regulatory monopolies, not competition across state lines, produces the “race to the bottom.” Bainbridge makes a persuasive argument that horizontal competitive federalism strikes the right balance between too little and too much regulation.
Gahrie, I wasn’t making either a normative or a legal argument in favor of the individual mandate. I was merely responding to Andrew’s statement that “Republicans have signaled a willingness” to go along with “codifying [the] mandate” that insurance companies not “den[y] coverage because of pre-existing conditions.”
My point was, and is, that it is “reckless, irresponsible and indefensible” to promote such a codified mandate unless one also supports either an individual coverage mandate or else something that will achieve the same goal, namely, to get & keep healthy people in the system despite the overwhelming incentive you’re creating for them to opt out until they get sick.
I was NOT saying it’s “reckless, irresponsible and indefensible” to oppose an individual mandate in any context — only that it’s “reckless, irresponsible and indefensible” to oppose an individual mandate while supporting a ban on pre-existing condition/uninsurability rules. Yet that’s exactly what the GOP is presently doing, because of course, it’s politically popular to support a ban on pre-existing condition/uninsurability rules, and the public at large is too ignorant of the mechanics of health care and insurance to understand the inherent contradiction of the GOP’s position. It’s a completely and utterly cynical stance.
Now, you say an individual coverage mandate is unconstitutional. Fine. But then you must also acknowledge, unless you have a constitutional alternative that will achieve essentially the same goal, that you CANNOT support a ban on pre-existing condition/uninsurability rules, given your principled opposition to an individual mandate. The two positions are just totally incompatible.
I suspect you, gahrie, do not personally hold those incompatible positions, and in fact oppose BOTH an individual coverage mandate AND a rule banning pre-existing/uninsurability denials. And that’s fine. Your position is at least consistent. The same cannot be said for the folks Andrew was referencing, and it’s to them (and him) that I was addressing my commentary.
In sum, if you oppose an individual mandate — whether on constitutional grounds or other grounds — AND you also oppose a ban on pre-existing condition/uninsurability rules, I have no problem with that, at least for purposes of this discussion. What I do have a problem with (and so should you, and so should everyone with a functional cerebral cortex) is the cynical, indefensible GOP/conservative position that’s anti-individual-mandate BUT pro-insurance-on-demand regardless of pre-existing conditions. Your constitutional argument does nothing to address that point or deflate the dangerous hypocrisy and cynicism of the position I’m criticizing. Thus, as a response to my comment to Andrew, your comment on the constitutionality of the individual mandate is a non-sequitur.
Having said all that… on the merits of your constitutional argument, let me just say this. It would surely be constitutional — unless you believe Medicare itself is unconstitutional* — for the federal government to raise taxes (which is clearly within its constitutional authority) and expand Medicare to cover the entire population (increasing the scale of the program doesn’t change it from constitutional to unconstitutional). So in other words, it’s constitutional to impose single-payer health care — a REAL “government takeover” — by way of higher taxes.
It would be odd — not inconceivable, but odd — if the far less drastic, less government-heavy, less centralized, more market-based solution proposed by Obama were deemed unconstitutional, when the far more drastic solution preferred by liberals (single-payer, government-run health care) is clearly constitutional. But that’s where your argument seems to lead us.
*Maybe you do believe Medicare is unconstitutional, and if so, bully for you. But if that’s your argument, surely you must recognize it’s purely an academic one. Good luck finding a Supreme Court this side of the early 1930s to give you even a single vote for that position. (Aw hell, maybe you can get Thomas.)
P.S. Put another way: you say the government can’t constitutionally force people to buy things, such as health insurance. Okay. But surely the government could raise taxes on everyone, but then create a “tax credit” for buying health insurance, which would effectively reduce the tax rates of insured Americans back to the old rates. Meanwhile, the difference between the higher tax rate paid by non-insured Americans and the credit-reduced tax rate paid by insured Americans would be equivalent to the amount of what is currently called the “penalty” for NOT buying health insurance.
That’s clearly constitutional, no? After all, it’s just tinkering with tax rates, and using tax credits to promote government-favored behavior, which is standard practice by both parties and all ideologies in the modern era. And yet it would accomplish the exact same thing as the more straightforward, transparent proposal that you say is unconstitutional. So really we’re just arguing about means, not ends. And you’re saying the more convoluted, less transparent means is the only one that passes constitutional muster. Maybe you’re right — sometimes constitutional law leads us in odd directions — but it would kind of be a shame if so, and I tend to think that any modern Supreme Court would recognize this and say that the individual mandate is A-OK under the Interstate Commerce Clause.
I find it interesting that the President can send an additional 17,000 troops to Afghanistan in February, and then 30,000 more in December, spend $80 Billion per year on wars, and not only are no Americans (or news outlets) upset by it, but there’s no discussion about the financial impact or broader long-term impact of such actions, it’s just done. But when it comes to tax dollars being spent directly to benefit Americans, it takes decades of procrastination, consternation and debate… and still never happens.
War and(/or) Health. It’s a not even close.
Brendan, I agree that a universal mandate to buy insurance can be done via the tax code in a way that passes constitutional muster. What I don’t think it passes is majority approval from Americans — I think it just goes against the grain of our culture.
As far as the impact codifying a requirement to not deny coverage for pre-exisitng conditions would have on the insurance companies, you are technically correct, but only because we are stuck in a hybrid third-party payer system with high levels of coverage mandates. If we remove these Lexus mandates and allow insurers to offer very basic levels of health insurance coverage, that helps. Improving healthcare portability and allowing individuals and small companies to more easily form insurance pools helps, too. Driving the market towards high-deductible HSA plans also helps. Finally, allowing insurers to consolidate plans and operations and sell insurance across state lines also helps (and goes along with my point about needing to remove Lexus mandates).
In sum, by no means does supporting this one part of Obamacare morally, politically, or philosophically obligate Republicans to support the rest of Obamacare and the single-payer outcome. The GOP is not being cynical, they are signaling very clearly what they theoretically can agree with, and so long as Obamacare makes it a combo, take-it-or-leave-it package, Republicans will end up saying Thanks but No Thanks.
What pisses me off to no end is your refusal to see any validity to Republicans’ actions here. Everything is cynical and political. Were this coming from a dedicated partisan like David K, it wouldn’t annoy me so much — it’d be par for the course. But coming from you, it’s incredibly damaging to your credibility on these kinds of topics. Unfortunately, your attacks on the motives of conservatives and Republicans has been de rigueur for quite some time, which is a large reason why I avoided commenting on this blog for so long. If you cannot accept that your loyal opposition has an internally consistent rationale and motive for their behavior that is legitimate and right in their own eyes — if everything they say and do is calculated, cynical, and self-serving — then you are no better than the worst partisan hack and have joined the world of Paul Krugman, Michael Savage, Bob Hebert, Glenn Beck, and other commentators whose opinions — no matter how well informed and interesting — are not even worth taking into consideration because they live in an ideological echo chamber.
I find it interesting that the President can send an additional 17,000 troops to Afghanistan in February, and then 30,000 more in December, spend $80 Billion per year on wars, and not only are no Americans (or news outlets) upset by it, but there’s no discussion about the financial impact or broader long-term impact of such actions, it’s just done.
Where were you when Dubya was president? He got hammered for war spending all the time. I won’t go back and check, but I bet you were among the critics. Quite obviously then, the simplest and most convincing conclusion that one would draw is that because the complaints came from Democrats and a liberal media, predictably those complaints would cease when the Democrats are in charge and the liberal media’s preferred candidate is president. IOW, this has nothing to do with healthcare.
It has EVERYTHING to do with healthcare. Healthcare is a necessity, this war was a choice, and continues to be a choice. There’s no threat from the Afghanistan army or government, and there’s no threat (and never was) from Iraq. Nobody (other than the intellectual minority like me, who has no voice) ever objected to the outrageous spending on these wars.
It’s hillarious that you say that now that Democrats are in office nobody in the media is criticizing spending. It’s my observation that all the voices criticizing Obama’s spending from Fox News, Tea Partiers, and Townhall debates were all silent about the ridiculous amount of money that was spent the last 8 years on everything from tax-cuts that benefit the billionaires and corporations the most to the most wastefull expense of all– A war we didn’t even need to fight. Now that money is finally being spent on Americans again, it’s “wastefull” or a burden to future generations. Furthermore, the money that’s wasted on the wars still is accepted with no debate or concern, so the fact still persists that tax dollars directly coming back to benefit Americans are actually least spent on Americans.
If we remove these Lexus mandates and allow insurers to offer very basic levels of health insurance coverage, that helps.
Why would anyone — particularly any young, healthy individual — buy even “very basic levels of health insurance coverage” if they know they can sign up immediately upon getting sick, and can’t be rejected because the insurance company is required to take them?
Improving healthcare portability and allowing individuals and small companies to more easily form insurance pools helps, too.
Allowing small companies to more easily form insurance pools might help bring down costs in the employer-provided group-insurance market (which I thought Republicans wanted to do away with), but we’re talking about the individual market — and its inevitable extinction if insurers are required to provide coverage for all without an individual mandate or some similarly effective plan to get & keep healthy people in the system — so that’s irrelevant. As for allowing individuals to more easily form pools, again, why would healthy individuals be interested in buying insurance, at any cost (and let’s be realistic, the costs will still be non-negligible under any plausible scenario), if they can buy in immediately upon getting sick?
Driving the market towards high-deductible HSA plans also helps.
Again, how, if you can sign up for high-deductible HSA after you get sick?
Finally, allowing insurers to consolidate plans and operations and sell insurance across state lines also helps
Again, you’re saying competition will lower costs, but I fail to see how it will lower them enough to make individual insurance something that healthy people will actually want to buy, if they know they can get insurance the moment they get sick. And if they don’t buy in, the system collapses in a clusterfuck of skyrocketing costs (even worse, far worse, than what we’re seeing now) and moral hazard.
You say I’m “technically correct,” but this is not a technicality. Neither the present individual insurance market, nor any realistic near-term vision of the individual insurance market after any conceivable combination of incremental conservative-style “reforms” are passed, can handle the sudden elimination of any ability to deny coverage based on pre-existing conditions / uninsurability rules. If you support the elimination of those rules, you’ve gotta come up with something better than “we’ll pass some incremental measures to gradually change the way the market works.” At the very least, you’d have to pass a comprehensive reform plan of some kind, doing all of these measures forcefully and simultaneously — and, according to Lamar Alexander & co., conservatives are “philosophically” opposed to the very idea of comprehensive reform (never mind that Lamar voted for Wyden-Bennett, which is more comprehensive than ObamaCare), because government, or more specifically “Washington,” just can’t do things comprehensively.
The GOP is not being cynical, they are signaling very clearly what they theoretically can agree with
Well isn’t that fucking great. Let the record show that I “theoretically can agree with” ending all war, eliminating poverty, and bringing happiness to all mankind. Look at me! I have awesome policy ideas!
Seriously, if the best you can say to defend the Republicans’ (dishonest, cynical) claim to “support” a politically popular proposal that cannot and will not work under any conceivable reform plan that they would support is that they’re merely stating a “theoretical” position, I think you just proved my point.
What pisses me off to no end is your refusal to see any validity to Republicans’ actions here. Everything is cynical and political.
I am observing & describing reality, Andrew. I’m sorry it pisses you off.
If you cannot accept that your loyal opposition has an internally consistent rationale and motive for their behavior that is legitimate and right in their own eyes…
I will accept these things when they become true. Presently, at least with regard to the Republican leadership, on the majority of big issues up for debate, they are not true.
— if everything they say and do is calculated, cynical, and self-serving —
Again: observing and describing reality. I’ve yet to see any reasonable, non-cynical defense of, just to cite a few examples, (a) describing a plan whose broad outlines they supported in 1993 (when it was the less-extreme alternative to HillaryCare) as a “socialist” “government takeover”; (b) asserting that the Democrats’ plan somehow involves “death panels,” when it manifestly involves nothing of the sort; (c) decrying “socialized medicine” and screaming about the deficit while simultaneously, blatantly stoking seniors’ fears that the Democrats want to (GASP!) cut Medicare (c’mon, even YOU can’t defend that one); (d) deliberately fomenting an atmosphere of irrational public fear and anger with an endless series of false and misleading claims about the actual content of the Democrats’ proposal (such that polling consistently shows rampant misconceptions about the content of the Democrats’ plan, as well as broad support for the vast majority of its individual components but broad opposition to the plan as a whole), then using that very fear and anger as a rationale for stopping the process in its tracks; (e) arguing that we should “slow down” a process that’s been dragging on for a year, and/or “start over” from scratch, with the obvious intention of getting us closer and closer to the midterm elections, when they know perfectly well that progress on major issues is all but impossible (in other words, pretending to support some degree of reform, when they actually intend to kill it altogether); (f) claiming to “support” various reforms, like the pre-existing/uninsurability thing we’ve been discussing, that they do not actually support, would not pass if they had the ability to do so (see: 2001-2006), and that cannot possibly succeed without some sort of comprehensive changes to, as you put it, our “hybrid third-party payer system with high levels of coverage mandates” — changes which they don’t support, and would not pass, because they’re “philosophically” opposed to the very idea of “comprehensive” change originating in “Washington.”
Those are just six examples; there are many more. If recognizing these core facts of our present political environment makes me “no better than the worst partisan hack,” so be it. I can only call it like I see it. That’s all I’ve ever done, and that’s all I’m doing now.
If you can make, or point me to, a truly convincing argument that I’m wrong about these fundamentals, I’m open to it; I think I’ve demonstrated over the years an ability and willingness to rethink my beliefs when it’s shown that they’re unjustified. But I’ve read a lot of commentary on this, including conservative commentary, including by people I usually respect (e.g., Peggy Noonan), and I’ve seen nothing remotely convincing on these points. So, thanks, but I’ll keep up my “partisan hackery” until I’m persuaded that I’m wrong. If there’s one thing I’ve learned from my flirtation with Bloomberg/Lieberman/Broder moderation-for-moderation’s-sake, it’s that sometimes — not always, maybe not even often, but sometimes — one side is right and the other is just wrong.
Brendan, I’ve wasted thousands of words in this thread doing exactly that. I’m done wasting my time trying to communicate reasonable points to unreasonable, demagogic hacks.
I’ve read every word, and remain totally unconvinced, due in large part to the logical holes in your arguments that I’ve pointed out. To you, the fact that I’m unconvinced by your arguments is, I guess, proof positive that I’m a “hack”; to me, it simply indicates that you’re wrong. I’m not sure why this disagreement rises to the level of me demonstrating once and for all (and contrary to prior years’ worth of evidence) my total unwillingness to consider reasonable contrary arguments, but to each his own, I guess.
Again, if you cannot accept that your loyal opposition has an internally consistent rationale and motive for their behavior that is legitimate and right in their own eyes, it’s not worth debating. It’s not about logical holes or whether you like it or not, it’s about assuming good faith on the part of the opponent. You’re clearly unwilling to do that, so this is a supreme waste of my time. Especially when half of my argument is spent having to undo words you’ve put into my mouth or twisted to mean something I didn’t say.
Not to mention, it’s the height of false modesty to say that you consider reasonable arguments when you start from the position that the side asserting the position opposite from you is being cynical, lying, irresponsible, acting in bad faith, and the list goes on. If that’s where I have to start from, why should I even bother?
In any case, I will respond to one substantive point: You’ve not pointed out any flaws in my argument, you’ve merely asserted things to be true which you do not know and cannot prove. For example:
1) There’s not a chance in hell that happens; go look up the word “actuarial” in the dictionary and study how insurance actually works.
2) This is baseless hyperbole; Obamacare will do little to reduce the pain of insurance companies having to accept people with pre-existing conditions based on how they’ve watered down the tax penalty, so if you did it piecemeal, the hit to insurance company premiums would be essentially the same.
3) This is standard liberal trope — that corporations exist to deviously sucker consumers, as if the market has no self-corrective ability — and not worth responding to.
And of course, the ever-famous “Everyone knows it to be true.” Here we are, living in a warped rerun of the AGW debate! The science is settled, folks, everyone can go home now!
Fact is, you know zilch about consumer-driven healthcare principles and have accepted a priori that universal coverage and single-payer are moral imperatives, leading to the unavoidable conclusion no matter what responses I give you that the status quo is evil, incremental changes are not enough, and therefore anyone who opposes these things is cynical and opposed for no reason but opposition’s sake.
Again, I might as well be arguing with the likes of David.
[You] have accepted a priori that universal coverage and single-payer are moral imperatives
I have??? Wow, that’s news to me. I never realized I was a supporter of single-payer… I always thought I was sort of a health-care agnostic, recognizing that there are real problems, some of them with (yes) moral dimensions, but unsure what the correct solution is. Good thing I have you here to set me straight about what I actually think!
As for the rest, while it may be true that I “know zilch about consumer-driven healthcare principles,” I have read & listened to a lot of smart commentary by people — not all of them crazy liberals — who DO know a lot about healthcare, and who say precisely what I’ve outlined above. Maybe I overstate it when I say “everyone knows it to be true,” but it’s certainly the exceedingly strong conventional wisdom among the experts, and while such CW is occasionally incorrect, I’ve yet to hear a convincing argument (from you, or anyone else) that it’s incorrect in this instance.
As for “assuming good faith,” I’d be happy to do that, if the facts I observe hadn’t contradicted the assumption many times over. Like any legal presumption, the assumption of good faith can be overcome by evidence of bad faith. You and other conservatives certainly accused the Left of bad faith plenty of times during the Bush years — saying liberals were opposing whatever policies he proposed, regardless of the policy’s merits, just because he was the one who proposed it — and I even sometimes agreed with you! When people act in bad faith, they should be called out on it. I didn’t “start” from the position that “the side asserting the position opposite from [me] is being cynical, lying, irresponsible, acting in bad faith”: I was drawn to that position by virtue of my powers of observation of their behavior.
When the Right starts meriting an assumption of good faith again, I will gladly grant it to them. Until then, sorry, but I’m sticking by my guns on this one. You were right with some (not all, but some) or your similar critiques of the Left in the mid-2000s… and I’m right about this.
Brendan – (independently paralleling Andrew’s response) for someone who is self-proclaimed “sort of a health-care agnostic” and “but unsure what the correct solution is”, you are remarkably certain that healthcare-related things supported by the GOP over the past decade or more are “calculated, cynical, and self-serving” …
This isn’t the Cult of AGW, Brendan … a lot of healthcare costs and requirements exist because of actuarial calculations (and, yes, in that respect are indeed calculated) – with health insurance companies relying upon said actuarial calculations to be able to stay in business paying out for sick folk out of funds taken in from all their ‘subscribers’ sick and healthy …
Pre-existing conditions actuarily are the equivalent of dividing by zero … the result does not have useful meaning (except for math geeks) …
Again, if your ideas are so sound, put ’em into practice … start a company along the lines you propose with your own funds … if you are right, you’ll take in money hand-over-fist like those greedy corporations … if you are wrong, I bet most of us would pitch in to help Becky and family …
I know which result is actuarily predicted …
“Again, if your ideas are so sound, put ‘em into practice … start a company along the lines you propose with your own funds”
Why would you even say something like this? Its a ridiculous and stupid atempt at an “argument”. I could turn around and say “hey,if you like the war in Iraq so much why don’t you go over there and fight!”. It doesn’t add ANYTHING of value to the discussion.
David – to the best of my knowledge, the US Armed Forces isn’t interested in 50+ year old resident aliens enlisting any time in the recent past … or was your most recent post a classic example of reductio ad davidkium ?
My suggestion is a scaled-down version of the idea that the Unions should buy out any reamining non-Union ownership in GM with the Union pension funds and run GM the way they want their employers at other companies to run those other companies … then we get to see if the Unions’ demands are reasonable or not …
Some of us put our “money where our mouth is” in how we live …
My opinions on the Cult of AGW are being vindicated day-by-day as more real science exposes the cultist “settled science” … we have been using solar water heating on our house since 1980 … we compost … heck, we even have a worm farm (cute little critters, and amazingly prolific – but I digress) … my family has recycled bottles and cans and aluminium foil and plastics all along … cuz it is the sensible thing to do … (not to mention t is the Scots thing to doas well as the conservative thing to do, conserving resources) (well, it was, when I was a kid)(Gordon Brown is NOT our fault! – had we known, his parents would not have been allowed to meet – but I digress, again) …
And *your* credentials are … ?
David ?
David ?
Bueller ?
(or even any remaining non-Union ownership) (sigh)
This thread reflects the health care debate in the sense that it mirrors the difficulty of dealing with this issue. Both Brendan and Andrew make good points here. Unfortunately neither defeats the other, and each illustrates a justifiably partisan way to address the problem.
Brendan says you have to have a mandate. This is a basic principle of insurance; you have to pool the costs of a catastrophic event across a wide swath of folks who might experience the event, as an example this is why your state requires you to buy automobile insurance. It makes no sense to let you contract for auto insurance only while the cops are on their way to a wreck you just caused; similarly it makes no sense to allow someone to buy health insurance only when they get sick.
However, Andrew’s counterpoints, which more or less echo conservative arguments, reflect the truth that health insurance is fundamentally different than auto insurance, homeowners insurance or life insurance. We pretty much buy auto insurance to pool the risk of a more or less discrete event: a catastophic accident. Life insurance is even simpler: we buy that to pool the risk of the ultimately simple event that we die.
But health insurance isn’t like that, because the outcomes we protect against are not simple. If you need a multiple bypass surgery, you can get the Cadillacish version at the Mayo Clinic for well into the six figures, or you can take your chances at your regional hospital for something in the mid-five figures. Or you can spend low-five figures in India, which advertises itself as being as good as the Mayo Clinic, but may in fact be worse than your regional hospital, you take your chances.
So there is some validity to Andrew’s (and conservatives’) argument that a high-deductible plan helps, even if the private market is voluntary, and even if there are no pre-existing exclusions: if the deductible were as high as $40 K/year, maybe you’d be more likely to roll the dice overseas, which saves money.
To which Loy might fire back, well, you can’t make the deductible high enough that the really expensive cases can a) still pay, and b) be willing to contract for the insurance. Maybe that is so, I don’t know the demographics.
As a general rule, the sheer complexity of “what to do about one’s health”, including the complexity of price and service levels – much more so than other types of insurance – makes it hard to draw obvious conclusions. In other words, this isn’t messy because Republicans are obfuscating. Its messy because its messy.
Just to further the argument about why high-deductible plans help in the private insurance market, separate from any pre-existing condition exclusion:
Suppose the deductible were something like $12,000/person/yr, with montly premia very low (close to zero). That’s $1,000/month, which is a lot, but many in the private insurance market are currently paying that much or more. Setting aside the really really difficult cases (autoimmune, slow-growing cancer, etc), suppose you had something serious but not catastrophically expensive, like GERD.
Maybe your GERD will need surgery, maybe the Nexium will take care of it, maybe there are a thousand other scenarios in between. Suppose on January 1 you are considering health insurance, with the GERD in mind, and suppose further your $12,000 deductible is protecting against the surgery scenario, which might cost you, in total (I don’t know, just guessing) $20,000. Then there are a bunch of other scenarios that would cost you usually much less than the $12,000 deductible.
Brendan argues that you wouldn’t contract for private health insurance until you knew you were in the $20,000 scenario. But – and this is crucial – your deductible clock wouldn’t start ticking until you bought the insurance. So if it took $9,000 worth of procedures to determine that you were in the $20,000 case, you would end up eating the entire $20,000 out of pocket ($9,000 + $11,000 out of $12,000 deductible).
Since the monthly premia are usually fairly small in high deductible plans, in fact a lot of people would purchase them, long before they got their bad diagnosis, for the simple reason that they would want their deductible clock to start ticking as early into their yearly medical spend as possible.
Further, the fact that folks were paying the first $12,000 out of pocket would go a long way to solve the problem of defensive medicine, and also improve price transparency. If you’re paying for that MRI, you will bargain for a cheap one, and you will avoid it if unnecessary.
Its true that this doesn’t solve the problem of the really hard, expensive cases. However, there’s too much upside to the high-deductible plan, even without pre-existing exclusions, to simply label them as empty political grandstanding. They are a major help to a) preventing defensive medicine and b) getting people to take responsibility for something that is extremely personal and unique, their health. A lot to say for them, even if support for them comes from politicians for the wrong party.
Alasdair, come back when you are an adult in mind, not just in age.
Jazz:
Your posts of 47 and 48 are exactly the reason why we cannot allow the government to impose a one size fits all single payer system on us, regardless of the fact that it is unconstitutional. A Feree market can accomodate different needs, a government fiat cannot.
Ditto Jazz @ 47 and 48.
Brendan @ 42, I can’t get into your brain any better than Becky or your kids can, but what I can do is read your arguments and rationally conclude on what assumptions they rely. You are quite clear, if fairly general, in your statements about the need for healthcare reform and what that entails, and your attacks on conservative options make equally clear what your approach assumes. Your arguments assume a priori a moral imperative to universal care and single-payer, whether you have internally articulated that or not.
You were right with some (not all, but some) or your similar critiques of the Left in the mid-2000s… and I’m right about this.
It was easy to peg the Left in the 2000s because their policies were blatant about what their intentions were: withdraw from Iraq, half-ass Afghanistan, “support the troops” by bringing them home, treat terrorism as a criminal problem, operate on the assumption that our moral standing in the world and tackling global poverty were more important than chasing terrorists and fighting regimes that supported them, and so on. The reason one could say the Left was arguing in bad faith was because their policies promoted these things, and at the same time, they would claim to be hawkish on terrorism and being tough on bin Laden. So, we had Kerry in 2004, the voters had a clear choice despite the obfuscations of the Democrats, the voters saw right through it and re-elected Bush.
The healthcare debate, you simply cannot compare, and that is supported by the fact that the Dems are getting trounced in every election that’s come up since Obamacare has been on the agenda. Opinion polls back this up even more. The GOP is not offering Trojan Horse policies, they are first and foremost stalling and pushing back against policies the public has made clear it doesn’t want, and second they are using the platform to galvanize and come together on alternative approaches that fit within their weltanschauung.
The GOP from November 2008 through summer of 2009 reached a level of powerlessness almost unparalleled in their history as a political party. It literally did not matter what our team said or did; all we could do was watch and hope that Obama would overreach, and we’d be able to pick up a few vulnerable seats held by extremely shaky moderate Dems in GOP-leaning districts and states. What has happened instead has more than vindicated the Republicans’ whining from the sidelines and morphed into a tidal wave that has delivered us Ted Kennedy’s seat and knocked formidable moderates like Evan Bayh into early retirement. Absolutely nothing the GOP has said or done needs to even be evaluated as to level of cynicism or good faith; the Democrats have fouled up their chances so badly that we’re going to be wielding power again no matter what we say or do. This is especially true for healthcare, and hence, the Dems’ empty posturing on the GWOT is not even in the same league for comparison.
Face it, Brendan: Your team got everything you wanted, they’ve blown it royally, and now you’re just pissed that the GOP is being proven right when all it has done is simply sit its ass on the sideline and laugh at the Dems’ bumbling.
You were rightly embarrassed enough by the Left’s treatment of the GWOT to back off from your formal affiliation with the Democratic Party, but as soon as the 2004 election, your true colors came right back. You were respectful of the Bush administration for, at most, two years, and even then that was only limited to sub-parts of the GWOT, then you went right back to a level of opposition and attacks on Bush exceeded only by the zealots ridiculously calling for impeachment. For you to claim some sort of fair-handedness in arbitrating which side has been more cynical than the other is totally belied by every position you’ve taken on the major political issues of the past ten years.
This history is easy to square with your self-confidence in your impartiality; the reality is your process and reasoning modes are for the most part impartial, but your going-in assumptions are almost never so.
James Taranto has summed up this entire thread quite nicely in his BOTW yesterday, more specifically in his recap of the back-and-forth between Jonathan Chait and John Podhoretz.
Read this, and then read this.
One thing should be abundantly clear: Bluster about the cynical, bad faith of the Republicans on healthcare is nothing but a diversionary response to avoid acknowledgment that we are witnessing a political train-wreck of historic proportions that Democrats have set in motion by themselves, for themselves.
Since I’ve used train analogies so much in this thread, allow me one more indulgence: Brendan’s attacks on the GOP amount to anger that the Republicans stayed at the station and refused to even get on board the train, which is now hurtling down the tracks to an inevitable, calamitous wreck — one which the Republicans warned would come if the Dems tried to push through Obamacare — and now Brendan and his ilk are angry that the Republicans aren’t on board the train with them to share the blame for the impending disaster: “Those cynical bastards refuse to even board the train; how can anyone trust their credibility on how to operate a locomotive?” Meanwhile, still ahead for Democrats: A smoldering heap of twisted metal, and The End.
gahrie
The specter of single payer health care may give you the willies, but the health care reform proposal before congress and being pushed by the White House is not single payer. In regards to constitutionality of the government being involved in health care i’d point you to the preamble of the Constitution:
“We the People of the United States, in Order to form a more perfect Union, establish Justice, insure domestic Tranquility, provide for the common defence, promote the general Welfare, and secure the Blessings of Liberty to ourselves and our Posterity, do ordain and establish this Constitution for the United States of America.”
It doesn’t seem unreasonable to me that making sure people have access to basic preventative care and keeping the cost of other life saving procedures from bankrupting them would be providing for the general welfare. No one should have to be forced to choose between poverty and death when we have the means to save them.
David K:
1) Single payer is bad, very bad. Forcing people to buy health insurance is unconstitutional and potentially much much worse.
2) No one is saying the government cannot be involved in health care.
3) The General Welfare clause of the Constitution does not mean what you think it does. It is not a broad mandate for the government to provide health care to the people. It just means the government can create laws.
gahrie, I get that you think single payer is bad, but the current plan ISN’T single payer, so why do you (and others) keep bringing that up?
David K:
gahrie, I get that you think single payer is bad, but the current plan ISN’T single payer, so why do you (and others) keep bringing that up?
1) I didn’t….YOU did.
2) How the hell do we know if the eventual bill is single payer or not? We haven’t seen it yet, and everyone involved in writing the bill has publically stated their support for a single payer system.
Correction…I see that I did refer to a one size fits all single payer system.
That was a rhetorical slip…I was primarily addressing the one size fits all concept.
gahrie – it is even simpler …
The Constitution says to “promote the general Welfare” – it doesn’t say “to provide the general Welfare” …
People have access to basic preventative care – and yet, just how many of ’em actually take advantage of that access ?
gahrie says,
How the hell do we know if the eventual bill is single payer or not? We haven’t seen it yet, and everyone involved in writing the bill has publically stated their support for a single payer system.
I think we can be relatively assured of that, given that we’ve seen a few versions of the health care bill so far and none of them have involved a single payer system. Also, if Democrats are struggling to pass what they have now, the idea that they’d write a whole new bill that would be even harder to pass is a bit, shall we say, unlikely.
Tim:
I think we can be relatively assured of that, given that we’ve seen a few versions of the health care bill so far and none of them have involved a single payer system. Also, if Democrats are struggling to pass what they have now, the idea that they’d write a whole new bill that would be even harder to pass is a bit, shall we say, unlikely.
Reconciliation only takes 51 votes…..
So you think that they try all this time to get a smaller, less extensive bill passed and then say, “Eh, screw it. Let’s just go crazy and pass single payer via reconciliation?” Really?
So you think that they try all this time to get a smaller, less extensive bill passed and then say, “Eh, screw it. Let’s just go crazy and pass single payer via reconciliation?” Really?
We’re talking about Pelosi, Reid and Rahm.
You bet your ass I do.
Oh, I see. Well, that’s just…adorable.
Tim:
1) What smaller bill have they been trying to get passed? Reid and pelosi are still trying to get the Senate or House bill passed, and rahm is trying to get the president’s new version passed. None of them are small.
2) Why should I trust Pelosi, Reid or Rahm’s intentions? What reason have they given me to? They have proven themselves to be partisan, dishonest and willing to use every weapon to demonize and marginalize those who oppose them.
Sorry, gahrie, about the confusion re: the size of the bill. To clarify I said “smaller” not small, as in not as big as being single payer. People’s feelings on the size of the current bill may vary, but I think we can at least agree that it represents a smaller change than moving to a single payer system, yes?
As far as trust, you don’t have to trust any of them, or anyone else for that matter. I would just think, given the lack of success these bills have had so far, and Democrats generally not grinding the opposition below their jackboots (despite your characterization of the Pelosi, Reid, Rahm trio), one could extrapolate that the chances of single payer suddenly being on the table is, as I said, unlikely at best.
You may disagree, and certainly seem to, but I just don’t think the future you foresee is the remotely realistic.
Tim – people’s feelings do indeed vary – and the more that people know about what Obama/Reid/Pelosi seek for healthcare legislation, the less they like it …
“Tim – people’s feelings do indeed vary – and the more that people listen to the lies Republicans are saying about what Obama/Reid/Pelosi seek for healthcare legislation, the less they like it”
Fixed that for you Alasdair
people’s feelings do indeed vary
Indeed. As I said. As for the rest of it, hey, feel how you feel. I have zero interest in debating you on the merits or lack of merits of the bills as you already, clearly, have your mind made up. My only intention, from the start, was to point out how unlikely it was we’d get a single payer bill or system out of this. That’s done with now, so…thanks for the memories.
My only intention, from the start, was to point out how unlikely it was we’d get a single payer bill or system out of this…
If you’re referring specifically to the bill that will likely be passed by the end of the month, I agree that Obamacare will not be single payer. However, if you’re arguing that the change of Obamacare will not lead to single payer (a ‘system’), that’s much less clear.
After all, Obamacare is a reform that will likely be quite expensive. I know that the CBO says otherwise, but having worked in finance for several years (though never having had the chance to model anything so complex as the health care overhaul) the actual cost of Obamacare is surely contingent on a universe of factors that are only CBO swags. Between the CBO and my lyin’ eyes, I’m going with my lyin’ eyes.
What my lyin’ eyes see is that several million Americans will have access to insurance that previously didn’t due to indifference, lack of resources, or too-expensive conditions. People with those too-expensive conditions will now have them cared for – and subsidized. That’s going to cost a hell of a lot of money. Which would be okay if the government were flush, but as our public debt is rapidly mushrooming to unprecedented levels, the inevitable costly nature of Obamacare is a huge looming problem.
What can the government do about this, when Obamacare proves itself to be what you think it is, another sinkhole of spending? Seems to me they have three choices: 1) cut benefits, 2) discontinue Obamacare, or 3) take, by government fiat, healthy (read: cheap) consumers from private insurance to improve the actuarial profile of Obamacare.
If your answer is #3, it won’t be long before insurance companies quit the business, since the help to Obamacare from taking healthy consumers is an equal hurt to the insurance industry. Soon enough you’ll end up in single payer.
In summary, why will Obamacare lead to single payer? Because of what Brendan has more or less been arguing throughout this thread: you can’t have a health “insurance” system without pooling catastrophic costs across healthy folks. Obamacare will definitionally bring lots and lots of catastrophic cases into its insurance rolls.
Where is it going to get enough healthy folks to keep costs in check? Magic?
In summary, why will Obamacare lead to single payer? Because of what Brendan has more or less been arguing throughout this thread: you can’t have a health “insurance” system without pooling catastrophic costs across healthy folks. Obamacare will definitionally bring lots and lots of catastrophic cases into its insurance rolls.
This is an excellent point, sort of. But I think you’re missing the boat on exactly what will lead to single payer via the mechanism you describe. I’ve been arguing for some time (in various personal conversations; I forget if I’ve said it here) that if the Democrats were really as single-mindedly liberal, indeed socialistic, as well as “partisan [and] dishonest,” as the gahries of the world portray them, and they wanted to find a way to get their supposed pipe dream — single-payer, government-run health care — then their game plan would be simple: pass the extremely popular ban on pre-existing condition / uninsurability exclusions, WITHOUT an individual mandate. If that had been the entirety of “ObamaCare,” the Republicans would have been awfully hard-pressed, politically, to vote against it (and we’d have been done with this whole process last summer, and Obama would still have approval ratings above 50%). Yet such a “plan” would be terrible policy for anyone who wants to maintain the private insurance system — but excellent policy for anyone who wants single-payer, as it would set into motion a chain of events that would lead to the self-destruction of the individual insurance market, which would, in turn, create an unprecedented political clamor for the government to step in and fix things. You know this is true: conservatives can call America a “center-right nation” all they want, but when people are PANICKING!!! about an obvious CRISIS!!! (as opposed to a looming, partially hidden crisis that mostly impacts… other people), they are strongly inclined (wisely or not) to turn to the government for a solution, and conservatives have a very hard time stopping that momentum. Single-payer wouldn’t be guaranteed in such a scenario, but it would be FAR more politically possible than it is now.
Put another way: if you wanted to pass such a drastic solution, you’d need to first create a far more drastic crisis than we presently have. The way to do this would be to take the cynical, irresponsible route I’ve described, and pass only the most popular, screw-the-insurance-industry part of the bill. The Dems could’ve done this. Easily. But they didn’t. Instead, they tried to craft a policy that’s at least arguably workable, but that’s LESS likely to lead to single-payer. In other words, they tried to govern, rather than operating from a purely cynical, political calculus. And for this, they are called lying, Machiavellian socialists who are hell-bent on ramming, or rather “Rahming,” a full government takeover of health care down our throats.
As for the rest of the arguments on this thread, I confess I haven’t had time to continue the tit-for-tat, and have had to take a step back, but rest assured I’ve read it all, and it’s very interesting and enlightening (hence my continually “bumping” it up the homepage), and I’ll even concede Andrew, Jazz, et al make some valid points. I still think there’s a lot of cynical calculation happening on the Right, some of mere politics-as-usual but some of it indefensible. However I have probably overstated the case a bit. I realize that’s an unsatisfying answer, but I need to go bill some hours now 🙂
But whether Obamacare 1.0 (the bill that will pass in a month or so) has a mandate or not, a not-too-much-later version of it logically has to have a mandate, on the way to pilfering healthy customers from insurance companies. Without a mandate, the budget-busting nightmare scenario is made worse, so a mandate in a later version would ameliorate some, though I would guess not much, of the problem.
Further, Obamacare 1.0 pretty much has to waive pre-existing exclusions, since if it follows the lead of private insurance (something like a 1 year waiting period), it won’t generate much support from the base. So I actually think we are well on our way to single payer, even with the bill that passes later in March.
Funny thing about the Republicans: seems like a big part of their perceived cynicism is really just incompetence. John Boehner. Deer in the headlights. That guy tried to explain his catastrophic pool idea during the summit, got savaged by the Democrats, looked like he might cry, got savaged by the media, even though, without a mandate, Obamacare 1.0 will look suspiciously similar to Boehner’s catastrophic pool, though not “private”, and so less able to contain the chaos.
At the end of the day, this conversation really comes down to whether you think the health care crisis in the US is access or cost. Obamacare claims to solve both, though the argument that making a cost-inefficient system bigger would make it cost-efficient is a bit counter-intuitive, especially when the current inefficiency happens on a case-by-case basis (i.e. few economies of scale).
Megan McArdle had a post a while back that said that the incidence of deaths due to lack of health care access in the US was quite low, far different than what Michael Moore and others suggest. I don’t know for sure, but once again I’ll trust my lyin’ eyes: I know a lot of people that have lost or are in danger of losing their jobs; I don’t know many – really any – that have died because of adverse health insurance decisions. I’m sure they exist. I just doubt they number in the millions.
So – in summary – if you’re going to conclude that the problem is more cost than access (and even that solving cost helps solve access, which is another conversation), then the question is how you get the best handle on costs. As I mentioned earlier, Andrew’s suggestion of high-deductible-type systems seems to me to be the best way to get the health care market to actually act like a market, which should do wonders to drive down costs.
Tim – you and David K have a lot in common, it seems …
By contrast, most of us commenting here seem to have not only read sizable chunks of the proposed bills in current proposed language, and when we apply our experiences in Life to what we read, we do not like what we see nor do we like what it bodes, whether economically or healthcarewise …
We would not like it even if the GOP were presenting it … we would not like it even if the Iron Maiden Herself were allied with a returned Ronald Reagan presenting it …
Alasdair,
You may be right. Is David K also nearly feet tall, shaves his head, grew up in CT, and has a tendency to keep commenting on stuff on Brendan’s page even though he knows it is a bad/fruitless thing to do?
Oh, you mean politically? Well, you may be right about that, too. But, again, that has nothing to do with anything. You can hate the bills all you want. I’m not a huge fan of them either, though I suspect for different reasons. I am not arguing against your dislike of them. I am just saying, for the last time (for reals this time), that no matter how you feel about the particular bills none of them, in the present form, call for a single payer system AND it is wildly unlikely the Dems will try to pass such a thing via reconciliation.
Might they secretly want single payer? Sure. Some of them not so secretly. Might a later bill call for that? Yes, that’s possible, too. Might the passage of the present bill inevitably lead to single payer? Eh… I have my doubts, but it could I suppose. All of that has nothing to do with the present bills which were the ones I was discussing way back when I said:
“I think we can be relatively assured of that, given that we’ve seen a few versions of the health care bill so far and none of them have involved a single payer system. Also, if Democrats are struggling to pass what they have now, the idea that they’d write a whole new bill that would be even harder to pass is a bit, shall we say, unlikely.”
Lastly, I never claimed that this was a Dem only thing. I haven’t even intimated anything that sounds remotely like, “If Conservatives were behind this, you’d LOOOOOOOOVE it!” I don’t know you, I have no idea if you would do that. I’ll take your word that you wouldn’t. But, come on, I never tried to say that you would. Dislike my politics, fine, but don’t try and pin something on me that I never even came close to saying.
Alasdair, you don’t have a clue what I have read.
Wait, let me fix that.
Alasdair, you don’t have a clue.
Brendan, I am not convinced that banning the ability of insurance companies to deny people with pre-existing conditions is quite the sure-fire calamity you claim it to be. I addressed much of that reasoning above in Comment 41, but the bottom line is, insurance companies would howl in protest, but eventually they’d follow the law and everybody’s premiums would go up.
To steal from Jazz, passing only the pre-existing conditions piece sufficiently solves the universal coverage part, but exacerbates the spiraling costs part. There’s a chance that the spike in premiums might drive a clamoring to solve the spiraling costs problem, but that door is equally open to both left-wing and right-wing solutions. For example, the GOP could very well propose my favored combo solution of allowing competition across state lines, subsidizing consumer-driven health plans, and forming a universal pool for basic catastrophic care coverage that is run by a government-controlled national insurance corporation and paid for by a payroll-like tax that functions as an insurance premium. That would greatly lessen the pain of having to open the doors to those with pre-existing conditions. Tax penalties could also apply to those who choose to forgo coverage while still in good health.
Either way, no matter how you slice it and dice it, the true problem here isn’t that forcing insurance companies to accept pre-existing conditions will bankrupt them and drive up costs for everyone. No, the true problem is that the rest of Obamacare purports to solve this problem, but in reality, it won’t.
a universal pool for basic catastrophic care coverage that is run by a government-controlled national insurance corporation and paid for by a payroll-like tax that functions as an insurance premium.
It just dawned on me that an even better way to fund this would be to A. tax healthy people who choose to not sign up to a healthcare plan, and B. apply a health tax on hospitals, doctors, and insurance companies — potentially in lieu of a standard corporate income tax. A. discourages people from gaining the system, and although hospitals, doctors, and insurance companies will largely pass through the cost of B. to healthcare consumers, it at least provides a mechanism that incentivizes them to be more cost-conscious, since such behavior would theoretically affect their tax rate and thus directly impact their bottom-line margins.
Tim – when I compare the two responses, from you and from David, I have to admit that the differences between the two of you are indeed obvious …
Your response shows that you have gravity … David’s confirms that, while he lacks gravity, he sure has density …
Your response shows an active and balanced sense of humour … David’s – not so much …
Your response shows analysis … David’s response only shows the first four letters of analysis …
So – I apologise for insulting you by my comparison of the two of you, I should not have set up a straw-David …
Perhaps a different analogy might help communication …
The proposed healthcare bills are like cutting off the oxygen supply … worse yet, they are like cutting off the oxygen supply to the lungs (not just the room) … they say nothing about brain damage (analogy to single-payer) … the normally-expected result of cuting off the oxygen supply to the lungs, however, is the brain becoming damaged (absent some heroic measures) …
David K – keep your day job !