Representative Conyers supports single payer health care, but has embraced “Obamacare” as a major triumph for the President and his party. He is right to do so. A massive expansion of access to health care has been the dream of progressives for decades, and after 40 years and many failed efforts it has now come to pass.
Harold Pollack tells me that the Affordable Care Act is the best domestic AIDS health policy in the history of the United States. I know myself what Jeffrey Buck has just documented: It’s also the best domestic drug and alcohol health policy in the history of the United States. In these and countless other ways it will literally prove life-saving to hundreds of thousands of people who live in poverty and near-poverty.
Ted Kennedy couldn’t do it; it was the greatest regret of his political career. Jimmy Carter couldn’t do it. Bill Clinton came into office with both Houses of Congress in his party’s hands yet almost ruined his presidency trying to do it. President Barack Hussein Obama did it.
Yet a persistent minority of putative progressives speak of holding their nose and voting for Obama against Rick Perry, or call the President a failure, a traitor to liberalism, an icy technocrat, a heartless plutocrat, more conservative than Barry Goldwater, I could go on but I won’t.
My condemnation of such people generated a strong reaction, both positive and negative. The only clarification I would make about what I initially said in case it wasn’t clear is that reasoned criticism of the President is everyone’s right and everyone’s duty, including mine. But I have lost patience and very evidently my temper with those sanctimonious ingrates of the Left who denigrate as a turncoat the President who took an extraordinary political risk to deliver for progressives and for the most vulnerable citizens in this country.
It may sound like what I am saying is that the Affordable Care Act is such a historic triumph for American progressives that a liberal would have to be deluded to direct any of the aforementioned slanders at President Obama.
Yes, that is exactly what I am saying.
I use the word “deluded” advisedly: These individuals believe things that are objectively untrue. If someone thinks universal health care would have passed easily if not for the President’s bumbling (or corruption by industry), then that person must think he is living in France 30 years ago rather than in the United States today. If someone thinks President Obama should have won every single political battle in which he has engaged, then that person is confusing the powers of a U.S. President with those of a king. And if someone thinks that somewhere out there is a politician who would never make a mistake as president, then that person is deluded about human nature.
Thanks for this. It bears repeating that the Affordable Care Act makes government-administered single-payer care in America more of a possibility than it was pre-Obama, and John Conyers clearly knows this.
The ACA provides federal funds to states and lets them opt out of the exchanges and use this funding for their own statewide health plans, if they can set up plans that do at least as good a job at providing access to affordable care. Vermont’s already passed a single-payer law to do exactly that as soon as the relevant provisions of the Act phase in, and there is a bill to do the same in California as well. So the only way it won’t happen in at least one state by the end of this decade is if (1) Vermont can’t make single-payer work as well as a subsidized exchange for the same cost, (2) the Supreme Court guts the ACA, or (3) a Republican is elected President and 2012 and halts implementation of the ACA.
My capsule take is that on the five great challenges facing him at his inauguration, Obama has succeeded on health care and Islamic terrorism, drawn on the rule of law, and failed on the economy and climate change. Your overall judgement of his presidency will depend on your weighting of these issues as well as your baseline of epxectations. Krugman’s an economist, so Obama’s failure on “his” issue and the comparison with Clinton looms larger for him. You are a doctor, so you put the health care success first. An environmentalist might rate Obama’s presidency even lower than Krugman does. The judgement on the dominant issue tends to spill over to the others by stereotyping.
The results are surprising to the detached observer, since health care was Obama’s weak point in the primaries, and it looked during the campaign as if there was a bipartisan consensus for a quite vigorous policy on climate change. But then, who’d have expected LBJ’s domestic triumphs and foreign policy disaster?
I’m supposed to rejoice that Obama signed a plan that Orrin Hatch supported in 1993? A plan that makes us pay private insurance companies, where I’m supposed to rely upon extra money from the government to make up the jacked-up prices they’ll charge for those with pre-existing conditions?
Keith, Obama is your candidate, not mine. He is a conservative of the last generation. You don’t style yourself as a liberal and certainly not a lefty. Please stop telling me to support the guy. You want to support him? Good for you. I wish you could vote for him.
Bill Maher understands better than most political scientists I’ve seen: The Democrats in DC became Republicans, and the Republicans in DC checked into a nut house.
“Bill Clinton came into office with both Houses of Congress in his party’s hands yet almost ruined his presidency trying to do it. President Barack Hussein Obama did it.”
And, as we may learn in 2012, thereby ruined his Presidency. Certainly lost his party the House, and maybe the Senate.
Certainly Obama isn’t the liberal messiah you yearned for. What he may just have been, is the most liberal President your party could survive.
As far as I know, progressives have soured on the president, not because of the ACA (except for the public option nixing deal early on, but that’s small grapes), but because of dubious military plans, an expansion of the Bush surveillance state, his prosecutions of wiretappers, his friendliness with bankers, his putting Social Security, Medicare, and Medicaid on the possible chopping block, his incessant posture of compromise, and his unwillingness to fight for the millions of Americans out-of-work, instead muddling his way through the “recovery” by talking about business “confidence.” I genuinely do not know who on the Left thinks that the ACA is anywhere close to the worst thing the president has done. Most seem to think it was a mediocre compromise, but better than nothing and a real step forward. So can you please name names, Keith? Seriously, who are these Leftists you rail against in this post? FireDogLake? Like I said, it seems to me that the public option thing is significant but pretty small in comparison to what really angers them (and me).
James Wimberly: “…drawn on the rule of law, …”
James, please forgive my rudeness, but you’re so far away from the truth here that it hurts.
President Obama has continued most of the Bush II policies, allowed *all* of the criminals to go scot free, with the exception of whistleblowers. If the Bushites were betting back in 2008 about what Obama’s policies would be here, I doubt that any of them would have bet that he’d be as close to their position as he is.
[note: Some policy positions are good. But in the grand scheme of things, Obama basically legitimized the Bush II crimes, and set the pattern for continuing and escalating them under whomever Bush III is.]
I think that part of what is going is a certain amount of resentment at the ACA’s supporters taking what critics see as a premature victory lap. Very little (and arguably none) of the ACA is currently “in effect” and it isn’t clear how the law will be implemented so as to provide the benefits claimed by the law’s supporters. Whether the ACA will, in reality, provide any benefits over and above the present system is entirely dependent on the effectiveness of health care regulators, the goodwill and cooperation of health care providers and the continuation of necessary funding. Going forward, I think all of these are in doubt.
The main problem seems to be an over reliance on a complicated regulatory scheme and the regulators who will enforce it. I would simply note how well a similar regulatory system worked during the recent financial crisis. There is every reason to believe that most regulators will become corrupted (as did those who oversaw the financial industry) and the few who don’t will be nobbled by Congress or easily corrupted state legislatures and governors. What’s more, the ACA seems to be particularly dependent on state regulators and on states enacting strong regulations to implement the ACA. Again, the experience with the financial industry suggests the likely outcome: Since banks and credit card issuers were allowed to operate nationally, they have bypassed state regulations and usury laws as states competed with one another in a regulatory race to the bottom. That’s why people in California have credit cards issued mostly in South Dakota and they get charged 30% interest.
Blue Cross just raised my premiums. They’ve already said there will be another, substantial increase next year and again in 2013 and 2014. How sure are you that if Obama wins reelection he will order them rolled back? If I get sick, how sure are you that my policy absolutely, positively won’t be canceled if doing so increases the insurance company’s profits? Basically, from my point of view, the ACA is going to force me to buy increasingly worthless insurance and pay higher and higher prices for those crappy insurance policies. Yes, some poor people will benefit from the ACA because the health care industry has grudgingly consented to allowing our tax dollars to be spent on subsiding health care for some poor people in return for compelling me (and others like me) to buy insurance from them. But I predict that the main beneficiaries of the ACA will be politicians, lawyer, regulators, lobbyists and fixers (and especially their offspring). Consumers and poor people, probably not so much.
So, here’s my question: What’s good in the law that doesn’t require either honest implementation or continued funding by the Congress? What are we guaranteed (as with, say, Medicare or single payer) and what’s on the come?
Nice little straw man in that last ‘graph. That’s a keeper. It’s also fun to watch someone burn bridges and lecture those on the other side about ‘political reality’. But funnest of all, is blaming the ‘firebaggers’ for the disaster that was the off year election of 2010 when the Dems in Congress ran for cover and wouldn’t defend the ‘greatest piece of legislation in the 21st century’ because, well, because…..So when you lose the center do you try to chase them or teach them? Please do tell, Mr. political genius.
If the effete snobbish left is so inept, so small in numbers, a bunch of political naifs, dreamers, ideologues and fart sniffers….why the frack do you care? You might as well rail against the communist snobs who belong to the flat earth society (there must be 2 or 3 of them). But if you value their political adherence and claim (OMG!!) that their “support” is essential to national party success then, if true, you and those who think like you are the fools. You get more bees with honey, or something.
But I feel Sean pretty much got the gist of it. Not that it matters. Lefties have “nowhere else to go”, right?
I agree with bobbyp that the last paragraph is nothing but strawmen but the ACA does seem to divide Dems more than any other issue. Even today I see it brought up, sometimes in conversations unrelated to healthcare. One side says it’s the greatest thing since sliced bread and the other side says it’s the biggest corporate giveaway in years. Both those statements can’t be right but my point is that Democrats aren’t listening to each other on this. They’re throwing the same type of barbs they throw at republicans and Democrats are never going to get anywhere that way.
Sean: “So can you please name names, Keith? Seriously, who are these Leftists you rail against in this post? FireDogLake? Like I said, it seems to me that the public option thing is significant but pretty small in comparison to what really angers them (and me).”
I second the challenge - Keith, name names, and names that matter (the third FDL blogger from the left in the 42nd row doesn’t count).
“…A persistent minority of putative progressives speak of holding their nose and voting for Obama”
I’ll be holding my nose and voting for ‘None of the Above.’
“Obama has succeeded on…Islamic terrorism”
Like Don Quixote succeeded on windmills, except for all the killing.
Come on people, follow the money. By 2018 annual funding for exchange subsidies is $100 billion. Medicaid/Children (CHIP) is $80 billion. That is a hell of a lot of redistribution!
http://www.cbo.gov/ftpdocs/113xx/doc11307/Reid_Letter_HR3590.pdf
BTW, it took me 45 minutes to find the value of the exchanges subsidies. I had to dig through piles of rightwing bullshit, piles of business analysis, and exactly zero liberal bloggers to find that CBO report. So Obama, the Democratic establishment, and everybody and their dog is to blame for not getting the word out.
chrismealy: So Obama, the Democratic establishment, and everybody and their dog is to blame for not getting the word out.
Not everybody failed:
https://thesamefacts.com/2010/03/uncategorized/time-and-cunning-and-talk/
That Kleiman post was a head-snapping moment…
James Wimberley’s comment is wise, but I’d observe that some of these policy areas can be quantified. Krugman isn’t just upset about ongoing 9% unemployment because he’s an economist, but because such levels of unemployment generate human misery that’s an order of magnitude greater than what’s at stake in all the other policy areas, health care included. I do give Obama credit for seeing the health care reform through. And there are limits as to what he could do in economic policy. Given the importance of economic policy, though, both politically and in terms of human welfare, Obama’s adoption of an anti-Keynesian framework is a disaster.
After Roosevelt’s term in office, a more moderate Republican party than today’s model was reduced to a rump for many years. FDR was a true leader and visionary in far, far tougher times.
LBJ had significant legislative successes but rightfully got hounded from office for killing 30,000 Americans and millions of Vietnamese in an empty geopolitical gesture. Still, a Democrat could have won the 1968 election.
Obama led the Democrats to a House loss two year after the worst president in American history destroyed the credibility of his party. Now a wingnut like Rick Perry fills centrist Democrats with dread; Perry could possibly get elected. Kleiman even worries about a loon like Bachmann. The inescapable conclusion: Obama must be one of the worst presidents in history - HCR or no HCR - right down there with GW Bush, LBJ, and Nixon.
Ditch Obama; find a better Democratic candidate. If the Democratic party can’t produce a better candidate than Obama, both parties are terminal in this “progressive’s” opinion. Which will make ‘None of the Above’ the only option for me come November 2012.
Obama didn’t get the ACA passed. He allowed Baucus to almost talk to it death, then after Scott Brown was elected he tried to tiptoe away from it as if it were a dying man in the gutter. Pelosi and Reid got the ACA passed. Remember “pass the damn bill”? That had nothing to do with Obama. His major contribution was to kill the public option provisisions.
Barry: you cite the bad things on the rule of law, and I agree. But the ban on torture, two decent SCOTUS appointments, and an end to the imperial presidency rhetoric of the Bush Administration (Yoo, the signing statements) have to be set against them. The White House made a respectable case that the killing of Bin Laden was in compliance with the laws of war, and his burial complied with Islamic law. However you rate all this, clearly a mixed bag. Greenwald’s vehemence is explained by high expectations: Obama has taught constitutional law and his failures in the area are surprising as well as disappointing.
Wimberley was right to view Obama’s record as a report card containing several divergent grades. But he left one very important course out: changing politics. This is, after all, what Obama ran on. So my report card (using Wimberley’s courses plus my own):
Health Care: A (I’m a tough grader, so he doesn’t get an A+)
Islamic Terrorism: B- (failed on Palestine; succeeded elsewhere)
Rule of Law: C- (I disagree with Wimberley; too much continuity with Bush administration)
Economy: D+ (If it weren’t for Republican obstructionism, he might get a C+)
Climate Change: D-
Hopey-Changey: E
GPA: 2.0
Let’s contrast this with Bill Clinton, who doesn’t get a grade on rule of law:
Health Care: E
Islamic Terrorism: C+
Economy: A- (would be A+, except he encouraged financialization)
Climate Change: D
Hopey-Changey: B+ (he restored the Democratic Party to credibility, at the cost of moving it to the right)
GPA: 2.1
Hmmm, about the same.
Mitch has it right.
More generally, I think a lot of center left types don’t get the extent to which there is actually an ideological gap between them and the left. This was true during the Iraq War too; a lot of Kerry and Clinton supporters didn’t understand that the left was actually right and their candidates were wrong on this fundamental issue, and that the left had a genuine ideological difference with the right wing of the Democratic Party.
So it is with health care. A lot of us on the left basically look at situation and say something along the lines of “for profit health insurance companies are the cause of the health care crisis, because the only way they can increase their profits is by denying the care they contracted to pay for”. That’s a very different diagnosis than the one made by the center-left, which usually has something to do with controlling health care costs and ensuring that everyone is enrolled in a private health insurance plan.
So when left wingers condemn ACA, it isn’t because we are unrealistic utopians who are too stupid appreciate what Barack Obama has done. It’s because many of us worry that he has made the health insurance system much worse by entrenching and empowering and delivering more customers to the for profit health insurance companies who constitute the health care crisis in this country. It’s the equivalent of solving the financial crisis by requiring that we all open accounts at the big banks who issued all the junk mortgages.
Again, I emphasize. This is an ideological difference. It isn’t that you guys are smart and we are too dumb to see what Obama delivered to us. It’s that you guys are on the right and we are on the left, and part of what it means to be on the left is that we understand that the rhetoric about the magic of free markets is BS when it comes to health care and that government provision of health care services is the only workable solution.
Well, Keith, it depends on what you consider the big picture, doesn’t it?
I won’t insult you with insinuations about what’s best for you and your friends, but at least some of us feel that the single biggest threat to the US is plutocracy shading into kleptocracy. Not only has Obama cheered this on, the ACA bill you love so much enshrines this view of the world, further empowering the medical-insurance complex and its pathologies, at the expense of alternatives.
And this doesn’t even include Obama’s further expansion of the imperial presidency, or his support for the torture of Bradley Manning.
“But the ban on torture, two decent SCOTUS appointments, and an end to the imperial presidency rhetoric of the Bush Administration (Yoo, the signing statements) have to be set against them. The White House made a respectable case that the killing of Bin Laden was in compliance with the laws of war, and his burial complied with Islamic law.”
Hmm. Libya would seem to suggest the imperial presidency, not so dead.
Bradley Manning would seem to suggest that torture remains A-OK — just do it “scientifically”, and against people who have offended THIS administration, not the previous one.
And regarding the killing of Bin Laden — well if there is anything we SHOULD have learned from wikileaks, it is that the US government and the US army are perfectly happy to lie when it suits their wishes, and that lie can remain hidden for quite some time. Would you be amazed to learn, in some leak in 2018, that there was a record of communication between the various soldiers involved that went something like
“OK, I see Bin Asshole in my sights. He’s waving a white flag and trying to surrender.”
“Screw that, shoot the motherfucker.”
“OK, he’s dead. So what’s the plan? We pour gasoline over his sorry ass, and set fire to it?”
Let’s recall one particular item from Wikileaks regarding soldiers in Iraq. Helicopter gunship starts shooting at enemy combatants. Combatants make motions indicating they wish to surrender. Gunship calls base. Base lawyer says “legally, combatants on the ground are not able to surrender to a helicopter. So, go ahead and kill the lot of them.”
Who are these “fellow liberals” of whom you speak? Obama’s no liberal. He stands clearly to the right of both Clinton and Carter, both of whom were center-right and far beyond the liberal pale.
Bobbyp has it right: either progressives are unimportant to the outcome of the election, or we ARE important. If the former, why waste your time complaining about an irrelevant minority? If the latter, then tell me what Obama’s going to do about my priorities, not yours.
Anyone who considers the ACA a failed bill needs to back and look at the original social Security from 1935. It had to be essentially restarted with coverage for most workers in 1951, disability had to be added in 1957 (under Ike) and then Medicare had to be added in 1965. After 30 years it was pretty good, but the initial plan was crap.
As was said earlier, it has taken over 4 decades since Medicare to get anything close to universal coverage and the various complaints about things like no public option are valid, but after Clinton’s totally failed effort to pass health care nothing happened for nearly 20 years! This is not because Clinton and Obama were inadequate - it’s entirely because our Presidential system is designed to stop such initiatives at the whim of a small but wealthy minority.
If there were true accountability for failure to act in the federal government it would almost entirely sit in the club of 100 representatives of great wealth called the Senate. Were some unfortunate tradeoffs made? No question, but without those or similar ones we’d be right where America was in 1996.
The ACA will place an improved health care payment system before the public and very shortly the public will look at it and realize just how inadequate it really is and demand that it be improved. Why do you think that Social Security was sharply improved in 1951, 1957 and 1965?
I have had my complaint with Obama, especially with his lack of leadership, but if he were a graduate of the Army’s Benning School for Boys leadership academy I have come to realize that every time he tried to present a clear proposal and to lead towards it there would be a total coalescence of the conservatives to kill it and nothing would have occurred since the panic over the Wall Street collapse subsided.
The problem is not Obama. It’s the fact that his enemies are the internal enemies of America and they are extremely powerful. The big problem in the 2010 election was not Obama’s tactics. It was the economy and the tactics of America’s enemies, the conservatives and their allies the social conservatives.
The trouble with progressives is that they know they cannot effect what the conservatives do and besides, that can be personally risky. So liberals and progressives snipe and chip away at their own side because that is easy and safe to do. America is in real trouble until the progressives unite and begin to go after the real enemies - preferably in the 2012 election.
Rick B:
Social Security was a government program. So was Medicare. Both those programs made the government bigger and displaced any greedy corporations who were providing the same service. The fact that they were incomplete is less important than the fact that they had the correct socialist structure.
The equivalent would have been a bill to lower the Medicare eligibility age to 55, or to allow children to sign up, or to allow poor people to get Medicare rather than Medicaid, or to expand the VA to provide government health care for more groups.
Instead, Obama is proposing to kick 65 and 66 year olds off Medicare and subject them to the ACA mandate instead.
This is not an accident. Social Security was not a perfect program, but it established the precedent that greedy corporations would not get a cut of workers’ savings. Medicare, similarly, established the precedent that the elderly would not be murdered by an insurance company whose profits come from denying care.
Non-universal socialism is superior to universal crap.
Dilan,
I agree with what you meant to say, but frankly find your terminology dated and useless. Social Security and Medicare are both insurance programs which are designed to solve social problems. The term “socialism” simply indicates to me that you have no idea how those programs actually work.
Both programs must cover everyone in order to solve the problems they address. The pool of covered individuals has to be universal or there are large groups not covered and there are large chunks of money that should fund the programs that is siphoned off by those who provide no real benefit to the entire group. No organization can control a social program if the organization is not at least as large as the problem itself. (True both for government and private problems. An air conditioning system must control all of the area to be conditioned and must be isolated from the uncontrolled areas.) The only part of this that might be considered socialism as far as I can see is that the programs have to be mandatory for everyone in order to avoid the free rider situation. But even that is simple insurance rules.
All insurance requires government regulations to be effective. (Lloyds is privately administered but has government sanction, rather like the SEC lets the AICPA issue accounting rules but can overrule them.) You would not trust an unregulated insurance company to sell life insurance. Companies are created, take in the money and then the owners disappear before paying out. Burial insurance used to be like that, and so did life insurance in Texas a century ago when they banned outside (Yankee) companies from selling insurance in the state and allowed anyone with $50,000 in the bank to start selling life insurance. Within a few years the frauds were so bad that the insurance sales people required government regulation. Unfortunately Texas has a long tradition of libertarian fools.
I don’t think the proposal to shift the age 65 and 66 individuals was ever considered viable. It would have been a trial balloon - certainly made of lead. I’m retired military and I well remember the bait-and-switch that occurred when retired military were shifted from military health care onto the much less attractive Medicare. But any large scale health insurance program is going to have administrative issues. The Medicare age 65 & 66 is one of those, not a core issue. If you can’t get universal coverage that kind of question becomes part of the landscape. The number of people who would delay care until getting onto Medicare would eliminate any apparent financial savings to the government.
Actually Medicare was instituted because private insurance companies simply refused to sell policies to anyone over age 65. Many - as I recall, most - large company insurance programs simply dropped anyone who reached age 65. Age is a preexisting condition and I can assure you means higher payouts to any insurer. So few over age 65 individuals actually had health insurance that there was no reliable pool of health cost data for that group and most companies would not touch that pool without tacking on an outrageous and unearned premium.
I am a strong single payer fan. If you think any of your proposals could have gotten through Congress then you live in an alternate universe from the one I inhabit. But what we are getting now is an overpriced health insurance system that will provide close to universal access. The very assurance of getting paid is going to cause health care providers to stop building in premiums so health care costs will actually begin to be priced by the market. That’s going to have two effects. First, costs will drop as prices actually approach the cost of delivering the care instead of including the premium required by cost-shifting and covering the uninsured. Second, the health care providers are going to put pressure on the politicians to provide a true universal insurance. That way heath care providers will provide health care instead of institutionalized wrangling over how to get paid. Between the universal care and the assurance of getting paid, health care providers will be able to predict their market and compete on cost. The pressures to remove the insurance companies with their waste, fraud and abuse will become impossible for the politicians to resist and we are going to reach a single payer system - with a few appendages left over from the current wild west lack of system.
There are two kinds of sets of goods and services that need to be provided. The first kind are mission-essential. They will be provided first and figuring out how to pay for them becomes secondary. The second kind is those goods and services which can effectively be provided through the profit system. Tell me - do you want to go to a health care provider who sees your health care as their mission, or do you want to go to a provider who views you as a source of profit for which they will choose any effective set of goods and services to offer you? Almost any dentist that advertises that they take medicaid patients will normally do unnecessary dental work that they are allowed to charge you for because it adds to their profit. (Recent personal experience.)
Oh, and the precedent for social security was set by Germany prior to the end of the 19th century. The rest of the industrial world only started catching up a generation later.
Rick:
you are contradicting yourself. If universality is a necessity, then how come the original social security and medicare worked?
The reason they worked was because they excluded the profit motive. Bush proposed to switch Social Security to the private sector, which would have transferred Americans’ money from the elderly to financial institutitons. I assume you opposed this. But the ACA did the same thing.
Similarly, Medicare works because the government has no profit incentive to deny care like insurance companies do.
The reason expanding Medicare or the VA didn’t happen is because it was never tried. Obama got hung up on universality, which may be a nice goal but isn’t worth putting our health at the mercy of for profit corporations.
In fact, I suspect Medicare for children or Medicare for 55 year olds would have been popular. S-CHIP was so poupular even Republiccans supported it. Gore endorsed Medicare for children in his 2000 campaign.
And you missed my point with kicking 66 year olds off Medicare. Of course it was a trial balloon, but it was enabled by ACA. And you just watch, the ACA will eventually destroy Medicare as conservatives realize that it is a perfect vehicle for forcing the elderly into private insurance.
I don’t care about rhetorically endorsing single payer. The point is, universal private insurance is bad because private health insurance is the cause of the health care crisis. The ACA made things worse by forcing more people to deal with denials of coverage, having to go through red tape while they are sick, and all the other aspects of our health care crisis that are caused by allowing for profit companies to provide our health care.
Rick,
I think Dilan is absolutely right. The structure of both Social Security and Medicare created incentives for providing the most service for the least cost (and an organizational culture that revolved around those values). By contrast, the structure of private insurance is to provide the least possible service and to maximize profits (which are essentially a cost to the system). By adopting the private sector “for profit” model, the ACA has created massive structural incentives to continue to deny care and “cherry pick” the healthiest, most profitable consumers while dumping the sickest consumers, who are naturally the most expensive to treat, onto the public system. As I said originally, the ACA tries to deal with this via regulations but, as we’ve seen in the financial sector, this isn’t likely to ever amount to much more than a band-aid on a terrible, festering wound.
And, as I said before, it’s irritating to have the ACA’s supporters take what I consider a premature victory lap by looking into the future to see how wonderful it is that the little seed they’ve planted will grow into something the functions reasonably well like Medicare or Social Security. But there is little reason to believe that a health care system which is focused on creating profitable opportunities for private health care insurers and providers will ever grow into something that works like Social Security or Medicare (which seek to limit, not enhance the profitability health care providers). You know, not every acorn is destined to become a mighty oak tree.
“Similarly, Medicare works because the government has no profit incentive to deny care like insurance companies do.”
Not quite true. Despite some fiscal delusions, government spending is finite. Denying care saves money. It loses you the vote of the person who dies, sure, and possibly even some of their acquaintances, depending on how well you justifiy the denial. But you might find something else to spend the money on which buys more votes than you lose by the senior citizen croaking. So the government, aka policians, might indeed in some instances have a profit incentive to deny care.
It’s just that they take their profit in a fashion you don’t notice.
Brett,
Given a choice between the two, I would prefer to error on the side of providing more, better health care rather than less. As an advocate of the social welfare state, I have no problem in saying that a society which errors on the side of improving the health of its citizens is much to be preferred over one which rations medical care on the basis of wealth. I would also point out that no other industrialized society uses our model which allows the financial profits of insurance companies and providers to be a significant drag on the fisc. Every other industrialized delivers equal or better overall results at a significantly lower cost in no small part because they have cut out the “for profit” health insurance companies.
Not quite true. Despite some fiscal delusions, government spending is finite. Denying care saves money. It loses you the vote of the person who dies, sure, and possibly even some of their acquaintances, depending on how well you justifiy the denial. But you might find something else to spend the money on which buys more votes than you lose by the senior citizen croaking. So the government, aka policians, might indeed in some instances have a profit incentive to deny care.
You aren’t totally wrong here, but I was simplifying for a blog comment. The point is, the incentives are very different because of what you note about voting. Politicians do face fiscal constraints, but they also face the possibility of getting thrown out of office by the voters if they deny care. Whereas insurance companies don’t face that possibility; denying care is how you make a profit as a health insurance company.
(It’s worth noting that the nations that have successful universal care systems that use private insurance all prohibit for profit businesses from selling health insurance. This would indicate that it is the profit motive- and the fact that you make that profit by denying care- that is the biggest problem. Still, I suspect making the decisionmakers democratically accountable is even more effective than just taking away their profits.)
Dilan,
The original Social Security did not work. It left out massive numbers of workers (domestic workers and farm workers in particular.) That’s why it was revamped in 1951 and effectively restarted. As for universality, Medicare covered all workers who were age 65 and eligible for Social Security, and Aid to the Aged covered the rest in 1965. Aid to the Aged, Blind and totally disabled were taken from the states and counties a decade later (75 I think)and became the SSI program.
For those below age 65 the insurance companies made money by excluding those who most needed coverage and by making everyone else afraid of losing their insurance. The insurance companies skim the healthy and throw the rest onto Medicaid or to the wolves. The individual pools of healthy individuals that each company maintains are isolated from each other by administrative gimmicks like networks of providers and by different administrative requirements for different insurers. This requires physicians to hire an average of 2 1/2 clerks each and training them in the different systems of insurance billing. Since each company maintains its own actuarial statistics and those statistics are skewed by the selection criteria, there is no common price set for each specific remedy. Then the insurance companies build in the cost of selling and of selecting the healthy and excluding the unhealthy. That jacks the price for care up quite a bit (I’ve heard that it is a minimum of 1/4 higher - I think that’s extremely conservative.) Then the different criteria for refusal of care and different processes for appeals with each company means that they can exclude expensive cases easily and throw those individuals onto the government rolls.
By requiring all insurances to stop excluding customers for preexisting conditions the ACA will save a lot of money for that one thing. The ACA will limit a lot of those unnecessary cost drivers and as the prices get established in the markets in a semi-reasonable manner the excess costs are going to be driven out of the system. But the key is to not have a pool of uninsured that anyone can be thrown into at the whim of a company that wants to avoid the expense of high-priced care. And that will be approached as universal coverage is approached.
The real trick in ACA is that there is government oversight and the costs of services is going to become more comparable. The end result is going to be either the Swiss system where the insurance companies are administrative arms of the government or a full public single payer system. Because the alternative - taking currently existing under ACA rights to insurance away from families is already politically impossible. It will quickly be seen that there is no way to reduce the costs of health care by excluding people from getting care as is presently the case. Sizable groups of uninsured will simply not be politically possible. So reducing the cost of health care is going to be done by removing the fraud, waste and abuse from the insurance companies - and possibly in some states by providing a competing public option.
That’s the magic of universality. It’s a health care thing. It’s not as necessary for retirement or survivor plans like Social Security since the purpose of SS is to replace income lost because a person stops working to retire. Only workers have to be covered for that.
From this I hope you realize that I see the use of private insurance companies as primarily a transitional process to moving to a more rational system. When there was no overall system as has been the case until now no such movement was possible. Now with a government supervised close to universal system the major problems will be identified and prices will be rationalized as the costs of shifting cost from public care to insured care or from emergency indigent care to the government will be removed from the structure where prices are set. When you see those stories about the massive differences in cost of care for the same services between different cities much of that’s caused by so many factors other than provision of health care being thrown into the prices setting process.
By the way, did you know that Medicare is administered by a private insurer in each state? How would you have gotten the payments from private employers for health insurance to the government if you had expanded VA or Medicare? We got ACA because it was what could be hashed out and passed. As long as SOMETHING passed and that something approaches universality there will be an overall health care system where the existing problems can be identified and fixed one at a time. Without universality as a goal we are left with the paralysis in the system that we saw after the Clinton plan died. The shift from the employer based system will begin soon.
See? No contradiction. Just transition. The problem with our current health care is the lack of any overall system permitting a lack of accountability, the resulting irrational prices for medications and treatments and the absence of universality. It’s quite amazing how many forms of corruption can be concealed simply be throwing expensive medical cases into the pool of uninsured patients.
Rick:
You believe that the regulatory progress will work. I believe it will fail, because insurance company profits depend on it failing.
You believe this will transition us to single payer. I believe that we will transition Medicare to the ACA, because Reublicans will demand it and the corporatists in the Democratic Party, including you, have told the left to shut up about the dangers of forcing people into private insurance.
I believe we have an ideological difference. I don’t believe in private for profit health insurance. You can’t refute that and have no business telling me that I have to support something that I oppose with every moral fibre of my being.
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Dilan,
I don’t think we disagree as much as you would like for us to. I just don’t believe that we can achieve a rational health insurance system by some form of government overnight fiat. The political will to do that does not exist and never will.
What I propose is a market system that imposes a norm of rationality on the insurance system - something which does not currently exist - and that by obtaining market data in rational markets the insurance system will be forced to move towards the only rational insurance system. Will the executives who currently are the pigs at the trough in the current system complain and fight it all the way? Yeah, but what’s new about that?
The resistance of current insurance executives is what killed the Clinton effort and close to neutered the ACA. In a nation that is so out of whack that 45% of the income goes to the top 5% of families, there simply is no possible political way to remove the private insurers from the current system. That would require a violent overthrow of the government and the creation of a totally new one. Needless to say that is not going to happen.
I want to see a universal system or something close to it before I die. I’m already on Medicare. My unemployed kid currently is undergoing chemotherapy for follicular lymphoma (which has no cure, merely an extension of the period of remission when possible) and I want him to be around for the cure that may appear in the next five to ten years. A purist position like yours will kill him soon because you are demanding the impossible.
But I don’t think we disagree on the goal. I just think we have different ways - and time scales - for achieving it.