Medicare vs. Universal Health Care: An Honest Question for the Right

Over the past two years, our country has raged over the questions surrounding healthcare reform.  The Democrats, for better or worse, have taken the need to address serious healthcare system flaws that threaten the country’s economic footing and reframed it as a duty to make sure that even the poor and underemployed have health insurance.

While this strategy has successfully fired up voters on the Left, it has greatly angered others on the Right.  There have been some arguments about affordability, of course, but those have been few and far between.  (If there have been any well known Right pundits arguing that universal health care is a great idea, and we should implement it just as soon as we get out of our recession I have not come across them.)  Far more often, the Right has chosen to argue that implementing universal health somehow transforms us as a people into something different and lesser.  It is not simply a matter of needing to make sure health insurance for all be something we can afford. Rather, it is necessary that any attempt to insure everyone be struck down.  Except, of course, if that person is on Medicare.  It is widely argued by the same people that Medicare is not only acceptable, but a good and necessary safety net.

The most common arguments against universal health care I see are some variation of the following:

  • UHC is by definition a socialist (and therefore bad) policy.
  • The very act of establishing UHC is an overreach by government – or if not it is certainly an overreach by the federal government.
  • UHC forces the rest of us to pay for people who have made bad economic decisions, or refused to take the correct actions to reverse their economic plight.  It is therefore unfair to those that make good decisions.
  • Related to the above: If there is no negative consequence to bad decisions, people have no incentive not to make them.  Therefore UHC encourages and rewards bad decision-making.
  • Also related to the above: There is a moral component to making sound choices in a capitalistic society.  Therefore UHC encourages and rewards moral failing.

I confess that I don’t personally find any of the above arguments convincing. Despite that, however, I can certainly comprehend the logic behind them.  I may not agree with the objections, but I certainly understand them – and understanding one another is the first step in finding a common solution.

But heres the thing:

When I review this list of objections, I cannot see a single objection that is not just as true for Medicare as it is for UHC.  It is certainly a socialistic policy that has been enacted by the federal government.  If a senior citizen had either been born into different circumstances or made different economic decisions during their younger decades they would not need a safety net – just as is the case for UHC.  I have spent some time trying to puzzle out what makes the one Good and the other Evil to half of our country.  I can only think of a few potential arguments, none of them great:

  • “We’ve never really thought about it that way before.”
  • “Old people have won a social prize by living as long as they have that, frankly, a poor child has yet to earn.”
  • “We like old people. We don’t like poor people.”
  • “We don’t really want Medicare either, but we have to say we do for reasons of political expediency.  We’ll be trying to get rid of it later.”
  • “It’s just an affordability issue, and we’re in a recession.  The other rights/Constitutional/moral arguments are just political tools we’re using to get the votes – we don’t really have a problem with UHC per se.”
  • “Europeans have UHC and Americans have Medicare.  Since everything European is bad and everything American is good, Medicare is good and UHC is bad.”
  • “I can easily see myself being old, but I can’t see myself being poor.  So I’m going to lobby for the one I think will pay off for me personally, and lobby against the one I think will pay off for someone else.”
  • “If the government won’t pay for Ma when she can’t pay the doctor I might have to. Best to make the government pay for it.”
  • “The above arguments are what we always use against liberals on any issue, and we’re too busy to start teaching our base new ones.”

Clearly, none of these seem remotely satisfying, and so I am concluding that there is something I am missing that others are seeing clearly. So my question to those that argue for the continuation of Medicare but the dismantling of any system that grants UHC is this:

What are the differences as you see them?  Why is one a Good Thing, and the other a Scourge Against Our Republic?

Extrapolating on whatever those answers are: Would there be a way that we might take the principles behind Medicare as you see them and make them universal? If so, what would those look like?

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372 thoughts on “Medicare vs. Universal Health Care: An Honest Question for the Right

  1. Hi Tod,

    Could it be just as simple an assumption of ‘-abledness’? That is, the elderly are presumed to not be as able-bodied (-minded), to go out and work to take care of themselves, whereas the poor (assuming reasonable physical and mental health) can?

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    • actually, you kind of hit this with ‘senior citizen had either been born into different circumstances or made different economic decisions during their younger decades they would not need a safety net’ so maybe not.

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      • On the gripping hand (I just like talking to myself) I really do think people in general are just more empathetic to the elderly, due to the -abledness question and the idea that they have paid their dues, so give them a break.

        Put another way – if I lose all my money to a Nigerian e-mail scam, y’all point at me and laugh. If grandma does, that’s sad, and we will try to bring the law to bear on the perps more vigorously.

        But if I lose the money now to the Nigerian scam and people laugh at me now, but decades from now need a safety net because I never recovered, people will still be inclined to give me help then. My dumb mistakes get ‘forgiven’ to an extent over time. While I am young, not so much. In part this may be an attempt at ‘shaming’, so I will hopefully learn not to do something so dumb again. With the elderly, it’s too late to learn any more lessons.

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        • Glyph, I think this is exactly right. There’s something in the American spirit about the ability to start and restart from scratch no matter what happens. With the elderly… the opportunities for such are limited. It’s a different situation. Not so different that I don’t think, the question is worth asking (the degree of dissonance between Death Panels and Socialized Medicine is pretty extreme – I lost a lot of respect for the GOP at that juncture – but I do see how distinctions can be made.

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          • I’m not sure I agree entirely. My feeling about the response from the right hasn’t been one that celebrated the spirit of renewal (or anything) so much as railed against mooches.

            I didn’t see inspiration; I saw contempt.

            This might have just been my perception, of course.

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            • Tod, I do think it is a question of perception – if you see me smack my kid on the butt, you might think ‘contempt’/abuse, whereas I might see it as needed and loving correction; unpleasant for both, but necessary.

              Now, is it better if I can instead ‘inspire’ better behavior? Of course. But sometimes the only way to learn something is the hard way. People who espouse this view are not just meanies who want everyone to die.

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            • Oh, I don’t think they sell it on the inspiration. But I think it’s lurking there. The contempt for the moochers is that, by and large, they could be working, but they aren’t (or aren’t working hard enough or whatever). Since the expectations for the elderly are so different, I think that does change the calculations at least somewhat.

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              • Hi Will, maybe this belongs as another thread, but something else that occurs to me is that another reason most don’t kick too hard about supporting the elderly is because we *can*. We can afford to do so because we are on average richer than they were, and are.

                If this was not the case, we might be telling grandma to get on that ice floe, there just ain’t enough blubber to go around this winter.

                This ties sideways into a thread that Kyle Cupp had going, about possible tradeoffs between innovation and access. I believe pretty strongly that innovation is a primary driver of access in a feedback loop. So if artificially increasing access causes decreased innovation, then that decreased innovation will likely also eventually cause *decreased* access (access will either eventually get narrower or ‘shallower’).

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          • It’s a different situation. except if you’re a fucking immigrant. Start a business at 50+? That’s just what you’re expected to do. And it’s what people did, including my greatgrandparents,who came to this country virtually penniless.

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  2. Why can’t we start by considering the problem contextually. UHC might be good and might be bad, but the context in which the libs have tried to implement it is bad and therefore should be opposed and reversed?

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    • So Koz, are you saying that it’s just this version you find unpalatable, but otherwise you would support a government-supported UHC program that provided no-cost insurance for the poor or underemployed?

      I would have bet a pint that you would not.

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      • Tod, think in terms of process if that helps. The substance of PPACA is really bad, if there were another hypothetical version of UHC on offer, there’s a decent chance I would oppose that as well. But what’s really killing us is the way the libs have attempted to implement PPACA, things that implies about America and the consequences for it going forward.

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        • With all due respect, Koz, you’re substituting the questions asked for one you feel more comfortable answering. I get that you don’t support Obamacare.

          But assume it doesn’t exist, or that it gets repealed. The Right still opposes any UHC, yes? And they still support Medicare, yes?

          My question is, why is that?

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          • Ok, I can answer all those questions but the first thing to understand is that the answers aren’t abstract, they are contextual.

            Especially in the context of lib thinking surrounding the various iterations of PPACA, libs have gotten into the mental habit of trying to simplify the health care debate into abstract policy issues. Those things are important. But my point is either accidentally or deliberately that train of thought ignores what’s even more important in the whole situation.

            As just one case in point that ought to be obvious. The GOP supports the continuation of Medicare. They probably wouldn’t support the creation of Medicare as it exists today, if in fact it didn’t already exist. Therefore the question of whether the GOP supports Medicare is a contextual question. To ask it abstractly is missing the point (same goes for UHC in general obviously).

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                • I think there is some truth to this in some quarters – I certainly would have anticipated your being against medicare, for example, BB, as well as other libertarians.

                  But I am still convinced that a lot – a LOT – of the GOP rank and file love Medicare, and would fight tooth and nail against any form of UHC.

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                  • There was a poll a year or so out that even 70% or so of Tea Party members don’t want cuts to Medicare or Social Security. I fully expect the GOP plan among “smart” conservatives who don’t want to blow up the world (aka Boehner/McConnell/etc.) was to get Obama to agree to a Grand Bargain w/ Medicare & SS cuts, run against those cuts, then never do anything about those cuts once you win.

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                    • There is wisdom in those words. The “bait-and-switch” is a tried and true political winner for the GOP, even tho it’s based on deception. But ironically (or incoherently) the conservative base eats that shit up. Conservatism cannot fail, even if realizing the Dream requires being outright deceitful.

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              • Getting warmer, though I’d venture that that’s a pretty reductionist way of putting things, and that too misses the point.

                What’s more important is the changing perception of the resources we have available (specifically about Medicare though it applies to health care in general as well). There’s an important point here that’s worth stating explicitly: a resource is something that we have credible operational control of. Just because some valuable thing exists, doesn’t mean that you or I or Nancy Pelosi can deploy it at will. As a result of many things, of which the prevalence of Demo unemployment is very very important, we have less resources than we used to.

                This is underlying the political food fights.

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              • This point is very true. Its always been about winning to the GOP rather than fixing this country for the better. For the last four years the GOP has worked twice as hard trying to get rid of the elected members on the right than trying to emprove this country. If you really love your country political parties shouldn’t matter. Don’t wait 4 year to try and better this country, try now because there is no guarantee you will win. Why would you want your president to fail!! If your President fail we all fail!

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              • and more to do with the ability to win political battles?

                Or more charitably, as conservatives, the longer and more established an institution, the more they support it (everything else being equal).

                To the extent that this is more a cast of mind than anything else. For any given set of reforms, presenting it as a minor modification of previously existing programs is more likely to garner conservative support. And possibly, putting all the reforms together into one bill satisfies something among the left (i.e. the sense that something useful has been done to solve the problem rather than merely tweak the system along the edges.)

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              • Koz’s argument sounds like shockdoctrine, to me. Koz seems like he’s sayint, “There have been several severe shocks, constraints on the system.” Notice he left out the natural disasters, as in Japan. “Because of these shocks, we must continue doing what we’ve already been doing — giving Medicare to the old folk, cutting taxes on the wealthiest, living with paying high prices for being the worlds’ pharmaceutical guinea pig and denying the sick health insurance because we cannot figure out how to control costs. Better not to try.”

                A mild version of shock doctrine.

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            • The GOP supports the continuation of Medicare.

              That’s not true. The GOP supports the continuation of a policy in which federal funds subsidize health care for the elderly. They do not, however, support Medicare (unless what you mean by “supporting Medicare” is dismantling it).

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                • (pedantry) This may be a semantic point, but I think it’s an important one: Republicans (in the House, surely, if acceptance of the Ryan plan counts as evidence of their beliefs) do not support Medicare as we know it, as the term is conventionally understood. What they support is ‘Medicare’: providing federally funded subsidies to the elderly to purchase private insurance. (/pedantry)

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              • “The GOP supports the continuation of a policy in which federal funds subsidize health care for the elderly.”

                Again, this is stripping the important context. It certainly is reasonable to say that the default GOP position is the Ryan plan. But even there, at least in the short term, say less than three years at least, I’d expect the continuation of typical fee-for-service Medicare will be the fallback GOP position, certainly above abolishing the whole thing.

                And that was the GOP position for about 25 years or so. The reason why it isn’t now, and why the GOP hasn’t been punished politically for advocating the Ryan plan, is lack of resources, just what I said before. Specifically, I’d venture that the perception of the social good that Medicare provides is pretty much the same as it was at the time that President Johnson created it, but the perception of the resources that it takes to provide it has changed wildly. (In fact, a substantial part of lib advocacy at the moment is engineer to avoid the acknowledgement of that very fact.)

                Therefore, for substantive and political reasons both, it’s important to ask, at the creation of any policy, what resources are required to implement this policy and what resources do we have?

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            • The GOP supports the continuation of Medicare.

              No, they don’t. They would love to privatize it (and Social Security) into extinction, but realize that the Tea Party Idiots they have supporting the GOP won’t go for that. UHC is Socialism for “them”, Medicare is a right from God for us.

              -10 history fail.

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  3. We have Medicare for the old, SCHIP for kids, and Medicaid for the poor, everyone else either doesn’t want insurance or isn’t trying hard enough. All of these programs would benifit from aggressive cuts and privatization.

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  4. One distinction between UHC and Medicare (and SCHIPs-type programs) is the expected need for health care.

    Both as a younger child (0-15 years old would be my personal range if forced to pick) and as an older adult (50+ ditto) the need for regular health care is important to catch and treat medical conditions. For healthy people 16-50 years old, you don’t really need to see a doctor until something happens (broken bone, cancer, migraines, pregnancy, etc). It’s still important to have health insurance in case something unexpected happens, but the point of the insurance is to handle the risk of something that can’t be planned. The need for health care is actually pretty low.

    Using myself and extended family as assumed typical cases: we go years without seeing doctors. I expect this to change as we move from the 40s-50s into the 60s-70s. My parents and in-laws see doctors much more frequently. Even though I have really good (employer-provided) insurance, I still don’t go until my spouse nags me about how long it’s been between mammograms.

    OTOH, a nephew with mild CP will always need health care his whole life. Loosing affordable health care when he’s no longer covered by his parent’s insurance will be devastating. His health challenges have been identified while a child, and aren’t going away just because he’s becoming an adult. He doesn’t need insurance (managing risk) he needs health care.

    We go to the dentist (really dental hygienist, but that’s another argument…) regularly for cleaning and checkups. I have dental insurance which pays for some of the care. Looking at the terms of the insurance, it’s clear it’s more pre-paid care (preventative cleanings covered at 100%, reconstructive stuff at 50%) rather than risk management for some unexpected care.

    So: Your request for the difference between UHC and Medicare: Assumed need for health care, based on the aging body.

    Note: I am definitely not a spokesperson for “the Right” but this was always a distinction that made sense to me.

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    • “For healthy people 16-50 years old, you don’t really need to see a doctor until something happens (broken bone, cancer, migraines, pregnancy, etc).”

      This is precisely the reason that private health insurers and their lobbies have had zero problem with both the very young and the very old participating in a UHC style public insurance plan rather than seeing them as lost customers. They are a bad risk and are not profitable to insure. Add to that pre-existing condition exclusions, and this is also why the status quo is unworkable.

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      • They are a bad risk and are not profitable to insure.

        That’s not how insurance works. Anyone can be insured profitably; it’s just a matter of setting the premium correctly.

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        • OK, check that. They are a bad risk to insure at a rate that both the market would bear without subsidies and be profitable for insurance companies.

          It is not difficult to see the path that we took getting to our current, awful system as one where:

          1) Taxpayers subsidize insurance for working age people via the health insurance tax deduction for businesses. This masks the real cost of both the plans and cost of services, allowing for greater profit at each point in both the business of health care delivery and insurance.

          2) Those that are not as profitable to insure (those more likely to be health service consumers: the old, the too-sick to-work, the very young) are shunted toward taxpayer financed UHC style programs. This is rent seeking by the insurance industry. Steering the structure of those programs towards fee for service payment plans is rent seeking by health care providers.

          3) And finally, patent laws siphon off trillions of dollars for protected drugs and equipment. There is no better example of rent seeking: taxpayer and consumer capital is extracted at an exorbitant rate by virtue of government granted monopolies. There is some benefit to research and development given by these patents because of the longer potential monopoly, but I venture that the return on taxpayer/consumer investment is terrible compared to direct research funding. We are talking trillions of dollars/year here.

          So, yeah, those without taxpayer subsides who fall into a more risky profile for health coverage because of age or past illness are not insurable at a rate that is both profitable to incumbent providers/insurers and affordable.

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    • First of all, excellent and well explained reply. This is certainly better than what I came up with.

      And saying that, I will counter with this:

      If the difference is what you say, then we agree it exists for people that need it, but any people are in anagram range where they almost vnever need it. Why not do everyone then, if the need is so small for the midrange ages, and have it cover the unexpected costs?

      I’m not sure I agree that it’s a convincing argument for me, but I can see the logic. I’ll be curious to see if more people from the Right agree with you.

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  5. I’m just a crazy libertarian, but yes, definitely, Medicare is clearly federal overreach under any good-faith reading of the Constitution. It’s also highly redistributive, since the tax is proportional to income but everyone gets the same benefits, and this is problematic for all the usual reasons redistribution is problematic.

    I suspect that there are two reasons Medicare is more popular among conservatives:
    1. Poverty in old age is more common than poverty in adulthood, and thus less blameworthy.
    2. People feel that beneficiaries have paid for it. This is nonsense, of course—it’s clearly redistributive. But people tend to be very bad at thinking clearly about income taxes, and often get confused about the difference between amounts and rates, leading to absurd rhetoric about the rich paying less in taxes than the middle class. I think most people honestly do believe that all or most Medicare beneficiaries have paid their fair share.

    And, of course, Medicare is more popular enough among the masses that it’s impolitic to speak against it, regardless of your true feelings.

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  6. Tod,

    I have no issues with a transfer program from the young to the old or from those well off to those temporarily down on their luck. These are proper uses of insurance. We can increase our utility by building smart safety nets.

    That said, Medicare is not very well designed, though I could probably rationally (not politically) solve that with a pencil, a napkin and a few minutes of thought.

    Obama care is an even larger and more poorly designed travesty of economics and politics. It is almost guaranteed to further separate the benefits from the costs, to misallocate decision making, and to eliminate competition and proper incentives. It leads to more waste, more rent seeking, less innovation, higher costs, less effectiveness and longer term lower quality of life especially for the poor than if we did nothing. It is “nucking futs.”

    Does this answer your question though?

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    • Um, no. And it might just be that the question isn’t necessarily aimed at someone like you, Roger.

      I’m not talking about Obamacare at all. I’m more curious why about half the people in the country (and about half the well known political pundits out there) speak of Medicare as a Good and Necessary Thing, whether it be in its current form or a redesigned model – and yet are still against any kind of universal health care, regardless of the model.

      The only reasons I can think of are some form of selfishness (I will be old but I won’t be poor; I don’t want to have to pay for my parents’ care; etc.) or a desire to give out largesse for purely emotional reasons (I like poor people but poor people make me uncomfortable, etc.). I am assuming that this is because I am not seeing a Very Large Point that most of the GOP rank and file sees, and I want to know what that point is.

      Otherwise I have to create my own cynical and not very flattering excuses for why they support one so strongly and rail against the other so mercilessly, and I’d rather not do that.

      In other words, I’m not looking for someone like you or Berg to come up with a good argument about the way the system should work; I’m more curious about why so many people have such strongly held opinions that seem so contradictory to me.

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      • I’d venture a guess that it boils down to two primary factors:

        1. It’s new. There’s a reason that conservatives are called conservatives. And that’s that they are resistant to new social and economic arrangements. And that is, in part, a healthy instinct: grand programs often have harmful or unintended consequences. Medicare has been around for the lifetimes of most of us, and it’s now a well-tread part of the social contract. HUC is new, and potentially very costly.

        2. The karmic model of society. Another part of the conservative soul (from my perspective) is an assumption that social arrangements are the exterior manifestation of a universal moral model (hence the acceptance of social heirarchies, relationships, and customs that favor one class of people over another). In this karmic understanding of society, there’s a reason that people are poor: they are unworthy. They haven’t shown the discipline, or character, or unity of purpose to transcend their condition. And for that reason, they are less deserving of social and economic benefits.

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  7. I’m all in favor of some kind of medical coverage* for people below a certain income level, but I don’t understand why it has to be so complicated. Food stamps are the best model I can think of for how medical care* should be paid for by the government, state and federal: You get a card loaded with money. You can spend the money as you see fit on the kinds of medical care you think you need and the government recharges the card based on whatever formula the pols have worked out with the lobbyists and the voters.

    The argument the Right likes to believe is that poor people have already proven they make bad decisions about money, so the recipients of “medical stamps” will waste the money on bad care. The argument from the Left is basically the same, that poor people are too stupid to know what’s best for them, so they need to be protected from the evildoers in the medical care system who will take the money and not give good service.

    Since I believe that people have the right to make bad decisions as well as good, then I don’t find the arguments from the Right or Left convincing.

    I think there are two steps that will make this entire problem much easier to deal with:

    1. Everyone under a certain income level, say $30,000 per person?, gets free medical care, via prepaid medical care card.

    2. Employers are no longer required to offer medical coverage for employees.

    I’m not saying these two steps will solve the problem, but I think they will get us closer the solution that will: Medical care is an economic good, just like all others, and giving people in the market the freedom to choose how much and what kind of medical care they get at the price they want to pay will lower the cost of the good.
    ———————-

    *Sorry, this rhetorical trick of calling it “health care” in order to use the word that has more moral oomph is total BS. “Health care” is when you take care of your health, you know, eat right and exercise and don’t smoke. We feel like good health is a natural right, so those who deny it are trampling on our personhood. “Medical care” is what we are talking about when we mean the commodity of drugs, devices, doctors, nurses and hospitals.

    Try it. Read these two sentences aloud:

    I want free health care.

    I want free medical care.

    Which one makes you feel more justified in claiming it?

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    • I don’t think Dems think that poor people are incapable of responsibly managing their medical finances – we think that the notion of responsibly managing your medical finances is a total fantasy for almost everyone. Disease and injury create costs that are far too large, varied and unpredictable to be budgeted in a reasonable way.

      Also, what’s not justified about asserting a moral right to free medical care if you, a law-abiding citizen of an affluent democracy, get in a car accident or are diagnosed with MS? If somebody is unlucky enough to be born with Diabetes type I, do they really have no moral claim upon the rest of us not to suffer easily preventable disability or death if they can’t pay for their own (extremely expensive and predictable) treatment?

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      • Don Zeko,

        Well, nobody has a moral claim on the rest of us.

        What the rest of us can do, and I agree we should, is figure out a way to provide ongoing medical assistance to others who don’t have enough money to buy it themselves. Bu this is because the price of medical care is artificially high, due to the intertwining of government and business in the medical care industry.

        I’ve offered my proposals for moving to a more free-market version of providing medical care, which will lower prices, as free markets do for all other economic goods.

        Do I believe people in America would be better off economically and in terms of their health if medical care were directly subsidized through taxation? Of course.

        Do I think the current members of our legislative and executive branches can develop such a plan? No. Nor do I see anyone in the opposition who could do so, either. Well, that’s wrong. “Could” they? Yes. “Will” they? No.

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    • I agree that “health care” vs “medical care” is a useful distinction.

      I also have a big issue between treating care and insurance as the same thing.
      Ideally insurance should be for managing risk across the population.

      Figuring out how to pay for and deliver normal, routine, expected medical care should be a totally separate discussion of how to handle expensive and rare care.

      (My own preference if I was dictator for the year: Universal coverage for all residents (citizenship status not an issue) with an approved list of covered services based on age. Services list generated by active practitioners in the fields, with ongoing review to prove the value (cost/benefit) of the treatment. Private moneys to pay for services not on the list, which are available for (private) insurance coverage.)

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    • This is already supported, to some extent, in the tax code.
      You have to itemize to get the credit (meaning that if you don’t itemize, you’re better off by not claiming it), and it’s everything in excess of 7.5% of AGI.
      The amount of the benefit of doing this is dependent on the marginal tax rate.

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      • …and I should have been more clear the first time around that persons with $30k or less in income would typically be better off with the standard deduction, or they don’t have enough in medical expenses to justify claiming the credit without other factors making it worthwhile to itemize.

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        • It has very to little to do with income. I was making six figures and still taking the standard deduction. Whether it’s worthwhile to take the standard deduction is almost entirely a function of how much mortgage debt you have, because mortgage interest is pretty much the only significant deductible expense middle-class people have.

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    • Are you familiar with the Oregon Medicaid study?

      http://web.mit.edu/newsoffice/2011/medicaid-study-0708.html

      Basically Oregon had a small amount of money available to enroll additional people in Medicaid; more then were on the wait list. So they held a lottery, basically creating a test and control group of its impacts.

      One of the biggest discoveries was that people who won the Medicaid Lottery had fewer ‘financial mistakes,’ fewer bills in collection, fewer foreclosures, etc. then those who didn’t win.

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  8. “…it’s too late for the oldsters to make any more choices, Tod. But they live off the fat of the land—”gleaning” they called it in the Bible.

    But everybody can’t live off the gleanings. That defeats the whole purpose of farming in the first place. Medicare is a free rider, paying steep discounts. Everybody can’t be on a steep discount.

    I’m all for financing our county health systems as the provider of last resort for the poor. And we ignore charity and clinics in this discussions as well, as if they don’t exist, despite them contributing on the order of $40-50 billion.

    That is what we as a society owe them, some minimum but not full health insurance—that defeats the whole purpose of working a farm. Why bother to farm when you can live off the gleanings of the next guy’s place? And indeed, free health insurance makes people consume health care at a much higher rate, a trip to the doctor’s for the sniffles.

    There must be some sense to all this.”

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    • Which if of course why the US places last among major industrialized in use of tests, antibiotics, pharmaceutical drugs, and other uses of medical care. Because 70% of have to pay premiums unlike those free loaders in the Canada and the UK.

      Again, free medical care isn’t free food. Almost nobody likes going to the doctor. Yes, if we passed Medicare for All tomorrow would health care expenditure probably experience a big jump for a year or two? Of course, because sick people w/ no insurance or crappy insurance would actually take the needed steps to take care of themselves and we’d be better off in the long run.

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    • And indeed, free health insurance makes people consume health care at a much higher rate, a trip to the doctor’s for the sniffles.

      I have to push back a bit on this, Tom. Health care isn’t the kind of consumer good that you consume for pleasure (hypochondriacs aside). Even with insurance health care isn’t costless. You have to take off time from work–which for most of the targeted population for UHC means forgoing income, drive to the office or clinic, sit in line, etc. And then you generally have deductibles and co-pays to cover. In my case going to the doc is a real PITA since my work is basically the lower 48 (truck driver) and scheduled home time is more of a wish and a prayer than any kind of sure thing.

      Have you ever actually experienced free health care? I did, for the nine years I was in the Navy. Medical, dental, vision, all of it. About the only thing I had to buy out-of-pocket were eyeglasses other than the “birth-control” version they gave you for free. I observed actual behavior in that situation–not the economist’s hypothetical–and I can attest that demand isn’t unlimited and very few sailors would go the infirmary for the “sniffles” unless they were trying to get out of work. “Malingering” was the term for that. That doesn’t work so well when there exist incidental costs like I laid out above.

      On the other hand, when you have a genuine medical need, demand is extremely inelastic wrt price. If you get a diagnosis of cancer, for example, your priority isn’t finding the most cost-effective treatment. It’s finding the most effective treatment, full stop.

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      • But Rod, it’s right in the stats and studies that people use health care more often when they have insurance.

        Public health—clinics—kind of suck, so yeah, people use them more sparingly. But this is a built-in feature of self-rationing.

        I’ve been to County-USC when a friend came down with AIDS symptoms, spent a week there off and on. It wasn’t the greatest but neither was he permitted to die on the street. And he could have bought health insurance, he just decided not to. Enough of his income was off the books that the IRS wouldn’t have fined him anyway under the Obamacare mandate.

        So frankly, I’m proud that America didn’t let Dan die, but neither am I real happy that he didn’t hold up his end of citizenship. So if County-USC is a little on the crappy side, I don’t think that was unfair—and being a Republican himself, he himself was more grateful than resentful.

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        • Sure, I’ll concede that they use it more. That’s my bad for not being clearer–or having my thoughts more focused before I commented. So let me try again because I truly appreciate respectful conversation with you.

          The relevant questions are these: You claim “much higher rate, a trip to the doctor’s for the sniffles,” implying… what? That people with insurance trot off to the doctor for any and every little twinge and sniffle? Do you have insurance? Do you do that? If the answers to those last two questions are “yes” and “no” respectively, why do you assume others would behave differently? Men in particular are notorious for neglecting their health, with or without insurance.

          What I was pushing back against is the libertarianish assertion–which I stipulate is not specifically what you were saying, but pretty closely related–that health care is just another consumer good, like TV’s or cars. Zero cost to the consumer does not imply infinite demand. You economically demand the care that you need, but if you don’t need it, you’re not particularly interested. I currently have no need for a cast on my leg or high blood pressure medicine and I wouldn’t want those things just because they’re free.

          So, for me at least, my support for UHC is predicated on the same moral impulse that you laud, the impulse that resulted in the charity care being available for your friend, combined with my belief–which I feel is strongly justified theoretically and empirically– that a free market in health care is unworkably defective. The incentives just don’t work right.

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          • Warning: Anecdotal evidence! I shall proceed…

            If my wife’s experiences are any indication, it’s not just a matter of people going to the doctor for the sniffles. The bigger issue is, as my wife phrases it, people “trying to get non-medical needs met through medicine.” Pregnant women seeking reassurance, lonely people seeking interaction, hypochondriacs, and so on. For the reasons you outline, and because I am (ironically) inclined against medical care, I would not have thought it an issue. But it really does seem to be. I’ve heard more than one doctor (including some liberal ones) talk about how nice it would be if some of these patients had to pay just a mere $5 (sometimes $20) per-visit, because they think it would cut down on it (they might be wrong, though I don’t personally feel in a position to say so). It’s arguably the case that the kinds of patients they are talking about are very likely to be on government medicine under the current system anyway (Medicare and Medicaid patients having more time to do such things).

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          • Rod,

            Let’s distinguish between “some people” and “everybody.” No, not everybody will overuse low cost (to them) medical care, but some people will. That’s straightforward demand theory–lower cost increases demand in the aggregate, even if everyone doesn’t increase their demand. (Make sauerkraut cheaper and I still won’t buy it, but my wife will buy a lot more, etc.)

            People afraid of being called malingerers, as in your Navy example, have a countervailing incentive that offsets the incentive of lower cost. A guy with a job like yours (and kudos–I could never do that job) is not in a position to use much more. And some folks are just too proud and/or stubborn to go to the doctor until a bone’s sticking out.

            But not everyone is like that. I personally worked with a guy who said, “I know the doctor can’t do anything for a cold, but I go anyway when I have one because it doesn’t cost me anything and it makes me feel (psychologically) better.” There’re also the people who will insist on needless tests, just to rule out the remotest possibilities and put their minds at ease.

            It’s a difficult issue. We don’t want to discourage people from going to the doctor when they need to go, but we don’t want to encourage them to go when they don’t need to, or to demand care they don’t actually need. But the law of demand is present in health care as much as in any other good or service.

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  9. Do we need to have another conversation about discussing things people said without actually presenting us with sourced quotes, and then claiming that you don’t need to provide sourced quotes because All Of Those People Always Act Like That?

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  10. I think the answer is relatively simple, and goes back to some core cultural beliefs of Americans. (Even if, by and large, those cultural roots have been forgotten).

    Whether we remember the roots of these are not, there are a handful of things that Americans seem to believe deep down. (Or at least many believe.)

    First and foremost, if you are poor it is your fault. In specific, people will allow for context. In general, however, the poor are to blame for their poverty. Generally in conjuction with a core sin — sloth or hedonism. They are LAZY or they are on DRUGS.

    Reagan’s welfare queens dog whistle was so effective not because it appealed to racists ( though it did) but because it was equally effective with a large group of Americans who firmly believe the poor are poor through sloth and drug use, moochers off society.

    Many Americans believe this of the poor — and act accordingly. We despise them, hold them in contempt, and begrudge any attempt to help them. Whether conciously or unconciously, the belief is there that ALL that seperates the poor from success is hard work. (And, of course, stop indulging in alcohol or crack or pot).

    Whether you want to blame it on our ingrained rags-to-richs fables, all the result of hard work, or our Calvisnist roots –where the poor are poor because they deserve to be for their sins, and should never be anything but — is up to you.

    But the old? We ALL grow old. No choice you can make, no planning you can do, nothing can prevent it. You eventually grow too old to work. That’s a forgiveable weakness, one society is willing to plan for — although even now that’s under assault.

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    • +1.

      I’ve lost track of how often on radio the repetitive meme was that if the poor would just “get a job” (nevermind high unemployment conditions and the realities of the workplace), “stop having kids”, or avoid whatever the pet “vice of choice” right winger of the day was railing against, they’d all suddenly be millionaires.

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      • I suspect the real reason Medicare and Social Security are under assault is because those making the calls come from a purely white-collar world.

        It’s one thing to work into your seventies (assuming you survive that long) if your job is behind a desk, in an air-conditioned office. That’s quite doable.

        It’s another if your job is blue-collar, and involves actual physical labor.

        It’s really easy for Ron Paul to talk Social Security and changing the retirement age (or outright ending it). He doesn’t need it, and his job means as long as he’s not actually required to wheel an IV around he can do it.

        But if his job had been construction, or carpentry, or any form of manual labor — he’d be well past the age of productivity there. The human body isn’t a machine.

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        • I don’t see either Medicare or SS as being under assault. I see a lot of people believing that the are in need of reform, usually for budgetary reasons. And even if you’re not inclined to agree with that viewpoint, it certainly doesn’t seem so outrageous a concern.

          But if there’s any kind of mainstream conservative movement to eliminate either, I’ve never seen it.

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          • You don’t look hard enough then. Privatizing Social Security was on the list, and Paul Ryan’s Medicare “plan” was effectively the elimination of Medicare.

            Sure, he didn’t call it that and Polifact said it was true (apparently if you get rid of Medicare and replace it with an identically named plan, it does not count as getting rid of Medicare. Not their best moment), but that’s the effect.

            Replace Medicare with a voucher system that doesn’t even keep up with medical inflation? Anyone with the vaguest sort of attention span can see how that would utterly collapse — first and foremost, there is no individual market for health insurance policies for 60 year olds. Especially not those with health problems. So, yah voucher. It won’t pay for the insurance, but that’s okay, because no one’s selling it.

            The fact that it doesn’t even keep up with the rate of medical inflation is sort of meaningless. After all, it’s not enough money for your average 60 year old to purchase health care, it’s not even enough for them to purchase health insurance — which no one is selling anyways.

            Thing about Medicare is — it insures the most expensive segment of the health marketplace already — the elderly. Medicare SHOULD be the single most costly health-care system in the US, so costly that in essence an individual needs to start paying for it as soon as he or she begins working, because only by paying up-front is it even possible to break-even on the large scale. (Which is, by and large, how Medicare works. You pay now, when you’re young, to recieve when you are old. The fact that it runs as a pay-as-you-go system is immaterial. There’s lots of good reasons for the US government not to sit on giant piles of cash.)

            The King of the GOP budget plan wants to axe it and replace it with something that, flatly, cannot possibly work. The GOP has rallied around his budget as the future of the GOP program.

            I can’t imagine that not being “under assault”.

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  11. The thing is, everyone would benefit from UHC. We would all be better off. We would pay less, and get better services. Expect that conservatives would be deprived of seeing “the other” suffer. I think is a perverse addiction to the suffering of “the other” that drives some to oppose UHC. Here is a choice between two systems:
    A. I benefit the most, unfortunately the people I do not like also benefit.
    B. I do not benefit at all, but neither do the people I don’t like.
    What do I chose? Well, it depends of what I value the most, my own benefit, or the joy from seeing my enemies suffer. I may sound callous, but think about it. There is a tendency among conservative of “my way or total destruction.”

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  12. I don’t see anything wrong with expanding Medicare to include basic coverage for all people. Or the VA system, for that matter.
    But I believe the coverage should be basic, and should be limited to annual caps.

    I remember reading an article by a psychologist that was talking about the decline of the conventional talking therapy. A big part of this is that insurance typically covers medication, but not therapy. As a result, we have the highest per capita rate in the world of persons on long-term medications.
    I say pull the plug on the medicine cabinet and get people into treatment.

    We need to have something basic that prevents treatable conditions from becoming severe long-term conditions.
    And I think a network of catastrophic injury protection and end-of-life care policies should make up the difference.

    I have life insurance, as well as a death benefit from my union, and some other stuff I’m not even sure what it is. I don’t expect UHC to alleviate the need for that.

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    • Two questions:

      1. How do you define “basic?”

      2. Why caps? Catastropic care is the area of largest concern.

      I completely agree that we need to establish limits on coverage that will allow for cost control. And that’s more likely in a VA type of system than a Medicare type (different incentives).

      But how you define “basic” will have an awful lot to do with how manageable your future medical costs are going to be. Will it include:

      Conditions that are annoying but not life threatening? (e.g. Moles? Cataracts? Flus? Acne?)
      Expensive treatments? (Patented-protected chronic conditions? Liver transplants? AIDS? Heart bypasses? Mood disorders? AIDS?)
      Extensive end-of-life care? (Maintenance of brain-dead patients?)
      High cost-to-benefit treatments? (UV therapy for psoraisis? Lower back surgery? Prostate management?)

      Medicare has a pretty much “pay for it, regardless” policy, and as a result it is threatening to overwhelm our economy in the long term. And yet, if there is any talk of “rationing” there is screaming about “death panels.” We cannot have reasonable universal health insurance without establishing some limiting principles. What would you propose?

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      • Personally, I would propose $2k/yr limits.
        What “basic” means is really the big sticking point.
        But with catastrophic injury & end-of-life care off the table (to be covered by supplemental policies), expenses could be managed somewhat; surely not perfectly, but better than they are now.

        Now, I’ve seen people on disability from the state for being too fat to work and for being an alcoholic– both of which conditions are exacerbated by maintaining the illusion of self-sufficiency. I would support group homes for most of those types of individuals, as well as making them available for seniors.
        Section 8 was a good idea for seniors, but it was another program where eligibility expanded exponentially until it made it unpalatable for everyone.

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        • 8 years ago, I had a kidney stone that ended up costing about $7k after insurance. Are you saying that I–had I had UHC–I should have been left to suffer or die?

          Did you know that median health care expenses are about $8k per person-year?

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          • Is there a dollar amount above which we should be willing to say “okay, we, as a society, think this money would be better spent on the Rock and Roll Hall of Fame”?

            Is there any limit to the dollar amount of medical care that any individual should expect society to provide?

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            • Two things here:
              1) Limits of practicality: Let’s say that everyone decided that large amounts of plastic surgery were necessary. $100,000 a year, every year. Obviously we couldn’t afford that.

              2) …? “doesn’t help” care.

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              • One can of worms that I’d enjoy seeing someone else open and/or engage with is the whole “should bullshit be covered?” part of insurance.

                Multivitamins? Chiropractors? How about those ring bells and smell essential oils people? (I have loved ones who tell me to use “Thieves”.) What about homeopaths?

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                • multivitamins prevent headless babies. I vote we keep those.
                  The rest can go to hell.

                  I’ll give some amount of credence to “placebo-based medicine” if they’re willing to make it ethical. Patients gotta agree beforehand, and there needs to be good guidelines for when “you’ve gone too far”

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          • Don’t know: a limit would be entirely appropriate. I wouldn’t be willing, as a taxpayer, to contribute my portion of the $200M that it might cost to pay for a body transplant.

            But the $2K/yr that Will was proposing seemed kind of unreal…

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          • Did you know that median health care expenses are about $8k per person-year?

            That has to be mean, not median. $8,000 times 300M is $2.4T, which soudns about right for total health care expenditures. Since health care expenditures are distributed very unequally, the median has to be much smaller than the mean.

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              • Whatever the basis for the criterion of coverage in your own particular case, were we funding the matter as a public, it would likely be to the extent that occupation is affected which would be of primary concern.
                Have to get people well so we can tax the fish out of them.

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              • Correct, Medicare covers it NOW, but didn’t for decades and still won’t cover ESWL for some other similar problems. It always seems silly to me when big monolithic government agency determines that it is somehow better to do an invasive surgery (for example) with all the complications that entails while not being interested in cheaper and more effective options. Blaise, you already are well aware of my distrust of big everything, gov’t, business, banking, it is all the same, once it gets too big, it is too big period. At least when corporations get too big they [can] get chopped up. Not so easy with governments.

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                • There’s a straightforward way of dealing with Big. Assigned designated handlers. When a problem develops inside IBM, they’ll assign one person to deal with that customer. He’s the single point of contact. You’re not dealing with IBM, you’re now dealing with Joe McCormick. Joe’s your guy. He’s your Customer Engineer.

                  Thus, a huge bureaucracy can be reduced to a single thread of conversation. Joe can work the bureaucracy. It’s just like in the military: only two people you never, ever piss off: your supply sergeant and your first sergeant. I wish more people understood how to work a bureaucracy. When those support people at the other end of the wire pick up the phone and say their names: write them down. When they give you a case number, write it down.

                  We fear and distrust what we don’t know. A good bureaucracy doesn’t have to be monolithic: given a chance and a decent attitude from both the CE and the client, you’d be amazed how flexible a big bureaucracy can be.

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                  • So it’s possible to get what you want from an interaction with an objective impartial unemotional system that’s focused on absolute equality…just so long as you create a good personal relationship with the right people.

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                    • To a large degree, yes, absolutely. A bureaucracy is composed of individuals, each of whom must balance two objectives: their own and that of the bureaucracy.

                      Dwight Eisenhower was a middling cadet at West Point but rose to lead the Allied forces in Europe. When one of his more punctilious classmates was promoted to the rank of General, Eisenhower scornfully observed that man had never bent a rule in his life.

                      Bureaucracies aren’t about equality. You’re just being obtuse, but then you always are. Hardly worth replying to you at all. Bureaucrats give life to laws. Cops are bureaucrats, they’re tasked with enforcing the law. Firemen, social workers and the like, all given mandate by legislatures. You just want to make up some straw man.

                      The genuinely awful bureaucrats are in the civilian world: they make up the rules as they go along but never shall we hear a word on that subject from you, nossir. A government bureaucrat is accountable to some public figure.

                      The only reason a bureaucracy seems unemotional is because it lacks a face from which we might infer emotion. My scheme puts a face on the bureaucracy and doesn’t angrily fart and carry on about the evils of creating a good personal relationship with the right people.

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                    • Aren’t things like Title VII supposed to make objective and truly-neutral bureaucracy a legal requirement?

                      See, I don’t mind the idea that you get things done by creating personal relationships with people. I think that leads to far better outcomes than wilfully foregoing independent thought in favor of a procedures written by committee and employed in a Procrustean manner.

                      But we’re told that doing things via personal relationships leads to cronyism, industry-government collusion, paying off regulators to look the other way. We’re told that it lets people govern by personal preference rather than law, which lets racism and other rights violations flourish (Joe at City Hall hates black people and doesn’t want any in his town, so suddenly no black person can get a permit for a sewer hookup outside of the Harvestone neighborhood. Jane at the police department thinks deer are cute and nobody should be allowed to shoot them, which is why there aren’t any gun dealers within city limits).

                      The industry I work in has been a twenty-year demonstration of what happens when you throw out partnerships in favor of bureaucracy. You don’t need to get all Poppa Gon Tell You TROOF at me about it. But neither you nor I are in the driver’s seat on this one.

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                    • What’s your beef with Title VII? This I gotta hear. Do you have a problem with the idea of prohibiting discrimination? A quick look at the legislation mentions “injunctive relief”. That means someone can go to court and expect some definition of discrimination to be applied to his problem.

                      Do you think judges are robots? They call it a “hearing” for a reason. Someone has to talk and someone else has to listen. All this talk of Cronyism and Wicked Government — hey, if we want to evict the crooked pols and their pimp cronies, I want their behaviour to be dragged into a courtroom where some dispassionate judge will dispense some industrial-strength justice.

                      It’s all about People. As you point out, with commendable wrath and insight, the perversion of justice can only arise when someone with power can push the rest of us around. Happens inside government, happens outside government. Thus I contend we must have a free press and an independent judiciary to fulfil the OWHolmes’ predictive description of law, where Bad Men refrain from badness according to the odds of the law’s predictions about punishment coming true.

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                    • Bureaucracies are about equality–that is, in the Angl0-American civil service tradition they are. Outside that tradition, not necessarily. As every public administration text emphasizes, one of the values of a professionalized bureaucracy is that it eliminates (eh,… diminishes) arbitrary and capricious treatment by making “you’re the wrong ethnicity” or “you’re my wife’s brother-in-law’s cousin” illegitimate grounds for distributing benefits.

                      That said, personal relationships remain personal relationships. A bureaucrat generally has no responsibility to make extra effort to help anyone. It’s easier and safer to say no than to figure out how to say yes. But by establishing a personal relationship with the bureaucrat you give him/her a reason–a non-bureaucratic reason–to put in the extra effort on your behalf.

                      That’s why anyone with any sense treats the low-level administrative staff at their place of business very well. They’re not obligated to go out of their way to help you, but if they like you they will.

                      That’s one of the two secrets to successfully working a bureaucracy to your own ends. The other is to figure out how to classify your goal in a way that allows it to fit into the regulations they have to follow.

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      • Any good solution has certain desirable attributes:

        1. This solution applies to conditions affecting a maximal number of patients.
        2. It is cost-effective: a minimum amount of money spent on it improves quality of life for a maximal period of time.

        Just start picking off the most statistically-prevalent conditions first. It’s sorta like draining the lake. Inoculations have drained the lake far enough to where we don’t have thousands of children dying of pertussis or measles.

        But other conditions have appeared. Arthritis is the Number One complaint, I see more ICD-9 code 710.0 in the system than anything else. People are living much longer lives, arthritis is what they get. Old people die of all sorts of things, circulatory disorders, ischemic heart disease, influenza and such. We all sorta know better than to get all panicky because more people are dying of ischemic heart disease on a percentage basis: in the long run, we are all dead.

        Apply my two rules above, you have your limiting principles. There’s no draining the lake completely, people just will go on dying, the bastards. Question is, how can we do the most good for the most people at the best price point.

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        • That’s kinda where I was headed, except that there’s currently a lot of mis-coding in order to get insurance companies to pay. Arthritis almost always points at some underlying inflammatory condition.

          Here’s a summary of the Oregon Medicaid program that I mentioned earlier (some rigor was used in trying to establish the cost-to-benefit ratio for different treatments).

          The conclusion that the Oregon experiment “failed” is somewhat debatable. Here’s an analysis that concludes that political and bureaucratic factors led to the program never having been fully implemented as designed in the first place.

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          • Fixed your second link.

            Not many people outside of healthcare statistics know about this study. Kudos for being up on this. I haven’t seen these documents before, but a quick scan of them is congruent with my own analysis: the problem with OHP was the paperwork.

            Want to solve the paperwork problem in health care? Oboyoboy… have I got an essay to write about that. First thing, get everyone out of the healthcare paperwork business who doesn’t at least have an RN. There are some excellent RNs I know, superb human beings, who I’ve worked with on just this problem. There are some speciality RN programs which focus on health care information.

            Put it this way, there’s a reason MUMPS never went out of style in good hospitals.

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        • My friends from Alberta tell me that they also have supplemental health insurance; and also that their insurance does not cover visual or dental.

          So we need to get back to the idea of “basic coverage.”
          What is “basic?”

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  13. With respect to conservatism-qua-theory, there is no principled different between UHC and Medicare. Medicaid, sure. Social safety nets are fine, even for us meanies. Older folks can get in line with all the other people who can’t afford medical attention.

    With respect to conservatism-qua-politics, taking away Medicare is a third rail. Conservatives like trying to be consistent with our principles, but we’d like to continue to exist as a relevant movement, thanks very much. You can talk about conservative principles till your head pops, won’t make any difference with John Q. Public who wants what’s comin’ to him. Entitlements are a one-way ratchet. That’s one of the reasons, by the way, we conservatives generally are agin’ ’em.

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    • Entitlements are a one-way ratchet. That’s one of the reasons, by the way, we conservatives generally are agin’ ‘em.

      Likewise the defense budget, which conservative pundits, at least, are telling us is still too low, placing our nation in grave peril.

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      • This is incorrect. Entitlements are a one-way ratchet, and defense spending is not, at least not in %GDP terms. In fact, defense spending as a percentage of GDP declined dramatically over the latter half of the 20th century, falling to an all-time low of just under 3% in 2000, down from 9% as recently as 1968. It’s up to about 4.7% now.

        In real per capita terms, military spending has been pretty much flat over the long run, with no discernible long-term trend in either direction.

        Entitlement spending, however, has been growing inexorably for more than fifty years, and is now up to 12% of GDP from under 4% as recently as 1966.

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        • If we look at spending adjusted only for inflation, ignoring population growth, then it is true that military spending has increased over the long term, but it’s been far outpaced by the growth in entitlement spending.

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        • Huh?

          It was very low in the previous half-century (up until WWII), but grew to over 10% of GDP as the Cold War took hold. It’s been shrinking in relative terms relative to that, but the US still spends a larger portion of its GNP than any other developed country except Israel and Saudia Arabia (by a pretty long shot).

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    • Agin’ as in against? Or Agin’ as in Aging? Let Medicare Part D prove these so-called Conservatives are all about getting their bennies at everyone else’s expense. These pedo viejo Conservatives are all so many outraged dudes in Bermuda shorts trying to get everyone else off their Entitlement Lawn.

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  14. An honest question — do conservatives lovey-kiss-cuddle their Medicare, thus showing their hypocritical nature by opposing UHC, or do they want to destroy Medicare. I just don’t know. Which is it? Maybe it’s either depending on how you want to frame an argument.

    http://www.dailykos.com/story/2012/04/30/1087693/-Conservative-Democrats-agree-Democrats-will-capitulate-on-privatizing-nbsp-Medicare

    http://politicalirony.com/2010/02/10/republicans-dont-want-to-gut-medicare-they-want-to-kill-it/

    http://www.washingtonpost.com/opinions/a-republican-mediscare/2012/03/16/gIQAfoWYGS_story.html

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    • I expect, like their liberal brethren, conservative politicians care first about getting elected. I don’t find this particularly either interesting or damning.

      So, if the true desire is to “destroy” medicare, likely it will require some obfuscation – or more charitably an attempt to replace with something else – as the GOP-leaning demographic skews towards the older.

      I can’t tell you what the average GOP politician thinks about Medicare. The ones that I’ve heard quoted on the topic have wildly different rhetoric over the years.

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      • Yes, Patrick, they sure do have wildly different rhetoric, for sure. Destroy, love, and other stuff. I just don’t know. Then I hear democrats/liberals/progressives say they want to reform Medicare, some say never touch Medicare, and some want to expand it to everyone. These are honest questions, and I don’t know the answers.

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      • I will say this: regardless of rhetoric, I don’t think the GOP wants to “destroy Medicare”. Medicare Part D is inexplicable under those terms.

        Frankly, I don’t see the GOP as being particularly interested in health care, as an issue. I see the Democrats being interested in health care, as an issue. I see the GOP being reactive in this dynamic: what they support, or don’t support, is largely a function of politics. There are individual exceptions, but the movement itself is not actively engaged in health care as an issue.

        I see the GOP as being particularly interested in taxes, on the other hand.

        I don’t see the Democrats as being particularly interested in redistribution for the sake of redistribution. Again, individual exceptions. I see the Democrats as being interested in other social welfare goals (which require some redistribution), though, and I see “higher taxes on the rich” as a political means to the end of funding those other social welfare goals.

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        • “Frankly, I don’t see the GOP as being particularly interested in health care, as an issue. I see the Democrats being interested in health care, as an issue. I see the GOP being reactive in this dynamic: what they support, or don’t support, is largely a function of politics. There are individual exceptions, but the movement itself is not actively engaged in health care as an issue.

          I see the GOP as being particularly interested in taxes, on the other hand.”

          I have to say in a post full of great possible answers to my question, Pat, this is perhaps the best. Or at least it’s the one that rings the truest to me.

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          • It’s odd; our political system more or less requires everything to turn into a Pick These Guys or Those Guys dynamic.

            But people forget that These Guys and Those Guys are only practically opposites. They’re actually driven by more core motivations; they act as opposites in many ways, but usually as a function of who is in power.

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          • That’s true, but it’s also not the whole thing either. In particular, the political perceptions are not monolithic either. Specifically, there has been a tremendous confluence of events, 2008 meltdown, greater appreciation of aging demographics, the Euro crises, etc., that have changed the perception inside and outside the political class of the feasibility and desirabilty of the welfare state.

            One big problem is, that the libs never internalized that any of these things represent a legitimate constraint on them.

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            • I’m curious as to how the 2008 meltdown represents a legitimate constraint on libs, in your head.

              It certainly hasn’t been internalized as a legitimate constraint on free marketeers.

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              • We have less government resources to fund welfare state programs with.

                For the most part libs do a much better job of understanding the ebb and flow of political developments as opposed to the ethical obligations of modern statecraft, but this is an exception in that for as much as libs have liked to complain about the political viability of funding cuts to this or that, as near as I can see they have never made any attempt to see why that’s the case.

                You don’t see it quite so much any more but 18 months or so ago, the libs were doing their best to third rail the GOP over Ryan plan but they have never come to grips with any understanding of why third rails aren’t third rails any more.

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                  • Yawn, if you must but you should understand that a significant part of the energy in current political culture is geared toward creating situations where you can’t yawn.

                    Specifically, this is why things like the debt ceiling crisis exist. In an environment where one party refuses to understand or accept the motivations of another, either you can capitulate to us, you can force us to capitulate to you, or we can collaborate on a huge swath of collateral damage. Whatever it is you do, you can’t yawn.

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                    • this is why things like the debt ceiling crisis exist.

                      Because one party consists of stupid, irresponsible assholes that would rather wreck everything than be out of power.

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                    • “Because one party consists of stupid, irresponsible assholes that would rather wreck everything than be out of power.”

                      I dunno Mike, it seems more socially optimal for all parties if Team Red and Team Blue could get together find places to cut or attrit government expenditures to cause minimum loss of service, social upheaval and/or political disruption. But IIRC we were never given that option.

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                    • “Obama never offered a deal that cut spending. Uh-huh. Right. Yeah. Sure.”

                      He didn’t.

                      Our Constitutional design contains nuts and bolts that work perfectly well to implement the practice of limited government. But over time, those mechanisms are bulldozed by other seeming more expedient concerns, and as such political dramas get fought in different places than they were before.

                      We believe in engagement. You believe in entanglement. You won.

                      As a consequence I expect to see more debt limit crises and the like.

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                    • I know Obama offered a plan to reduce the expected 10 year deficit. But did he offer a plan that actually cut current levels of spending, or just cut expected levels of spending (reducing the rate of growth of spending?

                      Frequently reductions in expected spending are called spending cuts, but that’s a bit misleading. (it’s also a bipartisan practice.)

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                    • In my timeline, neither President Obama nor any other significant Democrat offered to cut any amount of expenditures from the President’s FY12 budget request from that February until Sen Majority Leader proposed a deal along those lines approximately one week before it was feared that the US would not have enough borrowing authorization to fund its previously appropriated commitments.

                      Surely you know this, it’s why we went through the whole debt limit drama in the first place.

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                    • “But did he offer a plan that actually cut current levels of spending, or just cut expected levels of spending (reducing the rate of growth of spending?”

                      No, he never offered any significant cuts only modifications to the FY12 budget request until shortly before the resolution of the debt limit crisis. That was what the upshot of the drama surrounding the continuing resolutions that spring.

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                    • I have a slightly different perspective to the Cato blurb. It’s politically and substantively easier to cut expenditures in the out years. And, cuts in the out years are definitely not worth as much dollar for dollar as cuts in the current year. But, they are worth more than nothing.

                      The President’s unwillingness to find out year cuts during the whole debt limit deal was very disappointing, and one reason why the issue became as contentious as it did.

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                  • Cato’s Tanner: “Neither President Obama nor Paul Ryan actually cuts government spending. Rather, both are playing the time-honored game of calling a reduction in the rate of increase a “cut.” Thus, the president would increase federal spending from $3.8 trillion in 2013 to $5.82 trillion in 2022. That might not be as big an increase there might otherwise be, but in no way can it be called a cut. Meanwhile, Ryan, who is being accused of “thinly veiled Social Darwinism,” would actually increase spending from $3.53 trillion in 2013 to $4.88 trillion in 2022.

                    The president warns that Ryan’s spending “cuts” would “gut” the social safety net. And, it is true that Ryan’s budget knife falls more heavily on domestic discretionary spending than does the president’s — but only relatively. Over the next 10 years, Ryan would spend $352 billion less on those programs than would Obama, an average of just $35.2 billion per year in additional cuts. Given that domestic discretionary spending under the president’s budget will total more than $4 trillion over the next decade, Ryan’s cuts look less than draconian.”

                    http://www.cato.org/publications/commentary/obamas-paul-ryans-conflicting-budget-visions

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                    • Cato’s is making an argument that conservatives lost about 15 years ago. Government budget conventions use the idea of a current services baseline. That’s to say, because of increasing population served, increasing costs, or other reasons, it costs more to provide the same level of services. Most people would intuitively describe this as increases in funding, but according to the current services baseline it is no change in funding.

                      Conservatives fought this war with the lib intelligentsia and the Cllinton Administration and lost. We believe in engagement, they believe in entanglement. They won. Shtt is entangled.

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                    • Ok Tod, what say you?

                      Do you accept that the various things since September 2008 have changed the perception of what’s plausible in terms public funding for this or that?

                      As a followup, do you see a particular difference of what your perception of those things and what others’ perception might be (in such a way that it alters the current political landscape)?

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                    • “Do you accept that the various things since September 2008 have changed the perception of what’s plausible in terms public funding for this or that?”

                      Yes, but probably for different reasons than you would argue. My belief is that one of the paradoxes of a democracy is that we’re far more likely to want to expand the role of government in times when the economy is going gangbusters, and more panicked about any spending (even on things that might directly positively impact us, like safety nets) when the economy is bad. This leads to all kinds of circular problems, but suffice it to say for the purposes of answering your question that I think we are being more guarded against spending due to the recession.

                      In terms of what that means for the political landscape, I will say now – as I’ve said often here – that were the Republicans not in a rebuilding phase, trying to figure out amongst themselves what they were going to become, they would just about have the White House locked up already. As it stands, however, I think that they are going to miss a big opportunity.

                      I still believe Obama won not because of who he was or what he had done, but because he was able to craft a compelling vision and narrative of how he saw the country changing for the better. (That he did not become that president, for whatever reasons we might argue about, is partly why he really *should* be more vulnerable now.)

                      I do not see the right taking advantage of the situation in the way Obama did four years ago. I don’t see a compelling vision, I mainly see criticisms of liberals and the President in particular. But those are the things that drive ratings; they are not the things that win national elections.

                      So my short answer is that there should be a political shift happening right now, but its not going to happen… yet.

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                    • That’s a great answer Tod, but let’s narrow the focus a bit to the objective or subjective perception of resources specifically, ie, thinking about the political motivations as opposed to the political consequences.

                      I gather that, when put directly, you agree with or have no particular beef against the proposition that there are less resources available to us for government funding for this or that?

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                    • Not necessarily. One of the things I discovered in the Inequality Symposium, for example, is that after taxes the aggregated corporate profits are at record highs this year:

                      https://ordinary-times.com/blog/2012/06/the-leagues-inequality-symposium-starts-tomorrow/

                      So is there less? I’m not so sure.

                      However, I think the question of whether or not we should be looking to curb expenses is an unqualified “yes” regardless of that answer.

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                    • It is very true that corporate profits are high, which has relevance for many things but not necessarily this. And actually that relates to a huge comment I might write but for the moment lack the motivation for.

                      So for now let me repeat a narrower point that has some salience. We need to be able to think clearly and creatively about our resources. A resource is something that we have operational control of. If we don’t have operational control of something it’s not a resource. We don’t have operational control of corporate profits therefore they are not a resource for us.

                      Therefore, supposing that we (you and I, acting with fiat authority over the polity) raise corporate taxes rates and generate increased revenues, the new revenue is not a resource for us but the consequence of exercising a more fundamental resource, in this case the real or imagined fiat we have over the American polity.

                      Of course, there are limits to how much fiat authority we can pretend to exercise over the American polity or the American political class. And more importantly, there are limits to what either one of them controls outside the political process.

                      Given this, let me restate my question slightly. If, hypothetically, you believe that it’s feasible to continue the path of expenditures implied by American welfare state for the last twenty years + PPACA, what resources do we have that would be sufficient for this and how would they be deployed?

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                    • Oh, I don’t think there’s any question that we need to cut expenditures. I don’t think of money as being endless, and I think our habit these past 10 years of borrowing so we could pretend that wars and social programs were free was a terrible idea.

                      I believe HCR is needed, and not just for the poor – for our entire economy. I don’t trust the Republicans to do it, however, because of the current Grover Nordquist style of governing that’s in vogue with them these days. I’m not thrilled with Obamacare, and as I’ve said it’s going to have a lot of hiccups (and that’s a best case scenario) but it’s at least a first step, which is more than we’ve had for the past 50 years we’ve been saying it needs to be addressed.

                      Our other big spending items need big reform as well: military, SS, Medicare. I see no reason for someone like me, for example, to get SS benefits. I see no good reason for us to continue wars everywhere; they’re expensive and they’re counter productive. To quote Sorkin, we spend more on the military than that the next 26 countries combined, and 25 of those are allies.

                      So you have no need to convince me that we need to radically adjust the budget. WHere you and I part was, I think, is on these fronts:

                      1. You have a confidence that the GOP, if given the reigns, will work to cut government power, executive power, spending and the deficit. I have no confidence in this in that since I have been of voting age, every federal GOP campaign has run on these things but done the opposite when in power.

                      2. You think that government necessarily makes things worse. I do not. I am for safety nets, and while I like privatizing in certain areas I do not see them as being the low-cost high-efficiency panacea that I suspect that you do.

                      3. I’d like to move to a mindset where we cut government spending in boom times, and increase it in lean times. When unemployment is low and wages are up, we don’t need to ramp up safety nets. When budgets are so tight, we do. Sorry rich guys and corps, sometimes you just have to suck it up if you want to be part of the team. It may not be fair, but that’s life in the big city.

                      But I have no desire to continue spending the way we have over the past 10 years.

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                    • 3. I’d like to move to a mindset where we cut government spending in boom times, and increase it in lean times. When unemployment is low and wages are up, we don’t need to ramp up safety nets. When budgets are so tight, we do. Sorry rich guys and corps, sometimes you just have to suck it up if you want to be part of the team. It may not be fair, but that’s life in the big city.

                      FWIW, that’s the precise Keynesian prescription. We almost did it once, too. Except we elected GWB who declared that a surplus meant the government was taking too much of your money. I expect the surplus would have evaporated in any case with the dot-com implosion and then 9-11, but not as much or as fast.

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                    • I think you’re taking my comment in a slightly different spirit than what was intended. You responded with an expression of several preferences. And even if I don’t agree with them, your preferences are eminently reasonable given what you take to be the premises.

                      But for now at least, I’m not asking you to agree with me, I’m asking something different (and to be fair, considerably more difficult imo). That is, I’m asking you to explain why you think your preferences are plausible in the real world, or at least to describe the extent of your belief that they are. Or to put it another way, if you prefer A to B, I’m not asking you to switch to B if I happen to prefer B, I’m asking you to explain why it’s in your individual or collective power to choose either A or B.

                      So, given this context and allowing for a reasonable amount of fiat control over the American polity, do you think that it’s plausible that the path of the American welfare state for the last 25 years or so + PPACA can be funded indefinitely?

                      If the answer is yes, what resources would be sufficient for this and how would they be deployed?

                      If the answer to the first question is yes, can you imagine that other reasonable people might look at our situation and think the answer is no?

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                    • That’s a great answer. In fact it’s one that I might even agree with.

                      So, given the premise that indefinite continued funding for the previous welfare state + PPACA is barely in the realm of possibility it certainly shouldn’t be any surprise that I and substantial number of other Americans don’t believe that it’s plausible either.

                      So given this, I think we should eliminate PPACA and attrit the welfare state until such point as we view the path of expenditures to be at least plausible. Now, let’s say you disagree with this which is probably reasonable since it is substantially at odds with your prior comment.

                      Assuming that’s right, what resources would you deploy to fund prior welfare state + PPACA and how would you use them?

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                    • Well, see, this is where we part ways and talk past one another. I don’t see HRC as something that increases costs; I see it as a necessary thing to stop exponential cost growth. For me it’s not a question of, how would we afford whatever version of universal health care we might end up with, but rather how are we going to afford not having it?

                      Almost every idea that I have seen that is not universally expansive makes things worse for us, as a nation, financially. (e.g.: Get more carriers, because the more carriers we have the more competition will drive down prices.)

                      So I don’t see it the way you do.

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                    • RTod, you have a much more abstract perception of Hillary Rodham Clinton than I do… :)

                      More seriously, universal health care can be cheaper or it can be more expensive. The same is true of a patchwork system. As great of systems as I can devise, I have trouble imagining that a non-universal system that we implement will actually result in cost savings.

                      I hope that PPACA, or whatever comes after it, proves me wrong.

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                    • But will, in other countries that have a universal model, there is no exponential growth. A lot of this has to do with mandatory cost controls, to be sure, and those are not always popular. But cost growth is steady.

                      I am not understanding how you can look at the health insurance now as a way to curb costs?

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                    • Ok well over the 10-year CBO time horizon, PPACA is estimated to cost a huge amount of money, ie, over $1 Trillion for that period alone. Do you disagree with that finding or should we be looking at a different context instead?

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                    • Tod,

                      One of the big reasons that our current system has such large growth is because we have refused to implement cost-containment mechanisms. Our government side lends no more reason for optimism than our private side. Payouts are lower (generally speaking) but spending is nonetheless enormous. Maybe we could better contain that if we didn’t have the private sector to compete with, but I’m not optimistic on that score.

                      There are ways to contain costs on each side of the equation, but the biggest obstacle we have is culture. There are places with a productive culture where costs aren’t so severe (I believe El Paso is one of these places) and there are other places that are driving it through the roof. The big difference? Culture. Kaiser Permamente has a model that works, but we refuse to accept their model because (among other things) we want to pick our own doctor. We complain about medical costs, but we will pay more to pick our own doctor. Culture.

                      I see no obvious reason to believe that if we were under a universal-system umbrella that these things would change. We often cite fee-for-service as one of the great causes of our spending woes. Yet what do they have in Canada? Fee-for-service. It works in their culture, I don’t see it working in ours. The goal might be Canada, but the result McAllen.

                      (For the same reasons that Canada has a system that wouldn’t work as well here, I think they could actually make a patchwork system work.)

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                    • Ok, let me briefly summarize a couple points here that are worth mentioning, because for the most part they are not dwelled on but are in important part of the context of why the Right and the Left don’t understand each other or talk past each other.

                      First, the “preference” for preferences is secondary. We can’t make cut a deal or make intelligent choices about what we want to do until we figure out what we can do. This is imo a substantial cause of miscommunication between the Right and the Left.

                      It’s fair to say, I think, that Tod believes his policy path is plausible but has probably heretofore given relatively little thought to the subject. And he has not explained what resources are required to implement this policy path and how they will be used.

                      And, in PPACA his first major policy move will spend well over $1 Trillion over the next ten years according to the CBO.

                      Therefore at the very least there is strong prima facie case that the libs’ preferred policy path is not sustainable.

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                    • “It’s fair to say, I think, that Tod believes his policy path is plausible but has probably heretofore given relatively little thought to the subject. “

                      Actually, I think about it quite a bit – often for money. Creating large group health plans is one of the thing my firm does; in fact, it makes up almost 20% of our (and my) revenue. Any move toward universal care will negatively impact our financial position, to one degree or another depending upon what path we as a nation take. So I strongly suspect that I think about it more often than most people, and that I approach it from far less of an R v. D basis than most.

                      I’m not sure which part of the program you are talking about, nor am I sure where you are getting you facts. But I believe that the $1 trillion over 10 years is the cost of administering the program. If so, this number is most likely overly optimistic. Most independent figures that I have seen believe it will be up to 50% greater. But this cost does not occur in a vacuum; it is a cost you are already occurring. So lets take those numbers and say that a more likely number is $1.5 trillion. Plus, let’s assume that 60% of the country are going through independent carriers that add their own admin costs, which (lets round up to be conservative) adds another half a trillion over 10 years. The cost of admin and regulatory over site are now $2 trillion over a 10 year period.

                      Because of Incurred but Not Reported claims dollars the last year we have reliable drill-down statistics for national HC is 2010, where the cost of HC nationally was more than $2.6 trillion. If the trend over the past 50+ years continues, that amount will be $5.2 trillion in 2022.

                      Insurance admin costs are about 3% of healthcare expenditures in our country, state regulatory costs and taxes are also about 3%, and federal are about $2.5%. That’s about 8.5% of expenditures that that $1 trillion will look to replace. Let’s assume that we repeal PPACA tomorrow; further, let’s assume that over the next ten years costs remain stable – they do’t grow at all. (Why this might occur without government intervention I cannot begin to guess, but let’s pretend anyway.) That’s $221 billion a year on admin and regulatory costs, or $2.2 trillion over a ten year period. And that’s if costs don’t grow the way we’re expected to, in the way they have for 2 generations.

                      So when you say $1 trillion over a ten year period it doesn’t really shock me so much, because I don’t have the illusion we would be saving that money if we were to scrap any kind of universal coverage plan.

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                    • http://www.cbo.gov/publication/43076 and following, referring to the basic structure of PPACA: subsidies, exchanges, mandates, community rating, etc.

                      Clearly, in the absence of PPACA this cost would be not be borne by the federal government. I gather Tod thinks it would be paid in private sector somewhere, either from individuals, insurance policyholders, or employers. I think it’s a plausible but dubious argument.

                      But in any event it’s not relevant because it’s a dodge around the question of resources. Why do we think the government has the resources to fund this policy path? There’s a very good prima facie case to think we can’t. The private sector will fund it’s health care expeditures out of it’s resources, which is a different issue. And on that note, let’s note that while there are still problems there, private sector finance has gotten much stronger since the advent of the recession.

                      So, from the point of view of describing a path of public sector finance, specifically the US federal government, let’s avoid sloppy uses of “we” and “you” and describe with as much clarity as we can what it can plausibly fund going forward.

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                    • But I reject this framework; it’s uninformed. Neither the government or the private sector have “resources” they are dipping into.

                      Individuals or employers are paying premiums to one or the other. (Or, perhaps, people are paying taxes in lieu of premium.) Whether there is a single payer or multiple payers does not change this. Neither the government nor an unregulated insurance company is set up to dip into resources – each are pass-through systems.

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                    • Tod, I don’t think they will choose it independently. I don’t think they will choose it collectively, either (ie via our elected representatives). What’s required is an attitude shift (informed by unfortunate realities of unsustainability) that is far more important than “national plan” versus “patchwork.”

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                    • “Neither the government or the private sector have “resources” they are dipping into.
                      …..
                      Neither the government nor an unregulated insurance company is set up to dip into resources – each are pass-through systems.”

                      How? It seems to me there’s a very concrete way that can’t possibly be true. CBO has estimated that PPACA will cost the federal government over $1 Trillion dollars over the next ten years. That’s after the premiums and taxes.

                      We know this is more complicated and worse than a pass-through system because if that’s all it was nobody would care.

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                    • Also, I meant to mention that the cost of PPACA is partially offset by taxes, but a fair number of them have nothing to do with health care and even the ones that do have a tangential relationship at best to the services they are supposed to fund.

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  15. Arguing that conservative opposition to UHC is hypocritical because they don’t hate Medicare as much is like arguing that environmentalist opposition to petroleum-burning vehicles is hypocritical because they don’t hate trains as much.

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  16. ““I can easily see myself being old, but I can’t see myself being poor. So I’m going to lobby for the one I think will pay off for me personally, and lobby against the one I think will pay off for someone else.””

    I think this isn’t getting enough play (at least from the comments I read… about half).

    People’s ability to identify with others and/or their situation is HUGE. No, I’m going Mike Francesa … it’s HA-YUGE! As Stewart pointed out in that Rubio interview… Rubio’s proximity to immigration gave him a more nuanced understanding and perspective on it, just as Cheney’s proximity to LGBTQ folks gave him a more nuanced understanding and perspective on it. The ability to “otherize” a group of people is incredibly powerful. It’s the same reason, for some people, an American’s dog being shot by the cops generates more outrage than civilians being killed half a world away with a drone strike. It’s why 3000+ dead American soldiers is a bigger tragedy than tens of thousands of dead foreign civilians. It’s why my wife having a really shitty day at work resonates with me more deeply than a news report of a stranger being raped.

    Is it logical if we simply evaluate the varying responses? No, not really. But is it understandable given what we know about how folks intellectual responses are often dictated by their emotional responses, which in turn are highly predicated on their proximity and familiarity with an individual or an issue?

    This doesn’t explain all of it, as I think there are some far more insidious things going on for at least some of the folks you are wondering about. But I think there is a very real aspect of human nature that you acknowledged but seemed to “pooh pooh” and wrongly so.

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  17. Kazzy wrote:

    People’s ability to identify with others and/or their situation is HUGE. No, I’m going Mike Francesa … it’s HA-YUGE! As Stewart pointed out in that Rubio interview… Rubio’s proximity to immigration gave him a more nuanced understanding and perspective on it, just as Cheney’s proximity to LGBTQ folks gave him a more nuanced understanding and perspective on it.

    Spot on.

    To my mind, this outlines what is perhaps the fundamental difference between Conservatives (including Libertarians?) and Liberals.

    Cons find it difficult to imagine the need for–or they even rail against–public policy that reaches beyond their own limited realm of experience. (Cue all manner of “you lazy assholes/you ignorant poor/you sinners/find-your-f**king-bootstraps-already” rationalizations.)

    Libs, otoh, take a more egalitarian view regardless of their own experiential purview. (There is psycho-neurological research to support this, but no surprise to anyone that it’s all still a mite controversial. Such is always the fate of cutting-edge science.)

    An easy example of this political paradigm is the issue of SSM, but an equally easy example is, perhaps, UHC/MFA.

    I don’t see any reason to make the UHC/Medicare contradiction that exists within the greater GOP any more complicated than necessary, and I’d say that Kazzy has absolutely hit the nail on the proverbial head.

    To my mind, the more important question is this: why are there Dems who are so afraid of UHC/MFA? (C’mon. If we were all mostly on board with this policy concept, we would have had a much stronger, perhaps very different-looking, PPACA.)

    I think the answer to that lies within the way murkier waters of Dems than it does within the GOP.

    The fact is, the vast majority of Dems, like most Americans, possess relatively comprehensive health insurance. (PPACA has already kicked in some critical benies and so private insurance, for the bulk of us, has gotten better not worse.) As a collective, these already-insured Dems may indeed feel a conviction that all Americans should have a similar ease of access to health care regardless of income or employment status, but fear of the unknown keeps some number of them–enough of them to make a difference on The Hill–from getting on board with UHC.

    NIMBY, basically.

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