2017 Politics open thread, March 12-18

This is where we discuss politics.

Purple America Has All But Disappeared

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146 thoughts on “2017 Politics open thread, March 12-18

  1. 1992? That had H. Ross Perot in the race so I’m not sure if the trend is all that solid.

  2. Do you know how to read a graph? Even if you drop 92, it’s a very strong trend.

  3. If a non-Perot ’92 broke the trend then it would weaken the claim and ’16 could be an anomaly. Exclude ’92 and ’16 and you have a weaker trend.

    Scarlett might object, but how much of the ’04 and ’08 jump in +50 points, in primarily older and whiter rural counties, is the result of older white voters being uncomfortable with a black president?

  4. And there is the wisdom of drawing inferences from treating Harris County (pop. 4,538.028) and Loving County (pop. 86) as the same thing.

  5. Rhett, treating the population of the counties as roughly constant over time seems reasonable to me, although I agree that urban counties typically gained population and rural counties typically lost population from 1992 to 2016. You’re talking about the “share of voters” on the Y axis, and that is independent of the population of the county.

    In the NY Times “by county” map, Clinton had the widest margins in Los Angeles, the Bay Area, Seattle, NYC, D. C. and Boston, along with rural counties in Mississippi, Alabama, New Mexico and South Dakota that have low populations.

    Can you explain your concern again?

    http://www.nytimes.com/elections/results/president

  6. Rhett, treating the population of the counties as roughly constant over time seems reasonable

    They aren’t treating them the same over time they are treating them as the same in terms of population. In that chart Harris and Loving counties both counted equally.

  7. Oops, I misread the chart. I thought they were counting counties not weighted by population but they are weighted by population.

  8. So Trump promised to cover everyone and not cut Medicaid, but I guess the temptation of a nice fat tax break for himself and his wealthy buddies proved too much…

  9. Trump and his administration are liars. They lie about everything. No one is getting better insurance. The coal jobs aren’t coming back. Rich people are getting tax breaks. Trump, Conway, Spicer, Flynn, and the rest of the bunch are truly the worst of the worst. They make George W. Bush look like a kind hearted saint. The American public did this so there is no one to blame but ourselves.

  10. “there is no one to blame but ourselves”

    We never should have nominated Clinton. That was a mistake.

  11. I have been thinking about the ACA repeal legislation a lot over the past week, including my usual refrain than no one has yet to provide me with a good economic reason why health insurance should be tied to working for a company/government/non-profit that provides it. In all of the current discussion, still no one has.

    So I now conclude: we do not have universal health care as a basic tenet of our country/society because of racism. There is no cogent economic argument that can be applied other than “if we create a ‘Medicare-for-all’ system, it’ll mean we have to raise my taxes/cut into my wealth and that’s bad.”

    The rich & powerful, the ones who make the laws/rules (generally white, clearly there are some exceptions) are not interested in a benevolent system that benefits “people who are different than we are.”

    I said this to my best friend the other night (work as an upper level cop out west, and is a lawyer with poli sci undergrad) and after thinking about it he agreed. This was after he had already made the point that our tax rates are too low, and especially that the FICA tax should apply to all earned income, not be capped at $127k, or whatever it is this year.

  12. “reason why health insurance should be tied to working for a company/government/non-profit that provides it. ”

    I believe it’s historical, starting during a time of wage and price controls. Employers restricted from using higher wages offered health benefits as a means to attract/retain employees.

  13. Finn – yes that’s exactly why. I’m well aware. So before then, and I really don’t know this, only those who could afford insurance bought it privately? Or maybe there really was not health insurance…only those who could afford to pay the doctor, often by barter, went to the doctor?

    In any case I know how it has ended up with many people having health insurance from their employers and also how we have, societally, to take care of our elderly (Medicare) and poor/disabled (Medicaid). What I’m missing is why should someone need to be employed by certain entities or be >65 or be poor to get reasonably priced/free insurance? Why can’t we just have ‘medicare for all’ with a basic level of care a la the French? If you want a better plan you can buy it on the open market if you choose.

  14. @Fred – I am with you. I also think that companies could still add on a “premier” care level as a recruiting tool or a benefit for senior employees. Some already do now. It just doesn’t make sense that it is so tied to employment.

  15. Ah, the history of health insurance. This is something I actually have had to teach in a class. Back before the Depression, there was no such thing, in part because physicians had so little to offer, and were so low paid, that it didn’t much matter.
    The first health insurance plans appeared in the 20’s, sponsored by hospitals or teacher associations. These evolved into a system of nonprofit insurance called Blue Cross, not dissimilar from the nonprofit insurance plans used in Germany today, and they became very important in our system too.
    Medical associations of the time were opposed to insurance but started accepting and ecouraging it in the 30’s because otherwise they would have no patients. But the AMA fiercely opposed a Roosevelt plan to provide government insurance.
    In the 40’s, employer based insurance started because, as was noted, of wage controls. But it took off in the 50’s – and part of the driver was that with antibiotics, better surgical procedures, and other treatments, medicine finally was offering something that people really wanted badly. And medical prices were rising, fast. So the only way to afford this new, valuable healthcare was to be insured. Coverage skyrockted in that era.
    Medicare and Medicaid of course came about in the 60’s. In the 70’s, there was increasingly concern about costs. A number of cost control measures were tried via Medicare reimbursement setups, but they never did much. These were called Diagnostic Related Groups (DRGs) and were supposed to set a price per diagnosis, breaking the fee for service model.
    In the 80’s, people were getting more and more concerned about costs and insurance issues, and the first HMO’s appeared. There was also a lot of talk in Democratic circles about the need for single payer. In the 90’s, costs and lack of insurance became a crisis that went to the national forefront, and we saw the Clinton attempt at drastic reform. That of course failed, but a number of other reforms did come from that era – HIPAA, which prevented employer based insurance from discriminating against pre existing conditions if you could produce a certificate of continuous coverage, SCHIP to cover children, and a dramatic rise in managed care insurance, to the point where almost no one had the old style insurance, which mainly paid catastrophic costs, any more. That didn’t work to contain costs or reduce the uninsured either, so the whole thing bubbled back up again in the mid 2000’s, which led to the ACA.

  16. What I’m missing is why should someone need to be employed by certain entities or be >65 or be poor to get reasonably priced/free insurance?

    I don’t know that anyone gets reasonably priced/free insurance. Some people get health insurance as part of their overall compensation. It is not free, reasonably priced is subject to opinion, the cost is hidden, but it isn’t free. It is a benefit that is not subject to income tax, but it is not free.

  17. Fred, the French do not have Medicare for all. They use a mixed government/employer model of health insurance

  18. It is a fake fact prevalent on the left, that other countries all have single payer. Not true at all. Most countries do not have single payer. However, most countries with functional healthcare systems do regulate costs and insurance much more heavily than we do.

  19. @Pseudo – Yes, the value of our health insurance is definitely not free even though we pay very little. The thing that I worry about in dismantling the employer model is that they will just cut our compensation & throw us to the wolves. If they added the cost to my salary & there was a reasonable private market – fine. Doesn’t seem like either is likely right now.

  20. A friend who works for a union (but is not a member of the union) gets her insurance with virtually no out of pocket cost. It’s Kaiser so choices are limited, but when she retires she will keep that insurance at zero cost. The retired coal miners (who aren’t dead from black lung) have the same deal. I don’t know how such insurance coverage works with Medicare, but not every retired miner lives long enough to qualify.

  21. Scarlett, not true that retired coal miners get benefits. The reason is that there are not a lot of union mines left. I know there are none left in KY. The plight of coal miners that have lost their jobs is terrible.

  22. And even the retired mine workers who retired with union benefits no longer get them from the union. That is because the United Mine Workers could no longer afford the heathcare benefits, so the responsibility was dumped on the govenment.

  23. If Congress would pass the Miners Protection Act, the former workers would be ok. As it stands, they are pretty screwed. But not to worry. Ryan is going to give everyone access to insurance. Like they all have access to buy a yacht.

  24. @Scarlett – DH’s government job currently has a retiree health plan where the split of the cost is 50/50 for retirees/employer. This is a much higher percentage than active employees pay of their HC cost. Once they and/or dependents are Medicare eligible, the cost to both employee and former employer goes down as the plan becomes supplemental to Medicare.

    None of this is guaranteed for life though – just plan year to plan year.

  25. I believe the Miners Protection Act only applies to the miners who were supposed to get benefits through the UMW?

  26. MM, I think that the UMW Funds are still picking up the costs of both pensions and health benefits for retired miners.

  27. I think the Republican health care plan is going nowhere. Not only are many conservative Republicans against it, but now it seems there is growing opposition within Trump’s camp. And for good reason – it really goes against his “brand”. But this exposes the very deep fissures in the Republican party. If they can’t come up with something that makes both Freedom Caucus members and Trumps voters happy – and I cannot imagine that such a plan could exist – then what happens? This is going to come up again and again on a number of issues.
    https://www.washingtonpost.com/politics/trump-loyalists-sound-alarm-over-ryancare-endangering-health-bill/2017/03/14/cfc187e6-08dc-11e7-93dc-00f9bdd74ed1_story.html?hpid=hp_hp-top-table-main_trumpryan-0748pm%3Ahomepage%2Fstory&utm_term=.71242665695f

  28. Hi Everyone! The healthcare stuff has been fun to watch! After so man years of complaining, I suspect the Republicans won’t get much done and we will keep Obamacare. Too hard to take something away from people and there is no magical plan that will cost less and cover more. And they are all very cognizant that they get full blame for whatever happens next. Perhaps they should rethink all of the gerrymandering so that they have some Democrats to blame!

  29. The reason that there was such strong opposition to the Federal version of Massachusetts/Romney health care that was enacted soon after Obama was elected is simple. Once you pass a benefit program, it is very difficult to end it. Left wingers realized this and did not die on the cross of single payer, because they figured that this somewhat unworkable system would eventually be replaced by some version of Medicare for all.

    The Ryan bill, which is dead in the water, ends mandates, rolls back Medicaid expansion, eliminates the surtax on the wealthy, and offers a certain kind of choice. The trade off for mandates is that anyone who wants to buy in with no pre-existing coverage limitation will have to prove (bandwidth, recordkeeping, continuous income issues abound here) that he/she has no break in coverage longer than 2 mos ever, and if not pay the insurance companies, not the govt a hefty surcharge. As I have posted before, I had an inadvertent break of three months. I would have failed that test. The good part of the choice is that bare bones catastrophic plans will be offered – attractive to young or very healthy people. The bad part of the choice is that the cost to over 50s will become prohibitive even with tax credits, so most of them will go without insurance unless they can get it through an employer. Remember, a lot of those over 50s include younger spouses of Medicare beneficiaries who are below Medicare age. And unless the medical billing model changes, cash payers will have to negotiate with every single doctor or hospital for the cash rate, since even more people won’t be using the insurance gatekeeper to establish the 40-60% of list that is actually received by the provider.

  30. govt a hefty surcharge

    30% extra for 12 months is hardly hefty considering no one is going to do it unless their expected bills are higher than the total cost.

  31. As for the catastrophic plans how does that solve the adverse selection problem? According to the law, you can buy the cheap catastrophic plan and then if you get diagnoses with something chronic and expensive you can just switch to a Cadillac plan. We won’t even get into the adverse selection implications of only having a 30% for 12 months surcharge.

  32. One of my first thoughts on Trumpcare (or Ryancare if Trump is going to disavow support) – doesn’t seem politically smart to propose a plan that costs people of all incomes aged 50-65 more money, and in some cases significantly more money. I saw last night on Twitter that a Republican Congresswoman from South Florida is not supporting the bill for this very reason. Who goes after that demographic? Who riles up AARP? Those people vote, and they vote Republican more than anything.

    I also agree – it is really hard to take things from people. Remember the debacle with Social Security privatization? This has shades of that.

  33. Meme, why do you say “unworkable”? Many countries use a version of Obamacare with great success. The key is a stricter mandate and stronger regulations on the insurance plans. Contrary to what a lot of leftwing people think, single payer is not the most common way of handling healthcare in other countries

  34. Rhett – I can’t access the text of the bill right now, but the reporting is, as usual, sketchy on this. Some reports say 30% forever, 2 months whenever. Some other reporting says 2 mos without coverage in the last 12 mos, and a surcharge for only 12 months. If the latter is true, then it is not hard to re-establish base cost coverage by paying a finite penalty for those who just have a gap because of job loss or divorce or carelessness. I assumed it was like the Medicare surcharge – if you don’t sign up on time, there is an increasing each year you delay surcharge when you do sign up. However, the catastrophic plans are designed to take care of catastrophes and not doctor visits, and to provide a less expensive form of pure insurance coverage rather than insurance plus prepaid health care. If you have an acute problem, your out of pocket is limited. If chronic, you would be dropped in the old private market or hit the lifetime cap very soon.

  35. “30% extra for 12 months is hardly hefty considering no one is going to do it unless their expected bills are higher than the total cost.”

    Which is why that 30% charge will quickly morph to a 150% charge, or else premiums for everyone will skyrocket.

  36. Rhett – back in the bad old days, you couldn’t switch from catastrophic to Cadillac if you were buying things on the open market. Isn’t guaranteed issue going away (under Trump)?

    My mother bought insurance on the open market in the 10 years leading up to medicare eligibility. She paid about $600/month, for a plan with a 10k deductible – no coverage of mammography, routine health visits, nothing until she hit the 10k. She would have liked to have had a better plan, but she couldn’t switch – she was uninsurable because of an early (and fully treated) breast cancer. She was probably 75%ile for health for her age, but too risky to insure. She would have bought into the state high risk pool, but you had to be uninsured for 12 months to apply, and she was unwilling to let her coverage lapse.

  37. Mooshi – Unworkable is perhaps the wrong word, and too strong. Cumbersome bridge to a more universal system, crippled by states that refused medicaid expansion, inability of the private sector to make enough money at it to step in and provide choices, no bare bones affordable options for 20 somethings, executive orders that backfired, and with many unintended losers along the way is probably better. States like Kentucky that were able to rebrand the program to allow the people who need it to participate without making them feel “poor” or complicit with socialism are the true successes. California did a great job. No bare bones policies for 20 year olds is another.

  38. Ada, I think about questions like “most common” on a population basis, so Germany and Japan count heavier than Brunei and Bahrain.

    I agree completely with Meme’s post about the advantages and disadvantages of the Affordable Care Act. The real question is how much we’re willing to pay and how, a question not well answered by the current iteration, which has “temporary” subsidies and, in my state, a nightmarish exchange based on unrealistic assumptions.

  39. It looks like half are single payer, but the countries that are two tier like France or insurance mandate like Germany make up some of the countries we often compare ourselves with. France has a system that is so arcane that it boggles the mind – only French people could come up with something that bureaucratic – but everyone I know who has been in that system says it works very well, and I know they are considered to be one of the best countries to get cancer treatment in.

  40. This is a long but excellent article (and really, healthcare is so complex that it deserves long articles). My favorite lesson
    “When economists in Washington say they want to control health care costs, they mean something like this: People should buy less health care, or cheaper health care, so that total spending on health care falls.
    When voters say they want to control health care costs, they mean something like this: Someone else should pay for my health care so I can purchase what I need without much financial strain.”

    And this is the central problem
    http://www.vox.com/policy-and-politics/2017/3/15/14908524/obamacare-lessons-ahca-gop

  41. Another great quote
    “Perhaps the more fundamental issue is that both Democrats and Republicans are committed to controlling costs by making insurance harder to use and health care expenses more transparent for patients. That’s not how other countries with lower health care costs find their savings.
    “If you think about how much other countries spend, there’s basically no correlation between their spending and out-of-pocket costs,” says Hacker, the Yale political scientist who has done extensive work on health care politics. “What drives it is the strength of government bargaining power. But that’s not accepted even among liberal health policy experts in the US.” “

  42. Mooshi, I agree with your first nutshell.

    But on top of that, I think CoC hit the nail on the head with her comments about people not prioritizing healthcare in their spending priorities. I guess that’s related to the second part of your quote, but CoC was direct and succinct in making her point.

  43. It is a problem both individually and nationally. It is the reason that 20 somethings, even those making reasonable pay, won’t budget for health insurance. But it is also the reason people don’t want to pay taxes for a reasonable healthcare system. I guess that is a problem with people in general – we want lots of stuff, cheap :-)

    It also appears in the widespread viewpoint that you should only have to buy a health plan tailored to the health expenses you currently have. I listened to a show on NPR yesterday in which a 29 year old guy complained about having to buy a policy that covered too much. He said, listen, why should I have to pay for a policy that covers so many services when I am really healthy and never go to the doctor? Um, maybe because as a 29 year old male, you are still in a high risk group for catastrophic accidents, and the rest of us shouldn’t have to pay for your hospitalization costs because you bought a policy with very high deductibles and then went bankerupt. Or because at age 29 you are still in a group that may develop serious mental illness (schizophrenia tends to appear in the 20’s) and will end up needing mental health treatment. Or because at age 29, you are moving into the age category where you may develop real back trouble or type 2 diabetes or MS -chronic, high cost illnesses. The point of having insurance plans be comprehensive is that you don’t know what your needs are going to be. That is why it is insurance and not a prepaid healthcare card.

  44. That is why it is insurance and not a prepaid healthcare card.

    This is a huge point. We’ve gotten so far away from the concept of health insurance. Most people don’t complain about homeowners insurance being expensive, even though it’s likely they will never file a claim. Most people have accepted the auto insurance mandate (I know it’s not the same because nobody has to buy a car but everyone has to live). But people think health insurance should just be paying for what you use, and people don’t think of the possibility of what could happen, even to healthy people in their 20s.

  45. DD, ITA.

    One reason I like high deductible plans is they make the difference between health insurance and a healthcare plan a bit clearer.

    Another is that they, potentially, can actually reduce healthcare costs by eliminating a lot of claims processing. It is possible, for example, for people who don’t hit their deductibles to never have to file claims. And that does not seem antithetical to Mooshi’s 6:16.

  46. In addition to people being unwilling to pay for health insurance, many people have existing budgets that don’t include health insurance. My ex-SIL is uninsured in part because she can’t afford a policy but has to pay for half of private school expenses under her first divorce decree, and that decree is hard to change. She and BIL also bought lots of stuff on credit over time, so her divorce decree obligations aren’t her only financial challenge, but people’s financial commitments (high housing costs are another one) don’t change because their medical insurance goes away.

  47. “In addition to people being unwilling to pay for health insurance, many people have existing budgets that don’t include health insurance. ”

    Isn’t not budgeting for it an indication that it’s a very low priority?

    “but people’s financial commitments (high housing costs are another one) don’t change because their medical insurance goes away.”

    While they won’t just go away on their own, many people are not totally locked into financial commitments like high housing costs. People can downsize their homes or make commuting tradeoffs to lower those costs.

  48. WCE, I’m not saying that DD’s comment applies to everyone but there is a large group of people who can afford it but don’t want to. I have friends in both camps.

  49. “there is a large group of people who can afford it but don’t want to.”

    I have no sympathy for these people. If their own health is not important enough to spend money on that they can afford, they certainly don’t deserve having anybody else’s money spent on their health.

  50. Isn’t not budgeting for it an indication that it’s a very low priority?

    I think it’s often an indication of magical thinking.

  51. “I think it’s often an indication of magical thinking.”

    I wonder if those same people also don’t budget for other types of insurance.

  52. I concur with RMS that the people I know who lack health insurance engage in a lot of magical thinking. My political views are shaped by the fact that many/most of the people I know without health insurance don’t work as hard as I do and spend money in ways I choose not to.

    Until the penalty for not having insurance is as expensive as the health insurance, many people will prefer the penalty.

  53. “Until the penalty for not having insurance is as expensive as the health insurance, many people will prefer the penalty.”

    No health care? Bankruptcy if an expensive health issue arises?

  54. Finn, I don’t know the answer, but the idea that the working/middle class (i.e. my relatives and me) can continue to subsidize healthcare and education for the poor via taxes while paying high global rates for our own healthcare/education (because tuition and medical bills also have subsidies for the poor built in) is unsustainable.

    If government is responsible for providing healthcare/childcare/secondary education, I can reluctantly support the Scandinavian ideal of “everyone works, everyone pays taxes”. But that model isn’t holding up well to immigration in Scandinavia., and our society would have be to be less individualistic to get widespread buy-in here.

    And maybe I’m just annoyed that my SIL has/had the nice camper, the nice boats and the private school for their kids but aren’t willing/able to pay for health insurance.

  55. “And maybe I’m just annoyed that my SIL has/had the nice camper, the nice boats and the private school for their kids but aren’t willing/able to pay for health insurance.”

    Her kids’ private school lets them in without health insurance?

    She may be in for a rude awakening if her kids go to college.

  56. “the Scandinavian ideal of “everyone works, everyone pays taxes”. ”

    How do they deal with those who act on their preference for leisure? Or does that just not happen there?

  57. “I wonder if those same people also don’t budget for other types of insurance.”

    You don’t have a choice if you have a mortgage, or want to register a vehicle (at least in my state). But you also aren’t forced to buy an auto insurance policy with comprehensive or collision coverage if you would prefer to self-insure. Nor are you required to buy flood insurance if you live on a desert mountaintop. So there is a precedent in the insurance world for people being able to choose the risks against which they want to insure.

    There is some merit to the complaints by young single men about being forced to purchase health insurance with maternity coverage, for example. But health insurance is no longer a true insurance product anyhow. Perhaps that train has left the station on a permanent basis.

  58. Finn, even in a high deductible plan it makes sense to file a claim as that way you pay your insurers negotiated rate which is much lower than the provider’s cash price.

    Also for large insurers most claims are auto adjudicated, so at least they wouldn’t realize much, if any savings, from a reduction in claims submissions from HDHP subscribers.

  59. Just to be clear, I’m talking about claims submissions directly initiated by the provider, not paper claims, Which are pretty rare these days.

  60. DD mentioned that he doesn’t need to file claims for in-network services under the deductible.

    I don’t see why in-network providers can’t just bill patients directly at negotiated rates.

  61. There is some merit to the complaints by young single men about being forced to purchase health insurance with maternity coverage

    BS!! A 29 year old male is MUCH more likely to directly contribute to the need for maternity care than I am at my age. Are you suggesting that women alone carry the full cost of conception through birth?!

  62. How do they deal with those who act on their preference for leisure? Or does that just not happen there?

    They kick ass and take names. The social workers in Scandinavia are fascist. No one likes to look at that aspect, but it’s there.

  63. He doesn’t need health insurance coverage for maternity care if he is not seeking to include his wife on his plan. Neither does a woman who has had a hysterectomy, for that matter. These are separate matters from the question whether the costs of pregnancy and childbirth should be borne by the parents or society in general.

  64. You don’t have a choice if you have a mortgage, or want to register a vehicle (at least in my state). But you also aren’t forced to buy an auto insurance policy with comprehensive or collision coverage if you would prefer to self-insure. Nor are you required to buy flood insurance if you live on a desert mountaintop. So there is a precedent in the insurance world for people being able to choose the risks against which they want to insure.

    The difference with health care is that if you get sick or injured and incur major costs for your treatment and care and don’t have health insurance to cover it and can’t afford to pay for it, society will end up paying the bills. If your car is totaled and you don’t have collision, you are on your own to deal with it.

    As long as we are unwilling to let people die because they choose not to get health insurance, the comparison to other forms of insurance is not valid.

  65. DD mentioned that he doesn’t need to file claims for in-network services under the deductible.
    I don’t see why in-network providers can’t just bill patients directly at negotiated rates.

    That’s exactly what they do. The provider submit the claim to the insurer, because they don’t know what’s covered until the claim is processed. The insurer responds that none of it is covered because we haven’t reached our deductible and tells the provider what the allowable charge is under the negotiated rate, then the provider bills us directly for the allowable charge.

  66. “They kick ass and take names. The social workers in Scandinavia are fascist. No one likes to look at that aspect, but it’s there.”

    If we could do that here, that would open up a whole other set of options.

  67. BITD I had a plan with something like a $300 deductible. Most years I didn’t hit the deductible, and didn’t file any claims. I’d just directly pay the providers, who didn’t file any claims for me either.

    I don’t see why this model couldn’t work. In-network providers may want to first verify my coverage, but after that, they could just bill me the negotiated rate directly until I hit my deductible, and I could pay on my way out. If the deductible is really high, there will be many subscriber-years where it’s not hit, and all their activity would require no filing or processing of claims.

    Most of our in-network providers know exactly what our plan covers, at least for routine visits and tests, and bill us our co-payments on the way out.

  68. The problem with allowing people to opt out of maternity coverage is that everyone will opt out unless they are actually planning to have a baby in the near future. Insurers know that, and will price maternity coverage accordingly, making it unaffordable for most people. That, combined with the inevitable occurrence of unplanned pregnancies in people who never sought the coverage in the first place, would result in more babies being born without prenatal care, possibly sick or disabled as a result.

  69. Does “society” really end up paying the bills for those who, for whatever reason, lack health insurance coverage for the care they end up receiving? I thought that we needed the ACA to prevent vulnerable people from going without medical care, not simply to have health insurance pick up costs that previously were absorbed by “society” in the form of uncompensated care.

  70. Some European countries use midwives for homebirth as a care option for normal pregnancies with statistically excellent outcomes. Much could be done to make maternity care less expensive.One of my friends delivered her baby in eastern Europe and epidurals are not standard of care there.

  71. Finn, you seem to be implying that people should be responsible for tracking their medical expenses and then letting the insurance company know somehow when they’ve reached their deductible. As we’ve discussed many times, lots of people don’t have the bandwidth to handle that. I sure don’t want to have to deal with that.

  72. Scarlett, my point is that if we are going to let people pick and choose what is covered in their health insurance similar to auto and other types of insurance, we need to be willing to let them accept the consequences of not covering specific conditions. For example, if the healthy 29 year old male doesn’t want to pay for heart attack coverage because he thinks he is at such a low risk he doesn’t need it, then we need to be willing to not treat him if he has a heart attack and can’t afford to pay the costs.

  73. Yes, we do pick up the costs for uncompensated care. And the ACA is meant to allow more people access to healthcare at entry points other than the ER. If you don’t have insurance, you don’t get the negotiated rate, so you end up paying hundreds of dollars more per visit and per test than someone going to a doctor who is in-network to their plan. Looking at a family member’s bills that came in for a fairly routine visit that required some blood work, the billed charges were over $700. So someone without insurance is going to wait until the problem can’t be ignored, and go to the ER. If I’m going to be stuck footing the bill, I prefer to pay for the cheapest method of service possible. And I am not opposed to people being forced to carry at least catastrophic coverage, so that when they end up in the ER with a bill they can’t afford, that at least a portion of it is covered by insurance.

  74. I agree that we don’t want people to suffer and perhaps die because they can’t pay for medical care. I’m not convinced that handing them a medical insurance card will overcome some of the other obstacles to decent medical care, such as poor executive functioning or limited education or magical thinking or whatever causes people not to take steps to seek out care when needed and to comply with medical advice.
    Also think that mandatory catastrophic coverage funded by withholding like FICA is a great idea, though perhaps it has drawbacks too.

  75. Finn, I guess the point I’m trying to make is there isn’t much benefit to the insurance company to go down the route you’re proposing. Major insurers want you to file claims so they can administer care management​ programs on behalf of plan sponsors ( that is, your employer) or anticipate what percent of folks are likely to hit their deductible. They also integrate claims data with a HSA if you have one so that once a claim is processed, it’s a matter of a couple clicks on their website to issue a check to the provider directly.

    Again, with vast majority of claims being automatically processed without human review, I don’t see a benefit to the insurers with your approach..I work for one.

  76. Providers can’t just bill you for the negotiated rate because their billing systems don’t work that way. They don’t track the negotiated rates in their systems. Instead, they submit a claim for the amount in their chargemaster (list of their official rates) and then the payer sends back an electronic response with the negotiated rate or kicks it back with various error codes.

  77. Scarlett, I worked in health IT in pre-ACA days, and one of our major clients was a large NYC hospital that had a huge population of uninsured patients. The way it works is that if someone comes in through the ER, the hospital has to provide treatment that is immediately lifesaving and stabilize the patient. In addition, there were charity programs so that cancer patients could get standard chemo (no fancy new treatments though) and various other serious illnesses could get treated. How was this paid for? Basically, in two ways – there was a federal fund that paid for some amount of uncompensated care, which is of course taxpayer money. And in addition, the hospital set its standard rates high enough to help cover uncompensated care. Of course, not many people actually paid those standard rates, but the need to cover uncompensated care also affects the negotiated rates and makes those higher too. And of course that raises premiums. That was part of the reason why premiums were rising so fast in the early 00’s.
    And sad thing was that this system didn’t give uninsured people particularly good care, because the things that would help them maintain health – access to preventive care, access to outpatient care for lesser problems – were not accessible to them. They had to wait until they were quite sick, and then go through the hospital to get care.

  78. And if you have a deductible you must go through the process. You can’t just send in your receipts when you hit it to the insurance company with your privately negotiated payments to doctors. It only counts against the deductible if they have processed it at their negotiated rate. It is magical thinking to state that you won’t hit the deductible so why bother. An accident or cancer is not something that clean living and daily exercise can prevent.

  79. Finn, you’re obviously a very smart guy — you’ve accomplished a lot in your life. But your lack of awareness about how insurance works (and how HSAs work, and so on) kind of blows my mind.

    On the other hand, I don’t know how reservoirs work, so there’s that.

  80. Let’s cut school lunch programs because they aren’t shown to improve outcomes. Apparently the outcome of “poor kids getting one decent meal a day so they get some nutrition and aren’t completely starving all the time” isn’t good enough. And old people don’t need to eat either.

    http://m.motherjones.com/politics/2017/03/trump-budget-school-meals-on-wheels

    But there’s plenty of room in the budget to continue to pay for security for Melania at Trump Tower. Someone posted that 10 days of her security would pay for a full year of meals on wheels. I haven’t had a chance to fact check that.

  81. Denver Dad, I am torn between absolute white hot anger and fixing a bag of popcorn and watching the dodos who voted for him lose their jobs and their benefits. If people I knew and other good and decent folk wouldn’t be affected by this stuff I would choose the latter for sure.

  82. If people I knew and other good and decent folk wouldn’t be affected by this stuff I would choose the latter for sure.

    That’s always the hitch. Otherwise, yeah, guess what, some of that government money that you thought was going to black welfare queens was actually going to you, so now you can fucking suck it up, buttercup.

  83. And remember, kids and old people, if you don’t get school lunch or Meals on Wheels anymore you can always just eat your jewels.

  84. “I’m not convinced that handing them a medical insurance card will overcome some of the other obstacles to decent medical care, such as poor executive functioning or limited education or magical thinking or whatever causes people not to take steps to seek out care when needed and to comply with medical advice.”

    DD has pointed out that there is a difference between a health insurance plan and a healthcare plan.

    Similarly, there’s a difference between having health insurance and having access to healthcare.

    Another reason some people with health insurance don’t have access to heatlhcare is the lack of medical care providers, or of providers that will accept their insurance. This is often the case for medicaid.

  85. “Does “society” really end up paying the bills for those who, for whatever reason, lack health insurance coverage for the care they end up receiving?”

    Locally, it is a regular occurrence that the state legislature will provide funding to local hospitals to help offset the cost of services provided to uninsured patient.

  86. Lack of providers is certainly a barrier, and in rural areas, affects people of all classes. But I would argue that the first barrier to be overcome is lack of insurance (or ability to pay). Because if you can’t pay, it doesn’t matter whether there is 1 provider or 1000 on your block, you still don’t have access.
    Really, you need both. And I would argue that a population with decent, stable health insurance will attract more providers.

  87. “Providers can’t just bill you for the negotiated rate because their billing systems don’t work that way. They don’t track the negotiated rates in their systems. Instead, they submit a claim for the amount in their chargemaster (list of their official rates) and then the payer sends back an electronic response with the negotiated rate or kicks it back with various error codes.Providers can’t just bill you for the negotiated rate because their billing systems don’t work that way.”

    Typically when I see a provider, before I leave, the provider will have determined their charges, how much of that is covered by my insurance, and how much is a negotiated discount. What’s left is my co-payment, which I pay on my way out.

    A couple weeks or so later, I can go to the insurance company website to download a report showing those charges that I can use to request a reimbursment from our Flexible Spending Account.

  88. “And if you have a deductible you must go through the process. You can’t just send in your receipts when you hit it to the insurance company with your privately negotiated payments to doctors. It only counts against the deductible if they have processed it at their negotiated rate.”

    BITD when I had a plan with a deductible, that was how it worked.

    “It is magical thinking to state that you won’t hit the deductible so why bother. An accident or cancer is not something that clean living and daily exercise can prevent.”

    BITD again, there were years when I didn’t hit the deductible and thus didn’t file any claims. And we’re talking about plans with high deductibles; I would expect that many plan holders would have years where they don’t hit the deductible.

    If the deductibles aren’t high enough that there aren’t a lot of planholder-years in which the deductible isn’t met, then yeah, my idea won’t cut costs much.

  89. “And I would argue that a population with decent, stable health insurance will attract more providers.”

    I assume decent, stable health insurance will pay providers enough to offset their costs.

    Providing medicaid to a lot of people in an underserved area won’t attract more providers if it continues to reimburse below the cost of service.

  90. “But your lack of awareness about how insurance works (and how HSAs work, and so on) kind of blows my mind.”

    I’ve never had the option for a high deductible plan, and thus have never had the option for a HSA (should that be an HSA?), and thus have had neither experience with a HSA nor reason to investigate the details of how they work. So yes, I have a low awareness of how they work.

    Some of what is apparently perceived to be lack of awareness on my part is based on my experiences. Perhaps that perception is more reflective of a disconnect between my experiences and your awareness.

  91. I just cannot stand what Trump is doing tot this country! And I squarely place the blame on liberals who are foolish or naive enough to support right-wing islamists agendas. This support motivated the alt-right or even just closer to center right wingers to confirm me out and vote for Trump. Case in point, the support of women’s match organizer Linda Sarsour. Linda is nothing but a Islamic fundamentalist.

  92. Anon – you are blaming us for what Trump is doing when you voted for Trump?! LOL!

  93. Oh Anon, you must be new here. No one is gonna take that bait. Look elsewhere for that. Try HuffPo.

  94. There also seems to be a difference between consumption of medical care and improvement in measured physical health outcomes, according to an interesting, randomized study of Oregon Medicaid recipients.

    “Oregon’s health insurance lottery allowed researchers to study the effect of the first one to two years of Medicaid coverage on health care utilization, financial hardship, health, and labor market outcomes. In the first one to two years, Medicaid increased health care utilization, reduced financial strain, and reduced depression, but produced no statistically significant effects on physical health or labor market outcomes.
    Medicaid coverage resulted in significantly more outpatient visits, hospitalizations, prescription medications, and emergency department visits. Coverage significantly lowered medical debt, and virtually eliminated the likelihood of having a catastrophic medical expenditure. Medicaid substantially reduced the prevalence of depression, but had no statistically significant effects on blood pressure, cholesterol, or cardiovascular risk. Medicaid coverage also had no statistically significant effect on employment status or earnings.”
    http://www.nber.org/oregon/

    The actual study is here. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3701298/

    And ER visits went up, rather than down.

  95. Typically when I see a provider, before I leave, the provider will have determined their charges, how much of that is covered by my insurance, and how much is a negotiated discount. What’s left is my co-payment, which I pay on my way out.
    A couple weeks or so later, I can go to the insurance company website to download a report showing those charges that I can use to request a reimbursment from our Flexible Spending Account.

    And that’s exactly how it works with a high deductible plan. The difference is the “co-pay” is the full negotiated amount, not $10 or whatever, and you can withdraw the money from your HSA if you want (and there is money in it). But then after you’ve reached the deductible, the co-pay is $0.

  96. “Medicaid coverage resulted in significantly more outpatient visits, hospitalizations, prescription medications, and emergency department visits. Coverage significantly lowered medical debt, and virtually eliminated the likelihood of having a catastrophic medical expenditure. Medicaid substantially reduced the prevalence of depression, but had no statistically significant effects on blood pressure, cholesterol, or cardiovascular risk.”

    Lowering medical debt and substantially reducing the prevalence of depression sounds pretty good to me. In a one to two year study, you aren’t going to see big changes yet in cardiovascular stuff. Wait 10 or more years to study that.

  97. “Lowering medical debt and substantially reducing the prevalence of depression sounds pretty good to me.”

    Sure, it is pretty good.
    But we are spending $450 BILLION dollars a year on Medicaid. This study — the only randomized study to date — tells us that Medicaid isn’t doing what it is supposed to do, which is reducing non-emergent ER visits and improving health outcomes. Visits to the ER actually went up by about 40% in the group receiving Medicaid.

    Avik Roy has a detailed analysis of the study here, which shows that to the extent the study was flawed, it was biased in favor of finding improvements in the Medicaid group. And it didn’t. Also buried in the story is this interesting tidbit:

    “Of the 35,169 Oregonians who “won” the lottery to gain enrollment in Medicaid, only about 30 percent actually enrolled. Indeed, only 60 percent of those who were selected bothered to fill out the forms necessary to sign up for the benefits—which tells you a bit about how uninsured Oregonians perceive the Medicaid program.”
    https://www.forbes.com/sites/theapothecary/2013/05/02/oregon-study-medicaid-had-no-significant-effect-on-health-outcomes-vs-being-uninsured/#5c7b3b506043

    As Roy points out, if we wanted to reduce medical debt, it would be much cheaper simply to give money to low-income people rather than giving them a Medicaid card.

    Given the results of this and other studies, it’s hard to see why expanding Medicaid is a good idea.

  98. “which tells you a bit about how uninsured Oregonians perceive the Medicaid program”

    I think it just tells you that they didn’t sign up. We don’t know if that is because they didn’t know they were eligible, they didn’t know how to sign up, whether there are adequate providers, has the population been educated about the importance and value of preventive care? To just give a lower income, lower educated person health insurance with no education and assume they will use it to maximum value is like giving someone an IKEA bookcase with no instructions. I cannot overstate how the Medicaid population in general does not think or live like you and me. They are not necessarily motivated by the same things that motivate you and me.

  99. I’ve followed that study for a bit (first heard about it around 2012 on a NPR podcast). There are some things to understand about it. First, this was done pre ACA. I think that is important because a lot of infrastructure was introduced in the Obama admistration that was designed to better coordinate care and try to get people out of ERs, which simply wasn’t present in the time period studied. Oregon is a rural state and it is hard to understand what kinds of facilities might have been available to Medicaid recipients in that time period. Secondly, 2 years is too short to tell us much. People tend to not change their healthcare behavior that quickly, especially poor people. If you are used to running to the ER for everything, it might take a year or more to start modifying that, because you need to learn what other options are available, establish relationships with providers, etc. And again, what was available in pre-ACA Oregon? Were there urgent care centers and pediatricians with long hours out in the rural areas? A randomized study is great, but 2 years is not long enough to make any great conclusions. Heck, in the ped cancer world, Phase III trials go on for 10 years or more. My kid is still being followed on his trial.

    And I think the fact that medical bankruptcies were greatly reduced is wonderful, and should be a primary outcome. After all, I get insurance mainly to avoid bankruptcy, not necessarilly to cut my ER use – why should it be different for poor people?

  100. “They are not necessarily motivated by the same things that motivate you and me.”

    Everyone is different, but if you are trying to improve health outcomes in a population that opts out of FREE or virtually free medical care, then perhaps the Medicaid model should be scrapped in favor of a program that actually works. We are spending billions of dollars on a program that has failed to move the needle in measurable health outcomes.

  101. “A randomized study is great, but 2 years is not long enough to make any great conclusions.”

    The Forbes article addresses most of the issues you raise. For one thing, the study was conducted in Portland, not Oregon as a whole.

    “As the authors put it, “Medicaid coverage had no significant effect on the prevalence or diagnosis of [high blood pressure] or high cholesterol levels or on the use of medication for these conditions. It increased the probability of a diagnosis of diabetes, but it had no significant effect on the prevalence of measured glycated hemoglobin levels.” The study did a significant increase in the diagnosis and treatment of depression, but the authors did not measure a depression-based clinical outcome, such as improvement in the Hamilton Depression Scale.

    And all of that, despite the fact that the study had many biasing factors working in Medicaid’s favor: most notably, the fact that Oregon’s Medicaid program pays doctors better; and also that the Medicaid enrollees were sicker, and therefore more likely to benefit from medical care than the control arm.

    Where the study did show significant differences between Medicaid and the uninsured was in spending (Medicaid patients spent an average of $1,172 more than uninsured patients); and utilization of health-care services (which drove the spending). Some of that utilization was a good thing, such as an increase in cholesterol screening. But it didn’t result in better cholesterol health outcomes.

    In addition, the study showed a benefit in “reduced financial strain,” an unsurprising result, given that the Medicaid law strictly limits the degree to which enrollees can pay for their own care. But, again, that reduced financial strain didn’t result in better health outcomes. And if relieving financial strain is all we are trying to do, we’d be better off giving poor people the cash and letting them spend it how they choose.”

    It’s great that these Medicaid recipients were diagnosed with diabetes, for example, but they didn’t fare any better than their cohorts who were uninsured.

  102. After all, I get insurance mainly to avoid bankruptcy, not necessarilly to cut my ER use – why should it be different for poor people?

    Because poor people are using the ER for primary care and other things that you go to your PCP or urgent care for (or in your case, things your PCP would refer you to a specialist for :) ). So reducing ER use by poor people is a desirable outcome because it means they are getting better access to primary.

  103. I think it just tells you that they didn’t sign up. We don’t know if that is because they didn’t know they were eligible, they didn’t know how to sign up, whether there are adequate providers, has the population been educated about the importance and value of preventive care? To just give a lower income, lower educated person health insurance with no education and assume they will use it to maximum value is like giving someone an IKEA bookcase with no instructions. I cannot overstate how the Medicaid population in general does not think or live like you and me. They are not necessarily motivated by the same things that motivate you and me.

    Right. An example along these lines is my mother had really bad teeth because her parents never took her to the dentist when she was growing up. They were intelligent people and could have afforded it, they just didn’t know they were supposed to do it.

    In regards to Scarlett’s comments, the issue goes beyond healthcare to lifestyles. We’ve talked about how it’s more expensive to eat healthy, it’s much harder to find time to exercise when you are a single parent and/or working two jobs, etc. When you’re struggling to just pay the rent and feed your family, getting everyone five servings of fruits and veggies (if you even know you should be doing that) isn’t a priority.

  104. Denver Dad, I totally agree that reducing ER visits is a desirable outcome overall, but so is reducing medical bankruptcies. Really. It is important to society, just as reducing ER usage is. Bankruptcies, and financial stress due to high medical costs, are very distruptvie. And to the actual people involved, I bet they are far happier about reducing their bankruptcy risk than about whether or not they are going to the ER. I know when I think about my own insurance, I am much more concerned with protection against financial risk than I am about reducing societal healthcare cost.

    My point – reducing risk of bankruptcy and financial catastrophes is a primary reason for all healthcare insurance including Medicaid, and the fact that they got a good outcome there means the program succeeded. Reducing medical costs is a secondary goal, albeit a good one, and one that probably takes more work because it isn’t the central interest of the people involved.

  105. Mooshi, I agree that reducing financial liability is a very good thing. And if people are going to their PCP instead of the ER, their financial liability will be improved.

    The Forbes/Oregon article has me thinking: I would love to see a study comparing health outcomes of middle/UMC/upper class people with and without health insurance. My guess is there would probably be little difference in the conditions mentioned in the article, because they are all driven primarily by lifestyle factors. But I don’t think the uninsured cohort is large enough.

    And really, the study that needs to be done, and the only one that really matters, is the long-term mortality of the people who are on Medicaid compared to the uninsured. But that will take decades to complete, and there will likely be so many changes to health care coverage along the way that it will be very difficult to parse the data.

  106. Helping people avoid bankruptcy is a valid goal. But it’s unclear whether the “reduced financial strain” reported by the Medicaid group was a measurement of bankruptcies or something less significant. Again, how much money should we waste on Medicaid to achieve that goal? Why not give each of those people $20,000 and call it a day?

    The purpose of health care reform is to improve health care, not to provide poor people with Medicaid cards.

  107. Not according to Paul Ryan. He says the goal is to give “access” to healthcare, whatever exactly access means. Providing poor people with Medicaid cards definitely gives them access.

  108. Why not give each of those people $20,000 and call it a day?

    Because they’ll spend it on something stupid and then STILL insist that everyone else pay for their health care. Are you going to clutch your pearls and call me paternalistic? Go ahead. Party on.

  109. 20k is way too much. Except when it is not enough. Why not just subsidize insurance for everyone?

  110. And if the goal is truly better healthcare outcomes for everyone, keep in mind that the US is not very successful right now. We have higher costs and worse outcomes than most other industrialized countries. So why not follow one of the successful models at keeping down costs and getting better outcomes. Here is one to try on – Finland. Not the only one for sure, but one example

  111. I don’t have great information about the study referred to, but I know an acquaintance’s husband was on the board advising the governor about the medical insurance exchange and it was apparent to the advisors that the exchange would be a disaster. A colleague is married to an ER physician and the colleague says that the top reasons people come to the ER are attempts to get narcotics and turkey sandwiches (because they’re hungry). And while I usually agree with Ada’s HMO *philosophy*, Kaiser (HMO) doesn’t include perinatologists in-network outside Portland, so I was darn glad I didn’t have Kaiser during my pregnancies. Medicaid would help the responsible working class a lot, but it doesn’t necessarily help the people who drive U.S. health statistics.

    The effect of healthcare on health statistics isn’t going to be large, because mortality in people under 65 is heavily influenced by behavior. If people would stop using illegal drugs (marijuana in small quantities arguably excepted), use alcohol in sensible quantities, smoke at most an occasional cigar and not eat to the point of obesity, health statistics would improve by ~80%, independent of access to good primary care.

    Prenatal care helps women who are willing to comply with rules regarding not using drugs, not getting drunk, treating gestational diabetes appropriately, etc. It seemed that the majority of people at my high risk doctor’s office had social issues affecting their willingness/ability to comply with prenatal recommendations. The fact that I worked hard to comply with all suggestions during my month in the hospital made me unusual, according to the nurses.

  112. “So why not follow one of the successful models at keeping down costs and getting better outcomes. Here is one to try on – Finland.”

    Seriously? Finland is one of the smallest and least diverse countries on the planet. Less than 2% of the population of under 6 million is non-Nordic. https://en.wikipedia.org/wiki/Demographics_of_Finland
    It’s hardly a relevant model for the US to follow.

  113. So we could try lots of other countries.

    Please find me a country with a totally free market healthcare system that has better outcomes than us. I won’t even make you match us in terms of diversity.

  114. China is a large country that has had very basic insurance, not covering a lot of costs, even though most people have “access” to it, as Paul Ryan would say. They have very little in the way of a safety net. Even the rising middle income people are easily devastated by medical costs. One of the reasons so many kids with heart defects are put up for adoption there is because the surgeries and care are beyond working and middle income people. Because China has become much wealthier, its people are finding this unacceptable and are pushing for a better and likely more socialized model. They want to move away from free market and basic insurance, while the more conservative Republicans seem to want to move towards it. Really, this is what they want?
    http://fortune.com/2016/07/10/china-healthcare-costs-debt/

  115. Of course Kaiser doesn’t have contracted perinatologists outside of Portland, because there are precious few and not enough Kaiser enrollees to support one being employed solely for their members. In my experience, Kaiser (and other quality HMOs) will cover the cost of necessary treatment by a specialist outside the network. HMO models of care pay for the treatment they deem necessary. Perhaps they don’t think every patient with fibromyalgia needs a rheumatologist, or every kid with a greenstick radius fracture needs a pediatric orthopedist. However, one should not conclude that they will not cover the cost of care

    My child needs a pediatric nephrologist, which my HMO does not locally employ. She is seen at the children’s hospital and I pay the same co-pay as if it was an HMO physician. Patients in my city are not expected to travel 30 miles to be seen by a gastroenterologist; they are referred to private physicians and (if the health plan agrees it is necessary) seen at the same cost by someone more local.

    It is not fair to say that the HMO model doesn’t work because you reviewed the register of contracted specialists. Sure, there have been naughty HMOs. However, I would like to hear that 1. A specialist is needed. 2. The specialist wasn’t available in a reasonable time/distance. 3. There was an appropriate specialist available in a more reasonable amount of time and distance. 4. The HMO refused to pay for the specialist. Then, I will concede that the model doesn’t work for certain populations.

  116. You have far more trust in the system than I do.

    My experience has been that any physician/hospital that is out-of-network bills at out-of-network rates and requires a year of phone calls and/or letters to get billing issues resolved, almost regardless of what I’m told up front. I My colleague’s wife who is a managing physician for Kaiser says they expect people to drive to Portland in most cases. Kaiser doesn’t care if I have to take a day off work for each prenatal appointment and they are upfront that they have no specialists outside Portland. Too much risk for me! If they are willing to cover specialists in particular cases, that should be included in the plan description.

  117. “Why not give each of those people $20,000 and call it a day?

    Because they’ll spend it on something stupid and then STILL insist that everyone else pay for their health care.”

    This seems to be something on which folks from both sides can agree, albeit for different reasons.

    On the left, there is opposition to giving poor people money because the lefties know better than the poor people how that money should be spent.

    On the right, reasons for opposition include some combination of not rewarding/encouraging exercise of the preference for leisure and recipients not deserving of such largesse.

  118. Finn you hit the nail on the head! I’ve been reading the responses today and since I re-watched “The World’s End” over the weekend I think the following exchange can explain a lot – it does include the “f” word so skip if that offends or if you don’t want to be spoiled for the movie.

    The Network: At this point your planet is the least civilized in the entire galaxy.
    Gary King: What did he say?
    Andrew Knightley: He said we are a bunch of fuck ups.
    Gary King: Hey it is our basic human right to be fuck ups. This civilization was founded on fuck ups and you know what? That makes me proud!

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