2017 Politics open thread, April 30 — May 6

Yesterday marked President Donald Trump’s 100th day in office.

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260 thoughts on “2017 Politics open thread, April 30 — May 6

  1. WCE, right now private colleges are looking for paying students anyplace they can find ’em.

  2. Not sure what to think of the Clemson program. As Charles Murray has pointed out in the past, college work is beyond the ability of those in the lower end of the cognitive ability distribution. Students who are not intellectually disabled but nevertheless have low cognitive ability cannot realistically expect to attend or graduate from a university worthy of the name. Clemson does not currently meet the needs of the students who struggled or failed to graduate from high school. Does it make sense to bypass that group but reach beneath it to disabled students who cannot actually do college level work? Can they really live independently in a college community without being targets for, say, sexual assault?

  3. Does it make sense to bypass that group but reach beneath it to disabled students who cannot actually do college level work?

    But they aren’t doing college work, it’s work and life skills training under the Clemson umbrella. I’ve heard that it can be hard families of disabled kids because there are resources available when they are minors but once they hit 18 they are far fewer resources. Some help to bridge the gap into semi independent adulthood and whatever work they are able to do seems like a good idea.

  4. Reading the article – they aren’t doing college work or getting a bachelors degree. They are getting 2 or 4 year certificates, and it looks like a lot of it will be teaching them how to live indepenently. So in some sense, Clemson is simply running the kind of program that used to be the purview of social service agencies, probably aimed at the well heeled who can afford the tuition

  5. So they are pretending that these young people are in college. But they aren’t really.
    And most disabled young people don’t have helicopter parents to get them into these programs.

  6. So they are pretending that these young people are in college.

    Your tone seems a little harsh…

    And most disabled young people don’t have helicopter parents to get them into these programs.

    And?

  7. These programs seem patronizing.

    There is a serious problem with young adults who are intellectually disabled. They need suitable training and help to live independently. Creating programs that serve only a tiny fraction of this population, at considerable expense, is not going to help the rest of the kids, especially those from less advantaged families. Not trying to be harsh but realistic. If we want to open college to all (like K-12 for all) that is one thing. But we’re not doing that. The kids with normal but low IQ are left out, there are a lot more of them, and they do have the ability to live independently without any special support.

  8. They need suitable training and help to live independently.

    the ClemsonLIFE curriculum includes a variety of classes ranging from relationship skills and math to navigation and nutrition. All the while, the students are integrated with the rest of the Clemson population and work both on- and off-campus at places like the stately university Fike Recreation Center, local boutiques, and the Walgreens distribution center.

    Isn’t that what this is?

  9. The kids with normal but low IQ are left out, there are a lot more of them, and they do have the ability to live independently without any special support.

    So you oppose this because it doesn’t help every possibly disadvantaged group in order of ability?

  10. I don’t necessarily oppose it. Just don’t think that this program makes a lot of sense for most of the target group.

  11. Just don’t think that this program makes a lot of sense for most of the target group.

    You said this group needs “suitable training and help to live independently.” Which this appears to be. Is your objection the curriculum, or?

  12. I will put a recommendation in for Google Chrome cast. It plugs into a port on your TV.a and allows your browser to be shown on the TV. You can also use a phone app. The interface is superior to Apple TV (we also have this). It is especially handy if you use Chrome as your browser. We also are overhead lightong from this century. Worth it. Especially if you are over 50 and need the extra ambient light. Other products have been just ok or outright bad.

  13. There is no question that this program is aimed at the well heeled. I know several families in this demographic who have very intellectually disabled children (usually autistic though, not sure if this program addresses that) who are now aging out of the system. They would definitely pay through the nose for a program like this. There are existing programs and schools out there now, but they are very expensive (just as this program is) and don’t have enough slots. As for the non-well-heeled, well, there isn’t a lot for them because that would have to be done through the government or through extensive charity, and 25 year olds with IQs of 65 or with autism are just not popular enough to get much funding through either route.

  14. On Call the Midwife last night, one storyline was placement of an adult (21) with Down’s Syndrome after his mother died. No other family support was available. The choices were (1) someone from the local parish helps him, (2) scary psychiatric hospital, with patients of all sorts and (3) charity run home where others with Down’s Syndrome learn life skills (gardening). The charity was 1 of 3 in the country. More options were available for those under age 21.

    Amazing to me that these choices are still not so far off the mark.

  15. There are more group home placements than you might think. In certain areas, one particular ethnic group will have kind of a corner on the caregiver industry. In the Bay Area, it’s families from Tonga. They take one or two disabled adults in and take care of them. Some are great, some not so much. But it’s not something that’s on the radar if you’re not immersed in that community.

  16. “Creating programs that serve only a tiny fraction of this population, at considerable expense, is not going to help the rest of the kids, especially those from less advantaged families.”

    I kind of feel this way about the Duke TIPS program and Johns Hopkins Center for Talented Youth. It’s really nice that some families can spend 5k for a 3 week program, but it doesn’t really solve the problem of appropriate education for most people at the far end of the IQ curve.

  17. Creating programs that serve only a tiny fraction of this population, at considerable expense, is not going to help the rest of the kids, especially those from less advantaged families.

    So your argument is that since they can’t help everyone, they shouldn’t help anyone.

  18. Ada, CTY at least opens up the option of all kinds of online classes that a school willing to cooperate could allow a CTY kid to take in lieu of the normal offering. The advantage is that it’s a structured curriculum from an accredited institution, and at the high school level many of the offerings are AP, so the school can feel comfortable that it’s a ‘real’ class. Those still aren’t free, but they’re a lot less than the pricey residential programs.

  19. We had a thread about the Johns Hopkins programs.

    The primary intent of the program is not to provide the programs for the kids, but to do research on educating super smart kids. The programs offered to smart kids are an ancillary benefit.

  20. HM – that’s helpful, thanks. I started to look into CTY but life got in the way. Plus mine are still young.

  21. My argument is that this program is Fake College, and based on two fundamentally unsound principles — (1) That *anyone*– regardless of intellectual capacity — can attend and graduate from college and (2) That only those people who attend college have intrinsic dignity and worth. Those misconceptions are reflected in this quote near the beginning of the article:

    “You know, [a student might think], ‘My sister went to college, why can’t I?’ Well, you can. The opportunity is here.”

    And then there is this example of Bad Science:

    “According to Walters, the employment rate for students who complete Clemson’s four-year program is 100 percent. In other words, it’s working.”

    As the first comment to the Atlantic article put it,

    “Just because it’s at a University doesn’t give it any more credit than a special education school. This is a glorified participation trophy with good intentions, that’s all.”

  22. With the caveat that I haven’t read the article, Scarlett, I don’t get your objection.

    Our local colleges, including flagship U, offer a bunch of classes that aren’t for credit toward any kind of a degree, and fall more into the ‘adult education,’ and ‘continuing education’ categories, e.g,, how to set up a home network, the latest in preventing ground termites from eating your house.

    My perception is that your objection would apply to these classes as well, that the local colleges shouldn’t be offering them.

    Do you see these sort of classes, as well as the ones in the article, cheapening the value of college degrees?

  23. Finn, of course not. Those sorts of programs are exactly what community colleges are supposed to be providing. That is, IMO, where the programs for intellectually disabled students belong.

    The author tries to make the case that these kids are just like the other Clemson college students. But they aren’t taking real college classes, nor are they getting a degree.

    It’s a great idea to develop programs for these young people, but why at a four-year university?

  24. Why not at a 4 year university? If it is providing the students with the training/skills that they need and there is a group of parents willing to pay for it, what’s the issue?

  25. Scarlett can correct me if I’m misunderstanding, but I think her objection is to the pretense. If I take a noncredit language course at the local flagship there’s no suggestion that I am now ‘going to college’ at the flagship, and likewise if I take a one day culinary workshop at the community college it’s very clearly unrelated to the coursework toward a culinary degree. Whereas it sounds like the Clemson program is somewhat encouraging the students and their families to think of them as going to college, not attending a transitional life skills program that happens to be housed on a college campus.

    This reminds me of the time a truly obnoxious blowhard showed up at an alumni club event for my college, which is a name-brand one. After increasingly specific enquiries about his time there, it eventually emerged that he’d done a one or two week ‘leadership seminar’ deal branded through the business school, and based on that would tell everyone he met he was a Name-brand graduate.

  26. HM – Ha! My boss has taken one of those types of seminars – from your school, I believe – and it’s now on her resume.

  27. So the concern is that the students are going to pretend that they are real Clemson students?

  28. I think the concern is that it leads to unrealistic expectations all around for the students and their families and acquaintances, and dilutes the meaning of “college education.”

  29. From their website:

    The ClemsonLIFE Program offers a 2-year Basic Program that incorporates functional academics, independent living, employment, social/leisure skills, and health/wellness skills in a public university setting with the goal of producing self-sufficient young adults. Additionally, the ClemsonLIFE Program offers a 2-year Advanced Program for students that have demonstrated the ability to safely live independently, sustain employment, and socially integrate during the Basic Program. The Advanced Program progresses with an emphasis on workplace experience, community integration, and independent living with transitionally reduced supports. Students who successfully complete the Basic or Advanced program will receive a corresponding certificate of postsecondary education.

    I still fail to see the issue. Sounds like a good program that is available to only a few students with significant family support and resources.

  30. ” If I take a noncredit language course at the local flagship there’s no suggestion that I am now ‘going to college’ at the flagship”

    Semantics. Such course attendance could be literally described as “going to college.”

    But I get the point, which is what I was somewhat more clumsily trying to make earlier.

    Actually, local flagship and CCs often differentiate such offerings by offering them under auspices such as “Flagship extension,” or “CC continuing education programs.”

    Perhaps establishing something like a “Clemson Lifetime Learning Academy” might address Scarlett’s objection.

    The program itself sounds like an attempt to begin to fill a very real and growing need.

  31. I don’t think I would be able to find anyone associated with Clemson as a student, parent, or alum who sees the ClemsonLife program as anything but a positive. I’m unable to fathom how this program can be interpreted as fake college that diminishes someone’s EE degree. I’d love to see this idea spread and more opportunities open up for more young people. If I had a special needs kid, I would absolutely want something like this.
    The football coach has been employing kids from ClemsonLife since he came to Clemson. They are “trainers” and it doesn’t hurt the “real” trainers for these young men to have that title. No one is confused, no one is diminished.

  32. The Clemson program for students with developmental disabilities is eligible for federal financial aid dollars because of a 2008 redefinition of Title IV eligibility.

    One of the few reasons I am willing to pay higher taxes is for better services for developmentally disabled people, but I think that these costs should be clearly identified as expenditures, not considered loans or Pell grants. It would not be reasonable to expect the people benefiting from these programs to pay back loans. I couldn’t tell from the article what Title IV eligibility really meant.

  33. The question I would have is could at any point ClemsonLife be able to get student loans and or grants? I know for people who deal with children aging out of Public School resources that having access to Student grants and/or loans could either be a blessing or another way for someone to spiral down into debt,

  34. He is such a dummy. He also recently said there is no reason for the Israelis and Palestinians to be fighting. However! A conflict with North Korea? Probably can’t be avoided.

    What is even more troubling than how dumb our POTUS appears to be is that his loyal following doesn’t care.

  35. Re: college: The Clemson program sounds awesome, and I hope it works and spreads. My one concern is that ITA that supporting developmentally disabled should be a government obligation, and this appears to fill that need by shifting the obligation to the parents. Which, admittedly, will be a feature instead of a bug to some. But at this point, we don’t really appear to have any government will to spend money on social programs to support those who can’t support themselves, so it’s hard to criticize a program that is filling a clear need for parents and developmentally disabled kids.

    OTOH, the “dumbing down” of the degree is a real issue. My mom this year has a student that, fundamentally, I think must have some sort of disability. He literally cannot get basic plot points, and his mother comes to his conferences and drives him everywhere. And he’s a senior about to graduate; my mother’s big dilemma has been whether to fail him (as he deserves based on his work) or to give him a gentleman’s D and let him slide through. But I just have to wonder WTF is going on that someone who cannot comprehend a book (a) was admitted in the first place [because the college is desperate for paying students] and (b) has made it all the way to a Senior Seminar in English and the final semester before graduation.

    I guess the good news is that this has reaffirmed my mom’s decision to retire, which I think she was feeling sort of sad about until she met this guy. And his compatriot, Mr. “I am going to slide by without even reading the books because I am so brilliant” — who is also part of the “D or F” debate, because apparently even brilliant minds cannot intuit fiction without actually reading it.

  36. He literally cannot get basic plot points

    And I can’t find the beat. Maybe finding plot points isn’t his strong suit but he has other skills?

  37. @Rhett: Possibly true. But irrelevant to whether he should be allowed to take an advanced American Lit seminar (much less pass the class).

  38. The Civil War thing blows my mind. I did read the extended transcript, and in context, it’s really not much better.

  39. Well, truly, the Civil War quote (and I read it too, and giggled) is his usual gibberish. It is just because people think of knowing about the CIvil War as being a hallmark of being an educated American that it got such notice. I have said many times, and I will say it again – he has untreated ADHD. Read the article with today’s post on ADHD – you can see a lot of Trump in it. I also sometimes wonder if he has some kind of speech problem or if the word salads are simply because of his lack of impulse control

  40. One more thing – when Trump does his stump speeches, he kind of bellows, but whenever he is trying to use his “inside voice”, he ends up speaking in this weird little high pitched weenie voice. It is really odd sounding to me.

  41. “It is just because people think of knowing about the CIvil War as being a hallmark of being an educated American that it got such notice. ”

    Isn’t it though? And I don’t mean Totebag-educated, I mean a basic 8th grade education. It’s the Civil War! It’s probably the most studied thing in American History. And just the basics. No one was asking him about the flaws and trade offs in the Emancipation Proclamation. It’s not exactly snickering because someone doesn’t remember Calculus.

    “if the word salads are simply because of his lack of impulse control”

    My guess is this. Also he managed to lead off with some some random, and true, facts about Andrew Jackson – he’d been to the grave recently & probably has learned a bit about him. And then the word salad just came out.

    He’s far worse to watch live than it is to read the transcripts too because the delivery is such that you can almost see the word salad of nonsense being tossed.

  42. I’m feeling ill watching the Trumpcare vote. Because everything is all about meeee, do any lawyers have a setup where retired or semi-retired members of the firm can still access the group insurance? I don’t want DH to have to work til 65, and the other option is for me to go back to work at any job that has insurance.

  43. Trump agrees with Scarlett that the Little Sisters of the Poor were really infringed upon by having the onerous task of checking a box stating that they will not provide insurance and has issued an EO giving them relief!

    RMS – I don’t think the Senate is going to pass it.

  44. I know, Kate, but I hate that it’s even close to getting through the House.

  45. RMS–you’re screwed. I’m actually at a seminar today about health care, and it’s awful. Every speaker has basically said that.
    It’s not just the individual market. Even employer plan premiums are going to go up, and employer plan coverage could be cut back, as a result of this bill.

  46. Bunch of clowns! They voted a million times to repeal it when Obama was President. But when the rubber meets the road, they know they really can’t do it.

  47. You aren’t screwed RMS. According to Rep Pettenger, you’ll just have to move. Might I suggest Massachusetts?

  48. I need Colorado to reintroduce the universal care bill.

  49. I wonder if this will be the main issue going forward? They pass Trumpcare and it’s a disaster so just like democrats in 2010 the republicans are swept from office in 18. Back and forth, back and forth about Trumpcare continues until it’s repealed and replaced by Newsomecare. And the whole process begins again with whoever is holding the healthcare potato at the time of the election losing.

  50. The agenda of the Freedom Caucus is to get the government out of the business of subsidizing health expenditures, period. They would like to eliminate the corporate deduction/income exclusion for health ins and have everyone get paid in taxable income and purchase health care or ins in the free market – health savings accounts under individual control as the only tax favored vehicle. They would like to turn medicare into vouchers. This is only a first step. There would be many bad effects from this bill (unlikely to become law as is) on health care access and the ability to obtain insurance coverage for most people who can’t get it from a job – that is most members of the gig economy, most people over 55 or the younger dependents of medicare aged folks. However, the main purpose of this bill is to give a tax cut to the wealthy, and I know some coastal UMC types will also save, by repealing the Obamacare surtax and to reduce govt healthcare expenditures, principally Medicaid, by the same amount. The ability to provide inexpensive catastrophic coverage for healthy young males without addiction or mental health issues is offset by increasing the cost of a policy for a lower income 62 year old from 1000 a year to 10000 a year after credits. And wealth first daughters will save 200K per annum on their taxes.

  51. I just called my congressman and told the staffer I would never vote for him again. The staffer sounded a little stunned–I think they are not expecting that reaction.
    I am sitting in this health care cost seminar and I think the speakers are becoming stabby. And these are actuaries.

  52. I spent much of my morning contacting the NY reps on the fence, saying I would do everything in my power to see them unelected next time around.

  53. Thank you House Republicans for voting to make my child uninsurable again. Disgusted, disgusted, disgusted.

  54. Mike Coffman, the Republican one district over from mine, voted against it, but his Twitter feed is still full of “Nothing can save you! We’ll still exterminate you!” Wrong, wrong, people. Say thank you.

  55. RMS, I am going to send an email or post to each of the 20 republicans who voted against this thing, thanking them and telling a little of our story.

  56. RMS–just sat in an early retiree cost session. The actuary’s advice? Don’t retire early, at least not until you can Cobra to 65. I’m feeling stabby.

  57. I can accept that government should subsidize insurance costs for the poor, but why should government subsidize insurance costs for RMS and the early retiree cohort?

  58. The government has not now, nor will it ever, subsidize my insurance. At least til I’m 65. What the hell is your problem?

  59. My husband has Type 1 diabetes, which means he will eventually go blind, lose his kidneys, his feet, etc. I was kind of hoping that would be covered, but now it won’t be, not even through his employer’s insurance.

  60. Also — and I guess this is completely opaque to you — but some people actually care about the good of others, so I actually am kind of sorry that Mooshi’s kid is uninsurable. I guess that’s beyond you, though.

  61. Go ahead, tell me about how the VA sucks and that means that anything the Republicans want to do is justified.

  62. To be a little more Totebaggy about it, I guess I should try to figure out how to invest in medical tourism companies.

  63. I’m stabby too. Keep posting RMS!

    I believe everyone should have access to affordable healthcare. I can debate what the appropriate level of minimum healthcare availability should be. I am appalled as a Christian at the lack of compassion by conservatives.

    I’ve been frequenting some Dave Ramsey boards and so many of the people there are struggling to pay off medical debt. I think it is a travesty that we have to have bake sales for people to get healthcare.

    STABBY!

  64. “I am appalled as a Christian at the lack of compassion by conservatives.”
    Me too. Preach it, sister.

  65. “To be a little more Totebaggy about it, I guess I should try to figure out how to invest in medical tourism companies.”

    Or perhaps move to Mexico? I’m all about starting some kind of Totebag Retirement World down there.

  66. Or perhaps move to Mexico? I’m all about starting some kind of Totebag Retirement World down there.

    I don’t want to move there, though. I’ll be happy to visit. But people who get bariatric surgery down there rave about it. Medical tourism is really going to become big business, even bigger than it already is. People like me and DH, who have pre-existing conditions and won’t be able to get coverage for any price, will be relying on it heavily.

  67. ” I think it is a travesty that we have to have bake sales for people to get healthcare.”
    When my son was in treatment, and for some years beyond, I saw so, so, many families running endless bake sales, car washes, penny jars, rummage sales, trying to raise money for their kid’s treatment. In many cases, they had insurance, but it was bad insurance, with lifetime caps they had blown through, or very limited coverage of needed procedures, or high deductibles. Or they had no insurance, perhaps because a single parent had to quit work to take care of the child with cancer. Many of my views on healthcare insurance were formed in those years.

  68. Families coping with catastrophic health conditions still resort to fundraising ventures to help pay the costs of expensive treatment and the associated travel/lodging, even if they have insurance. No matter how generous the health care program, there will always be families for whom accessing medical treatment is a challenge, either because insurance doesn’t cover all of their expenses, because the condition is rare and treatment is still experimental, or because the families lack the bandwith to be assertive advocates for their patients.

    But the willingness of the “compassionate” to question the Christian commitment of those whose views regarding health care financing differ from their own is, itself, appalling.

  69. RMS and WCE,

    I think you may be talking past each other.

    WCE, I assume you agree with community rating and guaranteed issue. Everyone who is 30 years old pays the same (say $250 per month) no matter if you got cancer when you were 10 or got hit by a bus when you were 25. If you only make $18k a year the government kicks in some money. If you make 50k or 100k you pay the full $250.

    The question then, is should a 30 year old who had cancer when they were 10 have to pay more than someone who didn’t have cancer? Democrats and centrist republicans say no. Far right republicans say yes they should pay more as they are a bigger risk.

  70. Scarlett,

    Do you agree, like all centrist republicans, with guaranteed issue and community rating with a subsidy for those with a low income?

  71. Rhett, actually most Republicans do not agree with guaranteed issue and community rating.

  72. But the willingness of the “compassionate” to question the Christian commitment of those whose views regarding health care financing differ from their own is, itself, appalling.

    True, though.

  73. Before the ACA, guaranteed issue/community rating (aka not denying or charging more for pre-existing conditions) was very controversial and not popular at all with Republicans or even conservative Democrats. Without the mandate, it leads to skyrocketing premiums as was our experience here in NY, one of the few states with guaranteed issue and community rating before the ACA

  74. I think it was Mark Levin who said that just because you have a pre existing condition and/or can’t afford healthcare that doesn’t mean that it’s the government’s role to help with that. I can understand and respect that position. I certainly don’t agree with it but I understand and respect it.

    What drives me crazy are people like Mick Mulvaney who weasel and obfuscate and pretend because they know how unpopular their true position actually is.

  75. Rhett, actually most Republicans do not agree with guaranteed issue and community rating.

    Most centrist republicans do. One who did was bought off with $8 billion in high risk pool money (we all know how poorly high risk pools have worked out to date).

  76. views regarding health care financing

    Again I’d really like to know what you think should be done. I assume not what is currently being done. Big picture, in terms of the role of government, should we have a system where a 30 year old who had cancer when they were 10 pays more than a 30 year old who didn’t have cancer.?

  77. No matter how generous the health care program, there will always be families for whom accessing medical treatment is a challenge, either because insurance doesn’t cover all of their expenses, because the condition is rare and treatment is still experimental, or because the families lack the bandwith to be assertive advocates for their patients.

    So because we can never fully cover everyone, we should give up and just cover fewer people. It’s the same argument you made about the Clemson program – since they can’t serve everyone they shouldn’t help anyone.

    At least you’re consistent

  78. Rhett,

    There is a lot of obfuscating going on in every discussion on health care. What drives me crazy are those who insist on the Democrats = compassionate and good; Republicans = selfish and evil narrative. This is a very complicated issue, and every possible approach has winners and losers. If health insurance is true insurance, then providers should be able to take risk into account when setting premiums, and people who try to game the system by opting out when they are healthy should be penalized. If it’s pre-paid health care, then everyone should be in the pool and the government (which is us) should subsidize the poor, old, and sick. But we can’t really decide what it is that we want health insurance to be. We can’t even make the sensible decision to remove the long-obsolete tax incentives that tie health insurance to employment — why is it so surprising that we can’t agree on how to fix the content of that health insurance coverage?

  79. But we can’t really decide what it is that we want health insurance to be.

    What do you think should be done? I’m totally in agreement with breaking everything out of employment 401k, insurance, etc. BTW.

  80. But we can’t really decide what it is that we want health insurance to be.

    Some of us can.

  81. What drives me crazy are those who insist on the Democrats = compassionate and good; Republicans = selfish and evil narrative.

    It’s not a narrative. It’s God’s own truth, and clutching your rosary and gasping in horror don’t make it false.

  82. Republicans = selfish and evil narrative.

    Many of them are, Rep. Levin for one. It’s certainly a reasonably and consistent stance for him to take: he has a job and insurance and someone who has a preexisting condition or is poor should learn to do without. As sad as he agrees it is, it just ins’t the government’s role.

  83. The other thing we lose sight of in the debate over pre-existing conditions is the large cut to Medicaid. That could prove very problematic, not just to poor people, but to school districts that use Medicaid funds for special education, and for nursing homes that use Medicaid funding.

  84. It’s God’s own truth, and clutching your rosary and gasping in horror don’t make it false.

    Calm the fuck down! Scarlett is nice enough to offer her views on this and keep us from all sitting around agreeing with each other so cut her some slack. And that language certainly isn’t going to convince her to change her views.

  85. Scarlett said “This is a very complicated issue, and every possible approach has winners and losers. ”
    Take a look at the chart I just posted. The winners are who? The wealthy of course

  86. The winners are who? The wealthy of course

    And the young and healthy – we can at least be honest.

  87. RMS,

    I do love when you get your dander up but please be nice to the one who (along with WCE) is keeping it interesting.

  88. Calm the fuck down! Scarlett is nice enough to offer her views on this and keep us from all sitting around agreeing with each other so cut her some slack. And that language certainly isn’t going to convince her to change her views.

    I honestly do care about your views, Rhett, but no thank you, I prefer not to calm the fuck down.

  89. And claiming that you are Christian does not actually make you Christian.

  90. RMS,

    Please, we want her to at least keep it interesting and not leave like Milo did and maybe we can moderate her views on the subject via constructive and courteous debate.

  91. Please, we want her to at least keep it interesting and not leave like Milo did and maybe we can moderate her views on the subject via constructive and courteous debate.

    In your dreams. No, seriously really Rhett, that’s not how people wind up changing their minds.

    You know how everyone around here starts everything with “You know I love you, but” and then finishes with “fuck you and die in a fire”? Over the years I have truly come to appreciate your voice. I was iffy about you back on the old site; sometimes I thought you were over the top. But you are one of the few truly original voices on this blog.

    But I’m not going to stop calling out evil when I see it.

  92. No, seriously really Rhett, that’s not how people wind up changing their minds.

    WCE has significantly moderated her views. Milo did as well. It can and does happen. It’s not easy but it does happen.

  93. I use this site to sharpen my argumentation skills, so I need the opposition here :-). See, this is just practice for when I have to get out there and convince real people.

  94. I tried posting before but now don’t see it. I truly don’t see the compassion in the conservative agenda. I would love for someone to sell me on what exactly is compassionate about the conservative agenda without talking at all about the liberal agenda. I’d love to understand what is compassionate about it.

  95. I would love for someone to sell me on what exactly is compassionate about the conservative agenda

    To get into the details. Under Obamacare older folks can only be charged 3x as much as young folks. Under this plan (I not positive it’s in this version) older folks can be charged 5x as much. In theory you could have a middle class young family paying more so that someone like RMS (older and wealthier) can pay less freeing up money to pay the mortgage on her vacation home.

    Overall I’m not seeing the compassion but that is one issue that you could frame as being compassionate.

  96. To get into the details. Under Obamacare older folks can only be charged 3x as much as young folks. Under this plan (I not positive it’s in this version) older folks can be charged 5x as much. In theory you could have a middle class young family paying more so that someone like RMS (older and wealthier) can pay less freeing up money to pay the mortgage on her vacation home.

    I would be okay with income limits. There are many more people like my various middle-class friends who will be soaked beyond all possibility to pay.

    And I’ve paid tons of taxes to compensate for the WCEs and the Scarletts who can’t keep their legs crossed.

  97. Is Milo really gone?
    I’ve noticed his absence, but hoped it was temporary.
    And I joined this conversation against my better judgment, because, as Rhett pointed out, there really aren’t many different viewpoints on the politics threads anymore. But, like MM, I like to engage people here who disagree with me, so that I can figure out how to argue with what she calls “real” people.

    “What do you think should be done? I’m totally in agreement with breaking everything out of employment 401k, insurance, etc. BTW.”

    I think that we should separate out routine and predictable health care expenses from catastrophic ones, and focus health insurance on the latter rather than the former. You’ve asked whether the hypothetical 30 year old cancer survivor should pay “more” for health coverage than the 30 year old blessed with good health. But maybe your question is the wrong one. Thinking about other forms of insurance — we don’t object to higher auto insurance premiums for young men, or higher homeowner’s insurance premiums for those who live on the beach, or higher life insurance premiums for 60-year olds compared to 25-year olds. If health insurance is really insurance, we shouldn’t object to higher premiums for people who, statistically, are likely to have higher health care costs.

    But your question seems to presuppose that it’s somehow unfair that some people, who have the bad luck to get sick, have to use more of their own resources for health care than do those who are more lucky. And that it’s the role of the government to equalize those expenditures. Is that your view?

  98. And thanks Rhett for your efforts to keep the conversation civil and non-personal.

  99. And thanks Rhett for your efforts to keep the conversation civil and non-personal.

    Now do your part.

  100. Scarlett said “But your question seems to presuppose that it’s somehow unfair that some people, who have the bad luck to get sick, have to use more of their own resources for health care than do those who are more lucky”
    Because there is a fundamental difference: if you can’t afford your auto insurance, you take the bus. But if you can’t afford healthcare insurance, you forego treatment and possibly die.

    And in reality, because as a society we don’t want people droppiing dead in the streets, we all end up paying for the people who can’t afford healthcare insurance. We either do it really stupidly, as it was done pre-ACA, where we only start paying when the uninsured are really sick and unhealthy and expensive, in a patchwork kind of way so we are paying for expensive ERs rather than cheap family doctors. Or we do it in some kind of sane, controlled fashion, which the ACA was a stab at. While it wasn’t perfect, it was saner and more rational than what we did before, and if it had ever had an effective mandate, it may well have been enough for the US.

    It is the fact though, that people don’t want to die, and that we can’t morally stomach letting the uninsured just die, that makes health insurance quite different from car insurance.

  101. I have a hard time with the analogy to car and home insurance. While not always easy, there are ways to opt out of that system or reduce your risk. No beach home for you! Government subsidized flood insurance. Don’t drive a car. Stop getting DUIs.

    There is no way to effectively modulate your risk for most of the high-risk health insurance people. (Diabeetus! Smoking!! Eating too much pizza! – these are not the things that make you totally uninsurable). One child had a severe illness at the age of 3; that child still follows with transplant specialists as she is at risk for needing organs (yeah, more than one type of organ) replaced in the future. I suspect snowflake is uninsurable on the private market. I don’t really worry too much about it – under the current system and with her choice of the right parents, she is very likely to be continuously employed in a job that provides health insurance, or her parents can figure out how to provide.

    But it’s weird how her life choices are restricted. The military, the peace corps and a lot of other opportunities are off limits to her. Now also restricted is a few years working as a waitress in NYC while she writes a novel – because she cannot be uninsured.

  102. Also, on the high-risk pools — no one talks about how crappy the mechanics are. My mother had a very low grad breast cancer in the early 2000s. She was uninsurable after that time period except for a expensive, low-benefit, high deductible (10k) plan. Of course plans now have high deductibles, too. Plans now cover mammograms, colonoscopy, routine physical exam without charge – she often had 5-6k/year of expenses that went uncovered, after paying out of pocket 6-8k/year for insurance. This was on income of 40k/year. She made it work for a decade and got medicare around the time Obamacare rolled out. Happiest medicare beneficiary ever!

    So, why not a high risk pool for her? She would have had to be uninsured for 6-12 months in order to qualify. High risk pools are often restricted to the uninsured (just like mortgage bailouts are restricted to people who miss payments). She was unwilling to take the risk of financial ruin if her cancer returned while she was uninsured, so she kept her crappy insurance.

  103. Yes there are real differences between health and other types of insurance. But my question to Rhett was about the extent to which we want to minimize the difference in health care expenditures between the lucky healthy and the unlucky sick. Are we willing to live with any significant differences?

    And if not, are we also unwilling to accept different financial outcomes between the lucky smart and the unlucky average?

  104. High risk pools really did not work at all. They were tried in 34 states from the 90’s through the passage of the ACA. The problem was that they were so expensive that states couldn’t afford them, so they used all kinds of methods to keep people out of the high risk pools : high premiums, waiting periods (yep, you have melanoma, but you are going to just have to wait a year to get that surgery) , and waiting lists. Many of the pools would close midyear to new people. They only ever insured a small fraction of the population that couldn’t get insurance due to pre-existing conditions. That is one of the things that makes me the angriest about this AHCA mess – they claim they will provide for people with pre-existing conditions with high risk pools, but they make exactly the same mistake that was made before by drastically underfunding the pools. And the worst is, they KNOW IT. It was only 10 years ago that the press was covering the failure of high risk pools.

  105. And if not, are we also unwilling to accept different financial outcomes between the lucky smart and the unlucky average?

    How many hundreds of thousands of dollars did you save in taxes because you have many, many children? How many hundreds of thousands of dollars will I have to pay to compensate for your boys who will have many, many children?

  106. “the extent to which we want to minimize the difference in health care expenditures between the lucky healthy and the unlucky sick.”

    Personally, I want this difference to be as small as possible. And I’m happy to pay a lot to make that happen. It’s’ bad enough to be sick, but to have to impoverish yourself because you’re sick? Talk about adding insult to injury.

    When I was growing up, whenever I was upset about something, my mother always used to remind me that I had my health, that was the most important thing you could have; everything else, she told me, could be dealt with. “But if you don’t have your health,” she used to say, “nothing else really matters.”

    I think there is a lot of truth in my mom’s belief about how awful it is to be unlucky with your health. I think that is in stark contrast to someone who is part of the “unlucky average” in terms of being smart — I think we have all agreed on this board on many occasions that there are plenty of ways to have a happy life even if you aren’t Totebag-level, NMSF smart. But I don’t think there are many ways to have a happy life if you are ill and can’t afford to get well.

  107. I think the proper role of government is to ensure that health coverage is offered on an equal basis to everyone, whether rich, poor, old, young, healthy or sick. And I am more than happy to pay more for that.

  108. Are we willing to live with any significant differences?

    I’m not. But all within reason. For example: Do I think they should expropriate RMSs vacation home and give it to a homeless person? No. Am I happy to pay higher taxes so some kid who had cancer at 10 doesn’t have to go through life fighting the after effects of chemo and paying $1500/month more for health insurance? Sure.

  109. It is important to realize that the fact that many people will lose access to affordable medical insurance or to extensive medical care is a feature, not a bug, of the current move to reduce the government’s role in this process. I think many of us with very differing political views would like to see a system where everyone is covered by a catastrophic plan to prevent destitution (sliding scale cost, but mandatory) and where all children and pregnant women receive the basics of medical care with no or minimal cost. I even think most wouldn’t mind these being funded by some sort of taxes, payroll or value added or even out of general funds. But beyond that, people disagree, often vociferously. Different sides of the spectrum or different regions ascribe different health expenses to lifestyle choice and not random bad luck, so they want to exclude those from funding.

  110. Even if everyone has access to exactly the same health care plan, the unlucky sick will still have to spend at least some of their own money on deductibles and copays that the lucky healthy will be able to spend on fun stuff. That can amount to a substantial sum for those who are unlucky on a regular or chronic basis. Is that acceptable, or should the government be taking more resources from the lucky healthy in order to minimize the expense differential?

    Maybe the question is whether people should be expected to spend *any* of their own resources on health care? Not sure what the answer is, actually.

  111. RMS,

    I think Rawls’s veil of ignorance is a better way to convince Scarlett than your leg crossing comments. Don’t you have a phd in philosophy?

  112. Yes, the lucky rich should have to subsidize the unlucky poor. That is the only way this works. If you see healthcare a right, someone has got to pay for it. The rich should.

  113. “Different sides of the spectrum or different regions ascribe different health expenses to lifestyle choice and not random bad luck, so they want to exclude those from funding.”

    Well, the truth is that some health expenses can be directly attributable to certain behaviors, such as smoking, substance abuse, or diet/exercise choices. It’s not all actually random bad luck. So that complicates things.

  114. Don’t you have a phd in philosophy?

    Are you paying me a salary and bennies to use it? No? then shut up.

    Scarlett and WCE have been all about other women keeping their legs crossed. But when their own husbands push, they can’t say no.

  115. Not all of the unlucky sick are poor. Should the subsidy be restricted to the poor? Or is health care, like public education, something that the government should provide to all? So we should be looking at Medicare for all.

  116. Rhett is going to say that we need to do Medicare for all to get the buy-in from everyone. Personally, I would like to see bigger subsidies both in terms of HHI that qualifies and amount of subsidy. So, totally based on income. For reasons that I think are unique to the US, I don’t think I want single payer here. I quite like Obamacare if we can force everyone to get covered and we increase the subsidies.

  117. “If health insurance is true insurance, then providers should be able to take risk into account when setting premiums, and people who try to game the system by opting out when they are healthy should be penalized.”

    If it is true insurance, then the penalty for opting out will be only receiving the medical care they can pay for.

    But as a society we’ve already decided that is not acceptable, or emergency rooms would be able to turn away anyone without medical insurance.

  118. So we should be looking at Medicare for all.

    Sold!! I would love a two tier system. Medicare for everyone and private insurance to cover “extras” — xarelto instead of warfarin (fancy new anticoagulant that doesn’t require monitoring), breast reconstruction post mastectomy, erectile dysfunction medications, botox for migraines, etc.

    If we cut those things out of medicare and then covered every single person with access to insulin and sufficient blood test strips, proven generic blood pressure medications, 90th%ile cancer treatment, I’m totally on board.

  119. And when we start talking lifestyles, I hope we remember to include all the runners who ruin their knees and hips. Those people make choices that cost the system tons.

  120. “I think the proper role of government is to ensure that health coverage is offered on an equal basis to everyone, whether rich, poor, old, young, healthy or sick.”

    That seems to take away the choice of prioritizing one’s own health expenditures, and that of one’s family, at a higher level than others.

    I would find it more acceptable to provide a coverage floor, and allow people to opt for higher levels of coverage.

  121. Apparently I was typing when Ada posted. We seem to be of like minds WRT a tiered system, although I see it more as a continuum above a floor.

  122. I absolutely believe in either Medicare for all or National health for all with a side private option for those who can afford it. I think many of us agree that the employment based model is outdated. We have health care rationing now. Effective access is restricted by finances, by geography/transportation, by hours at which non emergency care is provided, by what we like to call bandwidth on this site, by age discrimination in employment, by dependency on the employment of a family head.

    And most of the knee replacements I see can be blamed on the virtuous middle class pursuits of skiing, tennis, hiking, not on obesity or hard manual labor, all of which can be seen to be personal choices, even the manual labor. There aren’t all that many things that can be without question attributed to nothing but bad luck/acts of God. Most illnesses can be attributed (by someone who wants to sit in judgment or cling to illusion of control over life’s smallest details) to actions or inactions or to the environment including his mother’s poor food choices or living with poor air quality while in utero.

  123. Well, the truth is that some health expenses can be directly attributable to certain behaviors, such as smoking, substance abuse, or diet/exercise choices. It’s not all actually random bad luck. So that complicates things.

    Or getting breast cancer. You could have had your breasts removed after your kids were weaned, but no. You weren’t using them. That’s on you.

  124. The total knee replacement patients I know are all older women with arthritis. The younger sports nuts had ACL repair. Maybe knee replacements are in the future for them.
    I continue to think that Alzheimer’s will be the scourge that hits the virtuous baby boomers and totebag types whose prudent health habits keep their bodies alive long enough for their minds to fail.

  125. I agree with Finn and Ada that a floor or two tiered system is the best. I would also like tort and pharmaceutical reform as well. So if reasonable actions were taken but there was a bad outcome, you can’t sue. I understand that there are research costs but the USA is being gouged on drug pricing. Furthermore, the one trade item I want is that if a pharmaceutical company sells in the USA, a reasonable price for the drug and future research is okay but we don’t need to subsidize one payer systems outside our borders.

  126. “Yes, the lucky rich should have to subsidize the unlucky poor. That is the only way this works. If you see healthcare a right, someone has got to pay for it. The rich should.”

    Not all rich are rich because they were lucky. Some attained wealth through hard work, and forgoing or delaying gratification.

    Let’s take two hypothetical families with similar earnings and health histories. One family lives it up, and spends most of its income. The other family is more frugal, doesn’t travel as much, or buy as many toys, and saves a lot of its income. After 40 years or so of these choices, one family is poor, the other rich.

    Why should the rich family have to subsidize the poor family?

  127. “I think many of us with very differing political views would like to see a system where . . . .all children and pregnant women receive the basics of medical care with no or minimal cost.”

    If only this were true. Sadly, many Republicans object vehemently to the inclusion of maternity coverage in the required package of essential health benefits. They would rather return us to the pre-ACA world where pregnancy coverage is unavailable on the individual market, or only available at prohibitive prices. I have often wondered if rebranding “maternity care” as “unborn child care” would increase support from conservatives.

  128. Kate, I guess we disagree on that. In the hypothetical case I presented, I don’t see any fairness in requiring the family that saved to subsidize the profligate family.

  129. “I understand that there are research costs but the USA is being gouged on drug pricing. ”

    IMO, the US needs to stop subsidizing pharmaceutical development for the world, especially for other developed nations.

  130. I don’t think it is fair, either. It is just the way it is. The people with $ have to pay more. There will always be winners and losers. And I don’t feel that bad for the people with $. They can always get rid of the $.

  131. Pres Bush’s Medicare Drug Benefit legislation specifically prohibited the US govt from negotiating favorable prices from pharma manufacturers. I used to work for a drug testing support company. One of the services was negotiating the drug prices on a country by country basis with the health system of every other developed nation in the world. The drug companies and the insurance companies – the forked tail – have won the financial struggle – and are wagging the dogs – the patient population, the MDs, the hospitals.

  132. If the US starts negotiating drug prices, that will put a big dent in the development of new drugs. Is that what we want?

    OTOH, as it is now, we are subsidizing the rest of the world, which is especially galling in cases when our money is going to foreign drug companies.

    Any good ideas on how to get other countries, particularly developed countries, to pay a larger share of drug development costs?

  133. Finn, I’ve long been a fan of international standards for drug safety. If it’s safe enough for other developed countries, it should be safe enough for us. Much of the cost of drug development is FDA compliance. I’m unsure what effect our court system has, but the fact that most of the rest of the world has a “loser pays” system seems like it probably has an effect.

    I also think that reducing drug and medical device development overall is probably a reasonable choice. We should focus on supplying a modest level of care to almost everyone rather than an optimal level of care to a smaller subset.

  134. Meme not only are they wagging us all but they have us barking and biting each other! The ACA did not address pharmaceutical reform either. I would like to see traction on this but at best it is ignored in each reform attempt and at worse works to that industry’s advantage. That lobby is so powerful that don’t know how we can address it. I believe that Rhett is right and each election cycle will be about healthcare but I don’t see real reform in sight.

    Kate – Finn’s example and the response of oh well you have to pay for your neighbor because they are irresponsible is exactly why people become upset. In his example, the “rich” made sacrifices and the response that their sacrifices would go to someone else who not only didn’t but spent their time and money having fun doesn’t fly.

  135. Why should the rich family have to subsidize the poor family?

    The alternative is leaving Bob to die in an emergency room parking lot and the public won’t let that happen. The other reason is we don’t know what the future holds for any of us. A little early onset dementia and you’ve lost all your savings in some scam. It happens every day, are you sure it won’t happen to you?

  136. UtL – I get it. But it is reality. It is similar to the housing crisis. A lot of people overextended themselves, got in to trouble and walked away without much harm. And the responsible people paid the bill for that. It is just how it works. I think we either consider healthcare a right or we don’t. If it is a right, someone needs to pay for it. Really the only people in the position to pay for it are those with money. As of now, we don’t have the stomach to deny people health care when they need it. So, the people with money are paying for it one way or another. I would rather it be in an orderly fashion.

  137. Kate, I guess we disagree on that. In the hypothetical case I presented, I don’t see any fairness in requiring the family that saved to subsidize the profligate family.

    This is a big argument in favor of a single-payer system paid for by payroll deductions (medicare for all, or just funded through income tax). That’s the only way to ensure everyone pays their fair share.

  138. So if reasonable actions were taken but there was a bad outcome, you can’t sue.

    How do you determine if the actions were reasonable? You still end up with a process that will be remarkably like a lawsuit.

  139. I think it was Dnever Dad who summed it up in a way that resonated best with me that liberals would rather help as many people as possible and know that some “undeserving” also received benefits while conservatives would rather know that no “undeserving” received benefits while knowning that some people wouldn’t be helped. It seems the same with healthcare to me.

    One of the reasons that I converted to being a Lutheran after growing up Catholic is the concept of grace. None of us are deserving. I think that is why I’m more accepting of those who don’t “deserve” benefits receiving them.

  140. WCE, I was referring to the pharmaceutical companies being able to reap much more profit from American patients, insurance companies, and taxpayers than from other countries, in large part because the US government doesn’t negotiate drug prices. It is my perception that for many drugs, most of the profits are from US sales.

    It would be interesting to see how other developed countries respond if our government starts negotiating drug prices, with the reduced level of development following. Will that be OK for them, or will they step up research funding?

  141. Finn, I agree that drug prices should be negotiated, with an eye to the long-term effect on the market so that any shortages (like what existed/periodically recurs after the vaccine market consolidated) are tolerable. Canada can be supplied with our excess drug manufacturing capacity; we can’t be supplied with Canada’s excess drug manufacturing capacity.

  142. “I would like payroll tax to fund it.”

    In my hypothetical example, it makes sense. Both the profligate family and the family that saves would pay the same tax, which IMO is fair.

    But to a large extent, that means the middle class would pay for it. Those whose income is from investments would not be funding it.

  143. “This is a big argument in favor of a single-payer system paid for by payroll deductions (medicare for all, or just funded through income tax).”

    Would the single payer pay for just the floor-level coverage, or would it pay for the upper tiers as well?

  144. We should exempt the first $75k or so of income. And also have a net investment income tax. I think there are lots of ways to actually fund it if we could actually get people agree that it is something to be funded.

  145. DD – auto insurance already has this in place in some states and a similar process can be followed. I went through this process myself with an accident to have it determined that I was not more than 50 percent at fault (just an FYI in many states if you are the person who is taking a left, you are automatically at fault in the accident, regardless of what the other driver did, and must appeal) I went through the insurance commission’s board with a hearing and was not held responsible and could not be surcharged on my insurance or lose points.

    I think there can be a group of providers who look at cases and decide that reasonable actions were taken. This is already done with case reviews at most facilities anyways. So if you cut out the wrong kidney that is not reasonable and the provider should be penalized up to losing their licenses as well as monetarily. But if you provided reasonable care for example getting an x-ray as opposed to an MRI because the patient lacked all other risk factors but in six months the patient was shown to have a cancer that would’ve been caught with an MRI you are not sued. As the system stands today that provider is going to pay. I believe that there are algorithms that can be used and others developed that would assist. But as it stands now with providers practicing defensive medicine we are over using expensive testing. I’ve also listened to some podcasts and read some recent articles and books on end of life and we are spending too much in that arena. But since people don’t have these discussions or when faced with the actual ending of treatment cannot stop themselves, we spend a great deal of money on fruitless treatment that at worst lessens the quality of those last days/weeks of life.

  146. It’s a mistake to view health care as just another commodity. If you were a grasshopper instead of an ant and now you can’t afford a Mercedes S class, well, that’s a shame. Health care is not in the same category.

  147. tcnmama, yes that was me. :)

    Usedtolurk, essentially you’re saying there would be a pre-trial hearing to determine if a lawsuit can move forward. I don’t see how that’s much different than the current system.

    Going off on a related tangent, the best way for true tort reform in any area is to implement “loser pays.” But that will never get adopted.

  148. I apologize for getting too personal and for dragging the children into the argument.

  149. Pursuant to a suggestion from another member, I apologize specifically to Scarlett and WCE for my disrespectful remarks.

  150. RMS,
    Thanks for the apology.

    Rhett,

    Had to Google Rawls. Here is an article suggesting that the veil of ignorance doesn’t necessarily lead to the outcomes favored by the left.

    “Maybe this is all deeply misguided. Maybe what’s better for the poor really is social housing and rent control and high minimum wages and labor regulations and socialized medicine and higher taxes on the rich. But here’s the thing: the veil of ignorance doesn’t tell you anything about that either way. The only way that the veil of ignorance gets you social-democratic policies is if you presuppose that they are better for the poor, which is precisely what most conservatives dispute. With or without the veil of ignorance we still have to use our very limited empirical means to ascertain which of various proposed public policies are better for the general welfare, and the veil of ignorance doesn’t get you an iota closer to any answer.”

    https://www.forbes.com/sites/pascalemmanuelgobry/2015/01/06/hey-kids-lets-take-a-trip-behind-the-veil-of-ignorance/#130d9f1151a3

    His very first argument is that the veil of ignorance should lead to pro-life policies, because you might enter society as an embryo.

  151. I think there should be a midpoint between ACA and AHCA that could work, and I think the suggestions here about a universal floor with the option to purchase higher levels of insurance makes the most sense. As noted, we won’t refuse ER treatment for anyone, and that is the most expensive way to access the system. If we set up better ways to access that minimum threshold and/or catastrophic care it would be more cost-effective. On the free things, I have seen studies saying there is not a link between fre preventive care and better outcomes or reduced overall costs. Describing things as “free” always troubles me because it’s so misleading. Nothing is free.

    I also think a functioning system will have to address rationing of care. Just like in every other aspect of life, we have a limited amount to spend and have to use it wisely. That might mean open heart surgery to extend the life of a 90-yr old to 91, or experimental treatment with a 5% success rate won’t be funded by the basic coverage. No politician will introduce that topic of conversation

  152. presuppose that they are better for the poor, which is precisely what most conservatives dispute.

    Is that why they dispute those claims? Many, like Rep. Levin, argue is simply unfair to use the power of the state to mitigate the effects of bad luck. I guess you can get into an argument about libertarians vs. conservatives, but it seems disingenuous to me to claim that many conservatives oppose these programs because they honestly don’t think they are good for the poor.

  153. Another one bites the dust.

    “The head of the largest insurer in the Mid-Atlantic region warned Thursday that the Affordable Care Act marketplaces were in the early stages of a death spiral, a statement that came as the company announced its request for massive, double-digit premium increases for next year.

    Projecting that by year’s end the company will have lost a total of $600 million since it started selling plans in the marketplaces four years ago, CareFirst Blue Cross Blue Shield is requesting a greater than 50 percent rate increase in Maryland, a 35 percent increase in northern Virginia and a 29 percent increase in D.C.”

    https://www.washingtonpost.com/news/wonk/wp/2017/05/04/one-of-marylands-biggest-obamacare-insurers-wants-to-hike-rates-50-percent-next-year/?utm_term=.5fb73e8eef1d&wpisrc=nl_daily202&wpmm=1

    Perhaps the House plan is seriously flawed, but it’s replacing another seriously flawed plan, not some health care ideal that many on the left insist we must protect.

  154. “Many, like Rep. Levin, argue is simply unfair to use the power of the state to mitigate the effects of bad luck.”

    Link?

  155. Scarlett,

    The only option for both the ACA and AHCA is to either increase the penalties or increase the refundable tax credits to the cost of a bare bones bronze plan and sign everyone up.

  156. Much of the current death spiral is due to massive uncertainty, The uncertainty is taking its toll in other ways too. Our healthcare IT and healthcare admin grads are having a terrible time finding jobs right now because the hospitals, insurers, and medical organizations are all in hiring freezes right now, at least in this area. No one knows what is going to happen, so they don’t want to hire.

    I said it when the ACA passed, I said it last year, and I will say it again: the main flaw with the ACA was the lack of an effective mandate. If they had an effective mandate, there wouldn’t be a problem. This system works well in other countries.

  157. The thing that just baffles me in this debate, and that no one seems to want to answer to my satisfaction is: we have numerous models of working healthcare systems that cost less than ours. So why do we want to go chasing a model that has never been shown to work before instead of just picking something that works? The common threads in all of the models that work, from Canada all the way to SIngapore, is that they are highly regulated, there are price controls and coverage is universal. The rest of the details may vary, but those two things always pop up.

  158. China is the one major country I know of that purposefully experimented with a free market model of healthcare (yep, Communist China) and it did not go well at all.
    “By 2008, China’s leaders had concluded that major reforms in both insurance and the delivery system were necessary to shore up the system and ensure social stability. In a fourth and ongoing phase of evolution, they officially abandoned the experiment with a health care system based predominantly on market principles and committed to providing affordable basic health care for all Chinese people by 2020. By 2012, a government-subsidized insurance system provided 95% of the population with modest but comprehensive health coverage”

    http://www.nejm.org/doi/full/10.1056/NEJMp1410425#t=article

    I personally think that China’s experiment with free market healthcare was a major driver of the terrible practice of abandoning babies, at least as much as the one child policy.

  159. I had Levin and Walsh confused. It was Walsh who said,

  160. “Much of the current death spiral is due to massive uncertainty”

    The health care exchanges have been headed toward death spiral for several years. They were supposed to be the centerpiece of Obamacare, and have not only failed the “if you like your plan” promise, but were never (IMO) intended to work properly. The incentives were not in place to persuade young healthy people to enroll.

  161. The incentives were not in place to persuade young healthy people to enroll.

    So that should be fixed, right?

  162. “The incentives were not in place to persuade young healthy people to enroll.” You mean like having an effective mandate? That is my main point.

  163. The limited government crowd at least does not pretend. They don’t want the new law, they want complete repeal of ACA and a further rollback that guts state authority to set standards for insurance purchased by residents. Employment based health insurance is also a target – let people be paid in cash and spend their money as they choose. They also want to consolidate all federal “charity” moneys – medicaid, education, disability accommodations – into block grants to states to spend as they see fit – no federal mandates to conform to. True libertarians don’t wish to force states to spend on religious school vouchers or forbid spending on Planned Parenthood, but the limited government movement in the US is closely allied with conservative religions so that is often an overlay.

  164. And Scarlett, what is your answer to the fact that highly regulated, mandated universal coverage works well in so many other countries, and that a market oriented approach was such a disaster in China? (read above link). I can’t seem to ever get conservatives to give me an answer to that other than “we’re different”.

  165. The limited government crowd at least does not pretend.

    And that’s why I can respect their position while not agreeing with it. I am somewhat surprised by Scarlett’s idea that those kinds of feelings and positions are so rare on the right.

  166. RMS, thanks for the apology.

    I agree with Mooshi that the ACA was doomed without an effective mandate. My job is making systems work cost effectively, and I find it impossible to separate moral arguments (healthcare is a right!) from financial ones (but if healthcare/food/electricity/housing is to be provided by the government, there needs to be a sustainable mechanism for its provision)

    When Obama ran against Romney, I observed that Romney had created a fiscally reasonable healthcare system in Massachusetts and that I couldn’t support a visionary as impractical as Obama. I still think that.

    I’m unsure if it is feasible to provide the same level of healthcare to everyone, given the significant differences in the wealth, health and priorities of the different states. Even in Europe, the system seems to be cracking under the needs of low skill immigrants. Massachusetts system would not work as well if it had average people with average characteristics. Its weather, geography and history make it culturally unique.

  167. Well, Rhett, there is a strong belief among small government conservatives that most of the redistributive spending is a waste of money. That the life of lower class minorities has not improved, even if many discriminatory barriers have fallen. That community and family breakdown and the lack of religious cohesion in most of the country is the fundamental cause of the plight of the lower classes, especially of the lower class whites whose status has fallen. That the media and educational system shoulder a great deal of the blame for that. That government redistribution formulae actually encourage further family breakdown. That immigration (legal and illegal), initially from Latin America for service and working class jobs, but also from Asia in the middle class and professional ranks, has provided a lower wage floor and squeezed out native borns. And anti immigrant feeling, and anti intellectualism and anti urbanism also have other darker roots that demagogues fan, until there it becomes acceptable to blame aloud heartland decay (real and perceived) on non Europeans or non Christians or the disabled or uppity women, and so it is appropriate to repeal policies and stop spending funds that give preference to them.

  168. This article on Venezuela explains why I so fear government.

    You rate that risk as higher then the risk of unchecked power accumulating in the hands of the rich? History is replete with many more examples of that than Venezuela.

  169. “I can’t seem to ever get conservatives to give me an answer to that other than “we’re different”.”

    Well, we ARE different. We are a huge, diverse country built on a foundation of personal freedom and limited government. My Australian friends can’t understand why the US doesn’t have a health care system like theirs, but Australia, though superficially similar to the US, was founded as a penal colony and didn’t fight a war of independence. It also is a remarkably homogenous and country, protected against illegal immigration by its remote location (don’t ask them about the island detention camps) and without the complications of slavery and the resulting racial issues.

    With regard to the mandate, it’s not clear that forcing people to buy standardized expensive policies with benefits they neither want nor need is the right approach to the problems posed by catastrophic health care costs, few of which can be attributable to the lack of free contraception or affordable maternity coverage. Shouldn’t the focus be on a universal catastrophic coverage program?

  170. Shouldn’t the focus be on a universal catastrophic coverage program?

    1. Define catastrophic. Does a $1200/month medication qualify as a catastrophe if you’re make 22k a year as a Waffle House waitress?

    2. Also cite some documentation supporting your idea that contraception and maternity care is the primary driver of cost. My understanding is the primary costs drivers are prenatal and end of life care along with the ongoing management of chronic diseases.

  171. Rhett, as far as I can tell, The Rich either ignore me or try to sell me stuff so they can become richer. Despite the fact that Bill Gates allegedly could buy every house in Washington, Oregon and Idaho, he hasn’t done so. The Rich actively try to understand and benefit from the inviolable laws of economics so they can get richer, unlike Socialists, who claim the laws of economics either don’t exist or don’t apply. To the extent I agree with your claim that The Rich have caused more problems throughout history than The Socialists, you have to remember that The Rich appeared about the time we stopped being hunter/gatherers.

    Oregon is currently debating “rent control laws” as a solution to our housing shortage. “We learn from history that we do not learn from history.”

  172. WCE,

    What do you think is the natural state of the world. Is it a large and prosperous middle class with a (relatively modestly compensated elite) as in the US c. 1955 or is it a world where wealth and power accumulate in the hands of the rich and well connected to the determent of the vast majority?

  173. To the extent I agree with your claim that The Rich have caused more problems throughout history than The Socialists

    So you agree they occasionally need to be reigned in?

  174. I think war and instability is the natural state of the world, with the aggressive constantly trying to achieve power and wealth for themselves and their families.

  175. Rhett, I’m not sure what I think about the rich in a global society where the rich are mobile. I think the Rule of Law is far more important than the distribution of wealth. I care far more that people are not starving, as in Venezuela, than I do about whether Bill Gates has 20 million or 30 million times my wealth.

  176. WCE,

    So then we organize society to mitigate and productively channel those tendencies.

    The natural state of the world seems to be a tiny elite exploiting almost everyone and only systems of government intervention and redistribution have been found to remedy that situation. Obviously, like anything, it can be taken to a destructive extreme.

  177. I agree that the rich should pay taxes and obey the laws and that the government should use those taxes in socially beneficial ways- transportation infrastructure, electromagnetic spectrum management, social order, military, education. I think we’re mostly debating when redistribution becomes a destructive extreme. One of the reasons I disagree with Charles Murray’s proposal to eliminate bureaucracies and redistribute money in a basic income style is that I believe disabled people are more deserving of the redistributed money than healthy people.

    I think you underestimate the extent to which people-who-could-be-rich will work less when taxes are high or, longer term, not bother to go through the hassle (such as neurosurgery residency) to acquire high value skills.

  178. I think you underestimate the extent to which people-who-could-be-rich will work less when taxes are high or, longer term, not bother to go through the hassle (such as neurosurgery residency) to acquire high value skills.

    Not at all, I’m well aware of the Laffer curve. We’re talking realistically about 35% vs. 37% and that 2% isn’t a significant driver in almost anyone’s decision to do anything. Obviously when we start moving through the 40%s that changes.

  179. Scarlett, the large number of countries that have working healthcare systems are all different from each other too. Every one of those countries could have said “we’re different” but they didn’t. Well, China did, but now they are moving away from the free market. The reality is, the model – universal, highly regulated coverage works across a large diversity of countries. The details change because these countries are different from each other – but the basic principles remain the same. I think that if we recognize the fact that universal, highly regulated coverage works, we could design a system with details that work for us.

  180. “Define catastrophic. Does a $1200/month medication qualify as a catastrophe if you’re make 22k a year as a Waffle House waitress?”

    Well, first you have to determine what routine and ordinary health care expenses are, as a fraction of income. 50% of gross income would clearly be a catastrophic expense. Would 10% of income be catastrophic? Don’t know. Some on the left regard *any* non-trivial health care expense as the responsibility of Someone Else, other than the patient, to absorb.

    “Also cite some documentation supporting your idea that contraception and maternity care is the primary driver of cost. My understanding is the primary costs drivers are prenatal and end of life care along with the ongoing management of chronic diseases.”

    Don’t think that was the argument I made. My point is that one reason health insurance plans are unaffordable is that they are required to offer “essential benefits” that not all consumers want or need, which ultimately drives both healthy consumers and insurance companies out of the individual market.

    Why is this not an acceptable approach?

    “We could try to make ordinary, non-emergency medical care more of an ordinary product, one that people pay for the way they pay for food and housing and cars and World of Warcraft expansion packs and the other necessities of modern life, allowing insurance to be insurance: a financial product that helps to mitigate certain risks related to unexpected health-care costs.”

    http://www.nationalreview.com/article/447361/heath-care-reform-no-cure-scarcity

  181. Rhett, overall tax rate or marginal overall tax rate? My marginal tax rate is 45% but my federal bracket is only 25%. You can’t just look at federal income taxes.

  182. “I think that if we recognize the fact that universal, highly regulated coverage works, we could design a system with details that work for us.”

    Perhaps the problem is that the American public does not actually WANT “universal, highly regulated coverage.” Then what? It has to be forced upon us by bureaucrats who know better?

    I don’t know whether it’s the “universal” or the “highly regulated” part to which people object (suspect the latter), but perhaps many would take issue with whether or not such coverage “works.”

  183. I think what Americans actually WANT is secure access to heatlcare so they won’t go bankrupt or have to forego treatment. That is why Obamacare started becoming popular once people were staring at the reality of losing it, and that is why the AHCA polled at 17% approval back in March when they were first trying to force it down our throats

  184. Most Americans do not think that a system like British national health where you have to wait for many months for routine non emergency procedures and appointments “works”, even if they don’t have the funds in hand to pay for said procedure or have to travel many miles and/or take unpaid leave from work to obtain the care. But I think it is the highly regulated that is the obstacle. If we can’t mandate infectious disease vaccinations for public school attendance, how can we impose any regulations on patients? If we expect doctors to finance their own education, how can we assign them to areas of need?

  185. “We could try to make ordinary, non-emergency medical care more of an ordinary product

    1. What percentage of care is that? If, as I understand it to be, the vast majority of the expense is pre-natal, end of life and chronic disease care, then it’s not going to make much difference.

    2. You could have a system where rather than pay $X to Aetna and $Y to Medicare the average American pays a smaller amount and then has the choice to fund an FSA/HSA with the difference. And, after 40 years when they need a knee replacement, they can dip into the funds they’ve been prudently and diligently saving and investing over the years to pay for it.

    The obvious flaw in that plan is that most folks wouldn’t bother to save enough and those that did would lose half of it to bad investments exactly like they’ve done with the 401k/IRA system.

  186. Meme, then how about the Singapore system, also highly regulated and universal, but with different details? In Singapore, everyone is mandated to have a health savings accoumt and primary care is paid from those accounts. But prices are low because the government regulates prices (and runs hospitals). There is also a universal catastrophic health insurance system. So, universal and highly regulated, but in a different way from Great Britain.

  187. Or Japan, which has mandatory health insurance, provided through a number of plans. The government tightly regulates prices, so even though the Japanese visit hospitals far more often than we do, their healthcare costs are about half ours, and they have better outcomes.

  188. Scarlett – the problem with making health care a “product” like any other product is that if people can’t afford that product, they might (and do) die, as Mooshi said above.

    Example – child with a congenital heart defect. If discovered in utero, I presume you would not want the mother to abort. If discovered at birth, open heart surgery required for survival, would you rather let that baby die if his/her parents don’t have the resources to purchase that “product”?

  189. “That is why Obamacare started becoming popular once people were staring at the reality of losing it, and that is why the AHCA polled at 17% approval back in March when they were first trying to force it down our throats”

    If you recall, Obamacare was also “forced down our throats” with zero Republican support and smug Democratic leaders who rammed it through before anyone actually read it, insisted that we could keep the plans and doctors we liked, and then couldn’t even get the computer system to work for the rollout.

  190. “Those whose income is from investments would not be funding it.”

    yes, I’m late to the game, but Finn, it’s all in the details. In my utopian world, we get rid of all the social engineering (deductions, exemptions, “loopholes”) and make it simple a la Steve Forbes’ tax return on a postcard:

    Total Income $1,000,000 <== includes everything.
    Multiply by e.g. 25%
    Tax Liability $250k

    And then we draw the line where paying 25% tax (or whatever) makes the most sense, meaning below than the rate is 0%. I truly believe we could have a fairly low overall tax rate covering healthcare "Medicare for all" if you will, defense, social security, national parks and everything else, and a reasonably drawn income line, if we truly had tax overhaul.

    But that'll never happen.

  191. “If discovered at birth, open heart surgery required for survival, would you rather let that baby die if his/her parents don’t have the resources to purchase that “product”?”

    Well, if you read the quote, it referred to “ordinary, non-emergency medical care.” And do “we” currently let babies who need heart surgery die because their parents are uninsured?

  192. “Massachusetts system would not work as well if it had average people with average characteristics.”

    WCE — Why do you think Massachusetts doesn’t have lots of average people with average characteristics? Sure, we have plenty of wicked smaht people, but I can assure you that we also have plenty of people who really are just like this:

  193. I think one of the issues is defining the rich. Most people answer the question of who is rich as anyone who makes more money then they do and don’t actually define themselves as the “rich”. They’re perfectly fine with saying that we should tax the rich more but they’re thinking that is happening to someone else and not themselves. I would argue that most “totebaggers” are considered rich compared to other citizens.

    My cynical side believes that architects of the ACA and those who rushed it through knew that parts would fail. They just expected when it did they would be in power to “correct” it and push for a more universal system knowing that once you give something to someone, it is hard to take it away. What has happened instead is a change of the party in power. The other issue is they don’t truly layout a way to pay for it. Until we solve the drug expense, I don’t see anything really working long-term to hold down costs.

    We talked last week or so about simplifying the tax code but if we do that we put CPA’s, estate lawyers and anyone else who makes their living on a complex code out of work. We complain about college costs but don’t seem to suggest that all college professors should take a 50 percent cut in pay since it would be for the good of society to have everyone educated. It has been floated here before that we should make providers move to areas to serve their fellow citizens disregarding all the time, money, effort and what that would do to their lives for the “greater good”. Why don’t we do that to all professions? How do we as a society come together and say, we value healthcare, education etc and then pay for those things? Do we say that any money you make over a certain threshold is seized by the government for the good of the country? To quote Forrest Gump: “Momma said there’s only so much fortune a man really needs and the rest is just for showing off.” And if we did that would anyone work beyond the threshold?

    DD – not a pretrial system but more of a review system that is constantly scanning for issues. Loser pays would be best but I agree that with all the attorneys who are in congress that is just not going to gain traction. But using technology and/or man power to do these things adds to the expenses. We need to curb over utilization especially since most of it does not necessarily improve anyone’s quality of life. MBT is correct that there will be rationing but no politician has the guts to really put that on the table. The last attempt got labeled as “death” panels. If we ration care or use some type of algorithm to determine the amount of care, most of us would be upset with that restriction.

  194. It has been floated here before that we should make providers move to areas to serve their fellow citizens

    I don’t think I’ve heard of forcing them but I have heard of forgiving their loans if they make the choice to serve in high need areas for a period of time.

  195. Scarlett said “Perhaps the problem is that the American public does not actually WANT “universal, highly regulated coverage.””
    Well, what some people liked in our old system was the ability to not pay for insurance, knowing if they had an emergency, they could go to the ER and someone else would pay for it. Conservatives always used to call such people freeloaders. So perhaps what some fraction of the American public wants is the ability to freeload?

  196. Mooshi, I want the ability to freeload (obtain medical care when I need it without paying for it) and I assume everyone else does too. Maybe that underlying assumption explains some of our differences.

  197. Mooshi, I want the ability to freeload (obtain medical care when I need it without paying for it) and I assume everyone else does too.

    I don’t understand what you mean. I’m more than happy to pay for the goods and services I receive.

  198. But WCE, as a conservative, do you really feel that a quintessentially American healthcare system must bake in the ability to freeload? Because that is really what you are getting if you have a system that doesn’t require people to buy into the system, but still pays for their care after their motorcycle accident. Only if we have a system that lets those people die do we have a system that contains both free choice and disallows freeloading. That is the system that the Chinese had from the late 80’s through the mid 00’s, which led to largescale abandonment of babies with even tiny medical issues, as well as terrible health outcomes and eventually, riots.

  199. “It has been floated here before that we should make providers move to areas to serve their fellow citizens

    I don’t think I’ve heard of forcing them but I have heard of forgiving their loans if they make the choice to serve in high need areas for a period of time.”

    Hasn’t this been going on for a while? Wasn’t this the premise of Northern Exposure?

  200. “So perhaps what some fraction of the American public wants is the ability to freeload?”

    I think I’m in agreement with WCE that this is probably a pretty large %age.

  201. “I’m unsure if it is feasible to provide the same level of healthcare to everyone, given the significant differences in the wealth, health and priorities of the different states.”

    So let the states set their own floors.

  202. When we talked about this sometime within the last five months, it came up that an MD could receive loan forgiveness if they moved to an area with need but there was still need because providers weren’t joining the programs. The tone then changed to we should make them provide this service. I don’t remember the exact date but I remember Cordelia mentioning should that also happen with farmers.

  203. I think any system must bake in the ability to freeload if we don’t want people to die for want of healthcare (or food or heat or any other human necessity). Some people will freeload by choice; some will freeload of necessity. Identifying the line separating these two groups is left as an exercise to the reader.

  204. The root of all of this political disagreement (not just healthcare but all social issues) is that Republicans think that the poor are poor solely because of their own choices, so therefore they don’t deserve any help.

  205. There are loan forgiveness programs for NPs and PAs as well. The problem is similar the earlier post on the rural teach shortage, people don’t want to live in those areas, even just for a few years.

  206. Denver Dad, I hope neither Democrats nor Republicans are foolish enough to think that there is a single root cause that accounts for poverty for each of the millions of people in poverty. Causes are multifactorial and include quadriplegia, psychosis, dementia, laziness, depression, addiction, caregiving obligations, racism and geography. See previous rants on “multifactor”.

  207. “Republicans think that the poor are poor solely because of their own choices, so therefore they don’t deserve any help.”

    I don’t think that’s universally true. I think a lot of people, including Republicans, think that some of the poor who avail themselves of these services are undeserving, e.g., those who could support themselves but instead exercise their preference for leisure, facilitated by government programs.

    Unwillingness to have social welfare programs extend to such people is one reason for opposition.

  208. Singapore has a unique system that has many different bits. It is also a small dense country, so there is no issue with geographic dispersal of services. Approximately 80% of Singaporeans get their health care from the the public system. All services cost something. Nothing is free. There are compulsory Medical Savings Accounts, ~8% of salary. The balances can be shared within families. Payment out of the account is only for approved services and drugs in the govt system and is subject to caps of various sorts, so that there will be enough left over for old age. There is also a mandatory govt catastrophic insurance scheme, newly beefed up in 2015. (the previous one would not cover anyone over 92, and was optional). You pay the premium out of the MediSave account. There are deductibles, coinsurance, etc. The govt endowed Medifund for the indigent is there to pay for those who have no funds for whatever reason, but it is not automatic. You have to apply and if there isn’t enough money or the hospital does not deem the expense worthy, you lose. No freeloading. All babies, not just ethnic Chinese or children of university graduates, get great care because there is a birth crisis.

    So there is government mandated individual/family responsibility for funding/choosing health care expenditures. The govt provides a basic level of care. The wealthy and the foreign have a separate free market system (care there is often covered by multinationals that offer private insurance). You may be able to use the govt insurance in the private system that serves 20% of patients (I can’t figure that out quickly) but if you do it only reimburses at public rates.

    The population of Singapore is 5.5million. Land area 277 sq mi. The population of New York City is 8.5million. Land area including staten island is 307 sq mi.

    If the successful real life experiment in Massachusetts is (as is often claimed) inapplicable to the rest of US because we are so different (and I am tired of hearing that), how could the Singapore system be applicable to anything but an orderly large metropolis?

  209. But WCE, we can prevent crass freeloading by simply having a mandate. Everyone must be in the system. Like every other country with a wellfunctioning healthcare system. Yes, some people are subsidizing others, but it isn’t the abject freeloading you see in our no-mandate system, in which your 20 something guys who think they are invincible refuse to be part of the system until they crash their motorcycle.

    I don’t get why subsidizing poor or sick people is bad, but paying for freeloaders is good.

  210. Meme, I am not proposing we wholesale adopt the Singapore system. There are lot of things about SIngapore that are quite different from everyone. All I am saying is that there is a global smorgasbord of ways to implement healthcare systems that are all different from each other, but the same on some very basic priniciples: universal, regulated, price controls. Even China, which dwarfs everyone in terms of population, which has a relatively unhealthy population, and a large land area, is going that way.

  211. “Unwillingness to have social welfare programs extend to such people is one reason for opposition.”

    Another reason for opposition is that the ACA spent billions to expand Medicaid, and the most reliable data available reveals that Medicaid doesn’t actually improve health outcomes or mortality. Social science data is Science, which many on the left marched last month to defend.

  212. Another reason for opposition is that the ACA spent billions to expand Medicaid.

    You say that and you raise your valid points. But am I correct to assume you don’t actually oppose a universal heathcare safety net.

  213. “I don’t get why subsidizing poor or sick people is bad, but paying for freeloaders is good.”

    Has anyone actually said that paying for freeloaders is good?

    I think some people are OK with paying for freeloaders as a cost of also providing for others in need of care.

  214. “Even China, which dwarfs everyone in terms of population, which has a relatively unhealthy population, and a large land area, is going that way.”

    But at this point, we don’t know how successful that will be.

  215. Well, their experiment with a free market system was definitely not a success!!

  216. “Even China, which dwarfs everyone in terms of population

    It doesn’t dwarf India.

    And a fact that has always amazed me, the third most populous country in the world after China and India? The United States.

  217. I could support a Singapore-style system and I definitely support a carefully defined, actuarially sound system of basic care with mandatory contributions. Note that Singapore doesn’t provide care for illegal immigrants.

    Meme, I understand you’re tired of the argument that Massachusetts, because of its demographics, is a unique case. I can’t tell whether you agree or disagree with the economics of the argument. Massachusetts has 0.86 households with incomes over $150k for every household with income under $25k. Compare that ratio to New Mexico (0.23), Alabama (0.20) and South Dakota (0.28). Those ratios describe the relative potential to tax the upper class to fund healthcare for the poor.

  218. Finn said “I think some people are OK with paying for freeloaders as a cost of also providing for others in need of care.”

    But subsidizing unhealthy people in an orderly fashion is bad. I know you weren’t the one to say that, but it seems to be the crux of the argument that conservatives make. They want no mandate, thus implying that paying for freeloaders is fine, but they don’t want to subsidize unhealthy people, because, well, payiing for people with the bad luck to get sick or old is bad. That is the contradiction I don’t get.

  219. WCE,

    Why should it be funded at the state level? I’m fine with MA paying to support MS. They are Americans too and deserve a decent level of care.

  220. Yes, we are high population country, though far behind China and India. Since we always use that as a reason why we have to be free market and not copy those weird little regulated healthcare systems, I thought I would point out that a country with an even bigger population gave up on free market and is moving to a regulated system.

  221. MM,

    And you raise a very good point, they had the most free market system in the modern world and it blew up in their face.

  222. “the bad luck to get sick or old is bad.”

    Living to old age is bad luck?

  223. No, Finn, according to conservatives, subsidizing their health insurance is bad.

  224. “how about the Singapore system, also highly regulated and universal, but with different details?”

    Singapore’s government, and its policies, is a fascinating case. They had the benefit of a visionary benevolent despot, so it will be interesting to see how long they keep things going without him.

    “In Singapore, everyone is mandated to have a health savings accoumt and primary care is paid from those accounts. But prices are low because the government regulates prices (and runs hospitals).”

    The concern with low prices is the availability of care. Will there be enough people who are smart enough and willing to make the time and financial commitments to become care providers without the promise of lucrative income streams?

  225. “We should exempt the first $75k or so of income.”

    Given that median HHI was $56,516 in 2015, this suggests that most people would not be paying for their own health insurance.

    I’d first suggest that such an exemption not be based on HHI, but on individual income. Using HHI provides a financial incentive to split up families (and I don’t get why our income tax system is set up to similar incentivize splitting families).

    I’d also suggest that all but the very poorest should have skin in the game. IMO, health care is a basic need, right up there with basic sustenance, shelter, and clothing, and far beyond things like smart phones, cable TV, and NetFlix.

  226. Rhett, much of the funding for the expansion of the care under ACA is expected to come from the states. I assume that if ACA continues, that will continue to be the case. I was trying to identify a simple number (ratio of high to low income households) that would demonstrate my point. If healthcare is to be funded, it has to be at the federal level. I strongly agree with Mooshi that state-funded high risk pools don’t work.

  227. Rhett, in case I was unclear above, states largely fund Medicaid, which accounts for the largest increase in coverage under the ACA.

  228. Unwillingness to have social welfare programs extend to such people is one reason for opposition.

    That’s my point. The Republicans want to prevent any of these people from benefitting even if it means genuinely needy people are left out, while the Democrats are okay with these people benefitting in order to ensure all the genuinely needy people are able to participate.

    There is also a significant difference of opinion between the two sides on how many people are genuinely needy and how many are lazy freeloaders.

  229. Rhett, in case I was unclear above, states largely fund Medicaid, which accounts for the largest increase in coverage under the ACA.

    IIRC that’s was 90% federally funded.

  230. I just started reading Imbeciles by Adam Cohen where the progressive liberals voted to sterilize the poor so I wouldn’t necessarily say they always have their best interests at heart.

  231. Rhett, the historic amount of federal funding toward Medicaid is around 60%. I know ACA had a temporary increase above that but we’ll see what happens to federal funding over the long term and how it changes depending on who is in office.

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