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The Actual Debate Over Health-Care Reform


A bit later today, I'll be putting up an interview with Nancy-Ann DeParle, director of the White House's Office of Health Reform. But there's a particular argument that I want to focus on. "When you step back," she told me, "there is broad agreement about 85 percent of what we're talking about."

You hear this a lot from the White House. In fact, you hear it often enough that it's tempting to think it untrue. But it's very true. And in this moment of violent town halls and ferocious controversy, it's worth remembering.

Here are the things that, broadly speaking, legislators agree about: insurance market reforms, including community rating, guaranteed issue, an end to rescission, an end to discrimination based on preexisting conditions, and an individual mandate. Subsidies for low-income Americans. Delivery system reforms. Health insurance exchanges. An expansion of coverage to about 95 percent of legal residents. Prevention and wellness policies. Retaining and strengthening the employer-based insurance market. Creating some kind of incentive for employers to offer, and keep offering, health benefits. Expanding Medicaid to about 133 percent of poverty.

Here are the things that legislators disagree about, but are discussing, and will probably figure out: whether subsidies should reach 300 percent of poverty or 400 percent. Whether there should be an employer mandate or something milder. Whether medium-size employers should be eligible to enroll in the health insurance exchanges. Whether health reform should cost $1 trillion over 10 years or $1.4 trillion over 10 years. Whether it should be paid for through new taxes on the wealthy or a change to existing tax subsidies in the health-care system.

Here are the things legislators don't agree about: whether we should have a public option that is open only to the minority of Americans on the exchanges or a co-op option. How to handle abortion. How to handle geographic disparities in insurance costs.

Here are the things that aren't under consideration but are alive in the public debate: socialized medicine. Euthanasia. Government-driven rationing. Death panels. Illegal immigrants.

The town halls might be reminiscent of the ferocious argument over Clinton's health-care reform bill, but the underlying reality is that the actual argument is much narrower. Clinton's bill, after all, reorganized the whole health-care system. It ended employer-based insurance. It changed the arrangement of every privately insured American. It imposed managed care on Americans (which they got anyway) and managed competition on insurers (which they escaped).

The bills under consideration now do none of that. The Democrats conceded so much up-front that the actual range of debate is strikingly slim. The public option attracts most of the attention, but the reality of the policy, even in the liberal House bill, is that it's limited to the insurance exchanges and isn't expected to serve more than 12 million people by 2019.

In part, that's why the debate has had to move toward fear-mongering and lies: There just aren't that many scary elements in the bills, because the legislation is oriented toward preserving the existing system and avoiding points of controversy. You can make an argument that the policy is worse because of its modesty. A more ambitious approach could save more money and do more to fix the system. But that's the way it is.

Insofar as there are real debates remaining, they are not about the policy. They are about whether people trust the Obama administration, and the government more generally, to do anything at all. They are about whether Republicans want some sort of bill, or whether they see more political upside in handing the president his "waterloo" on health-care reform. They are about whether people will fall to fear and retrench to the relative predictability of the status quo when faced with the chaos and polarization present in our political system. But beneath all that is a health-care bill that is not necessarily finished, and that is not necessarily agreed-upon, but is a lot closer to done than most people think.

Photo credit: Bradley C. Bower -- Associated Press Photo.

By Ezra Klein  |  August 12, 2009; 10:13 AM ET
Categories:  Health Reform  
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One word: reconciliation.

Posted by: newjersey_lawyer | August 12, 2009 10:22 AM | Report abuse

Do you honestly believe that community rating is non-controversial?

Posted by: spotatl | August 12, 2009 10:24 AM | Report abuse

The insurers have agreed to it. Key Republicans have agreed to it. Democrats support it. There's some discussion left over how much variation for age will be permitted, but as a principle in health-care reform, it's quite near consensus.

Posted by: Ezra Klein | August 12, 2009 10:28 AM | Report abuse

This is an interesting point: "Insofar as there are real debates remaining, they are not about the policy. They are about whether people trust the Obama administration, ***and the government more generally,*** to do anything at all."

I think there's room for the administration to spin the apparent distrust of government generally by linking it to the abuses, deception, and mismanagement of the Bush administration (and perhaps also to the deception of President Clinton as an individual).

Posted by: mjp8 | August 12, 2009 10:41 AM | Report abuse


I've been watching you bob and weave around this issue: how many legislators will return from the August break, scared witless by death threats against them and their families, and vote against the legislation? In other words, how serious is the risk that the legislation will collapse?

I know the situation is fluid, but you need to address this question rather than offering sanguine platitudes about there's no doubt in your mind that some bill will get through, even if it's a bad bill that does little beyond rewarding the insurance industry. Surely by now some doubt exists.

Posted by: scarlota | August 12, 2009 10:52 AM | Report abuse

> Here are the things that, broadly
> speaking, legislators agree about:

I am not sure what this is supposed to mean in an environment where a discredited minority can filibuster in the Senate. After all, there was "broad agreement" on the stimulus bill and it received zero Republican votes in the House and 3 (iirc) in the Senate. Regardless of what is agreed to for the text of the bill, the pressure on those 3 Senators to support a filibuster is going to be tremendous.


Posted by: sphealey | August 12, 2009 11:01 AM | Report abuse

let's take a look at two issues you mention above and see exactly folks might reasonably be mistrustful of government in general and Obama and particular. First, there is the issue of the individual mandate. Obama's original plan and campaign was very clear that they are plan did not include individual mandate and in fact attacked the Clinton campaign because it did. Then in March or April of this year, he had a "change of heart" and decided to include the individual mandate.

Secondly, one of the funding mechanisms talked about above is changing what you politely called the "changing the existing subsidies" to the health care system. what this of course is referring to is a change to the tax deductions for employer provided healthcare. In the campaign last year, Obama savaged McCain for his proposal to end deductions for employer provided healthcare.

So who exactly is being dishonest in this debate? Who exactly is demagoging the debate? if Obama can have a "change of heart" about an issue he campaigned on and can be so dishonest to pursue a policy that he is specifically attacked his opponent on in the last election, why are people now supposed to trust him in everything going forward? What in fact is there to prevent him from breaking his promises in the future? your editorials and comments seem to be saying that it's somehow beyond the pale of discussion for people to question whether Obama's plan will really be what he says it is, but there are now two instances where it will be (or might be) what he specifically said it wouldn't be before. So why exactly should the opponents believe that Obama's plan will really be what he says it will be, especially 10 years down the road?

Posted by: sgaliger | August 12, 2009 11:08 AM | Report abuse

You are absolutely correct that there is more agreement than disagreement, particularly when it comes to relatively middle-of-the-road proposals such as S. 391.

You are also absolutely correct when you say that a general fear of government interferes with the passage of health insurance reform legislation. I can't find "wrong headedness" in such fear.

Within the past month, I have seen well-liked, well-educated, and well-meaning individuals argue, complete with charts, that it would be best to abolish the Senate so that the current elected majority could rule unfettered by the influence of any minority. Within the past year, I have seen Californians decide by popular vote that a portion of its law-abiding citizenry was no longer to be afforded rights which might disrupt the voters' sense of tradition. Within the past score of years, I have seen able-minded citizens of my own hometown sterilized - physically castrated -- because they had been determined, by a competent Court, to be a burdensome blight on the economy which should not be allowed to reproduce.

So, yes, I freely and readily admit a reasonable and well-founded fear of an overly active government: I take comfort in the fact that Jefferson expressed a similar fear more than 200 years ago when he, like I, knew only the past and not the future.

The President is absolutely correct when he says that UPS and FedEx are doing OK and it's the Post Office that's having the problems. As a result, the Post Office is reducing service on certain routes. Why is the Post Office failing? Who decided the course of the Post Office? If we continue to have a Post Office, who decides which routes will continue to get the best service?

"We have seen more than once that the public welfare may call upon the best citizens for their lives. It would be strange if it could not call upon those who already sap the strength of the State for these lesser sacrifices, often not felt to be such by those concerned, in order to prevent our being swamped…" (274 US 200 at 207, O. W. Holmes delivering the opinion of the Court)

When considering each health insurance reform proposal, I ask myself "Even if the most despicable, deplorable, corrupt, unprincipled, and misinformed person was put at the helm of the bureaucracy created by this particular health insurance reform proposal, would I be proud to have supported its passage?"

Conscience should make cowards of us all. But should neither paralyze nor blind us.

Posted by: rmgregory | August 12, 2009 11:13 AM | Report abuse

EZ: "You can make an argument that the policy is worse because of its modesty."

I hardly think a plan cobbled together from five which collectively run to well over 1,000 pages in length and will cost, by your estimate, $1.0 - $1.4 trillion in its first ten years - assuming it comes in on or under budget, which I doubt - warrants the term "modest".

"Insofar as there are real debates remaining, they are not about the policy."

The Democrats made sure of this by delaying public "consultation" until they were already well far along in the bill writing process. And anyway, they are not interested in having a "debate" which would inform their policy making. They'd have preferred to have had a completed bill before the recess. Now they are engaged in a sales/propaganda campaign, not a debate.

"They are about whether Republicans want some sort of bill, or whether they see more political upside in handing the president his "waterloo" on health-care reform."

Virtually all of the negotiation in Congress has been among factions of Democrats and the Dems have made clear they are prepared to railroad the Republicans via the reconciliation process should it come to it. That's not good faith bargaining. As with the ill-fated Clinton plan, Democractic overreach and bungling, rather than Repbulican obstruction, are the key factors behind the rough public reception.

"...but is a lot closer to done than most people think.

I well believe it.

Posted by: tbass1 | August 12, 2009 11:33 AM | Report abuse

I hear you man. I'd rather hear us debating rescission than wasting time talking about death panels.

Posted by: ThomasEN | August 12, 2009 11:34 AM | Report abuse


I often think the same thing myself. But when other bureaucracies were completely turned on their heads, against their original purposes over the last 8 years (think Office of Civil Rights at DoJ, Interior Department, Office of Legal Counsel at DoJ), the Centers for Medicare and Medicaid Services (CMS) was not. It continued on its mission. I don't think this was due to their not trying to stack it with political appointees. Rather, I'd theorize it's because CMS has very strict rules on what it has to do, and it has a lot of people that depend on it and hold politicians accountable. I would think that's the case with any health reform, too.

Posted by: GrandArch | August 12, 2009 11:38 AM | Report abuse

> $1.0 - $1.4 trillion in its first
> ten years -

1.0 - 1.4 trillion - that's a scary number.

1.0 - 1.4 trillion IN ITS FIRST TEN YEARS - let's see - that's 100 - 140 billion/year. Oops - not such a scary number. Let's just use "1.4 TRILLION dollars" with no qualifiers and hope no one notices.


Posted by: sphealey | August 12, 2009 11:43 AM | Report abuse

You're right, Ezra, it's not about policy but politics and propaganda. And right now the GOP is thinking 1994 and "Waterloo". Possible exceptions are Collins and Snowe. The base is controlled by Rush Limbaugh and tea-baggers. Let's remember 59% of GOP don't believe in science, and a similar number are birthers.

On the other side Dem. office holders know one thing, if they fail, the party is gone, history, and out of power. And they know none of these idiots at the town halls are ever going to vote for them. So they will come up with a bill for sure, and will go to reconciliation, if need be.

Posted by: cmpnwtr | August 12, 2009 11:46 AM | Report abuse

"The Democrats conceded so much up-front that the actual range of debate is strikingly slim."

I think that's a big one. As you say, we can debate whether its good or bad, but that is the truth.

The other one not mentioned, which is more problematic for the current public debate-- so many details are not worked out in the legislation, but left to the appropriate administrators (HHS, IOM, etc.) to execute with fairly wide latitude. This was explicitly part of Obama's legislative strategy-- let's not get bogged down in details-- but its allowed both sides of the debate to interpret their own worst/best worlds. Both sides of these debates are arguing about fundamentally different end states from the current legislation. A more prescriptive package in some key areas may have lessened the public debate, but broadened the disagreement among legislators.

Posted by: wisewon | August 12, 2009 11:47 AM | Report abuse

When Congress reconvenes I doubt there is going to be much love nor desire for compromised nor collaboration after Dem. senators and reps have had their lives threatened,their offices defaced by vandals, and their public meetings disrupted by hate and fear mongers at the instigation and approval of their GOP colleagues.

And let's not forget that ideology and primary world view dictate the terms of the debate. The present dominant GOP world view is rooted in a 19th century social darwinist view of the world in economic policy, an 20th century literalist fundamentalist evangelical point of view in social policy. Ideology trumps science and empiricism every time for them. They can't win that debate in today's culture so they resort to fear mongering.

The Democrats approach policy making from a mix of New Deal progressivism, and neo-liberal corporatism with communitarian values. I don't see much room for "bi-partisanship" in any of this except around the edges.

When you peel away the rhetoric, the important poll was the electoral poll in Nov. 2008. The Dem. Congress and president must produce viable health care reform or their own voters will abandon them. The death threats, the screaming don't change any of that. Think "Reconciliation."

Posted by: cmpnwtr | August 12, 2009 12:40 PM | Report abuse


yeah, for that reason I wonder if congress won't dodge a million political bullets by 'pulling a HIPAA' and building in some language in the bill that says if a separate bill isn't passed in a certain timeframe that addresses whatever particularly contentious area of reform the Sec. of HHS will just write a rule.

Posted by: ThomasEN | August 12, 2009 12:44 PM | Report abuse

Ezra you are really overstating the level of agreement.
To start on small points. My understand is the gang of 6 will expand medicaid to only 100% FPL (expect for children).

The issue of state exchanges vs a national exchange is undecided. It is also not a "co-op" option it is co-ops. Hundreds of tiny worthless doomed co-ops that are almost destined to fail.

But most importantly there is no agreement on how to pay for it, how much help to give people, and what qualifies as basic insurance.

Thats like saying you are 85% if you agree to buy someones house, but you have not agreed on the price or when they must move out.

Posted by: JonWa | August 12, 2009 1:37 PM | Report abuse


"Oops - not such a scary number."

An honest appraisal would specify the present value of the benefit and the portion that is unfunded. Such calculations for Medicare yield a very scary number: an unfunded liability of $85 trillion - that's trillion with a "t".

Medicare, as currently comprised, is insolvent. Only some combination of significant future tax increases and reductions in benefits will change that. Far better, I think, for the Dems to put the existing public programs on a sound financial footing before creating yet another entitlement which only adds to our country's already considerable fiscal woes.

Posted by: tbass1 | August 12, 2009 2:31 PM | Report abuse

""The Democrats conceded so much up-front that the actual range of debate is strikingly slim."

The question is whether what is left will work in the sense that if it is to have any effect, will it be too expensive.?

tbass1 - Over what time period does Medcare have an $85 Trillion unfunded liability? (This is not a trick question)

Posted by: lensch | August 12, 2009 3:54 PM | Report abuse

Ezra in summary and with the bs filtered out:

This bill is a watered-down, costly, mish-mashed mess which will not achieve universal coverage and which will secure health industry profits at cost to the taxpayer (rich taxpayers or employers at first, but likely the middle class as health spending grows over the next 20 years) due to Obama's backroom deals with lobbyists.

I know why conservatives hate this bill, they'd hate anything Obama proposes. Why on earth any progressive would support these measly, status-quo worsening "reforms" I'm sure I don't know.

Posted by: DJK1 | August 12, 2009 4:08 PM | Report abuse

This is an intersting new spin, this "85% agreement", but either you have not read the bill or you are deliberately temporizing. You have left out a lot of the worst points in the bill and a lot more are smoothed at the edges.

I suspect this is what the congress will follow as a tactic when they get back. But it is terrible, destructive legislation.

And those who wish to comment should READ THE BILL (HR3200) or obtain an honest, concise summary. It is a horror story, believe me. You can't spin your way out of it. It needs to be scrapped.

Posted by: wbannard1 | August 12, 2009 4:15 PM | Report abuse

I know not what course others may take, but as for me (and I dare to presume, a growing number of American citizens) there is really no debate at all.

We don't want the stuff. Period.

We don't trust the president, politicians, organizations, insurance companies and pharmaceutical manufacturers that are trying to sell it to us using tactics that would make a used car salesman blush with embarrassment.

What, then, is there to debate? All the wonks and self-styled experts with calculators, Excel sheets, Powerpoints, comparisons, projections, breakdowns, analyses, etc. etc. are missing the forest for the trees.

Americans do not want the stuff. Americans do not trust the high-pressure salespersons and special interests that are constantly screaming SIGN HERE! and THIS DEAL CAN'T LAST!

Americans do not trust the media, either.

It's really not that we are stupid, racist, greedy, selfish, uninformed, misinformed, dupes of talk radio, snake-handling fundamentalists, or stuff like that. Honest.

We just don't want it and we sure as heck don't trust the folks -any of them- who are bound and determined to sell it to us whether we want it or not.

This seems a hard concept for the current establishment to grasp, regardless of political affiliation. In the weeks and months ahead the point will eventually be driven home - though it is taking a surprising amount of effort to get such a simple idea across: NO THANKS. THANKS, BUT NO THANKS. MAYBE LATER. NOT NOW.

The really comical part is that the harder the sale is to close, the more unhinged and desperate the salespersons are becoming. And that makes people who are already suspicious, REALLY suspicious.

The current administration and political leadership of both parties has no credibility and will never get anything of substance done for the duration. They could save themselves and the country a lot of trouble and expense if they just took a vacation and called the office to check in now and again to see if anythi
ng required their attention.

Ils ne passeront pas!

Posted by: Teleologicus | August 12, 2009 4:15 PM | Report abuse

lensch - Over what time period does Medcare have an $85 Trillion unfunded liability?

It is an estimate of the amount, in today's dollars, of the unfunded portion of the *future* liability - in other words, for all time. The calculation requires an estimate of the difference between revenue and expense on present trends, discounting the dollar amounts for future periods. Were the Medicare program a private insurance company it would be declared insolvent and closed down by governement regulators. It is similar in many respects the Ponzi scheme Bernie Madoff operated, the crucial difference being that contributors can be forced to continue paying in money and distributions can likewise be controlled.

Posted by: tbass1 | August 12, 2009 4:16 PM | Report abuse

I believe the issue is simple one of trust. They passed stimulus saying that if they did, unemployment wouldn't go above 8%. Also it had to be hurried because it was so critical. Less than 10% has actually gotten out there. The house hurried cap and trade because of it's importance.... Obama said he wouldn't sign legislation with earmarks. The omnibus had over 9 thousand. He said lobbyist would not be a part of his administration, and then made wavers for the ones he wanted....need I go on... this health care bill in the house is a disaster....

Posted by: ronsuev | August 12, 2009 4:22 PM | Report abuse

A secret deal with Big Pharma, so that it will continue to be a crime to mail order drugs from Canada? Let's keep those drug prices high! Not controversial at all.

Reducing Medicare's budget by five hundred billion dollars (that's $500,000,000,000) just as the Baby Boomers retire? Not controversial at all.

Passing a law that says existing health care plans can't enroll new members unless they are modified to comply with federal requirements (and no one has decided yet what the federal requirements will be)? Not controversial at all.

The consensus is just overwhelming ... The only reason I'm not at a townhall screaming is that I can't get time off from work.

Posted by: Quitaque1 | August 12, 2009 4:45 PM | Report abuse

Ezra lets stop smearing honest hard working Americans who disagree with Obamacare and address issues. I have seen the left call these decent Americans everything from Terrorists, Brownshirts, Nazis and Pelosi calls them UnAmerican. Liberals are making a huge mistake assuming all these protesters boarded a Bus at Rush Limbaugh Headquarters. According to GALLUP only 22% of Americans are liberals. 40% are Conservative and the balance are Moderates. MANY MANY of these moderates are protesting. Keep alienating them and you will lose.

Posted by: dencal26 | August 12, 2009 4:50 PM | Report abuse

Lets discuss issue by issue. In this post I will address Illegal Aliens. Obama claims his plan does not insure illegal aliens and he is correct that the Congressional Plan as written blocks insurance for them. But when it comes to dishonest Dems we always need to scratch the surface. 1) the 47 Million Uninsured figure comes from the US Census does not ask them their status. 2) Obama is pushing for Amnesty by years end as he stated which will legalize them all. Nice trick huh?

Posted by: dencal26 | August 12, 2009 4:57 PM | Report abuse

85% Agreement? Where on West End Avenue in Manhattan or Georgetown?

Posted by: dencal26 | August 12, 2009 4:58 PM | Report abuse


I think you miss a very valuable point. Although there may be agreement among 85% of the lawmakers, there is no such agreement among the people who elected them. There have been so many justifications floated for this legislation that no one can answer the simple question "why do we need this?" The President has said for financial recovery...but the bills being considered increase the unfunded liability. "It will make sure everyone has healthcare" Everyone has healthcare now...not everyone has insurance. It will lower one can show how you can increase coverage, not decrease choice and decrease costs.

If congress wants to pass healthcare reform, they need to start by addressing the government programs that are causing financial ills not, Medicare and Medicaid. When they can make those work as advertised, they can look at addressing the system that works.

Posted by: metairieorf | August 12, 2009 5:03 PM | Report abuse

If the congress cannot get a health care "reform" bill through both houses this year, you cannot blame the Republicans. The Democrats have a commanding majority in the House and a filibuster-proof majority in the Senate. Blame for failure rests squarely on the left.

Posted by: Curtis1967 | August 12, 2009 5:13 PM | Report abuse

Typical "in the Tank for Obama" media...

The writer glosses over that fact that 75% of the population are happy with their existing insurance.

It does not occur to the writer that fixing the things that are wrong does constitute a need for ' Massive Reform ", and all the disruption, cost, deficit that entails.

Yep... just another "in the Tank for Obama" DNC media representative.

Posted by: wilsan | August 12, 2009 6:05 PM | Report abuse

Every vote in the house that attempted to disqualify illegal aliens were voted down by democrats. There is no citizen eligibility requirement in any bill out of the House (It was explicitly voted down by democrats). So the peddling of the myth that illegal aliens won't be covered is a lie. It is also true (CAPP AMENDMENT) that abortion will be mandated in at least one policy in every region of the country, and in the public option.

Tort Reform has not be addressed, which means that trial lawyers get to remain unregulated and undemonized. WHY?

The American people don't understand why the following things are not being done first: deal with fraud in Medicare and Medicaid, require Insurance Companies to cover people who are in a group plan if they have a pre-existing condition, individual plans can't be mandated. TORT REFORM -- Massachusett's doctor study found 25% of tests are due to fears of being sued.

Of the 45 million, 15 million are illegals. Send them home or charge their home country for their care. 20 million are either children eligible under CHIP and their parents are too lazy or proud to register them, or they are adults who chose not to insure for privacy reason. The other group -- 10 million -- are what this is about. They either make too little to qualify for Medicaid or they don't have access to a group plan. The government should give incentives to insurance companies to insure these people.

You don't undo a system that employees millions and works for the overwhelming majority to deal with a fraction. If illegals are not dealt with, the huge problem remains that because they still show up at hospitals to get treatment. If they get covered, that US citizens will have to pay more in taxes to once again aid and abet those who are another country's responsibility.

Posted by: Cornell1984 | August 12, 2009 6:16 PM | Report abuse

There are a few points that still need to be resolved:
1. How to pay for it.
2. How to contain costs.
3. Will there be a "public option"
4. Will young, healthy adults be forced to buy something they don't need to subsidize the elderly?
5. What to do about Medicare.

Other than that, near complete agreement, right.

Posted by: sceptic5 | August 12, 2009 6:47 PM | Report abuse

Our President IS A TOTAL EMBARRASSMENT It wasn’t enough that he accused Doctors of removing tonsils for no reason except a fee, now he is accusing Doctors of cutting off the feet of Diabetics just for a $30,000 fee. THIS MAN IS A TOTAL EMBARRASSMENT. God bless us what have we done? This is something that goes on in Reverend Wrights church not the office of the presidency. NOW WHAT HAPPENS? I’m diabetic, I live in continuing awareness of amputation, if my Doctor ever reccomends it, am I supposed to listen to him or Obama? This man is totally insane, he has no moral footing. AND NO CLASS. What about my peace of mind if a doctor ever says I need an amputation? DO I call the whitehouse? Why does this man keep going off the deep end? It’s because we all give him a free ride. I ask you to do this country a service and ask the whitehouse not to interfere between Diabetics and their doctors. Do you really want to be a party to this? If they had nailed him on the tonsil comment he would have shutup. Now what, does this vomit continue for 4-8 years? There are 10,000,000 diabetics who should be totally pissed off. The man who says he wont interfere with your doctor patient relationship is already trashing it. How many amputees are now wondering if he is right, they cutoff their foot for money? HE IS SICK

Posted by: djmelfi | August 12, 2009 7:12 PM | Report abuse

I do believe -and I certainly hope- that the long-awaited and, in some quarters, much dreaded counter-revolution has begun. Americans are finally fed up. The Great Health Care Reform Scam is just the straw that broke the camel's back. Citizens are rising up against professional politicians and their cronies in business and elsewhere who are seeking to expand the Federal feeding trough to unprecedented dimensions. People are beginning to pay attention to what their elected representatives are actually doing as well as what they are promising, and people do not like what they are seeing. The elected representatives and public servants are actually offended by public protest and anger and are trying to convince themselves and anybody who will listen that it is all manufactured, not genuine, a plot against them, etc. Most of the media seems to agree with the professional politicians. It can't be happening, they say. It isn't real. It's all made up. It will go away soon - like a bad dream. But it is real,it is not made up, and it is not going to go away soon. We are seeing but the leading edge of the storm system. All who are wise will pack up their beach gear and head for higher ground. There is a Category 5 on the way.

Posted by: Teleologicus | August 12, 2009 7:36 PM | Report abuse

"The American people don't understand why the following things are not being done first:"

And yet another person brings out those strawmen which happen to exercise the wingnut fringe, but don't actually make a difference to the mess of healthcare in the US. And the BS numbers, too: I'm only surprised that they haven't reach the point of declaring that every uninsured person in America is an illegal immigrant, apart from one black woman who's just lazy.

Stop taking dictation from Limbaugh.

Posted by: pseudonymousinnc | August 12, 2009 7:39 PM | Report abuse

I've seen quite a few videos on TV and the Internet of "violent, angry mobs" at the townhalls. However, I didn't see anyone carrying a rope.

Posted by: ajp1474 | August 12, 2009 8:09 PM | Report abuse

The article is dead on with respect to the political reality in Congress, and the reasons for the alienation of a segment of society too.

As the later posts here demonstrate, the folks are out in force who have either 1) bought into the lies about HR 3200 (i.e., that it does really horrible things to seniors like me, as the article someone linked to in their comment stated) or 2) completely mistrust Obama. I check the posts below articles on health care reform frequently, and they often start with some balance and then go off at a tangent like this. You end up with, "What don't you understand about no?", without any other reasoning, along with the paranoid musings of those who see either the Fourth Reich or Stalinist Russia emerging, without any particular differentiation between the two. There is no hope for dialogue with folks who are that far out in right field. It is a matter of personal conviction period, and if you have a well reasoned article like this that presents an interesting point of view, it is utterly dismissed.

Too bad we can't have a discussion on the merits nowadays.

As for the reality of agreement on the basics of the bills among the stakeholders, including the insurance companies as well as the Republicans and Democrats in Congress, I think Ezra has it right - at least as of recess. Whether the insanity of the recess period itself produces some change, who can say.

Posted by: trulyb | August 12, 2009 8:47 PM | Report abuse

Great work again, Ezra. If a few more of your fellow journalists would cut through the circus BS to the reality of where and what this legislation is the country would be much better served.

Posted by: keller1 | August 12, 2009 9:12 PM | Report abuse

I actually don't think all the gnashing of teeth is about healthcare at all. Americans have come to distrust Government more now than perhaps ever, and as the details of the government's present involvement in our private lives comes to light many of us are both amazed and appalled. For example the degreee to which our families are already under the perpetual scrutiny of Social Workers is pretty horrible.

Posted by: jdcarmine | August 12, 2009 9:22 PM | Report abuse

I guess we couldn't expect a solution from partisan politicians that didn't attempt to increase the power of the government and protect their voting blocs, campaign contributors and cronies. This debate should have been conducted on first principles so that reason might prevail. First, the existing system works OK for some and is completely broken for others. Second, the system suffers from an excess of bureaucracy and its attendant paperwork and more in the form of an government entity will only make it worse. Next time you visit your doctor, look at the number of people who exist to do paperwork and remind yourself that they are not free and do not improve the medical outcome which is why you are there in the first place. Third, the type of care to be provided is not in the hands of your doctor, it lies in the hands of whatever your state legislators and the attending state bureaucracy have said must be done and paid for.
Solutions: Take the list of procedures out of the hands of the states. Establish a national marketplace where all insurers will compete. This will provide a variety of plans tailored for all the citizens of the US and possibly even those who are not. Allow any organization to establish pools of individuals so that the insurance industry can spread their risks and offer the most economically effective policies. Last, remove the tort lottery from the cost of the system by making the federal government the insurer of last resort. My impression is that the Wyden- Bennett bill comes the closest to accomplishing most of these things yet and is the only bipartisan solution. But for some reason it gets no respect. Lastly, figure out some level of funding for the indigent who truly cannot pay and adjust as the plan matures.

Posted by: marcusaurelius4 | August 12, 2009 9:26 PM | Report abuse

The American healthcare system costs half again as much per person, or as a share of GDP, as the second most expensive sytem (Switzerland) in the advanced world. It costs twice as much as healthcare systems in many advanced economies. Yet every other country has some form of publically provided health insurance, achieves universal or near universal coverage, no one has their insurance cut off when they need it, no one worries about losing insurance when they lose of change a job, and no one goes bankrupt due to medical expenses. And care ranges from just as good at the top and much better on average (France, Germany, the Netherlands, Singapore) to somewhat worse at the top and better on average (Canada, or at the bottom UK). (There are a mountain of studies regarding outcomes and access documenting the relatively poor level of care in the U.S. for those who don't have gold plated insurance policies--or Medicare, that government provided plan. The "We have the best health care in the world" mantra is a simple appeal to ignorance. Almost all the scare stories one hears about healthcare elsewhere are just that: Just ask Steven Hawking.) Why there is even a debate about this is almost impossible to understand.

Posted by: madhoboken | August 12, 2009 9:58 PM | Report abuse

Trusting government? Of course Americans trust their government. Who do they trust with social security, certainly not Wall St.? Who to they trust for their military security, national defense, and intelligence services? Who do they trust for medical and nursing home treatment for the senior population and disabled, certainly not corporate America? Who do they trust to tap their phones and computer communications? No problem there.. We've been screwed royally by the banks, Wall St., and the corporations. The government is the only thing left we can trust that is accountable.

Posted by: cmpnwtr | August 12, 2009 10:01 PM | Report abuse

I am no expert, but 85% agreement? I think that number is high. For me, I think all the other unfunded mandates need to be funded first before the Congress passes another. I work with a friend who has his insurance through the VA. He says it's a nightmare. He had to take off work two days to get cat scan. The first day they made him wait so long the VA asked him to come back the next day.

Also, I have read the house bill, most of it anyway. OK, without spin, someone who has read the bill please explain page 16 to me. I have my own opinion, but I'd like a supporter of the bill to explain it.

One more thing ... to me, this whole thing is about trust. I don't trust the politicians, Democrat or Republican.

Posted by: baseballguy2001 | August 12, 2009 10:43 PM | Report abuse

If the government creates a health care plan that it controls and then sets the rules for the private insurance plans, it is doubtful that the private insurers can compete with the government for very long. Congress may agree, but employers and employees don't. Obama says 73% of the people are happy with their plan. Then, why are we trying to remake the whole system for the minority? And, it is a small minority since over 1/2 the uninsured are between jobs and another large number are healthy and don't want coverage.

Posted by: rbolgard | August 13, 2009 1:21 AM | Report abuse

How dishonest can you get?

This is the same crap that Nancy Pelosi and Obama are telling us. To anyone who is "real" or not "astroturf" we're 85% in agreement.

Let's not get sidetracked by those pesky constituents, what do they know?

You skipped over the biggest problems of all, but I guess you are dismissing them because they come from fake people.

Your stupid article makes it sound like everyone's being silly, and that all we're arguing about is the color of the folder we want for the final bill!

Posted by: aristotle61 | August 13, 2009 2:07 AM | Report abuse

As is so often the case here, commenters are willing to put everything down to politics without seemingly noticing that both sides are up to their necks in it.

Joe Klein reported last week that a high profile Democrat on the hill said something would have to be passed now if only to save face. Grassley reported that Obama told a Congressman that failure would destroy his presidency. So, let's not pretend one side is politics and the other is principled.

Finally, the references to "violent" protesters which Ezra mentions as well...Two people have been roughed up thus far, one sent to a hospital and one scratched and the shirt ripped off his body. Both were "protesters" and in both cases, HCAN affiliated union members did the roughing up.

Somehow I don't think folks watching MSNBC (or commenting here) know that.

Posted by: captainhendry | August 13, 2009 3:56 AM | Report abuse

There's no need for debate on this. It's all very simple and straight foreward. Why would we, support a HEALTH CARE PLAN, for US and our FAMILIES, when the AUTHORS of the legislation think so little of it, that they have EXEMPTED THEMSELVES and THEIR FAMILIES from it? Hmmmmmm? If it's not good enough for them, then they can STICK IT. Read your ORWELL.

Posted by: GoomyGommy | August 13, 2009 7:34 AM | Report abuse

well here we go again. Wingnuts, the Black Healthcare helicopters are coming to get you, yes they are, can't you hear them Whop, Whop, Whop, right overhead. Grab your guns, get your bible andf head for the shelters. Those caught out in the open will be placed in FEMA re-education camps where the potential usefulness to society will be determined by a panel of useful expectancy. Those who don't mesure up will be disappeared. Whop, Whop, Whop can't you just hear them, Whop, Whop, Whop

Posted by: VeryBlueBoy | August 13, 2009 9:16 AM | Report abuse

One word: reconciliation.

Posted by: newjersey_lawyer | August 12, 2009 10:22 AM | Report abuse

two words: tort reform.

seriously though anybody who is a lawyer should know that reconciliation can't work here. they can be shot with so many holes that it will be completely ineffective.

Posted by: visionbrkr | August 13, 2009 11:11 AM | Report abuse

The consensus needs to be: What do the American people want? After all, the President is supposed to be President of all, not what the liberal Democrats want. Do we agree that there should be individual mandates. No-it is regardless of the arguments about responsibility a concession to get coverage for pre-existing conditions. Do we agree that we want to pay for policies that meet the government's criteria regardless of the cost increases that will inevitably come.-NO Do we want the tax increases that must come in one form or another for 1.4 trillion and WILL NOT control costs? No.
Do we want to lose the coverage we have now? A resounding no from all the polls. President Obama's continued argument that this will not happen is being questioned, even by the Post.
Do we want Medicaid and Medicare further endangered when they are already failing by cuts that are not put back to fix those systems, but to expand another entitlement? No
Do we agree that redoing the entire system is necessary to offer insurance to the people who need assistance? No
Is this whole mess necessary? No.
For the most telling argument against agreement, please once and for all publish and admit that the whole 47 million argument is bogus and breeds mistrust of the whole plan.
In one article on RCP, the figures were broken down as 10 million illegal immigrants who according to you will not be covered, 10 million people who qualify for government programs but have not signed up, 15 million people who choose not to have available coverage for cost or personal choice. Most of the remainder are people who have lost their jobs unfortunately. They have access to COBRA, but of course may have to choose not to access it after the stimulus assistance runs out. Where are the 47 million who must now be insured? Do you disagree with these figures?
Is there not an easier and much less expensive way to cover these people short of 1.4 trillion dollars, 150,000 new government employess in 20 something new agencies, boards, and regulators?
For the 1.4 trillion, it seems to me that the government could fix the systems they already have PROMISED the people and make arrangements for the absolutely uninsured.

Posted by: lidonna | August 17, 2009 6:07 PM | Report abuse

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