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Obama Promises Improvement, Not Change

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Barack Obama is considered a great speaker. But he's not typically been great at giving this kind of nuts-and-bolts policy speech. He's good at handling grand, sweeping topics. He's better at talking about how the arc of history bends towards justice than how the provisions of health-care reform bend the curve. During the campaign, John Edwards and Hillary Clinton were both more effective policy communicators than Obama. Particularly on health care.

In this speech, in fact, Obama needed to do the precise opposite of what he's best at. He needed to bring health-care reform down to earth rather than launch it into orbit. He needed to make it seem less dramatic and unknown. He needed to cast it not as change, but as improvement.

All of which he did. The vaunted specifics are not all that specific, and they seem to be getting less so by the second. In the speech, for instance, Obama gave an actual price tag for health-care reform. "The plan I’m proposing will cost around $900 billion over ten years," he said. But the plan released on the White House Web site doesn't include that number, or any specifics (subsidy levels, say) that would lead you to that number. But Obama had enough specifics to give listeners an idea of what's on the table.

That in itself is a remarkable achievement. Four of five congressional committees have passed health-care reform measures. The Senate Finance Committee is likely to follow next week. Obama isn't dictating whether the plan is $900 billion or $1.1 trillion at this point. That's a question of congressional votes, not presidential pronouncements. The fact that Obama could take the five proposals winding their way through Congress and settle on a single "plan" that comes pretty close to describing all of them, however, is evidence that health-care reform is quite a bit nearer to consensus than its opponents like to admit.

There were, however, some false notes. Not in the sense that they fell flat, but that they were actually untrue. Explaining the health insurance exchanges, for instance, Obama said "[This] is how everyone in this Congress gets affordable insurance. And it’s time to give every American the same opportunity that we’ve given ourselves." But under his plan, every American would not have access to the exchanges. Only small businesses, the self-employed, the unemployed, and the uninsured would have that right.

Later in the speech, in one of his great applause lines, Obama stared into the camera and declared, "I will not back down on the basic principle that if Americans can’t find affordable coverage, we will provide you with a choice." But because the $900 billion plan isn't enough to guarantee every American access to affordable health care, it includes an exemption freeing people from purchasing care that they can't shoulder. You can't choose what you can't afford.

But if Obama hasn't created the perfect plan, he's created something arguably more impressive: a plan that actually might pass. That plan might not do enough to change the system, and it may not spend enough to protect everybody, but there is plenty in the proposal that will better the lives, health coverage, and financial security for millions of real people. It will insure around 30 million Americans and protect tens of millions more from insurer discrimination, medical bankruptcy and rescission. It will bring more evidence to medicine and more competition to the insurance market. That may not be perfection, but it is improvement. And it is achievable.

At the beginning of the speech, Obama said, "I am not the first President to take up this cause, but I am determined to be the last." That too was false. He will not be the last to take up this cause. Reform is a process. This plan is not perfect, or anything near it. But it is better than what we have now. And stacking a lot of "betters" atop each other is the nearest we're likely to get to perfection. After all, as Candidate Obama would have told us, the arc of history is long. All President Obama can hope to do is bend it a bit toward justice.

Photo credit: AP/Jason Reed.

By Ezra Klein  |  September 9, 2009; 9:21 PM ET
Categories:  Health Reform  
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Comments

In his speech, Obama said that his plan would not cover illegals. Wilson shouted "lie". Who's correct?

While the plans in congress currently don't cover illegals, how can any plan to force all to be covered NOT cover illegals and still function as they wish it to?

And what plan is Obama referring to? He doesn't have a bill. How can he say what the bill will say in the end? How can he promise anything at this time?

So, is Wilson correct?

Posted by: WrongfulDeath | September 9, 2009 10:47 PM | Report abuse

wrongfuldeath,

It does not cover them through the bill but they are still covered in the system under EMTALA (and before pseudo and others speak i'm not for letting kids with tuberculosis (as the president said previously) infect my kids.

Also if immigration reform ever happens and Obama and the liberals "Path to Citizenship" is put through then those that are illegal today would be insured by the time reform happens. That's a lot of ifs but definitely a possibility.

Either way Wilson was wrong for what he did and he should (and I expect will) be reprimanded for it. You don't do that to the President under any circumstance. I wonder if the idiot was just trying to make a name for himself and get himself on Fox News???

Posted by: visionbrkr | September 9, 2009 10:53 PM | Report abuse

WrongfulDeath - As I understand it, in order to obtain coverage, a person would need to supply documents that prove his or her identity, similar to an I9 that an employee must fill out when applying to a job.

My assumption is that there would be some application process for both the open-market insurance and the public option, and that both would require a person to prove their citizenship.

Posted by: aust1nz | September 9, 2009 10:56 PM | Report abuse

Don't worry about the cost.

It will pay for itself with "savings" of waste, fraud and abuse in Medicare and Medicaid and some minor taxes on insurance companies.

Hahahahahahahahahahahahah

If you believe that I have some unpaid loans from GM I would like to show you.

Posted by: cautious | September 9, 2009 11:02 PM | Report abuse

Couldn't agree more. Obama's plan is full of great ideas, and it will have a big, positive impact on virtually all Americans' lives.

Is it perfect? No. But that's the essence of compromise. And Obama has compromised and crafted a bipartisan bill, though the GOP will never acknowledge that.

After watching the GOP response, it's clear that they're still committed to trying to win a political victory at any cost. Even Americans' fiscal and physical health, and their own party's credibility.

Posted by: JustinOhio | September 9, 2009 11:04 PM | Report abuse

The question is to what an extent President's Speech addresses a question / short coming identified by Steven Pearlstein - that has President provided 'political cover' to enough members of Congress to pass the bill?

I thought the politics was competent, since he was quite aggressive against the famous failures of Republicans - past or present. Will it help in the court of the Public?

For me - not clear what are answers to these questions.

Posted by: umesh409 | September 9, 2009 11:19 PM | Report abuse

Ezra does tend to dip his keyboard in purple for posts like this.

It was a good speech. It brought back focus to the core issues behind reform, after legislative drift and Crazy August. It called out liars. And it made the point to those who supported (and worked on behalf of) Obama last year that in America, you elect politicians and then have to campaign even harder for them to live up to their promises.

Tomorrow, we'll get back to what the lobbyists want, and mollifying Queen Olympia of Maine. And ideally, not spend any time on some pissant congressnobody from the state that gives North Carolina something to laugh about.

Posted by: pseudonymousinnc | September 9, 2009 11:44 PM | Report abuse

The speech left me thoroughly unconvinced that the plan is going to bring down the cost of care to where we can afford coverage for all. The line about "I will protect Medicare" sealed it. We need effectiveness analysis, HSAs and high deductible plans with percentage based co-pays, not more non-competitive services.

I am tired of people talking about how well loved Medicare is. That's politicians' logic about how to get votes, not the sign of a good program. The people that love don't see what it's doing to us.

Al Gore never got his lock-box, the baby boomers never paid into their health care fund, and now they're about to send the country into low debt rating land. We still need to help more people afford care, so let's stop avoiding the obvious solution of using a consumer focused system to drive down prices.

Posted by: staticvars | September 9, 2009 11:50 PM | Report abuse

The issue of whether various bills cover illegals is one of execution and practice, not one of specific inclusion of this group in specific language of any proposed law.

There is no rigorous requirement --- even a less rigorous requirement such as an I-9 --- in HR3200 or in the President's so-called "plan" to insure an applicant for government funded health benefits is in the country legally. All one must do is claim to be eligible by supplying a social security number.

House Democrats voted a number of times to defeat amendments to HR3200 which would have required the use of a government system such as e-Verify to determine eligibility. One can only guess at their motives.

There are so many hidden agendas in these bills that it boggles the mind. The WSJ is just running an article about the language in HR3200 that would result in widespread mandatory unionization of both hospital and home health care workers. The Baucus bill would require someone(?) to establish withholding accounts for independent contractors whose income is reported via 1099. There's a million of these items stuck here and there in this gigantic mess.

So, was Joe Wilson correct? We'll need to wait and see what happens. Just because "it isn't in the bill" doesn't mean it isn't going to happen.

Posted by: Curmudgeon10 | September 9, 2009 11:51 PM | Report abuse

NITPICKER!!!

Posted by: dld1761 | September 9, 2009 11:55 PM | Report abuse

Ezra: in this passage, I thought he was talking about getting leverage through the bargaining power of large groups, not about being part of the exchange:

"As one big group, these customers will have greater leverage to bargain with the insurance companies for better prices and quality coverage. This is how large companies and government employees get affordable insurance. It’s how everyone in this Congress gets affordable insurance. And it’s time to give every American the same opportunity that we’ve given ourselves."

Large companies obviously do not, and will not, get health insurance through the exchange, any more than Congress will. If he meant that they would, that would be, um, incomprehensible.

On the other hand, if he meant that they get affordable insurance using their size to bargain with, then "that" *is* how they get affordable health insurance, and how federal employees get affordable health insurance, and Obama's first point is not false.

Posted by: hilzoy | September 9, 2009 11:58 PM | Report abuse

That is to say: insofar as the exchange is designed to cover the market of people who do not have large employers, are not covered by Medicare, Medicaid, or the VA, etc., then arguably it is designed to cover the people who do not currently benefit from the bargaining power of a large group. In which case, extending it to them would extend it (not the exchange, but bargaining power) across the board.

Posted by: hilzoy | September 10, 2009 12:00 AM | Report abuse

Basically, people who bring up Joe Wilson's supposed "point" and then try to use it as the basis for a reasoned debate on his chosen issue, as though this is an acceptable way to bring up any topic, are rewarding him for disgusting behavior that embarrasses the Congress and the country.

He could have shouted out that he knew a cure for cancer or that I-95 should be repaved. The subject just doesn't matter, given his behavior. As far as I'm concerned, whatever topic he brought up should be subject to a voluntary "time out" for a week or two and simply left out of civil discourse. That's how you deal with bullies and tantrums. Take the microphone away.

Posted by: fairfaxvoter | September 10, 2009 12:21 AM | Report abuse

It's the Massachussetts plan, foisted on a diverse country that cannot afforded it. Health care executives are smiling tonight.

Posted by: bmull | September 10, 2009 12:30 AM | Report abuse

Joe Wilson cross the line on the House Floor. If this happen during a "House debate" all work would have stopped and a democrat would demand that wilson's words be "taken down"
C-span: "Words Taken Down is the House rule used to discipline a member for using inappropriate words in debate.
After the words are "taken down" by the clerk and read back, the chair rules on their suitability.
If ruled inappropriate, the member may not speak again on the same day without House permission."

Wilson ought to be ban for from speaking on the house floor for the rest of the year. The decorum of the House should be respected at all times. This is not a town hall meeting. This is a joint session of congress. The folks from South Carolina that I know don't act this way.

This behavior by the republicans is appalling. Goofy Gomert waving a sign doing the President's speech was lower than low. This is not another country. THIS IS THE US STATES OF AMERICA, were most people try to teach their children to act civil. The republican minority leader must take full responsibilty for his party's action and ban his members from watching their other leaders like glen beck, rush limbaugh, fox news and the like until after the work is complete on healthcare.

Posted by: MILLER123 | September 10, 2009 12:36 AM | Report abuse

That plan might not do enough to change the system, and it may not spend enough to protect everybody, but there is plenty in the proposal that will better the lives, health coverage, and financial security for millions of real people.

----------

Yes, well, if the plan doesn't change the direction of this:

http://www.cbo.gov/publications/collections/health.cfm

which, somehow, you managed to totally ignore, all those things you mention above will be temporary and the country as a whole will have a big financial pickle to deal with.

Whatever plan emerges in the months ahead had better deal with the financial dimension honestly, especially in the years beyond 2019.

Posted by: JamesSCameron | September 10, 2009 12:37 AM | Report abuse

Ezra,
Your kind of doing PR for the Administration and for Obama here in a way rather than examining the issue from the perspective of a journalist. I'm finding your sucking up to the Administration fulsome and beclouds your sometimes interesting insights into these issues.

For instance calling a bill that passes "more impressive" than what you, in a way disparagingly, call a "perfect bill" is a ringing endorsement for the backroom dealing approach to reform that the Administration has favored. What if a "bill that passes" creates a similarly dysfunctional or more dysfunctional health care finance/health care system?

Posted by: michaelterra | September 10, 2009 12:59 AM | Report abuse


staticvars, HSA's w/high deductible plans disincentive people from getting preventive services, even (and this is weird) when those services are covered. There's a health affairs study on it, something 'consumer driven health plans..'.

and do we think it's saying tax credits for individuals in lieu of subsidies, or as a kind of subsidy? McCain's idea was in lieu of, which was a dumb idea.

Posted by: ThomasEN | September 10, 2009 1:30 AM | Report abuse

Obama and his thugs have been lying to the American people since the day he took office. It's about time someone stood up to him publically. Joe Wilson just did what the Washington Post and other media has failed to do since Obama took office nine months ago.

Posted by: DenisH | September 10, 2009 1:30 AM | Report abuse

I'm so happy to see Snowe cop to being completely opposed to the Public Option in any form. It makes it crystal clear that the "compromise" position on "triggers" is nothing but another gaming of the process.

http://www.dailykos.com/storyonly/2009/9/9/155258/0604/718/779339

John

Posted by: toshiaki | September 10, 2009 1:38 AM | Report abuse

wilson should have been removed from the building by the secret service.

he should learn to control his temper around the president of the united states.
he doesnt deserve the privilege of being anywhere near the president.

does it ever occur to some people in political office, that children actually watch and hear about the crazy things that they do?

Posted by: jkaren | September 10, 2009 2:19 AM | Report abuse

The people Obama needs to move are not members of congress, but rather, the voters. Congress will move in whatever direction the voters do.
That said, this speech didn't really change anything for me. I am for reform, but deeply skeptical of the proposals before congress and of their ability to get it right.

Posted by: invention13 | September 10, 2009 2:35 AM | Report abuse

Ezra Klein is right for once! I just watched Obama's address to the nation again! I have to admit I didn't get it the first time, and came away very negative, but I've now changed my mind. Everything is wonderful in Obama's America. We are going to improve care for Seniors in Medicare by eliminating waste. With all that savings from eliminating waste we are going to pay for Obamacare for all. When we have Obamacare we will save so much money covering everybody in the country we will reduce the debt by trillions. Then once we are all in Obamacare, except for the President, Congress, and Federal Employees, and the program is by far the biggest government program we've ever had, we will be able to eliminate the inevitable waste in such an immense Government program and buy the entire world. This is a huge wonderful investment! So I've changed my mind. Why this could work like the stimulous bill. Obama promised if we passed it we wouldn't go over 8% UNEMPLOYMENT, and its succeeeded so wildly the recession is over and we have 3% full Employment again!!!! Oops I got overexcited...UNEMPLOYMENT is at 9.7% isn't it? Bad example. I know...cash for clunkers. That exceeded everybody's wildest dream. The plan was to spend $1 Billion and we spent $3 Billion!!! Oops.....spending 3x the original budget on something costing so many Trillions wouldn't be a good thing would it? Well surely Obama has done something since he became President that is truly a wild success. Whatever that is that's my example!!!!

Posted by: valwayne | September 10, 2009 2:37 AM | Report abuse

It is interesting that Ezra talks about exchanges.

Yet no where in Obama's speech is the word exchanges (plural) found.

He only mentions an exchange ... as in a national exchange (singular).

Posted by: cautious | September 10, 2009 5:26 AM | Report abuse

Obama talks about "my plan." There is no plan. There are four disjointed plans and none is a good plan. Again he is trying to use his rhetoric to dazzle the people.

Yes, we need health care reform - when we can pay for it, maybe incrementally. His cost figures are not realistic.

On another note, Joe Wilson's behavior was unconscionable and I saw a derogatory sign in the lap of one congressman. Weren't these men taught manners at home? We can disagree but we need to respect the occasion. The men were sitting in the House of Representatives of the United States of America listening to the president. Where is the respect?

Posted by: Kansas28 | September 10, 2009 5:40 AM | Report abuse

Mr. Klien, I agree with your article.

I do have one question. What's up with the Republican's treating a Joint Session of Congress like it was some kind of underage frat party?

Posted by: JoeNTx | September 10, 2009 6:42 AM | Report abuse

Last night Obama said, “"We did not come here just to clean up crises, we came to build a future," he said in a measured tone that belied the ferocious battles of recent weeks. "I am not the first president to take up this cause, but I am determined to be the last."

…. Even if it means if he can’t get a bipartisan vote to pass his “signature domestic priority,” he will encourage a reconciliation vote, denying representation for 46% of American voters.

Posted by: asmith1 | September 10, 2009 7:06 AM | Report abuse

What did the sign say that that one Congressman was holding?

Posted by: MosBen | September 10, 2009 7:26 AM | Report abuse

staticvars, HSA's w/high deductible plans disincentive people from getting preventive services, even (and this is weird) when those services are covered. There's a health affairs study on it, something 'consumer driven health plans..'.


Posted by: ThomasEN | September 10, 2009 1:30 AM | Report abuse


weren't these the kind of LIES that the president said should stop?

See below for the truth. HSA's include preventative care benefits as per the US treasury Dept or are they lying to us too???


http://www.ustreas.gov/offices/public-affairs/hsa/pdf/HSA-Tri-fold-english-07.pdf


Oh and some HSA's even include first dollar prescription coverage subject to copay and not deductible. Its called integrated vs non-integrated. Its amazing the amount of misinformation out there by some.

Posted by: visionbrkr | September 10, 2009 7:35 AM | Report abuse

The media has largely missed the purpose of the speech. The time for public vetting of grand ideas is over. So is the media's role. The members of Congress have had the chance to get an idea how their constituents feel about the issues. Now the ball is in Congress' court. The President outlined the job. He pointed out that everyone agrees with its core content and the need to get the job done. Then he challenged them to go do it. This kind of speech is what an executive tells his or her team to get them down to work on a difficult project. Whether the media or the public react emotionally to it as great oratory is of secondary importance. Neither the media nor the public will play much of a role in the remaining job of actually getting health care reform through Congress.

Posted by: dnjake | September 10, 2009 7:40 AM | Report abuse

so what? so obama spoke again and people (at least his supporters) were thrilled- again.

No one doubts he's a good speaker , but he does DO anything.

and why the heck are progressives even considering this handout to the insurance companies as "health care reform"?

Posted by: newagent99 | September 10, 2009 8:18 AM | Report abuse

Don't worry. There will be bipartisanship. Not a single republican in the house, and perhaps only two in the senate will vote for Health Care reform, but when it passes (which it will), republicans will claim a measure of credit when people's lives improve.

We saw it happen when the "bipartisan" stimulus bill was passed with a total of 3 republican votes. Interestingly, the vast majority of the republicans who voted against the stimulus had no problems going back to their home districts touting the stimulus when the monies began flowing in. You see, instant bipartisanship!

Posted by: ChrisNBama | September 10, 2009 8:22 AM | Report abuse

And you are right, Ezra. This bill is not change, but represents improvements to a flawed system.

My personal preference would be a single payer system, but what is abundantly clear, that even small changes to the status quo require herculean efforts on the part of the majority party.

The biggest understatement I've heard during this process is that, "change is hard". Hell, it's nearly impossible!

Posted by: ChrisNBama | September 10, 2009 8:29 AM | Report abuse

We don't have enought doctors to add 30 Million people to the system so there will be rationing, waiting in line, waiting for procedures - just like in Britain. As for illegals - you need to reform EMTALA and stop them from getting free Kidney dialysis at our expense as they do now. We need to get IDs from those in Emergency Room and if they are illegally we need to deport them. Without a strong verification program, which Obama did not advocate, illegals will get healthcare at our expense. Whether you like it not Joe Wilson was right to call OBama a liar.

Posted by: Lavrat2000 | September 10, 2009 8:39 AM | Report abuse

"Obama talks about "my plan." There is no plan."

This commenter is correct. Obama is all smoke and mirrors. He has no plan. How can he say what will be in it?

He lies as he has since taking office.

Posted by: WrongfulDeath | September 10, 2009 8:45 AM | Report abuse

Joe Wilson cross the line on the House Floor. If this happen during a "House debate" all work would have stopped and a democrat would demand that wilson's words be "taken down"
C-span: "Words Taken Down is the House rule used to discipline a member for using inappropriate words in debate.
After the words are "taken down" by the clerk and read back, the chair rules on their suitability.
If ruled inappropriate, the member may not speak again on the same day without House permission."

Wilson ought to be ban for from speaking on the house floor for the rest of the year. The decorum of the House should be respected at all times. This is not a town hall meeting. This is a joint session of congress. The folks from South Carolina that I know don't act this way.

This behavior by the republicans is appalling. Goofy Gomert waving a sign doing the President's speech was lower than low. This is not another country. THIS IS THE US STATES OF AMERICA, were most people try to teach their children to act civil. The republican minority leader must take full responsibilty for his party's action and ban his members from watching their other leaders like glen beck, rush limbaugh, fox news and the like until after the work is complete on healthcare.

Posted by: MILLER123 | September 10, 2009 8:57 AM | Report abuse

"HSA's w/high deductible plans disincentive people from getting preventive services, even (and this is weird) when those services are covered."

I think the answer is that HSAs provide the incentive for people to seek value in health care. Right now, we don't even get to see how much things cost, and we're depending on the insurance companies and Medicare to negotiate prices, without considering the value to the consumer, and with the consumer able to consume freely at a fixed cost.

At the very least we need percentage based co-pays so that I can save money (for you and me) by seeing a more efficient provider of care. Otherwise, we are making worse a broken market where there is a government set price for everything (all knee MRIs cost $800) and no room for providers to compete on price/quality.

Posted by: staticvars | September 10, 2009 8:59 AM | Report abuse

Lavrat is right. Americans are too stupid to become doctors and nurses in numbers required to treat their own people. In addition, given the awful conditions in this country, it is completely unrealistic to expect any foreign trained doctors to want to come here. The plight of the uninsured and untreated is there simply because we are a country that can't get medical care to all their citizens, so some of them have to be triaged. Lavrat just figures that it's better that it's "them" not him.

Posted by: tyromania | September 10, 2009 9:12 AM | Report abuse

tyromania,

are you serious? the awful conditions in this country??? You're view is more than a little slanted, no? Foreign trained doctors have already come over here by the boatload. Do you think a doctor would rather treat patients in Calcutta or New York City???

Posted by: visionbrkr | September 10, 2009 9:21 AM | Report abuse

We are left with the basic fact the reforms like preexisting conditions which even Republicans approved will be introduced immediately, while the expensive core of his program will be introduced in 2013. He is saying that it will work so poorly and will be so unpopular that he does not want to be judged on it in the 2012 election.

Roosevelt introduced Social Security in 1935 and Bush the highly important prescription drug health reform in 2003, both because they wanted to be judged on them in the next election.

Posted by: jhough1 | September 10, 2009 9:24 AM | Report abuse

We are left with the basic fact the reforms like preexisting conditions which even Republicans approved will be introduced immediately, while the expensive core of his program will be introduced in 2013. He is saying that it will work so poorly and will be so unpopular that he does not want to be judged on it in the 2012 election.

Roosevelt introduced Social Security in 1935 and Bush the highly important prescription drug health reform in 2003, both because they wanted to be judged on them in the next election.

Posted by: jhough1 | September 10, 2009 9:25 AM | Report abuse

So, is Wilson correct?

Posted by: WrongfulDeath
__________________

Yes, Wilson is correct. The forum for his statement was gravely incorrect. However the content of his statement was 100% on the spot. Look, do the math, is anything BO said last night make any sense economically? No, it can't be done it's pie in the sky he knows it therefore he is the liar.

Posted by: affirmativeactionpresident | September 10, 2009 9:26 AM | Report abuse


visionbrkr,

nah man, I said 'even when those services are covered'. There's some sort of perception problem that people w/high deductible plans have preventing them from getting covered, preventive services: http://content.healthaffairs.org/cgi/content/full/25/6/1529

After the company in the study began covering preventive visits, this was the study observation: "Overall, we found no changes in rates of cervical cancer screening, colorectal cancer screening, or well-child/well-adolescent visits after the differential cost-sharing arrangement went into effect."

Posted by: ThomasEN | September 10, 2009 9:33 AM | Report abuse

Ezra:

As a person who makes his living as a writer, you ought to be a bit more careful when parsing the words of others. To say it is false that Obama is determined to be the last president to deal with healthcare is itself, false.

In your attempt to embellish your writing with rhetorical flourishes, you've questioned the President's sincerity in enacting real healthcare reform. Was that your intent? Being fair, or "purple" as some people call it, doesn't give you license to call false those things whose validity you cannot judge.

I would hope that you don't believe that part of your role as a commentator is to bend the words of others to fit your desired "script". Moreover, I would hope that your future writing does not display this same arrogance. You do still work for a news organization, correct?

Posted by: geehosophat | September 10, 2009 9:39 AM | Report abuse

ThomasEN,

unfortunately i can't get in to see the study without a username and password. I would ask how small the sample size was.

Also if people weren't getting them before and aren't getting them now to me it shows an uninformed consumer base that wouldn't have gotten the screenings anyway even if you gave them away for free or paid them to do it. Well maybe if you paid them (like the safeway model) it would have helped some. It just shows the inherent laziness in some.

That does not mean that HSA's don't make sense. It just means they weren't effective in that case in increasing the number of preventative visits.

And either way the employer and employees saved costs becuase HSA's are much less expensive than your standard plans.

Posted by: visionbrkr | September 10, 2009 9:41 AM | Report abuse

So the improvement we'll get after all this - adding millions more to the costly and inefficient system. Who'll pay for this?

And if you couldn't afford health insurance before, you'll now get penalized for that? So you'll end up with no health insurance and less money in your pocket. Or you'll end up with a high deductible plan with less money in your pocket - and you'll be charged for all your health care until the high deductible is met?

Posted by: anne3 | September 10, 2009 10:29 AM | Report abuse

The Republicans' assheaded behavior probably killed any presumption of "bipartisanship" as far as House/Senate Democrats are concerned, and may possibly result in a better bill all the way around.
Obama is not royalty and it is perfectly fine to express disagreement with the President, but jeez. It wasn't so long ago (Bush II era) that a woman was friggin arrested and hauled off for wearing a GOP hissy fit inducing t-shirt to a State of the Union address.

Posted by: fishermansblues | September 10, 2009 10:39 AM | Report abuse

"Section 246: No Federal Payment for Undocumented Aliens: Nothing in this subtitle shall allow Federal payments for affordability credits on behalf of individuals who are not lawfully present in the United States." --House bill H.R. 3200, page 143, line 3.

Joe Wilson is a gift from the gods. The Democrats should hang a picture of Wilson around the neck of everybody trying to defeat this reform. He was rude AND he was wrong on the issue. He is refuted by the text in the bill that forbids healthcare to illegals. It is short, and it can be published in every small-town paper in the U.S.

On the cost issue, it sounds like Obama has accepted the Senate Finance number.

Posted by: Lee_A_Arnold | September 10, 2009 11:16 AM | Report abuse

Lee, over at talkingpointsmemo.com, I think some people understood the dynamic of what was happening: when Obama says something true, it is just part of a grand conspiracy for Obama to cover up what he *really* wants. The fact that Obama made a factual statement, which is clearly spelled out in a bill, and which contradicts Republican talking points, demonstrated the devious lengths that Obama will go to in order to establish communism in America. This was so angering and so agitating to Wilson that Obama would *blatantly* attempt to establish the facts in order to pass his agenda, that he couldn't control himself anymore.

Posted by: constans | September 10, 2009 11:22 AM | Report abuse

"It just shows the inherent laziness in some."

Ah, the "greedy doctors, dumb patients" line yet again? It's getting to sound really whiny.

The problem with HSAs and preventative care should be obvious: before someone gets screened, that person often has no idea whether something will show up. It's all very well saying that a pap smear or colonoscopy or chest X-ray is covered, but if the treatment that's recommended as a follow-up is priced to ruin you, then there's not much point in getting the test in the first place.

staticvars: what would be your objection to a split system, as in France, where there's a reimbursement tariff for procedures, covering about 80% of what's determined to be the going rate, leaving the rest to be settled either by a supplementary policy or out-of-pocket? That doesn't prevent clinicians from charging more if they think their expertise or operating environment supports the price, and it doesn't prevent people from using those doctors.

(I also learned yesterday that the career with the best prospects in my part of the world is "Medical Biller.")

Posted by: pseudonymousinnc | September 10, 2009 11:32 AM | Report abuse


Good point pseudonymousinnc. You sometimes see diabetic retinopathy rates go up if you cut eyeglass benefits in a plan. People don't bother getting check ups when the benefit that usually follows the check up isn't covered. Same deal sorta.

visionbrkr, it was 40K workers at Alcoa.

I'm actually not wholly opposed to high deduc plans coupled w/HSA's, I just think they need some tweaking. They might be a good fit for the 'young invincibles' in the 20's and such.

Posted by: ThomasEN | September 10, 2009 12:54 PM | Report abuse

The only way President Obama has any possibility of passing health care reform, is a commitment to remove illegal immigrants from gaining entrance to any public option? In the health care bill they must--PROVE--to the majority of the American People that--NO ILLEGAL FOREIGN NATIONAL--will be able to bleed the government extension in the package. An amendment to the 1000 page reform bill, must guarantee--IN THE WORDING-- that a very thorough background identity check is performed on any applicant who applies? E-Verify would be a progressive identifier, with an initial examination of Social Security number in conjunction with Homeland Security Databases.

To complete the operation of E-Verification this PC application, must branch out across the country as a permanent tool in business and industry for every worker newly hired or long time employee. Thousands or even millions of illegal workers could be hiding in plain site in the workplace, as they have never been checked as a citizen or legal residency compliance? It also seems that the auditing of 1-9 forms around the country, that the federal authorities forget to mention that irregularities by employers only allows them to dismiss the applicant? The fact is that ICE raids have trailed off, so that any illegal workers--ARE NOT DEPORTED--they can move onto yet another workplace. Anybody who is suspected of being in this sovereign nation illegally should be detained and held for ICE inspection, not released into the public mainstream?

We all know that Fraudulent ID is so prevalent, that all security systems have been compromised, with even al-Qaeda murderers who brought down three passenger jets. On 9/11 these terrorists had in their possession numerous authentic drivers’ licenses and other picture ID. E-Verify is not perfect and can be cheated, but as it's modified, collecting more tools to compliment the enforcement program it success rate will become exemplary. Those hired workers who then find themselves under suspicion, can have errors resolved through any Social Security agency. That special interest groups have remained silent about this matter, doesn't need any explanation? most Americans want enforcement at our borders, the workplace, so contact your reluctant politician at 202-224-3121 MORE HONEST INFORMATION AT NUMBERSUSA & JUDICIAL WATCH. REMEMBER NO MORE BLANKET AMNESTIES!

Posted by: infinity555 | September 10, 2009 2:01 PM | Report abuse

The problem with HSAs and preventative care should be obvious: before someone gets screened, that person often has no idea whether something will show up. It's all very well saying that a pap smear or colonoscopy or chest X-ray is covered, but if the treatment that's recommended as a follow-up is priced to ruin you, then there's not much point in getting the test in the first place.

(I also learned yesterday that the career with the best prospects in my part of the world is "Medical Biller.")

Posted by: pseudonymousinnc | September 10, 2009 11:32 AM | Report abuse


First off ALBERT, Medical billers also bill Medicare and would have to bill for HR 676 so don't go acting like that's a private insurance thing alone. If you want to get paid you need to bill someone for services. Unless we want to go back to the barter system that's what we need to do.

Secondly it would be nice if you had a CLUE of what you talk about. HSA's can and should be structured to have the least impact to those employees who can least afford it. For example, employees making $100,000+ could have a $1500 deductible and a cap of $3000 in maximum out of pocket costs. They can afford that. Employees that make say between 60,000-$100,000 should have all expenses covered but say the first $1000 in a deductible and $2000 in a maximum out of pocket cost. Employees $40,000-$60,000 should have a deductible of $300 and maximum costs of $900. This is very doable for all and it would reduce insurance costs for all. The whole "skin in the game" argument which you always retort back that they already have skin in the game in order to want to stay healthy yet they don't go for the preventative care like they should. They still eat like crap and are obese. You can talk that they have "skin in the game" in an effort to stay healthy but to back up that point we'd have to not have the high levels of obesity in this country that we have. I don't expect that to change even when we hand them free health insurance or semi-free based upon their income. ThomasEN's ALcoa example (thank you Thomas EN) proves that point.

Posted by: visionbrkr | September 10, 2009 2:11 PM | Report abuse

HSAs are basically a scam to convince people that they're going to get something for nothing. *Every* HSA salesman you find tells you how you can make lots of money on your HSA investments and really cash in at the end of the year when you want to get elective treatment like LASIK or something.

HSAs are great for people like me: young, very healthy, lots of disposable income, and would love to be able to get a new pair of stylish glasses every year with pre-tax dollars. As a public health initiative, it's a zero, but I suppose it's appealing to some people on a "I like to see people punished for their misdeeds" sort of level.

Posted by: constans | September 10, 2009 3:05 PM | Report abuse

"HSA's can and should be structured to have the least impact to those employees who can least afford it."

"Can and should," indeed. And a pony on top. No mention of HSAs on the individual market, though.

Stop talking your book and blaming everybody else.

Posted by: pseudonymousinnc | September 10, 2009 3:07 PM | Report abuse

And to make it clear-- "can" and "should" and "could" and "would" just clouds the reality of how HSA and HDHPs are marketed, sold and used across the income spectrum.

Posted by: pseudonymousinnc | September 10, 2009 3:16 PM | Report abuse


Eh. The example I cited doesn't prove laziness anymore than it proves a fear of follow-up costs or a fear of perceived non-existent costs. The study wasn't designed to idenify the disincentivizer.

I'm just gonna pretend thats a real word.

Also, from that speech and the rhetoric the last few weeks, I get the distinct impression the Bush tax cuts shouldn't go buying any green bananas.

Posted by: ThomasEN | September 10, 2009 3:34 PM | Report abuse

He gave a general speech about why reform was needed. His specific policy proposals were limited. I found myself muttering to myself the entire time, "that's nice but which bill are we talking about". all in all i considered the speech a waste of time. he got up there and asked us to support whatever congress says reform is.

count me as extremely skeptical. one thing that appealed about candidate Obama was he never talked down to us. President Obama however seems to do it regularly. Don't try and sell me something that you dont what it is. give us a single bill to work off of (and for god's sake dont make it 1000 pages. there is never a need for a 1000 page bill.) and we can talk until then it's a giant fail.

Posted by: PindarPushkin | September 10, 2009 3:35 PM | Report abuse

constans,

if you really had a clue you'd be dangerous. HSA's that have a cap set at reasonable levels like I mentioned above are absolutely a great idea. Its not as if I'm advocating employees making the poverty level having a $5000 deductible. Get real. When employers save in their premium more than they are allowed to fund the HRA and much more than the out of pocket exposure explain to me how its a bad deal. I will agree that the employer needs to ensure that they fund the HSA and there should be designs in place that require them to do that.

Something has to be done to slow down utilization. What's your way? All i hear from you and pseudo are complaints but no answers. You're as bad as Republicans. Oh wait we should throw everyone in single payer that abuses the system to the tune of hundreds of billions of dollars a year and is going bankrupt???


pseudo,

HSA's can and do work in the individual market in the same way that they do outside. And when the exchange is set up you can buy it there. Won't that be nice!!

and what will you complain about when costs are still skyrocketing and all of the President's measures are put into place???

oh and what is it you do for a living anyway?

ya right.

Posted by: visionbrkr | September 10, 2009 3:39 PM | Report abuse

constans,

oh really do you know any HSA salesmen? I've never spoken to anyone about the investments because since they are for short term use they should be in guaranteed interest accounts. No one is getting rich there they're not just becoming poor.


But really keep up your rhetoric on how everyone's out to get you. It really is funny.

Posted by: visionbrkr | September 10, 2009 3:43 PM | Report abuse

also most plans don't even allow for investment in anything until a substantial balance is set up just for those reasons but again keep thinking the world is out to get you.

Again it would be really nice if people stuck to something they have a clue about because when you make up random generalizations about things it makes you look silly.

Likewise I would like it better if the president when he's criticizing insurance companies for subjecting people to pre-existing conditions to just happen to mention that many states don't subject employees to pre-existing conditions in most all if not all cases. Below is the link that shows how pre-ex is handled on the small group market. It also gives a link to the individual market as well.

http://www.statehealthfacts.org/comparetable.jsp?ind=352&cat=7


I agree and always have that they shouldn't subject them to anyone in any instance but to just make blanket statements like he does is misleading and when he's calling for no one to be misleading, its hard to trust him when he's being misleading. Just tell the American people the truth and let them decide for themselves.

Posted by: visionbrkr | September 10, 2009 3:52 PM | Report abuse

visionbrkr, one of ezra's old blogs used to feature regular appearances on the part of an HSA salesman using precisely all of those arguments. We live in an era in which we are consistently told the appeal of tax shelters and tax-free goodies. HSAs are marketed by convincing people that they can get something for nothing.

Overutilitization is not occurring because people aren't forced to "feel the pain" of visits to the doctor or childbirth. This is why we have moderate copays. HSAs convince the "insured" that they are getting something for nothing and convince the employers that they can get away with offering really poor coverage to their employees.

You did have a rational moment a few days ago when you accepted the fact that a medical board with professionals depending on actual data would be a good method of setting "best practices" to prevent overutilization and procedures that do not improve outcomes. But the problem for you is that the insurance salesman in you always comes to the surface.

Posted by: constans | September 10, 2009 3:57 PM | Report abuse

constans,

I'm sorry but that wasn't me and I would never do that. People need to trust who they're buying things from and also people need to realize that not all salesmen are schisters (sp). I choose to work on the basis that if I'm honest to clients to my own fault (ie, reduction in income) then I can prove to them a better person to purchase from. Some will sell and burn but that's not my way. (oh crap it sounds like i'm trying to sell you something and i'm not).

I would disagree about your arguments about overutilization. I see it every time I go to the ER and they're littered with non emergent care. I have a friend who is an ER nurse who is that and I've asked her if that's because of the uninsured and she agreed that some are but many aren't. I saw a client today that took his 5 year old to the ER for an ear infection with barely a fever he said. This guy is an attorney with very good insurance. It only cost him a $50 copay but the total cost was likely $1000+. He should know better. I understand that when its your child its a different story but I'd like to think I'm rational about times like that but maybe I'm not. I've taken my kids to the ER about 3-4 times and the least emergent care of it was because it was a weekend and he got a nail in his head (don't ask, siblings).

And sometimes I can't get the insurance salesman out, its been 15 years in the making and please remember that not all of us live in the world of recision and meteoric profits. My world is guaranteed issue and modified community rating that is more than fair considering we don't have an individual mandate and need one desperately. As the president said "there's a place for insurance" and many of the people that work there are our friends and neighbors.

Posted by: visionbrkr | September 10, 2009 4:57 PM | Report abuse

To Lee_A_Arnold: I've seen you post that section from HR 3200 a couple of times on this blog in order to support your contention that illegal immigrants would not be covered under the reform bill. However, that sentence doesn't mean what you think it does, and we need to clear that up, because you are incorrect.

"Affordability credits" means the premium subsidy -- i.e., monies the government will pay towards an individual's insurance premiums to make sure they can afford coverage. (See section 241 at page 129 of the Energy & Commerce substitute bill, which defines an affordability credit.) So all that sentence means is that illegals are not eligible to receive premium subsidies.

If you look at either HR 3200 or the Senate HELP bill, you will see that the definition of an "individual" who must obtain coverage does not specifically refer to a U.S. citizen. In fact, neither bill nor any of the currently passed amendments to the bills defines just who is and who is not an "individual." Therefore, an individual could indeed include an illegal alien as well as a legal resident alien or U.S. citizen.

The President made an inaccurate statement about the two bills currently pending, but perhaps he will insert specific language in "his" bill (whatever that is) to correct this.

Posted by: Policywonk14 | September 10, 2009 5:30 PM | Report abuse

The problem with HSA/HDHP combos in the real world is that they run headlong into adverse selection. I'll quote a commenter from Ezra's old blog:

"When an insurer offers an HSA as one of several options, it knows that it is going to get a barbell-shaped risk profile, where the only people who buy into the HSA are (1) the healthy people who need no care and thus are happy to pay the lowest premium and (2) the sickest people who blow through the deductible so fast that their share of costs approaches zero. If it has no one in the middle to mitigate the right tail of this distribution, it has to raise prices on the lowest cost people. This indicates that offering an HSA is an absorbing state; if you give people the option to choose an HSA from among several different plans, eventually your costs will get so skewed that you will have to force everyone into the HSA."

Also:

http://www.commonwealthfund.org/usr_doc/Collins_WaysandMeans_Testimony__6-28-06.pdf

Posted by: pseudonymousinnc | September 10, 2009 6:02 PM | Report abuse

The problem with HSA/HDHP combos in the real world is that they run headlong into adverse selection. I'll quote a commenter from Ezra's old blog:

"When an insurer offers an HSA as one of several options, it knows that it is going to get a barbell-shaped risk profile, where the only people who buy into the HSA are (1) the healthy people who need no care and thus are happy to pay the lowest premium and (2) the sickest people who blow through the deductible so fast that their share of costs approaches zero. If it has no one in the middle to mitigate the right tail of this distribution, it has to raise prices on the lowest cost people. This indicates that offering an HSA is an absorbing state; if you give people the option to choose an HSA from among several different plans, eventually your costs will get so skewed that you will have to force everyone into the HSA."

Also:

http://www.commonwealthfund.org/usr_doc/Collins_WaysandMeans_Testimony__6-28-06.pdf

Posted by: pseudonymousinnc | September 10, 2009 6:08 PM | Report abuse

i so love when people who aren't risk managers try to be.

how about this albert. You do what RISK MANAGERS do. You do what INSURERS do. They don't offer it as AN option they offer it as the ONLY OPTION from the start. Then you base the cost based upon the salary of the employee on a sliding scale. Keep everyone involved in the cost but not so much as you would hurt them.

Posted by: visionbrkr | September 10, 2009 6:55 PM | Report abuse

Policywonk14, so what you're saying is that, as the bills are written now, an illegal alien would be required to carry health insurance and would have to pay for it, because he or she wouldn't be eligible for any government subsidy. In other swords, illegal immigrants would have to cover themselves. Obama stated that the anti-reformers' claim that illegal immigrants would be eligible for a government subsidy is false. So how was the President wrong, and how are you sure that the sentence means something I don't think it does?

Posted by: Lee_A_Arnold | September 10, 2009 8:19 PM | Report abuse

"...if you give people the option to choose an HSA from among several different plans, eventually your costs will get so skewed that you will have to force everyone into the HSA."

Lessee....this will happen, but a public option will not force everyone into the public option.

That about it?

And even if you forced everyone into HSA's, what's the problem? People would then have incentive to shop for services as they do other types of goods and services. Also, everyone could afford the inexpensive premiums.

Posted by: WrongfulDeath | September 10, 2009 8:31 PM | Report abuse

"People would then have incentive to shop for services as they do other types of goods and services."

And that Edmunds.com for doctors, procedures and facilities will be arriving real soon now, won't it?

Posted by: pseudonymousinnc | September 10, 2009 8:37 PM | Report abuse

*are you serious? the awful conditions in this country??? *

sigh. visionbrkr, it is called sarcasm. It was a response to Lavrat.

So much of the opposition to health care reform has as its basis that the USA is somehow uniquely poor and incompetent in a way that the rest of the industrialized world isn't.

Posted by: tyromania | September 10, 2009 9:31 PM | Report abuse

Stop abusing Sam

Posted by: WrongfulDeath | September 10, 2009 11:16 PM | Report abuse

@Lee_A_Arnold -- Here's a quote from the President's speech on the illegal alien issue, as reported by Ezra below:

"There are also those who claim that our reform effort will insure illegal immigrants. This, too, is false – the reforms I’m proposing would not apply to those who are here illegally."

Note, the President doesn't refer to subsidies, as you contend. He flat-out said (per Ezra's quote, assuming that's correct) that his reform proposals will not apply to illegal aliens, that his reforms will not insure illegal aliens. Prior to this speech we have not seen this provision in any of the vaguely worded positions or campaign promises that the President made on healthcare reform. As I said, maybe the President's reform proposal will actually make it into proposed legislative language in order to give his words potential legal effect.

As I said in my original post, you are incorrect to use the HR 3200 sec. 246 language to support the concept that the bills would not cover or apply to illegal aliens. Again, sec. 246 only states that illegal aliens will not receive government-funded premium subsidies.

How am I sure that the sentence means something you don't think it does? I've read both bills and the amendments many times, and I'm skilled in reading proposed healthcare legislation. But I'm genuinely curious -- have you found other sections of the bills that support your contention?

You don't have to believe me: go to both the HELP bill and HR 3200 and do a word search for "undocumented alien" or "illegal alien" or even "alien." You will find a few references to nonresident aliens in HR 3200, but of course those folks do not live in the U.S., so they would not be in the U.S. illegally. Also, look for the definition of "individual" -- typically definitions are in the first sections of the bills. If you find a definition of "individual" that exempts illegal aliens, then I'll agree with you.

Let me know if you find other bill language that you believe upholds your assertion.

Posted by: Policywonk14 | September 11, 2009 1:01 AM | Report abuse

*are you serious? the awful conditions in this country??? *

sigh. visionbrkr, it is called sarcasm. It was a response to Lavrat.

So much of the opposition to health care reform has as its basis that the USA is somehow uniquely poor and incompetent in a way that the rest of the industrialized world isn't.

Posted by: tyromania | September 10, 2009 9:31 PM | Report abuse


but he's not that far off in his assertions. We don't have enough doctors (Ezra's posted on this before), EMTALA does need reform and every time a republican tried to put language in the bills refusing coverage to illegals Democrats double-talked their way into shooting them down making excuse after excuse that it would hurt "legal americans". sorry that's crap.

Illegals (from all i can tell from the bills so far) can participate in the exchange. So they partake in the "discounted pricing" that legal working Americans paid billions (through their tax dollars) to have set up.

Posted by: visionbrkr | September 12, 2009 12:35 AM | Report abuse

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