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Selling insurance across state lines: A terrible, no good, very bad health-care idea

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The big Republican idea to bring down health-care costs is to "let families and businesses buy health insurance across state lines." Jon Chait has some commentary here, but I want to simplify a little bit.

Insurance is currently regulated by states. California, for instance, says all insurers have to cover treatments for lead poisoning, while other states let insurers decide whether to cover lead poisoning, and leaves lead poisoning coverage -- or its absence -- as a surprise for customers who find that they have lead poisoning. Here's a list (pdf) of which states mandate which treatments.

The result of this is that an Alabama plan can't be sold in, say, Oregon, because the Alabama plan doesn't conform to Oregon's regulations. A lot of liberals want that to change: It makes more sense, they say, for insurance to be regulated by the federal government. That way the product is standard across all the states.

Conservatives want the opposite: They want insurers to be able to cluster in one state, follow that state's regulations and sell the product to everyone in the country. In practice, that means we will have a single national insurance standard. But that standard will be decided by South Dakota. Or, if South Dakota doesn't give the insurers the freedom they want, it'll be decided by Wyoming. Or whoever.

This is exactly what happened in the credit card industry, which is regulated in accordance with conservative wishes. In 1980, Bill Janklow, the governor of South Dakota, made a deal with Citibank: If Citibank would move its credit card business to South Dakota, the governor would literally let Citibank write South Dakota's credit card regulations. You can read Janklow's recollections of the pact here.

Citibank wrote an absurdly pro-credit card law, the legislature passed it, and soon all the credit card companies were heading to South Dakota. And that's exactly what would happen with health-care insurance. The industry would put its money into buying the legislature of a small, conservative, economically depressed state. The deal would be simple: Let us write the regulations and we'll bring thousands of jobs and lots of tax dollars to you. Someone will take it. The result will be an uncommonly tiny legislature in an uncommonly small state that answers to an uncommonly conservative electorate that will decide what insurance will look like for the rest of the nation.

As it happens, the Congressional Budget Office looked at a bill along these lines back in 2005. They found that the legislation wouldn't change the number of the uninsured and would save the federal government about $12 billion between 2007 and 2015. That is to say, it would do very little in the aggregate.

But those top-line numbers hid a more depressing story. The legislation "would reduce the price of individual health insurance coverage for people expected to have relatively low health care costs, while increasing the price of coverage for those expected to have relatively high health care costs," CBO said. "Therefore, CBO expects that there would be an increase in the number of relatively healthy individuals, and a decrease in the number of individuals expected to have relatively high cost, who buy individual coverage."

That is to say, the legislation would not change the number of insured Americans or save much money, but it would make insurance more expensive for the sick and cheaper for the healthy, and lead to more healthy people with insurance and fewer sick people with insurance. It's a great proposal if you don't ever plan to be sick, and if you don't mind finding out that your insurer doesn't cover your illness. And it's the Republican plan for health-care reform.

Photo credit: By Mandel Ngan/Getty Images

By Ezra Klein  |  February 17, 2010; 2:12 PM ET
Categories:  Health Coverage , Health Reform  
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Comments

Hasn't Obama already caved on this point?

Posted by: scarlota | February 17, 2010 2:25 PM | Report abuse


You can make insurance very affordable to young, health people by allowing them to purchase insurance across state lines. Some states have onerous regulations that drive up premiums. Others load up insurance with too many mandated benefits, driving up premiums. There are other advantages. Ezra's just giving you a partisan view - take him with a grain of salt.

Posted by: RandomWalk1 | February 17, 2010 2:28 PM | Report abuse

The only Democrat idea is to firmly seat the federal government in the driver's seat as to what medical services provided to middle class family are "sustainable"....

http://www.bloomberg.com/apps/news?pid=20601070&sid=aGrKbfWkzTqc


By forcing all middle class families to buy into a new private sector managed Medicaid program, the Federal Government can do all the rationing of healthcare that voters permit.

Does that summarize the ideas presented by Democrats?

Do they offer one solution that can't be characterized that way?

Posted by: FastEddieO007 | February 17, 2010 2:29 PM | Report abuse

So, then, what do you make of the interstate compacts compromise? That would be a diversion from the ideal of federal regulation, right? If it is similar to the "terrible, no good, very bad health-care idea" that you describe, then why do it? Why vote for the bill?

Then again, Sen. Wyden, who you admire, wants to make a compromise happen: http://prescriptions.blogs.nytimes.com/2010/02/11/wyden-on-insurance-we-can-expand-competition/

I think the main problem is that you might be creating a caricature of the GOP plan. If, as you reported, Rep. Paul Ryan believes in things like minimum benefits, then maybe we need to look at the idea of interstate competition all over again. Consumer protection, plus competition, might be much better than what Rep. Shadegg proposed and the CBO reviewed.

Posted by: gocowboys | February 17, 2010 2:31 PM | Report abuse

doesn't this go hand in hand with the deregulation of the industry? You can't have your cake and eat it too Ezra. I've stated this issue before but if you make a mandatory floor that has a set list of requirements to be covered you could do it. The problem then is the richer, more liberal states (northeastern) would likely gravitate towards the middle and lose some benefits (and in honesty some cost) while the poorer more conservative states (midwest and parts of the south) would get some additional benefits and in turn increase their costs.

Wouldn't it be nice if we could all live in the 6 year benefit 10 year pay window.

Posted by: visionbrkr | February 17, 2010 2:37 PM | Report abuse

Actually you are short-circuiting how this idea arrives at a final solution....consumers will decide which inch insurance they choose...state regulators will choose how favorable they're state's offerings will be.

A key to this solution is its modularity.

Unlike a federal one-size fits all, there is no dynamic---no competition---no constant bargaining, and building a better health plan.

As time goes on, there is a process here that evolves....not the state mandated Russian model of swimwear=eveningwear=underwear that we used to see on those clever Wendy's commercial.

Posted by: FastEddieO007 | February 17, 2010 2:37 PM | Report abuse

I apologize for sloppy posts...I get a little excited when Ezra throws out this kind of fodder.

Posted by: FastEddieO007 | February 17, 2010 2:41 PM | Report abuse

Fast Eddie- you are assuming that each state sets their own standard. Why would insurers not all congregate in a state with the lowest standard (whatever standard that may be)?

Posted by: Quant | February 17, 2010 2:44 PM | Report abuse

I for one would like to by my health insurance from a Gecko.

Posted by: jduptonma | February 17, 2010 2:47 PM | Report abuse

I'm not sure the credit card company is a compelling argument. Different states have different regulations that make them attractive or less attractive, but I don't think you'll see all the companies consolidate in a single state based on a single set of regulations, especially if those regulations make them high price, poor performance offerings.

The other option is to let the federal government regulate insurance, but not micromanage their product line. Ergo, an insurance company can sell anywhere, the states don't say what the company can offer, but they can decide whether or not a policy covers lead poisoning or doesn't, and charge accordingly--while providing clarity in regards to what is actually covered and what is not. For example, for many people, a general purpose catastrophic coverage plus medical savings accounts might make more sense than health insurance that covers everything under the sun.

But, at this point, I'm really not expecting anything to happen with HCR.

Posted by: Kevin_Willis | February 17, 2010 2:48 PM | Report abuse

FastEddieO007,

You are wrong on both points. State regulators may choose how favorable their state's offerings will be, but that choice doesn't affect anyone, since all insurance companies will just move to the state that provides negligible regulation. Therefore, consumers WON'T decide which insurance regulatory regime they buy from, because there won't BE a choice (other than South Dakota or Wyoming or whatever state wins the race to the bottom).

On top of that, any state with community rating (such as Massachusetts) would have a system without insurers (or a few insurers that would have to charge ridiculous rates, since the healthy people would all be buying from South Dakota). So now, one of the few places where people with pre-existing conditions can go will now not cover them anymore.

Why can't conservatives just admit that their proposal is really just to end meaningful regulation for health insurance? I don't think it would be very popular to phrase it this way, but at least it has the advantage of being honest.

Posted by: JonShields31 | February 17, 2010 2:50 PM | Report abuse

@Quant: "Why would insurers not all congregate in a state with the lowest standard"

They might well, but what constitutes the lowest standard in this case? The state that allows them to offer the crappiest coverage and the highest prices? Then, even if they are all in that state, it seems there would be a market advantage if offering slightly better coverage and slightly lower prices . . .

That depends on what the consumers do, however. The only reason the credit card companies can skewer their customers is their customers allow it, and rarely vote with their feet. Still, I'm not sure which state would offer the "lowest standards", or what those low standards would look like.

Posted by: Kevin_Willis | February 17, 2010 2:53 PM | Report abuse

I would be more in favor of selling insurance across state lines if the insurance coverage was required to meet the standards of the buyer's state, not the seller's state.

That is, I live in California, and I like that lead poisoning coverage is mandated. But I don't want to research all the fine print when I go comparing insurance plans. I just want to know that all of the policies I'm going to be eligible to buy meet all of California's standards.

Of course it leaves loopholes, such as people faking their address so they can get cheaper insurance. Then they discover it doesn't cover some of their medical care. But isn't that the consumer's fault?

Posted by: billkarwin | February 17, 2010 2:54 PM | Report abuse

So, (i) states regulate health insurance, (ii) health insurance is outrageously expensive and inefficient, and (iii) ending this practice is a bad, horrible, terrible idea.

I don't know where you ever got the idea that state regulation is a good idea. Spend some time delving deeply into state regulation of utilities or insurance companies. You think the U.S. Congress is inefficient and corrupt. Pick a state, say, Mississippi or Maryland. You'll find willingly captured legislators, stupid regulators, and arcane regulations that almost no one but the regulated companies understands. If you honestly return from that deep dive still convinced that state regulation is a good idea, then you need a brain transplant.

Posted by: ostap666 | February 17, 2010 2:54 PM | Report abuse

Kevin-

Credit card customers have little transparency or power in the relationship, and that allows the card providers to abuse them. I have to imagine it'll be the same in health insurance without a strong market watchdog.

And assuming that a state is willing to deregulate itself to host these companies, then why wouldn't they all move there? Of course they don't have to offer only crappy, expensive policies. But why would any insurer stay in New Jersey when they could be in South Dakota and face less oversight?

Posted by: Quant | February 17, 2010 3:01 PM | Report abuse

ostap-

(i) states regulate health insurance, (ii) health insurance is outrageously expensive and inefficient, and (iii) ending this practice is a bad, horrible, terrible idea.


your solution (iii) should read "build a better regulator"

Posted by: Quant | February 17, 2010 3:02 PM | Report abuse

@ostap666
"I don't know where you ever got the idea that state regulation is a good idea. "

Federalism. It's part of the Constitution.

Posted by: wiredog | February 17, 2010 3:04 PM | Report abuse

I don't see why you can't allow insurance polices to be sold across state lines that also must adhere to the laws of the state in which the policies are sold.

Posted by: Lomillialor | February 17, 2010 3:22 PM | Report abuse

And assuming that a state is willing to deregulate itself to host these companies, then why wouldn't they all move there? Of course they don't have to offer only crappy, expensive policies. But why would any insurer stay in New Jersey when they could be in South Dakota and face less oversight?

Posted by: Quant | February 17, 2010 3:01 PM | Report abuse


Crappy expensive policies are CRAPPY AND EXPENSIVE becuase of their claims costs and a lack of accountability via an individual mandate. And I like the idea of requiring the "host state's" laws applying. That way you don't get people losing benefits. Then again you can't force insurers to enter the market now can you?

Personally I'm in favor of a middle of the road federal approach to regulation but then again isn't that what the senate bill is. SIGN OFF ON IT ALREADY NANCY and let's call it a year.

Posted by: visionbrkr | February 17, 2010 3:27 PM | Report abuse

Conservatives love this idea because I don't think the uninsured population is a big priority to them. What they would like is for healthy people to use health savings accounts and have a high-deductible plan for everything else. If you're healthy, this type of plan is cheap and doesn't require any "onerous" (emphasis mine) regulations of insurers. The sell-across-state-lines idea fits this paradigm well.

The problem comes when you get sick or you're already stuck with a pre-existing condition. Insurers probably won't cover you and if they do, they'll raise premiums for those plans to likely intolerable levels (thereby claiming they offer comprehensive plans while pricing out most of the consumers that need it). Without a robust baseline of benefits across states and a standardized way to view plans, there will definitely be a "race to the bottom" for insurers like Ezra said.

Health insurance is a different product than what the advocates of this plan want it to be. You don't predict every condition you will get or illness you will come down with - you need the coverage when you need it, and not anytime before. That's why it's useful for the states to note that certain things (like lead poisoning) are prevalent enough that they necessitate coverage.

State regulations for insurance however may be losing their practicality. We live in an ever-more inter-connected world, and it might be more efficient to have a national standard for what plans should cover. Then insurers can sell their plans wherever and the consumer is protected to some degree. In fact I believe this was proposed in the Senate bills with the national non-profit plans overseen by the OPM.

Posted by: kmani1 | February 17, 2010 3:29 PM | Report abuse


nah dudes.

This will result in MORE regulation, as the McCarran-Ferguson Act has kept the commerce clause on a leash with respect to insurance. Once it is repealed, you don't NEED a law to regulate insurance as you have an enumerated constitional authority.

The 'race to the bottom' concern is real, but also real will be the federal government's newly unlocked ability to create a vast regulatory infrastructure.

Conservatives should've been more careful about what they wished for.

Posted by: ThomasEN | February 17, 2010 3:32 PM | Report abuse

ostap666,

The solution to your problem iii is federal regulation, not no regulation. You identify the problem (state regulation is not great, to say the least), but your solution is in the completely wrong direction.

Posted by: JonShields31 | February 17, 2010 3:54 PM | Report abuse

The original purpose behind "buying insurance policies across state lines" was said to be the ability to form interstate risk pools that would allow individuals and small businesses to avoid the pitfalls of the individual market or an insurance company that would shaft a small business because an employee got cancer.

But now we here from conservatives that it's *actually* all about allowing insurance companies to sell poor products that the state wouldn't allow to be sold in the first place.

Posted by: constans | February 17, 2010 3:56 PM | Report abuse

ThomasEN,

I'm not quite sure I understand your argument. You are saying that if the McCarran-Ferguson Act is repealed, then health insurance will once again be considered interstate commerce, and the federal government will be able to regulate it. I get that part.

But the Constitution allows Congress to regulate interstate commerce, not the executive. The enumerated powers you speak of are Congress', not the executive's. So wouldn't Congress still have to pass a law to regulate insurance at a federal level?

Posted by: JonShields31 | February 17, 2010 3:56 PM | Report abuse

Anyone here want to make a bet on whether Republicans would accept a compromise that just sets a minimum level of federal regulation of plans (coverage for certain basics, mandated minimum medical loss ratios, maximum cost spread) in exchange for the ability to freely sell across state lines? Given that the federal compromise is what's in the current legislation, I'd even give 2-1 odds for someone gambling on bipartisanship.

What it really comes down to is how much cost spreading you want. You need to have some degree of the healthy subsidizing the sick. The trick is to do that in as efficient and equitable way as possible, and following the credit card, international shipping, offshore banking, or corporate governance markets is a pretty bad way to get there.

Posted by: etdean1 | February 17, 2010 3:57 PM | Report abuse

No one here has given any reasonable arguments to counter the "race to the bottom", credit card model of insurers moving their corporate headquarters (might just be a PO Box for all we know) to the state with the cheapest, most easily bought regulators and legislature. Requiring insurers to abide by the state regs that the insured people live in (as opposed to the state the insurer is in) is a step in the right direction, but it means that people in the states with lax or no regulation will be in the same sinking boat they were in before this "reform". Of course, that is how it is now with the red states in the south with the worst social safety nets and the highest % of uninsured. Setting a national minimum standard for coverage is the only way to get any kind of insurance coverage reform.

Posted by: srw3 | February 17, 2010 4:02 PM | Report abuse

etdean1,

The Republicans wouldn't accept a compromise that consisted of a low cap on malpractice awards and absolutely nothing else. It is (usually) in their interests to block everything.

srw3,

No conservative has given a reasonable argument to counter the "race to the bottom" because the "race to the bottom" is the entire point to them. The "race to the bottom" isn't some side effect that they are fine living with -- it is the primary objective of the policy. They wouldn't even be proposing it if it didn't completely gut state level regulation. The only reason they call it "buying across state lines" instead of "gutting all state regulation" is because the former sounds politically better than the latter.

They don't even try to hide this in this very thread.

Their insurance utopia is where young, healthy people get cheap, high-deductible insurance that doesn't cover much, and sick people have to sign up for extremely expensive high risk pools that they claim they want to fund but don't actually want to fund.

Posted by: JonShields31 | February 17, 2010 4:08 PM | Report abuse


srw3,

No conservative has given a reasonable argument to counter the "race to the bottom" because the "race to the bottom" is the entire point to them. The "race to the bottom" isn't some side effect that they are fine living with -- it is the primary objective of the policy. They wouldn't even be proposing it if it didn't completely gut state level regulation. The only reason they call it "buying across state lines" instead of "gutting all state regulation" is because the former sounds politically better than the latter.

They don't even try to hide this in this very thread


jonsheilds and srw3,

If federal regulation mandates a set baseline level then state regulation wouldn't be gutted it would be replaced (and it would end a longstanding liberal argument against selling across state lines. But i don't want to hear any complaints from the richer benefit states that may lose a little bit of benefits so that the poorer states can afford it and I also don't want to hear from poorer states that their costs are increasing (along with their benefits that we won't ever hear a positive word about).

Posted by: visionbrkr | February 17, 2010 4:19 PM | Report abuse

"You can make insurance very affordable to young, health people by allowing them to purchase insurance across state lines."

Yes, Randomwalk. You can make insurance very affordable, as long as you're willing to make it worthless.

As long as you stay healthy, it will be fine-- except that if you stay healthy, insurance is always (inherently) a bad deal. For insurance to be worth having at all, it has to work when you are /not/ healthy.

Posted by: adamiani | February 17, 2010 4:19 PM | Report abuse

The nominal 'theory' is that greater competition will be the mechanism here, not deregulation. Personally, I say call their bluff-- let insurance be sold without restriction across state lines, but impose stringent Federal regulations to replace the ones from the states.

Posted by: adamiani | February 17, 2010 4:23 PM | Report abuse

Kevin, I don't have time to read through everyone's comments, so if somebody covered this you can ignore it. The problem with the idea that there'd be an advantage to offering slightly better coverage or slightly better prices is that health insurance is complicated and people don't understand it. Most people don't know if they're covered for lead poisoning. Moreover, they don't know what the risks of lead poisoning are so they don't know if they *should* be covered.

Posted by: MosBen | February 17, 2010 4:26 PM | Report abuse

This whole thing is a moot point. Everyone here seems to be coaslecing around the idea of agreements between states to open up their insurance markets. And that's what's in the HCR bill right now, right? It's a pretty good compromise.

Posted by: Quant | February 17, 2010 4:29 PM | Report abuse

visionbrkr,

You seem to be more reasonable in that you agree that the "race to the bottom" is not the answer, and instead there should be some federal government regulatory replacement. But this is contrary to what most people I have seen advocate for this, who want the selling state to do all the "regulating" (meaning not regulating). This includes Republican members of Congress. (The closest I have seen to a minimum benefits proposal was that of Paul Ryan in his interview with Ezra Klein, who wanted a minimum benefit level to define what insurance is, though I have not seen proposed legislation to back that up and I have not seen any other congressperson support any federal regulatory oversight at all.)

However, this goes beyond minimum benefits levels. Right now, Massachusetts has a pretty stable community rating system (with no death spiral like New York). If the federal regulation did not call for community rating (which it couldn't do without a mandate and subsidies etc etc etc), allowing buying insurance across state lines would essentially gut MA's entire system (by allowing healthy people to buy insurance in non-community-rated states). This would really hurt anyone with a pre-existing condition in that state and effectively roll back their healthcare reform (which huge majorities of their state want to keep).

Posted by: JonShields31 | February 17, 2010 4:34 PM | Report abuse

@MosBen: "The problem with the idea that there'd be an advantage to offering slightly better coverage or slightly better prices is that health insurance is complicated and people don't understand it. Most people don't know if they're covered for lead poisoning. Moreover, they don't know what the risks of lead poisoning are so they don't know if they *should* be covered."

All good points. Alas, no easy answers. Then maybe a nationwide, federally regulated health insurance market is the answer.

Posted by: Kevin_Willis | February 17, 2010 4:45 PM | Report abuse

JonShields31,

I agree entirely with what you said but remember when we do that we're requiring those states that aren't up to snuff to get there and you only get there by adding mandated coverages and in turn mandating additional costs. When you do that please don't tell me you're going to save me $3000 a year on my healthcare or any other talking point that the Dems think up next to convince me that someone else is paying for it.

If this ever happened you'd see some serious rate shock in states with low regulation right now.

Posted by: visionbrkr | February 17, 2010 4:48 PM | Report abuse

also the fact that people dont' understand health insurance for whatever reason is not resolved by selling across state lines, state regulated policies or even a federal exchange. Can you imagine calling someone at the "public option" and asking them if the policy covers allergy testing where they draw blood as opposed to the stick test and if it is covered my doctor is sending it to XYZ labs, are they covered on my plan?? Do you really think you're going to get the right answer or a straight answer from anyone there? Do people really think it would be any different than people dealing with insurers now or is it to be this wonderful panacea that anything you submit gets paid in full no questions asked and Paris Hilton gets to pay for it all?

(cue the posts from tyromania whining about me complaining about how dumb the American public in general is)

Posted by: visionbrkr | February 17, 2010 4:54 PM | Report abuse

Mr. Obama promised that if you like your health plan and your doctor, you won't have to change.

He has since admitted to congressional Republicans that Pelosi & Reid's bills do not live up to the promise he made to the American people.

If Obama has any integrity he will demand congress to scrap the current legislation and start over! Why not start off with a simple bipartisan bill that gives everyone the same tax write-off for healthcare? Then we will finally know that Democrats and Republicans have stopped playing games.

Posted by: FastEddieO007 | February 17, 2010 4:59 PM | Report abuse

The deal would be simple: Let us write the regulations and we'll bring thousands of jobs and lots of tax dollars to you. Someone will take it. The result will be an uncommonly tiny legislature in an uncommonly small state that answers to an uncommonly conservative electorate that will decide what insurance will look like for the rest of the nation.


Isn't this EXACTLY what happened under the proposed national health care mandate? By buying off Nebraska, we were thisclose to having a standardized plan -- mandatory -- pushed off on all Americans.

Thank heavens you've come to your senses Ezra, and are now rejecting the manipulation of smaller states via bribery money that will eliminate freedom of choice on an issue as important as healthcare and impose one set of standards -- buy insurance! -- across the national as a whole.


Posted by: Mary42 | February 17, 2010 5:03 PM | Report abuse

Two things about insurance across state lines.

- An insurance guy told me long ago that you cannot trade dollars with an insurance company and win.

- You do not want to have the cheapest insurance if you really need it.

Posted by: gratis11 | February 17, 2010 5:06 PM | Report abuse

but it would make insurance more expensive for the sick and cheaper for the healthy, and lead to more healthy people with insurance and fewer sick people with insurance.

You say this like its a bad thing?? Seems to me, if we want the nation to get healthier and more competitive in our pricing models, then the idea that those with pre-existing conditions get treated equally as the healthy is a poor, poor idea.

Some of those pre-existing conditions were brought on by lifestyle choices. Ask Andrew Sullivan. That's fine that he gets treatment (and the poor too, via state government poor-people's insurance) but tell me again why healthier, lower class individuals are asked to subsidize it?

Charity care is fine, until the poeple on it starting thinking of it as an entitlement, not charity given out of the goodness of their hearts -- the healthier who pity the sick, and might voluntarily contribute, but not mandatorily agree to assume the costs of the coverage.

Posted by: Mary42 | February 17, 2010 5:07 PM | Report abuse


JonShields,

my understanding is that congress already has passed such regulatory authority - the FTC - and that authority would pick up where it left off 65 years ago. I'm a bit outside my area here, but this is my understanding...

Posted by: ThomasEN | February 17, 2010 5:09 PM | Report abuse

*if we want the nation to get healthier and more competitive in our pricing models, then the idea that those with pre-existing conditions get treated equally as the healthy is a poor, poor idea.*

O. M. G.

I am healthy now. I might not always be healthy. I want to know that if ever I become unhealthy, which could occur by a roll of the dice, that I will be treated equally as anyone else and that my health insurance will be accepted as readily as anyone else's.

Wow, Mary42, your attitude is not only sociopathic, it's antithetical to the very concept of *insurance*-- that we pool our risk so that we are hedged against the risk and danger of getting financially intractable medical illnesses.

Posted by: constans | February 17, 2010 5:17 PM | Report abuse

Mary42,

While you might consider it somehow a "good thing" that the sick pay much more than the healthy (as opposed to a very bad thing), you are in a very small minority there. Poll after poll shows that vast numbers of people support the premise that people should not be discriminated against on the basis of a pre-existing condition. Heck, even some Republicans in Congress like Enzi and Grassley support want to ban this discrimination. (Of course they don't have a workable plan to do so, but at least they don't pretend that it is somehow a good thing to have pre-existing condition discrimination.)

The main fallacy in your idea that it is a "good thing" to have such discrimination is that you go from "some of those pre-existing conditions were brought on by lifestyle choices" to essentially "screw those who have pre-existing conditions or genetic potential for them through no fault of their own." After all, the Senate bill allows for modest premium variation based upon factors easiest to identify as lifestyle-based (while not allowing premium variation on other things such as a family history of cancer).

You view the idea of the healthier subsidizing the sick as some sort of charity. As far as I'm concerned (and many other people as well), allowing the healthy to get a huge discount at the huge expense to the sick is the real subsidy (not the other way around). You essentially view everything from the framework of "let evolution run its course" as the baseline, as opposed to a framework where everyone pays roughly the same amount for healthcare services (where deviation from that should be looked at best with skepticism).

You are free to have such a Darwinian view. But please don't pretend that this is the only morally defensible baseline, or that it isn't soundly rejected by most Americans and by essentially every modern industrialized nation (even the ones that don't have single payer).

Posted by: JonShields31 | February 17, 2010 5:23 PM | Report abuse

Just to be clear, Mary42, you're saying that if a poor person gets sick and can't afford treatment, we should allow them to die?

Individuals with pre-existing conditions already face enormous rates in the individual market. No one's thinking "I'll get diabetes because I'm sure that I'll always have a job that provides me with health insurance until I'm 65."

Insurance is all about risk spreading. That necessarily involves healthy people paying more than their share if they get lucky and stay healthy.

Posted by: etdean1 | February 17, 2010 5:23 PM | Report abuse

Just to be clear, some premium deviations can be really good, when you have specific and controllable risk factors at play and the spread isn't too great. I'd love it if my healthy choices could lower my rates. But mostly, people just randomly get sick. If you could control your outcomes with any certainty, we wouldn't need insurance.

Posted by: etdean1 | February 17, 2010 5:26 PM | Report abuse

i hate to admit it but i prove my point made at 4:54 with Mary42's comments.

Posted by: visionbrkr | February 17, 2010 5:27 PM | Report abuse

Just to be clear, I can get really repetitive in the afternoon.

Posted by: etdean1 | February 17, 2010 5:30 PM | Report abuse

fasteddie007: "Why not start off with a simple bipartisan bill that gives everyone the same tax write-off for healthcare?"

Well that is called the wyden bennett plan and it got almost no support from either the repiglicans or the dems, so that is as much pie in the sky as single payer tied to medicare rates, or a VA style government owned health care system.

Posted by: srw3 | February 17, 2010 5:35 PM | Report abuse

JonShields,

It's more than just a community rating -- it's that the insurance rating rules have to be identical. Here in MA, we have a 2:1 age rating, 1:1 smoker rating (meaning no smoker rating), and 1.5:1 region rating. Let's say the the Senate bill -- with its 3:1 age rating, 1.5:1 smoker rating, and region rating determined by HHS -- became the law of the land, and the insurance rating rules applied to the state of residence of the insurer (which in the Senate bill applies to the state of the purchaser). WY, which currently has no insurance rating rules in the individual insurance market, could use it's 3:1 age rating, 1.5:1 smoker rating to cherry-pick those 27-year-old Bostonians. This still would leave the Commonwealth of MA with a much sicker risk pool, drive up costs for people with pre-existing conditions, and would begin the insurance death spiral here in the Bay State. So there can't just be a community rating: insurance rating rules also have to be identical.

That said, you are correct that the main effect of allowing insurers to sell across state lines is mucking up state community ratings.

Posted by: moronjim | February 17, 2010 5:41 PM | Report abuse

I don't understand why so much ink has been spilled over a topic that wouldn't change the fundamental problems of our health care non-system.

The object of the proposal to sell insurance across state lines seems to be to sell more policies, not to reduce actual expenditures for care. But people need health care, not financial products that don't pay for the care they need.

Selling more policies to young, healthy people that exclude expensive conditions, won't decrease provider costs for people who do have those conditions. And when one of those young, healthy people ends up some debilitating disease, the inadequate policy won't help local providers collect for his care; public agencies will still be picking up the tab for those expensive treatments.

Those who think that people who don't understand their policies deserve what they get really miss the point: Health care is a matter of public security. People buy what they can afford and all of us have to live with the consequences of a underinsurance. The insured bankrupts for example, who listed medical debt as a precipitating cause of their insolvency are the same people whose empty houses are depressing home values across the country.

Having "yours" doesn't protect you from the consequences of a dysfunctional model.

Posted by: Athena_news | February 17, 2010 5:43 PM | Report abuse

I have a B.A. in political and I'll be the first to admit that I AM NOT SMART ENOUGH TO UNDERSTAND INSURANCE POLICIES.

This is fundamentally why "across-state-lines" insurance will not work.

There are genius people, with Masters degrees, PhDs, etc. who are paid millions to create confusing and complex policy options, SPECIFICALLY DESIGNED, to get me to pay the most money for the least actual coverage.

I simply cannot negotiate with the insurance companies when they have millions of times more money than I do, thousands of geniuses working for them, and thousands of lobbyists writing the laws in their favor.

THIS IS WHY WE NEED MEANINGFUL HEALTH CARE REFORM, because there is no way an individual with a mere's bachelor's degree, much less someone who didn't finish highschool, successfully negotiating a good health care.

THIS IS WHY THE AVERAGE AMERICAN SPENDS TWICE AS MUCH ON HEALTHCARE AS A BRITISH WHILE RECEIVING LESS COVERAGE.

Are conservatives really so outrageously arrogant/stupid that they think they can negotiate with a Billion dollar Insurance corporation to get a fair price??!!

Posted by: maquih | February 17, 2010 5:48 PM | Report abuse

State regulation PLUS a large state employee pools causes local monopolies as a state's population can only support a limited amount of insurers and one or two are granted a large block of them. Any competitor would suffer as they would be left with the leftovers.

Posted by: cprferry | February 17, 2010 5:59 PM | Report abuse

maquih,

i'm sorry but i have a BS from an "average" college and I understand it although I will agree that it is complex to most. I likewise know CEO's that don't get it but honestly its mainly common sense. Every policy has a certificate booklet that details exactly what is and isn't covered. If not call someone at your insurer and get their name as a reference point.

They also don't purposefully create complex insurance polices. They are forced to create more complex policies because of costs and regulation. Back in the olden days of indemnity style 80/20 plans it was very simple because of cost. Now every medical provider wants to get theirs moreso than ever and there are pitfalls all along the way. That's not an insurers fault.


oh and btw, you don't need to negotiate with insurers on price, price of premium normally set by the insurer and regulated by the state (i should preface this and say most states). Its doctors and hospitals you need to negotiate with. I know, i've done it and they want to receive something for their uncompensated care even if its as low as 30 cents on the dollar.

Posted by: visionbrkr | February 17, 2010 6:14 PM | Report abuse

"Wow, Mary42, your attitude is not only sociopathic, it's antithetical to the very concept of *insurance*-- that we pool our risk so that we are hedged against the risk and danger of getting financially intractable medical illnesses."


Voluntarily. We "voluntarily" pool our risk so that we are hedged...

The simple truth is: by forcing the healthy into this Ponzi scheme mandatorily, and making no distinction between the healthy and sick, then you are forcing one group to pay for services the others are getting. Not everyone collects equally you know, so why not leave the system alone to price the premiums according to this basic business fact?

Do you want to keep healthcare costs down, and encourage people to adopt healthier lifestyles? Then make the sick pay more for their premiums to cover the increased services they are getting.

And turn to charity care to help the rest. And let them know they're not entitled to equal premiums and treatments, but folks are VOLUNTEERING to help them. Don't force anyone to subsidize the personal health choices of others though.

That's what Americans are telling you on this mandatory health insurance thing, if anyone's still listening...

Posted by: Mary42 | February 17, 2010 7:49 PM | Report abuse

Just to be clear, Mary42, you're saying that if a poor person gets sick and can't afford treatment, we should allow them to die?

No. I think they could pursue charity care -- many places have fundraisers for those hit with unexpected medical bills and no way of paying for them.

Are the sick entitled to my money though, because some bleeding heart liberals think their unmet needs should be subsidized out of my pocket? No, I don't think so.

Take away the "mandatory" part of healthcare insurance reform, and let everyone who want insurance hop into the pool, and let the premiums be set within that group.

Just please: don't tell me I'm constitutionally required to pay for something because other people are hurting financially and can't afford to meet their own needs.

Compassion, charity? Yes. Entitlement? No.

Posted by: Mary42 | February 17, 2010 7:55 PM | Report abuse

"But mostly, people just randomly get sick."

I think if you want a healthy America, this is the exact mindset you have to first conquer.

Take responsibility for your lives, and your health. And if you are not entitled to have others pay to care for you, you'd be amazed at how many people start seeing the link between their own personal choices and actions, and their personal health.

Posted by: Mary42 | February 17, 2010 7:57 PM | Report abuse

Mary,

Do you have car insurance because your warped view would consider that "FORCED" as well. God help you if you or anyone you care about ever gets an illness that is beyond their control. Look I'm with you that people need to be healthier and I'm all for charging people LESS that live healthy lifestyles but sometimes, its beyond their control. I'm also totally against "permanent welfare" for those that milk the system but you go too far. Way too far.

Posted by: visionbrkr | February 17, 2010 8:16 PM | Report abuse

No. I think they could pursue charity care -- many places have fundraisers for those hit with unexpected medical bills and no way of paying for them.

Posted by: Mary42 | February 17, 2010 7:55 PM | Report abuse


I knew a 4 year old who died at age 5 with neuroblastoma (sp). I don't think she had "life choices" that affected her health and no amount of bake sales in the world could have paid for the millions spent to try to save her life. Sorry, you're wrong and I hope for your sake you don't ever have to find out.

Posted by: visionbrkr | February 17, 2010 8:18 PM | Report abuse

Visionbrkr:

Wow, this little baby dies because she was uninsured, and was rejected for cancer treatments because her parents were unable to pay her bills?

Or... the child contracted an illness, and despite the best efforts at curing her, she passed away?

If the former, what a shame. Did the family try to work with the hospital's charity care plan, or did they reach out to friends and families to help pay her medical bills so that the medical providers had the money in hand to treat her?

If the latter, I'm so sorry. Bad things happen. But asking me to pay out of my pocket for the expenses incurred by her family (children's expenses fall to their parents, naturally) ... well, if you "ask" I might give to help as I have attended benefits for family friends raising money for healthcare needs.

But to demand I pay for the expenses that essentially fall to the parents? I'm sorry, but providing for my own family's health takes precedence for my dollars than being forced by bleeding heart liberals to pony up for somebody else's child. Ditto education.

Perhaps since you know the family in their time of need, you might have stepped up to solicit donataions on their behalf, if indeed it was the lack of payments that kept her from getting the needed treatment that would have saved her little life.

Posted by: Mary42 | February 17, 2010 8:52 PM | Report abuse

"Do you have car insurance because your warped view would consider that "FORCED" as well."

Only the liability part is mandated. Which "forces" me to pay for the damages my actions cause others.

I'm fine with that. And guess what? They PRO RATE my policy, so that my premiums are calculated by my past history and presumed risk rate.

So poor or unlucky drivers necessarily pay more for their higher risks, and greater likelihood to draw on the necessary services the insurance covers.

Can you see a distinction here?

Posted by: Mary42 | February 17, 2010 8:55 PM | Report abuse

visionbrkr,

Amen. Thank you. There is plenty of room to disagree about the best public policies for health care, but when we start to blame all illness on personal behavior, we have run off the rails.

Posted by: Patrick_M | February 17, 2010 9:03 PM | Report abuse

Mary,

no her parents had insurance but for some strange reason they wanted to be with their child when she was dying so they took leaves of abscence from their work but they were lucky and their jobs continued their insurance for them at their employer's expense. Not everyone's that lucky though.


Just please: don't tell me I'm constitutionally required to pay for something because other people are hurting financially and can't afford to meet their own needs.

Compassion, charity? Yes. Entitlement? No.

Posted by: Mary42 | February 17, 2010 7:55 PM | Report abuse

So can I assume by this that you're uninsured and if so, by choice?

Posted by: visionbrkr | February 17, 2010 9:14 PM | Report abuse

Not everyone's that lucky though.

I don't know. For every dying baby story that is trotted out to convince us of the need for mandatory insurance for all because... babies are dying!!, very often it turns out the dead person received the best available medical treatment and passed anyway.

And surely nobody is talking about a pool where unaffected others are forced to pony up to cover the parents decision to take time off work to be with their dying child? I'm sympathetic to their hard choices, and having to forgo income to be with your dying child surely can be a hardship, but personal choices are there for the taking. And very often, in this case, loving family and friends can step up to plug holes in the family's budget, if the unexpected illness causes financial hardship.

I'm just at a loss how forcing health people to pay the same premium rates as the more sickly does anything to bring this child back to life. Or are you relying on everyone to back down from rational arguments when you wave the "I know a little girl who died at 5 flag!" ?

Sadly, most all of us could tell a story like that. You know what? One day, those parents will realize ... life indeed does go on for the living. Bills need to be paid. Often, other children cared for.

Insurance can't protect one against heartbreak and it doesn't guarantee miracle outcomes. You understand that by now, don't you?

Posted by: Mary42 | February 17, 2010 9:34 PM | Report abuse

when we start to blame all illness on personal behavior, we have run off the rails.

For the record, my argument is that instead of turning the whole racket into a giant Ponzi scheme, insurance premiums should be adjusted according the payments going out, and the risk factors involved with having a pre-existing condition.

Otherwise, you do realize we are going to be in the same boat 20 years from now, when costs continue to be uncontrolled because somebody else's paying, and we've run out of healthy people to force to subsidize the health of others.

Posted by: Mary42 | February 17, 2010 9:37 PM | Report abuse

I know conservatives like to trumpet charity care or nonprofits as a solution to what they're unwilling to pay for (and depend on the kindness of others to make sure society functions, while not paying a dime for it), but Mary42 taes this to a whole nother level. I have to conclude that he/she is a brilliant troll. Well done sir/madam!

Posted by: Quant | February 17, 2010 9:43 PM | Report abuse

i can't belive it but I'm liberal (no progressive) compared to Mary42.

You never did answer me though. do you have health insurance?

If so why would you participate in what you call a "ponzi scheme"?

If not I sure hope you're rich because one serious illness will bankrupt you.


Otherwise, you do realize we are going to be in the same boat 20 years from now, when costs continue to be uncontrolled because somebody else's paying, and we've run out of healthy people to force to subsidize the health of others.

Posted by: Mary42 | February 17, 2010 9:37 PM | Report abuse


You do realize that people are being born every day, right so as you put it the "supply of healthy people" won't end.

Posted by: visionbrkr | February 17, 2010 9:49 PM | Report abuse

Quant,

I'm sorry but there's a difference between conservative and crazy.

Posted by: visionbrkr | February 17, 2010 9:49 PM | Report abuse

I'm not saying that... there's crazy on all ends of the spectrum. Mary is just the conservative argument taken to the logical extreme. Plenty happy to let other people take care of the dying poor children, so long as she doesn't have to pay for it.

Posted by: Quant | February 17, 2010 11:02 PM | Report abuse

Mary42,

You wouldn't be "constitutionally required" to "subsidize" sick people through insurance. You would be statutorily required to do so by law passed by a democratic legislature, just like you are currently statutorily required to subsidize senior citizens for medical care and retirement income. (Programs that are wildly popular.) After all, Massachusetts has community rating, and over 85% there want to keep it. They don't have to rely on charity or any other voluntary mechanism to get the care they need. They get it because they are entitled to (according to the law in Massachusetts), and this is not particularly controversial among the vast majority of MA's population.

In fact, such a community rating "entitlement" is in many ways less controversial than Medicare and Social Security.

First of all, community rating itself doesn't burden the government's balance sheet. It certainly isn't a ponzi scheme. One can argue that Social Security is a "ponzi scheme" because variations in birth rates over time can cause imbalances that lead to financial problems (like the impending baby boomer generation retirement). But as visionbrkr points out, there isn't an impending shortage of healthy people to help "subsidize" the sick (nor do I know of such a time historically or a mechanism to produce such a situation in the future). You might not be thrilled with having to spend your money to help other people, but that doesn't make it a ponzi scheme. With a mandate (as in MA), it would be quite stable.

In addition, such an "entitlement" would (much of the time) help people with deal conditions outside of their control (despite your repeated assertions to the contrary). While you should feel free to pretend that you can snap your fingers and have "individual responsibility" prevent diseases people are genetically predisposed to, this assertion is so far from the actual reality we live in that I don't even think the opposing point of view is even particularly controversial among experts.

This is a direct contrast between community rating and SS/Medicare, since in theory, one can avoid needing SS/Medicare by saving throughout the course of their lives (as opposed to catastrophic health expenses, which are often genetic and out of your control, and require amounts of money far higher than almost anyone would or could have at any time.

Posted by: JonShields31 | February 17, 2010 11:27 PM | Report abuse

Quant:

I am a proud liberal, but I agree with visionbrkr that Mary42's condescension, indeed contempt, for the poor and the sick, are well past the extreme. I don't think Mary42 is at the logical extreme of conservatism any more than I think that Mao's Cultural Revolution was the logical extreme of liberalism.

I tip my hat to visionbrkr for wrestling with Mary42's revolting rhetoric.

Indecency is not the logical extreme of either conservatism or liberalism. When you reach pure amorality, you are somewhere else entirely.

Posted by: Patrick_M | February 17, 2010 11:55 PM | Report abuse

Does this only apply to the individual health plan market? One of the reasons so many people oppose the health reform bill in general is that they get group coverage through their employer and, even with spiraling premium costs and higher deductibles on group plans, many people fear that they will be dumped into the far worse individual market.

Posted by: ElrodinTennessee | February 18, 2010 12:23 AM | Report abuse

funny - you'd figure if they could make it work for car insurance - that they could make it work for Health insurance.

And last I saw (though I haven't really checked) all auto insurance companies aren't clustered in one state.

Posted by: flintdavis | February 18, 2010 4:34 AM | Report abuse

You would be statutorily required to do so by law passed by a democratic legislature, just like you are currently statutorily required to subsidize senior citizens for medical care and retirement income. (Programs that are wildly popular.)

Ain't gonna happen, my friend. You seen the poll numbers on the popularity of this saving plan? The People don't want it.

As for the popularity of SS programs? Sure, very popular because we all LOVE to pay to provide your mother a nice old age home, while many choose to care for their own under their own roofs. We love subsidizing wealthy elderly people without a means test, because goodness knows, if we asked them to spend some of their accumulated wealth on their own housing and medical needs, how would we be able to leave a sizeable inheritance to junior and his offspring? Priorities, people.

And I predict the popularity of those social programs will end when the money runs out.

(Btw, it won't pass, but forcing a person to buy a product they don't want or need in order to subsidize others? Unconstitutional, my friend.)

Posted by: Mary42 | February 18, 2010 6:51 AM | Report abuse

You never did answer me though. do you have health insurance?

Because I don't ask you to pay my bills, I still operate on a presumption of privacy. You see how the two go hand in hand?

FWIW though, if I were you I wouldn't spend any time worrying about my health or how I define and pay for my "health care."

You take care of yours; I'll take care of mine. If you need a donation to help with yours, feel free to ask me. But don't threaten to force me to pay your medical bills, due to your bad luck, personal choices, or poor financial planning.

PRO CHOICE is impossible if you try to net everyone into some big government redistribution scheme with regulatory oversight.

ps. If you think fast food calories are the same as food prepared at home in terms of preservatives and active nutrients/amino acids, then probably it is best to throw in your lot with the medical "fix it" industry.

How do you suppose the Mennonites live such healthy lives and only have occasional need to visit -- and pay for -- doctors services?

Posted by: Mary42 | February 18, 2010 6:56 AM | Report abuse

"Mary42's condescension, indeed contempt, for the poor and the sick, are well past the extreme."

And how many lives have you saved today, sir? Where are the hospitals and clinics you are building? How does taking away my personal choices, and forcing me to subsidize yours, take away from my voluntary donations to charity causes to support those who you deem most worthy of receiving treatment?

Face it: we all have pet causes, and some are more efficient at servint them than others. Now -- if there are any more dead baby/children stories to pull out for emotional value, feel free to share. I hear it has cathartic value, and we all know the value of mental health parity these days ... I'd rather you spew here than run up a bill on talk therapy that you generously pass off to others in your insurance pool.

Good day all!

Posted by: Mary42 | February 18, 2010 7:00 AM | Report abuse

"Plenty happy to let other people take care of the dying poor children, so long as she doesn't have to pay for it."

I tithe regularly. But not at the government's mandatory insistence for those they've deemed to be societal victims.

Posted by: Mary42 | February 18, 2010 7:05 AM | Report abuse

Mary42,

usually when you say "Good day all" you then don't put another psychotic post up but then again that's not nearly the worst thing you've said on here. Listen I agree with a small portion of what you say but you take it to the insane degree. You cry "PRIVACY" when I ask you a simple question and yet you bash me for making a point about how not all can help their illnesses. I was not going for sympathy (I'm sure I'd never get it from you) but merely pointing out that if you had any clue what medicare care cost in this country you'd know that you couldn't come close to pay for it with the nickels in your couch or a nice bake sale.

I hope you don't have health insurance because if you did that would make you quite the hypocrite. Also don't put your money in the bank (that's another ponzi scheme), don't invest in the stock market (another one), don't pay your taxes (another one), see where we're going here?

Posted by: visionbrkr | February 18, 2010 7:50 AM | Report abuse

There's one piece missing. Who decides if Californians can buy insurance from a company in Alabama? If it's California, then why is this a federal issue at all? And if they want California to be forced to admit insurance from Alabama, what does this say about the alleged Republican view on states rights?

Posted by: chase-truth | February 18, 2010 8:01 AM | Report abuse

Mary42, civilization has had 6000 years to figure out how to provide universal health care for everyone via private charity. Private charity has a 6000 year track record of failure in this regard. This is because the problem is large, complicated, and lends itself to collective action, which is where we do find the problem solved.

Next, I'm going to try to reason with you here. First, it is reasonable to point out that the healthiest and the lowest-paid (the young) are also going to pay to manage the risk of those who are older and in their peak earning years. I agree that this is an issue. To a degree, that's the nature of "risk pooling": we're all a big risk pool, and the young and healthy today may be the young an unhealthy tomorrow and will almost _definitely_ be the old and unhealthy many years down the road. But this is also why these universal health care proposals have a _cap_ on the maximum portion of their income that a person can be expected to pay on their health insurance (protecting the young and not-well paid) and why many proposals plan to fund coverage with money from an income/payroll tax (generating more money from those who are highly paid, which skews older).

Finally, another note about private charity and its pitfalls: the last thing I or anyone wants is for someone who needs health care but can't afford it or can't afford coverage to be forced to pass through the gauntlet of judgment from those self-righteous people who deign to offer "charity." Health care shouldn't be contingent on passing a test of moral and personal virtue on the part of self-styled benefactors who decide to provide or withold their "charity" at their own whims.

Posted by: tyromania | February 18, 2010 8:18 AM | Report abuse

a little to the discussion and I'm sure others may have pointed this out, but aren't life, auto, fire, and other forms of insurance sold across state lines?

I sure see a lot of competition from auto insurers for my business, why can't the same be done for health insurance?

Posted by: pakurilecz | February 18, 2010 9:35 AM | Report abuse

Like a good little communist, Mr. Klein is entirely concerned about the cost to his everaching federal government.

Mr. Klein, frankly, nobody gives a rats arse about the cost to them, how about the millions upon millions of actual people who have to pay extravagant prices for insurance in California and other places to cover things which they have zero chance of getting.

In typical fashion, the conmunist solution in Obama's healthcare takeover doubled down on this stupidity by requiring everyone from 80 year old grandmothers to gay men to contribute an amount each month to cover abortions?

The reality of the debate is that the Left and their adolescent followers want someone else to bare the expense of paying for their healthcare so that they can continue to spend their own money on "fun things". So confiscating some money from those other people allows these leeches to keep their own money for more pot, parties and tatoos.

And Pelosi\Obama love it because it allows them to dictate how people vote and to whom to direct huge sums of money, supporters of themselves, of course.

Posted by: LogicalSC | February 18, 2010 10:04 AM | Report abuse

Yes. LogicalSC, that is it: Pelosi and Obama are engaged in a devious Communist conspiracy to get voters to support them by creating and passing policies that benefit the voters. Yep, that's a real humdinger of a subversive Communist scheme, there. Un-American I tell you!

Posted by: constans | February 18, 2010 10:49 AM | Report abuse

LogicalSC--A very illogical response to a serious issue. Every state has mandates that reflect the majority opinion of their representative government. In our current system if the state government implements a mandate that is unpopular and drives up costs unnecessarily, it is the state's elected representatives that make the decision to strip it.

Abortions are an easy strawman--and are really not the issue in most state mandates. In fact if you took the time to look at the link provided by Ezra Klein listing you would have seen that abortion is not even one of the Mandated benefits at issue.

The problem with mandates is that individually most contribute to less than 1% to the cost of an insurance plans, however when you add them up, it can make a significant cost difference. Many are services that people generally don't use or need, but if they do it is expensive--like Bone Marrow transplants. Others are services such as routine exams that everyone should be using and plans should have built in.

All Ezra is saying is that in order to sell insurance across state lines you have to have some kind of mandate standardization (ie federal solution)or the states have to come into some kind of agreement of what a standardized benefit package would look like. Otherwise out of state plans will automatically undercut local plans, not because they are more efficient or do a better job, but because they don't cover things that the state requires in-state insurers to do.

Given our federal system that allows states to govern best for their local citizens we will have in effect given Utah, South Dakota etc, the ability to circumvent the will of the people (as expressed through their legislature) of every other state in the country.

Without accomodating this issue first with a clear plan---and there are ways to do it---any proposal to sell insurance across state lines is nothing more than politics.

Posted by: joe_potosky | February 18, 2010 11:56 AM | Report abuse

Ezra, I think your problem and the problem of most liberals is that you think the American insurance consumer basically is an idiot. This person according to liberals can't pick out his or her health insurance on his or her own. They have to have the loving embrace of big government to keep them from doing something stupid. Amazing how the consumer is able to buy car insurance and home insurance across state lines but they can't possibly figure out what's best for themselves and their families when it comes to health insurance. I can sit down at my computer to buy my auto insurance. I punch in the levels of insurance mandated by my state and it'll in moments spit out how much it'll cost me. I can even go over the minimums required by the state if I want to pay more. Isn't that great? Capitalism at work. If I underinsure myself and and get involved in an accident then I pay the difference out of pocket or if I don't have it I declare bankrupcy and pay the price of my gamble or stupidity/greed. Unfortunate? Yes. Tragic? No. Life goes on. Why should health insurance be any different. The states set their minimum coverages. A consumer sits down at his computer, brings up the medical insurance version of Geiko, puts in his minmum coverages (more if he wants) and out comes the estimate of what it'll cost him. What's great is the consumer can even see what his state mandates cost him versus other states (liberals really hate that aspect) and if they don't like it can either take political retribution against the folks who set those over priced mandates or can move to a state with less regulation. That's the way it works for everything else. Why should be any different for health insurance? As for the folks who have chronic health conditions: forcing insurance companies to cover them is called welafare not insurance. Insurance is not meant for people who have already suffered the bad outcome you are insuring against. I guess in the same fashon you should be able to call a home insurer to get coverage on your house as a flood is washing it away. If you want to deal with people with chronic health problems then the government could step in and create a high risk pool subsidized by the government to deal with this group of people. And lastly people who genuinely can't afford health insurance could get a tax credit to go out and buy their insurance in the open market. There you go. Everything taken care of without the government running everything. By the way individuals should be able to write off their health insurance costs on their taxes just like businesses do now.

Posted by: RobT1 | February 18, 2010 12:18 PM | Report abuse

Car insurance is not sold "across state lines." It is strictly regulated, state-by-state. Geico is beholden to the regulations of the state in which it sells insurance, just like every other car insurance company. You can't buy Geico insurance if you live in Massachusetts, for example.

It's amazing that right wing crusaders have to LIE in order to argue their points. It indicates that their own side is in the wrong, since they have to resort to dishonesty, ignorance, and distortion to defend themselves.

Posted by: constans | February 18, 2010 12:27 PM | Report abuse

I never said that Geico wasn't beholden to the individual state regulations. It most certainly is and I say that in my post. What I'm saying is the transparency of buying your state mandated health insurance coverages should be the same as the state mandated car insurance coverages. Why shouldn't a consumer be able to see how much his state's mandates cost him? If you get right down to it I personally don't believe the state has any business telling me what type of insurance to buy be it health insurance or auto insurance. But that's probably too radical for some people. Too much freedom.

Posted by: RobT1 | February 18, 2010 12:40 PM | Report abuse

robt1,

the idea behind mandating it is that it reduces the costs because its spread throughout the population. Its not always fair but what is. a small employer with 5 single employees in their 50's has no use for maternity but in most states its in there. I believe KFF has on their page a listing of state mandates if you care to look.

Posted by: visionbrkr | February 18, 2010 1:34 PM | Report abuse

RobT1,

Just to give you a little background, I am an employee benefits broker and my job is to help employers and employees select health plans. Based on my experience I can tell you that the average consumer is clueless when it comes to selecting a health plan. It isn't because they are stupid, it is just that there are so many moving parts on the plans and the language as far as what is covered, not covered, specifically excluded is so detailed that no one can figure it out. That is why I make the big bucks that I get.

On your point regarding the poor person who has a chronic medical condition and therefore doesn't have something covered, that is what insurance is for. You buy insurance to cover expensive risks that you personally cannot afford to bear yourself. That risk get's spread against the general population so that the cost is shared equally (because you never know if you will personally have that need tomorrow).

What is so insane about your post is that like all Conservatives you seem to think that insurance reform is some "welfare" program so that a welfare queen get's something for free and the tax payor gets hosed again. The moral hazard excuse. The problem is that you are paying (and dearly) for the uninsured.

Let's take your typical person who is a diabetic and doesn't get it treated because they don't have medical access. It continues to go untreated until the point that they show up in the emergency room and get admitted to the hospital for a week. One year latter the condition worsens and after a 3 week stay in the hospital (including all necessary medical care) they pass away.

The hospital is left with a $200,000 bill---the estate doesn't have a penny, so the hospital is left holding the bag. Their only recourse (remember they need to make a profit) is to bill out higher rates to insurance plans (which is then reflected in your bill).

It would have been a lot less expensive to pay the $50 a month office visit and the $100 a month medication for this poor person than to dump the expense on society using the most expensive care.

Our system is collapsing because the weight of the unsinured is driving up costs across the board. The objective to healthcare reform is not to hose you but to get these people into a less expensive delivery system (and maybe improve their health at the same time).

The problem with the Republican approach is not that individual policies sold across state lines is necessarily a bad solution, it is that they ignore the impact that the uninsured and underinsured have on the total cost structure of healthcare. They want to do it on the cheap, and as a result will not solve the problem.

Posted by: joe_potosky | February 18, 2010 2:05 PM | Report abuse

More thoughts:

Isn't the best treatment for diabetics to reform their diets? Isn't the linkage between what we put in our bodies, and how our bodies generally operate? Do you think that making people aware of these connections makes them more or less likely to control their health risks than counseling them, "You know, if only you had better insurance, all your bills would be paid and your health problems would go away?"

Until you teach people that their health risk factors are indeed within their control, and personal health is a personal responsibility, expect more incidents of treatment at sky high costs to go through the roof.

Remember, we're not addressing those costs -- just figuring out how we can get healthy others to share in them.

Re. "usually when you say "Good day all" you then don't put another psychotic post up but then again that's not nearly the worst thing you've said on here"

Usually when you start a sentence, you press the shift key to capitalize the letter. Touche on the style issues.

I also think it's a bit disingenuous to label as "psychotic" somebody who objects to injecting insured dead 5-year-olds who likely would have passed anyway into a discussion on the merits of forcing everyone to participate in a failed business model.

I also wonder if her parents know people are exploiting the child's death online to score cheap points (rejected!) in pushing their political agendas. Sad. Very sad.

Posted by: Mary42 | February 18, 2010 2:20 PM | Report abuse

By the way, unreimbursed care is why your Geico analogy is off base. I can choose to not get insured and if I have an accident then I can choose to junk my car, no harm to society. If they other guy get's hurt, in most situations they will have uninsured motorist coverage so they are protected. However all states require that you have coverage because they know that it is not in society's interest for uninsured motorists going around to force people to have to rely on uninsured motorist protection.

With medical expenses, unless everyone is covered, an individual can choose to not get coverage and all of us will be required to pay for their care when the hospital is unable to recover from the uninsured person's estate.

The car insurance example has minimal cost to society as the number of uninsured motorists goes up. As the number of uninsured for medical coverage goes up, so does the cost to society.

Posted by: joe_potosky | February 18, 2010 2:22 PM | Report abuse

Mary42. I agree with you. The best solution is get everyone to lead healthier lives. Chronic obesity, diabetes, heart conditions due to diet, lack of exercise are all major problems that each of us needs to address. I know that the moral argument that we shouldn't penalize people because of something they have no control over is not high on your radar, but it is a factor here in many situations.

The real problem is that these behaviors have a cost to society in the form of unreimbursed medical care. If we can't route these people to less expensive treatment paths then they are currently taking the costs are huge and it is imploding healthplans, government budgets etc.

The easiest solution I guess would be to deny treatment to people without insurance. I think that is cold hearted and cruel and would never be accepted by a sane and rational society. However, if you were to take that position, it could never be implemented. Therefore the only solution to solving the healthcare problem is get people to less expensive delivery systems and in the process educate them about proper nutrition and excercise.

Posted by: joe_potosky | February 18, 2010 2:35 PM | Report abuse

"The easiest solution I guess would be to deny treatment to people without insurance. I think that is cold hearted and cruel and would never be accepted by a sane and rational society. However, if you were to take that position, it could never be implemented. Therefore the only solution to solving the healthcare problem is get people to less expensive delivery systems and in the process educate them about proper nutrition and excercise."

"the only solution?"

we would all like "less expensive delivery systems" but just what does that mean?

you think that more exercise and better diet will eliminate illness among the uninsured (or the insured)?

1. This is a great argument in favor of universal health care, wherein every American will have an annual check-up, routine blood tests, get nagged about poor health habits, and experience early detection and treatment of entirely preventable diseases which, if caught later, are expensive to treat.

2. While there is no doubt that Americans would be healthier with more exercise and better nutrition, good behavior only goes so far. While we all can and should minimize risky behaviors, none of us can eliminate the possibility of illness or disease.

Posted by: Patrick_M | February 18, 2010 5:50 PM | Report abuse

Patrick_M--by less expensive delivery system I mean anything besides Emergency room and hospital care. My argument is that Universal health coverage is the only solution.

Posted by: joe_potosky | February 18, 2010 10:09 PM | Report abuse

EK: Thank you for approving/allowing my lengthy comment upthread. It's appreciated. I wasn't so sure it would come through when I got that message.

Posted by: Mary42 | February 18, 2010 11:16 PM | Report abuse

maybe im just missing something but it doesn't sound like too hard of a problem to fix. Each state has different regulations for car insurance so geico, for example, tailors its coverage for each state. what's so hard about that? Is the only solution to have insurance federally regulated?

Posted by: batigol85 | February 20, 2010 7:28 PM | Report abuse

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