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The conservative compromise that is the Senate health-care bill

Take Rep. Paul Ryan's health-care plan -- described here and here -- as the conservative pole on this issue. Then take single-payer and place it on the other side of the spectrum. Where does the Senate bill fall?

It's closer to Ryan's plan than to single-payer. A lot closer, in fact.

Unlike Ryan's plan, it doesn't privatize Medicare or Medicaid. But unlike single-payer, it doesn't nationalize the private insurance that covers 70 percent of Americans. Advantage? Ryan.

Unlike single-payer, it does not try to save money by using federal bargaining power to force down the prices of various drugs and treatments. Instead, like Ryan's plan, it works to contain costs by creating a simpler, more transparent, more competitive market for private insurance, centered around exchanges that are meant to make it easier for consumers to comparison shop. Advantage? Ryan.

Unlike most single-payer proposals, it does not rely on straight progressive taxation to fund itself. Instead, like Ryan's plan, it tries to begin unwinding the employer-based market by attacking the massive tax subsidy that underpins the arrangement. Ryan repeals the subsidy altogether while the Senate bill uses the excise tax to begin balancing it out. But the theory is similar. Advantage? Ryan, again.

The simple fact of the matter is that the insurance market envisioned by the Senate plan looks a lot more like what Ryan wants than what John Conyers wants. I don't really think this is even arguable.

Toward the end of my interview with Ryan, you saw this come out a bit. Asked about his objections to the Senate plan, Ryan first mentioned that the Senate bill empowers regulators to define what counts as insurance, But pressed on the point, he allowed that his plan did much the same thing, in much the same way. "You need to define what insurance is," Ryan admitted. "I agree with that."

Then Ryan moved to criticize the exchanges in the Senate bill. In his plan, he said, insurers didn't need to participate in the insurance exchanges, and nor did individuals. In the Senate plan, by contrast, individuals who aren't in the employer market do need to participate in the exchanges. This will affect about 10 percent of the population. You can argue whether Ryan is right or whether the Senate bill is right, but this is small ball. Compare Ryan's objection with that of a liberal, who doesn't believe that private insurers should exist.

That's not to overstate the conservatism of the Senate plan. The subsidies and the individual mandate are aimed at a very liberal goal: universal coverage, or something very near to it. But the road the bill takes to get there is based on a vision of functioning markets rather than government provision. It's a far more conservative take on the issue than most realize. And that makes the calls for further compromise tinny indeed. We can talk about tort reform or selling insurance across state lines, but that's very small stuff. On all the big stuff, the Senate bill is already a compromise, and most liberals would go further and call it a simple concession. But few conservatives have given it credit for incorporating their insights.

By Ezra Klein  |  February 4, 2010; 10:51 AM ET
Categories:  Health Reform  
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Comments

At this point, Republicans are operating in an entirely political manner. There goal is to win in November, and everything else (including elections in 2012) will be punted.

It really doesn't matter how conservative HCR is or isn't. At this point, they will remain in opposition.

I'm curious how much support Ryan's bill would get. It's very sweeping in it's changes, and such an approach is always fraught with danger. There's always an implicit assumption that everything will go perfectly in implementation, there will be no sabotage, and that the markets and individuals and, heck, illness and disease, will do all the things we expect them to do and nothing we don't.

From a Republican standpoint, I think it is a lot easier to be against what is perceived as the liberal Democrat's plan than it is to be for the Ryan proposal.

If Democrats really want to put pressure on the Republicans, they could put in serious tort reform, explain how the bill will allow insurance to be sold across state lines (in no uncertain terms) and maintain and expand healthcare savings accounts. Of course, then it would practically be a Republican plan. And Mitch McConnell would still vote against it.

Posted by: Kevin_Willis | February 4, 2010 11:04 AM | Report abuse

"like Ryan's plan, it tries to begin unwinding the employer-based market by attacking the massive tax subsidy that underpins the arrangement. Ryan repeals the subsidy altogether while the Senate bill uses the excise tax to begin balancing it out. But the theory is similar."

Nah, not even close. One eliminates the subsidy for everybody, the other only eliminates it for a very small percentage of the population. In this respect, very different.

"it works to contain costs by creating a simpler, more transparent, more competitive market for private insurance, centered around exchanges that are meant to make it easier for consumers to comparison shop"

Right. Doesn't the Senate bill restrict the exchanges to left-handed midgets who were born in Peru and can prove they speak fluent Russian?

Posted by: ostap666 | February 4, 2010 11:05 AM | Report abuse

Kevin Willis:

If Democrats really want to put pressure on the Republicans, they could put in serious tort reform, explain how the bill will allow insurance to be sold across state lines (in no uncertain terms) and maintain and expand healthcare savings accounts. Of course, then it would practically be a Republican plan.

Why should dems unilaterally give in on these items when as you said, no repiglicans will vote for it? Isn't that what we did with medicare for all, public option, the stimulus, etc? I can't wait for the senate to water down financial reform to nothing and still get no repiglican votes. Dems start with a compromise position and then get no repiglican support. Why do dems insist on bargaining with themselves? Bush never did. In fact, he made a point of saying that he wouldn't bargain with himself before the dems stepped up and offered compromises. Is there a need for a spine transfusion for dems or what?

Posted by: srw3 | February 4, 2010 11:23 AM | Report abuse

The Overton window is located pretty far to the right these days.

Instead of one pole being single-payer, that pole could be the British NHS or the U.S. Veterans Administration system.

Single-payer is one big step away from that approach. A public option is one big step from single-payer.

The next step would be the heavily regulated system akin to what's in Switzerland or the Netherlands.

Then you cross over the threshold of universal health care systems into the U.S. model.

If you take a step any further to the right a person starts moving backwards in time and/or down the chain of economic development.

Ryan's plan has the potential virtue of killing the poor, the working poor, the old, and the young.

It's the dream world of both conservatives and sociopaths.

But perhaps I'm being too redundant.

Posted by: JPRS | February 4, 2010 11:26 AM | Report abuse

this underscores the Republicans' strategic "brilliance." The Dems were shadow-boxing all year. The had nothing to contrast their ideas with, nothing to hit. In a 15-round fight that you can't end early because you initiated for it, that's gonna take a lot out of you.

Posted by: andrewlong | February 4, 2010 11:32 AM | Report abuse

"The subsidies and the individual mandate are aimed at a very liberal goal: universal coverage, or something very near to it."

But the public's interest in this is not universal coverage, it's rising costs. In fact, they're conflicted interests, since expanding coverage to people who don't pay clearly promises to *raise* costs for everyone who does.

And everything you say to make it appear otherwise falls into the same category as taxing for ten years to pay for six years of benefits: Deception, rationalization. Lies.

Regardless of the "conservative" ingredients, liberal leadership used an opportunity for real reform to cook up an ideological brew. That ideological priority disaffected Republicans who do in fact want real reform, including some of the aspects within this bill.

And what libs never counted on was that this ideological power grab was so alarming to the public that they took one of the most liberals seats in all of Congress to voice their opposition.

Face it: you had an opportunity to fix many problems. But instead, you opted for the ideological holy grail, and now your very majorities are in jeopardy.

It's truly insulting to see liberals behaving, speaking, lying, manipulating -- all on the grounds that they know what's best for everyone else. The hell you do.

Posted by: whoisjohngaltcom | February 4, 2010 11:37 AM | Report abuse

*since expanding coverage to people who don't pay clearly promises to *raise* costs for everyone who does. *

No, that is the situation *without* universal coverage: people using and not being able to pay for emergency services are raising costs on the rest of us.

*, you opted for the ideological holy grail,*

The ideological holy grail was single payer, which was immediately rejected beforehand in favor of a conservative compromise.

Posted by: constans | February 4, 2010 11:51 AM | Report abuse

Enough with tort reform. We need malpractice reform and it's in the bill. Selling insurance across state lines (deregulation) is a bad idea: http://healthcare.change.org/blog/view/why_health_insurance_dergulation_aint_enough

The idea is to try things that work.

Posted by: eRobin1 | February 4, 2010 11:55 AM | Report abuse

"people using and not being able to pay for emergency services are raising costs on the rest of us."

I can't begin to count the myths this line of reasoning is based on.

Extending coverage for every hangnail and headache does not pay for itself by reducing ER visits.

People with coverage still consume expensive life-saving care, so extending more free coverage will only partially reduce the emergent care the uninsured receive.

"Preventive" procedures like colonoscopies are cheaper to treat than cancer on an individual basis, but screening everyone is not cheaper than simply treating the few who are sick.

You come up short if you're trying to make a convincing argument that free riders get cheaper with more free benefits. A nice, but all-too-familiar rationalization.

Posted by: whoisjohngaltcom | February 4, 2010 11:59 AM | Report abuse

whoisjohngaltcom,

The notion that the Senate bill involved some hard ideological position ignores reality.

If this was the product of an ideology it would have been put into effect after one month of "negotiations" sometime back in February.

Debates on this issue pre-date the 2008 election. Even after 18 months and multiple revisions to the bill, the bill still hasn't found it's way to the president's desk.

At a minimum that would suggest that 60 people had a hard time arriving at a consensus in part because they don't all share uniform views or interests.

In reference to cost, the fact is we spend 17-18 percent of GDP for partial coverage of our population when everyone else is spending 8-12 percent of GDP for universal coverage.

At a minimum that should clue people into the fact that we have some massive inefficiencies in our health care system. People don't realize, or simply can't believe that they are paying more for less.

Posted by: JPRS | February 4, 2010 12:08 PM | Report abuse

I'm not sure that the premise of this--that Ryan's plan is at one end of the spectrum and single-payer is act the other--is rock solid. The opposite end of the spectrum would be elimination of Medicare and Medicaid and a private-only health system. Both single-payer and entirely-private would mean dismantling entire systems and rebuilding from scratch. The Senate plan surely is more "reform" than "revolution". Some folks on the left may have wanted their ultimate ideal of single-payer, and this is not it. But I also don't think it's closer to the right's ideal. It's closer to the middle, left-leaning.

Posted by: edmullen1 | February 4, 2010 12:14 PM | Report abuse

The idea is to try things that work.

Posted by: eRobin1

////////////////////////////

It depends in some cases.

For some the idea isn't necessarily to try things that work [for the population generally]; but rather to preserve a system in which they benefit.

The select few then have an easy time playing on the fears of people like "whoisjohngalt" in part because they have the means and capacity to play them.

Posted by: JPRS | February 4, 2010 12:14 PM | Report abuse

Ezra, the issue the GOP has is both political and ideological. Politically, they don't want to give Obama and the Dems a big win. Ideologically, while they support some aspects of the bill, they are completely opposed to providing the subsidies to expand coverage.

Posted by: truth5 | February 4, 2010 12:21 PM | Report abuse

edmullen1,

A true conservative position would not even involve subsidies.

In addition to elimination of Medicare and Medicaid we would also eliminate the VA. That would be an ideologically pure and consistent position.

For military service members we could also follow a true private market approach ala Blackwater and have each of our service members acting as independent contractors. Each would have the freedom to decide whether or not he wanted to use his income to purchase health insurance.

That would be the freest society imaginable. e.g. A veritable Ayn Randian paradise.

Posted by: JPRS | February 4, 2010 12:28 PM | Report abuse

"The notion that the Senate bill involved some hard ideological position ignores reality."

If you want to see reality being ignored, I suggest you look here: Democrats had a mandate to address rising healthcare costs for people who actually pay for health insurance, and instead they attempted to solve their pet problem of people who don't actually pay for insurance.

That, my friend, is where this train first turned off the reality tracks.

Posted by: whoisjohngaltcom | February 4, 2010 12:31 PM | Report abuse

Ezra, I'd also argue the community rating is tighter and the minimum benefit packages -- certainly in the House bill -- are more generous than what most Republicans would advocate. That's also important, too. I have yet to find a universal health insurance system that lacks any of the following three items in some form: community rating, individual mandate, and minimum benefits package.

Posted by: moronjim | February 4, 2010 12:35 PM | Report abuse

"like Ryan's plan, it tries to begin unwinding the employer-based market by attacking the massive tax subsidy that underpins the arrangement."

A little bitty tax on plans in excess of $24,000 per year from which the Democrat's main constituency is exempt is a pitiful attempt to begin unwinding the massive tax subsity that underpins the arrangement.

And without unwinding that subsidy, the Democrats' pretense of deficit neutrality and bending the cost curve down is a laugh. This conservative could tolerate a lot of the other deficiencies rife in the Democrats' plans if they just confronted that one, single issue head on. But instead, they perpetuate it. And doom us to exploding health care costs by adding tens of millions of subsidized consumers into the same broken system. It's insane.

Posted by: bgmma50 | February 4, 2010 12:43 PM | Report abuse

whoisjohngaltcom,

All three Democratic candidates ran on the issue of expanding health care coverage.

Obama won election during the general election on the basis of expanding coverage.

So this notion that the only issue of concern to Americans was cost-control is false. Maybe some people believed this, but I suspect most understood what they were voting for.

What's more both bills actually do address the cost issue for ordinary policy-holders (as well as other quality issues like rescission).

I agree that the bills don't go far enough, but I suspect we would disagree on what the substance of the short-comings entails.

Obama did NOT run, for example, on the privatization of Medicare and Medicaid (which I suspect might be one of your favored approaches).

I also disagree with you that health care really has any major implications for the current electoral environment. Some people are just opposed to the idea of having a black guy in the White House (a black guy who doesn't at a minimum have Rush's validation).

The majority of swing voters though are simply pissed off at the current economic environment and they are rejecting the status quo regardless of party or other causal factors.

Posted by: JPRS | February 4, 2010 12:50 PM | Report abuse

"Some people are just opposed to the idea of having a black guy in the White House"

Um, weren't you the one who was assessing other people's connections with reality??? You honestly think America would be more receptive to a white socialist than a black one? It's a race problem, is it?

Posted by: whoisjohngaltcom | February 4, 2010 12:54 PM | Report abuse

whoisjohngaltcom,

For starters you're talking about an ideological minority within an ideological minority.

Most elections are simply a referendum on whether people saw an increase in their income.

If yes, they vote for more of the same.

If no, they have a tendency to vote for change.

Carville was right: "It's the economy, stupid".

During good times it's sometimes possible to distract voters onto tangential issues, but most elections are a referendum on economic progress.

As far as socialism goes, I realize that Obama has also had the fascist and communist label attached -- all are perversions.

Bernie Sanders is a self-described European socialist. Barack Obama is not.

In one extreme corner of America the label "socialist" affixes a little more easily to Barack Obama because of his race. If John Edwards was in the White House right now (and hadn't screwed around with his mistress), I suspect he would be treated differently. Even though Bill Clinton was called a lot of things, "socialist" was not a label that ever really stuck to him. Race is part of the equation.

Posted by: JPRS | February 4, 2010 1:08 PM | Report abuse

whois....,

Your attachment to reality or lack thereof is betrayed by your casual use of the "socialist" label for Barack Obama. Obama is right of center on most economic issues.

Posted by: michaelterra | February 4, 2010 1:14 PM | Report abuse

So you think Massachusetts voters put Scott Brown in Ted Kennedy's seat because of the economy? Even though Kennedy held that seat through 47 years of recessions? And even though Brown ran on stopping the bill?

Posted by: whoisjohngaltcom | February 4, 2010 1:16 PM | Report abuse

whoisjohngaltcom,

Unfortunately, we don't have exit polls from MA.

However, national polls put the economy far and away as the top concern by almost 20 percentage points. Health care lags in the 40+ range. In that group I suspect there is probably an even split between those who favor reforms and those who are strongly opposed.

http://www.pollingreport.com/prioriti.htm

Right now the official unemployment rate is 9.4 percent in MA (the under-employed numbers and "no longer looking for work" numbers probably boost the real rate well into the double-digits).

If unemployment was going in a different direction, Brown would have lost by a large margin.

Coakley ran a terrible campaign, which certainly didn't help. And the far right opposition to all things Obama probably provided a fair amount of energy behind Brown's candidacy. Wall Street and financial services money certainly provided a nice boost to the Brown campaign (he outraised Coakley by 5 to 1 with financial services money from bailed out banks).

Unless MA is a complete aberration, the decisive factor was almost certainly the economy and jobs.

MA already has a near-universal health care program -- it's plan is actually pretty close to the one that the Senate is currently proposing.

So I wouldn't be surprised if health care was a lower priority for MA voters -- especially on the pro-reform side of the equation.

The NY-23 results in November also suggest that Coakley suffered from an anti-incumbent bias (or anti-incumbent party bias).

Posted by: JPRS | February 4, 2010 1:40 PM | Report abuse

"Obama won election during the general election on the basis of expanding coverage." posted by JPRS

He also ran on closing Gitmo, but that didn't work out so well once the voters realized what the ramifications would be. Those of us who opposed closing Gitmo had already worked out that there weren't a lot of good alternatives. We just had to wait for the rest of the country to work it out.

Obama made a whole lot of promises on health care. Those of us who worked things out in advance realized that many of his promises were inherently self contradictory and that he would be unable to deliver on it all. The rest of the country is in the process of working it out now. My guess is that universal coverage will have about as much appeal as closing Gitmo once they finish working it all out.

Posted by: bgmma50 | February 4, 2010 1:42 PM | Report abuse

michaelterra:
"Obama is right of center on most economic issues."

LOLOLOLOLOLOLOLOL!!!!!!!!!!

Posted by: whoisjohngaltcom | February 4, 2010 2:05 PM | Report abuse

bgmma50,

It's not just Obama who favors closing Gitmo. Pretty much every major figure in the national security establishment favors closing Gitmo on the grounds that it is a major recruiting device for Americas enemies.

Most voters don't have the time or the luxury to think through these issues, so it takes time for reason to triumph over emotion. If anything the trend-lines suggest more support behind closing Gitmo than otherwise in the time since it first opened. Even so, in terms of national priorities its way down the list for most folks. Other issues occupy their time.

In reference to universal health care, there are challenges in over-coming deeply ingrained prejudices. Most Americans haven't had and will never have the time or the money to spend extended periods outside of the country. So it's easier for them to rationalize away the fact that the American health care system is the most inefficient and costly in the world. Some probably believe that we are pay more because what we're getting is the best. Isn't that how the market is supposed to work? A higher price means higher quality?

Of course, there's a lot of hard evidence to suggest that that really isn't the case. For better or worse people tend to make judgments on the basis of their experience. There's also a tendency to fear change -- especially during times of economic distress. In the case of health care some of those factors are working against achieving a universal system of coverage. People may not say: "I want to pay more for the same or worse care that others get elsewhere". Effectively though that's what the status quo means for the majority of Americans.

Posted by: JPRS | February 4, 2010 2:23 PM | Report abuse

Bigmama hit the nail on the head. Once people unwind and examine Obama's proposals(whether it health care, Gitmo, TARP, you name it), they quickly find out that they are very expensive, poorly thought out and doomed to fail. Everyone was so excited about change, we elected an inexperienced amateur. Being president in times like these is much to complicated for on-the job-training. I hope people realize that before too much damage is done!! Reign him in and then vote him out.

Posted by: doug1945 | February 4, 2010 2:26 PM | Report abuse

JPRS, you observed that healthcare is a lower priority than the economy.

Now, if the goverment focuses on healthcare anyway -- even as the public clearly sees the threat healthcare reform poses to the economy -- then how is it inconsistent for a public whose greatest concern is the economy to make stopping that reform its highest priority? It's completely consistent.

Posted by: whoisjohngaltcom | February 4, 2010 2:28 PM | Report abuse

whoisjohngaltcom,

The main problem is that the evidence doesn't really support that view.

The polling evidence suggests that most of the public sees health care and the economy as separate issues. If the two issues were inter-linked in the minds of voters you wouldn't have a 20 point drop-off when the two issues were polled in tandem.

It might be interesting to see a third question asked: Do you believe that the economy and health care debates are inter-related, or are these two separate issues?

The main complaint that people seem to have is that Obama and the Dems spent a year working on health care when they should have focused on job creation (i.e. they don't see the two as inter-linked).

The view that you articulate may be linked in your own mind, and there probably are other people who share your view. However, I just don't see the hard evidence to back up the view that the majority of people think that health care reforms are destroying the economy.

The reality of course, is that the recession proceeded the debate on health care by over a year. Current job losses are connected to a massive debt bubble. Rising health care costs are actually one small part of that equation. However, a debate over health care reform isn't part of the equation at least as far as current job losses are concerned. The rate of job losses has actually slowed down since the debate started picking up steam in Congress. So one view might be that the debate has actually had a positive impact on job creation. As the saying goes: "correlation is not causation". To the extent that the debate in Congress has had any impact on the overall economy, it's probably been a marginal positive one over the very short term in terms of job creation for media companies and PR firms.

My own view is that health care inflation is related to the overall health of the economy. (e.g. rising costs over the past 10 years have eaten into family budgets and they've had an impact on lost wages due to increased employer costs; the money spent in an inefficient market sector sucks money away from more productive uses, which has a net effect of reducing overall economic growth). However, my sense is that most people don't really think about health care reforms in those terms. They see jobs and the economy in one mental box and health care reforms in another.

Posted by: JPRS | February 4, 2010 3:06 PM | Report abuse

Galt:
"Face it: you had an opportunity to fix many problems. But instead, you opted for the ideological holy grail, and now your very majorities are in jeopardy."

I promise you-- I *promise* you-- this is not the ideological holy grail. A large swath of left haaaaates the Senate bill, and most of the rest are willing to begrudgingly tolerate it. The left tore itself up over the Senate bill, it's an incredibly bitter pill to swallow, and half of us don't want to. Ezra actually spent quite a bit of time trying to talk us off the ledge, as it were.

Single payer is generally what the left wanted; a public option was the pragmatic compromise we were willing to accept (who, after all, could object to people being given the option to buy into a government health plan?); Medicare expansion was what we bargained down to. We don't even get that.

"they attempted to solve their pet problem of people who don't actually pay for insurance."

45 million Americans without insurance is not a 'pet problem' -- to say nothing of the 87 million who go without insurance at some point in any given two year span of time.

Posted by: adamiani | February 4, 2010 3:25 PM | Report abuse

"45 million Americans without insurance is not a 'pet problem'"

No. 45 million people without health *care* is not a pet problem. 45 million without insurance is something quite different. And based on your own 87 million figure, two out of three of those 45 million are only temporarily uninsured.

I'll bet I can find an awful lot of people in that 45 million who are simply choosing not to buy insurance. I believe that what you're trying to fix is called "freedom."

Posted by: whoisjohngaltcom | February 4, 2010 4:09 PM | Report abuse

Several observations,

Several months ago I was on a cruise which was dominated by Canadians. Once they found out I was American they all wanted to know why Americans didn't embrace universal health care. They were all quite satisfied with their care and all routinely purchased insurance before coming to the United States to avoid the off chance of winding up with an outrageous bill in the case of an emergency. Several had stories of friends or relatives who had found themselves is that predicament.

Being relatively close to Canada I have had several elderly patients who, while visiting Canada, had an emergency and were expertly treated and not released until they were able to travel again.

A good deal of the research in this country is funded by the NIH, our money.

The only time in my career as a physician when I could practice medicine by doing what my patient needed without a bureaucrat looking over my shoulder was in the military, aka a government run health care system.

Rationing goes on every day, every time someone can't afford a needed treatment or medication.

Those who oppose health care reform obviously have health care insurance. God forbid they should lose it.

My state has an insurance pool for those that get refused or have certain problems. It costs $1200/mo for 3 or more in a family. What average income family can afford that, let alone one with a below average income?

If you don't require insurance companies to be part of an insurance pool, none will be in it. Even the "not for profit" insurance companies care only for the bottom line.

Posted by: MDforchange | February 4, 2010 4:11 PM | Report abuse

"Those who oppose health care reform obviously have health care insurance."

Few people oppose healthcare reform. But there are many who do not view the proposed legislation as effective reform.

That includes a lot of people who supported the bill only after winning exemptions for their own interests. Take it up with them.

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

Hey Ezra, Thanks for attempting to start us on the road to some sort of compromise. My hope is we can get past the partisanship and help the American people. I have very good insurance ( according to some) and it cost me almost $5000 last year for a fairly simple ( i.e. no surgery) broken arm. That's on top of the $4000 a year in premiums. A fairly large percentage of my salary. I'll be paying for that for years. We wonder why kids stay inside and play video games! We can't afford to pay for any sports related injuries!

Posted by: bluecollarbluejeans | February 4, 2010 4:43 PM | Report abuse

"I'll bet I can find an awful lot of people in that 45 million who are simply choosing not to buy insurance."

According to a study that I read:

around 20% of them are not citizens

around 57% of them are childless adults, which coincides with the 63% who are under age 34. I can attest from experience with young adults of that age that many of them prefer their iphones to insurance, and won't voluntarily pay for coverage.

19% have actually declined employer coverage

Then there are those who are eligible for government programs like Medicaid and CHip, but not signed up. And those who are actually enrolled in government programs like Medicaid and Chip, but identify themselves as uninsured.

And those who are between jobs and only temporarily uninsured.

There is obviously overlap among these groups, but it's pretty clear to me that the 45 million figure so often bandied about grossly misstates the size of the problem.

Posted by: bgmma50 | February 4, 2010 5:23 PM | Report abuse

bgmma50,

Does an iphone have ongoing costs of at least $2,000 a year? (the cost of a half-way decent individual plan for a healthy 20 something carrying a plan with a $500 deductible).

Also, how does a person afford any insurance with zero income? (e.g. we currently have over 10 percent unemployment).

Posted by: JPRS | February 4, 2010 6:36 PM | Report abuse

In the real world, JPRS, a young, single employee's out-of-pocket share of his healthcare benefit is in fact much closer to the price of his iPhone. It's not like your employer gives you the cash value if you decline to participate in the company plan.

Posted by: whoisjohngaltcom | February 4, 2010 8:16 PM | Report abuse

"Does an iphone have ongoing costs of at least $2,000 a year? (the cost of a half-way decent individual plan for a healthy 20 something carrying a plan with a $500 deductible)." posted by JPRS

More like $1200 per year, which is the cost to a twenty something in my state for insurance with a $2500 deductible and $35 copay for Dr. visits. This I know, having purchased plans for my offspring. Really, really basic coverage can be had for $75 per month.

You define "decent coverage" as a deductible of $500 or less. That is precisely the mindset that makes me crazy. That is the mindset created by gold plated employer provided insurance subsidized by taxpayers. That is the mindset that these bills are doing nothing to counteract, but instead are perpetuating and institutionalizing.

Where is it written that we are entitled to spend no less than $500 per year and 20% out of pocket and force others to pick up the tab on our health care, while enjoying iphones, cable tv, vacations, and restaurant meals?

"Also, how does a person afford any insurance with zero income? (e.g. we currently have over 10 percent unemployment)." posted by JPRS

The same way they do now. Medicaid.


Posted by: JPRS

Posted by: bgmma50 | February 4, 2010 8:48 PM | Report abuse

Regardless of all the comments for, against, undecided, etc... The fact remains that our health care system is in drastic need of reform. Regulation does need to be employed...Period! Costs in this country are out of control, and this is not only due to people not being able to pay their bills. Medication costs, surgical costs, preventative medical costs; they are all out of whack. Physicians definitely deserve to be compensated for their expertise, but I resent the fact that these same people demand such exorbitant fees, and as a victim of this economy, I cannot get the medical care I need because I cannot afford it.

Irony at its best... Being unemployed, I make too much money to get any form of assistance. In twelve weeks my income will likely be gone since I've exhausted my benefits and there are no more extensions available to me.

Some may ask;"why not get a job"? Well, I apparently can't. I may technically be "temporarily" be between jobs, but I've been between jobs for nearly a year and a half.

Now, I'm taking loans to further my education, because, being unemployed, I make too much to receive a Pell grant. I've enrolled in Michigan's "No Worker Left Behind" program which has no funding for me as well. I'm having to retrain so I can enter a different career, since my 25 years experience in my previous job field seems to mean nothing.

As I'm sure some will agree, the whole system is broken. There are solutions, but apparently the people we have elected are too busy arguing to actually come together on one. As an individual, I would gladly pay the $90.00 per month I was paying for my coverage while I was employed, but because of my medical needs, most insurance companies won't even talk to me. The few that will want to put heavy riders on my policy with extremely high deductibles with a minimum of $600.00 per month to get coverage close to what I had.

Under the proposed plans I have seen, I'm basically one of the few, the proud, the screwed. How many others are in this situation? Even if it's not the 45 million mentioned, the number is certainly in the millions.

Sorry this has turned into a rant. I'm just tired of politician's trying to figure out what's best for me, or telling me what I need. It's time for them to remember the original definition of the word politician "for the people" (loose translation), and ask the people what would be an acceptable compromise, and come up with a plan that falls in line with that.

On the other side of the coin... Fix the economy, and much of this would no longer be an issue.

Posted by: robrock_68 | February 4, 2010 10:15 PM | Report abuse

whoisjohngaltcom,

Right, Americans are "spoiled" in the sense that we are the only developed democracy where our people face bankruptcy over medical emergencies and death because of lack of access to good primary and preventative care.

Instead of just levying one tax and covering every one, we tax it for some, we have private plans for others, we have pseudo-insurance for another class, and none for a wide swath of the population.

All while paying 2x and in some cases even more than that for only partial coverage.

If you think that makes people "spoiled," well that just goes to show that you have the standards of a plantation slave.

Just trust the massa and everything 'll be alright, eh boy?

Posted by: JPRS | February 4, 2010 11:57 PM | Report abuse

bgmma50,

Medicaid has eligibility limits -- even for the recently unemployed. A case in point that I know about from a friend at Yale Medical:

"Case in point - saw a 63 year old man today, laid off 6 months ago, helping to support his daughter (who only has a part-time job - read, "no insurance") and her two children, who is now newly uninsured and unable to pay for his insulin for his profoundly out of control Diabetes. [Bleeping] insulin, people! There is no excuse in the civilized world for Dermatologists to be able to make $800K annually doing Botox injections, while 47 million citizens can't get mother-loving insulin. Of note, my patient does not qualify for Medicaid because he owns the home where he and his family live. Today he mentioned that he could sell the home and then he might qualify for Medicaid so he could get his insulin covered. Brilliant. Otherwise, he'll just have to go the next two years (until Medicare kicks in) with a blood sugar in the 400's (that's fantastically high), so that when Medicare finally picks him up, he'll have his first heart attack or stroke (on our dollar) due to the irreversible effects of uncontrolled Diabetes. The patient loses. The tax payer loses. Employer-based private insurer? Big winner!"

Btw, sorry whoisjohngalt -- the remark about plantation slave standards was meant for bgmma50, not you.

Posted by: JPRS | February 5, 2010 12:08 AM | Report abuse

Thank you for some clarity JPRS. As usual those opposed to reform have a very narrow world view and are ignorant of the facts. They are of the me, me, me party though some claim to be independent.

Posted by: Falmouth1 | February 5, 2010 8:27 AM | Report abuse

"Medicaid has eligibility limits -- even for the recently unemployed."

Has it not occured to you how easy it would be to change Medicaid eligibility requirements in response to a disastrous economy? The Stimulus package alloted 30 billion dollars to pay for COBRA benefits for the unemployed. There is no singe more expensive form of medical insurance than COBRA. It's sheer insanity.

I've always viewed Medicaid as the appropriate mechanism for a public option. Much better to tweak the eligibility standards, allow buy ins with means testing and so forth, than create yet another giant medical program.

Posted by: bgmma50 | February 5, 2010 10:15 AM | Report abuse

"Btw, sorry whoisjohngalt -- the remark about plantation slave standards was meant for bgmma50, not you." posted by JPRS

I have plantation slave standards because I believe in paying for my own and my family's basic health care needs and insure against catastrophic events and object to paying for gold plated coverage for other people who can afford to do the same but would rather not?

Maybe so. I do object to being made your plantation slave. I do object most strenuously.


Posted by: bgmma50 | February 5, 2010 10:28 AM | Report abuse

"Thank you for some clarity JPRS. As usual those opposed to reform have a very narrow world view and are ignorant of the facts. They are of the me, me, me party though some claim to be independent.
Posted by: Falmouth1"

I assume you are referring to me? I'm not opposed to reform. I'm opposed to the House and Senate bills.

And why is it all about me me me if I object to paying for gold plated health care for others when I won't buy it for my own family? I think that the people who are demanding that I do so are the ones that are guilty of me, me, me.

Posted by: bgmma50 | February 5, 2010 10:31 AM | Report abuse

Whether we look at Rep. Ryan's plan or the Senate plan, or a combination of both, I think most of us agree the issue of healthcare insurance needs to be addressed.

And we may not get it totally right the first time; it may need to be tweaked down the road. And virtually any plan we think of will disadvantage some people who fall into the cracks.

What's important is to start, unless you own a healthcare insurance company that may not like any approach. I'm retired and covered under my younger wife's plan--even though I've qualified for Medicare for a couple of years. Virtually every year, this plan cuts benefits or increases co-pays or boosts premiums, and that's not likely to change unless the system is improved.

Posted by: bulldog6 | February 5, 2010 11:55 AM | Report abuse

bgmma50,

I agree with you that COBRA is far from ideal.

In reference to the ease of passing Medicaid expansion through, the reality is otherwise. A large part of Medicaid's costs fall on the states. When the economy is tight and revenues start falling, the states are inclined to scale back coverage, not expand it.

In terms of the federal response, it isn't so easy. Especially with the national GOP solely focused on near-term political objectives.

Posted by: JPRS | February 5, 2010 1:57 PM | Report abuse

Late reply to whoisjohngalt:

Putting a LOLOLOL!!! in your reply isn't an argument but an admission of the emptiness of your thinking.

Obama's reform proposals are almost entirely right of center: healthcare reform was managed almost entirely with the cooperation of healthcare industry groups. His reform proposal (through the medium of Congressional Democrats) delivers tens of millions of new customers to a barely reformed private health care industry. His bank reform was "wait and see if the economy picks up". He has called bankers "fat cats" once, which is poor substitute for principled reform.

If Paul Volcker appears to be the "left" of Obama on bank reform....he is pretty much right of center.

You are displaying your ignorance of both American history and current reality in most industrial countries.

Posted by: michaelterra | February 5, 2010 2:49 PM | Report abuse

Thank you, Ezra Klein, for one of the few cogent descriptions of the reality of the Senate Bill. While not perfect it would be a good start that could (if rationality prevailed) be supported by both parties.

Posted by: RockyRetired | February 5, 2010 7:48 PM | Report abuse

Thank you, Ezra Klein, for one of the few cogent descriptions of the reality of the Senate Bill. While not perfect it would be a good start that could (if rationality prevailed) be supported by both parties.

Posted by: RockyRetired | February 5, 2010 7:50 PM | Report abuse

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