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I think the world of Jon Gruber, the MIT economist who helped design both the Massachusetts Health Plan and the Health Insurance Exchange provisions of President Obama’s Affordable Care Act. So I was more than a bit dismayed to read this quote from Jon: “I’m frustrated that the future of the American health care system rests in the hands of one or two of these unelected people who might make the decision based on political grounds.” The “unelected people” that Jon is referring to are justices of the Supreme Court. Jon almost seems surprised that the Supreme Court has a say in the matter.

The Health Insurance Exchange is an idea that economists have floated for more than three decades and thanks to his hard work, that idea has become a reality in Massachusetts and perhaps the rest of the nation, provided that the Supreme Court doesn’t block this fine bit of economics. Unfortunately for supporters of the exchange (including myself) the health insurance purchase mandate – an essential element of any economically viable exchange – might be unconstitutional. God forbid that the U.S. Constitution might interfere with beautiful economic theories.

There is a solution. I am almost too modest to say it but I proposed this idea in my book Code Red long before Barack Obama put his hand on the bible to be sworn in as Regulator-in-Chief. The beauty of the solution is that it respects, nay, was inspired by Jon’s work in Massachusetts, and is constitutional to boot! The solution is in its own way conservative, because it does not mandate a single approach to health reform. Congress should have given each state a block grant conditional on expanding health insurance coverage. The states could have chosen how to proceed. The U.S. Constitution might prohibit a federal mandate to purchase insurance, but it says nothing about what the states may do.

Some states might have chosen to adopt their own versions of the Massachusetts Health Plan. A few states may have centralized insurance, creating their own versions of single payer systems. Others may have given individuals vouchers and encouraged the growth of private insurance exchanges. This would be the closest to a free market solution, keeping the government out of it, except as a vehicle for transferring wealth. Perhaps all of these ideas would have been better than the status quo. Perhaps states could have learned from each other. Even Jon Gruber might have learned something new! Through this experimentation, we could have rapidly expanded health insurance coverage and also put lots of theories to the test. I still think this is a terrific idea. But in 2009 when politicians and economists huddled together to write the Affordable Care Act, no one invited me to the party. Alas.

When it comes to research, the best economists are rather conservative. We put our own findings under the microscope, trying every which way to prove ourselves wrong. We cannot publish unless several peers have given our work the same scrutiny. But when we are given the opportunity to make policy, we often abandon this conservatism. Perhaps this is because we are so rarely given the chance to make policy. Economists like Jon Gruber were privileged to have substantial input into the future of the health care system, and may have thought that their work was done when Congress embraced their models. But that was never the end of their work. The Constitutional challenge to the insurance purchase mandate is part of a process that should have been anticipated from day one. There are no surprises here.

P.S. Jon Gruber has stated that he cannot understand why Mitt Romney is disowning the Affordable Care Act when it is modeled on the Massachusetts Health Plan. Perhaps Romney believes that the Massachusetts Health Plan is good for Massachusetts, but might not be so good for other states. I know I believe it.

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80 Responses for “The Constitution Is Not a Turkey”

  1. Peter1 says:

    The myth of health insurance exchanges, constitutional or not:
    http://www.nytimes.com/2009/03/16/health/policy/16mass.html?pagewanted=all

    “Those who led the 2006 effort said it would not have been feasible to enact universal coverage if the legislation had required heavy cost controls. The very stakeholders who were coaxed into the tent — doctors, hospitals, insurers and consumer groups — would probably have been driven into opposition by efforts to reduce their revenues and constrain their medical practices, they said.”

    If we believe insurance claims that 85% of premiums go to providers, 10% to administration and 5% to profit where are all the savings to be had by going through an exchange, especially if insurers must accept all comers into mandated minimum coverage at level pricing?

    Massachusetts is finding (and so will the rest of the country) the non dead-end-road to controlling costs is less reliance on a private system and more imposition of government management and control – a single pay system, or at least a single managed system.

    • Nate Ogden says:

      like the ones working so well in Europe right now? When you have single payor government insurance and your economy collapses and you default, what happens to your healthcare? Or do we bury our heads in the sand and pretend half of Europe won;t have collapsed before our next President takes office?

      • steve says:

        What is not working about the health care systems in Europe? They cost less and provide comparable care. Are you conflating the problems caused by the banking crisis?

        Steve

    • Nate Ogden says:

      http://www.imtj.com/news/?EntryId82=297309

      If you weren’t 10 years behind on your facts you would see how much better off we are then Europe.

      • The quick fixes that most European Union member states adopted in response to financial pressure placed on their health care systems during the global economic crisis have compromised the sustainability of their systems and the quality of the care they provide.
      • Hospital closures were the order of the day in Romania during the recent economic recession. The number of employed health care professionals reduced by 25% in 2010.
      • Rather than implementing measures to improve health care efficiency, most nations opted for the quick fix of slashing health care budgets, staff and services covered by national health plans, without a view to long-term sustainability or potential health consequences.
      • Worsening quality and reduced access to care, particularly in poorer nations, are already being seen as a consequence of cuts in the number of health personnel.
      • All the while, demand for health services continues to rise.
      • Cuts were imposed in all nations.
      • Cyprus, Portugal and the United Kingdom were among those that introduced hiring and salary freezes, while Luxembourg passed legislation that allows the government to cap the number of health professionals over the next five years.
      • Most states also imposed strictures on replacing retiring health professionals, allowing as few as one new recruit for every 10 retired professionals. Finland strongly encouraged doctors to take a year’s leave without pay.
      • Other countries, including Belgium and the Czech Republic, increased funding to train nurses to take over doctors’ duties but offered no additional monies to offset their increased workloads and responsibilities.
      • *Governments also scaled back funding for hospital services. In Latvia, 67 hospitals have been shut down, while no additional monies have been provided to the nation’s 39 remaining hospitals to handle the influx of patients resulting from the closure of others.
      • 40% of French hospitals faced deficits in 2010.
      • 12 hospitals in Hungary were privatized, faced disruption and were then brought back under public governance.
      • Hospital mortality rates are on the rise in many nations.
      • The costs of care are being shifted onto the shoulders of patients, dramatically reducing access to publicly paid for care.
      • Even countries such as Sweden, whose health care systems were exempted from budget cuts during the economic crisis, saw patients take blows in the form of increased out-of-pocket, direct and co-payments, or reductions in sickness benefits, drug coverage, nursing care and other forms of specialized care.
      • In France, reimbursements for drugs were reduced from 35% to 25% in 2010.

      • MG says:

        Yes they had to make notable cuts almost instantly to meet the austerity demands of the bond market but health care costs in comparison to the U.S. generally aren’t an issue for the result of the immediate financial (solvency) crisis in Europe.

  2. Nate Ogden says:

    “Jon Gruber, the MIT economist who helped design both the Massachusetts Health Plan and the Health Insurance Exchange provisions of President Obama’s Affordable Care Act.”

    This explains why the Federal Exchange will be a complete failure, it was written like the person had no idea how the industry actually worked, which was because it was written by people that have no idea how the industry actually works. It’s one thing for a state to choose to implement a half witted reform plan (TennCare) it’s another to have the federal government dictate one on everyone. The problem is when these ideas fail miserably people like Jon and the politicians that engaged them are never held accountable (HMO Act 1973).

    “quote from Jon: “I’m frustrated that the future of the American health care system rests in the hands of one or two of these unelected people who might make the decision based on political grounds.”

    Jon does know he is an unelected person making decisions on political grounds……doesn’t he?

    Now we get to the part where your hubris fails you. You, and Jon and the entire economist puddle, are just that, economist, sitting in a room, far removed from the reality of our healthcare system. Your lack of real world knowledge is matched only by your personally perceived level of expertise.

    “the health insurance purchase mandate – an essential element of any economically viable exchange”

    Really? Please explain how CalChoice has been running for 10+ years without any such mandate. How about COSE or Las Vegas Chamber plans, while not full blown exchanges represent most of the workings, which have been running for over a decade. Your ignorance on this subject is really annoying to those of us that actually know the business. Even more annoying is a person like you or Jon that get credence and press with these silly claims. What is the federal employee plan if not an exchange? An exchange is nothing more than a cafeteria plan done on a much larger scale, a cafeteria plan that has been around for 30 years, and never had a purchase mandate.

    There is NOTHING essential about a purchase mandate for insurance to operate; there is EVERYTHING essential in a purchase mandate for the social engineering and wealth redistribution that those pushing this have dreamt about for 100 years.

    “The solution is in its own way conservative, because it does not mandate a single approach to health reform.”

    “Congress should have given each state a block grant conditional on expanding health insurance coverage.”

    You contradict yourself in the same paragraph. Expanding health insurance coverage is a single approach to health reform. Why not lower the cost of health care so one doesn’t need health insurance? Why not publically employee providers and go for an uber efficient Cuban style system? What about a model where care is provided via community organizations or paid for via taxes at the county level? There are numerous solutions that don’t involve insurance and you wish to forgo consideration of all of them.

    Your solution is no way conservative, most would argue it is itself unconstitutional. For the Federal government to tax citizens of a State then place conditions on those receipts before returning the money back to the State is not constitutional, especially in a matter not delegated to the Federal government in the first place.

    “.S. Constitution might prohibit a federal mandate to purchase insurance, but it says nothing about what the states may do.”

    Then why is the Federal Government involved at all but to siphon off some of the money and manipulate the situation. The logical answer is to remove the federal government, not block grants. The Federal government serves no purpose in your proposal, why is it there?

    “Others may have given individuals vouchers and encouraged the growth of private insurance exchanges. This would be the closest to a free market solution, keeping the government out of it, except as a vehicle for transferring wealth.”

    The term free market doesn’t belong anywhere close to that paragraph. Besides the wealth redistribution “service” the government would also be determining who is allowed to sell the service, what the service being sold looks like and how it is delivered. Through tax deductions they would also be incentivizing the purchase and punishing those that don’t. While technically true one is closer to a free market then the others none of these options even begin to approach any level of a free market.

    “Through this experimentation, we could have rapidly expanded health insurance coverage and also put lots of theories to the test.”

    A history of our healthcare system would serve you well here. If your interest in low uninsured and lots of experimentation then your best bet is to reinvigorate the self funded market. With State exchanges you have 50 supposed experts, most of whom have never worked a real day’s labor in the business, deciding what will be tried and what wont. If you left it up to the market you have millions of plans, all far more knowledgeable then Gruber or anyone at the 50 states, coming up with new ideas and testing them. I have ideas on my shelf, that have been sitting there for over 10 years, far more effective than anything Gruber has ever come up with, that will never see the light of day because they don’t fit into the perceived solution some politician and economist have come up with. There has been a big push for ACOs, we have been wanting to capitate primary care for 15 years but it requires an HMO license which isn’t economical for employers to capitalize. If those licensure requirements hadn’t been holding us back all these years the benefits of ACOs and Medical Homes would have been common practice now. Employers are saving billions of dollars with high deductible plans and self funding back to low deductibles for their employees. I don’t know if this is directly Gruber’s fault but some dumb ass outlawed high deductibles starting 2014. The problem was their ignorance, instead of requiring employees have a deductible under $2500 and allowing the market to figure out a solution they outlawed selling a deductible over $2500(or close to it) which means everyone has to deliver the product their way. Just one more example of why economist shouldn’t be anywhere near health reform. Haven’t they failed big enough on the economy to be worry about something else they apparently don’t understand?

  3. Peter1 says:

    “like the ones working so well in Europe right now?”

    You might be right if not for all the European countries who have universal health and are doing well economically, not to mention Canada. What you ignore is the cost cutting controls in those systems that the U.S. “system” refuses to implement and why they do it for about half.

    So don’t look to health care as the cause.

    • Nate Ogden says:

      “cost cutting controls in those systems that the U.S. “system” refuses to implement ”

      You mean that our politicians outlaw. Its not the systems fault we are governed by a bunch of liberal idiots that think you can require the system to cover everything and it wont raise cost. Our system is fine, its the politicians and economist that keep trying to fix it that are the problem.

  4. Nate Ogden says:

    “European countries who have universal health and are doing well economically,”

    I notice you have an “S” on countries there, I can’t think of one, who are these economically well performing countires you speak of? A simple list will suffice for an answer.

    • steve says:

      Norway, Sweden, Finland and the Netherlands. However, you should remember that those in trouble are not there because of costs generated by their health care systems, but rather by their banks. Might as well blame their defense spending.

      Steve

      • Nate Ogden says:

        Not true at all Steve, they are their becasue of their debt incurred from their welfare states. They have been racking up debt for 40 years, it was not from the financial disaster two years ago. The only thing the financial crisis did was reduce the number of suckers willing to buy their worthless debt. Most of these systems will not last till our next President takes office

        • MG says:

          Que? Yes all of them will be hurt by a real Euro collapse and the inevitable GDP decline (as will the US too) but you are making ridiculous generalizations. Norway has reduced its GDP as a % of debt the past 10 years (2010 to 2000). Ditto Sweden. Finland and the Netherlands have had very modest increases:

          http://www.mint.com/blog/trends/then-and-now-the-european-debt-crisis-112011/?display=wide

          • Nate Ogden says:

            http://themoderatevoice.com/10997/the-swedish-welfare-state/

            Do a search for decline swedish welfare state and you can see endless opinions that its dying.

            Its not a question of sustainability but just what day it dies.

            Sweden is in a sense an ideal natural experiment in economic policies. Sweden was an impoverished nation until capitalism was introduced in the country during the 1870s. Although the socialdemocrats had a strong influence during the first half of the 20th century, they were pragmatic and slow to expand the size of government. Sweden was one of the freest economies in the world during this period and experienced the second fastest growth in the world between 1870 and 1970, second only to Japan. During the 60s the socialdemocrats radicalized and a rapid expansion of taxation, the regulatory burden and government occurred. Sweden became the country with the most extensive welfare state in the world, the highest taxes, the strongest unions and the longest period of one party rule (the socialdemocrats have been in power 60 of the past 69 years). Between the 1960s and the 1980s the government’s share of the Swedish economy increased from about 30 percent (approximately the same as the US) to about 55 percent.

            From this period and onward, the Swedish model has been on the decline. Entrepreneurship has declined to an international low, none of the 50 largest Swedish corporations have been started after 1970, the working morale has declined drastically and unemployment is staggering high. But the government does its best to hide the figures that show the bad performance of the Swedish economy. In this paper we discuss the drop in entrepreneurship and working ethics in Sweden and examine the countries high hidden unemployment.

            The image of the Swedish welfare state abroad is still that of the beginning of the 1970s, when we did not have higher taxes than other European countries, respected private property and had a strong free trade policy. By highlighting the problems that have arisen in Sweden since then, we hope to give a more balanced view of the Swedish model.

            As the Swedish welfare state has expanded and economic incentives reduced, entrepreneurship has dropped. In a study of 37 developed countries that was conducted in 2002, Sweden was ranked in the 31:st place when it came to entrepreneurial activity and was one of the countries where entrepreneurship had fallen the most between 2000 and 2002. An important contributing factor is that the marginal tax on entrepreneurs is approximately 70 percent and that they are required to pay additional fees to the state, such as when their employees go on sick leave.

          • Nate Ogden says:

            I have a feeling this is one way you and most of THCB would not like to be like Sweden;

            http://www.brusselsjournal.com/node/4059

            One notable success has been pension reform. Sweden was the first nation to implement a mandatory government retirement system for all its citizens. Sweden, like the United States and most other countries, was then faced with an increasing, unfunded social security liability as a result of low birthrates and people living much longer.

            After studying the problem in the early 1990s, the Swedes approved in 1998 moving toward a Chilean private pension system, first developed by former Chilean Labor Minister Jose Piñera. (Seventeen countries have adopted variations of the Piñerian system, which has been very successful in Chile.)

            The new Swedish pension system has four key features, including partial privatization, individual accounts, a safety net to protect the poor and a transition to protect retirees and older workers. The benefits have been substantial budgetary savings, higher retirement income and faster economic growth.

        • steve says:

          Nope, dead wrong. Germany has slowly been resolving the debt it incurred from reunification. Italy ran up debt in the past, but has been in budgetary surplus. The Nordic countries have had debt under control. (Greece is a special case having been in default 2/3 of the last 150 years. Being such a bad long term credit risk, did the banks charge them higher interest rates? No.) These countries have been functioning well (with a few duds), until this crisis. Before this, they had manageable debt.

          But back to health care, the point of this post, health care costs make up a smaller percentage of their GDP than does ours. It is not their health care costs causing them problems. I think that they spend too much on other social welfare items and they will probably need to be cut, but health care is not causing their problem.

          Steve

          • Nate Ogden says:

            if their healthcare is not a problem why are they slashing spending, closing hospitals, and reducing the number of providers? Is it their only problem? Not at all, but it is a problem and growing. They are suffering the same inflation we are and only perform better due to drastic rationing

            http://people.bu.edu/kotlikoff/Health%20Care%20Spendingdraft4-28-06.pdf

            Over the past 30 years the annual rate of growth in real per capita government spending on health care was highest in Norway (5.3 percent), followed by the United States (5.1 percent) and Spain (5.1 percent).

  5. Peter1 says:

    “I can’t think of one, who are these economically well performing countires you speak of?”

    No, you don’t want to think of one. But any I might give you you’ll just find a hair to split to attempt at getting the last word. But here’s an opinion article you might want to read to broaden your neanderthal brain.

    http://www.social-europe.eu/2011/11/sustainable-good-society-why-the-european-way-is-still-the-best-hope-in-an-insecure-age/

    • Nate Ogden says:

      You have to be joking Peter1, but the turkey leg down you have obviously ODed.

      “because it is more rooted in an awareness of the need for comprehensive sustainability, as well as the institutions and practices that have grown from that awareness.”

      PIGS are aware of sustainability? They are collapsing specifically because they don’t grasp the concept of sustainability. They over indulged and depleted the resources they had and are now paying the price. In regards to institutions, anyone claiming the EU/Brussles grasp sustainability and should be modled is a blind ideologue. Heck they just determined after three years water doesn’t prevent dehydration.

      “At the same time, the goal is to provide sufficient jobs”

      20% unemployement is now called sufficient? LOL

      ““Europe doesn’t need the economic growth rate of China or the United States because its productivity is so high, and because it is so good at spreading the wealth around more evenly and efficiently than those two countries do.”

      Europe didn’t spread wealth they spread borrowed money, your link doesn’t appear inteligent enough to grasp the difference, and thus the sheep that believe this are equally unaware.

      “Fifty million Americans have no health care at all”

      LOL this dumb ass doesn’t even know the difference between healthcare and health insurance. Damn you Peter I feel dumber having read this. I should have known better to actually read the crap you do. Reading your material is like junk food, put crap in your body your going to feel like crap. I’m going to stop reading this joke before my brain cells start commiting mass sucide.

      • steve says:

        “They over indulged and depleted the resources they had and are now paying the price.”

        Much too simplistic. Start with interest rates pre and post unification. Then figure out who benefitted. The EU tried to function w/o adequate fiscal unity. The German and French banks benefitted greatly, as did the exporters in those countries (mostly Germany). If you look at hours worked, Greece beats Germany. If you look at benefits, Greece is very close to Germany and France. Italy is actually in budgetary surplus right now. This is much more complex than some country overspent. At this point, it is the French and German banks that will be bailed out if the ECB does come through.

        Steve

      • MG says:

        Depleted the resources they had? What natural commodities exactly did Portugal/Ireland/Greece/Spain had that they squandered? That was the issue 18 months ago.

        This crisis has moved way beyond these countries anyways too at this point. What matters is the Italian bond market which given its size and liquidity is the domino that will dictate whether the Euro lives or dies. If it defaults, the Euro will collapse regardless of what the ECB/IMF does and then we will have a real Great Depression 2 globally with everybody getting clobbered including the US, China, and Latin America.

        At best at this point, the U.S. muddles along for another decade with anemic growth with periodic minor recessions without the floor really falling out. Basically a case of bad or really bad at this point for the next decade. If things really do get really bad in the US in the next year or two, it won’t be the orderly and dignified like it was in Japan after Fukushima either. We’ll eat one another with marshal law being imposed where and as necessary. It is the CIA’s biggest concern next year besides a traumatic oil spike due to a conflict with Iran.

        The real question is whether the U.S. Treasuries market continues to be seen as the ultimate safe haven or if at some point much sooner than later whether the Treasury Dept has to significantly raise the yields to attract enough builders because rolling over ~$150B monthly.

        If that happens, cuts including to healthcare will be sudden and severe too just like they have been the US with the only difference being that there will simply be large numbers of people with limited/no access to healthcare services.

  6. Gary O. says:

    “Free markets” are Nate’s answer.

    As Steve Klingaman aptly put it in his piece “‘Free Markets?’ — Look There’s a Unicorn!”:

    The issue is not that markets are over-regulated; it’s that they are rigged. That’s why, as Robert Reich said to Occupy L.A. on November 5, economic output has doubled over 30 years or so and the One Percent captured most of that growth while real middle class got, essentially, nothing. That’s right.  Nothing

    Nate bemoans the “Federal exchange” and mandate being “written by people that have no idea how the industry actually works.” Wrong. Of the few people Obama actual did get into a room with, Karen Ignani (AHIP) and Billy Tauzin (PhRMA) came out with the scales tilted their way. The insurance companies got unregulated, uncompetitive mandate; the pharmas got prohibition of drug importation and no negotiation by Medicare for drug prices. That’s the way so-called “free markets” work in this country. Greed and self-interest know no bounds. Neither AHIP or PhRMA care if the economy collapses under a health care system that absorbs one-fifth (and rising) of our GDP. Of course, the grand-daddy of all rigging was the hundreds of billions of your and my tax dollars to bail out the big banks who completely mismanaged risk in a de-regulated environment that they paid the politicians for over the past decade. They came out with unabated bonuses in the billions, larger and therefore even harder to fail, no meaningful investigations or reforms, and business as usual, just waiting for another handout after another failure.

    Time for some redistribution the other way.

    • Nate Ogden says:

      you obviosuly don’t know what the word unregulated means. Why did Obama write his bill to benefit BUCA who represent a minority of the insurance industry? Doesn’t sound like a free market when the government regualtes the system to a benefit of a minority

    • BobbyG says:

      Markets properly exist to serve the net benefit of civilization to the extent possible. Anyone arguing otherwise is arguing Might Makes Right, the validation of Greshman’s Law.

      Moreover, “markets” differ materially, some being inconsequential to all but the participant actors, others being quite consequential to society writ large. “Free markets” is a red herring phrase. “Just markets” are the only sustainable ones if humanity is to advance — notwithstanding the very real short-term “winners” that exist even in zero- or negative sum games.

  7. Gary O. says:

    Let me say this simply, one more time. Our markets are rigged. They are rigged for the benefit, not of society as a whole, but for the highest bidder — the ones with the most campaign contributions. As Senator Dick Durbin said, “The banks — hard to believe in a time when we’re facing a banking crisis — that many of the banks created — are still the most powerful lobby on Capitol Hill. And they frankly own the place.”

    • MG says:

      Yup. We have returned to an era that is similar to the late 1870s until TDR began president after McKinley’s assassination in 1901 where the US federal gov’t was captured by moneyed financial interests and the various interlocking series of industrial trusts.

      One of the things that I will agree with the right on is that the increasing amount of regulations since the early 1970s as evidenced by the increase in the size of the Federal Income Tax Code and Federal Register has generally been a bad thing because a number of the regulations have typically been written to favor vested established industries and large firms to the detriment of a better functioning economy and society.

      On the opposite end, wholesale ‘deregulation’ those also isn’t necessary the answer either as we have seen what that has accomplished and ‘laissez faire’ capitalism is a pretty crummy system with serious limitations and pretty awful consequences for most. Even Adam Smith recognized and criticized it accordingly which is ironic because I constantly here Adam Smith being cited as a huge proponent of it. Problem is that finding the right balance between regulation and market for an industry is tricky and ever-changing due to technological, societal, and other changes. Dangerous people are ideologues.

      Wish we would have just used the Wyden bill as a basis for healthcare reform and just modified on the edges but political wonks have a long history even in the Senate of getting nowhere with their ideas.

      • steve says:

        Not ironic at all. Most people do not seem to realize that he wrote two books. If you read them, not easy and best done young while you have the stamina, you realize that he was primarily concerned with moral behavior. For Smith, economics was intimately associated with morality. Smith understood that if you left two or three businessmen alone together, they would scheme to set prices.

        Steve

      • Nate Ogden says:

        deregualtion doesnt mean bad players are free to do as they please. Government should require transparency and pass laws to accomplish as much. Regualtion fails when government attempts to legislate outcomes, which never works.

        The federal government should not be dictating who sells insurance, what it looks like, or who buys it. They should make sure that which is sold is honestly depicted, no collusion, and no monopolies.

        • MG says:

          Health insurance as you basically describe here would leave out a majority of people in the U.S. including almost all of the elderly. That’s the problem with ‘laissez faire’ capitalism is that while it works spectacularly for some and increases wealth (as long as you have a growing population with abundant natural resources but that is another issue) it leaves wide segments of the population to suffer various negative consequences with some being pretty drastic.

          You also contradict yourself when you state that the federal govt should require transparency yet at the same time basically have no direct oversight on who sells insurance in the first place but only that is it ‘sold honestly as depicted.’ That strikes me as a incredibly foolhardy for several reasons not the least it which you would see large amount of fraud and harm in such a system.

          I guess the federal gov’t shouldn’t regulate who sells what fire extinguishers and that they should only enforce some type of penalty on the fire extinguish manufacturers after someone’s house burns down.

          Kind of like the relevance that some conservatives speak of late 19th century America lately. They can largely get away with it because American history taught in schools is generic and how many Americans are going to read late biographies and books on life in late 19th century America?

          Late 19th century America was generally a pretty rotten place for most Americans especially those in urban cities and those working in industrial settings. Men (and women in some limited professions) worked 6x a week for typically 10-12 hrs/day with no vacation, sick pay, worker’s comp, etc. If you got maimed or fell ill unable to work, you were useless and cast aside. You worked until you died or you were incapable when it was up to the responsibly of your family to take care of you.

          It wasn’t a picnic either for the South where most of the population were poor sharecroppers (black and white) who at best eeked out enough annually to have enough to eat and not be in hock at the end of the growing season so much that they couldn’t afford to buy the necessary supplies next spring. Better than serfs in Czarist Russia – yes but not by much especially blacks who always had to worry about the threat of violence especially in the Deep South (MS, AL, GA).

          Steve is right though. Some one will fill the power vacuum and dynamic in the market place. If the gov’t doesn’t do it, the producers or creditors will. When I hear someone rail about ‘economic freedom’ and ‘free markets’ I don’t pay much attention because it is almost always meaningless empty rhetoric.

          I would much rather have that the federal gov’t does away with health insurance linked to private employment, comes up with a vehicle where financing is arranged federally through a tax credit (including for Medicare) and a straight forward tax, sets out some basic guidelines that to be followed to comply with federal law, and allows states to fill in the specific details and oversee the plans.

          • Nate Ogden says:

            “Health insurance as you basically describe here would leave out a majority of people in the U.S. including almost all of the elderly.”

            why would it leave out anyone? I could design insurance products that could cover anyone. I’ll guarantee you can’t come up with any scenerio where 95% of the population couldn’t have covereage tomorrow.

            “You also contradict yourself when you state that the federal govt should require transparency yet at the same time basically have no direct oversight on who sells insurance”

            Just becuase the solution is beyound your comprehension doesn’t mean it doesnt exist. There was no contridiciton at all. You can have open regualtion that would allow anyone that follows certain pratices to sell insurance. That would be contrary to our current laws that require large payments to government agencies, you rproducts must be a certain type. There is no flexibility in licensing, i.e. if I want to capitate primary care doctors, very low risk and small dollars I need the same multi million dollar license as a full blown HMO in most states.

            “That strikes me as a incredibly foolhardy for several reasons not the least it which you would see large amount of fraud and harm in such a system.”

            If it strikes you as foolhardy its becuase your not very informed. There is tons of fraud and harm in our current system. Look at our financial markets and in spite of all their regualtions they are full of fraud and harm. Excessive regulation breeds fraud, it provides cover for abuse and gives buyers a false sense of security. An unregulated free market where its buyer beware is always safer then an over-regualted system that codies fraud and abuse and tricks the public into thinking they are safe. Don’t be so naive and simple, just becuase there is 10000 pages of law saying you can’t rob people doesn’t mean a crook is any less likly to do so.

            I rather know fire extinguishers are unchecked and I need to do so myself then think the government is doing their job then find out after my house burnt down that the inspector wasn’t doing their job. Couple years ago in Vegas there was a big scandal about casino’s having work done and they found out the building inspectors where incompetent. Whats worse, thinking your safe when your not or not knowing if your safe and acting accordingly?

            “how many Americans are going to read late biographies and books on life in late 19th century America?”

            Far more conservative American’s then liberal. Us on the right care about our country, most of the left is to busy self indoctornating themselves with Che to be bothered.

            “Late 19th century America was generally a pretty rotten place for most Americans”

            Compared to what? Where in the world would they have been better off at that time in the world? No place on the planet provided more freedom and opportunity and that is why the entire world was dieing to get here, and most still are.

            “worked 6x a week for typically 10-12 hrs/day with no vacation, sick pay, worker’s comp, etc. If you got maimed or fell ill unable to work, you were useless and cast aside. You worked until you died or you were incapable when it was up to the responsibly of your family to take care of you.”

            Why are you so opposed to work? That is what builds great nations, its what Sweden and other European nations where known for before they went soft and became weldare states. Its this aversion to work that is killing Europe. Its that aversion to work that is destroying America.

            It should be our families responsibility to take care of their own, it sure the hell isn’t societies.

            I’ll pass on your healthcare ideas, we have already seen that scheme fail, no need to repeat it so verify the same result. Government has no right nor roll in healthcare period.

  8. MG says:

    “why would it leave out anyone? I could design insurance products that could cover anyone. I’ll guarantee you can’t come up with any scenerio where 95% of the population couldn’t have covereage tomorrow.”

    Yeah, right. When you talk specifics on certain issues you make some valid points but you are often just largely full of BS and this is another example. Maybe catastrophic only coverage but how in your right mind could you up with affordable insurance for elderly people who required full-time nursing care?

    “If it strikes you as foolhardy its becuase your not very informed. There is tons of fraud and harm in our current system. Look at our financial markets and in spite of all their regualtions they are full of fraud and harm. Excessive regulation breeds fraud, it provides cover for abuse and gives buyers a false sense of security. An unregulated free market where its buyer beware is always safer then an over-regualted system that codies fraud and abuse and tricks the public into thinking they are safe. Don’t be so naive and simple, just becuase there is 10000 pages of law saying you can’t rob people doesn’t mean a crook is any less likly to do so.”

    I agree that just because there are laws on the books doesn’t mean that there isn’t fraud and abuse if there isn’t adequate enforcement of these laws by the proper authorities. It has been a huge problem especially with mortgage underwriting. Instead the DOJ has been trying to buy off state AGs for the past 2 years with a settlement where the mortgage underwriters would pay a lump settlements that would be in the tens of billions to avoid civil litigation by the states (and implied to avoid state criminal prosecutions too).

    It is kind of funny though about how you bring up the financial system. So the financial system worked well in the late 19th century largely without huge amounts of speculation, fraud, etc? People are honest and ethical by nature and are firms and will largely due the right thing in business dealings?

    “I rather know fire extinguishers are unchecked and I need to do so myself then think the government is doing their job then find out after my house burnt down that the inspector wasn’t doing their job. Couple years ago in Vegas there was a big scandal about casino’s having work done and they found out the building inspectors where incompetent. Whats worse, thinking your safe when your not or not knowing if your safe and acting accordingly?

    This is just idiocy. You would check every fire extinguisher you might need to use before you ever use it/? How exactly does that work? Your stating that you would create a society where you could largely only rely upon your logic and understanding to know if a product was safe, etc By your logic, why even have zoning regulations for building? Why even have an FDA or food inspectors?

    This kind of society works in a smaller society that is homogenous that isn’t complicated and is in a relatively limited geographical area. Not for a society that is approaching nearly 400M, is incredibly heterogeneous, and over such a widespread area.

    “Compared to what? Where in the world would they have been better off at that time in the world? No place on the planet provided more freedom and opportunity and that is why the entire world was dieing to get here, and most still are.”

    Political freedom – yes. Economic freedom – not so much unless they were willing to seek land which of course was largely enabled through wars of economic convenience and opportunity (Mexican-American War of 1846-8; varied conflicts with Indians). Americans largely just killed and took what they wanted in the way of land/resources which of course today largely isn’t permissible.

    Look at where most immigration came from in the mid to late 19th century. It was European countries that were either under foreign rule (e.g., Greece, Poland, Ireland) or countries that hadn’t enacted more liberal reforms after the widespread revolutions of 1848 that wracked the continent. Immigration from more liberalized places including France, Great Britain, and Germany (after unification in 1871) that had voted in more economic reforms and basic suffrage in their home countries had very limited/limited emigration to the U.S. especially at the later part of the 19th century.

    Basically it was a ‘tallest among the midgets’ argument. If you lived in a European country which didn’t have political freedom, there was widespread emigration to the U.S. but not nearly as much in countries that had male suffrage.

    People aren’t coming to the U.S. either in such large numbers either of late especially Mexicans and Central Americans who have basically crawled to a trickle the past 3 years. America is still a place that lots wants to come but let’s talk facts instead of generalities.

    “Why are you so opposed to work? That is what builds great nations, its what Sweden and other European nations where known for before they went soft and became weldare states. Its this aversion to work that is killing Europe. Its that aversion to work that is destroying America.”

    So treating workers largely as disposable assets is an ideal model that society should seek? Workers will not tolerate too for long and will take action ranging from collective action to much more radical action including sabotage, threats of violence, and actual violence. You either work on reforms or put jackboots on people’s throats to keep them in order.

    It also sounds like you advocate the late 19th century approaches by American industrialists that widely supported using private sources and state militias & federal troops when necessary to use violence & kill Americans if necessary to keep them in order if they stepped out of line. We’ll see how long that continues to work for China as they continue to largely use the rule of force and simply detain/kill workers and citizens too.

    You keep ranting about the Scandinavian countries like Sweden and Norway with generic talking points which either aren’t true (Debt to GDP ratio) or without any valid assertions. I would agree that the Scandinavian models of capitalism isn’t applicable to the US largely due to the size and demographics of the countries but these countries especially Norway & Sweden have a hell of a lot more going for them than you acknowledge especially Norway with its oil reserves and large sovereign wealth fund.

    • Nate Ogden says:

      “Yeah, right. When you talk specifics on certain issues you make some valid points but you are often just largely full of BS and this is another example. Maybe catastrophic only coverage but how in your right mind could you up with affordable insurance for elderly people who required full-time nursing care?”

      Your the one tossing out generalities, and to answer your question by not waiting until they are an elderly person in a nursing home. Use a little common sense, we sell LTC insurance now which covers old people in nursing homs. We sell million dollar life policies that pay off when old sick people in nursing homes die. If someone waits till they are at the admit counter of the nursing home to worry how they are going to pay for it they are not in search of insurance they are in search of charity. The first thing we need to change is use insurance as insurance not bastardize it as we do now.

    • Nate Ogden says:

      I’ll also remind you MG until the government started tinkering with insurance it was very common for employer based plans to cover retirees and their spouse until death. Its not creating something new its returning to what was done for decades minus the government regulations that drove everyone out of it.

  9. Gary O. says:

    Nate: “Government has no right nor roll [sic] in healthcare period.”

    Public funds account for something approaching 50% of national health spending of $2.6 trillion and you contend that government has no role in making sure that money is appropriately spent. This is the same mindset that was satisfied paying over hundreds of billions of dollars to Wall Street crooks, guys that totally failed in managing risk, all this payout being done without the government demanding any accountability or reform even after the colossal failure.

    • Nate Ogden says:

      Don’t be so blind Gary. The question is not rather the federal government should have a role in making sure their 1.3 trillon is appropriately spent, the question is why they are spending 1.3 trillion in the first place. That is not the role of the federal government.

      If sheep like you would stop giving the federal government the money and power to give wall street trillions of dollars we wouldn’t have to worry about wall street blowing it in the first place.

      You want reform, that is exactly what I am proposing,defund DC so they can’t squander another 15 trillion of our money.

  10. I think you hve described the Romney plan. Am I wrong?

  11. John M says:

    I share Jon Gruber’s frustration. I have worked in health policy for over 20 yrs and spent 8+ yrs on Capitol Hill. An individual mandate was originally advocated by Republicans as an alternative to the Clinton Healthcare Reform proposal and was being pushed as recently as 4 yrs ago by Newt Gingrich as a way to deal with the uninsured. It was only after it was adopted by Obama that Republicans went nuts about it.

    Also, there is not a serious constitutional lawyer out there (i.e. – one who is not bought and paid for by ideological think tanks) who believes the mandate is unconstitutional. 2 US Appeals Courts with conservative majorities have ruled that the mandate is constitutional. The idea that a highly political Supreme Court might rule the mandate unconstitutiona is scary and frustrating.

    And what few people discuss is that a ruling that the HCR mandate is unconstitutional would reverse 100+ yrs of interpretation of the Commerce Clause and likely to open up the potential reversal if many other regulatory structures we take for granted. It would have a much larger impact than many people realize. This is why in the end I suspect the Supreme Court will not overturn the mandate because the impact and consequences would be very broad.

    • Nate Ogden says:

      “there is not a serious constitutional lawyer out there (i.e. – one who is not bought and paid for by ideological think tanks) who believes the mandate is unconstitutional.”

      There is not a serious American out there, i.e. one who is not a european socialist or outright communist,) who believes it is constitutional. Pretty easy to make an argument when you frame it right.

      Use to be a time you didn’t need law degree to know what the constitution said, we can thank the same people ramming this down the public’s throat for that.

      • John M says:

        Ah yes. The originalist interpretation of the constitutional. I suppose you think we should go back to the original, unamended constitution with slavery, blacks being 2/3 (or was it 3/5 people can’t remember) people, denying women the right to vote, election of Senators by state legislatures, etc.

        I think it is pretty clear the founders expected the constitution would need to adapt with the times or else they wouldn’t have created the amendment process or permitted Supreme Court interpretation of the document.

        And yes – I think a Medicare for All solution would probably be the most efficient way to provide healthcare in the US so I suppose that makes me a European Socialist.

        • Nate Ogden says:

          no you racist we have the 13th amendment which corrected that. There really is no place in an advanced society for raciest like you John.

        • Nate Ogden says:

          and when was the last time we had an amendment, which is the proper way to expand federal power, not through stacking the court with ideologues.

          • MG says:

            Courts are stacked with ideologues of both persuasions and yes I would rather have federal judges get politically appointed than have to be elected and raise large amounts of funds to do so.

            So you suggest that the Supreme Court shouldn’t be able to challenge/overturn laws? What exactly is your point?

          • Nate Ogden says:

            it starts with the failure of our legislature to write clear and concise laws. They purposefully write vague bills then leave the details up to the courts and bureaucracy to hash out.

            There should never be court decisions like Roe v Wade. That is a clear case of something not addressed or envisioned by the original authors. Congress should be forced to sit down and deal with these issues not pass the buck.

  12. John M says:

    Nate – Your words – “Use to be a time you didn’t need law degree to know what the constitution said, we can thank the same people ramming this down the public’s throat for that.”

    I took that to mean you want the originalist interpretation of the constitution. Sorry if I was wrong.

    And you shouldn’t call people the names you are using (I won’t use them) knowing absolutely nothing about my background or family. I am about the furthest thing from the horrible description you used.

    • Nate Ogden says:

      you shouldn’t project arguments on other people, especially cheap ones like “putting it out there” that someone wants to bring slavery back. I run my mouth plenty you don’t need to be speaking for me.

      Being able to read the constitution and know what it says, good and bad, by no means implies someone wants to bring back slavery and ignore the amendments. Your smart enough to know that but were going for some cheap points. Its a very common game liberals play so I have a very effective defence for it. If you don’t want to be labeled a racist don’t drag race into arguments as a weapon.

      If being a racist is so bad why were you so quick to try and label me with it? You remind me of Maggie maher and how she would label people secist because they were smarter then here in arguments. Don’t play the game you wont get hurt.

    • BobbyG says:

      When all else fails, Nate repeatedly reaches for the race card.

  13. John M says:

    Nate – I never said you wanted to bring back slavery. What I was pointing out is the original constitution, while a brilliant document, also had some major flaws something constitutional originalist rarely want to admit. And when people talk about returning to the original interpretation of the Constitution, my first reaction is you mean when ….

    BTW – Your European Socialist comment was meant to get my goat but it doesn’t really bother me.

    I’m done now. Have a nice day.

  14. BobbyG says:

    “the original interpretation of the Constitution”

    a.k.a. The Ouija Board School of Jurisprudence.

  15. Nate Ogden says:

    Why Health Insurance cost as much as it does

    We have a small client that has a fully insured plan. Under the carriers fully insured plan they take a little bit of the risk, i.e. they reimburse part of the employees $5000 deductible. This can be very cost effective, as long as you don’t encounter are incredibly inefficient government.

    They have an employee who is dual covered with Medicare but this plan is primary. Even though we tell her every month we are prime and her providers need to bill us she has them bill Medicare.

    Medicare aware that she has primary coverage, then looks to recover what they paid from the primary carrier. Being a well ran single payor governemnt plan like it is they of course go after the small employer who is liable for at most $3000 a year. An amount they have alredy paid. The amount they are looking to recover, $72,000+. We have already been over this with Medicare 3-4 times, they need to look to the insurance company. Every time they promise to fix it, every three months it starts all over again.

    This latest time I have been on hold 37 minutes so far, they did warn me the hold time was over 50 minutes. This was after trying to call a few times earlier but the hold time was so long it just disconnected new callers. Think how many people are sitting on hold right now wasting time becuase of this grossly incompetent government ran insurance program.

    Not only is it a failue of an insurance plan but it drags every other plan down with it. How 10s of millions of americans can support and advocate for such failure defies logic.

    • Nate Ogden says:

      73 minutes on hold till the call was answered.

      After a pointless coversation the question I am left with is why would any employer sponsor a healthplan when the federal government will send you threatening demand letters then garnish your account or withhold funds becuase they have poor record keeping. You are left with no choice but to spend hours on the phone dealing with these people who have no accountability or motivation to resolve problems or apply common sense or stop offering insurance to your employees.

      Next time you liberals want to bad mouth employers for not offering coverage remember how impossible our government makes it.

  16. DeterminedMD says:

    Have no interest in the above thread, but see no other recent posting that the following link would apply, so sorry for disrupting this debate, but I think the column by the author, a physician and relative of Mr Obama, has merit.

    http://www.washingtontimes.com/news/2011/nov/28/bye-bye-berwick/

    With all the unraveling that has transpired since the legislation was forced, er, passed and put into motion, who would want to talk about PPACA as an ally to their cause. Only the liars, cheats, and clueless.

    Happy Holidays?

    • Nate Ogden says:

      Since the topic has been raised I’m surprised Bobby hasn’t linked this article about the evil of big business in relation to healthcare;

      http://www.futureofcapitalism.com/2011/11/obama-and-billy-tauzin

      Billy Tauzin, the former congressman turned pharmaceutical industry lobbyist, was paid $11.6 million in 2010, the year he brokered a deal with President Barack Obama that helped pass the health-care overhaul.

      After the law was signed, Tauzin left his job as head of the Pharmaceutical Research and Manufacturers of America, or PhRMA, as the highest-paid lobbyist among groups most involved in the overhaul debate. Karen Ignagni, leader of the insurer lobby, was paid $1.5 million in 2010 while Tom Donahue at the Chamber of Commerce made $4.8 million, tax records show.

  17. Peter1 says:

    Not sure who you’re trying to disparage Nate, Obama, Tauzin, Republicans, or crony capitalism?

    “Billy Tauzin, K-Street’s Drug Kingpin”

    “When he was acting as a field marshal for the Medicare prescription drug bill, Tauzin upset the true believers on both ends of the political spectrum. Conservatives were outraged that their party was creating a new federal entitlement. Liberals fumed that the bill prohibited Medicare from using its purchasing power to negotiate prices with the drugmakers. Detractors on both sides thought the bill amounted to corporate welfare for the drug industry.”

    “When Tauzin announced just weeks after its passage that he was retiring, the speculation immediately began: Would he cash out to the drugmakers?
    Sure enough, Tauzin is today the chief executive officer of the drug companies’ lobby.

    “Billy Tauzin, former congressman from Louisiana, is best known to us pharmascolds for his appearance in Michael Moore’s Sicko, shamelessly mugging for the camera while holding the outsized cardboard check for $2 million as he celebrated being hired by PhRMA as their CEO, immediately after he had successfully pushed Medicare Part D through Congress with multiple provisions handcrafted to suit the desires of the drug industry.”

    • Nate Ogden says:

      all of them including big government that even makes this possible in the first place. If the federal government would stay out of matters it has no constitutional business being in trash like him wouldn’t exist. Your never going to eliminate people like Tauzin or Obama, you can eliminate the corrupt system they feed off of though.

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