The GOP’s Endless War on Obamacare-and the White House Delay

The GOP’s Endless War on Obamacare-and the White House Delay

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The official reason given by the Administration for delaying, by one year, the Affordable Care Act’s mandate that employers with more than 50 full-time workers provide insurance coverage or face fines, is that employers need more time to implement it. The unofficial reason has more to do with the Republicans’ incessant efforts to bulldoze the law.

Soon after the GOP lost its fight against Obamacare in Congress, it began warring against the new legislation in the courts, rounding up and backstopping litigants all the way up to the Supreme Court. Meanwhile, House Republicans have refused to appropriate enough funds to implement the Act, and have held a continuing series of votes to repeal it. Republican-led states have also done what they can to undermine Obamacare, refusing to set up their own health exchanges, and turning down federal money to expand Medicaid.

The GOP’s gleeful reaction to the announced delay confirms Republicans will make repeal a campaign issue in the 2014 midterm elections, which probably contributed to the White House decision to postpone the employer mandate until after the midterms. “The fact remains that Obamacare needs to be repealed,” said Senate Republican leader Mitch McConnell, on hearing news of the delay.


Technically, postponement won’t affect other major provisions of the law — although it may be difficult to subsidize workers who don’t get employer-based insurance if employers don’t report on the coverage they provide. But it’s a bad omen.

The longer the Affordable Care Act is delayed, the more time Republicans have to demonize it before average Americans receive its benefits and understand its importance. The GOP raged against Social Security in 1935 and made war on Medicare in 1965. But in each case Americans soon realized how critical they were to their economic security, and refused to listen.


Robert Reich, former U.S. Secretary of Labor and Professor of Public Policy at the University of California at Berkeley, has a new film, “Inequality for All,” to be released September 27. He blogs at www.robertreich.org.

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177 Comments on "The GOP’s Endless War on Obamacare-and the White House Delay"


Guest
Tash
Sep 23, 2013

The new bill in Co Senate bill 60 has effectively put a bounty with required and rewarded actions to file fraud charges against providers and billers with no evidence in regards to Medicaid fraud. Physicians are now being scared off from submitting bills with fear of baseless fraud charges. I know this because a family member spent last wed. in jail with no charges against her and told she needed to confess as others had. The people she was told confessed are still doing business as usual and this is obviously a lie.
Gestopo anyone.

Guest
Jul 21, 2013

What I was trying to get across is this:

– having universal social insurance programs in a nation does not mean that the citizens of that nation are all kind and tolerant.

What it means is that at one point in time, the political groups that want social programs had a large legislative majority and strong leaders…….and they were able to put universal programs into law.
(e.g., FDR and LBJ)

At the same time, the fact that a nation does not have universal programs does not mean that all its citizens are mean and selfish. It only means that the opponents of universal programs have a lot of legislative strength.

What the heck, if we eliminated the bizarre filibuster rule we would already have more social programs. Without any revolution in our national character.

Guest
Al
Jul 21, 2013

Bob, universal insurance is not the same as access to health care. Based upon one’s definitions the US has universal healthcare. These are foolish terms unless defined.

“What the heck, if we eliminated the bizarre filibuster rule we would already have more social programs. Without any revolution in our national character.”

I want to help people in need not create programs to make me feel good about myself.

Guest
Al
Jul 21, 2013

Peter1: ” Biggest drag on advancing this country forward is southern mentality of still fighting the Civil War.”

Much of the fight revolves around the issue of states rights and that issue is nation wide.

“…in order to prevent misconstruction or abuse of its powers, that further declaratory and restrictive clauses should be added:…”

Amendment X

“The powers not delegated to the United States by the Constitution, nor prohibited by it to the States, are reserved to the States respectively, or to the people.”

It is easy to demonize southerners, but a lot less easy to demonize the tenth amendment.

Guest
Peter1
Jul 21, 2013

“Much of the fight revolves around the issue of states rights”

The right of a state to continue an economy on slave labor or segregation?

Guest
Al
Jul 21, 2013

We all agree that slavery and bigotry were wrong. Even most of our founders knew that and many tried to end it in the compromise. It wasn’t ended until the Civil War and the country paid dearly for that black mark.

But, why do you think bigotry is limited to the south? It was the northern textile workers that passed a minimum wage so that jobs would not move to black persons in the south. Who but the progressives advocated eugenics in great part to prevent the propagation of what was considered inferior people entering the American blood stream. That was aimed at blacks as well.

Ted Kennedy the great Liberal who demanded equality for blacks permitted black inequality on his own streets in the town of Palm Beach.

Guest
Peter1
Jul 21, 2013

“But, why do you think bigotry is limited to the south?”

Where did I say that?

“It was the northern textile workers that passed a minimum wage so that jobs would not move to black persons in the south. Who but the progressives advocated eugenics in great part to prevent the propagation of what was considered inferior people entering the American blood stream. That was aimed at blacks as well.
Ted Kennedy the great Liberal who demanded equality for blacks permitted black inequality on his own streets in the town of Palm Beach.”

What have those myopic comments to do with states rights or the civil war or my comment?

http://en.wikipedia.org/wiki/Textile_workers_strike_%281934%29

Guest
Al
Jul 21, 2013

Peter1: “What have those myopic comments to do with states rights or the civil war or my comment?”

Your argument against the south “slave labor or segregation.” If your argument wasn’t so one sided I wouldn’t have commented.

Now what was myopic about my statement concerning the progressive and Liberal fantasy of keeping American blood pure (eugenics)?

Guest
Jul 21, 2013

I know that several collective tongues are in several collective cheeks on of these posts, but I would lo head off one misconception —

namely, that national policies are always traceable to national character.

Canada has solidarity in health care, but certainly no solidarity about the sovereign status of Quebec. Germany has tolerance for sick persons in health care, but has been home to some of the worst racial and religious intolerance in history.

America has no solidarity in health care, but since about 1950 has extended Social Security to everyone over 65. (It took that long to overcome the Southern Dixiecrats and include farm workers and domestics.)

I believe that national laws are created by political initiatives and institutional opportunities. Whereas national character flows and changes much more slowly.

Guest
Al
Jul 21, 2013

Bob, I am asking this as a question, not part of a debate. Does Canada truly have “solidarity in health care”? Does not each province handle their health care needs differently? Is there not a marked difference between the care provided to Canadians and the Inuits along with other natives? Is there not a marked difference between the haves that can get care in the US or jump queues from the have nots?

Guest
Peter1
Jul 21, 2013

“Does Canada truly have “solidarity in health care”? Does not each province handle their health care needs differently? Is there not a marked difference between the care provided to Canadians and the Inuits along with other natives? Is there not a marked difference between the haves that can get care in the US or jump queues from the have nots?”

Al, you seem to have researched this already to form an existing opinion. Maybe you can give us your search results to see who you are believing?

Guest
Al
Jul 21, 2013

Yes, Peter, I don’t shoot from the hip, but I know Bob and he is an honest broker. He made a statement and I presented some things I believe are factual. If Bob chooses he will put them together and we will then better understand what he was trying to get across. It is Bob’s conclusions I am interested in, not my own.

Guest
Peter1
Jul 21, 2013

“It took that long to overcome the Southern Dixiecrats”

Not overcome yet Bob. Biggest drag on advancing this country forward is southern mentality of still fighting the Civil War.

Guest
Jul 20, 2013

Seriously, I don’t think we can truly have “universal healthcare” that works without a global budget of some sort. I do think the Europeans are very good at managing healthcare resources – I personally think that’s impossible with an open-ended benefit as it appears to be here. I think this is why we have so much trouble controlling Medicare expenditures. But we’re a long way off from thinking that in this country. Perhaps it would take an unprecedented crisis to get Americans to accept that.

Guest
Al
Jul 21, 2013

Sandra I think we overuse the term “universal care” without a unified definition of what it means. I don’t know that any western nation is terribly good at managing health care resources though the way they do it may seem more organized since the Europeans seem to use and accept force more easily. I don’t think the American mindset permits that type of control by government. Neither does the Constitution, but that is another debate.

Along with reasons you are alluding to we have so much trouble dealing with Medicare expenditures because our type of federal government is incapable of handling this type of social program. I presume that is why the founders left it out of the Constitution and created a division between the feds and the states.

Guest
Jul 20, 2013

Thanks for explaining. I have run into this analysis before, I’m afraid. I don’t know enough Europeans to assess their collective attitudes, but I do know quite a few Americans. I respectfully disagree with your assessment, but that probably comes from the fact that I view them through the lens of the culture with which I identify. I’ve heard some interviews with Greeks who are finding it more difficult to obtain healthcare, and in many ways they also sound confused about healthcare economics – or perhaps economics in general. Not that I’m an economist.

Guest
Uwe Reinhardt
Jul 20, 2013

By the way, I elaborate a bit on my views in this post

http://economix.blogs.nytimes.com/2010/01/22/america-the-unbalanced/

and here

http://economix.blogs.nytimes.com/2009/07/31/a-common-sense-american-health-reform-plan/

I find Americans a very charming people, and in so many ways very smart, but they are also forever young, if you know what I mean. I did not realize it until our kids grew to be teenagers

Guest
Uwe Reinhardt
Jul 20, 2013

Ms. Raup:

I recently gave a talk to an utterly august audience, titling it

IF YOU ARE NOT CONFUSED ABOUT HEALTH CARE, YOU’RE JUST NOT THINKING STRAIGHT.

So you are in good company.

Love and warfare are easier to comprehend.

Guest
Al
Jul 21, 2013

Confusion makes the experts seem brighter and causes large expenditures by our federal government on those experts.

Health care isn’t all that difficult unless people are trying to turn lead into gold wanting to get something for free.

Guest
Jul 19, 2013

I would like to bring up an issue that I’ve never seen addressed when speaking of a free market health insurance (like auto or life insurance) vs. something more government-mandated and/or controlled. As you age, you are nearly without exception going to run into significant healthcare costs, primarily out of your control no matter how “preventive” your behavior. We all would like to fall asleep and not wake up after an entire lifetime of no health problems, but that is just not going to happen, so any actuarial healthcare insurance policy will be more and more expensive as you age. For auto insurance, that doesn’t happen – you don’t necessarily have more claims just because you age. For life insurance, you purchase it for future benefit when you are less likely to die so, if you’re lucky, you’ve paid in a substantial amount before you die and you more than likely won’t get more than what you paid in. If we had a true insurance model that allowed you to purchase it without having your premium increase as you age and take on more health problems, that would make sense for people to purchase. Right now if you’re a 20 year old, you don’t think you’re purchasing the health insurance you’ll use when you’re 80, so what’s the point of paying for older people now? And once you’re forced to purchase insurance or pay a penalty, you probably aren’t thinking, “Yes, I’d love to pay 10 times more for my insurance than the penalty even though I’m not likely to use it because all those older people need my premiums for their care.” For two good reasons – (1) there’s no belief that the same is going to be done for you; and (2) it’s so expensive you’re giving up a great deal of purchasing power to have it. If this is going to work, there has to be a way that this makes sense to every population. Back in the ’90’s it may have looked like you had to satisfy the “stakeholders” because of their political power – hospital associations, medical and other professional associations, pharmaceutical companies, insurance companies nursing home association, etc., etc., so the only way to get health reform was to buy them off. I think that was “fighting the last war”. Now, people need to buy into whatever is implemented, and that means it doesn’t “bankrupt” (or overburden financially) healthy people. I am hoping that something like what Truman did with government contractors during WWII will happen – bring in the stakeholders and give them a global budget to work with that’s reasonable, and see what kind of system can be created that works for Americans. There has to be a solution that stops this political bickering between the “right” and “left” perspectives and that’s based on our basic values. Is that too hard to do?

Guest
Uwe Reinhardt
Jul 19, 2013

I believe that the main difference between young Europeans and young Americans is this:

Young Europeans conjecture that with high probability they will grow old.

By contrast, young Americans think that with high probability thermonuclear WWIII is just around the corner, wiping out everybody, so that going deeply into debt and insisting on medically underwritten health insurance premiums makes perfect sense.

It can explain why life-cycle health insurance models are de rigeur in Europe but not available in the US.

This belief helps me understand U.S. health care.

Guest
Jul 21, 2013

Uwe, I understand that if there were a thermonuclear war, that’s a pretty good excuse for not turning in my Econ paper. But what about if I don’t turn in a paper because I’m sure there is about to be a thermonuclear war? Surely that’s an economically rational position, and you can’t penalize your students for being rational economists, can you?

And BTW I assume that most term papers are delivered in electronic format. Are dogs eating students’ computer files these days?

Guest
Uwe Reinhardt
Jul 21, 2013

Where is the money going? Have you ever seen our lawns?

Guest
Al
Jul 21, 2013

“Where is the money going? Have you ever seen our lawns?”

Uwe your lawns are beautiful and obviously well fertilized. That is something that seems to come naturally from institutions of higher learning so no expenditures are necessary.

Guest
Uwe Reinhardt
Jul 21, 2013

Matthew,

We’re not penalizing any student for not turning in their paper. We just assign an F to it.

As to turning in papers electronically, a university would have to be crazy to allow it. Maybe Yale or Harvard allows it, not Princeton.

If the student sends it electronically, the poor prof has to print it out and use university-bought paper. By requiring students to submit printed papers, the cost of printing it, including the paper, is shifted to the student (or the student’s Mom & Dad).

Guest
Jul 21, 2013

You mean Princeton’s $16bn endowment (and I understand quite substantial tuition fees) don’t allow for the purchase of electronic reading devices for Professors (and their TAs?). Where is that money going then?

http://en.wikipedia.org/wiki/List_of_colleges_and_universities_in_the_United_States_by_endowment

Guest
Jul 20, 2013

That disappoints me, Uwe. I hear from economists that “people act rationally”, and what makes sense to me is that we look at what drives the calculus here vs. Europe rather than talking about what we think young people think. Why would young Americans think thermonuclear war more than Europeans? And can you truly characterize populations with such a broad brush? That’s nuts! I think American culture is more individualistic and therefore we are less risk-averse – perhaps we have not experienced homeland war and think everything will always turn out okay. I don’t think young Europeans are responsible for saving for their healthcare because they’re thinking about growing old; policy decisions were made decades ago. Now, in the U.S., policy is also made by old people who probably, when they were young, thought the world would be blown up before they grow up. What I’ve noticed is that young people are young people around the world – variations across each population, but all with the same hopes and dreams for their futures.

Guest
Uwe Reinhardt
Jul 20, 2013

Ms. Raup:

I resorted to the thermonuclear war hypothesis merely as an act of kindness.

The real story is less flattering. You say that relative to Europeans Americans are more individualistic, which could mean many thinks. It could mean selfishness, for example. You also claim that relative to Europeans, Americans are less risk averse. Really?

My view is that when the going gets tough in America, the tough usually run to the government for succor – whether it is people who could have bought health or flood insurance but went without it, or people who build houses where they should not, or bankers who defecate all over their balance sheets, figuratively speaking, and then ask government to clean them up again. It is the American way, I am afraid to say.

Now you can see why, sweet and polite fellow that I am, I use the thermonuclear theory instead. It has a certain elegance.

I recall a segment on the Jim Lehrer show in which Judy Woodruff had a conversation with a handful of real Americans (in 2009). A Libertarian in the group who professed his disdain for government and said he did not need it said he was poor and unemployed. Judy asked him what he would do if he got sick. “Go to the emergency room of the nearby hospital,” he said, without even realizing how absurd his view toward society was. And Judy is much too polite to take him to task for his twisted view of society.

I have never seen or heard Americans who rail against a mandate to be insured also rail against EMTALA. Too many Americans seem to think that with rights do not come commensurate responsibilities. That is also true, of course, in connection with health behavior.

In an interview published in Health Affairs (http://content.healthaffairs.org/content/29/8/1442.full?sid=232fdde1-abfa-449e-84dd-98b1eaf4039f) the former Swiss Secretary of Health was asked how he could defend a mandate on individuals to be insured. He replied:

“That’s easy. We will not let people suffer and die when they need health care. The Swiss believe that in return, individuals owe it to society to make provision ahead of time for their health care when they fall seriously ill. At that point, they may not have enough money to pay for it. So we consider the health insurance mandate to be a form of socially responsible civic conduct. In Switzerland, “individual freedom” does not mean that you should be free to live irresponsibly and freeload from others, as you would put it.”

It amazes me why so many Americans cannot follow that logic. “Individualism” often just reflects a lack of civic duty here.

Because I would have great respect for true Libertarians, if I should ever come across some, I have proposed a US health system that can accommodate the Libertarian’s dream of freedom, but also holds him or her responsible for their own misery, should it strike. See http://economix.blogs.nytimes.com/2012/06/29/health-care-solidarity-vs-rugged-individualism/ . Under the proposed regime, we could all be happy.

Guest
Al
Jul 21, 2013

“You seem to think that when there is Tsunami in Indonesia or an earthquake in Turkey or in Japan the U.S. is the only nation sending help.”

Uwe, I know other places showed up, but their wallets weren’t as thick and their pledges weren’t always paid. I do understand what you mean by being tax deductible, but I have also heard people, maybe you, stating that Americans are under taxed compared to others so if that is the case then the dollar amount given by Americans was even higher. By the way a lot of Americans that give take a standard deduction so the amount given doesn’t affect their taxes

You are quibbling as to where the charitable money goes. The problem you have is that we give so many multiples of what is given by the French or the Germans that you can remove many of these contributions and the multiples still remain. I won’t include the Canadians because they are far more generous than the French or Germans even though they have health care insurance just like the Germans and the French. Your excuse is therefore a very bad one and should be given the same grade as the excuse ‘the dog ate my paper’, an F.

The fact that the Germans and the French were at the lowest end of the chart is in part explained by you because “because everyone there has access to health care.” First let me correct your statement for they are insured and insurance doesn’t guarantee equality of access. In any event it is possible that this over dependence upon government makes people tight with their money and not willing to separate from it without a bit of government coercion.

You make a big deal about foreign aid. You say: “I am amazed, though, how quickly you write off foreign aid as a form of charity. Do you find data on that inconvenient?”

I don’t find it inconvenient for I don’t include foreign aid in with charity from my government and it certainly doesn’t count as charity for private individuals. Furthermore, even though it isn’t a huge part of federal expenditures I question whether we should be giving such monies in the fashion we do.

I am proud of the charity Americans provide both in time and money and in permitting many people from around the world to settle here especially when they are discriminated against in other parts of the world.

At present you seem to have a deep seated dislike of America. Maybe this evening you had an American dinner you didn’t like and you are reacting to it just as it is reacting to you. I don’t know, but maybe you should take an aspirin and go to bed. The Uwe at the table isn’t much fun to be with tonight. I hope you wake up tomorrow in a better mood.

Best.

Al

Guest
Uwe Reinhardt
Jul 21, 2013

Al,

You seem to think that when there is Tsunami in Indonesia or an earthquake in Turkey or in Japan the U.S. is the only nation sending help. I can see why you might think that, because nations generally show on TV only their own countrymen helping. Are you sure Europeans do not show up for help at those places?

As to what we call charitable giving in the US, you evidently have not read my posts in the NYT on that. First of all, a sizable chunk of what we call charity is actually public expenditure, because charitable giving, so called, is tax deductible.

Secondly, I would not define donating money to museums or the Lincoln center or even to churches charitable giving, but merely voluntary financing of public goods. As I note, the true charity in charitable giving in the US is quite small.

Germans, the French and Canadians, for example, do not have to rely on charitable giving for health care because everyone there has access to health care.

But if you want to believe that Americans are the most charitable people on earth, I would not want to rob you of that belief, if it makes you feel good.

I am amazed, though, how quickly you write off foreign aid as a form of charity. Do you find data on that inconvenient?

Guest
Al
Jul 21, 2013

Uwe, addendum on charitable giving:

take a look at:
http://www.cafonline.org/pdf/International%20Comparisons%20of%20Charitable%20Giving.pdf

The UK takes second place in charitable giving. The US provides twice as much charity as the UK and ranks first.

The ranking continues: Canada, Australia, South Africa, Ireland, Singapore, New Zealand, Turkey, Germany and last is France.

Guest
Al
Jul 21, 2013

“There are some things we Americans should not read.”

Is that the Constitution or the Declaration of Independence?

Uwe, Danes are wonderful people, but that doesn’t mean that we should change the data or is that what you advocate? But, I wasn’t talking about our foreign aid programs rather unexpected assistance to nations that faced catastrophic tsunamis, earthquakes and the like. Charity.

For your information I am not one that supports the way we provide foreign aid, but charity is a different story especially when it comes voluntarily from individuals. You do understand what I mean about voluntary as opposed to coercion, right?

Now if you can explain your point again?

Guest
Uwe Reinhardt
Jul 21, 2013

Al,

One more piece on U.S. foreign aid

http://web.mit.edu/cis/fpi_foreign_aid.html .

See also

http://economix.blogs.nytimes.com/2011/01/07/how-private-is-private-charity/

on “charity” in general, where “charity” is a very loose term.

And this

http://economix.blogs.nytimes.com/2011/01/14/how-efficient-is-private-charity/

Uwe

Guest
Uwe Reinhardt
Jul 21, 2013

Al:

Further on foreign aid. See Figure 1 in the article at this linkhttp://www.fas.org/sgp/crs/row/RS22032.pdf. It shows how little Denmark gives relative to the rest of the U.S.

I urge you, however, not to read the rest of the article and especially not to look at Figure 2.

There are some things we Americans should not read.

Uwe

Guest
Uwe Reinhardt
Jul 21, 2013

Al,

You are right about the foreign aid. I once saw a bar graph comparing the dollar amount (PPP $s) Denmark gives in foreign aid with the dollar amount America gives, and our bar dwarfed Denmark’s. I found it puzzling, because on the surface the Danes seem such nice people.

Uwe

Guest
Al
Jul 20, 2013

Uwe,

“It could mean selfishness, for example.”

…And when tragedy hits around the world, which government generally provides the most relief? Yet it is not just money America has supplied but it has also used its army, navy and air force to help other peoples in need. That costs bundles as well. But we cannot forget that when these catastrophes occur the American people give privately as well, more so, I believe, than the people of any other country.

Yet, you wish to label the American people as selfish in a backhanded way.

“My view is that when the going gets tough in America, the tough usually run to the government for succor –”

That is a very superficial interpretation. Some believe in more self reliance, but if they are forced to pay into a system why shouldn’t they take advantage of it?

I will agree that most are asking too much of their government and our leaders are pandering to the most juvenile emotions of a great people, but that too passes. Take note of our history and how the Americans were always downplayed by the Europeans, but in the end always towered.

I would be careful of overplaying your scenario with regard to libertarians. Many or most believe in some government involvement and most people are a blend of ideologies. You seem to be generalizing to the extreme.

“Individualism” often just reflects a lack of civic duty here.

That is totally wrong. Individualism in context with the discussion at hand means civic responsibility without coercion. That is how this country was built. Perhaps civic duty elsewhere requires coercion or at least that is what you seem to be saying.

P.S. Maybe the dog ate the post you submitted and the editors substituted this one.

Guest
Al
Jul 20, 2013

Uwe,

“This belief helps me understand U.S. health care.”

IMO there are so many better explanations that I am unnerved by the conclusion you draw. On an anecdotal basis I see nothing close to what you are describing. Has this opinion been studied?

Guest
Jul 20, 2013

Ha Ha Ha

I’m unsurprised that after all these comments we’re now back to where we started a few weeks ago—discussing Uwe’s psychological condition!

http://thehealthcareblog.com/blog/2013/06/28/three-reasons-uwe-reinhardt-blames-purchasers-for-everything/

Although I wonder if it will be regarded by Uwe as a valid excuse for his undergrads not turning in their term papers, after all Thermonuclear war is imminent!

Guest
Uwe Reinhardt
Jul 20, 2013

Matthew:

I do accept thermonuclear war as an excuse for missing papers, because I simply cannot believe that there are so many dogs dumb enough to eat paper.

Uwe

Guest
Jul 18, 2013

It is true that Germany has had some form of national health benefit since the time of Bismarck, so that gives a little time for trial and error.

Also, Germany and Japan and England built their current national systems after the devastation of World War II. The effect of the war was to wipe out many vested interests, and it also wiped out the right-leaning political parties.

Still and all, the Germans do point out one way of insuring all citizens with multiple insurance companies and few if any citizens in debt over health care and (by US standards) quite moderate costs.

As Dr Reinhardt suggests, the burden of proof rests on us Americans if we feel that the German method is wrong.

Guest
Al
Jul 18, 2013

You have it backwards. It is the burden of the party that wishes to impose a burden on another to prove his case. I don’t think Dr. Reinhardt suggested anything different.

Guest
Peter1
Jul 19, 2013

“You really believe that a person earning $40,000/yr doesn’t know they can’t afford a half a million dollar house?”

They may be that stupid – but their lender should not be that stupid. Lenders are supposed to assess loans for payback despite what borrowers might think they can handle – hence the fraud.

I’d suggest a book titled – “Who Stole the American Dream”, Hedrick Smith.

Guest
Al
Jul 20, 2013

Thank you for your recommendation. I don’t want you to think for a moment that I only blame the person who over-leveraged his home. Not for a minute do I believe they were the only one’s at fault. They foolishly allowed themselves to think that government was there to protect them when more correctly they should have believed that government was protecting Wall Street.

We, the people, rely too much on leaders that are incompetent and self serving. We are permitting a fascist state to grow and we have noted an uptake in this speed of change in the last decade. I think (only read reviews etc.) Smith’s conclusions lean towards the side of corporatism and that IMO leads to fascism.

As a side note regarding the $40,000 individual. Look at Florida and all those people that leveraged their futures based upon the belief that Florida real estate could only climb. At the time I was investigating the real estate market in certain areas. I walked away and the next time I looked there were for sign sales and foreclosures everywhere. It was sad to see so many lose everything on a gamble.

Guest
Jul 17, 2013

Al, it sounds like some features of German health insurance would please you. Premiums are level over life. Companies cannot shed the sick through targeted rate increases.

Companies with healthier insureds actually give up some of their profits to a reinsurance fund, which assists the companies with poor claims experience.

Anyone who wants the basic plan pays 7% of income. So does their employer. There are absolutely no rules about 50 employees, part time hours, and all the nonsense of the ACA. No retail chain can avoid these payments.

Individuals who make a high salary (I think the level is about $85K in US dollars) can buy a private plan instead.

Good or bad, I cannot say. But America is light years away from this level of regulation. I think you have an enormous challenge to create an equitable insurance system in the US.

Guest
Al
Jul 17, 2013

Bob, I don’t think I care much for what you state above.

Guest
Uwe Reinhardt
Jul 18, 2013

Al

So do you think Germans are stupid or ignorant to have that kind of system, rather than our great American system?

Just curious.

And classy (Princeton — need I say more?)

Uwe

Guest
Al
Jul 18, 2013

Oh, Mr. Madison Chair, you totally misjudge me, but you are classy. Why would I think Germans are stupid or ignorant? Maybe you have one of those complexities (:-)) like the inferiority complex. Absolutely no need. Let me refer you to a book by (what you might call) a complete right winger, Thomas Sowell. What do right wingers know anyway? (Maybe economics?) He wrote Migrations and Culture(?) a decade or so ago. Read it and you will be proud of your heritage. Imagine that, you agreeing with Thomas Sowell.

But I do wish to make it clear. Germans are not stupid, but that doesn’t mean they can choose for themselves a health care system that would work for the US. But, Mr. Madison Chair, you knew that already.

I thank you for this robust jousting. You have always been kind and a gentleman.

Guest
Al
Jul 16, 2013

@Bob: “However, the free market in health insurance from 1955 to the present has been all about letting healthy groups buy cheaper insurance”

Bob, that is the problem with insurance. You can’t have other people pay for your house if you buy fire insurance for it after it burns down. That is the same with health insurance. The flaw we can correct is one that penalizes the individual that suddenly becomes ill and who already carries insurance. We need to rate individuals one time and that is why it is essential that we concentrate on insuring the young.

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Peter1
Jul 17, 2013

“We need to rate individuals one time and that is why it is essential that we concentrate on insuring the young.”

Isn’t that what Obamacare is trying to do?

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Al
Jul 17, 2013

@Peter: “Isn’t that what Obamacare is trying to do?”

Not really. It is penalizing the young.

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Peter1
Jul 18, 2013

“The young are charged higher than their risk as a type of tax to pay for others. That money is not being used to secure level rates for them later in life.”

Well you’re concern for the future of the young is commendable but then you’re for our present system of insurance of assessing premiums based on risk? The young and healthy get the best rates and the old and sick get the worst?

How do you feel about Obamacare getting rid of pre-exist rating and establishing community rating?

By the way, under Obamacare as the young get older they will benefit from the same rating for the young as they had to take pressure off rates for them when they get old.

So how come you’re uninsured – the present insurance rating system not working for you?

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Al
Jul 19, 2013

“How do you know that?”

Uwe, I am sure your little grandson’s love thinking about those mice eating that big glob of cheese that we see almost every night before we sleep. Have they decided which type of cheese it is? The God Apollo11 can tell them when the time has come.

You tell me that the NSA hasn’t yet caught me and ask “Or thinke, that the moon is made of gréene chéeſe” (JH 1562). I await with great anticipation that communication from John of Goodman.

Al

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Uwe Reinhardt
Jul 18, 2013

Al:

You write: “By the way the moon is not made of cheese.”

How do you know that? I just wrote my two little grand sons a long, illustrated letter proving that the moon is, so, made of cheese. And there are mice up there as well. I had pictures of that as well.

I’ll send John Goodman the letter and he can forward it to you, as he knows your e-mail address but I don’t (even the NSA doesn/t).

Uwe

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Al
Jul 18, 2013

Peter1, I am not as concerned with health care costs as much as you are. I am concerned about providing necessary care without spending a ton of pooled funds on those that can spend and waste their own money. In my mind a lot of health care is a luxury item including a lot of health care that I receive.

I believe that the market place should manage most of our health care concerns. I believe government can have a roll, but its roll should interfere with the market place as little as possible. I believe Hayek had a similar feeling, but I am not sure. Perhaps Uwe is a bit more knowledgeable of Hayek’s works than I and I note he is aware of our postings and trying to help you out.

“Why did you need to negotiate with the hospital to reduce and forgive your obligations if you had insurance?”

That is a change from the questions I am most frequently asked such as ‘why is the sky blue?’ or ‘is the moon made of cheese?’. Not all insurances are low deductible. They didn’t forgive me the money. They realized their actions were reprehensible and decided to forget about it. I didn’t care one way or the other, but I was willing to spend any amount I had to not to pay them the ridiculous fee they demanded. They were very embarrassed.

“Most of that was lender fraud.”

You are a true Obamanite. Always blame someone else and don’t take personal responsibility. Leave Nancy P and H. Reid to catch the greased pig in the mud while you laugh at them. You really believe that a person earning $40,000/yr doesn’t know they can’t afford a half a million dollar house? By the way the moon is not made of cheese.

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Al
Jul 18, 2013

Thank you Uwe. You are indeed a friend and made me see the light. It is good that we all help each other. You are an economist and good with numbers. Can you help me balance my check book?

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Peter1
Jul 18, 2013

“but rather than destroy the marketplace I would manage those groups separately with the eventual goal of mainstreaming everyone.”

How would you “manage” those groups? How does that reduce costs?

“any attempt at universal insurance should be focused on the young.”

For the most part the young don’t need insurance, that’s why it’s so cheap for them. The young get old and the older you are the more you get pre-exist and the more you need/use health insurance.

“I even carried it when I lived in a slum and didn’t have enough money for a city bus, TV, entertainment, home furnishings, car, good clothing etc.”

That’s hard to believe. Why did you need to negotiate with the hospital to reduce and forgive your obligations if you had insurance?

“How did that type of thinking go for all those people that bought homes they figured they could afford a number of years into the future?”

Most of that was lender fraud.

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Uwe Reinhardt
Jul 18, 2013

Al,

Peter1 evidently was just worried that you might be uninsured and exposed to financial risk. Why do you call that lack of class? Now, knowing how well inside you are, Peter can sleep in peace.

Uwe

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Al
Jul 18, 2013

Peter1, Yes I believe insurance should be handled on a risk basis. That preserves the marketplace. Of course that means we have problems with certain groups, but rather than destroy the marketplace I would manage those groups separately with the eventual goal of mainstreaming everyone.

We have no choice but to manage the pre-existing problem and that is why any attempt at universal insurance should be focused on the young. Community rating is bad because it causes death spirals, unnecessarily high premiums, and destroys the market place.

I believe in paying for things as you go. It appears that you pay for things based upon your expected future earnings. How did that type of thinking go for all those people that bought homes they figured they could afford a number of years into the future?

“how come you’re uninsured”

How come you are so nosey? It is not becoming, but since you have asked so many times and already demonstrated a lack of class, I will respond. From the time I left home I always carried health insurance. I even carried it when I lived in a slum and didn’t have enough money for a city bus, TV, entertainment, home furnishings, car, good clothing etc. I carry it today to protect my assets.

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Peter1
Jul 17, 2013

“Not really. It is penalizing the young.”

Al, you never seem to be consistent in what you advocate – and hence my earlier comment about your shifting sands of reason. As well you never expand on anything you advocate in an attempt to convince us.

You stated you wanted individuals rated one time, if you advocate that you can’t also say Obamacare penalizes the young for charging them more to spread the risk. If individuals are to be rated one time they’ll have to accept higher rates when young to get lower rates when old.

I come back to a question – are you uninsured? Please tell us.

If you are uninsured are you going to welcome subsidies under Obamacare, and lower rates because the young pay more and the sick don’t get rated.

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Al
Jul 17, 2013

Peter1, I am have been totally consistent on this blog. You just see to do too much interpretation of another’s words. Stop reading the Book of Soundbites and start thinking in terms of concepts.

The young are charged higher than their risk as a type of tax to pay for others. That money is not being used to secure level rates for them later in life. Chances are at the rate we are going we won’t leave them with these entitlements, but we will leave them with a lot of debt.

What difference does it make if I am insured or not? We are dealing with health care policy not my personal health insurance needs. You are a nosey fellow.

I don’t support policy just because it supports my interests. I love this country so I support the policies that made it great and will keep it that way.

Guest
Jul 16, 2013

The costs of that liver transplant caused the employer’s health insurance premiums to rise to $30,000 per family, and that was from a non-profit co-op not a major insurer.

The employer had to drop their plan. A few employees got onto the pre-ACA high risk pool in MN, which was a good one. Other employees had large financial problems when they needed care.

Maybe this is an argument for larger insurance pools, so that one employer is not devastated.

However, the free market in health insurance from 1955 to the present has been all about letting healthy groups buy cheaper insurance, or self insure, and tough luck for the unhealthy groups.

This is not left wing canard, it has just been the pursuit of self interest. Read the book Strong Medicine by George Halvorson (president of Kaiser) for a good history of this.

There are many areas of life where the free market makes nearly everyone better off. I contend that health insurance is not one of them.

Guest
Jul 16, 2013

Thanks, Al, that does help.

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Bob Hertz
Jul 16, 2013

Al, I do have a tendency to use the term ‘bloated’ when I mean ‘huge’.

My nephew received a liver transplant at age 3 and has run up bills of close to $2 million since then, he is 18.

Maybe each bill was not bloated, but the total is.

His parents are bankrupt, the city govt health plan they were on is nearly bankrupt, and the poor kid will likely die in the next year.

These huge claims drive up insurance costs faster, in my opinion, than the more frequent but much tinier claims for extra tests, contraception, and the other mandates.

The ACA is going to outlaw any policy that has a maximum benefit like $250,000. My viewpoint was very different. I think people should be able to buy a cheaper policy with a lower max benefit. When the hospital comes calling for more than $100,000 on one life, the hospital should be told that reimbursement has ceased and the family has no liablilty either.

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Al
Jul 16, 2013

@Bob: “has run up bills of close to $2 million since then, he is 18.”

Bob, I am glad your nephew got what he needed and I applaud those doctors and the hospital that were able to do the procedure. Your nephew was lucky to live in a country where the procedure could be done.

Firstly was that the bills or what was paid? I am assuming those bills were for the 15 years including the transplant and whatever follow-up was required. That amounts about $130,000 per years in billing or actual payments for the cost of the transplant and all complications that followed over a period of 15 years.

The total cost of the liver transplant averages $577,100. Recognizing that there is less elasticity in this type of patient can you tell us what you would like to cut out to make the cost more affordable?

http://www.transplantliving.org/before-the-transplant/financing-a-transplant/the-costs/

“When the hospital comes calling for more than $100,000 on one life, the hospital should be told that reimbursement has ceased and the family has no liablilty either.”

Are you advocating that the hospital go bankrupt?

I am sorry for your nephew. Obviously he has had complications and that likely made his costs rise dramatically. Do you think he shouldn’t have had the surgery?

Guest
Jul 16, 2013

Al, a couple of questions about the costs listed, in case you have more information. The top 2 items on the list are “insurance deductibles” and “insurance co-pays”. Does that mean the rest of the costs listed are not reimbursable by most payers? Also, I’m assuming these are estimates for people with insurance (because it does mention insurance deductibles and co-pays). Would these costs be different if a person was not insured? How about Medicaid or SSD? Just curious in case you know – I find all these statistics (and discussions about healthcare costs) confusing generally. Whenever I have in the past tried to draw conclusions from these types of reports I’ve found they usually tell only part of the story.

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Al
Jul 16, 2013

Sandra, I don’t want to interpret what the site says. I simply did a quick Google search for the site to find a reasonable number.

People without insurance are frequently scr-wed. It’s horrid. Cash should be king, but in this case cash can mean that one is going to be fleeced. Hospitals can charge many multiples of what they expect to collect. I’ve had that happen to me and I told them where to go. The price was reduced to the average payment received in one case and completely dropped in the other.

If you want ball park estimates of what to pay you could consider looking at the Medicare fee table and figure paying 20-30% more. Alternatively I think John’s Hopkins has a specific fee schedule that actually matches what they are paid. (Some sort of agreement?) I have also seen places on the net that can provide estimates of costs.

Medicaid pays less than Medicare, but that fee schedule depends upon the state.

I hope I answered your questions.

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Al
Jul 16, 2013

@Peter1: “But Al, isn’t that the private “competitive” market you seem to keep telling us will solve health care costs?”

Absolutely not. We have not had a truly private market at least since WW2. Government control underlies the entire health care industry. They start by controlling who can get the tax deduction and under what circumstances. That lead to third party payer which certainly doesn’t represent a free market that is more organic in nature.

“By the way it appears you’re uninsured??”

One way or the other, what difference does that make? In any event that demonstrates how unaware you are of how people might be insured. Example: A person has to pay out of pocket until he meets his deductible.

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Peter1
Jul 16, 2013

“People without insurance are frequently scr-wed. It’s horrid. Cash should be king, but in this case cash can mean that one is going to be fleeced. Hospitals can charge many multiples of what they expect to collect. I’ve had that happen to me and I told them where to go. The price was reduced to the average payment received in one case and completely dropped in the other.”

But Al, isn’t that the private “competitive” market you seem to keep telling us will solve health care costs?

By the way it appears you’re uninsured??

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Peter1
Jul 16, 2013

“We need to insure those people that can afford insurance. We need to help those that are borderline so they too can be insured with the general population.”

Isn’t that the definition of Obamacare?

“Those that remain (and that number is not all that high) may need to be treated differently”

How?

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Al
Jul 16, 2013

Peter1 Should I answer you? Last time when I provided facts that left you without an appropriate response you became frustrated and resorted to insults. Why should I explain to you something you are unwilling to hear and perhaps unable to understand.

I will answer your questions and provide a six word explanation for the first question and a one word explanation for the second instead of a more detailed explanation. You can go to the books to find out what I mean.

“Isn’t that the definition of Obamacare?”

NO.

The poor will be crowded out.

“How?”

Subsidies

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Peter1
Jul 16, 2013

“Last time when I provided facts”

You provide NO facts, insightful comment or credible links (studies). You do provide platitudes.

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Al
Jul 16, 2013

Peter1,

My words and quotes even of major highly respected health care studies speak for themselves and your vulgarities speak for you. I don’t expect you to understand complexities such as how competition lowers prices. Say what you will, your comments are in black and white.

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Al
Jul 16, 2013

@Peter1: “Al, I have been on this blog almost since it’s inception and yes my comments are in “black and white”, as many long time posters will attest.”

Peter1, so far where we have engaged I have not been impressed by what I have seen so the laments I hear from you in this post might very well be due to your inability to appropriately converse with one that is not of similar belief to you.

I note your quotation with regard to markets. It doesn’t take much to find something to quote. To understand it takes more. All different sectors of our economy have some of these same problems. Nothing is perfect, but the market place functions better than a socialist economy. That has been proven by history.

“That’s why no other country in the world has chosen the U.S. model ”

When the US was founded then too the rest of the world had chosen differently. Yet through two world wars the west that you wish us to follow had to be bailed out by the US and even fed. Those present at the Jonestown massacre that drank the Kool-Aid must have felt like you, ‘everyone else is doing it’, drank it and died. Those that didn’t were killed anyway on the say so of their despotic leader who like you didn’t believe in personal choice.

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Peter1
Jul 16, 2013

“I don’t expect you to understand complexities such as how competition lowers prices.”

Al, I have been on this blog almost since it’s inception and yes my comments are in “black and white”, as many long time posters will attest.

I have been through countless posts and comments about how to lower costs in health care. What comes up over and over again from simple solution conservatives is “competition” will save us – yet they never seem to recognize (or accept) that health care is not like buying a fridge or a car. If it were we’d have the “solution” at hand. The health care market does not exist in a true competitive environment.

“Perfectly competitive markets exhibit the following characteristics:

There is perfect knowledge, with no information failure or time lags. Knowledge is freely available to all participants, which means that risk-taking is minimal and the role of the entrepreneur is limited.

There are no barriers to entry into or exit out of the market.

Firms produce homogeneous, identical, units of output that are not branded.

Each unit of input, such as units of labour, are also homogeneous.

No single firm can influence the market price, or market conditions. The single firm is said to be a price taker, taking its price from the whole industry.

There are a very large numbers of firms in the market.

There is no need for government regulation, except to make markets more competitive.

There are assumed to be no externalities, that is no external costs or benefits.

Firms can only make normal profits in the long run, but they can make abnormal profits in the short run.”

Now you can argue that no present day good or service can meet the above definition, but health care is the furthest from the above and needs a much more complicated management – usually a heavy dose of government regulation. That’s why no other country in the world has chosen the U.S. model (as if we designed it this way).

Even Taiwan, which had the opportunity to craft a system from scratch chose one with heavy government control.

Guest
Jul 16, 2013

Al, I like your stubbornness. Like me you are convinced that what we call normal health insurance costs too much.

I would locate the causes somewhat differently than you — I look at the bloated charges for a bariatric surgery or hip replacement or open heart surgery or transplant, and you look more at the mandates.

We may both be right.

Just to clarify one point: until the ACA, the underwriting for individual insurance was in fact just like the underwriting for disability insurance……
if the applicant had a condition, exclude it or rider it, and if you could not exclude it then reject the applicant. I worked at one point for an insurance company.

The ACA changes this, but we get much higher premiums as a result.
This gives me a sense of futility about non-group health insurance, and it is why I look to social insurance solutions.

Bob Hertz, The Health Care Crusade

Guest
Al
Jul 16, 2013

Bob, what you call stubbornness, I call adherence to the facts on the ground and in our own respective ways it appears we both do the same.

It is true I look at external causes and blame many of them for the high costs, but what I think you might be leaving out when you talk about bloated charges is that more frequently than not bloated charges are caused by market failures. In this case the market failure is predominantly government intervention or dumb intervention since I believe that under the best of circumstances some people that fall through the cracks will need help.

But before you go any further, you indicate that heart surgery is a bloated cost. We might be able to bring prices down somewhat, but bloated? I can think of a lot of things one might want to refer to as bloated, but that wouldn’t include heart surgery unless you mean things in a different fashion than I interpret. Break down heart surgery into its costs and then show me where it is bloated. Be careful when you evaluate costs. Make sure you are looking at what is paid, not what is billed and look at the median amounts not the outliers.

” it is why I look to social insurance solutions.”

That is where I believe your thinking goes astray. You are confusing involuntary charity with insurance. We need to insure those people that can afford insurance. We need to help those that are borderline so they too can be insured with the general population. Those that remain (and that number is not all that high) may need to be treated differently, but our goal should be to ultimately mainstream them as well.