Health Reform: A Class Act

Tim-greaney A few headlines from coverage of the passage of the health reform bill:

Winners, Losers in the House Healthcare Bill (Reuters)

Health Reform: What’s in it for you? (US News) 

Already Insured? Get Ready to Pay More (CBS)

Almost immediately after the House vote on Sunday, the media switched its “horse race” coverage from analyzing the politics of the affair to what it characterized as a clash of economic classes. Analysts were often quick to suggest that the average American might find himself in the loser column.  Others offered the conventional  ”on the one hand, on the other hand” pseudo-journalism, probably leaving most to assume (not unreasonably, based on their experience under trickle-down economics) that they have little to gain.  And inevitably, confusion spawns cynicism: The first question on Monday from my 91 year old uncle  was:  ”Do I still have Medicare?”

If we are going to do a triage by economic class, lets get it right:  I’m still waiting for a headline writer to capture the real story of the legislation: Health Reform Law Reallocates Opportunity to the Working Class

One unassailable fact that emerged from the year-long legislative debate is that the working poor and those in the middle economic stratum are the primary victims of our dysfunctional health system.  It is widely recognized that health care debt ranks at or near the top causes of personal bankruptcies. Less commented on, however, is the effect of widespread financial insecurity resulting from the high cost and lack of access to care.  More than 4 in 10 people earning under $40,000 per  year say their household has had problems paying medical bills over the past year. Not only does that statistic imply that many households are adjusting their budgets away from socially-important expenditures, like childcare and education, but it also reveals the personal toll imposed on lower income individuals and families. For those who have insurance, increasing premiums have forced them to take on more risk: Nearly one in five Americans say cost increases caused them or their employer to switch to a less comprehensive health plan, while almost half of all people purchasing insurance in the dysfunctional individual market say they have had to switch to a less comprehensive plan.

The misinformation spread throughout the debate has lent credence to those who would paint health reform as a victory for elites.  Judging from the expressions of outrage about health reform by some middle class citizens, many appear to carry the misapprehension that the primary beneficiaries of the legislation are those unwilling to work.  Nothing could be further from the truth; today’s uninsured are predominantly found in working families. In factover 15% of employed workers and a stunning 41% of low income workers lack health insurance. And given the stampede of employers dropping health care coverage for their workers, the epidemic of uninsurance or underinsurance is undoubtedly spreading upward in the economic class order.

Also under-reported are the many ways the current health care system works to disadvantage the working class. Most prominent is the tax benefit which gives a significant and regressive tax subsidy to wealthy elites.  Excluding employer contributions for health insurance from taxable income–at $168 billion per year– is the largest “tax expenditure” in the budget– and obviously benefits the higher brackets more than the lower ones. (Revising this indefensible and economically inefficient  redistribution would have been a sensible way to help fund reform, but Congress settled for adding some progressivity to the payroll tax and some other taxes aimed at upper income citizens).

In addition, the health care system perversely redistributes wealth in a variety of other ways.  For example, as Mark Hall and Carl Schneider have made clear, hospitals and physicians price discriminate against those with lower incomes:  the uninsured and those in the individual market –who generally lack the bargaining power to command lower prices–pay higher prices to hospitals (often as much as two or three times higher) than those with group insurance.

Even less widely acknowledged is the fact that insurance favors the upper classes in subtle ways.  Co-pays, for example, burden those with low incomes much more severely than upper class insureds. Havinghurst and Richman aptly summarize the “distributive injustice” of the system:

[C]onditioning eligibility for insurer payments on patients’ willingness to make certain out-of-pocket payments causes lower income participants in employee health plans to get disproportionately fewer benefits than their more affluent coworkers receive in return for equivalent premiums

To be sure, the health reform legislation does not assure equal access to care among the social classes; but it certainly is a big step in the right direction.

I doubt that most Americans accept the idea that social class should dictate vast differences in opportunity for our citizens.  The capacity of health reform to lessen the economic and physical burdens imposed on the working class then should be headline news.

A nationally recognized expert on health care and antitrust law, Professor Thomas (Tim) Greaney has spent the last two decades examining the evolution of the health care industry and is a vocal advocate for reforming the health care system and protecting consumers. He also has a strong interest in comparative antitrust law, having been a Fulbright Scholar in Brussels and a visiting lecturer at several European law schools.

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  1. I think it is very true that “the working poor and those in the middle economic stratum are the primary victims of our dysfunctional health system”. It might be a good idea to learn from Canada’s health system.

  2. Important to realize that snoring could get progressively worse as children get older. So it can can good to consider trying low cost methods to try to curtail the snoring. One method can be to strengthen the voice and airway by having the children take up a wind instrument or singing.

  3. Very enlightening. It is very important that everyone realize the new reform is a stepping stone to improve healthcare. I feel that point was displayed very well.

  4. ***The harm of children snoring!!
    Not only adults snore when they are sleeping, but also the children. Some parents treat children’s snoring sounds as a signal of good sleep. However, the related experts caution that it may be a sign of sleeping breath obstruction. At some level, that may affect the children’s intellectual and physical development. What’s worse, that may induce sudden death when the children are sleeping.

  5. I`m 66 and anyone who has delt with insurance companies/ hospitals and doctors on serious, expensive medical issues has experienced first hand many of the situations and issues in your article. In Texas, Blue Cross and Blue Shield has a virtual monopoly on health insurance. Their influence in Austin ranks among the most powerful in the state. Profits soar. Their exclusion from the anti-trust law should be eliminated.

  6. [Comment delayed by posting issues (and then I posted this to the wrong thread)…]
    Ryan –
    I’m only addressing here the analysis that Mr. Greaney is offering – i.e., that the issue is class. I have not argued that anyone “deserves” not to have healthcare or that not having it is not a burden. I have not offered arguments against the current bill, because I don’t object to the current bill, as far as it goes. I’d just don’t share the Marxist perspective, and I think it leads down blind policy alleys.
    As regards your numbered points, I think you overstate the burdens on young people who cannot get healthcare outside the emergency room. I suspect that the vast majority stay healthy long enough to get jobs that provide coverage, if they touch all the other bases. Most of the people who have jobs that do not provide health insurance are in those jobs for reasons other than that the lack of health insurance keeps them from advancing. Lack of health insurance after a year of work is more likely a consequence of not advancing than a cause of it.
    I agree that fewer and fewer jobs have healthcare, but I lay the blame for that on our trade policy, which has made healthcare too expensive for employers to provide. But, remember, I am FOR universal coverage, and for whatever additional opportunity it creates (which I just think is less than you think it is), so don’t expect me to make the case against it.
    I do not see anyone “greasing” the pole to keep competition out. Well, I do, but you may not like my take on who’s doing it to whom. The only pole-greasing I see is White men’s decision in the 1970’s to give economic opportunities to their women instead of to Black men. If you want to talk about greased poles, look at the number of two-earner White households and zero-earner Black ones. (I am not unsympathetic to Marxist arguments per se, just to bogus ones.)
    I hear you when you say that efficiency can provide the resources for universal care. I would like to be able to agree, but I want to see the case made in more than a conclusory way. A weakness of the current bill is how little it does to enhance efficiency, trying instead merely to wring the profits out of administering claims, which is why I see demonizing insurance companies as counter-productive. I’d like to see incentives for PCP’s to reduce utilization. Others think we can reduce “unit cost,” but I don’t see how that affects resource utilization. (“Energy” does not appear in my posts. When I speak of “resources,” I mean mostly the human ones – man-hours and educational attention. Competing needs are for good government, industrial innovation, and infrastructure, to name a few.)
    I’m not sure why my assertion that race played a part in BHO’s election bothers so many people. We’re talking about a freshman Senator with no legislative achievements. I can see lots of good reasons why he beat McCain. But Hillary? Pundits pretend the differences were tactical, but that’s just not enough. The proof will come in the 2012 elections, when Black turn-out falls and coat-tail incumbent Democrats lose. (Elsewhere, I think the Dems will have a surprisingly good year, unless jobs, not healthcare does them in.)

  7. “Keeping it home how did housing projects and welfare work out for those decendents of slaves?”
    Not very well. But if you’re interested in reading a bit of unbiased history of Chicago’s projects you’ll find more than enough vilains, least of all your hated “liberals”. Blacks had always been segregated to a slum ghetto, concentrated housing still in the ghetto did not solve anything.
    “The city’s aldermen, responding to the violent, racist opposition of Chicago whites to integration, blocked the CHA’s proposed sites on vacant land in outlying white areas.”
    http://findarticles.com/p/articles/mi_qa3945/is_200104/ai_n8939181/?tag=content;col1

  8. “2) Disparities in starting position may be a good motivator, but disparities in opportunities surely are not,”
    Am I the only person that grew up working fast food? What disparities in opportunities does the left keep refering to? You show up for all your shifts, learn basic math, and don’t steal and 3 months later your a shift supervisor. six to nine months of not screwing that up your a shift manager and a couple years of that your a store mananger. With that resume you get out of fast food or food all together and get a real job. It’s not the white man or the system that forces those stuck in the entry level job to miss work, not learn math, and steal. It’s the idiots who can’t hold a basic job. They deserve to make $5 an hour, have no insurance, and no government assistance. It is no one elses fault these people never rise out of this level. They make stupid mistakes and pay the price. If and when they ever grow up and act like a responsible person they can advance and move up. They want it handed to them and liberals want to blame some make beleive evil whitey for it.
    “In fact any reduction is good.”
    BS if it is an artifical taking from one person to give to another with no merit it is terrible and what leads to the desctruction of civilizations. If they are entitled to a living wage without earning it why aren’t they entitled to a new home or fancy car. Why should they work for anything? Society can not survive with an entitled class that doesn’t produce anything.
    Where do you stop Wendell? Should a person who refuses to work not only have the same healthcare as me but get to eat in the same restraunts? Should they live in the same neighborhood? Should they get the same private education as my kids? Please share how far you want to take this so we can clearly see your ideology.
    “Nate, was it “liberalism” that transported millions of blacks here for slavery”
    No Peter it was boats, and trails from the jungle. Beyound that I didn’t follow anything you were saying. I’m sure there is a point in there but I can’t find it, what is it your trying to say?
    Can you name a thriving city ran by liberals? How about a successful socialist state not on the finanical brink of collapse. Keeping it home how did housing projects and welfare work out for those decendents of slaves? Slavery 2.0 was worse then the first time.

  9. “Why do you assume that poor people are financially irresponsible?”
    Becuase of all the studies that show average credit scores for income classes and the fact poor people have the lowest.
    “Are you saying that all poor people are debtors?”
    And here she reverts to liberal argument, you lefties are so predicatable. You even copied what I said!
    “A low income person” Notice the two Ls missing, if I wanted to say all I would have said all. Why do you guys play these silly word games?
    “Are you saying that poor people are drunks and otherwise irresponsible?”
    You forgot the word some, and again countless studies have measured and proiven this.
    “Are they biologically more sturdy or more expendable?”
    biologically maybe marginally, enviromentally yes but that wasn’t the point. A poor person doesn’t have savings and can’t afford to be out of work. Thus if you were to insure this person you would want immedate assistance. An afordable catostrophic policy gets them in the system and the premium savings covers first dollar needs. People with assets can afford to miss a few weeks or a month and are more concerned about protecting long term goals and needs. The first goal on insuring risk is identifying the risk.
    Facts aren’t colored they are what they are.

  10. “I could argue all day your party and ideology are stuck in the 19th century. I can’t imagine how looking back at the last 100 years you think liberalism and socialism will do anything but destroy lives and nations.”
    Nate, was it “liberalism” that transported millions of blacks here for slavery or denied their constitutional and other rights through segregation in a virtual police state? Was it “liberalism” that decimated an entire Native American culture and civilization for expansion, greed and money, and then forced them onto under funded and under serviced reservations? Is it 21st Century “conservatism” that rescues financial corporations from their own self-inflicted bankruptcy with billions of public money which also preserves the bonuses of the people who got us here? Was it Catholic “liberalism” that enabled the Inquisition to exist for 600 years, and which only ended in Spain when Napoleon invaded? What part of “Let them eat cake.” was liberal ideology, but I guess in your reality “Let them buy insurance” is the same attitude? Was it “liberals” who started a personal vendetta war with Iraq through lies that killed/displaced/maimed 100’s of thousands, yet rewarded corporate supporters with billions in contracts? You might also want to research how the U.S. supported the Khmer Rouge and enabled Pol Pot.

  11. Wendell, I suspect that if I would have been born in different times and very different circumstances, I would have been a pesky missionary. Nobody is beyond salvation, not even Nate 🙂

  12. “The trouble with this sort of analysis is that it assumes all disparities between haves and have-nots are bad, so any reduction is good.”
    In fact any reduction is good. In absolute and for the good of all collectively and individually.
    Class differentiation is a fact of society, but one that should be discouraged rather than encouraged.
    Access to healthcare in the USA is unquestionably a function of class and income. That is wrong in absolute for any society with the least level of decency and morality. USA society is grossly immoral in regard to healthcare and medical services and in many other aspects. In regard to the level of immorality it is astonishing that so many USAers consider themselves to be followers of Christ for example.
    Further: “PC scolds”? Otherwise people who have another viewpoint and the facts to back it up?
    Margalit: Please, please do not encourage Nate to write anything more than whatever natural impetus drives him write in the first place. Just seeing Nate’s signature on a comment makes my eyes ache.

  13. Lawrence–
    Healthcare in the US is a hodgepodge of government, businesses, consumers all fighting one another, and a system that can not be ever 100% streamlined. I think I’ve sufficiently acknowledged the complexity of the system to re-enter the debate.
    I think you are right to point out that socio-economic issues are inter-related. I never made the case that health care is the end-all be-all of the fight against gross disparities. But it is a problem to be a hard worker, and climb the ladder, if your constantly dealing with basic health questions in life. Though I enjoy your pointing out the Marxist origins of that argument, for heuristic purposes I assume, regrabbing that high ground you surrender later on. Your missing the spirit of the argument. Even if its true that these people are not literally on deaths bed, not only do they have to worry about upward mobility, but they are also constantly dragged down by one of the basic aspects of living, health. It’s hard to climb the ladder with more weight on your back than the guy next to you, obviously not impossible though.
    On that issue of disparities I think your off the mark. Yes inequalities are inevitable. Some make more than others, some excel, some don’t. I mean the notion of insurance is itself inefficient, forgoing current earnings for what could be a non-existant benefit in the future.But your argument is wrong for two reasons:
    1) The health care disparities are only growing. Fewer employers are offering it, especially small employers who offer less than stellar wages, while wages are not getting any better. Furthermore, those young people you are talking about are people too. Just because they are new to the workforce does not mean they should have to go through some iniation by fire, via not accessing healthcare. Just because you suffered doesn’t mean others should have to, as well. As well, in hard economic times, studies have shown younger people are more likely to stick with the jobs they first enter the market, so your talking about keeping these young people uninsured for longer periods.
    2) Disparities in starting position may be a good motivator, but disparities in opportunities surely are not, and may have the opposite effect. Someone at the bottom of the totem pole clearly wants to fight there way to the top because they see it off in the distance, but if the guy at the top is greasing the pole to make it harder to get up there, would it not be natural to just give up after awhile.
    I’m a bit confused on how you support the competitiveness argument for universal care, but also make this energy argument? I guess you draw your distinction in that resources used on healthcare are resources lost in other places. But you yourself admit that the health care system is inefficient. It is not about reallocation of the pool of societies resources, but instead incentivizing the current pool of health resources to be used better.
    As for the morals question, I think calling it a question of competitiveness or our economic superiority just leads us back to the same rhetoric that started this health care debacle. America’s health care system should not be like Europes, or the rest of the worlds, because we are exceptional. The exceptionalism inherent in competitiveness talk gets shifted to all facets of social question. It is also the same sort of rhetoric that shifts the burden of health care reform from the societal to the individual level. As in the blaming the lower-income for not working harder etc. that I talked about earlier.
    As for the political rhetoric of health care, obviously it’s inflated, these people are politicians in an economically uncertain time. I don’t think ascribing white guilt to voting trends helps re-educate the conversation much. But I digress, I would be happy for a debate on the nuts and bolts of current reform, divorced from grandiose name-calling, because from what I’ve seen you’ve yet to make an argument against it.

  14. Let’s look at your arguments then, Nate.
    “A low income person who doesn’t pay their medical bills on average doesn’t suffer any adverse consequence they aren’t already suffering. Medical bills aren’t their only derogatory credit hits. The left wants to paint it as a catastrophe when it is nothing more then an after thought. ”
    Why do you assume that poor people are financially irresponsible? Don’t you think that they can live within a budget just to be derailed by an unexpected illness? Are you saying that all poor people are debtors?
    “I don’t see smoking or alcohol mentioned once. You expect us to believe they are forgoing education and childcare but fail to mention they still afford their vices. Obviously the problem is priorities not medical cost.”
    Are you saying that poor people are drunks and otherwise irresponsible?
    “If these people spent one day actually working with the poor and seeing their health needs they would know they would best be served by a dirt cheap catastrophic policy ”
    Is that somehow true for poor people more than other people? Are they biologically more sturdy or more expendable?
    “These people live pay check to pay check they aren’t worried about wigs if they get cancer, or in vitro fertilization, they can’t afford to miss work to start with. ”
    So poor people don’t care about how they look? Being poor implies being ugly, or just indifference to being ugly?
    BTW, what happened to all of them being a bunch of loitering bums? Are you saying now that they do work hard?
    See how your attitude colors what you say?

  15. I’m not sure whether I should be happy or sad about the new health care reform. The first thing my parents aksed me was ” What’s gonna happen to my medicare?” I think a lot of people including me are really confuse about the new health care reform. I’m happy for the ininsured and glad the government is stepping in to help. However, who gonna pay for this??
    The middle income people are always the one that get stuck. Our government is already in debt, this bill for sure will put us in further debt. Is is always easier said that done. We can try to be like Camada and provide health care for everyone, however do we have enough financial support for this. I guess I would have to wait to see what’s going to happen?
    One positive thing I know for sure about the new reform is that, this will provide a job gurantee for us nurses and advance practice nurses. There are going to be a lot more jobs available. HOwever, there will definetely be a discrepency between health care demand and health care supply. There are just too many peole for such few medical providers.

  16. Peter –
    My ideas on healthcare are scattered throughout my blog. Just click on my name below. It’s not as widely read as this blog – that’s why I visited this one – but there are no PC scolds there, either.

  17. “Your statement that “we can feel good about electing a Black man” is very much in line with nineteen century attitudes.”
    Exactly what century is “I get a tingle up my leg”?
    What was Reid’s remark, Well Spoken for a negro?
    I could argue all day your party and ideology are stuck in the 19th century. I can’t imagine how looking back at the last 100 years you think liberalism and socialism will do anything but destroy lives and nations. Just looking back to SS and Medicare I would think you would learn the errors of your way yet like you say, those darn 19th century attitudes and ways of thinking just keep comming back.
    “But we cannot debate whether homeless people, or poor people, or any other demographic group, are indeed people like you and me, because they are by definition. This is the basic axiom of democracy and any ambiguity here will propel us into a very ugly situation.”
    No one but you ever implied any different. Instead of responding to the substance you built a straw man and moved the argument to one defining what a person is. Now that we all know what a person is my points still stand. And stand unaddressed.

  18. “Happy to have hit a nerve. It would be nice if people would offer ideas, though, instead of splenetics.”
    “But where are his ideas?”
    My idea(s) is universal single-pay government controlled healthcare,always has been for over a year on this blog. Your ideas are, above the general term “universal”?
    “Peter seems not to like what I said.”
    No, I’m trying to have you justify how you got to what you said, the like or dislike has nothing to do with it.
    “Where are his counter-arguments. All we get are snotty rhetorical questions.”
    Why do you assume they’re rhetorical? Or was that rhetorical, now you got me going crazy? Your posting style seemed to want to provoke thought, did mine not do that?
    “(See “I wonder what part of “I support universal health care” Peter failed to grasp,” above.)”
    Is “see” a stupid paraphrase? Now is that rhetorical?
    “WE don’t do the limiting. The market does the limiting. But I don’t worship the market.”
    Maybe so, but when you need healthcare is doesn’t matter how it’s being limited or if you worship it, because you need it anyway and there are few options.

  19. I didn’t think I had to explain, to an American, the connotation of “peculiar” in this context, as in “Our peculiar institution”. Your statement that “we can feel good about electing a Black man” is very much in line with nineteen century attitudes.
    As to crappy schools, there are plenty of poor people attending good schools and the system is not built on the presumption that those who “go nowhere” are not entitled to quality education for their children who should be entitled to the opportunity to go somewhere or nowhere.
    I guess Mother Theresa was “going nowhere” according to your definition of going places.

  20. Happy to have hit a nerve. It would be nice if people would offer ideas, though, instead of splenetics. Peter seems not to like what I said. But where are his ideas? Where are his counter-arguments. All we get are snotty rhetorical questions.
    I wonder what part of “I support universal health care” Peter failed to grasp. Maybe he didn’t read that far, reading only to find affront to his liberal sensibilities. I may be a strange bedfellow, but I’m on his side. Go figure.
    There’s no “suck it up” in my post. Not a hint of it. I’m just demanding that those who support removing obstacle X explain why it’s different, more important, easier, etc., than obstacle Y. If you want to make the case to remove all the ills of poverty, go for it. Just explain why you chose this one.
    I don’t get the question about education at all. I think access to healthcare and access to GOOD education are similar. Poor people can go to the emergency room and they can attend crappy schools. They would have better life chances if they could go to doctors and attend good schools. So?
    Does anyone really think that “So, [stupid paraphrase]?” is a useul form of debate? I don’t. Peter’s attempted paraphrases of my positions are substantively wrong, so I don’t see any point in responding to them. Suffice it to say that something does not have to be necessarily true to be frequently true.
    I don’t know whether healthcare “removes ambition.” Where I come from, some people react differently from others. For some, it surely would. For others, it surely wouldn’t. Duh.
    Peter asks what else we should limit to create a prosperous economy. I haven’t advocated limiting anything. (See “I wonder what part of “I support universal health care” Peter failed to grasp,” above.) WE don’t do the limiting. The market does the limiting. But I don’t worship the market. (See “I wonder what part of “I support universal health care” Peter failed to grasp,” above.)
    I’m fine with Margalit’s list of bad slogans. I tried to pick one from each side. There were plenty of lies to go around.
    Why would I need to explain “going nowhere” to an English-speaker. Some people are upwardly mobile, and some aren’t. This is news?
    And of course you can add that you find my view of the last Presidential election “peculiar.” It won’t actually tell us what you think, but feel free to jerk your knee meaninglessly if that makes you feel better.

  21. Lawrence, if you wish to discuss moving votes, than I believe “death panels”, “government take over” and Socialist/Marxist slogans, do a much better job at that.
    Yes, health care costs money and yes, there is a limited amount. But, so does “educating our young” and providing legal due process, and fire protection, and law enforcement. Are you suggesting that the adults “who are going nowhere” or “the kids on their way up” should also receive less of those resources?
    And what exactly is your definition of “going nowhere”?
    May I also add that your view of why President Obama was elected is a bit peculiar….

  22. “But are those difficulties different in kind from those posed by absent fathers, drug-and-gang-infested neighborhoods, and any of the other trappings of socioeconomic hardhip?”
    So, it comes with the neighborhood, suck it up?
    “I asked how it was different from other real advantages that the haves have and the have-nots have not.”
    Is it different from access to education?
    “The poor pay of starter jobs is as much a goad to ambition as it is an act of oppression.”
    So, providing healthcare removes ambition? When did you assume these were starter jobs?
    “but you need to show, I think, that we can limit economic disparity to luxury goods only and still have a competitive and inventive economy.”
    What else should we limit to create this competitive and inventive economy? Do the children of the well off succeed more because they have hardships placed before them or doors opened for them?

  23. Lisa, a test, if done timely enough may just prevent those larger (preventable) surgeries which you say was never needed – but only if they took steps to prevent it far enough in advance. No arguement from me about, “unnecessary medical procedures and treatments being performed just for the sake of generating revenue”, but that would have to be argued with the surgeon. We pay too much for stuff, that’s where our costs are.

  24. Ryan –
    I think you are right about the difficulties that inadequate healthcare poses for those who suffer it. But are those difficulties different in kind from those posed by absent fathers, drug-and-gang-infested neighborhoods, and any of the other trappings of socioeconomic hardhip? Recall, I didn’t ask how healthcare was different from flatscreen TVs; I asked how it was different from other real advantages that the haves have and the have-nots have not.
    I think you are overstating the Marxist case that denial of healthcare is how one class keeps another down. My first job had no healthcare. My second had healthcare. The poor pay of starter jobs is as much a goad to ambition as it is an act of oppression. Why look through only the oppressive end of the telescope? Jobs that don’t pay well are held by kids on the way up and by adults who are going nowhere. The jobs were not created to serve or oppress either of those consituencies.
    I don’t take a holier-than-thou moral stance on this. Life’s not fair, and we ought to do what we can to make it as fair as possible. But the battery needs poles, or there won’t be any energy produced. We have all the stuff we have, including the healthcare we misallocate, because people can get rich making it available. Do drugs cost too much? Sure. But would they exist if they didn’t? Disparities motivate. How much motivation, and, therefore, how much disparity is optimal is a fair question to debate. But to assume that elimination of a disparity, even with regard to something important like food, shelter or healthcare, is a good thing without a calculation of the externalities is wishful thinking masquerading as policy analysis.
    I support universal healthcare, but I do so unsentimentally. I think it makes us a more secure and competitive nation. The moral dimension is not irrelevant to that position. National self-esteem is a big deal, and at some point, we become embarrassed as a nation by some of the inequalities we permit. I suspect that the election of BHO was about national self-esteem. He was full of crap on most substantive issues, but we weren’t thrilled with what the other party had brought us, we saw nothing (politically) attractive in what they were offering, and BHO gave us a shot at expiating centuries of racial guilt. At least we can feel good about electing a Black man, even if he lies about mandatory coverage being the price of eliminating pre-existing conditions clauses. (Do you believe he was too dumb to understand the issue, considering it was a key difference between him and an opponent who had spent two years working on it as First Lady?)
    But the moral element plays – can play – only a supporting role. Changes have to be practical, taking into account such things as the economic incentives that exist in an increasingly socialized system. You ask “Why do people who hold jobs get denied coverage just because their pay scale is different?” The answer is obvious: the medical coverage is the payscale. You want it to be only about flatscreens, but you need to show, I think, that we can limit economic disparity to luxury goods only and still have a competitive and inventive economy.
    Healthcare is a hard problem. There is no end to what we could spend – i.e., what resources we could divert – to caring for each others’ ailments. But a man-hour spent on healthcare is a man-hour not spent on something else, and there’s a lot else to be done. (It sometimes helps to strip money from the conversation; the issue is not how much money we spend but how much brain and muscle we take from defending our shores or shoring up our infrastructure or educating our young or inventing green electricity or, or …)
    All I’m asking is that someone on either side of the debate admit that the issue is complex, and that there really are sound arguments to be made on both sides, even if they are not being made by either side on account of they’re too complicated and don’t move votes the way “f*** the insurance companies!” or “Get a damn college degree!” does.

  25. Nate, there is a big difference between operational decisions and the underlying belief system.
    We can debate the appropriateness of providing housing or food to the homeless, and maybe you are right and maybe I am right and more likely the right approach is somewhere in the middle.
    But we cannot debate whether homeless people, or poor people, or any other demographic group, are indeed people like you and me, because they are by definition. This is the basic axiom of democracy and any ambiguity here will propel us into a very ugly situation.

  26. Peter, first of all a test is not going to prevent heart bypass surgery, if needed. A test isn’t treatment.
    The reason we spend so much more and healthcare care costs us so much, is because there’s a whole lot of people having “$100k heart bypass surgery” who never needed it to begin with. There’s a lot of unnecessary medical procedures and treatments being performed just for the sake of generating revenue. Patients are not involved in the decision making process, we believe whatever we’re told/instructed instead of being informed and involved. We don’t really have standards of care or good data regarding outcomes. If basic care is “free” to the individual, this vicious money-driven-medicine cycle will never end, it will only escalate. More patients=more treatment, it doesn’t mean healthier population or better outcomes.

  27. “In my mind we need less comprehensive plans coupled with a new way to do business on the routine services.
    Does that need to happen now? I’m not smart enough to know that but we cannot continue to expect nearly every healthcare expense to be pushed through insurance and realize any meaningful cost savings. I can site example after example where I would be talking to a billing clerk at a clinic and they will say that a visit/procedure only costs $20. I have to remind them that is just the co-pay and that the other $140 is part of the cost. There usually is just silence on the other end of the phone.”
    Catmandu, you just answered your own question, why does the “routine service” cost $160? Why can other countries cover routine services and still pay about half what we do for healthcare? Do you think the $160 is an impediment to getting the test, and if we cover that cholesterol test then maybe the patient won’t need the $100,000 heart bypass?

  28. “so you didn’t end up with a job such as a ditch digger (no offense to ditch diggers-The world needs ditch diggers too, Danny).”
    Yes and the world needs restaurant servers, retail clerks, ag workers, building cleaners and a whole army of low skilled, low paid workers. Even if our community colleges and universities could handle everyone not wanting a low paid/low benefit job were would you find the workers to fill those jobs – maybe Mexico? The first one to complain that those low paid jobs had to pay more to attract higher educated workers with benefits added which would increase the cost of the goods and services you buy – WOUlD BE YOU! And who would scream the loudest when all those suddenly better educated people made you compete for your job. This is about healhcare, not Cadillacs or 5K sq foot homes we are providing. As with access affordable education, access to affordable healthcare evens the playing field to allow people to succeed in life and not make them tax supported.

  29. Hmmmm. There is one phrase from your piece that I cannot seem to get out of my mind:
    “…while almost half of all people purchasing insurance in the dysfunctional individual market say they have had to switch to a less comprehensive plan”
    While you only point to the individual market, I think one of the major downfalls of our current system is that it *is* so comprehensive that we file a claim to get routine things like a cholesterol test. What risk is there in getting that test that requires insurance?
    In my mind we need less comprehensive plans coupled with a new way to do business on the routine services.
    Does that need to happen now? I’m not smart enough to know that but we cannot continue to expect nearly every healthcare expense to be pushed through insurance and realize any meaningful cost savings. I can site example after example where I would be talking to a billing clerk at a clinic and they will say that a visit/procedure only costs $20. I have to remind them that is just the co-pay and that the other $140 is part of the cost. There usually is just silence on the other end of the phone.

  30. I fall somewhere between Nate and Margalit on the social issues, although Nate has to remember that alcohol and nicotine use are addictions and therefore disease themselves. (Remember Mike Deaver and the bottle of Jack Daniels in his desk at the White House?)
    However, a point not yet made is that health care just plain costs too *#%**%$#!! much. As a physician with a high deductible plan, I know that getting charged $50.00 for a stool guaiac (blood) test is just flat extortion, and imaging costs are also high markups. Inefficient and low quality hospitals charge the same or more than efficient ones – and get it, if their market share is high enough. Let’s work on the cost side of health care and then maybe a basic insurance package will go further for everyone – then the rich can pay out of pocket for their “extra” care.

  31. Example for you Margalit,
    I see 100 homeless people getting buy and 1-2 might freeze to death. Sad but it happens, help were we can.
    You hear this, are appaled, get on your soap box and declare we are better people then that. You round up all the homeless, move them into projects were 10 of them die and create a culture of welfare slavery afflicting generations.
    To top it off you name the project after yourself and declare your moral superority at every opportunity. Besides your self esteem you haven’t helped anyone. The same 2 people died that would have died anyways and on top of that you killed 8 more. On top of that top you always burdened society with a cost to maintain this death camp that reduces its ability to help those that really need it.
    Moa, Pol Pot, Stalin, they all thought like you. You Chaves, Penn, and Glover could have a great dinner party praising all the success he has had down there, is that your goal for America?

  32. Margalit, denial of these generalizations has lead to far more suffering and death then accepting they are true.
    Our education system has been destroyed trying to make sure those kids that dont care about their education had the same outcomes as the kids that did care.
    Our welfare system has been bloated by those people that don’t make an effort to improve their sitution, draining resources from the hard working people who with a little help could work their way out of it.
    Our healthcare system suffers under the cost of those people who don’t care about their health or all the money from others they waste because of that attitude and thus making insurance and healthcare unaffordable for the people that do pratice healthy living and smart consumption.
    If you want to study history Margailt look into the sustainable success of Communism and Socialism and how they always collapse. My ideology allows a small number of individuals to fail and die, your ideology murders entire civilizations.

  33. Thank you to those who voted in favor of health care reform! It is about time someone decided the health of Americans is a top priority and recognized that the insurance industry is taking advantage of us.
    I am a nurse. I have a special perspective because I have first hand knowledge of our current health care system, but do not benefit financially by taking advantage of people needing services. I see people struggle with affording health care all of the time. Those who haven’t had significant health problems, yet, do not understand the financial devastation that they can cause.
    Low income people, including seniors and those here illegally, are covered by our government system. Wealthy people are covered by private insurance they can afford.
    It’s about time the government stepped in to protect those in the middle class. Those who don’t get free care and struggle with insurance premiums and copays. Those who pay a disproportionately high amount of taxes because they do not have enough income to shelter their money from taxes as the wealthy can. Those who work for the wealthy and help them to amass their wealth. And, those who’s taxes support the health care needs of the poor.
    Health care should not be reserved for the rich or the poor. No one should live in fear that an illness could cause permanent financial ruin. We aren’t talking about cosmetic surgery. We are talking about cancer care! And, let me tell you… Cancer can happen to any one of us. According to SEER Cancer Facts, it will happen to 40.58% of us. The treatment is EXPENSIVE. And under our current system, insurance companies can refuse to pay for it, even wealthy people’s insurance companies. And, they often do because the lawsuit that might ensue is cheaper than the care, so they have nothing to loose.
    Wealthy people, get in line with the rest of us. You don’t deserve care more than the rest of us because you earn more money. And, make no mistake, you are at risk under our current system too. Poor people, you don’t deserve special privilege to health care just because you are needy. All of our health is important to this country. Those who don’t see that are short sighted.
    Thankfully, we don’t live in a society that values the “every man for himself” attitude, that would be India or Peru where the wealthy turn a blind eye to the masses of poor people living in the streets.
    We live in a country where people value human life and believe that we should provide certain basic things, like education to our children and health care to our seniors. We believe that it is the government’s responsibility to protect us from people and industries that would take advantage of us or harm us as evidenced by the FDA and the BBB. And, we believe in pooling our resources for the protection and advantage of all citizens. That’s why we pay taxes.
    The wealthy 3% of the population can afford to lobby against health care for all and, with advertising, can appear to be the majority. Don’t be fooled by the propaganda.
    Special interest groups, such as seniors, may lobby against inclusion of all in lieu of special treatment for themselves because they are afraid of loosing what they enjoy, government sponsored health care. And seniors didn’t pay for their own health care, they are using way more money than they contributed to the system.
    These groups may use scare tactics, such as the idea of rationing care, but don’t buy into them. The fact is that we already ration care. Did anyone ever believe that there were infinite resources? The rationing is just done inequitably and without guidelines by doctors, insurance companies, and healthcare facility administrators to their advantage. At least, with government intervention, guidelines may be created so that the rationing may be done based on who can be helped best by the care instead of based on who knows who or how much money you have or what your insurance company is willing to pay for.
    Some will say that the government can’t run anything well, but I don’t know anyone who prefers private insurance coverage over Medicare. To the contrary, I know many seniors who were relieved when they finally became eligible for Medicare and didn’t have to “deal with” the insurance company anymore. And, I don’t hear politicians complaining about the inadequacy of their government sponsored health care plan.
    And, don’t buy into the idea that wealthy people’s money is more important than anyone else’s so they deserve all of the tax breaks they get and shouldn’t have to pay the same proportion of their gross income in taxes as the middle class do. We all deserve to enjoy the money we have earned. And, we all have a responsibility to pay our share of taxes. The wealthy do not deserve to keep a higher proportion of their income to themselves just because they are wealthy.
    And let’s not pretend that our current health care system doesn’t have room for improvement. The fact is that The CIA World Factbook ranked the United States below 40 other countries for infant mortality rates and 45 other countries for total life expectancy. Among OECD nations for which data are available, the United States ranked third last for the health care of women and fifth last for men.
    In the end, the wealthy will still be able to pay out of pocket for special care and extra services. But, government intervention is a step in the right direction toward better health care for all. Ultimately, the wealthy (3% of the population) have nothing to loose except for some money on taxes (that may be recouped if health care costs are controlled by regulations) and the poor (35% of the population) have nothing to loose because they already receive government sponsored health care. While the middle class (62% of the population) have everything to gain by finally being recognized. And, their health and stability will benefit the entire country.
    Are we really willing to sacrifice health care for the middle class to protect the rights of the wealthiest citizens and the benefits to the poorest?
    Our Representatives are concerned about special interests. Good! Let them ignore the requests of special interests when laying out the health care plan. They are concerned with increases in taxes. Good! Let them figure out a ways to increase the efficiency of government programs and find creative ways to fund a health care plan. They are concerned about citizen’s rights. Good! Let them create a plan that will enhance health care while still respecting our rights. But, don’t let them give up on protecting the health of our people.
    We can merge the best of our current system with the best of other countries systems, maintain choice via public and private health care options, close the gap in coverage, protect citizens from unscrupulous business practices, and do all of this in a fiscally reasonable way.
    Expect more from your representatives. Expect them to deliver what is difficult, but possible.

  34. Lawrence–
    Mr. Gearney’s analysis about those who work in low-income jobs being the primary ones without insurance seems to hint that this is not just a money issue, its also that social stratum individuals are in. Though yes they do make less money, so I am conflating how much one makes with class, it seems the article goes a bit further than that. The slow chipping away at those at the lowest end of society, as Mr Gearney says a large percentage of those at the lowest income levels have no insurance, forces those individuals to take only bare bones coverage, trade offs with other life necessities such as education, as well as, take on stress associated with making medical payments. This is emblematic of creating a tenuous life necessary to deny opportunities to groups. One of the best ways to make a group stay subjugated is to create a constant threat to subsistence.
    This inherent trade-off required by health care expenses is exactly what makes it distinct from other “luxury” goods. I can choose to not get that flat screen, because I feel ok about my lame five year old tv, it still does what it is supposed to do and I get pleasure from it. But I can’t just get up and make a choice not to cover my medical expenses. Opportunities will inherently become limited in a world where I decide to suck up my chronic condition. My work performance will probably decline, not including just my sheer work hours missed from ailments, as well as, the inconvenience of being sick itself on other aspects necessary for the functioning of my life.
    I just feel that what Mr. Gearney is attempting to elucidate is how the health care cost issue reflects the ignoring of the opportunities lost by those who don’t have adequate coverage. To call it solely a money issue, and not look at the entire system, creates some easy scapegoats. If only those people had saved a bit more, if only they had been more financially aware, if only they had found a better job? Yet why do Medicaid patients, who have coverage, get turned away? Why do people who hold jobs get denied coverage just because their pay scale is different? And Who is to make the judgement that these individuals economic choices are less productive than some CEOs, or high paying people on wasteful, high-coverage plans offered by their employer? At some level, the question of opportunity, money, and class are all interlinked to create the current health care market we live in. A broken one.

  35. Nate, you are making some very unfortunate generalizations. Generalizations that led to nothing but horror and destruction throughout thousands of years of recorded history, and obviously there’s more to come…

  36. sorry Margalit but life is full of these people. There are billions of people that are not my equal. Some are inferior through no fault of their own, born with a lower IQ, but most are inferior by choice. While I studied others partied, while I work others go out drinking. To say those people are entitled to everything I earn is BS.
    To deny those people exist is to deny reality

  37. Thomas–
    Thanks very much for this post.
    This country has been redistributing income and services upward for 30 years. Now, this health care bill has begun to redistribute downward.
    Conservatives (who understand our $$$MONEY culture better than many liberals) recognize this. And this is why they are freaking out They understand that this is a powerful bill that will hit the industrial-medical complex that has been profiting from runaway health-hcare inflation (I’ve written about this on http://www.healthbeatblog.org_

  38. The trouble with this sort of analysis is that it assumes all disparities between haves and have-nots are bad, so any reduction is good. Certainly, some such disparities are bad, and some reductions are good. But you have to make the case for any given equalizer, and Mr. Greaney begs that question entirely.
    Our economic system allocates wealth on the basis of economic contribution. It doesn’t always get it right, but successful entrepreneurs and professionals earn more than the people who work for them, so the former get to have more stuff. Now, just what are the things they get to have more of, and why isn’t healthcare one of them? People work hard to live in safe neighborhoods with good schools. How is that different from having access to the best docs?
    These questions are not rhetorical. It may well be that in a decent society healthcare should be beyond allocation by price. I’d just like to hear how it differs from the other things wealth buys that make life less daunting for people of means. Is economic disparity really just about luxuries?
    I think Mr. Greaney can sense the weakness of his argument. He writes about whether “social class should dictate vast differences in opportunity for our citizens.” But social class is a matter of birth, not money. Earning enough money to have healthcare is not membership in a “social class,” as anyone in the upper class will be happy to tell you. And what “vast difference” in opportunity does the healthcare disparity represent? Sure, kids with access to care have a statistical edge over those without. But “vast difference in opportunity” seems a bit over the top.
    Mr. Greaney’s piece is about money, not class. The obviously relevant version of his premise goes like this:
    I doubt that most Americans accept the idea that people with more money should get better health care than people with less.
    That seems pretty straightforward, and it also seems to be Mr. Greaney’s thesis. And yet he talks of social class and vast disparities in opportunity. I understand that if you’re going to doubt out loud, it’s a good idea to doubt something that’s genuinely doubtful. But shouldn’t the thing you doubt be just a little bit relevant to your position?

  39. Nate,
    “These people” are people just like you. Don’t ever forget that. There is no such thing as “these people”. Never, ever, under no circumstances. Period.
    Now try writing your post again…..

  40. “It is widely recognized that health care debt ranks at or near the top causes of personal bankruptcies.”
    widely propagandized and equally well disproven. Someone who was making 100K a year with 5K in medical debt was not driven to BK by the debt. A more accurate gauge would be how much of total debt is medical.
    “More than 4 in 10 people earning under $40,000 per year say their household has had problems paying medical bills over the past year.”
    What happens from unpaid medical bills, they don’t throw you on the street or take your transportation away and they surly don’t take back the treatment you receive. In fact they don’t even prevent you from receiving more care. A low income person who doesn’t pay their medical bills on average doesn’t suffer any adverse consequence they aren’t already suffering. Medical bills aren’t their only derogatory credit hits. The left wants to paint it as a catastrophe when it is nothing more then an after thought.
    “Not only does that statistic imply that many households are adjusting their budgets away from socially-important expenditures, like childcare and education”
    Like all propaganda this study and post ignores the obvious in its all out effort to sell an opinion. I don’t see smoking or alcohol mentioned once. You expect us to believe they are forgoing education and childcare but fail to mention they still afford their vices. Obviously the problem is priorities not medical cost. Your average low income household supposedly forced to declare BK because of our cold hearted system leaving them with 1K in medical debt spends more then that annually smoking and drinking. Why do you never ask those questions? How much do you spend a year on cigarettes? How much do you spend a year on Alcohol? The answers would kill your entire narrative.
    “Havinghurst and Richman aptly summarize the “distributive injustice” of the system:”
    Classic logic of someone that doesn’t know anything about healthcare or insurance. Your solution is to mandate the purchase of plans the poor can’t afford, we have seen that played out in CA, MA, NJ and just about every other state liberals run. Yes you require great comprehensive insurance but it cost so much they can’t afford to buy it. If these people spent one day actually working with the poor and seeing their health needs they would know they would best be served by a dirt cheap catastrophic policy that gave them access to the system at the discounted prices everyone else enjoys. These people live pay check to pay check they aren’t worried about wigs if they get cancer, or in vitro fertilization, they can’t afford to miss work to start with.
    “who generally lack the bargaining power to command lower prices–pay higher prices to hospitals (often as much as two or three times higher) than those with group insurance.”
    BS, Anthem individual members get the same discount Anthem group does. Nothing true about that statement. Your also confusing what is billed to what is paid. A hospital might bill an uninsured person $100,000 but will often settle for $10,000. Again great propaganda but no fact to it at all.

  41. Tom,
    Thoughtful post, thank you.
    I wonder what you think of the legislation from an antitrust perspective. No interstate competition, no anti-trust exemption reversals. There is a clear over-concentration in many markets. Are you disappointed in that? Greater competition among the stakeholders would help to level the field across classes, right? What now?

  42. “One unassailable fact…It is widely recognized”
    It’s almost cliche that things that are unassailable and widely recognized are in fact assailable and not true.
    “More than 4 in 10 people earning under $40,000 per year say their household has had problems paying medical bills over the past year.”
    Shocking! You are not trying to say that people that earn less money have more financial challenges than those that earm more? First, smoking is bad for you and now this. Please don’t post anything about Santa Claus. If less than $1,000 of out of pocket expenses in one year (2 out of your 4) forces you into bancruptcy, you were headed there anyway.
    “In factover 15% of employed workers…lack health insurance.”
    Actually, fact is the percentage of people that want health insurance but cannot get it is less than 5%.
    “and obviously benefits the higher brackets more than the lower ones.”
    Because most of the people in the lower ones don’t pay any income tax. Crazy how that works.
    “the uninsured and those in the individual market –who generally lack the bargaining power to command lower prices–pay higher prices to hospitals (often as much as two or three times higher) than those with group insurance.”
    Most individual medical insurance products use the same networks with the same negotiated discounts as the group market.
    It is not the fact that they are uninsured, but the fact that these people are not enrolled in a network of discounts (which they could for about $10/month regardless of health status) that subject them to the suggested retail price with all the shipping and handling, under coating, and extra delivery charges.
    “I doubt that most Americans accept the idea that social class should dictate vast differences in opportunity for our citizens. The capacity of health reform to lessen the economic and physical burdens imposed on the working class then should be headline news.”
    Based on the fact that you wheeled out your 91 year old uncle as a prop, I will guess your mother is not with us any longer. Yeah, I’m bring your mother into this.
    It’s ashame I can’t call her and ask her if when you were growing up she may have suggested that you stay out of trouble, and apply yourself, get as much education as possible,so you could get a good job, where you made good money, perhaps like a doctor or lawyer, so you didn’t end up with a job such as a ditch digger (no offense to ditch diggers-The world needs ditch diggers too, Danny). God forgive her if she was such a cold hearted, elitest, pushing you in the direction of the upper class where you might achieve un-equal access to care. Thanks for listening. LD

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