Book of the Month

John Roberts goes rogue?

by PeraclesPlease 6/28/2012 - 8:16 pm

Roberts delivered a delight today.

Not only did he pull out a justification for the mandate, he did it in a way that still slams the overreach of the Commerce Clause, provides insight that it's fungible as a tax, and aligns with liberals for the first time in.... never.

It's tickling in one sense to see him acting as a real conservative - the mandate *was* an overreach for Commerce - by breathing, the government can make you buy *anything*?

Second, the mandate's a freeloader tax in essence - if you haven't paid, you need to. Certainly there's an issue with Norquist fans, that it's much better politically to label something a contribution to the devil than a tax - we know which one has more Likes on Facebook. And it may not be ideal for Democrats to crow about - "greatest regressive tax yet, Millions of poor people insuranced-up despite their druthers" 

Third, is Roberts about to become a Sandra O'Connor? Teaming up with liberals to create a coalition? But he won't be interested in the state of  peers on the way.

Is Roberts ready to shift focus on rulings in general? Would alter the compromise & conditions drastically. We'll stick to justice and opine, but intriguing if Roberts is offering the Fifth Man, ability to talk with Democratic actors, find useful interplay, rein in overreach as much as retaining country club rights for all.

We'll see - could spare us a lot of fretting unnecessarily re: SCOTUS polarization. Has John Roberts simply had enough?

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PP:

This decision is an iron fist in a velvet glove,  Justice Ginsburg's concurring opinion is a must-read.  She highlights the implications of the Chief Justice's tortured obliteration of the scope of the Commerce Clause.  As Ginsburg notes, the Chief Justice ignores 75 years of precedent in which the courts have deferred to Congress on: (1) what does and does not have a substantial effect on interstate Commerce; and (2) what constitutes appropriate national social and economic policy arising out of interstate commerce.   Ginsburg calls Roberts' decision "retrogressive" and she is absolutely correct.  I am not celebrating today.

by bslev 6/28/2012 - 9:38 pm

 Was any precedent established? It would seem that the the court decided by five to four that the mandate was unconstitutional, but does that have any affect going forward when the policy in question, the one that is, apparently, unconstitutional, is allowed to stand based on other rationalization? 

 Roberts was the only one out of nine who decided based on the legal reasoning which he used. Does his legal argument stand as any sort of precedent?

by A Guy Called LULU 6/28/2012 - 9:57 pm (re: bslev)

The short and I believe correct answer is that the Chief Justice has opened the door to extraordinarily dangerous precedent.  Five justices, including Roberts, rejected the power of Congress under the commerce clause, and did so by disregarding an undisputed record demonstrating that the individual mandate is at least rationally related to the goal of providing affordable healthcare for all Americans.  And, to paraphrase Forrest Gump, precedent is as precedent does.  This decision will live with us for decades to come, and not in a good way. 

I cannot overstate the importance of reading Justice Ginsburg's concurring opinion.  For the life of me I cannot understand the lack of emphasis being placed on the Court's rejection of the Commerce Clause argument.

 

by bslev 6/29/2012 - 9:29 am (re: A Guy Called LULU)

How can the Interstate Commerce Clause target those people not engaged in a particular Commerce area (neither intra- or inter-state) and force them to participate in that Commerce?

It's like using NASA to handle subways, forcing them up to the surface and into the air.

by PeraclesPlease 6/29/2012 - 10:49 am (re: bslev)

The point was and is, they ARE engaged in this particular commerce ALREADY.

We cover them already. They have the insurance. They will use the services. They are ALREADY adding to the cost of everyone's insurance, not to mention to the cost of the underlying medical services.

This is emphatically NOT like the government forcing everyone to do something NEW--say, buy a smartphone--or eat broccoli--because the pencil heads think it's a good idea or in their best interests.

The government is simply recognizing that everyone ALREADY IS doing this something, but in a very bad, inefficient, unproductive way and trying to rationalize it a bit so that it's fairer, more effective, and less costly.

by Peter Schwartz 6/29/2012 - 10:57 am (re: PeraclesPlease)

No, these are people who don't have insurance. And I've gone 30 years without seeing a doctor except to get a broken bone looked at (but not set) where I paid out of pocket, to get a vaccination, and to get a form signed. I don't add to everyone else's insurance, though you might make the case that as I get older, the chance of that changing increases. But if I get hit directly by a bus? Society's had a freebie.

 

by PeraclesPlease 6/29/2012 - 12:51 pm (re: Peter Schwartz)

The actualities aren't the whole story.

When you buy insurance, you pay for it even though you may never make a claim.

So what are you paying for?

Aside from all the "peace of mind" stuff that's marketed, you're paying for the ability or capability or right (however you want to put it) to make a claim.

In this case, we are paying for the existing requirement that anyone must be treated when and if he walks into a hospital, regardless of insurance status.

by Peter Schwartz 6/29/2012 - 1:07 pm (re: PeraclesPlease)

You've been incredibly lucky, but not everyone is. And, if you discover you have a disease, be it life threatening or not, at least now you can get coverage whereas before ACA, you could not. And what about children? People had been making the determination to IGNORE what might happen with their own children had they developed a condition that would prevent them from EVER being able to get insurance.

 

by stillidealistic 7/1/2012 - 6:16 pm (re: PeraclesPlease)

Good question, and a fair one too.   It's not that the Chief Justice's argument is irrational.  In fact his argument is eminently rational, and for the precise reason you suggest.  But what has happened is that the presumption of rationality has for 75 years been afforded to Congress, i.e. Congress' power under the Commerce Clause is recognized to the extent that legislation is rational.  Thus, for example, in 1942, in Wickard v. Filburn (sp?), the Court held that a guy who grew wheat only for his own consumption and didn't sell it in interstate commerce could still be subjected to restrictions on the amount of wheat he could grow.  Here, how does the Court find that it is irrational that: (a) everyone uses healthcare eventually, and (b) the decision not to buy insurance results in an increase in insurance costs for all Americans by approximately 1,000 dollars per year (forgot offhand if that's households or per capita)?  

I'm on vacation away from the office but I just had a telephone chat with one of my much younger and much smarter associates.  I asked him when the last time it was that the Court rejected commerce clause arguments as a basis for federal legislation.  He gave me two examples from the late 90s, early 2000s: (1) a federal law banning handguns within 100 yards of a school; and (2) a federal law responding to domestic violence.  But, so as far as I can tell, these are not the precedents upon which the Chief Justice relied.  Rather, he comes up with a new doctrine, unsupported by stare decisis (respecting precedent (a conservative doctrine if there every was one)), but as you suggest an absolutely rational and reasonable one, namely that regulating Commerce doesn't permit Congress to regulate inactivity.  It's a good argument, I agree, but it's a new doctrine, and the way things work is that it opens the door to all kinds of challenges to the power of Congress to make policy per the Commerce Clause.    

 

 

by bslev 6/29/2012 - 11:06 am (re: PeraclesPlease)

regulating Commerce doesn't permit Congress to regulate inactivity.

Except that it isn't "inactivity."

by Peter Schwartz 6/29/2012 - 11:13 am (re: bslev)

No, I agree with that.  My point is that I think the Chief Justice's argument is a rational one.  It just seems to me that so too is Congress' finding, and stare decisis (a conservative doctrine) should have led the Chief Justice to give greater deference to the decisions of the elected officials in Congress on what is rational and reasonably related to interstate healthcare issues.

by bslev 6/29/2012 - 11:18 am (re: Peter Schwartz)

Right. And perceptive, or opportunistic conservatives, are already pouncing on the bigger game in this game: The use of the CC that, as you point out, has undergirded ALL of the progressive legislation since FDR.

Liberals have held the "common wisdom" for so long, they've been lulled to sleep with the thought that they had defined "normal." But conservatives have been seething since FDR (which, frankly, came as a shock to me) about ALL of the legislation that "we" take for granted.

This suit by 26 states seemed quixotic at first, but now has even so-called progressives convinced. Who would have thought that so many otherwise rational people would be truly worried that the government might force them to eat broccoli?

Although this decision would seem to strengthen the idea that government has powerful taxing authority, I wonder if it won't weaken the argument (constitutional and political) for single payer or Medicare For All?

by Peter Schwartz 6/29/2012 - 11:26 am (re: bslev)

If it's Medicare for all, there's no dispute that the government has the right to do that as noted in Ginsberg's opinion.  It's a government paid welfare plan.  

The question is can the government mandate you per the Commerce Clause to buy something because the government perceives it's in the national good.  It is good that people buy hybrid cars, therefore the government mandates that you must buy a hybrid car.  Justice Roberts says no, and I fully agree.

Can the government issue a tax on people who don't buy hybrid cars?  Roberts held that it could.  Usually it works the other way around: buy a hybrid car and you get a tax credit.  You put money away in a 401(k) you get a tax credit.  He held that Congress has the right to penalize for someone for not buying a hybrid car.  Seems like a regressive poor tax to me where you are taxed for simply not being able to afford a car or anything else that is defined as a societal good (Rather than tax credits for higher education, we can just penalize anyone who does not go to College in the name of subsidizing and expanding higher education).  But *shrug*, Congress gets to set (stupid) policy, and the Court just reviews whether it's constitutional.  And now poor taxes, where you get penalized for not being able to afford something.  What a wonderful world.

by dijamo 6/29/2012 - 11:39 am (re: Peter Schwartz)

How many divisions does Ginsburg have?

What I think Bruce has been alluding to is that a lot, maybe all, major pieces of progressive legislation have been argued on the basis of the Commerce Clause. Weaken that clause and you give precedent to the conservative argument (since FDR) that the government has no consitutional right to do X.

The broccoli, hybrid car, and smartphone argument aren't the argument. That's the argument from inactivity.

The actual argument is that commercial activity is ALREADY being engaged in and not paid for, or rather, being paid for in a very bad way.

A lot of this has to do with what insurance is. It is something you buy with the expectation that something (sickness) will happen and you will need it.

So you have it, and it costs money now, but you may not be "using" it yet, even though you will certainly use it at some time, which is why you buy it now.

(This "expectation" is stronger or weaker depending on the risk. For most people, fear of floods is pretty weak. But everyone will consume health care sooner or later.)

Put differently, you're using it--it's protecting you--even when you're not using it, and that's why it costs money from the day it starts protecting you.

(You can't tell the insurance company to waive your premiums until you start making claims, i.e., until you start "using" your protection.)

This isn't true of broccoli, hybrids or cell phones. You buy them to use them now.

However, interestingly a year or two back, when we were converting to digital TV, the government did buy, or give credits for, TV converter boxes for people with analog TVs because they were being "forced" into a certain kind of economy activity--digital TV.

People don't "need" TVs, strictly speaking, yet "everyone" had one, and everyone was already in the market as the market was shifting beneath their feet.

Here, everyone--because they are breathing beings--are health care consumers, whether they are "using" health care in the small sense of "use" now. And we cover them all now, given that we are certain they will use those services.

by Peter Schwartz 6/29/2012 - 12:13 pm (re: dijamo)

They. Are. Not. Covered. After. Paying. The. Tax.  

I am not sure what part of that you are not grasping.  It's not like Dan's example where they walk away with a free smartphone. They get NOTHING except a tax bill for not buying a private service.

by dijamo 6/29/2012 - 12:45 pm (re: Peter Schwartz)

They're covered BEFORE they pay the tax, and the tax merely pays for the coverage they have already enjoyed.

If they were not covered, then when they showed up at a hospital, the hospital could turn them away. They are guaranteed treatment.

In fact, whether they get a bill for those services is somewhat immaterial inasmuch as people who have insurance-insurance are often not fully covered, or covered at all, for services they think they're covered for and use.

by Peter Schwartz 6/29/2012 - 1:10 pm (re: dijamo)

This is why Scalia snarkily retored to Verrilli: "Un-obligate yourself."

IOW, don't insure these people.

Or Paul who said, "Let them die."

by Peter Schwartz 6/29/2012 - 1:12 pm (re: Peter Schwartz)

Clueless. The tax doesn't pay them for any coverage. I can walk into an airport and buy a ticket cash, or charge it and pay it off. Does that mean I have some mysterious plane ticket coverage?

"Guaranteed treatment" means they have to be served and they have to pay full rates. Insurance in the usual use of the term implies minor co-pay or free service. Insurance doesn't "guarantee treatment" - if the hospital's full, they can turn you away, and you go elsewhere. (unless an emergency, as you seem to be discussing - there is no "guaranteed treatment" for non-emergency procedures. Just because I show up to the emergency room with cancer doesn't mean they have to put me in a bed and line me up for chemo for 3 months - they have to make sure I don't bleed to death immediately or some other preventive measure.

If the airport charges non-ticketed passengers $30 to enter the airport, it doesn't mean my ticket is any cheaper, that that $30 covers my ticket in some way - it's just a penalty or surcharge, however you think of it. I'll pay that $30 whether I buy a ticket or not.

For the new insurance rules, you pay the fine for being insurance-less, whether you then go on to buy insurance or not. You get *ABSOLUTELY NOTHING FOR THIS "TAX"*

 

by PeraclesPlease 6/29/2012 - 1:22 pm (re: Peter Schwartz)

I didn't know you got to pay for your ticket AFTER you'd arrived at your destination. You can't get on a plane UNLESS you've paid.

We have a LAW that says people have to be treated and get to incur expensive service even without visible means of paying it. We've obligated ourselves to providing this expensive service to everyone. Even if they don't end up paying for it.

This is why Scalia said: "Un-obligate yourself" (financially).

Why Paul said: "Let them die" (if they don't have insurance).

Because we don't do that. We have obligated ourselves and we try not to let them die. And that costs money.

The fact that it's limited care is immaterial (it can be life and death care). There are bad insurance policies that won't take care of much either. So what? It's not the point.

Yes, they are billed, but whether they pay those bills is another matter. Most doctors will ask for your insurance card up front because it gives them some assurance they will get paid.

by Peter Schwartz 6/29/2012 - 2:56 pm (re: PeraclesPlease)

Congress passed EMTALA to combat the practice of "patient dumping," i.e., refusal to treat people because of inability to pay or insufficient insurance, or transferring or discharging emergency patients on the basis of high anticipated diagnosis and treatment costs. The law applies when an individual with a medical emergency "and a request is made on the individual's behalf for examination or treatment for a medical condition." [1] It does not matter whether the condition is visible to others, or is simply stated by the patient with no external evidence

by Peter Schwartz 6/29/2012 - 3:21 pm (re: Peter Schwartz)

Gee, they bill you after you arrive.

What a breakthrough way of doing business.

The plumber that sent me a bill after he'd fixed my pipes - I'll let him know he's on the cutting edge of commerce.

Banks regularly give people more credit than they can afford, to run up bills they can't pay - because they know they can hound them and collect high interest and overall make it a very profitable business even if a few default.

Try this - walk up to First Class and sit down in that plane. Quite likely they'll let you sit there - and charge you when you land. Expensive service after the fact.

The health law of course doesn't require they give you plastic surgery, or give you physiotherapy or cure your skin condition. It requires they provide life-saving treatment, to which they can then push you off to regular care.

And the charges for these services are ratcheted up, so that the numbers of no-pays are easily covered by the excess charges. It's not exactly brain science - except when it is.

 

by PeraclesPlease 6/30/2012 - 1:17 am (re: Peter Schwartz)

Medicare is a welfare plan?  Since when?  Social Security and Medicare were both set up with the edict that the workers who will benefit from those programs MUST pay into them through a payroll tax.  Millions of workers paid FICA taxes and died without ever collecting.  Things happen.

My husband and I receive SS and Medicare benefits.  Medicare takes $102 a month out of each of our SS checks, making our health care insurance expenses over $600 per month with supplemental.  There is also an annual Medicare deductible of $150 each that comes off the top before they cover anything.  Medicare coverage is usually 80% of our total bill, which is why we have to carry supplemental insurance,which also has a deductible and co-pays.

I don't feel like a welfare recipient.  That's because I'm not one.

And it could be why I don't see a problem with mandated health care expenses.  We already have it, and it works pretty darned well.

by Ramona 6/29/2012 - 12:18 pm (re: dijamo)

Medicare is administered by the government as a welfare plan (well-fare), a public benefit.  People pay into it as premiums, and receive the benefit directly (or not depending on their luck).  Just because it's a welfare plan does not mean it's free or no one pays for it or that people don't deserve it.  I work in HR and we administer health and welfare plans, so I use it that way.  

This is as opposed to the government saying everyone must invest in the stock market for your retirement and if you don't, we'll make you pay a penalty tax for which you'll receive diddly squat.  This is Obama's individual mandate for health insurance.

by dijamo 6/29/2012 - 12:39 pm (re: Ramona)

Medicare is a social insurance program, not a welfare program.

The important distinction is:

social insurance – where citizens contribute on a regular basis to protect themselves against a loss of earnings – and means-tested benefits – where money, food, or housing is provided to people in need.

by tmccarthy0 6/29/2012 - 12:46 pm (re: dijamo)

Welfare may be what you call it internally in your workplace, but that's not how it's seen in most other settings.  To add to TMac's argument, AARP doesn't see it that way, either.

To stretch this even further, millions of workers have taken jobs that require a FICA deduction without ever earning enough points to actually collect because they've worked at other jobs longer that didn't deduct the payroll tax.  Freelancers, for instance, or railroad workers. 

What ACA proposes is not that far-fetched or unprecedented, especially considering the threats are somewhat toothless. (No real established penalty.) It's simply a means to help fund a program that could be a benefit to everyone.  It's not all it could be but it is a start.  (It'll be all it could be when we can eliminate the insurance companies altogether.  But since we can't (realistically), this is about as good as it gets for now.)

 

by Ramona 6/29/2012 - 1:30 pm (re: dijamo)

Public social insurance is a type of welfare plan.  Unemployment insurance is a welfare plan.  It's intention is to maintain a certain minimal living circumstance.  I acknowledge that some liberals/progressives dislike calling it a welfare plan because they feel it less subject to attack from conservatives by calling it a social insurance plan because it emphasizes people pay into it.  I prefer to annoy conservatives by pointing out the many forms of public welfare they benefit from :)  You say potato, I say potato.

The tax is not like Medicare/ Social Security because there is absolutely nothing anyone gets out of paying it.  It's not that in the future theoretically when you hit age 65 you'll get the benefit.  Nope. You are just as uninsured as you were the day before but 2% of your salary poorer for not having insurance.  Not. Equivalent. At. All.

by dijamo 6/29/2012 - 2:03 pm (re: Ramona)

You are already getting it.

by Peter Schwartz 6/29/2012 - 2:37 pm (re: dijamo)

You are not getting it, and I've given up hope that you're just willfully blind. 

by dijamo 6/29/2012 - 3:29 pm (re: Peter Schwartz)

Well, aside from the fact that your sentence doesn't parse...

I DO get that the person doesn't have "insurance" in the straight sense of the term.

The whole point of the "tax" is to motivate people who are able to buy insurance.

The point of the subsidies is to make insurance more affordable for those who can't afford it now. And motivate them to get it.

If those subsidies are insufficient to make it affordable, they need to be increased to the degree they can.

But there will be people who fall through the cracks, as there are in any system. Hopefully, many fewer than now go without insurance.

Your argument seems to be: "This is worthless and irreparable because we don't have a public option."

But the means-tested public option that was on the table was ALSO going to leave out some people and force many to pay for private insurance.

And if we went for a non-means-tested public option, as you suggested in another thread, then what we have, essentially, is single-payer. Why would anyone NOT choose it unless it covered many fewer things than a private plan, i.e., was a much poorer form of coverage?

But given that this is where we've gotten, I really don't get your rejection of the improvement approach...and I really don't get why you'd want to burn it down with the expectation that the way to single payer or a public option is through Romney.

Seems far more logical to get a wide swath of the American public using and comfortable with this change, confident that it isn't the devil's work, and then say:

"Gee, you know what would make this soup better? A nice juicy public option to fix this, that, and the other problem."

And then later...

"Heck, why are we taking half measures? The public option is working beautifully. Let's expand it to cover more people."

See, if you think Ken Cuccinelli's (or Romney's or any GOPer's) chief concern with this bill was it's unconstitutionality, you are sadly mistaken. They hate it because it's Obama's plan, or because it's a "liberal" plan.

Put forward a different "liberal" plan that doesn't have an obvious constitutional weakness, then they will hammer at it from a different angle. Frankly, the suit was only an attempt at a coup de grace. Their PR blitz--and Obama's lack of a defense-- had already put huge holes in the plan's political viability.

They don't care that some poor people won't be able to buy these plans. They don't care that the plan might not have been constitutional. They're not going to welcome a public option or MfA because, hey, it's constitutional!

They don't want an expansion of government, period, constitutional or not.

I say, take the beach head. Defend it. Expand it. Soon enough, you'll be able to take off your flack jacket and enjoy the sun.

 

by Peter Schwartz 6/29/2012 - 4:56 pm (re: dijamo)

what about the fixed costs of having the appropriate level of ER staffing available based upon. population (including. counting you). The real problem, of course, is making the "risk" of healthcare need like the risk of rebuilding your fire destroyed house. One is an individual certainty, the other acturarily certain across a population.

by jollyroger 6/29/2012 - 4:19 pm (re: PeraclesPlease)

Interesting. Thanks.

But I'm still celebrating.Nervously.

by Flavius 6/28/2012 - 10:07 pm (re: bslev)

Second, the mandate's.......- if you haven't paid, you need to.

NO, NO, NO,  there is no, haven't paid; its taken out by your employer every time you get your paycheck.

Now all we need to do is take it out at tax time, on all reported income. (bonuses, dividends, interest, etc)

TAKE OFF THE CAPS, ON ALL INCOME. 

Its all about did you pay your share and your share is determined by your income. Flat Rate Taxation.

To Mitt; everyone in America will be rooting for your success, because we all benefit. We all get Medicare, the Universal Healthcare plan, with a risk pool as big as the US workforce and the rich.

by Resistance 6/28/2012 - 9:55 pm

Flat tax! Good catch, I'd missed that. Obama joins the Flat Worlders.

by PeraclesPlease 6/29/2012 - 2:52 am (re: Resistance)

The government can still make you buy anything it wants.  All it has to do is buy the stuff itself and then tax you for the bill.

by Dan Kervick 6/28/2012 - 10:51 pm

Yes, "stuff mandate" - unconstitutional.

"Stuff tax" - A-Okay.

Wonder if I get auto phone upgrade & free minutes with my government phone plan. Let me guess - they'll low bid to some flaky outfit in Shenzhen running DogOS. And that Chinese proprietary SCDMA data service that's never quite worked.

by PeraclesPlease 6/29/2012 - 2:54 am (re: Dan Kervick)

; )smiley

by Resistance 6/29/2012 - 3:51 am (re: PeraclesPlease)

True. That's what SS, Medicare, Medicaid, Medicare For All, dams, roads and bridges, the military, FEMA are all about.

We "get" to buy these things whether we want to or not.

by Peter Schwartz 6/29/2012 - 10:59 am (re: Dan Kervick)

I don't know if anybody has approached it from this perspective.

If it was Medicare for All, paid for through FICA, on all income; the only costs incurred, except for the administrative costs, would be the actual cost of the medical care. 

Why should the CEO of United Health, make a profit from insurance premiums paid, and no service rendered.

Whereas: Medicare pays the bills, as they arise and the projected price for next years services, determines the premium. Without the profits taking.  

Insurance is a protection against loss and if there is no loss, the insurance premium was unnecessary.

With Medicare..... No loss = rebate 

The government doesn't take a loss, it just raises the the Medicare payment to meet the projected outlays. 

Any profit, would be derived by the insured, managing there own healthcare.

BTW  Isn't this similar to the Republican Medical Savings Accounts. Citizens rewarded.   

Medicare for All is the insurance, (assurance)  that you will be cared for, without profit seekers, jacking up the price to make a PROFIT.   

We don't need a middle man, gate keeper, skimming profits.

hmm is that an interference in Commerce, "you will go through this set of middlemen" 

by Resistance 6/29/2012 - 1:46 pm

I agree, it eliminates the cost of the profit and bonuses, etc.

But FICA payments are like premium payments except in form.

And, on top of that, people DO pay premiums to Medicare when are eligible for it.

If we added in the younger and healthier, who would still pay in but use relatively few services until they got older, it could shore up Medicare's finances some.

by Peter Schwartz 6/29/2012 - 2:41 pm (re: Resistance)
There's a (perhaps ) better way to frame it: Everyone ends up on the Medicare A risk for hospitalization, ie, catastrophic &/or end of life events. The 2% penalty/tax is, (coincidence ?) exactly equal to the ongoing Medicare levy, ie, a doubling. We also have in place a graduated penalty of 1%/mo for deferring enrollment in Med B once eligible. Do not those who eschew the available Obamacare preventive interventions make more expensive their eventual burden on Medicare A, hence justifying a "pre-payment" as it were, of the resulting anticipated costs?
by jollyroger 6/29/2012 - 4:03 pm (re: Peter Schwartz)

I didn't know about the deferment penalty. Is that because the deferment of care means a heavier treatment/cost/administrative burden once care begins? Good points.

by Peter Schwartz 6/29/2012 - 5:02 pm (re: jollyroger)
Dunno. presumably to avoid the wait til I. get sick to join strategy, which is the flip side of cherry picking in any guaranteed acceptance system.
by jollyroger 6/29/2012 - 5:32 pm (re: Peter Schwartz)

To the user, FICA is more like pre-paying over a lifetime in order to get an insurance plan at retirement that offers Part A free (but with a significant annual deductible) and Part B, for most income levels, at a major discount. (Added note: apparently unknown to many who argue that the rich should pay more, for several years now Medicare has continually been raising the Part B premium "higher income beneficiaries" must pay.)

Also I'd like to note that there is the irony in saying this: If we added in the younger and healthier, who would still pay in but use relatively few services until they got older, it could shore up Medicare's finances some in that Medicare got created in major part to remove the troublesome burden of elderly from the rest of risk pool

On another note, I also wonder if what you suggest is that accurate, should the hypothetical younger-people's- Medicare stay with the fee-for-service model, the medical industrial complex might just rise to the occasion and make sure the youngsters started using more better high tech tests for which they would then need to be treated with the medical industrial complex drugs, specialists, surgery and other assorted treatments, giving them side effects and iatrogenic illnesses which also need to be treated I admit that's a "what if," but so is your theory

Suffice it to say that after reading many "Medicare for all" progressive proponents comments and blogs over the past few years, I am very cynical that many of them know much about Medicare at all or how it works or what its problems are. And I very much suspect that many of them wouldn't be happy at all with it if they got it, they would be bitchin' about the ever higher premiums necessary to keep it solvent, and the decisions about coverage like co-pays deductibles, whether payments were high enough to keep doctors accepting it, whether enrollees should have that new cancer drug by Big Evil Drug Company covered, etc.

I think Jolly Roger is correct in the past with his suggestion of a VA option for all--which would be a health service providing all care and not insurance and not funding the for-profit medical industrial complex--is what a lot of progressives really want when they say they want Medicare-for-all, not a Medicare-for-all option, that they don't understand actual Medicare.

by artappraiser 6/29/2012 - 4:50 pm (re: Peter Schwartz)

P.S. HHS put out this press release in October that said they were able to keep Medicare Part B premiums and deductibles lower than they expected this year because of effects of the Affordable Care Act.

Now I am not one to buy into every government communique, but I do think most people who argue about ACA on the net haven't a clue about a lot of the reforms in it, not that I claim to, just that a lot of arguments are based on extremely limited understanding of a huge bill. Therefore, lots of hypotheticals, fun for debate lovers, maybe, but not helping very much with individuals who have to deal with the reality of it.

P.P.S. In looking up the above stuff, I just ran across this lovely 36-page PDF tome by the Center for Medicare & Medicaid Services: Medicare and Other Health Services: Your Guide to Who Pays First .Off to print it out for Dad; maybe it'll cut down on the instances of asking me to look up related on the internet.

by artappraiser 6/29/2012 - 5:19 pm (re: artappraiser)

I agree, people just don't know what's in the bill.

But I do wonder, since most of it, I THINK, hasn't gone into effect, HOW it could already be serving to reduce premiums and deductibles.

That seems extraordinary to me, but maybe just reflects the fact that there's a lot I don't know either.

If you discover the "mechanism of action" for these reductions, I'd be interested in knowing.

Other people, of course, claim that ACA is already causing their premiums to go up. Whatever. I think the truth is, people don't know what the impact will be really until it goes fully into effect.

Best to your Dad. He has a good daughter.

by Peter Schwartz 6/29/2012 - 5:39 pm (re: artappraiser)

Thanks for your comments. Very interesting.

I accept your characterization of FICA, but wonder if it makes a difference to my point, which is that Medicare isn't free any more than private insurance is free. We pay for it.

Your second paragraph is also interesting. But perhaps that was because back then the elderly were the tail and the young were the dog. Soon the elderly will be the dog, and the young the tail. So now it might make sense to dilute the problem dog with some healthy tail.

My understanding of insurance is that you want to spread the risk as widely as possible. Some people end up paying more than they would've on their own. Some people less. But since no one knows which of these two groups he will fall into, it's a good bet on the future for everyone.

The for-profit model, as I see it, wants to eliminate as much risk as possible by having the healthiest pool it can get. And since each company is a private entity with only its shareholders to worry about, it doesn't care where the unhealthy, old, and poor go, as long as they aren't on its rolls. They know they will pick some bad apples, so that's why they have caps, rescission, pre-existing exclusions, and all them folks looking for any reason to reject claims.

I'm not really following your "what if" or its import... If the young and healthy stay with the for-profits, they will be lured into expensive treatments and drugs which will make them sick? Don't get where this leads or how it's rising to the occasion.

Some skepticism is always warranted, so I'm with you. People will always complain and will always get some bad treatments and get charged too much. I believe in kaizen--constant improvement.

The VA option, as I understand it, would be like the NHS in England where the provision of health care is delivered by the government. That is, the doctors are government employees and the hospitals are run by the government. You may be right, and that would cause the right to rupture ALL its blood vessels. Never say never, but we will never get that. And it would have problems, too.

At the heart of the American psyche is the desire to get rich...or at least get ahead. I can't tell you how many debates I've had with conservatives who've claimed that the only reliable way to motivate people to do a "good job" is financial reward. Take that away...and take away the ability to own your own practice, your own destiny... and the person will slide into sloth and mediocrity. Then they haul out all the NHS horror stories, and stories about relatives flying in from the UK to get their teeth fixed and gall bladders removed so they wouldn't have to wait a year for a botched job by a government hack with a stethoscope.

by Peter Schwartz 6/29/2012 - 5:26 pm (re: artappraiser)

I'm not saying the VA is bad, and you may be right that that is what many progressives REALLY have in mind. I don't know.

So many people want to keep "their own" doctor, I'm not sure you're right, but you could be.

I've heard good and bad things about the VA. My aunt was a military widow and had her cancer misdiagnosed at the VA and died as a result. But don't we all have a story like that?

There were some advantages to the old days when people were forced to confront the fact that life is largely a crap shoot. You do the best you can, try to improve knowing that nothing's perfect, and you hope there's rain and the crop comes up.

by Peter Schwartz 6/29/2012 - 5:34 pm (re: Peter Schwartz)

Yes, single provider. like NHS. government. hacks, bringing. the best care anywhere at 1/2 the cost, WITH catastrophic injuries to treat. www.time.com/time/magazine/article/0,9171,1376238,00.html

by jollyroger 6/29/2012 - 5:51 pm (re: Peter Schwartz)

I think the irony is that if progressives were screaming "we want an NHS option" (instead of the "Medicare option for all" mantra that I believe many actually wouldn't like if they got it) they might actually have a chance of getting it, beee-cause enough right wingers would foolishly go along believing the option would be a massive failure with death panels, like Medicaid, and all that hokum.

I believe there are enough fed-up young docs out there (& crucially trained differently than the troglodytes running the AMA) to staff it if the salaries were halfways decent (especially if they've actually done the numbers for themselves about what it costs to deal with all insurance, private and public both.) And I suspect it would end up popular enough to really put a a most necessary fire under the whole stinking medical industrial complex, really get some of the necessary reform going. Lots of people who have actually had to deal with putting in a lot of claims, whether to public or private insurance, would love it. Think of how nice it would be, Mrs Retired and her worried children, of how instead of shlepping to all those specialists giving you 20 different prescriptions/proscriptions, your doctor himself had email conferences with specialists and sorted out what they said and coordinated it all in a treatment plan for you that he directed?

Somebody's got to start breaking away from money-driven medicine to show  more evidence that the alternative is good for one's health. Riding hard on private health insurance companies ain't going to do that, that's just a recipe for stoopid cost cutting, and incentivizing unnecessary preventive testing  that causes unnecessary treatment,  and iatrogenic illness, not smart medicine. There's got to be someone somewhere in this country willing to start showing wholistic care works with a large diverse group.

by artappraiser 6/29/2012 - 6:12 pm (re: jollyroger)

Added thought: I have noticed lots of younger doctors are already on the way, congregating themselves in large sort of "doctor malls" where they all get a salary and don't have to do any paperwork or insurance claims nor even have a receptionist, nor deal with test companies, they don't have to hire anyone else except a physician's assistant if they like working with one.

by artappraiser 6/29/2012 - 6:21 pm (re: artappraiser)

I think the irony is that if progressives were screaming "we want an NHS option" (instead of the "Medicare option for all" mantra that I believe many actually wouldn't like if they got it) they might actually have a chance of getting it, beee-cause enough right wingers would foolishly go along believing the option would be a massive failure with death panels, like Medicaid, and all that hokum.

It's a thought...

by Peter Schwartz 7/1/2012 - 2:18 pm (re: artappraiser)
While getting over my neck, I met a nurse who just relocated from some Midwest VA hospital. She said the nurses there topped out at 100k, and the chief gastrointestinal resident pulled down 250k. I offered my opinion that this was not a life of penury. She agreed, but also said the same chief GI resident in a non VA hospital would get 750k. wherein our 17% GDP burden.
by jollyroger 7/1/2012 - 5:18 pm (re: artappraiser)

the same chief GI resident in a non VA hospital would get 750k. wherein our 17% GDP burden.

I'm with ya 100%!

But now I wanna see ya go and 'splain that to the firedoglakers without getting flamed wink I think most of the liberal blogsophere are where I waz like 10 years ago, they just sooo wanna scream and rant about insurance companies (not realizing that Medicare and Medicaid are just insurance, too, with many of the same attributes, perhaps more given that they are quite open to the affects of lobbying Congress.)

by artappraiser 7/1/2012 - 5:34 pm (re: jollyroger)
Bringing to mind the purse pinching (!) blue dog who weighed in during the HCR debate that he'd be fine with expanding medicare to younger people but only of we raised the doctors' fees!
by jollyroger 7/1/2012 - 7:17 pm (re: artappraiser)

Private hospitals may be much more responsible for evildoings than private insurance cos:

[....] ''There's no rhyme or reason for how patients are charged or how hospitals come up with charges.

''There's no other industry where you get charged 100 times the same amount, or 121 times, for the same product,'' she said [....]

Dr. Hsia, whose research was supported by the Robert Wood Johnson Foundation and the National Institutes of Health, reviewed charges for 19,368 California adults under age 60 who had had uncomplicated emergency appendectomies in 2009 and were sent home after hospital stays of fewer than four days. She and colleagues found huge variations in price, even within the same county. In Fresno County, for instance, the researchers found the smallest range of charges, but there was still a difference of $46,204 between the highest and lowest hospital appendectomy charge.

For-profit hospitals tended to charge more than county hospitals, and charges increased with a patient's age. Charges were also higher for Medicaid patients and the uninsured, and for patients with other health problems like diabetes and congestive heart failure [....]

from

Confusion On Pricing At Hospitals Adds to Pain
New York Times, April 24, 2012

by artappraiser 7/9/2012 - 3:06 pm (re: artappraiser)

wonder if it makes a difference to my point, which is that Medicare isn't free any more than private insurance is free. We pay for it.

It was supposed to add to your point (You and several others here get so into lengthy arguments that you get into automatically thinking a reply is always a challenge?  Reminder: some rare people actually like to use sites like this to riff off of one another rather than argue cheeky) And I will add--I think one problem with it is that it also has become very expensive, because of its fee-for-service model.

I'm not really following your "what if" or its import... If the young and healthy stay with the for-profits, they will be lured into expensive treatments and drugs which will make them sick? Don't get where this leads or how it's rising to the occasion.

No, I said that if the young and healthy were moved to Medicare that that might happen.

Like it has happened with the retired, my opinion and that of many others. The fee-for-service model (Medicare being one of the few still practicing it) is the main thing fueling the medical industrial complex, i.e, money-driven medicine, where the consumer rules and the consumer is at a disadvantage as to knowledge about the things being sold to him really being good for his health.

How it "rises to the occasion": you said it might help Medicare costs if more young and healthy were in it, I say more than likely it wouldn't, not if the same thing happens as has happened with the retired. Not unless it is changed from a fee-for-service model. Why do you think the medical industrial complex is 17% of our GDP? Read Atal Gawande or Maggie Mahar's work on money-driven, consumer-driven medicine ( Pre-emptive to those who might try: I  don't consider the argument that it's all insurance company profits a serious one backed by facts, so don't bother.)

by artappraiser 6/29/2012 - 5:51 pm (re: Peter Schwartz)

Why do you think the medical industrial complex is 17% of our GDP?

My first guess;  is because they're blood sucking leeches. 

by Resistance 6/29/2012 - 9:53 pm (re: artappraiser)

Sorry for my argumentativeness. Appreciate your slowing me down.

I agree entirely about the fee-for-service piece of what you say.

by Peter Schwartz 7/1/2012 - 2:11 pm (re: artappraiser)

I should add that I was never felt that arguing against a Medicare-for-anyone-who-wanted-it was worth the time and that it was just fine with me if it happened. Because I think this has to be an evolutionary process, just like it has been in virtually all other countries and just like it was with introducing Medicare, and Social Security, for that matter. And more people getting on Medicare and finding out it wasn't what they thought and not liking it, and costs continuing to rise, would bring up the same reforms as going about it the way we are now or perhaps better and faster. Or maybe not,who really knows?

I had just come to think status quo/doing nothing was the only wrong option, everything else has to be a process. All of this is trial and error, it is always a process, countries with systems that work well  are always shifting what gets covered, who gets covered, what and who pay etc; there is no perfection.

There was an excellent example of the nuanced realities about CHIP that so many like to herald in this article on Texas uninsured in the Times the other day. A father turns down pay raises and even asks for pay cuts so that the little daughter with unusual illness can be on CHIP, also turns down some employer supplied health insurance because that coverage is not apparently going to cover all she needs. Meantime, he gets cancer and is not covered for that because of what he did, and now with lower income which he gave up for her to be on CHIP, has to figure out how to pay for his own treatment. But wait, there's more, lest you think government-insurance-for-all solves their problems, at the end their story continues: CHIP has just turned down paying for $17,000 of genetic tests that the little girl's doctor says he needs; they are in the process of appealing that decision.

There are winners and losers in every health care system, it is always a judgment of "less worse system than these others" and a nation's priorities. It is also a constant process of keeping a system working decently because of the constant change in medical care and technology. Like it or not, people are going to try to sell longer life because most people want that, even in a communist system capitalism will break out in this one front, it's inevitable.

by artappraiser 7/1/2012 - 5:07 pm (re: Peter Schwartz)

Medicare as it is now, may not be the perfect solution.

But like all other messaging problems, the democrats have;

Why reinvent another program, with a new name?

Medicare has the positives already.

Could we improve it?

MEDICARE FOR ALL, only needs to be tweaked to make it better.

"MEDICARE FOR ALL" fits better in a 30 second message, rather than saying 'We want the same healthcare the Senators and Representatives have.

Democrats will form a circle and debate it to death; "Whatever   should we call it?"

"Doh, I dunno. maybe we can call it Medicare two too?

"Doh! Why not call it PP ACA and confuse everyone?"  

If we tweaked Medicare,to deliver what WE the People want, to bring us the same medical care the Senators and the elites receive , who cares what we call it.

KISS 

Ps. Once the floor is established, theres no reason to not have, the opportunity to purchase extras; provided by private insurers. 

If you want 14 virgins swinging palm frongs, to keep you cool;  Maybe United Health has a plan, just for you? 

You want a longer stay in the hospital, than Medicare provides, buy a supplemental plan.

Everyone in Medicare as the primary insurer, increases the risk pool, to cover our brothers and sisters with preexisting conditions. 

by Resistance 6/29/2012 - 9:57 pm (re: artappraiser)

John Cassidy opines quite interestingly on topic:

John Roberts and Mitt Romney: Two Peas in a Pod
Après Roberts, le déluge.

by artappraiser 6/29/2012 - 11:22 pm

 

The politics and economics of health care are plain wacky. From the moment, in early 2009, when Obama backed away from the public option and embraced Romneycare, things have been turned upside down, with liberals supporting a costly and hideously complicated giveaway to the health-care industry, and conservatives depicting a reform that originated at the Heritage Foundation as a socialist takeover. People on both sides are spouting claims that five years ago they would have dismissed as arrant nonsense.
This paragraph should get some kind of award for best description in fewest words.
 
 
by EmmaZahn 6/30/2012 - 10:11 am (re: artappraiser)

I agree, except...

I believe liberals moved to this solution because they thought it was a compromise with the anti-big-government-ers that could get bipartisan support.

That Medicare For All couldn't have gotten through at all.

It's not so much that we are arguing for an expensive and complicated giveaway as it is that we are trying to defend one step forward.

IOW, we aren't arguing for this as a end point, but as a step along the way...and arguing against undoing this step forward because undoing it would (we believe) would be a step backwards.

by Peter Schwartz 7/1/2012 - 2:16 pm (re: EmmaZahn)

It's not so much that we are arguing for an expensive and complicated giveaway as it is that we are trying to defend one step forward.

No, what it does is prop up a collapsing system.  Plus, I do not remember reading any opinion- leading progressives or liberals even trying to promote anything different.  What, no left sided think tanks could hire insurance specialists and actuaries to run the numbers, maybe figure out actual plans and premiums to quote just like private insurers do?   Negotiations started where exactly where they ended with a hideously complicated giveaway.  And do not even get me started on why no one ever thinks about developing a decentl healthcare system.  No, it's all about insurance e.g. how to pay for the healthcare hell we have now.

 

by EmmaZahn 7/1/2012 - 5:25 pm (re: Peter Schwartz)

Altho this is a brilliant discussion , does it matter? The ACA is the first step in a long process that will get us to........something. And during that process precedents will be honored by both sides when it suits their interests.

As in Bush v Gore.

The basic test of Obamacare has always been .....will it result in people living who would otherwise die, will it result in people avoiding pain they will otherwise experience?

"Broccoli" was just a smoke screen ,a distraction..

As to this week's legal decision, ditto. In the NYR Dworkin wrote that it came down to whether a government can .....govern..  Roberts decided that in this case it can.  His reason ?As the saying goes "You don't ask a whore her reasons, you ask her her price"

.By which I don't intend to call him a whore

 

 

by Flavius 7/1/2012 - 6:09 am

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