The Bishop and the Butterfly: Murder, Politics, and the End of the Jazz Age

    We Were Wrong About Obamacare

    By Flavius on Sat, 02/04/2012 - 12:58am |

    Many of us.  

    It's commonplace to read here that Obamacare is flawed, could have been better, and we might be better off without it.

    What Bernard Avishai says, correctly, is:

    “If Obamacare is killed it will....cast doubt on whether Americans will ever be able to hold  their fears in check and summon the elementary decency toward the sick that characterizes other democracies.”

    He says it in six pages of the Feb 12th  Nation while refuting what  some of the most thoughtful contributors here have said and still say about Obamacare.

    What Avishai says is

    “Obamacare , in short, was healthcare reform’s best-and last-shot and it would be unconscionable for liberals  not to defend it.

    It’s ...time to discard the  misguided assumption that with.........more of a “fighter” in the White House something (better)might have been(or might sometime fairly soon be) enacted .

    These and other judgments you should read and think about, occur while he is reviewing  Paul Starr's

      Remedy and  Reaction.

    The Peculiar American Struggle over Health Care Reform.

    which Avishai clearly considers  the best thing ever written on the subject. More important, he feels that

     “Nobody who reads it could doubt how sensible and brave was the president’s effort to get it passed."

     Avishai’s review FWIW is the best thing I’ve read. Not on the economics of Health Care ( That was Kenneth Arrow's  1963 analysis in the American Economic review. which I labored through here a couple of weeks ago) but specifically on Obamacare.

    Starr, writes Avishai, 

    "is particularly good at explaining the permanent counter-forces ...(in) Washington....the Senate was designed to give ..power to the (small) states.....(which) favored Midwestern and Western Rural  states...and the Democratic Jim Crow South.  Universal healthcare....meant....coverage for  the working poor...that inescapably included ...laborers and ....blacks"

    "Getting legislators from the West and South to support this....was hopeless"

    "We somehow....forget that Obama's....majority in the House was  of no account-none-without a super-majority in the Senate+

    which ended after 5 months in 2010

    Then economics rears its head. Premiums, says Avishai, had risen from 9%o of GDP in 1980 to 17% today. Which Starr points out,

    "created an alliance in favor of 'bending the cost curve' down while keeping the benefits up."

    And voters weren't equipped to evaluate the spurious claims of Health Industry "experts" i.e. lobbyists.

    "Which is why it would have been irresponsible for Obama to try to pass reform without first lining up groups like the AMA Etc."

    Which is sometimes discussed by Dagbloggers as if it were somehow discreditable. And by the media of course

    "journalists have..colluded with Republicans  by scoring politicians more on their guile than on their policies. Republicans have....assumed that Obama would be blamed for any economic difficulties, even if they created.....them"

    During much of 2009 there was the  Max  Baucus ,Olympia  Snowe caper but

    "did this mean Obama was deluded by his own rhetoric of bipartisanship and (should have)been more combative? Not at all...Obama's real goal was 'bipartisanship in one party'"

    He went along with Baucus not in a futile attempt to romance the Republicans but to hold those Western senators whose votes were absolutely needed to combat the automatic Republican filibusters which would have defeated the act unless Obama held every democratic senator.

    "What emerges....from reading Starr is how reckless it was for critics to charge Obama with not making his own views clear enough.....because (he let) Congress (do) the work of filling in the details."

    Maybe that would have been recognized, Starr/Avishai say,

    "but for the righteous indignation Obama endured  during (early 2009)....over the bailouts....when the determination to regulate rather than nationalize the banks gave critics....on the left an opening to depict the president as a creature of Wall Street."

    ...and start campaigning for a Bernie Sanders challenge.

    Starr points out that though they were nominally allied with Obama,  in parallel,

    "the health insurance industry wrote an $86.2 million check to the Chamber of Commerce to(oppose)  the legislation."

    Meanwhile Starr/Avishai say the left,

    "spoke of the 'public option' as the holy grail and of Obama as its perfidious guardian..."

    "Perhaps (because) members of Obama's team were mostly disciples of  Robert Rubin.....perhaps....Obama's half heartedness about a public plan, which he knew the Senate would never give him."

    Then Avishai metaphorically shakes his head in wonder at   the nonsensical  claim that if Obama hadn't passed the Affordable Care Act ,somehow unemployment would have magically been reduced (and pigs could fly).

    Shifting grounds  towards the end of the review Avishai discuss the "integrative power of information technology to achieve administrative cost reductions which in the past would have required the public option

    "Physicians wouldn't need a single-payer system to (cut) administrative costs any more than they would need (everyone) who pays with a credit card to be customers of a single bank."

    And Avishai (and I ) concludes

    "It would be a shame, Starr warns, if the president  (was defeated) by a Republican claiming the need for leadership" in the White House- a double  shame if misinformed Democrats nursing their 'disappointment' continue to help make that need seem plausible."

    Amen

     

     

    Comments

    I recall the long arguments at TPM when this legislation came to the fore. I recall reading proposal after proposal being considered in both Houses of Congress.

    Once it passed I felt; at least we got something which is more than the Clintons ever got.

    I first started scratching my head when Palin started screaming that our entire country was at risk as long as 'Obama Care' stayed on the books and since then all the repubs scream this crap day in and day out and I cannot figure it out.

    Does it hurt the citizens of Georgia to open up their options with regard to purchasing health insurance elsewhere?

    Do repubs really think that prior 'conditions' should prevent someone from the right to procure health insurance?

    During a period of severe unemployment is it that bad that a 22 year old might receive coverage through a parent's health insurance policy?

    And yet I have heard repubs actually attack all of these provisions.

    I might be confused because the dems are not forming their arguments so that the Average Joe understands what 'Obama Care' actually entails?

    Maybe health issues and coverage issues relating to 300 million people are just to complicated for anyone to understand.

    If repubs can just scream socialism, surely the dems can do better than that with some good rhetoric.

    Now my understanding is that last year some provisions went into effect and new provisions will go into effect over the next three years.

    I think the idea was that as these provisions go into effect, the populace would begin reaping some tangible rewards from health care reforms. And once concrete rewards were had, more and more people would be satisfied with the reform.

    I cannot get into the crania of the repubs on these series of arguments unless it all has to do with health insurers bribing their way to greater profits.


    by Richard Day on Sat, 02/04/2012 - 6:54am

    Late in life my father moved to small New England town. He had no particular education-a year of high school , but he was good at fixing things.Replaced the sills on our large 200 year old house by taking a series of ordinary car jacks and slowly raising each one,  one turn at a time.

    He became friendly with Cyrus ,a crusty old  local who had those same sort of interests and skills.

    It was after WW2 and the town was trying how to spend the large fund it had accumulated for a War Memorial. Already had lots of them: Civil War,Spanish American War, WW1.What it didn't have was houses. All over town returning vets were marrying and having kids while still living with their parents.

    They decided to use the money to build some veterans' housing. No one seemed to want to run the project and the selectmen asked my father to do it. He said, sure. Why not?

    Cyrus said to him :"Are you really going to help build those houses? " and dad said he would

    And Cyrus never spoke to him again.

    Where does that mind set come from?Dunno.But you can bet that Cyruus was a Republican. 


    by Flavius on Sat, 02/04/2012 - 9:02am

    This is a great personal story from your own family.

    Never spoke to him again!

    And good for your Dad!

    A self-taught, talented New Englander.

    You really cannot beat that combination!


    by Richard Day on Sat, 02/04/2012 - 1:09pm

    What none of those who are so vocal and abusive about 'ObamaCare' ever address, is the abuse of the insurance companies and the massive amount of profits they compile.  Nor do they bother to mention that due to their investment in stock of healthcare interest based industries, the 1% gleefully continue counting their return$, and are the ones who always profit from the 99%'s plight.  

    I'm furious, that none of the media ever show pics/tell the stories of the children dying every minute solely due to the inability of their families to pay the obscene costs of obtaining needed quality medical care to save their children - and asking these rich candidates specifically what would they do to save these children.  And not let them blather on with empty rhetoric.

    I'm thankful you posted this valid and factual blog.  

    I hope we keep seeing more of the same on this topic.


    by Aunt Sam on Sat, 02/04/2012 - 1:02pm

    You're right. It's not just a debating topic. People die and suffer because we get this wrong. And we waste money at the same time.

    Sure it would be good if Obamacare were better.But millions of people will suffer if it is repealed .

    It's understandable that those  who fought hard for a public option are disappointed.They were right.But now they should fight to protect Obamacare.

    Thirty years ago there was an overly popular book of business wisdom called In Search of Excellence.Mostly platitudes but with one good slogan. Do It, Fix It.

    That's the way the dagbloggers should  look at Obamacare. .Obama has done it (maybe). Later they can fix it .

    But first  we have to keep it from  the Republican wrecking crew,.

    As Madison was leaving the hall after the Constitution had been approved someone  asked What have you given us, Mr. Madison? He answered: A republic. If you can keep it,

    Obama's given us a start on something that shows the

     'elementary decency toward the sick that characterizes...democracies'

    if we can keep it.


    by Flavius on Sat, 02/04/2012 - 2:29pm

    Obama's real goal was  "bi partisanship in one party"

    The Senate Super in its short life was never a Super Majority on issues like single payer or the stimulus package because in order to consider it a majority, they would have to be on the same page.  Which they weren't. 

    But on thing that also needs to be considered in evaluating Obama on this matter was that at the time he took this issue up, just about everyone was clamouring for him to focus on "jobs, jobs, jobs."  It would have been easy, in fact would have been the better political strategic move to say now wasn't the time to deal with health care, and instead to focus on jobs.  That we should pick up the issue of health care later in the near future.  Had he done so, there would have been no near future.  It would have been best pushed until after the 2012 election.  If we were lucky.


    by Elusive Trope on Sat, 02/04/2012 - 2:29pm

    Avishai deals with that. Unfortunately Obama's Dec 2008 Stimulus plan undershot the target. But he probably only had one bite at that cherry.

    In the summer of 2009 -after the unpopular bail outs-the odds were against  his getting  enough  more stimuli out of Congress to significantly affect jobs over the balance of that House's term.  Or to ensure a majority in the next one. But he thought he had the votes for Health Care altho Biden and Rambo were doubtful.

    Turns out he did. Just barely.

    l know this is not your position but I particularly disagree with those who say he should have deferred health care to work on jobs and that he should held out for the public option. Doesn't compute.

    If he didn't have the votes to do  health care and Stimulus II in parallel then he probably didn't have the votes  for even a stand alone health care plan including the public option.(Socialized medicine, horrors!)

     

     


    by Flavius on Sat, 02/04/2012 - 3:05pm

    Oh, boo hoo.

    You know, sometimes I get through almost the whole week without thinking about the Obama administration or campaign.  And by keeping the television off, which I do, I am mostly able to ignore the Republicans too.  I assume that there will be an election in November, and that hardly any of the blather that will transpire between now and then really makes any substantive difference to the nature of choice that people will be presented with.

    But then along along comes another of these hectoring whiners picking fights with the left, and it just makes my want to turn off the internet too.  Isn't there any escape from this crap?

    Bernard Avishai can stick it, along with his neoliberal Harvard Business School view of the world, and their endless excuses for four decades of expanded plutocracy and retrenchment by the left.  he's made a career our of offering consulting services to some of the most wealthy and privileged people in the world.   He has near zero credibility in my eyes.  His generation of thought is on its last legs, and I'm pretty sure something very different and more interesting is on the horizon.

    You know I did my duty for the health care thing, arguing like crazy for the public option, and then sucking it up to tell people to support it in the end, and to just pass the damn bill even after the Scott Brown election when a whole bunch of other Dems said to pack it in, end even though I thought the act was very flawed and that we were just going to have to go back and address health care all over again five or ten years from now.   I wrote my members of Congress and told them to vote for it.

    I can deal with being a slave.  But I have no patience with these self-appointed foremen of the slavemasters who go around to push our faces into the manure and tell us to stop bitching.


    by Dan Kervick on Sat, 02/04/2012 - 4:28pm

    We can disqualify your whole diatribe because you didn't call him "Braveheart" and didn't affirm it's the best-piece-of-legislation-in-70-years. You're just helping Ron Paul take over government - don't you feel ashamed?


    by PeraclesPlease (not verified) on Sat, 02/04/2012 - 4:43pm

    I know next to nothing about Avishai. I agreed with his review irrespective of whom he has worked in the past. .

    I also know next to nothing about Paul Staff who is chiefly responsible for the material in my post. With all of which I agreed. FWIW  I read that he teaches at Princeton and with Robert Kuttner and Robert Reich founded The American Prospect and "closely advised the Clintons on health strategy in the 90s." I don't know whether that prejudices you for or against him. It doesn't affect me at all.

    You did what you could for the act. I can understand that you're unhappy  it isn't better. So am I. 

    What I'm not, is aggrieved with Obama. I think he got the best act he could given that his  60 Senate  votes required him to depend on Joe Lieberman, Ben Nelson, Max Baucus and Kent Conrad. Perhaps you think they would have voted for a public option. I don't. 

    Now it's law I very much want it to survive because I think that however flawed  it will help  a lot of people will avoid pain, debt and death .

    Having worked for the passage of the Act (good for you) I suppose that despite your unhappiness you want to see it survive. So I suppose you feel  your bitching isn't going to cause any one to vote wrong the November. 

    What I feel is you have to decide which side are you on. You're a vigorous and  influential writer and, you're going to reduce the Democratic vote next November. If that's not what you want quit writing stuff which will cause that to happen.

    If that is what you want , it's good to know where you're coming from.  . 


    by Flavius on Sat, 02/04/2012 - 5:31pm

    There are more than two sides.  I've written a lot of stuff recently, and it has little to do with the Democrats or the Republicans.  Which side are you on?   The side of people trying to think about how to change society, or the side of people who can't get enough of the stupid televised reality show that is the election campaign?

    I encourage everyone to vote in the stupid election, and as always to choose the lesser of two evils.  In the meantime, there is no point in wasting a lot of intellectual energy on that drivel.  I can't believe how much time is spent by people around here sniffing and analyzing the gaseous mouth farts coming from the Republican candidates.   Are you all that bored?

    I don't hate Obama.  I just don't think he is a bold leader, or that he has responded to the crisis of the past three years in a particularly insightful or meaningful way.   Like just about every other  politician in America, he works for the assholocracy, out of either preference or political necessity.

    Is it really necessary for everyone in America to admire or love some politician of choice?   Or to pretend to have some level of enthusiasm that nobody will by anyway?  You think if I jump up and down and start pretending I think Obama is awesome, anybody would believe me?  How can I pretend I don't thoroughly despise people like Daley, Geoffrey Immelt, Hillary Clinton and Leon , and the rest of America's corporate ratio leaders?   I hate them all, along with all of the Republicans.

    Why are the mainstreamers so determined to force the left into not just going along with some miserable duty to pick one candidate, but to also puke up their self-respect?


    by D Kervick (not verified) on Sat, 02/04/2012 - 11:49pm

    Geez Dan, if you find it all so irritating, why do you still hang out and comment?  Sounds as if you're the one that's bored or perhaps you are suffering from the need to indulge in a gaseous eruption such as you referenced. cheeky

     


    by Aunt Sam on Sun, 02/05/2012 - 12:39am

    I have an annoying compulsive habit if trying to influence people.


    by Dan Kervick on Sun, 02/05/2012 - 1:06am

    What do you want me to do? LEAVE? Then they'll keep being wrong!

    http://xkcd.com/386/


    by Verified Atheist on Sun, 02/05/2012 - 9:12am

    Why are the mainstreamers so determined to force the left into not just going along with some miserable duty to pick one candidate, but to also puke up their self-respect?

    surprise  indecisionsmileywinksmileyenlightenedenlightenedenlightened ......yesyesyes


    by Anonymous LULU (not verified) on Sun, 02/05/2012 - 1:13am

    Fair enough.

    Of course you have to be true to your beliefs. And I wouldn't argue with you about any issue other than health care.

    That's  not just a  theoretical debate,real human beings are affected. 

    If you're out of work, that's terrible. If you lose your house ,you're desperate. But if you are in pain from a cancer that could have been treated and would have  been if we did not have our disgraceful health care non-system ,  that's something that shouldn't be permitted by any society with pretensions  of being civilized.

    The ultimate test  : would I vote for Romney if I thought he would  actually be more  apt to save Obamacare than Obama ?. With  enormous reluctance I write : yes.

    Cheers


    by Flavius on Sun, 02/05/2012 - 11:32am

    Obama supporters do consider themselves to be the Left. When some who also considered themselves to be on the Left expressed admiration for Ron Paul, many were amazed.


    by rmrd0000 on Sun, 02/05/2012 - 12:18pm

    You keep focusing on personalities and labels, not policies, which is why you stay perpetually amazed.

    If you say the words "anti-war", "pro-constitution", "anti-corruption & patronage", "equal access to judicial recourse", it starts to make sense.


    by PeraclesPlease (not verified) on Sun, 02/05/2012 - 3:16pm

    As I have said many times in the past, we should simply not communicate. We do not agree on this issue along with many others. Argue elsewhere.


    by rmrd0000 on Sun, 02/05/2012 - 6:18pm

    How can the words "anti-war", "pro-constitution", "anti-corruption & patronage", "equal access to judicial recourse" make sense in and other them.  These have as much meaning as saying "hope" and "change."  What is critical is understanding what the politicians interpretation of those words (not the interpretation they want you to believe they have), how these interpretations will be influence and guide them development and implementation of policies, and what will be prioritized based on those interpretations.

    Of course, it will be an assumption and interpretation by each citizen that will develop their personal understanding of those things.  There is no way around that.  And based on those assumptions and interpretations of Ron Paul, it starts to make no sense.


    by Elusive Trope on Mon, 02/06/2012 - 11:21am

    And Ralph Nader points out the fraud and corruption in the health care industry. Something I have also harped on as well.

    Health care bills come with hefty levels of fraud. From the historic study twenty years ago by the then General Accounting Office of the Congress to the present estimates by the nation's leading expert in this field, Professor Malcolm Sparrow at Harvard University, fully ten percent of all health care expenditures are the result of computerized billing fraud and abuse. That will be $270 billion this year.

    Dr. Sparrow, an applied mathematician, says it could be higher if the federal government would simply do a more detailed study. He adds that the enforcement budget should be one percent of the estimable volume of fraud. In actual practice, the enforcement budget is less than one/tenth of one percent, even though every dollar of enforcement brings in at least seventeen dollars back. (See Dr. Sparrow's website: http://www.hks.harvard.edu/fs/msparrow/)

    Obviously the corporate fraud lobby is stronger than the taxpayer/consumer lobby in Washington, D.C. But why the health insurance companies, a formidable force in their own right when it comes to protecting its turf against single payer or full Medicare insurance (see singlepayeraction.org) do not do more to stop fraudulent billing practices, is a puzzle.

    All in all, the health care industry is replete with rackets that neither honest practitioners or regulators find worrisome enough to effectively challenge. The perverse economic incentives in this industry range from third party payments to third party procedures. Add paid-off members of Congress who starve enforcement budgets and the enormous profits that come from that tired triad "waste, fraud and abuse" and you have a massive problem needing a massive solution.

    Add to that the prescription laws the went into effect in the late 1930s which requires one to see a physician to get a prescription even if the condition is one that is continuing and only treatable. There by feathering the pockets of the physicians as well as the pharmaceutical industry.

    A nice little twosome that.


    by cmaukonen on Sun, 02/05/2012 - 1:28am

    OT...Chris...I really liked your diaries at FDL on Junk and Urban White Trash. I could relate to both of them. Very good writing.

    by trkingmomoe on Sun, 02/05/2012 - 3:53am

    I'll award myself the last comment.

    Whatever its weaknesses it's good that the Affordable Care Act (aka Obamacare or the ACA) was passed. Some people will now not die or suffer pain from conditions that will be cured and wouldn't have been without it.

    It couldn't have been passed  unless the drug and insurance industries were persuaded not to repeat their outright opposition a la Harry and Louise.  

    While the size of Nancy Pelosi's majority was encouraging ,what counted was the need for one vote each from  every one of the 60 democrats  in the senate. Which included Lieberman, and Ben Nelson  Let's see where are the  headquarters of  The Hartford and Mutual of Obama?

    While the voters' support  for the public option was interesting  ,what counted  was its being supported by  L& N along with Conrad and Baucus. And they didn't. And wouldn't  support an  ACA   including it. 

    No amount  of  "leadership" on Obama's part could change that.  A leader  in governing  is someone who gets to sign  a bill  that makes things better. Obama did.. End of story.

    Almost.

    I'll read Paul Starr's book and give you another long boring report. Unless one of you wants to beat me to it. Dan,  interested?

     

     


    by Flavius on Mon, 02/06/2012 - 1:43am

    I'm not one to lionize Obama (and neither are you), but I am 99% certain I'll vote for him in November (most of the remaining 1% uncertainty arises from the possibility of my death, incarceration, etc., but there's also a very remote possibility something will change my mind).

    You raise a very good point that this might have been (close to) the best we could have gotten passed with the Senate we had.


    by Verified Atheist on Mon, 02/06/2012 - 7:01am

    I understand the stimulus being too low but by April of 2009 I think he should have reduced Geithner's influence .

    I think he's not fought hard enough against the use of military tribunals.

    I think his education policy places far too much emphasis on high stakes testing.

    But on every such issue Romney would be worse (none of the other R candidates are even worth discussing)

    And on health care Obama hit a home run but the dagblog umpires missed seeing the ball go into the net.


    by Flavius on Mon, 02/06/2012 - 8:00am

    It's cute that Avishai has deputized himself with the authority to tell the left which of our beliefs are conscionable and which are not.  When it comes to the ACA I can accept that Obama got the best he could out of his own fractured party.  Blue Dogs and Nelsons and Liebermans can't be counted on for much.  I get it.

    What I don't get is why Avishai's having such a fit over this. What does he think that progressives owe Obama?  Our money?  Our time?  Our silence when we disagree with him?

    Avishai and I could argue endlessly about whether or not information tech can drive down the cost curve without single payer.  Actually, I suspect he's even right.  We are better now at integrating systems than we were thirty years ago.  Where we're not going to ever agree is on the moral issue.  I don't think the government should mandate that I buy health insurance if the government isn't going to offer me a public option.  I also don't think that the ACA should force me to buy my employer's plan of choice rather than letting me shop the local exchange if I want to.  Whatever.  These are policy disagreements.  How does it hurt Obama for us to argue about them?

    I don't know any liberals who are actively harming Obama.  Is Avishai's complaint that they are simply not excited enough?  Or is it that we somehow undermine the president by expressing dissatisfaction?

    The other mistake that Avishai makes is in thinking that dissatisfaction with Obama is all about health care.  It isn't.  I'm miffed that he put Geithner in charge of the Treasury and that he signed a PATRIOT Act extension without even suggesting revisions (at least in public).  I'm miffed that he has allowed his surrogates to repeatedly malign lefty Americans.  The ACA would be a lot easier to take if it wasn't part of a pattern of illiberal decision making that started when candidate Obama went to the Senate floor and voted for telecom immunity.

    Avishai is missing the larger picture and his message seems to be nothing more than, "Shut up, liberals."  Which is exactly what we heard from Rahm Emmanuel back in 2009. 


    by Michael Maiello on Mon, 02/06/2012 - 12:53pm

    Des, it doesn't undermine the President when the folks who want to continue to discuss, on and on ad infinitum the merits or lack-of-merits of ACA.

    But I am going to offer this to you from an example you supplied above: you don't like that you can't pick whatever insurance you want, whether it is through your employer or an as of yet uncreated exchange.

    Wow, every poor person who has never had access to any kind of insurance, who has never had a primary care physician, who has only used the Emergency room as their access to health care, who had never had a yearly checkup, wishes their only worry is that they want more choices in their plans.

    When you are poor and you work your employer for the most part doesn't offer health insurance to their employees. Or as in the case of WalMart and those kinds of employers they don't adequately subsidize plans so their employees can afford to purchase insurance, they also have a habit of offering substandard insurance policies as well, they screw their non-unionized employees over every single day of  the year. We must stand up for them.

    This bill was always about the 45 - 55 million uninsured people in America. There were things thrown in the bill for you and me, kids being on your insurance until they are 26, and a whole host of other things like that, but this bill isn't for you, it is about getting the uninsured access to basic health care.

    You all need to accept this fact and accept that the working poor deserve this, especially if you believe everyone has a fundamental right to health care, whether you are rich, poor or middle class. Suck it up hon, this time, this legislation just wasn't about you or what you want.


    by tmccarthy0 on Mon, 02/06/2012 - 1:32pm

    I agree with you, TMac.  It's easy to forget that the point of the legislation was insuring the uninsured.  It's exactly the kind of thing I'd have wanted back when I was an hourly retail worker who'd wind up with expensive pneumonia every winter.  I get it.  And, you're right, the uninsured deserve that.

    The issues left on the table though, which I think Avishai wants to avoid, is that private health insurance is not a great deal for anyone, when measured by bang for buck.  The big problem with not throwing a bone to the currently insured is that after the ACA past, premiums went up pretty much across the board.  Now, you and I both know that they would have gone up anyway.  They went up every year under Bush, who had no interest in wide ranging health care legislation at all.  But still, ACA past and everyone who already had insurance saw their bills go up.  That's no way to make nice with the middle class.  But, again, we've been through this.  Also, I doubt you're the one I need to spend time trying to convince.

    My real problem with Avishai has nothing to do with the details and everything to do with his self appointed authority, his hectoring, his lecturing and his failure to recognize that Obama's friendly critics on the left can't be reduced to a bunch of whiny children who are still mad about the ACA two years later.


    by Michael Maiello on Mon, 02/06/2012 - 1:50pm

    Private health care is expensive Des, just as public health care is, like NHS.  The fact is that in Europe, in places like Great Britain, they don't just have the NHS, that is for the very poor, as many people in GB also purchase health insurance through private plans, which gives them better access to services, even in the socialized world there is class disparity, except that everyone has access. The public system itself, is extremely expensive, (I know more about NHS than other systems although I have some experience with research into the French system), those public systems don't experience fewer spending funds, but as the demographics change and society ages, those expenditures always rise, no matter what system we are observing and/or analyzing. The fact is American have a habit of wanting to pay fewer dollars but receive the same services for those dollars, and that just isn't logical, but conservatives have convinced them it is, and democrats, liberals and progressives have been unable to alter that narrative in any significant way.

    Avashai wants to keep the argument the same as it has been from the beginning, continue to pit the like minded against each other instead of discussing facts, facts that could indeed alter the discussion.

    • Fact: health care is expensive.
    • Fact: we are going to spend more money on health care per person, now and in the future.
    • Fact: we can keep some costs from rising too quickly but we cannot keep them from rising over time. 
    • Fact: insuring the 45-55 million uninsured in America outweighs waiting for something better.
    • Fact: Americans will have to pay more whether that system is entirely public or private or a hybrid of sorts like European systems.

    The American public has failed to demonstrate they are willing to accept the fact that they must demonstrate a willingness to pay for a "public option" if it is to happen. In that their paychecks will appear smaller, I am pretty sure this will not happen in the near future.

    But yeah, we mostly agree. I just stay away from those kinds of writers, because their purpose I believe is to keep the controversy alive. Keeping that controversy alive serves the purpose of selling his book or get people to read his papers or column or whatever, but doesn't address the need to convince the non-political public, how important this legislation is, why it is important and how to continue to make the system better.


    by tmccarthy0 on Mon, 02/06/2012 - 2:37pm

    What I don't get is why it's so hard to communicate the truth: your paycheck is going to appear smaller anyway.  It doesn't matter if the government or Aetna takes the money.  Well, it does.  Because Aetna might take the money and give it out to its shareholders as a dividend.  The government would have to, you know, deliver health care with it. Sigh.


    by Michael Maiello on Mon, 02/06/2012 - 3:10pm

    Des, continuing to argue amongst ourselves over this erases opportunities to work towards a stronger bill. We are lost in the intricacies of a policy battle, of which the general public cares little, rather than affording ourselves the opportunity to defend the bill, using the victory to get more liberals elected to congress, and continuing on the crusade to make it better. That is exactly what I think.

    By-the-by Aetna, et al are now required by regulation to use 85 - 85% of premiums to deliver health care. Another regulation imposed by ACA, that private insurers hate and oppose, too bad. It is one more example that the bill works.


    by tmccarthy0 on Mon, 02/06/2012 - 4:26pm

    I believe that as more boomers enter Medicare we will finally see the national discussion go more towards the level that I wish to talk on: money-driven medicine. And hopefully get off the focus on the "evil insurance companies," which anyone who has had to deal with serious health care problems these days comes to realize is really a drop in the bucket of the problem and a distraction from the real problem.

    I sometimes find myself reading these same old arguments in the blogosphere and wishing so hard that there had been a teeny lousy public option in the bill just so everyone would realize it's no panacea to the real problems of cost and care in this day and age and just shuddup about it. I figure I have to wait now until more are on Medicare for the discusion to get real.

    You can't research a health problem on the internet for yourself or  a family member without finally coming to grasp that money-driven medicine is what we really have to deal with internationally, and all the ramifications about how medicine is practiced, how medicine is sold, how innovations are deal with, etc.

    For one instance, I recently was trying to figure out what to do about a really bad case of sciatica type pain. So I go to American forums about it where everyone is bitching that the doctors here send you for  all the MRI's and cat scans and then want to blame it on a herniated disc and want to do surgery on the herniated disks when there isn't sufficient evidence that that helps, but they won't give you a prescription for pain meds. Then I go to UK forums on the same and find everyone bitching that they can't get the docs to give them an MRI, that all the docs are doing is giving them pain meds On either side of the pond, neither are getting the intensive physical therapy that would probably work best for most, because of monetary choices (on one side, for profit reasons, on another for saving money reasons.)

    Another example on a different level: they've recently had a big controversy about a certain company's breast implants in the UK and France, that the implants are dangerous and should be removed Now everybody who got one of those high tech innovations probably paid for it out of pocket, so then when it comes to the health complications of who pays for that, does the NHS, where's the liability, how do we prove a complication is related, should the taxpayers just pay up the kazoo, nobody was forced to get a breast implant, how much, yadda yadda yadda. ad nauseum.

    High tech medical innovation makes for a moral mess, whether it's a for-profit system or a totally non-profit national health service, and everything inbetween (money is the consideration--on one end, profit making by providers, on the other end, saving money for taxpayers.  What happens when all the boomers want a state-of-the-art nanotech knee surgery on Medicare's dime? Or there's a story going viral on the internet that Medicare is supposedly lying that a certain generic is a fine replacement for a new innovative brand name drug?

    Right now we have a lot of people on Medicare getting bad treatment, we have a supposed explosion in old-age dementia, which is really far too many serniors taking far too many drugs from far too many specialists, making them loopy. No one is coordinating what drugs they are taking, there aren't enough gerontologists nor anyone gatekeeping their care.. That's one way the "public plan" we already have is not working, just profiting the drug companies, and some specialist's pockets, of course.


    by artappraiser on Mon, 02/06/2012 - 4:03pm

    Wow, well said AA, thanks for weighing in, I agree completely.


    by tmccarthy0 on Mon, 02/06/2012 - 4:27pm

    Thank you, but it the was the highly focused quality of your comment that gave me the inspiration to come up with some lucidity. Usually I just look at health care discussions and go aaargh! why bother!


    by artappraiser on Mon, 02/06/2012 - 5:12pm

    tmac, 

    Why is it that everyone thinks that we would have to mimic Canada or other nation's programs?  I would hope we would learn the good, bad and ugly about these and 'design' a better process.  Now there's a blog that needs to be done (IMHO). wink


    by Aunt Sam on Mon, 02/06/2012 - 9:45pm

    Auntie,

    That is a damn good question, I would love an answer, but I sure don't have one. You are right though, that would be an excellent subject for a blog!


    by tmccarthy0 on Mon, 02/06/2012 - 11:05pm

    I say we choose someone and harangue them until it's posted!


    by Aunt Sam on Mon, 02/06/2012 - 11:19pm

    Yes, we are always going to have to make morally difficult decisions on what percentage of our total resources to spend on health care.  Health care is a finite good; and it always costs something to produce.  And there will always be expensive new technologies expanding the boundaries of existing capabilities.  Al we can ask is that the care options that exist at any one time be distributed equitably, and that we do what we can to limit the waste and inefficiency that can gum up the delivery of what health care goods we happen to posses - especially the inefficiencies that come from granting extravagant rewards to some of those who work in the delivery system.

    A public option for delivering health care would be an excellent way to get the public foot in the door, and to begin to drive down costs, by forcing private sector providers to compete with lower-cost, not-for-profit public alternatives.


    by Dan Kervick on Mon, 02/06/2012 - 10:08pm

    As Arrow suggested 50 years ago and Dean Baker last week, we could  train more doctors, immigrants if necessary and even under the good old market economy some of them would charge less in order to get market share.

    Even under the exchanges and no public option system ..........

    o procedures costing over X should automatically be elevated for review. You don't really need the MRI of the week.

    o every blood test  should go into your personal history. Charted.

    Usually if a specific result is abnormal the last score is also reported. But just the last test. A hematologist looked at one of my counts two weeks ago  and said he really wished he had more history.

    I did. At home on pieces of paper.

    From which I extracted the data ,charted it and sent it to him..

    Seems to me that besides being alerted when one of my specific items went abnormal it would have been more than merely interesting information if a chart showed what was in fact the case that over a couple of years and a number of tests that count for that item had been  trending  directly towards the abnormal score it  reached last week. But for that to happen somebody had to have had it assigned. 


    by Flavius on Mon, 02/06/2012 - 10:53pm

    Flavius,  Isn't this what Obama keeps talking about, a central data bank that medical professionals can utilize (from password patient delivers)? 

    Have you given any thought to doing a blog about ideas for a positive healthcare system?  hint.cheeky


    by Aunt Sam on Tue, 02/07/2012 - 12:08am

    I suppose what I describe is a small part of what Obama has in mind. 

    By accident  I  had a concrete example  as I sat with one of  New York's Best Doctors and he was handicapped by the lack of information sitting on pieces of paper in my files.

    I'm certainly open to the charge that I am being overly optimistic about the impact of such a specific improvement and that health care costs can only be reduced by some major change. Rationing is usually evoked.

    Maybe true.  Or maybe the solution is a "cocktail" : a composite of  measures rather than one major change. So major that it will clearly never be made and therefore we're told  to just give up and let the poor die on the door step of the locked Emergency rooms.

    Obama isn't talking about shrinking  our medical costs but about bending  the cost curve.Seems like a reasonable approach.  

     


    by Flavius on Tue, 02/07/2012 - 9:50am

    Fact, the US is paying twice as much ($5711) as the UK ($2317).

    So why should we pay *more* when we're already paying twice as much as the UK, and much more than any developed country. 

    http://www.creditloan.com/blog/2010/03/01/healthcare-costs-around-the-world/

    So what happened to containing health costs? Instead we're on the hook for more outrageous increases. Yes, we're getting screwed.

    Why should we "pay" for a public option? It should save money by pooling together the ranks of the insured. It should lower costs through better bargaining position and managed care. 

    We're paying for the luxury of supporting lots of inefficient billing departments who are figuring out more and better ways not to pay claims that they should.

    Like Bain Capital, we're paying for the privilege of letting them skim off the "healthy" patients and pass on costs for the sick to the government. Why is that model surprising? It's the way our scumbag capitalist leech system has evolved, primarily because we let it evolve.

    #Occupy Big PhRma.


    by PeraclesPlease (not verified) on Mon, 02/06/2012 - 4:00pm

    If your hoped for public option is fee-for-service like Medicare, where everyone can go to all the specialists they want and get all the high tech and brand names they want, you won't see that ratio change very much. They don't hand out MRI's like candy at the NHS, Medicare does. It's not the piddling insurance cos' profit that is the cost problem differential. It's the lack of coordinated protocols, it's allowing the market to decide via manipulation of the end customer who thinks he/she should be empowered to choose everything he/she wants from the hugely profitable medical marketplace at the cost of the taxpayer. Yes, we do need death panels, if you want to call them that. Yes, civil libertarians left and right will always be screaming about their decisions. And yes, like always, in every country, the rich can get all the newest health care thingies and the poor and middle class can't. But guess what, sometimes money is stupid when it comes to health care, look at the Steve Jobs case for instance.


    by artappraiser on Mon, 02/06/2012 - 4:18pm

    Yeah, right - my wife went through a year of cancer treatment in a much less prosperous country, and all the procedures were very well coordinated, including CATscans, MRIs, various transplant treatments, et al.

    Daughter had similar access to a myriad of treatments - much easier to get coordinated than in the US - my father had bulging legs from some lack of circulation or other, but his doctor who handles about 200 seniors by his lonesome didn't even notice.

    This is the myth of the huge waiting lines in other countries, and the always exceptional US.

    Here, look at another chart - piece together the URL - 

    (www) kff.org/insurance/snapshot/OECD042111.cfm


    by PeraclesPlease (not verified) on Mon, 02/06/2012 - 4:32pm

    Um, I for coordination, ala NHS, not against it. Fee-for-service, which Medicare is, doesn't have any coordination beyond setting amounts it will pay for certain things, and declaring some things not covered as medicine. The patient  does his/her own coordination if any.

    And nowhere did I make a "waiting lines" argument. I basically implied that physicians there do not immediately offer MRI's for every mysterious pain, as is becoming common in the US. Because there are so many MRI facilities in the US. Because they are so profitable. Because the huge Medicare market will pay them a certain amount per scan and the US insurance companies will basically go along with what Medicare does......


    by artappraiser on Mon, 02/06/2012 - 5:02pm

    Aha, got your argument reversed. Thanks for clarifying.


    by PeraclesPlease (not verified) on Mon, 02/06/2012 - 5:06pm

    There is hope (truly) in the air with the training of new doctors. I found one (after a costly search, costly in time, money and pain) who has recently used a turn of phrase that I approve of highly. I am not insured, pay out of pocket. When discussing treatment options, I went through what I had learned from experience with the providers I hadn't been happy with and my own research throughout. .And I explained why I would rather not have an MRI at this time, not just because of having to put it on a credit card, but because I thought it might cause him to misdiagnose and that would lead me down a path of more wasted time and money. I wanted it to be the last option, not the first.. He said that though he would still love to have MRI input, it wasn't totally necessary to proceed and that:

    We treat the patient, not the test

    I think that is really a key to a lot of our cost problems, the whole system is set up to do tests and then treat what is on the tests with drugs or surgery; doctors using tests instead of listening to patients symptoms and using their brains is causing a lot of iatrogenic illness in this country, and iatrogenic illness is a big part of the cost problem. I've been through enough experience now with elderly and sick relatives friends and acquaintances to see it. Doctors making people sicker by treating tests, giving them drugs and treatments they see in advertising, especially Medicare-aged people, and then treating them for the adverse effects of what they've been getting and then treating again. It happens especially if people don't have a coordinating primary care doc. (The specialists do not talk to each other, you'll hear that complaint time and again from many seniors.) That's a great money maker for the medical industrial complex, I think it's a big part of why it's such a big proportion of our GNP.  It's basically evidenced in Atwal Gawande's articles in the New Yorker about differences in Medicare costs at different hospitals..

    Docs also have had so much continual development in high tech and profit-making drugs to keep up in the medical journals, with that they have no time to investigate non-profit treatments like, um: vitamins or massage or physical therapy. There's no profit for medical research in vitamins or massage, nobody willing to pay for studies like that except the government or non profits.

    If my doc got that phrase from medical school, I think there is hope.


    by artappraiser on Mon, 02/06/2012 - 5:43pm

    The waiting lines argument had its day in the sun under the  reign of the good queen Maggie. 

    Somehow when I thought  of her  my mind went to Non sum qualis eram bonae  etc. etc.   "things are not as they used to be under the reign of the good queen Cynara" .Resurrected by Cole Porter,naturally , as 

    "I'm always true to you darlin in my fashion"

    She created lines in the NHS and talking points for the AMA.  I had at least one daughter living in London from 1980 to 2010 so I was kept posted as Maggie's waiting lists went from days, to weeks, to years, to forget it. And were then reversed during the Blair/Brown epoch..

     If she hadn't wanted there to be lines , there wouldn't have been.Since there were, she did.

    ......................................................................................................................

    Hadn't realized that Avishai had bruised so many feelings here.  Probably he feels the same way and whines about the liberals' circular firing squad.

    . I'm reminded of the final line of a Henry Green novel

     

        And the next day they all went on the same

    Cheers.


    by Flavius on Mon, 02/06/2012 - 10:19pm

    I think maybe a sports analogy works.  Avishai sess Obama as the head coach whose team has been riddled with injuries, and what players he can put on the field are mediocre.  The team would be lucky to go 8 and 8, and miss the play offs.  But he is able to motivate and develop a game plan that allows to scrap their way to 10 and 6 record (with a lot of close games) and into the playoffs.  They go up against a superior team in the first playoff game and lose 17 to 16.  He sees the liberals as if they were the fans who are calling for the coach's head because they didn't blow out the other team on their way to the Superbowl.   As Avishai writes in the beginning:

    Nobody with a sense of history—that is, nobody who reads Starr’s book—could doubt how sensible and brave was the president’s effort to drive the Patient Protection and Affordable Care Act of 2010 through Congress.

    So it seems he is coming from the point of view that people need to contextualize the actions taken (and not taken) not only within the realities of the present moment when they occurred, but also within the flow of history which led up to this moment. 


    by Elusive Trope on Mon, 02/06/2012 - 1:48pm

    Or 

    the world wasn't created yesterday

    Mary McCarthy.

    I wish I said it, but she did.


    by Flavius on Mon, 02/06/2012 - 10:21pm

    I'm one of those not satisfied with Obama care ... it failed to go for the first down. And I don't so much blame Obama as I do the Senate for letting their personal ideology interfere with the legislation and allowing the GOPer's carte blanc access to make it useless, open to criticism and open to funding cuts one little cut at a time to let it die a slow death.

    That said, here's an interesting discussion I heard this week-end from Up with Chris Hayes and pretty much nails my opposition to the Obamacare the Senate pork machine produced.

    During the discussion concerning over women's conception with Obama's new policy and religious hospitals anger over being forced to provide reproductive services that go against their religious beliefs, Mellisa Harris-Perry said the following.

    " ... in order to accommodate real concerns with the ability of the faith community to practice their own faiths, heathcare and health insurance should not be provided through employers. It ought to be a right of citizenship not to an organization of workers because one's health care needs and prescriptive services should not be at the behest of their employer ... "

    I've parsed to to make my point understandable. Ms. Harris-Perry eloquently says what I haven't been able to articulate. I have had multiple heathcare plans and each one is dependent on how much the employer was willing to provide. One actually provided a vision plan, but the employee had to pay both the employer and employee fee for the service. Furthermore, there have been a number of recent news reports where employees of religious-based entities have had issues over employee rights with the court system refusing to get involved with the state refereeing an employee vs religious institution.

    That said, Obamacare doesn't address the fundamental issue ... removing a disinterested party from the personal healthcare process of citizens. And employers have no skin in the game since back in the day when Ford Motor Company was mass producing autos off assembly lines, they forced the government to back off considering government health care because it would be cheaper for businesses to provide their own.

    Too bad the Democrats didn't compare the multiple heathcare plans on the market, both group and individual, and their costs with one comprehensive universal plan laying out what services would be available and the cost to each citizen. That may have turned the tide in UHC's favor by the public.

    BTW ... here's the url to the discussion I have used. The talking-point I used is found at the 15:25 mark.

    url : http://www.msnbc.msn.com/id/3096434/#46271969


    by Beetlejuice on Tue, 02/07/2012 - 10:48am