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November 5, 2004

Marching orders
Posted by Teresa at 10:00 AM * 47 comments

Atrios has helpfully identified Really Bad Ideas That the Media Loves and Democrats Must Resist. These include privatizing Social Security (“this will just be the Treasury Looting Act of 2005”), medical savings accounts, tort reform, bankruptcy reform, and further tax cuts (“the bond market’ll snap like a twig at some point”). Read the piece. Take the points. Spread the word. Write to your elected representatives. Because Atrios is right—and a miserably impoverished old age is nothing to look forward to.

Comments on Marching orders:
#1 ::: Ginger Stampley ::: (view all by) ::: November 05, 2004, 10:27 AM:

I was talking to my mother this morning about the election and Bush's "moral values" and I told her that my moral values included keeping old people from starving in the street. There's your moral values sound bite.

#2 ::: Kathi ::: (view all by) ::: November 05, 2004, 11:01 AM:

I was talking to my mother this morning about the election and Bush's "moral values" and I told her that my moral values included keeping old people from starving in the street. There's your moral values sound bite.

Thanks, Ginger--that's a much better sound bite than the ones I was wrestling with, like, "Big Business plays with the environment--can you afford a maid to clean up after them?" or "As a child, my grandfather rode to church in a buggy. I didn't think my grandchildren would, too."

I'm afraid moderates need to learn good spin--fast.

#3 ::: elizabeth bear ::: (view all by) ::: November 05, 2004, 11:29 AM:

my moral values included keeping old people from starving in the street.

Ginger, thank you for a snappy comeback I'm going to keep and use, and use, and use.

#4 ::: mayakda ::: (view all by) ::: November 05, 2004, 11:54 AM:

Ginger, excellent. I'd like to quote that.
And not to be blog-ho-ing (or just this once anyway), I started a new blog called votermom. It's my response to Lakoff's challenge to reframe.
My hope is that it will mutate into a shared blog at some point.

#5 ::: Stefan Jones ::: (view all by) ::: November 05, 2004, 12:14 PM:

That MoveOn ad that shows kids working in factories could be repurposed.

If fact . . . how about another ad contest, for pieces that specifically oppose the stupid ideas?

#6 ::: pericat ::: (view all by) ::: November 05, 2004, 12:20 PM:

my moral values included keeping old people from starving in the street.

I like that. It's a repeatable.

As long as we're sharing moral values, these are the ones I've been holding: Feed the hungry. Heal the sick. Clothe the naked. House the homeless.

I'm not much of an original thinker, of course.

#7 ::: Linkmeister ::: (view all by) ::: November 05, 2004, 01:32 PM:

This needs work, but:

"Privatize Social Security. The brokers are broke."

That's something that hasn't (to my knowledge) particularly been mentioned in the debate(?) about this idea. It's basically a billion-dollar giveaway to Wall Street. It's one of the reasons those folks were among the heaviest contributors to GWB.

#8 ::: Bill Humphries ::: (view all by) ::: November 05, 2004, 01:48 PM:

I think the appropriate response to the privatization scam is a photo of a gold watch, a bottle of vodka, and a handful of sleeping pills with the caption:

"Your New Retirement Plan, courtesy of the GOP"

#9 ::: Katherine Mankiller ::: (view all by) ::: November 05, 2004, 01:49 PM:

My moral values include voting against gay marriage amendments. "Whatever you do to the least of these, you do to me." Doesn't that mean that if you tell a gay couple that their love means less than the love of a straight couple, you tell God that His love means less than the love of a straight couple?

Enshrining hatred and intolerance in a state constitution is not a moral value!

#10 ::: mayakda ::: (view all by) ::: November 05, 2004, 01:58 PM:

I'm such a political newbie, so here's a naive question.

Is it a good thing to support moderate conservative republican senators, or should we let them lie in the beds they made?

It looks like Sen Arlen Specter(R)from my state is already being bullied by more right-wing senate Repubs. Specter, in his victory speech, said it was "time to rebuild the conservative middle" and that he considered Roe v Wade inviolable. He's the lead candidate for judiciary committee but his remarks have him under attack from the neocons. Google on "Specter" in the news tab to see some attacks.

Is the enemy of my enemy my friend?

Link to interview with one of "them" that left me queasy.

http://www.salon.com/news/feature/2004/11/05/viguerie/

#11 ::: Alex Cohen ::: (view all by) ::: November 05, 2004, 02:29 PM:

It's not a naive question at all; it's vitally important. In 2006, there are only three Republican Senators up for reelection from states that Kerry carried: Olympia Snowe (R-ME), Lincoln Chafee (R-RI), and Rick Santorum (R-PA). Now Santorum is an idious bigot and deserves to be defeated, but Snowe and Chafee are quite liberal, except for their vote for Majority Leader. Should we expend our efforts to defeat them?

There are a further six R Senators up for reelection from reasonably purple states, and frankly I'd rather concentrate my resources building up the Democratic party infrastructure there, while waiting for Snowe and Chafee to resign on their own schedules.

#12 ::: fidelio ::: (view all by) ::: November 05, 2004, 02:32 PM:

mayakda, I'm very much inclined to the idea of recuiting from among their disenchanted. In the case of voters, reminding them of things like Teresa's "Just because you’re on their side doesn’t mean they’re on your side," and such is worth while, especially when paired with specific citations and reasons. In the case of elected officials, like Specter, we have to work carefully. Make it plain what you expect from them, and that your support is strictly conditional on getting it. If any, such as Lincoln Chaffee, or possibly Snow and Collins [from Maine] show signs of bolting, even if only to become independents, they need to feel supported, not as if they now have no safe place left. People like Specter can get to taking you for granted, though, so they need to know that your support has definite and specific limts and expectations tied to it--or else.
I do believe that the Republicans, having won this election, are now going to try "cleansing" their own ranks--and these people will need a place to go. I don't want to slam the door in the face of people like my brother-in-law, who this year bit the bullet, voted for a Democrat for president for the first time in his life, and even put out a yard sign [until it was stolen, but that's another story]. I want my party to benefit from them, if at all possible. As the archives of the Shrillblog show, there were plenty of doubters in the old ranks, who may need a new place to be soon.

#13 ::: Larry Brennan ::: (view all by) ::: November 05, 2004, 03:01 PM:

Alex - I have to disagree. I think that the best way to make progress in Maine or RI is a two part strategy. The first part is to field a very strong candidate (I know nothing about local politics in either state, so I have no idea who that would be) and to get the Republicans to eat their own.

Snow and Chaffee are RINOs. If you can get them to face a stiff primary challenge, it'll be easier to beat them. The problem in PA this year was twofold. First, Specter won the primary and second, Hoeffel just didn't have enough backing from the party, and may not have been the best candidate to begin with. (Again PA politics are a mystery to me.)

I'd really like to see Santorum de-elected in '06. Hopefully PA will agree.

#14 ::: Steve Eley ::: (view all by) ::: November 05, 2004, 03:25 PM:

Hmmm. As one who believes both in helping people when they cannot help themselves, and in taking personal responsibility for helping oneself, this probably is not the thread for me. And I'm quite done with arguing about Social Security. But the Devil's Advocate reflex is irresistible sometimes...

Medical savings accounts strike me as a wonderful idea and the only sane option for someone who doesn't incur a lot of health care costs. I have read up on the criticism against them, and it seems to boil down to "They're too good an idea." The risk is that they'll remove all the relatively healthy people from the pool of traditional health insurance, and because healthy people are the ones funding payouts for unhealthy people, the insurance plans fall apart and everything becomes even more expensive for everyone, and fewer will be able to afford it.

It's a valid objection. My answer to it is, everybody knows right now that traditional health insurance is screwed anyway. If the MSA is the bullet that finally puts it out of its misery, perhaps that's not such a bad thing. I don't have all the answers, but I do know that the catastrophic insurance that underpins MSAs is dirt cheap, and there's no good reason why employers or the government can't subsidize your MSA instead of subsidizing standard insurance. It'd still be cheaper for them, and cheaper for the employee's portion as well.

For people without jobs (who are screwed today), perhaps a certain "floor" MSA can be made free to everyone that at least offers the catastrophic portion, funded by interest from all the other accounts, with the deductibles to come out of Medicare. Or perhaps a hybrid health plan could flourish, where you pay into an MSA and a more traditional pool at the same time.

I don't really know what the perfect system is. I do know that I'd like to see MSAs become more available, and consumer responsibility and smart shopping become a more active force in health care. People should help other people, yes. But forcing people to stay in a plan that's far worse for them than they can do for themselves -- that only hurts the community, it can never improve it.

#15 ::: Robert L ::: (view all by) ::: November 05, 2004, 04:33 PM:

a miserably impoverished old age is nothing to look forward to

I expect to be found with a red pencil clutched in my cold, dead hand.

#16 ::: Lis Carey ::: (view all by) ::: November 05, 2004, 04:35 PM:

Steve, the flaw in your argument is that almost no one is healthy forever. The vast majority of the people who are "in a plan that's far worse than they can do for themselves" will someday--quite possibly tomorrow, with zero prior warning--be in a position where they need more care on an ongoing basis that MSA+catastrophe insurance will give them.

MSAs "work" for people who are young, healthy, and well off. Ordinary working people can't put aside enough untouchable money to make a difference if they get sick and need care.

All you're doing is arguing against the whole idea of insurance in favor of letting those who have health problems do without, because no one will be able to pay for it, while those who don't currently need health care are encouraged to imagine that they will never need it.

I have asthma. I have never seen a "catastrophic" plan that would have covered my hospitalizations for asthma, but at the same time, I've never had so much disposable income that I could have afforded to accumulate and tie up the capital needed to cover them myself. This is particularly true because, the first time, I was recently out of school and had school loan payments to make, as well as rent to pay, and I was a relative innocent in the ways of asthma: I'd been reasonably careful about my medication and trying to avoid known triggers, but I'd never had a full-blown asthma attack like that, AND I had no idea that the seasonal difference between MA and MD would result in a much higher concentration of my known triggers in MD at that time of year.

On another occasion, I'd had no idea that getting the flu would do that, and no one told me.

On yet another occasion, I'd learned the flu lesson, and had had my shot--but in July, I got something that was probably West Nile. The practical effect was the same as getting flu, with the difference that there was nothing I could have done to avoid it. No West Nile vaccine.

This year, of course, even though I'm "high risk", I'm unable to find a flu shot anywhere. I'm terrified, and more terrified because, this time, I have a much higher deductible than on the previous occasions. Thisi s not because my employer is nasty and cheap; my employer has actually worked pretty aggressively to keep benefits very good but cost to the employee managable. What's screwing us over is health care as a for-profit industry, the multiple additional layers of management to make sure that no one gets anything paid for that the insurance companies can avoid paying for, and the hugely inflated salaries and bonuses of people who contribute nothing to actual delivery of actual health care.

As for "consumer responsibility and smart shopping", how would you suggest that I engage in either one when I'm not able to breathe? When I can't breathe, I call someone who can help and let them help; judgment, on my part, has to wait until I won't actually die if I spend time asking questions.

#17 ::: Larry Brennan ::: (view all by) ::: November 05, 2004, 04:59 PM:

Lis Carey: MSAs "work" for people who are young, healthy, and well off. Ordinary working people can't put aside enough untouchable money to make a difference if they get sick and need care.

You hit the nail square on the head. How dare little people ask for health care! The gall of them.

MSA's are the first step in making sure that only the right people get medical care. The argument that we can't afford universal health care is laughable. People aren't dropping dead in the streets of Canada or the UK, last time I checked. And they don't seem substantially worse off than we are either.

There's a common argument that the US has the best health care system in the world. I'd argue that we have the most advanced system, but if we had the best, it would be more cost-efficient and we'd live longer and have lower infant mortality than other industrialized countries.

Of course, the right people do live longer and have low infant mortality.

We choose not to have universal health care, because of our twisted values. When wealth is equivalent to virtue and greed is lauded as civic responsibility, we all suffer.

Individual responsibility is to be encouraged, but people should not be held responsibile for things they cannot control, such as the wealth of their immediate familiy and the bad luck of getting sick.

[/rant mode]

#18 ::: Steve Eley ::: (view all by) ::: November 05, 2004, 05:11 PM:

Lis Carey wrote:
MSAs "work" for people who are young, healthy, and well off. Ordinary working people can't put aside enough untouchable money to make a difference if they get sick and need care.

And yet they can pay two or three hundred a month in insurance? Because that's pretty much the amount it would take.

That said, your asthma example does make a good point. Perhaps the best approach might be some sort of hybrid system, where one-time emergencies are covered by MSAs: the flu, heart attack, getting bit by a charging iguana (don't ask). Chronic care conditions, like asthma or cancer or other ongoing costs that aren't catastrophic but would quickly drain an MSA, are covered by traditional insurance, which everyone carries (because you never know when you'll get sick like that) and which would be a lot cheaper than it is now. And then you might have a low-end preventive medicine plan as well, to cover routine checkups, getting yelled at about your cholesterol, etc.

I don't know what you'd do about pregnancy. It's expensive, but doesn't seem to fit neatly into any of the above categories. For that matter, I don't know how MSAs handle it now.


What's screwing us over is health care as a for-profit industry, the multiple additional layers of management to make sure that no one gets anything paid for that the insurance companies can avoid paying for, and the hugely inflated salaries and bonuses of people who contribute nothing to actual delivery of actual health care.

Yes, exactly. That problem could be sharply reduced by making the fundamental transaction a consumer-to-doctor or consumer-to-hospital transaction for most services. That to me is the main benefit of MSAs.


As for "consumer responsibility and smart shopping", how would you suggest that I engage in either one when I'm not able to breathe?

You don't, obviously. When you can't breathe you go the nearest emergency room. And then, when you can breathe, you interrogate them over each and every line item on the bill until you understand exactly what it was and where it came from. A huge fraction of hospital bills contain errors. If it's too much anyway, you're probably stuck, unless you decide to move somewhere with cheaper ERs.

But for non-emergency medicine, you can shop around. And that'll be a whole lot easier if we can move toward a culture where medical offices can easily tell us what their prices are.

#19 ::: Larry Brennan ::: (view all by) ::: November 05, 2004, 05:21 PM:

Steve - stipulating that saving $200-300/month would be sufficient for most individuals, why is that inherently better than putting that money into one big MSA (called insurance) and letting the big buyer (insurance company or government agency) duke it out with big sellers (HCA or HealthSouth, for instance)?

That at least provides some parity in market power between the parties involved in the transaction. Now all that needs to be created is an incentive to actually keep the insured healthy.

I think Kaiser Permanente is a pretty good model for providing affordable health care. They are actually quite agressive about prevention, and while they can be bureaucratic sometimes, my experience with them has been better than it has with any for-profit insurer.

By the way, I've been fortunate enough to never have been really sick. I'd still rather have good insurance on a go-forward basis than the maybe $75,000 I'd have built up in an MSA over the past 20 years. All it would take would be a bad accident, and the funds would not only be depleted, I'd be broke too.

#20 ::: Steve Eley ::: (view all by) ::: November 05, 2004, 05:22 PM:

Larry Brennan wrote:
Individual responsibility is to be encouraged, but people should not be held responsibile for things they cannot control, such as the wealth of their immediate familiy and the bad luck of getting sick.

I'll agree with you on the "bad luck of getting sick." I disagree strongly that wealth is inherently out of one's control (it cannot be entirely controlled, but then, what can?) but that's an argument for another day.

I don't think we have different goals here. I too would like everyone to have adequate health care. The difference is that you're seeking solutions for everyone to be given all the health care they need. What I'd like to seek is a solution where almost everyone can afford it; it then becomes their choice, and we can concentrate our giving on the few with very complex needs or who can afford nothing at all.

I suspect neither goal is entirely attainable. And the truth, as with most things, is probably somewhere in the middle. As I said at the outset, I have a Devil's Advocate reflex.

#21 ::: Steve Eley ::: (view all by) ::: November 05, 2004, 05:27 PM:

Larry Brennan:
Steve - stipulating that saving $200-300/month would be sufficient for most individuals, why is that inherently better than putting that money into one big MSA (called insurance) and letting the big buyer (insurance company or government agency) duke it out with big sellers (HCA or HealthSouth, for instance)?

Because the people who are putting the money in and receiving the services have no representation. Therefore our money is used inefficiently and the services are not always rendered appropriately. And because most of us have little or no choice which "big MSA" to buy into, short of changing employers, we have no recourse with which to hold them accountable, and they have no incentive to improve quality.

That's where we're at. If it was working, this wouldn't be an issue.

#22 ::: xeger ::: (view all by) ::: November 05, 2004, 06:06 PM:

Larry Brennan comments:
I think Kaiser Permanente is a pretty good model for providing affordable health care. They are actually quite agressive about prevention, and while they can be bureaucratic sometimes, my experience with them has been better than it has with any for-profit insurer.

My experiences with Kaiser Permanente have been uniformly dreadful. They're interested in getting your money, spending as little time with you as possible [not counting the time you spend waiting for them], and getting rid of you without any serious investigation.

On one occasion I went to emergency because I was having breathing difficulties. When they finally were able to see me, several hours later, the attack (whatever it was) had passed. This is fortunate, since if it hadn't, I'd have been passed out (and probably dead) under a chair in the waiting room [which was dark, dirty, never checked, and full of other people waiting in various stages of distress]. They were very prompt about getting my credit card information before letting me get near triage - and about sending the bill afterwards.

On another occasion I went to one of their clinics complaining that my shoulder was so painful that I couldn't sleep. They checked my lungs for pneumonia, gave me a prescription for a somewhat stronger asprin (which I'd indicated I wasn't able to take, as it caused stomach problems - which they steamrollered me on), and sent me away.

Fortunately I was able to get better coverage shortly after, and determined that the shoulder issue was a rotator cuff impingement, which can be addressed with physio or surgery. Drugs don't do much for it, outside of mask symptoms until they get worse.

Kaiser? Pfeh -spits-

I'd trust them as far as simple broken bones and flu shots only, thankyouvery much.

#23 ::: Linkmeister ::: (view all by) ::: November 05, 2004, 06:32 PM:

Warning: anecdotal data ahead

I pay $245/month to Kaiser for my (single) self. That gets me a $15 co-pay for each prescription (currently 2 per month) and a 50% co-pay for lab/xray type stuff. If I make $1,000/month, I'm paying 24.5% of my income for health insurance. This is not my idea of a good health plan.

The way I understand the proposal (which is incomplete) I'd be paying my $245 into an HSA and hoping I didn't use all of it per month, accruing the balance. That way it doesn't sound too bad as long as I don't need a $2,000 MRI, so it can't be the way it works.

Anybody know how this thing really might work?

#24 ::: Larry Brennan ::: (view all by) ::: November 05, 2004, 06:46 PM:

Linkmeister - You got the concept right, although there's also the option of buying bare-bones insurance that pays some of the cost of a catastrophic illness. Whether said insurance would pay for the $2k MRI is a big question. Plus you'd actually have to find one of those plans, which are required to have really, really big deductibles that would eat up the paltry $2k in your MSA anyway.

xeger - Note that I said my experience with Kaiser has been pretty good. Anecdotally, I have a former co-worker who's son was unfortunate enough to need some really costly and relatively experimental surgery to repair a bone defect in his leg - with a minimum of fuss, Kaiser paid for it out of system because the right person for the job was at Cal Pacific and not at Kaiser.

My experience is recent; I understand that they have improved a lot in the past few years. And, since I'm on my own dime for now, they are not only less expensive and more comprehensive than other plans, they were the only ones willing to write me a policy. Everyone else (Blue Cross, PacifiCare, et al) told me I was too fat (5'11"/230lbs) for health insurance.

#25 ::: Marilee ::: (view all by) ::: November 05, 2004, 08:55 PM:

I have Medicare and Kaiser. Medicare's premium increase is going to eat up about half my COLA next year, but Kaiser's premium isn't going up, and all my co-pays are going down (makes me wonder if a batch of us really sick people died recently...).

Kaiser's spent more than $2M on me so far, and while they've made mistakes, and the occasional doctor has been fired for what they did to me, I'm still alive and I'm quite sure I wouldn't have been without them.

#26 ::: Lis Carey ::: (view all by) ::: November 05, 2004, 10:37 PM:

Lis Carey wrote:
MSAs "work" for people who are young, healthy, and well off. Ordinary working people can't put aside enough untouchable money to make a difference if they get sick and need care.

Steve Eley wrote:
And yet they can pay two or three hundred a month in insurance? Because that's pretty much the amount it would take.

People with good employers don't pay that directly out of their own pocket; their employers should some or all of the burden. It's tax deductible for the employer, and if they've set things up right, the employee can pay their share out of pre-tax income, too. And even where the employer isn't paying very much, at least they've been able to bargain with the insurer on somewhat more equal footing than each employee doing so individually. All of this means that it costs everyone involved less than if the employer paid the employee what they otherwise would (absent the expense of the empoyer's share of health insurance), and the employee bought insurance individually.

Of course, this still leaves anyone without an employer, or with a bad employer, or with an employer too small to bargain effectively with large insurance companies, on their own and unable to get decent health insurance. It's not just that individual plans are more expensive; without a major employer behind you, you often can't even get the same level of coverage, except at enormously greater expense.

On "consumer responsibility and smart shopping:
You don't, obviously. When you can't breathe you go the nearest emergency room. And then, when you can breathe, you interrogate them over each and every line item on the bill until you understand exactly what it was and where it came from. A huge fraction of hospital bills contain errors. If it's too much anyway, you're probably stuck, unless you decide to move somewhere with cheaper ERs.

I do examine the bills carefully afterwards. I do question anything that seems odd or wrong.

But "cheaper" isn't the only important metric in health care. If the ER nurses, before I ever see the doctor, don't truly understand that asthma is a life-threatening condition, I'm screwed, no matter how "cheap" they are. And no, that's not a weird and improbable scenario that would never happen in real life. People die all the time because other people, even medical personnel, often don't understand that asthma is a directly life-threatening condition.

On one memorable occasion, while barely moving any air through my lungs at all, an N.P. me that there was nothing seriously wrong, I wasn't even wheezing. I demanded a lung capacity test, and got it--and everything went into high gear around me, because I "wasn't wheezing" because I wasn't moving enough air through my lungs to wheeze.

But I'm in my forties, I'm a librarian and I know how to do research, and I spent ten years as a pharmaceutical and biotech librarian. One of my employers was a major producer of asthma drugs. Plus, in my twenties I connected with a doctor who was asthmatic herself, and taught me the practical stuff she'd learned as well as paying attention to my symptoms and actually treating me. (I had the symptoms since toddler-hood. Even devoted parents didn't really listen to what I was telling them, when the doctor said, "it's just a cough.")

The lives of people who are elderly, or children, or less educated, or just more docile than I am, are not worth less than mine. We can't all become experts in every medical condition we might need to know about for our own health, and that means that our ability to be "educated consumers" in regard to health care will always be limited.

But for non-emergency medicine, you can shop around. And that'll be a whole lot easier if we can move toward a culture where medical offices can easily tell us what their prices are.

See above. Price isn't the only consideration in medical care, and health care isn't really amenable to "normal" market forces because most people cannot acquire enough information to make fully informed medical choices, if they can't start by trusting their doctors.

#27 ::: pericat ::: (view all by) ::: November 05, 2004, 10:50 PM:

Anybody know how this thing really might work?

Um, socialized medicine? No, really, y'all seem to be reinventing the wheel here. Just nationalize that sucker.

The way it works for me is, I pay my little bit every three months, my employer pays a bit, since I'm employed, and it means that if a low- to no- income person gets sick, they get cared for.

Having fewer chronically sick people dotting the landscape means that I stand less chance of catching nasty bugs. I used to get colds and flu all the time before I moved up here. Part of that is that I come into contact with fewer people on the whole day-to-day, but also that when I do meet up with folks, they're much less likely to be coming down with something or just getting over something. So I pay that MSP bill right off, you betcha. Lord knows it's considerably less per month than Linkmeister's, and no fuss about deductables or co-pays for basic diagnostic work.

I have a cold right now; it's my second in the last six years. I almost didn't recognize it, thought it was just extra-fierce allergies related to the bumper mushroom crop.

#28 ::: Bruce Baugh ::: (view all by) ::: November 06, 2004, 01:31 AM:

Lis touches on something very important about the advantages of education and knowing how to do research. I know as much as I do about my complex immune and other problems because my parents were wealthy enough and persistent enough to keep pushing for answers after early dismissals of "school phobia" and the like. Someone without their assets, physical and mental, wouldn't have been able to. So the working-class black version of me went through life being sick and miserable and never knowing why, much more strongly tempted to drug abuse for sheer escape, unable to work productively...and like as not dead from complications by now.

The same thing is true of many other conditions. How many drug addicts are undiagnosed, untreated severely depressed people, I sometimes wonder. And people can carry a lot of misery and still stagger on somehow. But dammit, they shouldn't have to. We have the wealth to take care of people's needs, and we ought to.

#29 ::: Patrick Nielsen Hayden ::: (view all by) ::: November 06, 2004, 01:50 AM:

"How many drug addicts are undiagnosed, untreated severely depressed people, I sometimes wonder."

Yeah, I wonder too, but every time I do, some Steve Eley starts lecturing me about "personal responsibility." What good lives they have.

#30 ::: Steve Eley ::: (view all by) ::: November 06, 2004, 02:41 AM:

Patrick:
Yeah, I wonder too, but every time I do, some Steve Eley starts lecturing me about "personal responsibility." What good lives they have.

No, Patrick. No. My dog's not in that race. I've said three times in this thread that I don't have all the answers. I respect all the objections raised, and I haven't said one word to invalidate them. I've said nothing at all about the subject you're evoking me upon here. Of things I did say, in the same sentence in which I uttered your dreaded goblin, "personal responsibility," I also said that I believed in helping people who could not help themselves. Did you think I was lying? Or was the goblin so mean and scary that everything else I said became invisible?

I'm not The-Man-in-training, Patrick. I'm not trying to put you down, and I'm still not in favor of killing Grandma. I'm trying to present another perspective, trying to raise a question. If you feel it's an invalid question, say that. Rip me, rebut me, eat my vowels. Whatever you like. But don't accuse me of trying to shut down discussion just because I offered another opinion; and don't turn my name into a fucking category. You can assault my statements all you like, but you have no grounds against my name.

#31 ::: Lis Carey ::: (view all by) ::: November 06, 2004, 05:58 AM:

Steve, it may be that we're misunderstanding your feelings on this because your "another perspective" is one that assumes that everyone has the same abilities and resources as a well-educated, well-off man with no serious health problems. You want healthy people to not have to pay for insurance--and to provide for the possibility of becoming ill in a way that's only workable and adequate for the very well-off with no responsibilities to anyone else. The rest of us, in your proposal, can have insurance--except that we can't, because with all the healthy people out of the "insurance" system, no one who's left would be able to afford it. You think that's somehow unfair to the healthy--just as if they're never going to move into the category of "not healthy" and need other people to bear some of the burden in their turn.

Or, if that's not what you're saying, you should know: that's what it sounds like.

The free-market model doesn't work for health care, because individuals can't bargain for health care like companies bargain for the best price on widgets. Individuals can't even have enough information to bargain for all the kinds of health care they might need, and price is not necessarily a controlling factor in doing so intelligently. If in a health care free market I go out to buy myself a flu shot, and Chiron is offering a better price than Aventis-Pasteur, absent heavy government regulation, how the heck do I even know that Aventis-Pasteur has better quality control than Chiron? How am I going to find that out?

#32 ::: Bruce Baugh ::: (view all by) ::: November 06, 2004, 09:39 AM:

Lis, you keep leaving me with little to say but "Right on!" Well, right on!

You've touched on another point near and dear to me: some people become sick or injured after a period of productive health. But others don't. I went from really quite healthy to thoroughly and permanently ill over a single summer, when I was 15, and then spent a lot of years being completely dependent on my family. If I hadn't had the good fortune to be born the son of a NASA engineer, I...don't quite know how it would have gone, but it would have been bad. Others are born with defects, or have chronic situations develop when they're still young. Many of these conditions go unrecognized, but keep them from ever being capable of holding a lucrative job long enough to build up savings.

There's a distinct separate problem with the way we provide health care in the US. Thanks to poorly chosen criteria and poorly administered supervision, there is powerful incentive to lie. Anyone who is anything short of completely incapable of doing anything ever is likely to be denied if they do not misrepresent themselves. This is true even for people with clearcut obvious needs, like my friend with cerebral palsy and epilepsy that doesn't respond well to medication, who was denied several times before she stopped acknowledging that she could sometimes work a day or two in the course of a week, some weeks.

I place a high value on the "work ethic" virtues, including honesty, interest in self-sufficiency, and ability to cooperate with others as equals. One of the reasons, I believe, that the underclasses have problems with crime and violence is that their dealings with the state encourage dishonesty. It wouldn't really take a whole lot more money to replace a vast swath of inspectorates with a very simple review process and much more lenient grants, and I believe it would pay off in a much healthier culture. I don't want people to learn through their experience that good things come through fraud.

#33 ::: Steve Eley ::: (view all by) ::: November 06, 2004, 05:46 PM:

Lis Carey wrote:
Steve, it may be that we're misunderstanding your feelings on this because your "another perspective" is one that assumes that everyone
has the same abilities and resources as a well-educated, well-off man with no serious health problems.

No, it isn't. Far from it. If you'll go back and read the middles of my messages, you'll see I've been bending over backwards to figure out how a system that includes MSAs might be made useful for everyone: hybrid plans, free "base" coverage, diverting account interest to the public good. It's entirely possible that all those ideas suck. I'd like to know that too, which is why I was hoping people would talk about them. Instead people are only tearing apart the surface description of MSAs, as if I'd never said more than that. I agree, MSAs alone are not adequate for our country's health care.

You've mistaken me on one key point, Lis. I do believe that the interests of the relatively self-sufficient (and it doesn't take being "well-off") should be represented in the health care discussion. Yes, I'm in that category. You want your interests represented too, yes? Is it wrong that both of us should have voices? I am not saying that the self-sufficient should monopolize the discussion (and yes, that is a threat under the Bush administration); and I am not committing the fallacy you accuse me of, believing that everybody falls or can fall into the same bucket. I never said it and I don't believe my words carry the implication.


The rest of us, in your proposal, can have insurance--except that we can't, because with all the healthy people out of the "insurance" system, no one who's left would be able to afford it.

But I thought the problem was that few can afford it now. That's the only reason it's even worth raising the question: there seems to be widespread agreement on all sides that the current health system is hopelessly broken. Am I right? Why, then, criticize other ideas solely on the basis that they're bad for the current system?

The free-market model doesn't work for health care, because individuals can't bargain for health care like companies bargain for the best price on widgets. Individuals can't even have enough information to bargain for all the kinds of health care they might need, and price is not necessarily a controlling factor in doing so intelligently.

Fair objections. I think this could be ameliorated somewhat by having advocates on the consumer's side. We hire real estate agents when we buy or sell a house, because they know more about the market than we do. We hire literary agents, investment agents, etc. Would a market spring up for "health agents" whose job was to find us the best treatment? If so, would there be a way to extend that same representation to the poor as a public service?

As for price not being the controlling factor: you're absolutely right on this. And this may ultimately be a reason why private health care must fail -- because health is at the very top of our hierarchy of needs, above and sometimes in opposition to financial security itself. (There are other needs above finance too, but they either don't cost money or are supportive of financial security.) I'll have to think more about that.

Meanwhile, assuming we're not going to move to universal health care next week, I'll say it again, hoping that repetition might lead to notice: I do not believe that MSAs are the One True Answer for healthcare. I believe they're an effective improvement on the current system in certain contexts, and I would like to see whether those contexts could be expanded and developed without making things worse for anybody else. I'd like to see other answers too.

It may be, after all, that universal socialized medicine is the best answer. I'm actually reading up about it, trying to learn more. I don't believe it would be a simple answer -- it's not ideal in Canada or Europe, and the U.S. has certain features they don't that might make it problematic. But it might be better after all than improved privatization. I'm open to being convinced.


Thanks for the sane and thoughtful response, Lis. Encouraged by such, I'll keep asking questions and keep raising proposals to be shot down. Because someone has to give you something to be right against, right? >8->

#34 ::: Patrick Nielsen Hayden ::: (view all by) ::: November 06, 2004, 06:29 PM:

Steve, no offense, old bean, but for many of us whose lives have been permanently bent out of shape by the crazy American insistance on "free market" health care, this is just not a subject we're prepared to be all polite and theoretical about.

Basically, what Bruce and Lis said. I'm too tired.

#35 ::: Bruce Baugh ::: (view all by) ::: November 06, 2004, 08:54 PM:

I remarked in one of my LiveJournal entries that I now feel about US health care like I do about NASA's manned space activities. They've done good things in the past, and could in principle do good things now, but they aren't doing enough good things now and they won't do more in the future because of institutional barriers to anything short of flat-out demolition. NASA continues to run a kickass unmanned program; US health care has much to recommend it in many cases. But enough time has gone by that we can now say "Alternatives must happen."

#36 ::: Steve Eley ::: (view all by) ::: November 06, 2004, 10:49 PM:

Patrick wrote:
Steve, no offense, old bean, but for many of us whose lives have been permanently bent out of shape by the crazy American insistance on "free market" health care, this is just not a subject we're prepared to be all polite and theoretical about.

As you see fit. I still object to "some Steve Eley."

Would it appeal to your sense of irony to know that over the course of today, I managed to get sick as a dog with some sort of stomach virus? Therefore I don't have the energy either. Thanks very much to Lis, Bruce and Larry for giving me things to think about.

#37 ::: Bruce Baugh ::: (view all by) ::: November 06, 2004, 11:41 PM:

Glad to help, Steve. I did not abandon the belief that non-state-directed solutions could cover my country's health needs lightly. I still believe that in principle they could. The problem is that those with the power to make decisions do not wish to make the effort it would require, and there simply is no alternative except to have the state do it. A population that is vulnerable to untreated illness and disability is a threat to everyone's security and prosperity. And a population who suffers that vulnerability while knowing that much of what it's suffering from can be treated is a risk to the peace of the whole society. The gap between disappointing reality and clearly accessible possibility is where the monsters of revolution, tyranny, and other badness breed. Bismarck was entirely right about that. So, for all his failings, was Henry Ford. Their heirs in state and business have become stupidly complacent, and brought this on themselves.

#38 ::: Paula Lieberman ::: (view all by) ::: November 07, 2004, 02:45 AM:

Health Ssvings Accounts? They're like mail-in rebate certificates at stores, but worse

-- someone who paid in to an HSA but never sent in the paperwork for reimbursement forthe out of the pocket expeneses, back when I was employed... it's a big fat scam fattening up insurance company profits.

#39 ::: James D. Macdonald ::: (view all by) ::: November 07, 2004, 07:43 AM:

People who can't afford medical insurance can't afford MSAs either.

If yachts were made 100% deductable, the number of yacht owners wouldn't go up by a lot.

#40 ::: Lis Carey ::: (view all by) ::: November 07, 2004, 10:29 AM:

Steve Eley wrote:
But I thought the problem was that few can afford it now. That's the only reason it's even worth raising the question: there seems to be widespread agreement on all sides that the current health system is hopelessly broken. Am I right? Why, then, criticize other ideas solely on the basis that they're bad for the current system?

The current system is badly broken and is leaving ever-increasing numbers of people without health insurance--but for people who have large-enough employers that are sufficiently responsible, or who are old enough to be on Medicare, it still kind of functions somewhat adequately. Your proposed "solution" would destroy its usefulness altogether, by removing from the equation all the currently-healthy, currently-well-off, driving the per-person cost up to levels that no one in need of insurance could possibly afford it.

This would not be an improvement.

Lis Carey wrote:
The free-market model doesn't work for health care, because individuals can't bargain for health care like companies bargain for the best price on widgets. Individuals can't even have enough information to bargain for all the kinds of health care they might need, and price is not necessarily a controlling factor in doing so intelligently.

Fair objections. I think this could be ameliorated somewhat by having advocates on the consumer's side. We hire real estate agents when we buy or sell a house, because they know more about the market than we do. We hire literary agents, investment agents, etc. Would a market spring up for "health agents" whose job was to find us the best treatment? If so, would there be a way to extend that same representation to the poor as a public service?

Agents in other areas are paid out of the money their efforts gain for those who hire them. "Health agents" would be an additional cost on top of the cost of the medical care itself. I know that you don't intend to be indifferent to the needs of people who aren't healthy and well-off, but have you stopped to contemplate for a moment what this would mean to the parent who's already trying to balance the cost of the medication their child needs to live, against the cost of the food the child needs to live? Or the person who's trying to decide whether to pay the rent or the heating bill first--in January in a Frost Belt state--and then finds themselves ill and in need of medical care as well?

Again, you're talking about something that would save money and improve the quality of health care only for those well able to fend for themselves, while making things even worse for people who are doing badly or in precarious circumstances under the current system.

#41 ::: Bruce Baugh ::: (view all by) ::: November 08, 2004, 03:13 AM:

Lis' comments just brought a couple things together in my brane.

It's often pointed out that even the poor are likely to have a fair number of luxuries, from TVs with cable to game consoles to multiple cell phones, and so on. What's seldom pointed out is that the cost of many of these together does not equal what people without jobs that cover a lot of insurance would have to pay for anything like decent health coverage. A whole bunch of items costing $20-50 a month plus some bigger purchases a few times a year is still likely to come far short of the several hundred dollars a month that families have to pay. If anyone in the family has chronic conditions, the cost goes up even more.

So we end up with a boom in consumer goods partly because there's no real reason not to. Doing without all that stuff wouldn't make a difference, not in an era when real wages stagnate while the cost of insurance rises 10-30% in the course of a year. No amount of savings available to people working steady but unlucrative jobs can close the gap. If it were possible to get good coverage for a family of four for, say, $75-100 a month, you'd see a lot of luxury spending among the poor drop off because they'd like to have their health and well-being attended to. Some folks no doubt don't care. But many do care, it's just that they can correctly work out that the important thing they want is simply out of reach for them.

#42 ::: Paul ::: (view all by) ::: November 08, 2004, 09:59 AM:

Can I just say that from an external point of view, the idea of having to have health insurance (if you're not sufficiently poor) still seems weird to me...

#43 ::: Kathy ::: (view all by) ::: November 08, 2004, 02:07 PM:

". . . but for people who have large-enough employers that are sufficiently responsible . . ."

Which I am lucky enough to have. The company pays enough of the montly premium that I can afford health insurance for my family. Looking a the numbers quoted in the thread, I am luckier than I ever realized.

#44 ::: Bruce Baugh ::: (view all by) ::: November 08, 2004, 11:08 PM:

You are, Kathy. It's a thing to be appreciative for. It's good you have it! Use it well. :)

#45 ::: Jonathan Vos Post ::: (view all by) ::: November 08, 2004, 11:43 PM:

Paul:

If you HAVE to have health insurance (not a bad idea if your family has preexisting conditions and is prone to cancer), and are required by law to have homeowner's insurance, and are required by law to have automobile insurance... then it is actually taxation. It is a very regressive taxation at that. It means that I, a humble middle-middle-class homeowner with one fairly new car and a couple of ancient clunkers, am actually (once you add Federal and State income tax, and social security tax) paying roughly 50% of my income in de facto taxes. I mean my joint income, as my wife is also working more than full time. And I apply very sophisticated (legal) tactics on my several small businesses, one of which is me and my wife as Science Fiction authors, to get down to that 50%.

Historically, when you tax the folks in the middle 50% or more, or so I'm told, there is revolution.

#46 ::: Larry Brennan ::: (view all by) ::: November 08, 2004, 11:54 PM:

JVP - I'm not sure what Paul is saying. One possibility is that he is wondering why health insurance in the US is provided by private companies (at least for able-bodied adults under 65). The other possibility (which I think is less likely) is why health insurance is required - which it isn't. Although not having it if you can afford it is foolhardy.

I disagree with your position equating mandated insurance with taxation. Nobody told you to buy a house or to drive a car. Yes, there are plenty of good reasons why both are practical and/or useful, but neither is required. And it's your bank that mandates the homeowner's policy, not the government.

#47 ::: Jonathan Vos Post ::: (view all by) ::: November 09, 2004, 01:01 AM:

Larry Brennan:

Hmmmm. I admit that it's voluntary to own a home, or a car. But it irks me that this presumes my consent to have mandatory pseudotaxation. On the homeowner's insurance issue, the bankers have lobbied the government to make it a requirement, which is why I consider it de facto taxation under color of authority. The bankers have gone a step further. They spontaneously declare that many people who DO own homeowner's insurance do not, say so, and unless the person responds promptly, they execute a "forced buy" of overpriced crappy insurance, charged as principal on your home loan. In Southern California, mortgage bankers have been caught doing this, and had their hands slapped with a class action suit with 50,000 victims, who do not recover the full amont that had been stolen. This has happened to me TWICE. The second time, after I sent them proof of insurance twice, which they ignored, I wrote to the mortgage banker that I would initiate the class action, and become a named plaintiff. They backed down.

I call it taxation, and I say the hell with it.

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