A less esoteric version of this analogy might involve early-stage enthusiasts of multilevel marketing schemes:

You just can't stand the fact that the entrepreneurial spirit and free enterprise is alive in America! You can have your death panels and socialist toilet paper rationing if you want!
[/glassy eyed believer rant]

Stefan@1:

A less esoteric version of this analogy might involve early-stage enthusiasts of multilevel marketing schemes:

There was a friend of mine who got caught up in one of these a few years ago. We were already living across the country from each other and only talking every six months or so, but he talked my ear off about this fantastic new job he found. I listened patiently to his explanations, watched the online slide presentation, and concluded that it was a pyramid scam. He didn't understand how I'd arrived at that conclusion and started trying to refute my arguments (all the while assuring me of his soon-to-be-new-found wealth) and then got defensive and angry when I stuck to my guns.

He's always been the credulous sort, ever since we were kids, and I wasn't really surprised at how the conversation went. Anyway, I didn't talk to him again for about three years, but we reconnected recently.

I haven't heard anything about how the scheme went, and I haven't asked, because the answers are pretty obvious and I don't see the need to embarrass him over it.

Anyway, both that comparison and the vanity-press one ring pretty true. I hope there's more to be learned from the analogy.

I have started to tweet horror stories I read about the current system calling them Palincare

http://search.twitter.com/search?q=palincare

I think it important to pin the current system on someone and u no hoo (spelling it so she won't know) has nominated herself (imho)

Part of the motivation on the part of those who have yet to be savaged by the current system may be the fear that any change will make it worse for them. And another part is almost certainly a carry-over from past assaults on governmental operations such as the tax revolt starting with California's Prop 13 that has so badly damaged the US' public educational system. The meme that "the government screws up everything it touches" has caused a lot of people (those whose oxen haven't been slaughtered by the damage) to fear the government's participation in anything at all. In both cases there's a lot of "I'm all right Jack; don't mess with what works for me!" in the mix.

the final embittered realization that they’ve been had

Not to sound too partisan, but when a Republican politician says something is going to be good for me, I assume I'll get screwed. I should probably extend that logic to assume that, if a Republican politician says something will be bad for me, I should look into it.

Bruce:

The grain of truth to the complaint is, there have been quite a few high-profile massive f--kups by government. The public schools in some places are an example of that at a local level; the DHS is an example at the federal level. Congress and Washington more generally seems just barely capable of doing anything well. Things still get done well at various levels of government, and some of them are very important, but there are at least times where that seems nearly miraculous. (I think the explanation is largely that the screwy, destructive incentives that exist in politics large and small are damped down within federal/state/local agencies, which are often inhabited by people who really give a damn about the quality of their work and the job they're supposed to be doing.)

But this argument isn't too convincing against government involvement in healthcare for three big reasons:

a. Government is already massively involved in healthcare finance by providing Medicare and Medicaid. We've already decided what we are, and we're dickering over the price now. (If we're whores, let's at least get a decent wage for it.)

b. The current system has huge problems, appears to be doing massive damage now, and is apparently unsustainable in even the medium-term.

c. As Abi has pointed out, we have dozens of examples of various kinds of healthcare systems that seem to work quite well, without kind of problems ours has. To quote Jerry Pournelle, what man has done, man can aspire to.

One irony here: I'm pretty convinced that the stuff on the table now will solve part of the damage done by our healthcare system (assuming there really is a public option that plays straight), but will not address the impending disaster of endlessly increasing medical spending. Indeed, making sure everyone can get medical care will make that worse. But fixing *that* problem means goring a huge number of well-fed oxen, with big staffs and investments and massive sunk costs in expensive educations and expensive machinery. God knows how we'll manage that, especially once the personally painful to the voters part of the problem (the threat of being ground up in the gears of the system when you lose your job just after your kid is diagnosed with diabetes) is temporarily resolved.

We are already "Beyond the Healthcare Event Horizon." It's a hideous, grasping octopus that's already eating close to 20% of out Gross Domestic Product - and maybe that's the way to portray it. Don't respond to Teabagger talking points about "Euthanasia Councils" or whatever bullshit they're spouting. Find a way to visualize the problem in terms of what it means for the economy, or compare it to other forms of oppression. Would we ever give 20% of our GDP as tribute to an invading enemy? Would we ever pay 20% interest on a home loan? (Maybe that's not a good comparison - come credit cards charge more than that.) Would we give up the total production of ten separate states to any giant corporation? If IBM came along as said, "We need Michigan, Maine, Oregon... etc., would we hand over the land?

"Would you personally hand 20% of your paycheck every month to a person who is much, much, richer than you?"

"Would you allow a ravenous octopus to suck away 20% of your blood supply every day? And 20% of the blood supply of your friends and family?"

Something like that, anyway.

I dunno. I wasn't kidding when I said we're thinking seriously of leaving for Europe. I mean, serious to the point of realizing there's three weeks before school starts in Hungary serious.

I already killed a business trying to stop the Iraq War. If America wants to commit healthcare suicide, I'm just going to go stand over there and try not to let my family get hit. I'm forty-two years old, I have no retirement plan, and I can't afford health insurance even though I made a shitload of money last year (this year, not so much). (Of course, our health coverage in Puerto Rico was just fine.) I've kinda had it with America. My f---ing "Representative" is Mike Pence (R-Hell), who essentially has a monomaniacal need to ... hell, I don't even know *why* he's against rational healthcare, I just know he's no representative of mine.

This stupid country just plain bites.

We are already "Beyond the Healthcare Event Horizon." It's a hideous, grasping octopus that's already eating close to twenty percent of our GDP - and maybe that's the way to portray it. Don't respond to Teabagger talking points about "Euthanasia Councils" or whatever bullshit they're spouting. Find a way to visualize the problem in terms of what it means for the economy, or compare it to other forms of oppression. Would we ever give 1/5th of our annual production as tribute to an invading enemy? Would we ever pay twenty percent on a moortage? (Maybe that's not a good comparison - come credit cards charge more than that.) Would we give up the total production of ten separate states to any giant corporation? If IBM came along as said, "We need Michigan, Maine, Oregon... etc., would we hand over the land?

"Would you personally hand one fifth of your paycheck every month to a person who is much, much, richer than you?"

"Would you allow a ravenous octopus to suck away twenty percent of your blood supply every day? And a similar percentage of the blood supply of your friends and family?"

Something like that, anyway. (Hopefully this version won't get caught in the spam filter...)

It seems to me a particular case (in reverse form) of the "one day *I* may get rich so I don't want rich people to be hurt" variant of optimism.

The line of thought goes like this: if there is government involvement in healthcare, there *will* be mistakes. If there will be mistakes, I *may* be hurt by them. OMG! CAN'T LET THAT HAPPEN! GET GOVERNMENT OUT OF HEALTHCARE!

That's a fear-based response, and when people are working from fear, they don't think too well, they don't respond to logic or data coming at them from the outside, and they tend to engage in fight or flight responses. I think we're seeing mostly the "fight" option, because realistically, there's nowhere to flee TO.

So they're fighting.

And since the healthcare resources are not infinite, the "healthcare will be rationed" trope is actually correct. It isn't "death panels" but there will indeed be cases where the question of whether to allow a particular patient access to a particular resource will be decided by people. In panels or boards or groups. And sometimes, they'll say "no".
For people who are well aware of their own biases, and that there are other people with similar biases against them, that must be terrifying: if they need a treatment and the people-they're-biased-against are on the panel, they are afraid of being discriminated against.

(Imagine a panel of white people in a racist region deciding yea or nay on a very expensive treatment to a black patient. Not a nice thought.)

The way we usually get around this sort of thing is by putting rules in place and allowing appeals and so forth - but the people who are so terrified of universal healthcare don't believe anyone would obey rules if their life was on the line. So they're afraid of being left behind and cheated out of a system they paid for, with no recourse.

Those fears aren't crazy. What I'm not is sure how to alleviate them when the population feeling the fear is being worked up into a fearful frenzy by skillful manipulators.

The argument that Bruce points to (4) reduced to something like this:

P: For something as important as x, we can't tolerate mistakes.*
p: Government sometimes makes mistakes.
C: Therefore, both:
   c1: The private sector will do x better than the government, and
   c2: Sending x to the private sector will not create any other negative externalities.

Anyone with half a braincell can spot the missing warrants in c1 and c2. The problem with c1 is that nobody ever compares the actual problems under government control with the problems under private-sector control, let alone does so in a numerically sound fashion. In management-speak, nobody does year-over-year comparisons, or makes sure that there's no outside factor that makes the comparison invalid (say, the invention of the automobile cutting into the buggy-whip market). The problem with c2 is simple and obvious; and the Supreme Court has already ruled that it can be unconstitutional (Marsh v. Alabama).

So my response is not to point out the many things the government does right; it is to start pointing out the many things that the private sector does wrong, epitomized by the tobacco industry, the US automobile industry, etc. And when the whinge comes back that government regulation killed the automobile industry, I ask why the greater "socialist" regulation in Japan and Europe hasn't done so there.

* Leaving aside that every human endeavor has them.

Dena @9 - sure, those fears aren't crazy. But they *do* describe the system we have now. If it were a government panel, at least they wouldn't be killing your grandmother to make a down payment on a bigger yacht.

Michael @12 - I hear you and agree with you. But I'm not the problem, 'cause I *already* want healthcare that is free-at-the-point-of-service.

How do we get the people who are in a frenzy of fear to hear that, consider it, and decide to risk their lives on it?

My point is that the people who are afraid aren't necessarily evil or crazy. They're misinformed and terrified and unwilling to trust their lives to anyone.

I'm trying to figure out how, functionally, to help them over the gaping chasm of their fears - when the fears shut their ears to facts and reason.

When evil people make billions of dollars a year feeding on that fear, and they own all the media?

My Dad voted for Obama, is on pension from Chrysler and fears for it after the recent uproar, has two children both self-employed, and still thinks health care reform is not what America needs because the government can't get anything right. He's not stupid, and thinks Fox is the opiate of the masses, gets his news from CNN, and they've played him up, down, and sideways.

Michael @14 - that's why "I'm trying to figure out how" rather than saying "here's my brilliant plan, let's do this, that, and then the other thing and they'll all come around to our way of seeing things."

It is a WHOLE lot easier to shatter a discourse by beating people into a frenzy than it is to rebuild a discourse after such a frenzy.

Dena, #10: I recognize that line of argument. It's the one I used to hear from my parents as a kid in the form of, "GET AWAY FROM THAT SQUIRREL, IT MIGHT BE RABID!" And there was absolutely no logical argument (it's not letting me get close to it, it's not acting abnormal, squirrel rabies in this area is virtually nonexistent, etc. etc.) that would budge it. They were completely, impenetrably convinced that any squirrel in the yard might suddenly become rabid and attack without warning.

If enough people are caught up in that kind of thinking, we're hosed.

Dena #13:

It's also not nuts to worry that what we get out of some kind of healthcare reform will make things worse for a lot of people, including those like me who have good insurance now, including people who have Medicare. It's possible to have well-run nationalized single-payer healthcare, and it's possible to have well-run regulated insurance and private healthcare side by side--we have existence proofs of both. But that doesn't mean we will get one of those things.

Look, it's possible to have well-run, basically sensible drug policy, or urban public schools, or public transit, or federal and state tax systems, or anti-terrorism policing, or federal and state budgets. There are examples of countries that do pretty well with each of those. But that doesn't mean we are one of them. Perhaps I'm being too gloomy, but it seems to me that we (the US) aren't too functional at the big-political-decision level, that when our congress gets involved in some fired-up urgent issue we get a lot more Patriot Acts and DHSs and massive bailouts of oligarchs who made bad bets and ethanol-as-energy-strategy than we do missions to the moon or sensible policies. The healthcare system is like a fifth of our economy, and it has entrenched interests the way a stray dog has worms and fleas. There's a great deal of opportunity for bad decisionmaking to happen here.

The short-term thing that we know how to do is to extend some government provided insurance--something like Medicare or Medicaid--to anyone who wants it at some nominal rate[1]. This would fix a great deal of the current damage being done by the system we have now, but it's unsustainable if we don't get costs under control.

[1] We can't say we're providing Medicare to everyone, because Medicare recipients are scared to death by the prospect of big changes to Medicare--for exactly the reasons I mentioned above. And Medicaid has the welfare-program stigma--useful when you want to provide charity for the needy without feeding the able bodied lazy, but not what you want here.

albatross @17 - we should say we're allowing people to buy into Medicare, providing a much-needed infusion of cash into the system. Who could possibly argue with that? Somebody should literally do the math, figure out how much it would cost for a family of four to buy into Medicare. It has to be cheaper than a for-profit insurance company.

Dena - I get what you're saying. I'm really not feeling good about America right now, having lived elsewhere for a while and strongly suspecting that coming back was kinda boneheaded. I should just shut up and let y'all have some good ideas. Just me, personally, I'm done with it. America seems bent on staying as stupid as it possibly can - who am I to stand in its way?

Me @18 - duh, of course people have done the math. And it would be cheaper - private Medicare handlers spend 16.7% of receipts on non-medical costs (administration and profit, profit being 6.6%) versus Medicare itself, which spends only 3%.

It's that 6.6% of profit that makes it impossible for America to do the right thing.

I am not a particularly political animal--I vote, certainly, but I tend not to be much of an out-and-abouter as far as volunteering, taking public sides on an issue, etc., are concerned--but this evening I attended a town hall meeting held by a Blue Dog US Representative (Adam Schiff, CA-29--and yes, my first thought on reading his name was Law and Order-related) who happens to be in favor of a public option, which seems to me a realistic solution for at least some of the problem.

Wow.

The event was supposed to take place in the community hall in the Alhambra Civic Center Library (accommodates ~300 people) but was moved onto the lawn next door, and I heard estimates of between 1000 and 2000 attendees. I'd believe it.

Lots of signs. Some only 8-1/2"x11", some larger placards, some printed at home, some hand-made, some obviously done by professional printers. The ones favoring health care reform seemed, in the main, to speak to the issue itself ("People, not Profits," "Universal Healthcare Now," etc.), while those of the opposition included comparisons of Obama to Hitler, mentions of death panels, and "Don't bury my grandma" sentiments. (I will admit that perhaps there were equally tasteless signs on the pro-reform side, and I just didn't see them.)

The format was laid out by Rep. Schiff during his opening remarks: Dr. Bruce Hensel (practicing physician and medical editor for NBC in LA) would be moderating; we would hear brief remarks from panel members Dr. Benjamin Chu (President of the Southern California Region of Kaiser Permanente), Dr. Richard Brown (Director, UCLA Center for Health Policy Research), Jerry Flanagan (Health Care Advocate with Consumer Watchdog), Leeba Lessin (President, CareMore Health Plan), and Dr. Francine Kaufman (Director, Comprehensive Childhood Diabetes Center and Head, Center for Endocrinology, Diabetes & Metabolism of Childrens Hospital Los Angeles); then Dr. Hensel would alternate between reading a question from a batch submitted by audience members before the start of the event and taking a question from the audience for Rep. Schiff to answer.

As it happened, I was standing just in front of a group of about 15 extremely vocal reform opponents. During Dr. Hensel's remarks and the statements from the other panel members, they would shout things like "I didn't elect YOU!" or chant "ANSWER QUESTIONS!", thus making it nearly impossible for me (and most of us in the general area) to hear anything the panel members said. When the Q&A did start, they either shouted down the question as cherry-picked or softball, or shouted down Rep. Schiff's response as nonresponsive or flat-out lies.

I was amazed at how much I wanted to slap the whole bunch silly, not for opposing reform but for being jerks. And on the rare occasions I tried to interact with them, such as pointing out that some of us wanted to hear what was going on, their general response was that Schiff was lying anyway so what did it matter.

I left about half an hour before the event was due to end, because I just couldn't take the noise...or my own emotional reaction, which was "pissed off in the extreme".

Fascinating, but kind of scary.

From Digby:

This point is one that continues to amaze me. These people are coming unhinged over expanding access to health care. It's not about taking away guns or mandating abortion or outlawing churches or some other issue about which you could understand these people having such strong feelings. They have worked themselves up into a complete frenzy over helping sick people.

As she then says, either ruefully or dismayedly: "The right wing noise machine is awesome."

#10:

Panels that decide which individuals get treatment and which are left to die are an extremely American phenomenon. In America, private HMOs decide, on an individual basis, who gets treated and who dies. However, neither the Canadian or British single payer systems have any equivalent process. Various panels decide which treatments are covered under public insurance, but anyone who needs (in the opinion of their doctor/doctors) a covered treatment will get it, no questions asked. There's no individual review.

The demented fcskwits who are protesting against improved access to health care have been so thoroughly programmed with RNC and insurance industry astoturf that they're utterly unreachable. The best hope at this point is to fight enough of a rear-guard action to prevent the teabag-astroturf movement from turning into a brownshirt army. If the RNC is able to use violent mobs fighting against their own interests to kill health care reform then there is absolutely nothing stopping them from using violent mobs to completely destroy the democratic process.

Health reform is a sideshow in comparison to the risk of the RNC getting its own brownshirts.

"You know, if I was a terrorist, I'd totally be funding some insurance lobbyists. They make sure heaps of Americans die. It's great. Way easier than blowing up buildings."

Blue Tyson, that quote is awesome. I'd like to use it as my sig--did you come up with it or is it in some piece of pop culture somewhere?

As an American living in Europe who has seen both kinds of systems with a chronic illness, I've been both horrified and fascinated by the level of discourse. I think that the kind of rabid noise and Orwellian-speak of Palin (death panels! hee!) are actually indicative of a weak position.

It seems to me that really dangerous notes in the opposition comes down to two factors. The first is the fear (just) that people might end up with something that feels worse than they have now. And there is very little way around that, honestly. And it isn't an unreasonable fear. The second note is a kind of weird Calvinism: the people who get chronically ill have somehow brought it on themselves-- through bad lifestyle choices, whatever. If you put those two things together, you get really basic and dangerous opposition. ("Me and my family could be in danger because of people who get Diabetes because they can't stop eating at Burger King.")

The trick is, I think, not to focus as much on the uninsured (illegals! the conservatives will shriek.) and focus more on the underinsured. The Joe-the-Plumbers who suddenly have their coverage cut off because they had a life-threatening illness. The graduate students who discover that 80% of hospitalization paid leaves them with huge debt if they end up with a major illness. People who become prisoners of preexisting conditions.

Also, I think that we should hit harder on the fact that we're already paying a huge tax bill for the current policy. This will *reduce* the amount of taxes-- or, at least, allow more of the tax money collected to be diverted to paying down the debt or making the quality of life better for the everyday person. Talk the costs-- point to the money trail.

But, you know, the people afraid of this bill aren't stupid and they aren't all radicals. Talking to them as though they are stupid won't win the point. We need to keep talking to the center and address their real concerns.

(sorry for the length)

If IBM came along as said, "We need Michigan, Maine, Oregon... etc., would we hand over the land?

What worries me from afar is that if IBM asked for those specific states, the people now forming the anti-health care claques would say, "Sure, take them."

So much of this, like every issue that has arisen since Obama emerged as a serious candidate, has been overdetermined by the unfinished business of 1861/5 that I wonder if you'll ever achieve anything until you settle that.

I think the answer to abi's question partly depends on the forum. In online debates, for instance, there's often the choice between trying to convince a speaker to reconsider their position, and trying to convince others that the speaker's position is unreasonable. Ideally, you'd like to do the former, but in some cases, that's not nearly as practical or effective as the latter. (And the two approaches involve somewhat different techniques.) The same may be true in some offline contexts.

I've been in some online forums where people realized pretty quickly that the latter approach was the way to go. (When you have forums debating the things like the existence of the Holocaust or the legality of the income tax, the only people investing lots of energy in the minority position are pretty hard-core nutters.) But in other cases, vocal folks in one position are more amenable to argument one way or another. I think that can be the case here-- as we've seen in examples above, there are some legitimate worries about government healthcare that can be addressed to various extents. (In particular, the issue of entrenched profit-seeking interests capturing the system even more for their benefit over that of patients is, I'm afraid, a legitimate concern given the recent track records of US federal and state governments.)

One crucial question that can help point the way to the kind of argument that will be be most effective is: "What evidence would you need to change your position?" If the person you're speaking to doesn't have a scientific background, they might not be ready to answer that question immediately as stated, but I think most reasonable folks can come up with an answer after some back-and-forth. (To help ensure you're arguing in good faith, you should ask the same question of yourself.)

Depending on the answer you get, or don't get, you can get some idea of whether the other speaker's position is rational, and what their main concerns or priorities are. Then, depending on the forum and your relationship with the speaker, you can decide how best to proceed.

Re the rationing/"panels" stories- problem is, I guess that if a bill gets passed, every case of coverage refusal or limitation that still happens afterwards will be blamed on the reform by the usual crowd, even if it's less strict than what would have happened without reform.

The worst scenario would probably be if a bill gets passed which contains neither a public option nor any effective ways to prevent insurance companies from doing the kind of treatment refusal they routinely do now, but which does contain provisions meant to make insurance companies cut costs. In that case insurance companies would most likely do even more refusals of needed treatments than now, many people would only see that this started after the bill got passed, and Republicans could pretend that this would be exactly what they warned everyone about. I wonder if this might be one of the reasons why the Right is spreading the specific scare stories it is spreading.

One of our Representatives held a town meeting last night in Rocky Mount, NC. The opposition complained he held it in a Democrat-heavy area to "bias the audience" and whined that there wasn't enough room for all of "them" to attend.

From the media reports, though, it certainly appeared that enough of "them" showed up to turn the meeting into a very confrontational situation. We had elderly men nearly crying over their fears of being told they had to die from a "death board", younger men yelling that the plan was going to insure illegal aliens, and others telling the Representative that if he wouldn't take the new plan, why should they?

These town meetings need to be restricted to the representatives' voters only; let them show proof of residence or something and keep the others out. At least then the wharrgarblers and Astroturfers would get excluded (except for the locals, of course).

When a swastika is painted on the signboard of my congressman's office, I'd say that the situation has gone too bloody far. It isn't just a matter of turkeys who have voted for both Thanksgiving and Christmas; there is a distinct odour of the 1930s in the air.

Well, whatever they do, I hope they make it so that it works reasonably well. At the moment, my gyn doesn't take Medicare patients because she says she can't break even if she does. She's already given up the obstetrics part of her practice because of the costs of malpractice insurance. I am entirely in favor of national coverage, but am also wondering what the system would be like if health insurance companies were non-profits ...

As I said in another thread, a great deal of the governmental dysfunction we've been seeing is the direct result of Republican sabotage of various governmental systems. ("Heckuva job, Brownie!")

Trying to discredit government altogether is one of their long-term strategy goals -- also supported by their campaign of disinformation and denigration.. Unfortunately, the only way I can think of to fight that effectively, is a political "Hail Mary pass" -- push through some massive, meaningful reform, and keep pushing it until the beneficial effects come through.

Frumiousb @25 - that's the point I was trying to get at: talking down to people alienates them.

Counter examples involving people who may be identified as "real Americans" (ie., people that the anti-healthcare individuals may have seen around them and identified with) are a good, non-data-intensive idea.

Lee @16 - that's what I'm afraid, too. I think our entire political discourse me have been hosed by profit-mongers and fear-mongers and so forth. But I love America's people and culture (it has brought forth some wonderful things and some horrors. The ones I love are the former, not the latter) and will remain here until certain red lines have been crossed. It is quite possible that America will go bankrupt and restructure itself enough to align life here with my values again, but if I'm not here to fight for it, I'd never forgive myself (after 30.5 years of yearning for it from afar, living here is a big deal for me.)

"If IBM came along as said, "We need Michigan, Maine, Oregon... etc., would we hand over the land?"

Well, we did build I-287 for ATT and IBM.

More to the point: aren't these scams at bottom selling fantasies of power to low-status hominids? Difficult to undercut the scams, for that reason, who wants to feel like a loser?

I hope the Congresscritters who are getting all the threats & harassment get disgusted & go back to DC & pass a kickass bill.

#34 Building a highway doesn't bother me much - infrastructure is usually a good thing.

I hope the Congresscritters who are getting all the threats & harassment get disgusted & go back to DC & pass a kickass bill.

I'd like to see that too!

they’ve taken the line about how “if it seems too good to be true, it probably is” a little further than even life in this vale of tears really requires

Speaking of Calvinism above, I live among people who feel that it's Godly to accept whatever you are given by life. Only prayer can get you anything better. The deduction they make from these principles is that "if it seems good at all, reject it" because anything the powers of this world (i.e. government) can give you is either secretly bad, or, if good, is an ungodly attempt to take the place of God. That's why Bush's hostility to public services made sense to them -- only churches should be helping the needy. If only that dastardly government would stop helping people, churches would step up and really start taking care of needs -- it's the government's fault they don't.

So, in response to Dena at #33, any argument aimed at such people is going to have to be congruent with their basic view of the world. I'm not sure how to do that, and I live among them. Maybe pointing out how many government services they already take for granted would help some, but it's not the whole argument.

frumiousb @ 25: "But, you know, the people afraid of this bill aren't stupid and they aren't all radicals. Talking to them as though they are stupid won't win the point. We need to keep talking to the center and address their real concerns."

That's not entirely true. Sarah Palin, to name one well-known stupid radical, has been the one talking up these "death panels."

Republicans love to tie up their opponents in knots by dancing that fine line between reasonable and radical. Liberals fall for it over and over because we just want stuff to make sense, and so when presented with a mass of people deadset against healthcare reform, we invent reasons for them. We sit around and dissect utter fantasies like "death panels" to find the secret underlying sense of it, and assure ourselves that it's really quite reasonable, and that all we need to do is explain, carefully and sensibly, why it isn't really going to happen that way and then everyone will agree with us and unicorns and rainbows and puppies!

But fear of "death panels" isn't reasonable, and we aren't going to explain away old peoples' fear of mortality. Death is scary, and the purpose of bringing it up wasn't to illuminate the issue but to exploit it. Just like they exploited Americans' fear of death to push us into war, to torture, to do god knows what else.

The bottom line is that talking about "death panels" and shouting down public speakers isn't a disagreement about what constitutes good healthcare and how to get it. It's about bare-knuckle winner-takes-all politicking. Taking it seriously lends it power. What we need to do is to point out how insane and hollow it is.

Well, I got into an online argument here, and somewhat regret it. I do think that the people on the board are authentic, but:

1) Seriously distrustful of any government
2) Uniformed
3) Certain of their views

I mean, one commenter said, "show me the language in the bill where you can pick your doctor."

It's not in the bill, I replied. Since you can pick your doctor now, and the bill doesn't retract that right, logically you still have the right.

"Not good enough - it's not an innumberated right. Therefore..."

Impervious to logic.

Michael Roberts @ 16-17

"Somebody should literally do the math, figure out how much it would cost for a family of four to buy into Medicare. It has to be cheaper than a for-profit insurance company....And it would be cheaper - private Medicare handlers spend 16.7% of receipts on non-medical costs (administration and profit, profit being 6.6%) versus Medicare itself, which spends only 3%."

No, you're missing something.

Buying into Medicare should cost more than buying into a working-age group (medical expenses rise with age), but say it costs the same. Then buy-in Medicare would cost about what large-group insurance does today--for a family, $1000-$2000 a month. For most people, that's not less than private insurance. Expected medical costs, like medical costs, are very very skewed; a lot of the "administration" cost is in trying to charge less than average to people who are expected to cost less than average.

See my comment in the other thread for a more detailed example.

#38:

"Impervious to logic" is right. Arguing with paid shills is like arguing with a brick wall. Arguing with the unpaid brownshirts is just like arguing with a young earth creationist. Logic does not penetrate.

Anti-creationist debating tactics may be useful against both camps. Require them to substantiate every absurd claim they make by citing a specific page in any of the proposed bills. Go on the offensive by questioning their motives and asking what they get out of lobbying for the insurance industry. Question their patriotism for putting the interests of the insurance industry above the interests of the people. Goad them into making racist statements about how reforms would let the 'wrong' type of people get health coverage.

Putting the facts out is not a winning strategy against the best propaganda the insurance industry can afford and the best propaganda K Street can design. To persuade the undecided, aim to humiliate K Street's shills. Make them look like the unreasonable, unhinged, racist, bigots they actually are.

As I understand it, about half the US healthcare budget goes into the insurance industry, not medical practice.

So why not simply nationalize the insurance companies and run them as non-profits? Or if that's dangerously close to socialism, tax the hell out of them unless they adopt a sheltered non-profit status. (Said non-profit status to be incompatible with prior-condition exclusions, i.e. being willing to take on anybody who applies.)

Slogan: "It's just like the current system, except they won't be allowed to turn you down if you get cancer."

As I understand it, about half the US healthcare budget goes into the insurance industry, not medical practice.

Somewhere between 10% and 20% is more like it. (IIRC, loss ratios in the health insurance industry are about 80%--80% of premiums go to pay claims).

What may be as high as 50% is the combination of what the insurance companies eat (the 20%) and what they spoil (all the people in every medical practice who make a living fighting them).

One big problem with the currently proposed reform is that it doesn't seem to do anything about the spoilage problem.

Hmmm

What I'd like to know is what percentage of health care costs goes to marketing vanity medicine, and health care and insurance company executive compensation.

First of all, it's "exorbitant", no "h" in there.

Second, when your income is zero, then even $800 a month is too high.

Third, when the non-Americans are pointing out European rates equivalent to $800 per year, then American COBRA rates are definitely too high.

Micahel @ 19, Sam @ 39:

The difference in overhead between private and public plans exists, but only becuase of accounting for the costs.

Medicare admits that it has a 7.5% fraud rate, and most believe it is actually much higher, as much as 10% (so that the actual winner in overhead costs are private plans.) That means that some of the administrative costs of private plans are offset by fraud in government plans - private plans will spend up to $1 to prevent $1 in fraud, as they should. Government clearly does not.

They also pay less than market value for heath care services, so basic economics tells us that there will be implicit rationing, though assumedly only of low value medical activities. This is a cost - we get less service under this system, partially in exchange for the lower overhead. (This doesn't mean lines at the hospital. It means not covering certain things that are now standard, like ineffective treatments, or low value added, high cost services in hospitals, like extra day stays in the ER for noncritical patients or 3 day stays after birth for healthy mothers.)

It's complex. Very complex. It needs to change. Hopefully soon. But we should still tread very carefully when doing so.

David Manheim @45, I don't think your math works the way you think it does.

Medicare admits that it has a 7.5% fraud rate, and most believe it is actually much higher, as much as 10% (so that the actual winner in overhead costs are private plans.)

That's only true if fraud is 0% for private plans, which does not seem to be the case. The noirishly-named Prescription for Peril has a variety of statistics about prescription drug diversion and the secondary cost impact of doctor-shopping. There's other insurance fraud information on the site, and even though the stats aren't broken down the way I'd like it seems like private insurance is hit for about 1/3 of the total health insurance fraud. Since government is already paying slightly more than half of US health care costs, the private fraud prevention seems to be cutting fraud down by a fair chunk but that's still a lot of fraud left on the table. Including fraud by the insurance companies themselves. And you are familiar with Blue Cross, Blue Shield's distinguished record of recission?

Also, according to that Coalition Against Insurance Fraud, $2 million spent on fraud prevention stops $17 million worth of fraud. So it's not $1->$1; relatively little of that overhead is going to fraud prevention. The rest is going to minimize loss - i.e., to try to get someone else to pay for health care. That's the global impact to the system that SamChevre is talking about: the staff at insurance companies that processes claims, and the staff at hospitals, doctor's offices, and private companies that has to feed them paper. You seem to have missed that part of the argument.

You are right that Medicare pays less than hospitals, but many believe that the reduced paperwork hassle for hospitals makes up for the cost. It takes far fewer admins to support government billing than private billing.

Another missed topic is profit; a 6% benefit on Medicare's side. All things being equal, I would prefer that 6% in profit over 6% in fraud, but all things are not equal.

As someone who pays to have her health care managed by a large, not perfect but pretty good non-profit organization -- Kaiser -- I'd support nationalizing the insurance companies and turning them into non-profits. But "nationalizing the insurance companies" is impossible in this country. Could not happen, even if you called it something else. They are too big and they have spent too much money buying large pieces of the Senate.

By the way: evidently Senator Diane Feinstein's San Francisco office has been flooded with constituents (organized by Obama for America, yeah!) showing up to support health care reform. According to reports, their arrival has made her staff quite cranky.

David @ 45, I hear what you're saying, and really, when you get down to it, I disagree. Fuck treading carefully; this country, right now, wants my son to die because he may need a new kidney someday and I'm not a millionaire. That's what it boils down to. A bunch of really, really rich guys don't want my ten-year-old to cost them anything. Oh, they love it when they can fear-scam their way into making me give them more money - but when it might come the other way, forget it.

Meanwhile, anywhere else in the world, it doesn't work that way. And I'm told that this is what makes America great.

So yeah. By all means, let's tread carefully when depriving those poor wealthy parasites of their gravy trains; we wouldn't want to live in Europe, after all.

When all's said and done, I guess I'm a Trotskyist - let's blow it all up, let the pieces fall where they may, and keep the parts we like. Accelerated evolution.

Second thought, on preview: why should we tread carefully with health care, which might actually help Americans, when we didn't tread carefully with Iraq or the Patriot Act? Or torture? What happened to the Cheney policy that if there's a 1% percent chance Americans could get hurt, we had to put all the resources we had on it? How come all this only ever benefits really rich people and/or assholes?

And then the pharmacy companies put out stupid shit that the ads say, "Hey, grows thicker eyelashes". Yes it has side effects, it could make you go blind but hey, you'd have great eyelashes. And they have BROOKE SHIELDS doing the commercials, like she couldn't figure out making her eyelashes thicker with cosmetics.

As well as a lot of other bullshit.

The pharmaceutical companies are a big part of the bad stuff. They have to make up new drugs for stupid shit to make money.

Michael @48 - you're absolutely right, of course.

Which probably means that the game is over and we've lost. :-(

24

Greg, no, that is all mine. Use it all you like. :)

Cheers,

bt

Aw hell, lets give in. Put a no death panel clause in the bill. And while you're at it, no death squads. Or death penalties. Or Ninjas. Cause, really, the government shouldn't be in the business of death.

(well, ninjas would be cool, but I don't need to support them with tax money. they can raise their own with movies and merchandising)

eric @ #52, You've been reading Christopher Hayes at The Nation, right?

Or the Daily Kos diary (can't find the thing, sorry) which said the strategy ought to be "OK, we'll put something in the bill that says we won't euthanize people and we won't pay for abortions (which the Hyde Amendment says we can't do anyway, but we don't need to tell them that), etc., etc."

It's a small thing, but surely the "in Britain they leave old people to die" thing can be refuted by one data point (well, two): life expectancy is higher in the UK than in the US. So if we really are murdering old people, we're clearly not doing it in anything like the numbers you manage in the States.

A paper on supercentenarians including a table showing national distribution.

The figures for the USA are "incomplete", only 18 being recorded in the dataset used for the paper, with an estimated 184. That's a much lower average "catch" than the ratio between known and estimated for all the incomplete countries.

And here is the population age-distribution for the UK. What's interesting is the sharp spike for the immediate post-war period, and the 20-years-apart bulges.

And here are the statistics on aging in the UK.

While this is some info on age distribution in the USA. It lumps together everyone over 85 into the same group, which makes comparisons a little difficult.

Anyway, nobody is allowed to use facts in a political debate.

Here’s a table of overall life expectancy vs. health care expenditure by country.  Whether it’s reliable (sourced partly from Wikipedia, it says) or whether the site is politically tainted (swivel.com), I’m not sure, but it’s in line with other statements that the US spends far more on health care than European countries (except, oddly, Luxembourg) for a worse life expectancy.

Here’s a table of life expectancy at birth, placing the US at 50th, just above Albania.  This is the CIA World Factbook, so presumably irreproachable.

But as Dave Bell says, facts are irrelevant in a political debate.

It looks very much like no-one in the Administration or Congress realized what kind of fight they were going to be in for. I can only wonder why. Obama may be the most astute pol in a generation--did he really think his radical-right opposition was going to let this go without a fight? He's been a Senator--why did he trust the Senate?

The demented fcskwits who are protesting against improved access to health care have been so thoroughly programmed with RNC and insurance industry astoturf that they're utterly unreachable.

Not necessarily. I find applying basic facts about health insurance works fairly well on right-to-life types.

Less than half of all states mandate *any* kind of coverage of pregnancy. That means if you're a woman of child-bearing age, the insurance companies in those states treat you as having a pre-existing condition, just for being female. Adding pregnancy coverage to an individual plan will roughly double your premium so for a healthy female, it'd go from around $500/mo to about $1000/mo. You might manage less than $1000/mo, but you're not going to get it below $500/mo. That's assuming your only pre-existing condition is having the misfortune to be born with two X chromosomes.

It seems to work especially well on right-to-life types with daughters. And when you start comparing it to how much it costs to rent an apartment in the same area... it gets through to an awful lot more. When you go into the fact that being turned down *once* means that you're pretty well un-insurable in that state... mostly, they shut up.

I haven't found an argument that works well on a lot of other folks. But I'm happy enough to have one that works at all. Most people who believe in right-to-life really aren't stupid, and they understand that if a young woman gets pregnant, it's very expensive to go through with it and have the baby. They often don't understand just *how* expensive tho.

@56: Wikipedia's figures are sourced from the OECD and WHO, so should be fairly accurate. Those figures are for total (public and private) spending on health, though, so they miss the most alarming point: that the US government spends more per capita on healthcare than anyone but a handful of European countries (which handful does not include the UK). The WHO has lots of data.

I know a single mom who was pregnant a few years ago, without any healthcare insurance at all (she's a waitress). She worked multiple shifts, saved every penny, and when she needed the more basic pregnancy checkups she either went to a clinic or the ER (that was for when she had to walk 6 miles to pick up her car while she was 4 months along, started bleeding).

She worked herself to exhaustion right up to the day she went into labor, worried herself sick that she wouldn't be able to pay her utility bills, and still ended up paying only part of the bill for the C-section and hospital stay.

Torillin #58 :  well, but this is insurance.  That’s how insurance works.  Insurance companies charge premiums according to risk:  that’s why, as a young person, if you have the good fortune to be born with two X chromosomes your auto insurance will be lower than if you haven’t.  Females of child-bearing age are at significant risk of getting pregnant, with expensive consequences, therefore their premiums are higher.  The only way out of that problem, surely, is non-insurance-based health care, or maybe regulation that says they have to ignore pre-existing conditions (risks) – which would negate the concept of insurance.

Maybe someone who lives in another nation (Canada, Holland?) with insurance-based health care can tell us whether women of child-bearing age pay higher premiums there too?

John Stanning @61:
Maybe someone who lives in another nation (Canada, Holland?) with insurance-based health care can tell us whether women of child-bearing age pay higher premiums there too?

Nope from the Netherlands. But insurance rates are set by law, as are coverage levels.

well, but this is insurance. That’s how insurance works. Insurance companies charge premiums according to risk

Well, that's part of it. The other part is risk pooling, where you apply the same premium to a wide population, only some of whom will incur the insured risk. (Otherwise you're just operating a fancy savings plan.)

If you split your pool of insured people into men vs women and by ages, then you get different rates, because they have different risks. The more you split, the more different the rates, which is shiny for the young, male and healthy-unto-the-tenth-generation and sucks varying strengths of rancid lemon for anyone else. Eventually, insurance only becomes affordable for a small set of people, and here Americans are today.

In the Netherlands, the whole country is one pool. Does that mean a fraction of my premiums go to someone who's sicker than me? Ja, zeker, as they say here. I'm not complaining, partly because the rates are affordable, and partly because I think universal health care is a good idea (even when there isn't a pandemic flu going the rounds).

abi #62 :  yes, that’s a better way of doing health insurance;  in fact, if everyone pays the same premium, it sounds just like the British NHS, only privately- rather than state-funded.

But in the US system, health insurance seems to be just like any other insurance.  Here in England, my car insurance is higher or lower depending on a mass of risk factors:  what model of car it is, where I live, whether the car is parked in a garage or on the street, whether the drivers have recent crashes or traffic tickets, how old or young the drivers are, and so on and on.  Property insurance works the same way.  Even if I took private health insurance here (which I don’t, because the NHS is good enough, but about 5% of people in England do), the rate would vary with the risks indicated by my age, my profession, where I live, whether I smoke, whether I ski or fly (as pilot), etc.  Nobody seems to think that any of this is strange.  In England and NL the idea that general health insurance might be like any other insurance is off our radar, but conversely in the US, maybe it doesn’t occur to a lot of people that general health insurance can be different from other insurance.

Mark Fiore has a great animated cartoon about the loonier paranoid fantasies. (The bit about Guerilla Obama coming to cut out your heart really had me giggling.)

It's true that women are more likely than men to get pregnant, but as men are equally likely to cause a pregnancy (with its associated expenses), it seems quite unfair to use pregnancies as a pretext for charging women higher insurance rates.

men are equally likely to cause a pregnancy ...

I wouldn’t be too certain of that ...

Non-profit: An organization where what would otherwise be profits are paid as salaries and expenses.

FungiFromYuggoth@46:

You are right that Medicare pays less than hospitals, but many believe that the reduced paperwork hassle for hospitals makes up for the cost. It takes far fewer admins to support government billing than private billing.

You meant that Medicare pays less to hospitals (than private insurers), correct? Just trying to make sure of your point. But as to the second part - that it takes far fewer admins to support gov't payors than private. Where did you get that information? I'm in health care, in hospital billing actually. I'm on the IT side rather than the business office side, but that is opposite from everything I've ever heard. Is it a regional difference, maybe?

Jason at 67, are you suggesting that administrators and executives at Kaiser are paid significantly more than administrators and executives at for-profit hospitals and/or insurance companies? I'm not going to do the google thing, but I very much doubt it; I've not seen that claim anywhere else. If you aren't suggesting this, then what is your point?

Dena Shunra @ 50:

I figured that the game is over and we've lost when our (Democratic Party) Leaders started talking about "Health Insurance Reform".

What we need, IMHO, is Health _Care_ Reform/Improvement -- including coverage of just about everyone in the country -- and it looks as though the best we can hope for along that line is an application of a layer of cosmetics that will start peeling-off in a few years. *grumpf*

John, if you want to drive a Ferrari your insurance will go through the roof, but it's your choice.

The risk isn't entirely arising from your actions, but if somebody else causes the loss, their insurance company can expect to pay.

Medical insurance, there often isn't anybody to claim against. A virus doesn't take out insurance against infecting people. Cancer? You can certainly choose not to smoke, but how many cancers have a significant correlation with personal choice? And how many have we known about for long enough that people can choose to make a difference?

And who can you sue over the consequential losses of being a woman?

And one advantage of a system such as the NHS, or the BBC in its field, is that standards are set. If the Insurance Companies in the UK didn't compete with the NHS, if they behaved like those in the USA, people would just walk away.

At the very least, the USA has a medical care system which is based on a totally wrong model of insurance.

A non-profit hospital may not be paying its executives as much, but that doesn't mean that they don't make a buck. They don't call it "earnings" or "profit", but rather "reserve", as in reserves for capital expenditures. Some non-profit hospitals can have reserves of hundreds of millions of dollars.

Lizzy L @ 69:

I think Jason @ 67 has a valid point (though it probably ought not be perceived as being aimed at Kaiser, judging from my dealings with them).

Yup, not-for-profit organizations _can_ direct ridiculously large sums into salaries, directly or indirectly (via nepotism and cronyism). Most notably, some charitable organizations are scams utilizing that technique.

This is something that can (& should) be fixed (at least well enough to cease being a significant problem) by proper oversight and regulation, so I don't find Jason's point persuasive. (Although... what with the recent trend towards get-the-government-off-our-backs de-regulation, it suggests that the return of Republicans to Power would be disastrous. But then, I already knew that.)

Steve C & 72:

Yup. And the logical thing to do with those Reserves (when they get sufficiently more than large enough to cover practically any potential emergency) is to build another (and more state-of-the-art) hospital -- which will both make them more profit and increase the quality of healthcare for a significant number of people. That's what Kaiser-Permanente seems to be doing here in southern California, albeit gradually. (I'll try to remember to check with them, but wouldn't be surprised if the (comparatively) recent facility in Baldwin Park cost several hundred million dollars to build & equip. It's certainly several hundred times as large as some houses I've seen for sale with an asking-price of over 1M.)

Found on Salon.com...

Former Alaska Gov. Sarah Palin is back on Facebook, and she's talking about "death panels" again, responding to the criticism she's taken for promulgating that particular myth about Democratic healthcare proposals. This time, though, it doesn't read quite like Palin wrote it herself -- there's less rambling, for one thing. And there are footnotes; 11 of them.

Eleven footnotes?
Is Sarah channeling Abi?

Serge:

Eleven footnotes?
Is Sarah channeling Abi?

And what unmentionable act did Abi perform on your cornflakes today to deserve that ugly suggestion?

"You know, if I was a terrorist, I'd totally be funding some insurance lobbyists. They make sure heaps of Americans die. It's great. Way easier than blowing up buildings."

How do you know they don't?

Someone with terrorist ties knew to short airline *and* insurance companies around 9/11... and we've never, ever heard the name of a person or a company who profited from those trades.

If you wanted to kill America and had a Ten-Year Plan, and you knew that with the repeal of Glass-Steagall any mofo with a hedge fund could effectively purchase and loot any US insurer, given time and a collapsing regulatory system, well, would you lead the charge in every Al-Qaeda operation, or live in one of your many houses, use your vast family fortune to participate in the Meltdown, and issue the occasional tape from your studio cave?

That's why I know we'll never get a full accounting of the Meltdown. If our enemies gamed it, so did our intelligence agencies, just like the drug trade. Our infrastructure and governmental collapse becomes a national security secret. As soon as Obama bought into the lies that keep people renditioned, and criminals held without an accounting of their crimes, in even a closed court, I knew we were in for four more years of gaming the system until it fails.

Sure, call me a nutbar conspiracy theorist. I still have my totebag, and it's still of use.

I find applying basic facts about health insurance works fairly well on right-to-life types.

That's because right-to-lifers still intersect planet Earth, at least occasionally. Birthers are orbiting Pluto. Also, they think Neptune is Earth, because it's blue and all blue planets are the same, am I right?

Bruce E Durocher II @ 76... Yeah, that didn't come out quite right.

Lizzy @ 69: No, I was not referring to Kaiser. I was snarking a bit about non-profits because some think that non-profits necessarily prioritize their function over the good of the people running them. Sometimes true, sometimes not.

There are many non-profits run by dedicated people doing excellent work. Some are run by nest-featherers and empire builders. Some see themselves as doing good work and reward themselves too much for it. I work in state government and see state money going to many non-profits. In aggregate, that's a good thing. But some of those people pay themselves too much for what they do.

cgeye@77: how do we know it was somebody with terrorist ties? There are always shorts against nearly any stocks, for hedges if nothing else, and so somebody was going to profit when those stocks tanked. They needn't have had foreknowledge of the attacks.

Now, if the point is that there were much BIGGER short positions than normal, and no other simple financial reason for them, that might be suspicious. Is that's the case?

Steve@72: A non-profit hospital may not be paying its executives as much, but that doesn't mean that they don't make a buck.

It does, however, mean that they're not making their decisions primarily on how many bucks they will make. In particular it means that they're not giving people bonuses for denying health care to customers.

I wrote a letter to the editor! (The Palladium-Item, Richmond IN)

I'm writing in response to Kathleen Parker's editorial "Real Angst Heats Up Summer", which I just read. Is Ms. Parker really meaning to imply that people are alarmed because they might get a better deal on health care? Are her three out-of-work friends really worried that our existing system, tying health care to your existing employer, might be changed to their benefit? And why on God's green earth does she think that Rush Limbaugh, multi-millionaire, should be trusted when it comes to the motivation of people worried about money? Of course Rush doesn't want change - he's just fine!

Me, on the other hand - I'm self-employed. Since my kids have existing health problems, I don't get health coverage. And unlike multi-millionaires like Rush Limbaugh, I can't easily afford health care on my own, so I'm gambling with my kid's lives just by staying in America.

Maybe Ms. Parker thinks that real people are experiencing angst about changing an untenable situation, but I really think the major angst out there this summer is the fear on the part of the insurance companies that their easy gravy train is coming to an end. Personally, my only angst is that thanks to the efforts of the media, we will fail to give Americans - including me and my kids - the health care coverage we need.

Whaddaya all think?

#83: Sounds just fine!

Serge, Bruce:
Eleven footnotes?
Is Sarah chaneling Abi?

To be honest, I prefer Elven footnotes¹, given the choice.

--------
1. O! What are you wishing
And where are you going?
I'm out with the fishing
The pipeline is flowing
O! tra-la-la-laska
up north in Alaska!

To be fair:
http://www.snopes.com/rumors/putcall.asp

It mentions that the trades were 'innocuous', but this investigation was part of the 9/11 Commission's work, so I still have my doubts.

It didn't have to be a company with ties to Al-Qaeda; it could just as well be people with foreknowledge of the attacks and a lack of a moral compass, financially. The Al-Qaeda warning report was given to the President in August -- and the FBI monitored the AQ pilots while in training, but were ignored by higher-ups. Arbitrageurs who spend their days piecing two and two together could have put trading programs in place, just in case.

Did I mention owning the term 'nutbar conspiracy theorist', or at least leasing it every once in a while from here?

And #83 Michael Roberts: good work.

The Raven @57, Obama may be the most astute pol in a generation--did he really think his radical-right opposition was going to let this go without a fight? He's been a Senator--why did he trust the Senate?

Some stuff I've read during the campaign about his previous achievements made the impressions that he spent a lot of his time in the Senate with the handful of sane GOP Senators working on issues where they didn't have any financial reasons for blocking solutions. And apparently that describes some of his time in the Illinois State Senate, too. That might have given him some rose-colored views about dealing with the GOP.

Meanwhile, Steve M. makes a rather harsh comparision.

#87
He's not the only one.
If I had a dollar for every time a senator says 'bipartisan' or 'working across the aisle', I'd have a lot more money. (Far too many of those senators are democrats with seniority. Apparently they've been asleep for the last ten or fifteen years.)

I may be an incurable optimist (pun intended?) but I'm not worried that we won't get health care reform. The Democrats have enough of a majority that a reasonable facsimile of the current bill will go through. (This doesn't mean we should slack off on efforts to promote it - all politicians need encouragement to do the right thing.)

The Democrats may lose a couple of seats in Congress come 2010, although even that requires the Republicans to find some competent candidates.

Chris Gerrib, I'd say "The Democrats" don't have any kind of majority because "The Democrats" don't exist. The US Senate seems to consist of 40 Republicans and 60 people who form their own one person parties. (20-30 years ago you might have said that it consisted of 100 people who formed their own one person parties, but the Republicans seem to have gotten more disciplined since then.)

What always gets me is that the current system is so BAD for exactly the kind of person the Republican Party makes a big deal of being "for" -- the independent, self-made American, the small businessman, the inventor, the entrepreneur.

All of these people get shitty healthcare in the American system.

Worse, entrepreneurship and innovation are actively squelched by a system in which only those with no health-care worries can strike out on their own, leaving everyone else tied to big monolithic employers because they need the coverage.

Fact is, socialized healthcare would be great for small business. It'd allow them to compete on more even terms with big business, which currently can afford to compensate its employees better through economies of scale.

And then there's the cost of all the employees who are not dealing with their serious health problems because they can't afford it -- who are thus much less productive, and who eventually may end up in a much worse state, more costly for their employers in terms of absence.

Very short answer (I'm in the middle of a project right now): there are two basic ways to get a Publish America author to see the light. One is to wait until PA screws them over. Trouble is, by the time that's sunk in, many of them are so exhausted and depressed that they don't want to hear about it.

The most effective method is to show them a bunch of other PA titles. They may not be able to judge their own work, but it's abundantly clear to them that other PA authors and titles are not ready for prime time. Other realizations naturally follow.

(This, btw, is why PA now strongly discourages its authors from putting up sample chapters on their websites.)

If health care is like books, and the audience is like authors, then everything is All About Them. Trouble is, no one fantasizes about how happy they'll be when they need lots of health care. They're good at not thinking about their own vulnerability. They might respond better to stories of other people a lot like them who did everything right, tried as hard as they could, and got nailed anyway.

You could also collect stories from former U.S. residents who've moved to countries that have national health care. They'd hear from people a lot like them that the standard of care in those other countries is just fine.

Since it's All About Them, you have to keep the hypotheticals concrete. For instance: no matter how well they drive, anyone can have an auto accident and be seriously injured. The current cost of extended hospital care and rehabilitation is more than most Americans can handle, even if they have insurance. After that, they lose their house and their retirement savings. Those are all easy to understand: auto accident, long hospital stay, house, savings.

One child with a serious illness can have that effect too. Sick children are very concrete.

Whenever possible, use small numbers, like "one in six." Most people have a gut-level understanding of the numbers between one and one hundred. Fewer of them are on cozy terms with four-digit numbers. And for more of them than will ever admit it, when numbers have five or more digits, and most of the digits to the right of the first comma are zeroes, it all starts blurring together like heat-shimmer on a highway.

Raphael @ 90:

In particular, there's a claque (I'd call them a clique, but they're too noisy) of "Blue Dog" Democrats, who seem intent on filling the niche of the old Southern Democrats, the ones who turned into Republicans when the Federal Government started talking about considering black people as full human beings. Half of the damage to Obama's agenda has resulted from attempts to keep them happy, or at least content enough not to vote against their own party's President.

Chris, #89: The Democratic Party has a conservative wing, but the Republicans don't have a liberal wing. That's how W. Bush was able to have his war.

Raphael, #87: I suppose it's possible that the GOP Senators been working all the time Obama was in the Senate to set him up for defeat, the way LBJ set up Humphrey. Oh, wow. If that's what's been done, I don't think Obama is going to take it lying down. "Honey, break out the popcorn!"

The Blue Dog Democrats are traitors to the party and their voter constituents and should just get the hell out of the Democratic party to join their fellow travelers among the Republicans. Then the illusion of liberal power would be wiped clean, and we could finally come to terms with the fact that the progressive cause is lost for yet another generation.

Is that depressing enough?

tnh, #92: "They might respond better to stories of other people a lot like them who did everything right, tried as hard as they could, and got nailed anyway."

These are the stories that public health care advocates have been telling all along. Maybe that's why Rush and all are pushing people to shout rather than listen--the propagandists know they might lose, if their audience listens to the other side.

Teresa @92, I think you're saying that the only way to handle this is through storytelling. Tell a compelling story of why universal and reformed healthcare will be good for YOU-audience-member, a specific case of your general principle about story being a force of nature.

Did I read you correctly?

Yeah, I am concerned about Blue Dog Democrats. Not enough to think that they are going to block the bill. They may get some cosmetic amendments (explicitly banning "death panels" or whatever) but I suspect enough of them will vote "aye" to move the bill.

But that's just my opinion, so I could be wrong.

I got one of these "16-page analyses" of the health reform bill in the email today. It challenges the reader to check the analysis against the bill.

I went through the first three specific claims, and sho'nuff, all three were simply false when compared with the actual bill. A limitation on copays was being read as "rationing of healthcare". I guess someone saw the word "limited" and, without reading the rest of the sentence, or the definition of "cost-sharing" included in the bill itself, and ass*u*me-d that there was a limitation on payments out. That it was a limitation on payments *in* escaped them utterly.

I'm left with: either these guys are illiterate fools, or they're lying propagandists who take Americans for illiterate fools.

(Either that, or there's an allegorical message here somewhere, but for the life of me, I can't find it - viz. Maimonides on rabbinic tales)

You can find it online, with my response, and pick it apart yourselves.

Melody @68 - I was basing my statement on the most convincing of proofs: the anecdote I read on the Internet and now can't find again. Sigh.

Yes, the first part was agreeing that Medicare pays less than private insurance. One way of looking at it is cost control, another way is forcing private industry to subsidize health care, and the third way that I was going with was that Medicare is less hassle than private insurance.

As I recall it, the anecdote was that at Miskatonic General or wherever, it required one admin to support three doctors working for private insurance. When dealing with medicare/caid, the ration was one admin per ten to fifteen doctors.

I certainly could be wrong; this isn't my area of expertise, and my personal experience with health issues has primarily been with socialized government-run health care. No argument that there's room for improvement all round, but it does seem that private insurance in poorly regulated states is profoundly underperforming.

It's frustrating that so much of this discussion is anecdote-driven. The numbers must be out there, they just aren't public.

Michael Roberts, #48, I'm very sorry about your son's situation. After all, I've survived two renal failures myself and am currently spilling protein like crazy because of the prednisone. But where do you think he'll get a kidney? There aren't enough kidneys donated for everybody who should have a transplant, much less kidneys that match. You could buy one from China, but you'd have to live in an undeveloped country and that would be as bad for his health. I don't think you can blame lack of kidneys for transplant on the US. You have to blame it on Americans.

#100
I've heard doctors, or their staffers, complaining about dealing with insurance companies and their paperwork requirements often enough that I'll go along with the idea that medicare/medicaid is easier to deal with, although less profitable for the doctors (because they don't get as much in reimbursements as they'd like).

On the other hand, I don't see any requirement anywhere that doctors live in expensive houses and drive luxury cars, so I have to assume that what those complaints about reimbursements are about is more that the doctors aren't able to pay off their education loans and, at the same time, live the lifestyle they assume they're automagically entitled to.

Marilee @101, I suppose we could blame airbags, helmet laws, and people sensible enough to wear helmets and seatbelts for the lack of kidneys for transplant?

#102 PJ Evans - I can't speak to Fungi's doctor to admin ratio directly, but I volunteer with a doc who deals only with street people. Those who have coverage are all Medicaid or General Assistance. When we started billing those who have coverage three years ago, it took a volunteer on sabbatical 6 months to write us a billing system. There are still over a dozen payers to deal with. We don't have enough funding to support a billing assistant for Doc, and he spends almost as many hours on billing as he does seeing patients...

The sheer complexity of dealing with the government programs was enough to crush a planned start-up venture of my own, that of providing Emergency Room visit follow-up care on the streets instead of back in the ER... It became clear that without a dedicated computerized billing system, I simply would not be able to spend enough time actually seeing patients to be a viable option for the county hospital...

"On the other hand, I don't see any requirement anywhere that doctors live in expensive houses and drive luxury cars, so I have to assume that what those complaints about reimbursements are about is more that the doctors aren't able to pay off their education loans and, at the same time, live the lifestyle they assume they're automagically entitled to."

I find that statement a little... hasty, perhaps? Unless you're quite familiar with loan costs and other factors such as Resident's pay scales, and malpractice insurance costs for independent doctors...

Ten years ago, for a senior project, I did a comparison of an 18 year old becoming a new MD in Internal Medicine (the adult version of a GP), and an 18 year old high school grad getting a job with General Motors (under UAW contract). Between lost income during education, loan repayments, higher taxes, and malpractice insurance, the MD was 54 years old before he surpassed the auto worker in lifetime net earnings. Specialists reach that figure at a much lower age.

The doc I volunteer for drives a 10 year old VW, lives in a smaller house than mine, and is relying on loans to put his 2 daughters through local colleges.

Cutting doctor's pay will solve little, and could well contribute to future MD shortages, especially in rural areas.

This is the only place in teh entire Internets or news that I'm bothering with reading/hearing about this stuff because I am one of the uninsured. My job had always been with a company that was willing to cover Jim and I for a rate that was commensurate with my salary.

Then I got laid off. COBRA was $900 a month, about 75% of what my unemployment would end up being so I didn't sign up for it. I have hypertension, but my doc has been giving me my medication in sample form for the past year and a bit more than a half.

I've got an idea of starting a business but I'm scared not to try to look for "regular work" because I really really ought to have insurance coverage. I'm reasonably healthy right now but am aware that catastrophes can happen.

But It I am having a really hard time even finding 'regular work' because of the economy and the fact that I'm more of a generalist rather than a specialist. Plus a fiction writer, which won't buy a cup of coffee anywhere.

Serge@75:

Eleven footnotes?
Is Sarah channeling Abi?

Cargo Cult Abi; next on Salon.com.

Recently back from Mauritania, and I must say what I saw there, what I know from personal experience living in France, and what I'm reading of the current US health-care debate is driving me clause to that strange laughter/tears state (no, not the good one).

#103 Rickibeth - Ummm... did that come out like you intended it? This sub-thread about organ donation has shown what an emotional hot-button it can be.

My own father was furious at me for signing up as a donor. He was under the impression that the donor (or their survivors) had to pay for the donation. There's a lot of similar misconceptions (like the utterly false but persistent rumour that donors are allowed to die in ERs to get their organs) that keep people from signing up. As a nation, we could do a lot better at volunteering to be donors, which is what Marilee was saying.

#57:

Obama's problem is that he spent too much time in the politician's bubble and not enough time reading FreakRepublic. What elected GOPpers say in private is one thing, but there is no better place than FR to learn how Democratic policy initiatives will be treated GOP operatives in public.

Obama's other problem is that he hasn't realized that the Washington village only regards right wing ideas as acceptable and will only accept right wing leaders as legitimate.

edward oleander @107: I did sort of mean it as a bleak attempt at humor, but it's not an especially funny subject.

I'm signed up as a donor. I may, someday, be in the position where an immediate family member needs a kidney, and the question in my mind is whether I'll be healthy enough then for it to be a possibility.

I also have a lot of friends who ride, and who are understandably safety-conscious, so the grisly humor comes up from that angle.

I probably shouldn't have said it.

While trauma is the #1 killer of people under forty, there are lots of other ways to die (for people of all ages) that leave their kidneys, corneas, skin, etc. perfectly useful for transplant. And there are lots of traumas where all the seat belts, helmets, and airbags in the world won't help.

What really slows down the available organs for transplant is the lack of donors.

(Nor do I ever ask (or have any real way of finding out) anyone's donation status when I go to them. I'm not there to get organs; I'm three to fight the Angel of Death one-on-one and kick his scrawny ass.)

Edward, #104: Good point; the perception of doctors as "obscenely rich" is driven largely by people looking at specialists in rich-people fields such as elective cosmetic surgery, stomach-stapling, etc., and at top-of-the-line specialties such as neurosurgery. Has anyone ever done a survey on MD earnings broken down by specialty?

It occurred to me earlier that for a lot of us, one counter to the "death panels in other countries" meme (at least among our circles of acquaintance) would be, "Two words: Stephen Hawking." For people who know who he is in the first place, it can be pointed out that if he'd been born here he would have been dead long ago due to insurance-company rationing of care. But under a system of "socialized medicine", he got the care he needed to realize his potential as a brilliant scientist.

#109 - Rikibeth - And I should have known better and given you the benefit of the doubt... sorry for being kind of grumpy about it...

MD² @ 106... Cargo Cult Abi? I guess next time she flies in to the Bay Area, we'll have to bring huge ostrich-feather fans. Do we also need a miniature volcano?

Lee: the Irony machine sure is working overtime right now, since there's a statement making the rounds -- I believe it was made by Senator Chuck Grassley (R-Idiot Wind) -- that if Stephen Hawking had had to rely on the National Health in the UK all these years, he would be dead, since the British system, on account of rationing and all, wouldn't treat him...

Of course, Stephen Hawking is a British national and has been kept alive by National Health all these years.

These people are stupid and insane.

Lizzie L @ 114... Speaking of Hawking, people might want to see this photo on Mary Dell's blog.

Another aspect of "socialist medicine" that might weird some of you out; average pay of British doctors in general practice in 2004-05 was over £104,000, or around $160,000, putting them on average in the top decile of wage earners (according to the Treasury) ... and liability insurance and student loans are both much lower in the UK than the USA. The BMA disputes these figures and say that employee GPs earn on average around £70,000 (but note that their employers are the ones who get to pay the insurance premiums).

So: if the Treasury figures are right, under "socialist medicine", GPs earn more than cabinet ministers, circuit court judges, and Army generals. And even if the BMA's more parsimonious estimates are correct, they earn as much as or more than MPs.

Sometimes I wonder why we don't have a huge government incentive plan for people going to med school. If med school seemed much more affordable than, say, law school I think we'd have a lot more doctors.

The is an interesting piece by Uwe Reinhardt about how so-called common sense about health care is anything but.

Common sense health reform

All the back and forth about the NH is idiotic, anyway, since NONE of the various bills currently being written creates a system that looks like the British system, or the Canadian system either. Is that a good thing? Yeah, probably. But the nutjobs on the right keep screaming "Britain! Canada! Be afraid!" as if this were relevant.

I repeat, insane, stupid.

I'm going to bed, now.

Whole Foods just lost my business.

Summary: Whole Foods CEO John Mackey outlines an "alternative" to Obama's plan which would effectively remove ALL regulation from insurance companies, and includes "tort reform" so that people could no longer sue doctors or hospitals for legitimate medical-malpractice injuries. Includes several of the main flat-out lies being pushed by the insurance lobby, including the following:
Even in countries like Canada and the U.K., there is no intrinsic right to health care. Rather, citizens in these countries are told by government bureaucrats what health-care treatments they are eligible to receive and when they can receive them. All countries with socialized medicine ration health care by forcing their citizens to wait in lines to receive scarce treatments.
Oh, and wanting affordable health care is now an "entitlement".

See if I ever spend another penny in his store.

Were I an American, the most I would be able to say on this subject would be "Br-ai-ns!"

A discussion of the merits of medical procedures, leading to a moment of revelation.

Abi #85:

I object. There is a canonical "tee-hee" or "ha-ha" missing:

O where are you goin'?
And where are you sailin'?
There's Balin, and Dwalin
And that nutcase Palin
O tra-la-la-laska,
Up north in Alaska.
Ha-ha!

Lizzy L.@114

Actually the source of the Hawking story was an editorial in Investor's Business Daily.

I don't think Grassley has been involved in spreading that particular story. According to a Washington Post article on August 13, he did claim that Ted Kennedy would have been denied care for his brain tumor because of his age if he lived in the UK.

(The claim appears to be false.)

Lee@120: Don't forget the bit at the end where he shifts to saying that all we need to do to avoid disease is eat foods from his stores.

It's as if he accidentally reached into the box of nutritional absolutist talking points instead of the box of free market absolutist talking points.

Lee, Whole Foods is a very cynical operation. They've been anti-union and anti-environmentalist for a long time, and the position of their CEO is no surprise at all.

Serge@113:

I'd say what would be needed is more something among the lines of a coconuts made software parser (or maybe a lactose intolerant volcano, I'll give you that).

MD² @ 127... Lactose-intolerant volcano gods? Is that covered by their health plans?

Maybe it's just my ignorance showing (I've been out of the country most of the last while, and haven't had much chance to look at newspapers) but I'm still trying to get my head around exactly *what* is involved in the health care reform bill being pushed by the administration.

I've heard a lot here and elsewhere about scary rumors and town hall disruptions; and about single-payer and public-option provisions that don't appear to be in the current administration proposal (even if there's a notable consituency that wants it). But not much discussion of the actual proposed reform.

Going over to whitehouse.gov, I click through a few links, and find what seems to be a bunch of patches on the current private insurance system, mostly aimed at requiring the maintenance of a certain level of coverage for everyone. (Though I don't see anything very definite about premium cost control, or whether all policies have to be comprehensive, or how adverse selection will be avoided. Without those, effective health care could still be as unaffordable as ever for those with chronic health conditions.)

This could in theory be something approaching what they do in the Netherlands (where I gather from abi and others that insurance remains private, but regulated effectively enough that you get affordable universal coverage nonetheless). Or it might be quite a different beast. I don't know enough to say.

I'm also not sure what the Democratic strategy is trying to do. There seems to be both an effort to get something passed fast (it's August or never!) and to hold a bunch of town halls. What are the town halls for? If they're to consult the public on what they want in health reform, then they have to allow more time. If it's to sell the public on a bill that's basically decided on and ready to go, it seems to be handled rather ineptly. If you don't make it clear what you're proposing, it's easy for fear-mongers to fill in the information gap with lots of scary rumors.

To bring it back to the vanity-press analogy, we've developed some very useful simple principles for what makes a good deal vs. a bad one. (E.g. Yog's Law: "Money flows towards the author".) What are the simple principles that need to be put forward here?

Serge@128:

Is that covered by ours ?

Jim Macdonald #110:

What really slows down the available organs for transplant is the lack of donors.

I want my Organ Donor selection on my Driver's License to be binding. Unfortunately, ownership of my flesh instantly passes to my next-of-kin on my death*, who then have to be consulted.

*Your jurisdiction may vary.

I'm [there] to fight the Angel of Death one-on-one and kick his scrawny ass.)

Which is exactly how it should be. Until the Angel of Death has irrevocably won, the sole focus of those on the bleeding edge of health care is "Live damn it, Live!", and rightly so.

Hence the strict firewall setup isolating the organ team from the care providers.

John Mark Ockerbloom at 129 asks a very good question -- what are the basic principles we want here? Having just come away from yet another argument on Facebook about health care reform where we split down party lines and seem to be talking about entirely different things, this sounds to me like a good starting point.

Do we have a long-term goal we can agree on? Can we break it down into stages of accomplishment, or do we need to do it all at once? Is there a moral underpinning that we need to keep in mind?

One starting point has been articulated here -- no one should ever be afraid that necessary care will mean financial disaster. What many conservatives I've talked to seem to be most worried about is who determines what is NECESSARY care. They want to make sure no one will run some arcane formula and decide that they are valued less than some other person and therefore won't get some procedure. On the other hand (and I'm not seeing this coming form the supposedly fiscally conservative Republicans!), who determines that a procedure is postponeable or cosmetic and that taxpayer money should not be spent on it? So who should be making these decisions?

MD² @ 130... Not sure if I'm covered for that, as I am disgustingly healthy, but that wouldn't mean anything either way. I'm not a god, and gods get special treatment.

What do I want, to the extent that I have standing to want it?*

Speaking personally, I would say that I want universal access to basic, affordable health care.

Universal access means that people are not denied coverage for pre-existing conditions, unemployment, or poorly chosen ancestors. Everyone has a way to see the doctor.

basic is the marker of where I think we can give on the ideal of "everyone gets every treatment for free!" I shared a hospital room when I had my kids, and many non-essential services are not available on the NHS (plastic surgery, for instance, except under particular circumstances). That turned out to be fine with me.

affordable means that people with expensive diseases can still both eat and get treatment. This is going to require a wide risk pool to get, and will mean that the (currently†) healthy will subsidize the sick.‡

Now, I really do not care how we get to these ideals. I've lived in two systems that do the same thing in very different ways. But a system that doesn't cover this ground ain't much of a system at all.

-----
* I have such standing in two ways: I have friends and family in the US, and I would like to be able to return to the US without gambling on my health.
† Barring sudden death at a young age, we are all, at best, currently healthy rather than healthy.
‡ I am deeply ashamed of how many of my fellow countrymen have a problem with this, even if the risk pool is wide enough to make it a relatively low amount of subsidy per person. It also ignores the realities of childhood poverty and contagious disease, both of which have impacts that cross the "I've got mine" line.

Best thread ever! I haven't been following the debate much, I've been tied up trying to forestall bankruptcy in our family business.

The 'death panel' argument panders to our societal refusal to deal coherently with end-of-life issues.

My little addition to the discussion.

A few years ago, my 80-year father fell deathly ill. He had developed non-cancerous blockages that prevented him from eating and eliminating. He was in horrible pain.

One doctor laid it out to the family. Dad was dying. They could control the pain and give comfort care to help ease him across the threshold. Basically, hospice style care. Estimated time, one to two weeks.

Dad had made it clear that he hated hospitals and didn't want extraordinary care to keep him alive. He wasn't in an hurry to die, but had his own definition of living and it didn't include hospitals. In general, most of the family were ready to deal with it.

Out of nowhere, another doctor announced that he wanted to do surgery and he believed he could clear the blockages. Once cleared, Dad would be able to eat and, ta-dah, those nasty deathbed decisions could be forestalled.

The surgery was horribly invasive with a prolonged convalescence and the chance of success was less than 10%.

The second doctor hammered on certain members of the family that the surgery was covered by Medicare, so money wasn't an issue, and if they didn't take this opportunity that they were killing their father.

End of long story. Surgery was performed and it was successful. Well . . . successful in that the blockage was cleared. Dad's recovery was horrible and he had to go into a nursing home because no one in the family was willing to take him in. He lived another 5 miserable years on a babyfood diet, unable to walk or care for himself.

The cost of this procedure? To the family - nothing (in money anyway). To the Medicare system - probably $500,000 or more if you factor in all the convalescence costs.

I was opposed to the surgery. It was time to let dad go. I firmly believe that the surgeon saw an opportunity to experiment with a risky procedure. If he failed, so what, dad was dying. If he succeeded, he was a hero.

Had the hospital had a 'death squad' to review this risky, invasive, unnecessary, and ultimately heart-breaking procedure and advocates to counsel the family instead of twisting their arm into accepting it, a lot of pain and resources could have been saved.

I am an attorney and regularly am appointed as a guardian for the elderly. I have an issue with people being forced into warehouses to preserve their life for a few more years rather than allowing them to live at home with help and die as they lived - independently. Even if that death comes earlier than it might in the warehouse.

Whether society likes it or not, more resources need to be put into end-of-life counseling and decision making. The right-wing-nuts are using this reality to fan the fear fires with visions of sending the old folks (who vote in prodigious numbers) out onto ice floes to be eaten by polar bears (hey, this could be a growth industry for Palin's homestate!).

Shame on the fanatics for manipulating the issue like this. An elderly man cries at a rally because he believes he will be forced to die for lack of care. Yet, ask that same man if he wants to be kept alive strapped in a wheelchair wearing a giant diaper and being spoonfed strained peas, he will likely say 'no'.

I applaud those with the courage to open the debate on this issue.

Janet Croft @132:
What many conservatives I've talked to seem to be most worried about is who determines what is NECESSARY care. They want to make sure no one will run some arcane formula and decide that they are valued less than some other person and therefore won't get some procedure. On the other hand (and I'm not seeing this coming form the supposedly fiscally conservative Republicans!), who determines that a procedure is postponeable or cosmetic and that taxpayer money should not be spent on it? So who should be making these decisions?

It matters less who makes these decisions than how they are made. They should be made generically (ie, general rules applied to everyone rather than individual decisions) and transparently. There should then be an avenue of appeal to allow some flex in the system.

At the moment, the opaque and un-accountable insurance companies make individual decisions. We have no idea whether they're being discriminatory or not. Anyone wanting to stick with the current system should be reminded of this fact.

What I find most ironic is that those who are screaming the loudest about "death panels" are hard-core born-again Christians.

Does this suggest a certain degree of doubt about the status of the salvation of their loved ones?

cgeye, way up there at #77 and #86:  apart from David Dyer-Bennet’s valid point (and good question) at #81, it occurs to me that if there were short positions that nobody seems to have profited from, then maybe that was because the people who took those positions were in some of the many trading firms that were based in WTC.

Now Fox News is claiming Britains NHS is a terrorist recruiting tool.
http://www.youtube.com/watch?v=2c-JEx-Kfvc

This crap makes me so fucking angry I want to kill someone.

Occasional (very) commenter delurks once more.

I just posted the following on a different forum.

It was the third comment in a sequence: (1) I pay extra taxes for healthcare, but I think it's worth it. (2) How much extra tax? (3) As follows:

The question about "how much extra tax" isn't straightforward, because how much tax someone pays depends on their income.

However, there are some figures that may give you an idea:

First, in the US government and personal expenditure on health comes to about 16% of GDP, compared to about 10% on the UK. So, if all those bills were shared out equally, that leaves me paying 6% less.

Second, in actual numbers: in the US expenditure is about $7,000 per person; in the UK about $3,000.

Third, in terms of quality of care: life expectancy is slightly higher in the UK.

What that means is that IF the US switched to the UK system (which I know is impossible from the current starting point, and probably not desirable - the NHS isn't perfect!), that would still leave the "average American" with an extra $4,000 dollars a year to pay for extra/better/quicker services.

Fourthly: how much is peace of mind worth? I know that (a) I will always get medical treatment when I need it, and (b) I will never find myself in the position of having to sell my house/cash in my retirement savings/go bankrupt to pay for my health.

Does any of that sound potentially persuasive, or is it just fuelling controversy?

#139:  what a load of cr*p, indeed.  But give credit where credit is due:  it’s very skilfully done.  If you were already inclined that way, and didn’t know (or didn’t want to know) the truth, it would all sound so plausible.

Surely there are a few Muslim doctors in the US by now?  I tremble for them.  The lynch mobs may already be forming.

JohninCambridgeUK: excellent facts, and thank you, but the people who are opposing health care reform aren't interested in facts. Still, we'll be able to use that information for more reasonable people who haven't based their opinions on who can shout the loudest.

John Stanning #141

While calling GWB "Hitler" was childish, the parallels between Fox News and 1930s Nazi propaganda is much more disturbingly accurate. This is just Evil.

I haven't seen any discussion of two "patches" that could at least help the current system crush fewer people underfoot as it lurches along:

1. Free checkups for everybody, always. Your recommended medical, dental, and optical checkups would be covered at 100 percent whether you had insurance or not. This would have to be paired with a PR campaign to convince everybody to get those checkups, on time and every time, because of the many conditions that are cheaper to treat when caught early. (Currently the only way to get a free, or at least cheap, physical is to apply for life insurance and then back out before paying the first premium.)

2. Caps on the amount that can be paid in punitive damages in medical malpractice cases, a la New Zealand. Doctors have to cover the currently absurd cost of E&O/malpractice insurance somehow. If there are no longer multi-million-dollar punitive damage claims, perhaps the pace of the increase in health care costs can be slowed a bit.

#143: Oh, let's not equate Fox News with the Nazi propaganda machine.

It's evil, but an entirely new kind of evil, one we haven't figured how to fight yet.

You can point out Fox News's every inconsistency and hypocrisy, mock its shameless pandering hosts, and point out its political and financial connections and it won't convince one of the viewers that something is wrong.

I envy the Italians. Burlusconi is going to die someday. Fox News will live on as long as there are racist soreheads who need talking heads to justify their resentments.

Joyce, #137: I don't think so. The reason that fundies are up in arms about this is their belief that suicide is absolutely proscribed by the Bible, and that this includes a terminally-ill person who just wants to get it over with a little faster, or an elder who'd rather have pain management at home than heroic treatment in the hospital for their last few weeks or months. But that argument increasingly doesn't fly with mainstream America, so instead they turn to the "death panels" meme with squeals of glee, because NO ONE wants that!

John Stanning, #141: "Surely there are a few Muslim doctors in the US by now?"

More than a few.

Jenny Islander, #144: tort reform is greedy nonsense. Malpractice played a role in both my parent's deaths. It is hard to sue for malpractice. The insurance companies, when times are good, usually start making risky investments, get caught up in every bubble, and end up raising rates, at least for a while. (I think then inflation erodes the rates, and the process starts over.) Then the insurance companies start complaining that it's too easy to sue for medical malpractice, and they want the laws changed to make it more difficult. I am so not sympathetic to the insurance companies.

As the parent of a pediatric cancer fighter/survivor (we're 3 years post-chemo) I can attest to the cost of healthcare in the US of A. Fortunately my son was signed up with a charitable organization that covered 100% of hospital, drug, travel, etc..., that was not covered by my insurance company. However, I get to see all the bills before the charity pays them. Our family would have to have paid $30K a year simply in CT and MRI costs, or made the exceedingly hard choice of whether to forgo said scans. I thank the 4 Diamonds Fund every day for my boy's smile.

I've seen the failure of both US and UK systems firsthand, but at least the UK families didn't have to deal with bankruptcy after the drawn-out death of a loved one.

I like the sound of a national rate of insurance that can be subsidized by the government for those that need it.

Serge @133 -- haven't you learned that if someone asks you if you're a god, you should say "Yes!"?

Very important story, Terry @135. Aren't the people who are objecting to "end of life counseling" the same people who object to the "Nanny state"?

On rereading the above post @148, my last statement came off as a little "left-field".

I was referring to abi's reference to the Dutch system @62.

Stevey-Boy, it didn't seem out of place to me. Moving story, in fact. Thank you, and bright blessings for the continued health of your son.

John Houghton @ 131: I want my Organ Donor selection on my Driver's License to be binding. Unfortunately, ownership of my flesh instantly passes to my next-of-kin on my death*, who then have to be consulted.

*Your jurisdiction may vary.

As I was pleased to discover when I renewed my driver's license last month, California is now one of the jurisdictions where this is no longer true:

Historically, while signing a donor card and placing the pink “DONOR” sticker on your license served as an important symbol of your intent, it did not place you on any list or registry. Now, through the Department of Motor Vehicles, the Donate Life California Registry guarantees that your wish to be an organ and tissue donor will be honored after you die.

Prior to the registry, the responsibility for giving consent for donation fell solely to the donor’s family. Unfortunately, family members are not always aware of their loved one’s wish to donate. Registering with Donate Life California eliminates any doubt about your wish to be a donor. Your family will be provided proof of your registration at the hospital so that your life-saving wishes can be fulfilled.…

Your registration will serve as a Document of Gift as outlined in the California Uniform Anatomical Gift Act. A Document of Gift, not revoked by the donor before death, is irreversible and does not require the consent of any other person. Parental or guardian consent is required for persons under 18.

Should your death result in the opportunity for you to be a donor, an official record of your consent will be readily available and cannot be overturned by your family. (Parental or guardian consent is required for persons under 18.) Thus, should you be medically eligible to donate, your wishes will be respected and your family will be relieved of making a decision on your behalf.

Thanks Xopher. We were lucky our pediatrician referred us to an oncologist that was recognized by the charity, as it's something of a zip-code lottery.

My wife is very active with on-line support for families dealing with pediatric cancer and she's seen the full gambit. It's really scary when parents and their children's doctors are trying to decide treatment based on what the insurance will cover, instead of what will work most effectively with minimal side-effects.

Sometimes it's not fancy drugs, but something as simple as protein shakes. When your kid drinks 3-4 a day, just to avoid a feeding tube, it adds up and it's not a medical procedure, so no insurance. But hey they'll cover the feeding tube!

Just so we're clear. I have really good health insurance, but costs not covered would still have taken the house, car, everything, if we had not had the charity there as our security blanket.

I don't post much, but I'd like to thank everyone that shared a relevant personal story in this thread.

North Carolina also does not require family consent to organ donation if you have already signed up, under SB1372, the NC Heart Prevails Act. Family must be notified but they cannot veto the donation. (See Donate Life NC. And if you're a North Carolinian who isn't a donor, you can sign up there -- no DMV trip required.)

I'm also making the backup plan of donating my body to science if my organs are not usable. You cannot do both at the same time, but you can have body donation as a backup plan. I really want my body to do someone some good once I'm no longer using it.

I did not get to go to the health care town meeting here last night. However, a friend of mine went. Most of the people holding signs outside were pro-health-care. It doesn't seem to be covered much by local media this morning, probably because there wasn't much juicy right-wing shouting and most people there seemed to support the public option.

So the popular support here is made invisible. Great.

Pardon me, I'm having a grumpy day today. In reality I do have a small suspicion that something will get passed. It won't be great, it'll suck up to the insurance companies to no end, but it'll do a small bit of good in expanding access to health care. And we can work from there.

Clip from a BBC radio comedy show today:

“Some people are complaining loudly that health care for all is socialism and the government better not interfere with Medicare, forgetting that Medicare is a program to provide senior citizens with exactly the socialist health care they’re complaining about.  It only goes to show that while Medicare works well in the US, it obviously doesn’t provide adequate treatment for dementia.”

Jenny Islander @ 144: Tort reform was enacted in Texas, it's next to impossible to get a med-mal judgment there.

It has not saved Texans one penny in insurance premiums. It has only succeeded in making the insurance companies a tiny scotche more profitable.

I would like for my ashes to be cooked into a dinner for health care/insurance industry executives: if you can't beat them, join them.

JohnInCambridgeUK @ 140:

I think your figures might need some adjustment -- in the less-pleasant direction -- to account for the addition of coverage of those who are not now insured.

That quibbled, a good Universal Medical Care Program probably wouldn't result in any or much increase in my taxes (I'm close to the median/average income, I think) combined with Medical Care costs.

In a sense, I wouildn't _like_ an increase in my tax bill, but could easily afford one of up to c. 10%, maybe 20%, and would consider it worthwhile for the improvement of the social infrastructure (which has a considerable influence on my quality-of-life) that would certainly be effected.

Other than the above quibble (which amounts merely to questioning whether the savings would quite equal the additional spread), I'm in general hearty agreement with all your points.

(Actually, I like & am reasonably satisfied with my current HMO (the not-for-profit Kaiser-Permanente) c/w Medicare and would like to retain it, but the currently-considered plans don't seem to be inconsistent with that. Note, FWIW, that I'm currently in fairly good health -- for an 80-year-old male who smokes, that is -- have a stent in one coronary artery, have had radiation & surgery (rhinectomy) for carcinoma, and my major current concern is the prospect of having to drive directly across the LArea to UCLA several times in order to get another replacement prosthetic nose. The latter will be rather expensive, but only because of the many bookstores & fancy restaurants over on the WestSide.)

In reality I do have a small suspicion that something will get passed. It won't be great, it'll suck up to the insurance companies to no end, but it'll do a small bit of good in expanding access to health care. And we can work from there.

An alternative point of view expressed here by Atrios seems to me to have a higher reality quotient:

"Given the way things work in that stupid town, we get one big bite at the apple. An "ok" bill lets the insurance company skimmers keep stealing their share for doing nothing useful other than denying people care. Maybe it means they get to do this a bit less aggressively than they do now, and maybe it means some more people get somewhat better health care, but it also leaves the skimmers in place."

Rikibeth, #103, no, actually, you can give one kidney when you're well. You don't have to wait until you're dead. And even then, most people don't give organs when they're dead.

abi, #134, the first two big things that happened to me happened because doctors ordered/told me to do things that turned out later to be wrong. They didn't know; the procedures were standard.

When I started getting arthritis in my ankle, they told me to take Motrin, and I turned out to be sensitive to NSAIDs and the Motrin killed my kidneys.

When my stepmother made my blood pressure go up while I was in the hospital with that renal failure, the doctor ordered nifedipine sub-lingually and it dropped my BP so low so fast that I didn't get oxygen to my brain for a while (sort of like bleeding out) and I had a stroke and was in a coma for six weeks.

Now, both of those are known problems (a study a few years later even showed that people who didn't have the nifedipine had fewer strokes than the people who did) and everything else that is wrong with me has cascaded from those two things. There's no way to know that's going to happen.

After a couple of back-and-forth emails with the Hawai'i Organ Registry, I've learned that

Hawaii is a first person consent state. As stated on Donate Life Hawaii
(www.donatelifehawaii.com):

"Once you sign up with the Donate Life Hawaii registry, your donor
designation grants authorization for organ and tissue recovery. Should you
be in the position to donate, your next of kin will be informed of your
registration, but will not have the power to override your decision. It is
important to let your next of kin know your wishes so that they may be
prepared to provide the health care team information about your medical
history."

And that signing up to be an organ donor on your driver's licence adds you to the registry, so your family can't renege for whatever reason.

I like abi's basic goals as stated in #136, and I think those are ones that, well expressed, would have support in principle of a good-sized majority of people. (Not quite everyone-- the hard-core government-out-of-my-business libertarians and the I've-got-mine-those-people-don't-matter folks wouldn't support it-- but a clear majority would, and apparently do, if those numbers on single-payer support are reliable.)

Of that majority, though, not everyone believes that those goals are *attainable*, or at least not without some serious hurt to themselves either in much higher taxes or degraded care. We can use stories of real people in other countries, and their health care systems, to show that it's possible in principle, and in a variety of ways. But we also need to come up with a plan that people can readily (and reasonably) believe will meet those goals here in the US, without undue hardship.

(And we have to be honest that there are going to be some tradeoffs; we can't simultaneously satisfy all the "Common sense health reform" desires given in the piece linked from #118, as the article makes clear. But we can make the case that the benefits justify the tradeoffs for most people.)

Atrios' concern quoted in #160 is one that we should take seriously as well, no matter what our general recommended approach is. For instance, one "public choice" scenario that I'm sure many private insurers would love would be one where they manage to unload all their most expensive patients on the "public" agency, keep the low-cost people, and leave everything else more or less the same. But that would not be economically and politically sustainable. Moreover, it could make more comprehensive reform more difficult, because those same insurers could point to the high expenses or compromises in the adversely-selected "public" pool to argue "see, government health care doesn't work!"

I wish this thing would work out without so many assholes jumping up and trying to shout it down.

It has gotten so I can't really bear to watch any TV items about it, I can feel my blood pressure go up even though I am on a powerful anti-hypertensive.

I can't bear to call my mom because I'm sure she's going to bleat about RL's affirmation about the 'death panels' (she listens to him every day on the radio) and I'm uncomfortable being mean to an old lady. She insists that he Tells the TRUTH!!!!, don't you dare try to tell me otherwise! All your people are lying to you.

I've been unemployed for more than a year and a half and have not really even had any good prospects even though I've tried and had a bunch of interviews. I'm a generalist, not a specialist, and that is working in my disfavor. So the insurance thing is a big deal.

My doc has so far kept me in samples of my BP medicine (which runs about $100 a month otherwise...). I hope he can keep it up.

John, #163: Given the availability of a public option, there are going to be a LOT of people like us who will sign up for it -- normally healthy, but self-employed or otherwise without access to employer-based coverage, and falling into the gap between "poor enough to qualify for Medicaid" and "rich enough to afford private insurance". That may prevent the insurers from bottom-loading it with their worst risks to the point of failure.

Paula, #164: Would it qualify as "being mean to an old lady" if you were to explain to her what Obama's plan would mean for you personally? Does she WANT you to die because you can't afford medical coverage? I wouldn't think so.

Stefan, #145: the profit-hungry conservative press is an old story in the USA--look up the history of the Spanish-American war. Used to be there was a thing called the Fairness Doctrine, and numerous restrictions on media concentration, to prevent it from dominating television. These rules were largely rescinded by Reagan.

But, oh, can you imagine Fox News under the Fairness Doctrine? They'd have to dig up a Trotskyite for balance.

My dad just forwarded me the Axlrod email...everyone seen that, or should I post it?

Abi, post it, please.

The Raven @166, Fox would have no trouble at all coping with the Fairness Doctrine. Ever watch their show Hannity & Colmes? They paired up a conservative and a liberal to talk about issues. The conservative is a good-looking guy with broad shoulders and a deep voice who brims with self-confidence. The liberal is a sickly-looking, rabbity fellow with a high-pitched voice who hems and haws and hesitates and stumbles his way through his sentences.

I only get to see US TV standards through The Daily Show.

The last time I saw somebody shouting at their audience like that, it was a guy selling cheap china on a market stall in Grimsby's Freeman Street Market.

I could at least see the crockery that guy was selling.

Dave Bell @ 170: We can see the crock these arseholes are selling, too.

Times like this, I think if not for my daughter I would be so completely DONE with this country.

The fearmongering extremists have organized campaigns exhorting and pressuring commercial media advertisers, politicians, and so-called new organizations to comply with the extremists' agenda. They stage events, stage protests, and promulgate phone and letter campaigns, including scripts and those abominable "talking points" they promulgate for themselves and their associates to harangue and pressure with.

The media and politicians and advertisers are not being hit with effective counters, including outrage and anger and ridicule and belittlement and marginalization at these tactics and strategy and imposition of the loud strident organized anti-democratic fascist minority marginalizing and disenfranchising everyone else and gag-ordering not only those who oppose them, but anyone questioning their motives and interests and goals and methods....

Notes:
A. Forget civility, the comment about wrestling with pigs in the mud wallow applies.
B. True Believers don't Go Away of their own volition--mobs and extremists are examples of what engineering defines as "positive feedback" -- movements which reinforce themselves and get more extreme, not less, and don't reach an "equilibrium" state of harmony with others....

Some ideas.
o Big showy spectacles. Burn giant effigies of Fux Spews Media Personalities with "Hatemongering Liar!" painted on the effigies. Make YouTube videos parodying the Fux Spews types and particularly Rupert Murdoch. Do NOT be kind, be vicious, use their words, and caricature them--though that might be difficult, because they already are living caricatures of responsible adults....
o create images and sound of misery effected by the logical results of Fux Spews advocacy--homeless in the streets with running sores urinating and defecating on public sidewalks and in public building corridors where the offices of Fux Spews and Republic [they drop the "ic" from "Democratic," the same disrespect should be commensurately applied to them] Congresscreeps, and to images of the lawns of those others advocating the literally ruthless, self-centered, greedy agenda of "I get mine, I keep mine, your labor benefits ME, you get nothing" politics and (im)morals (lack of) ethics.
o Campaigns, organized, pressuring advertisers to pressure The Media to cease and desist their partisan support and presentation of roadwrecker Republican personalities and views as "mainstream" and to go back to reporting as observers rather than opinion-makers, and to include actual responsible thoughtful good=-communicator representives of not only progressive and "liberal" views, but true lefists--to show what REAL socialists and communists believe in (as opposed to smear tactics of labelling those who aren't anywhere near the true social center, as lefty extremists....)
o create media clips and sound bites promoting centrists and liberals and progressives of the past
o Dig up clips of Richard M. Nixon and of Eisnehower with their social and economic policies, showing how those Republicans were far more "liberal" and than even many of today's Democrats, and create media sound and visual bites
(gas rationing, anybody, which Nixon did and prevented $4.00 a gallon gasoline...)
o Dig up quotes from other historical personages of US history, which condemned those advocating and implementing gag orders on freedom of speech
o Dig up the records of the start up of the Public Health Service founding and the its activities take to deal with gonorrhea and syphillis epidemics a century or so ago.. and all the opposition it faces who yelled "morals!" while being hypocrites in the extreme, regarding just who and how the epidemics involved (hint, some of the loudest screamers, were among the most virulent vectors...)
o Go after multiply-married apparent sex tour patron and junkie Rush Limbaugh, particularly... attack the person and how what comes out of his mouth, is so lacking in consistency with his personal behavior
o Bring up Guckert.... he was the favorite alleged member of the press corps of the misadministration of 2001-2008 until unmasked as pornographer--but the misadministration and "the media" never got the full excoriation they deserved for foisting the scumbag on the US public as if he were actually a credentialled competent deserving-of-respect reporter... and just WHO kept making all those overnight visits to the White House, was it, anyway?
o Make caricature sound bites and video bites of the likes of Karl Rove etc. trying to get healthcare, bleeding and sore-covered and being told, "no.".... on second though, create image of Rove etc., dining with full tables full of turkeys, tureens of soup, desserts, and starving rag-covered workers around them with bleeding sores asking for help and medical care, and being instead kicked in the teeth...

#114 Lizzie Lynn

"These people are stupid and insane."

Yes, HOWEVER, those who control the allegedly public airwaves, and most of the mass media otherwise, are portraying them not as rabidly vile and offensive and vicious minority viewpoint holders, but rather as responsible proponents to emulate and respect, who represent the mainstream and have earned public lectern promotion denied their detractors and opposing viewpoints....

(Images of Fux Spews in flames being destroyed and caption, "Freedom of speech and sanity begin to return!"... and Rupert Murdoch as a Homeless Person begging for booze money surrounded by empty bottles marked "Lies")

Insurance Companies Want You DEAD!!!

As long as you're alive and healthy, your medical insurance company will love you. Just as a cheap whore loves you when you hand over your money. But when you fall sick, they want you dead, quickly, because they know they'll have to pay out far more than you ever paid them. Yes, insurance is about playing the odds, but everyone gets sick, and thats when they'll kick you out of the game, permanently.

They won't even pay for the funeral.

#175 Dave

Azi from C. J. Cherryh's Alliance/Union universe--their genetic codes contain timebombs that kill them at age 40, before they can develop expensive debilitating diseases, would seem to be the ideal customers from insurance companies' points of view.

#6 albatross

The Rovians and Cheneyistas though were what caused much of those governmental failings to occur--the usual suspects of Republicrappy types who believe in "free enterprise" of the robber baron sort--the robber baron gets the exclusive franchise for sitting perched at the controls of the supply chain and access choke points, and extorts payment from all in the vicinity who aren't robber baron cronies.

Government of the fascists, for the facists, and by the facists, and they shall not allow their control to perish from the earth....

There have been a number of newspaper articles--not within the past two months, however...--regarding US citizens traveling to the likes of India or South America for surgery, because the same level of competent medical procedures in those places, has a pricetag ten percent in dollars of what the procedures cost in the USA. And, the healthcare insurers are the ones promoting it, because it saves them lots of outlay money--it's less expensive to send someone on a long expensive plane flight to India, and have surgery there, with accommodations and recovery there, and plane flight back to the USA, than have the surgery done in a hospital local to the patient....

#20 Syd
Back when I was in college I drove away a noisemaker who had a bullhorn, by outshouting him.... Civility in real time to domestic terrorists does not work. Reasoning with rabid weasels does not work. Gags would... force majeur would. Yelling louder than they, would. Allowing them to shout down and disrupt, gives them the win.... They were exercising the heckler's veto, the only solution to that is, again, a gag, or the majority making it very clear the heckler is a provocateur whose agenda is NOT going to derail the discussion and who instead is an offensive, unacceptable, and not to be tolerated agent of disenfranchisement.

For that matter--months ago, under the misadministration, anyone even in an audience with a slogan on a shirt that the Rovians objected to, was removed from the audience. Why weren;t the domestic terrorists removed for interference, disruption, and interfering with the rights of others to hear the discussion?!

Here in Making Light there are controls on civility such as disemvowelling, and those who persist in acting out, get banned. Why are the domestic terrorists not removed in Town Hall forums?

Hmm, another thought occurred to me--big signs saying "Who's paying you to disrupt this forum?"

#49 Paula
And don't forget the tabloids and the fashion magazines showing the Fashionable Female People all wearing spike heel pointy-toed shoes, which cripple the ordinary mortal female who then needs $16,000 in surgery to be able to continue walking.... The magazines are full of articles extolling how fashionable such shoes are... and not "wear this and you are helping impoverish the US public and enrich surgeon and health insurance companies."

Paula #176:

The DHS and War on Terror are genuinely tied to the Bush administration, which is the poster child for mixing incompetence with evil. But the DC and Baltimore and Detroit public school systems were wrecked long before W arrived on the scene. The disastrous war on drugs and the prison-industrial state have grown up for many years, in many states, under both Democrats and Republicans. The Patriot act was pushed for by the Bush administration (and was really a wishlist from the FBI and NSA, I think), but was passed by essentially everyone in Congress, a few very courageous Pauls and Wellstones aside. Most of the braindead airport security theater was in place before W came to power--remember how TWA flight 800 justified imposing ID requirements at airports, which didn't go away when it was determined to have been an accident? Passenger rail in most of the US was a disaster when W was still doing the drunken frat-boy thing at Yale.

These are broad-based failures, which I don't believe can be laid at the feet of either Democrats or Republicans exclusively. They bode ill for what we finally get from health care reform.

Paula #172:

There are some uncomfortable echoes with the coverage of the opposition to the War in Iraq. I recall seeing protests with my eyes, reading many people opposing the war online, but seeing zero coverage of them on TV. The MSM is simply not very resistant to manipulation by organized pressure groups, for whatever reasons.

Organized pressure groups, in this case, aren't just Republicans. In fact, I think party affiliation is pretty much irrelevant to these guys. The pressure is from companies and individuals who are dependent on the current way things work for their living--and there are a lot of those companies/people, making a lot of money.

#177
showing the Fashionable Female People all wearing spike heel pointy-toed shoes

spike heel pointy-toe platform-soled shoes
(one-inch platforms, but still ...! I hope they have a good orthopedic surgeon in their insurance future.)

abi #134:

I like your basic summary of goals. The critical thing to understand, though, is that this whole issue is driven by medical costs, which get higher every year and grow faster than both inflation and growth of the economy. Without cost control, the current system or anything better is unsustainable.

The cost problems are a behind a lot of the day-to-day issues, here. COBRA is so expensive because it makes visible the entire health insurance premium for your employer's group plan. Many people voluntarily do without insurance, because it's so expensive. Even places where an uninsured person has access to treatment (for example, showing up at the ER in the middle of a heart attack), he still faces some incredible bills.

This is the biggest issue here, one I think is discussed pretty well at this blog[0]. There has to be cost control. The current proposal (which I don't think anyone fully understands--in many ways, this is the bailout or the stimulus package or the Patriot act or the DHS all over again) appears to address these access issues, but not the cost control issues. But the US government can't keep paying for healthcare, even on the people it's currently paying for. Medicare is an impending budget crisis as it is. Adding millions more people via some subsidized[1] public option means moving this budget crisis closer.

How do we cut costs? The closest I've seen to discussion on that issue is some kind of panels to determine effectiveness of different treatments--which is sensible (though you sure could imagine it being done badly), but which don't seem, to my amateur eye, likely to have the scale of impact that's needed. More fundamentally, Medicare doesn't have a track record of preventing cost increases. Nor does private insurance in the US, neither old-style we-cover-everything types, nor HMOs, nor PPOs--and those private insurance companies are dealing with people healthy enough to keep a job or to manage to get insurance in the first place.

Leaving out the discussion of controlling costs while guaranteeing everyone access to affordable, basic health care is like deciding to liberate the Iraqis from the tyranny of Saddam, without working out how many troops will be needed for how long to hold the place down after the invasion, and the two issues are avoided for the same reasons--they're painful.

All the ways to cut costs other than the generic never-realized "we'll cut waste and fraud" are painful as hell for various people. Specialists with a decade of training and debts to match are going to suddenly have to lose half their salaries[2]. Some people who currently get expensive care are going to have some of it denied, because we just flat can't afford all the care that's being provided. And in the end, despite all that painful and unpopular stuff, taxes will have to go up, or the deficit will have to keep growing at frightful levels[3], or other programs will have to be cut, just to expand coverage to currently uninsured people.

[0] If you don't read for irony in his posts, though, you will massively miss his point, as did the Good Math, Bad Math guy a few weeks ago.

[1] Unless you think all the insurance companies are leaving vast sums of money on the table, a public option will have to be subsidized, or it won't be substantially cheaper than private insurance.

[2] Note that specialist care and procedures are arguable overcompensated by Medicare, due to what looks to me like a fairly classic case of regulatory capture by one part of an industry.

[3] IMO, unprecedented and larger-eery-year deficits are scary as hell. I do not believe anyone on Earth knows what will happen as a result of them, because of the US' unique position in the world's financial system. It'll probably just keep working, until the day it doesn't, anymore. And then we'll find out what's next.

Terri # 135 --
Part of the denial may simply be, denial.

My father died from "complications" from esophageal cancer.

After he was admitted to the hospital for what would be the final time, it was obvious to all that he was going to pass fairly quickly. He was unconscious, all his vital systems were shutting down and not going to recover

The attending doctor offered that he could up the dosage of the opiate pain meds drastically for more effective palliative relief.

My mother was willing to give consent when my sister piped up and started ranting about how "he will become an addict!"

Now, admittedly, sometimes my sister skates close to the twilight zone, but I think this sense of denial of reality is some kind of defense mechanism that may be more common than many people want to admit.

Robert Llewellyn (Kryten from Red Dwarf) talks about the National Health Service here:
http://www.youtube.com/user/bobbyllew#play/uploads/0/4sQKTArZRcU

Warning: Contains Language! Opinions! Accents! Facts! (If you're at work put headphones on.)

#177 :  stupid women* in spike-heel shoes ruin wood floors as well as their own health.  Among many other things I maintain a church with wood floor – after every wedding the floor is that much worse.  They should be banned or ridiculed (spike-heel shoes and stupid women, both).

* That is not a general statement about women, please.  I speak of specific women, who IMHO are stupid to endanger themselves and destroy expensive floors.

#182
That's right up there with the DEA going after doctors who prescribe opiates for the same reasons: they're afraid that the recipients will become drug addicts. I think they need to take remedial English classes, so they understand what 'dying', 'terminal', and 'palliative' mean, rather than spend the same time going after people who are actually doing what they're supposed to be doing.

#181 alabatross

What I almost never see is any accounting of the money trail--who gets how much, for what?

There are such fun things as GE charging thousands of dollars for "service calls" for MRI systems which involve replacing an essentially cosmetic panel light, with the light emitting object being worth perhaps $1.00 and the servicing taking five minutes--that was why GE quite literally swapped the something like 60%share it have of the television and radio consumer electronics business that it had including all the factories, to Thomson of France in return for Thomso's medical imaging business--to be able to charge completely extortionate continuing fees to the medical care market along with selling the high-priced equipment with the GE-exclusive (held up by the US Supreme Court controlled by the corporatists if I recall correctly) service contracts....

Other issues are "lifestyle" services--penis enlargement, Viagra, etc., and self-inflicted damage by lifestyle choices... those who CHOOSE to live dangerously pay more for e.g. car insurance and insurance if they fly airplanes, why not charge more for lifestyle choices regarding health care... apparently it turns out that people who get rewarded for healthy lifestyles, actually do engage in healthier lifestyles...

abi @ 134

Universal access means that people are not denied coverage for pre-existing conditions, unemployment, or poorly chosen ancestors. Everyone has a way to see the doctor.

It also means that no one is denied coverage or any particular procedure for any reason other than medical, or that a procedure is not provided for all, or for some class of people (don't give transplants to persons over 80, for instance). I'm specifically referring to the very common practice of insurance companies denying coverage arbitrarily as a way to improve their profits.

Serge@133:

I meant it the other way (but then things are always confused in my congenitally perturbed head): "What, you gave cheese to a lactose-intolerant volcano God ? We're sorry, but the natural catastrophe clause of your insurance is invalid".

186: Oh dear, what did my husband do now?

Albatross@181

a public option will have to be subsidized, or it won't be substantially cheaper than private insurance.

If it doesn't restrict what it pays for, yes. I actually have "public option" health insurance at the moment -- the State of Washington runs a health insurance plan for state employees, and at my university this competes with other insurance/HMO coverage. You can get the state-run plan as an employment benefit or pay the difference to get one of the other plans. The state-run plan is cheaper than most of the others, but not much cheaper.

AFAICS the sort of big cost savings seen in other countries would need
- the ability to reduce coverage for treatments that aren't cost-effective (ie, explicit rationing, not real popular)
- reducing the costs from malpractice litigation (not on the table, and if anything the Democrats are worse here than the other lot)
- bargaining power with suppliers (a public option won't have any more bargaining power than, eg, Kaiser does now)
- compulsory insurance to reduce adverse selection (but this only reduces average cost, not total cost)
- reduced use of ER departments as a substitute for primary care (potentially a big one, but the savings are mostly state and local, not federal)

albatross @ 181: "Without cost control, the current system or anything better is unsustainable."

This is true. However, some (including myself) argue that universal coverage is an important step towards cost control. Once you have everyone covered, then you have the constituency necessary to push through politically difficult cost control measures. We're getting cost control anyway: we're just doing it by denying people coverage. When coverage is mandatory, we'll be forced to deal with cost control directly instead of laying blame on "the market."

"More fundamentally, Medicare doesn't have a track record of preventing cost increases."

It does, actually. It hasn't prevented them entirely, but as Ezra Klein points out in this post, over the past decade Medicare has kept cost growth three percent below that of private health insurance. Presumably its ability to control costs would go up as its size (and negotiating clout) grew. World-wide there's a pretty clear positive correlation between government presence in the healthcare market and lower costs, with the US and the UK anchoring each end of the trend line.

"All the ways to cut costs other than the generic never-realized "we'll cut waste and fraud" are painful as hell for various people. Specialists with a decade of training and debts to match are going to suddenly have to lose half their salaries."

Truth be told, I'm pretty okay with that. There's no ineluctable natural law that guarantees a +200k starting salary for cardiac surgeons, and I'm not convinced that the high cost of medical school justifies it.* Given the choice between specialists paying off their school debt a few years later and buying slightly smaller yachts, and patients dying because they couldn't afford their services, I think I know which is the lesser evil.

And that's doctors, who of all the healthcare industry have by far the lion's share of my sympathy. I'm really, really okay with pharmaceutical companies and medical device manufacturers tightening their belts a bit, and the thought of insurance companies locking their doors for the last time actually puts a smile on my face. The "painful as hell to some people" is certainly true, but I take it as a tactical observation, not discouragement.

*Actually, the high cost of medical school seems like an economically harmful barrier to entry. It enforces a false scarcity, as those with the talent and work ethic but not the cash don't enter the profession--and we the patients end up paying more. But then that's part of another impending catastrophe: the mounting costs of higher education.

Given the choice between specialists paying off their school debt a few years later and buying slightly smaller yachts

Or having to wait a few more years to buy the yacht (or the airplane, or the luxury home in the gated-and-guarded development).

Thomas @ 190: You left one item off the list, or included it only by implication - while reducing treatments that are cost ineffective, we can also eliminate treatments that are ineffective, full stop. That's what the proposed advisory panel for best practices is about, to examine the relative efficacy of treatment and under what conditions expensive tests and procedures are really necessary, to avoid the problem observed in McAllen, TX.

Mark@193:

Yes, stopping ineffective treatments is useful. I'm not sure there's that enough scope for cost saving in it. After all, medicine nearly everywhere in the US already costs less than in McAllen, TX.

It's true that there is some expensive and ineffective medicine out there (most treatment for chronic low back pain, for example). Overuse of testing, especially testing in response to concerns about litigation, is also a good target, but I don't see how that can be reduced without a major chance in malpractice law, which would need to be accompanied by some sort of no-fault compensation system like the New Zealand model. We'd also want a change in the FDA approval rules for diagnostic tests. They are currently approved based on being effective for detecting the condition they are testing for, rather than based on evidence that they improve eventual outcomes.

Archie Cochrane thought that eliminating ineffective care would save enough money to allow everyone to receive all the available effective care. That might have been true in his day, but now there is a lot of expensive, modestly effective treatment available. There has been tenfold (inflation adjusted) increase in US prescription drug expenditures since 1980, and most of these new drugs really are at least slightly better than nothing, even if they often aren't importantly better than existing drugs.

As a concrete example, Terry Pratchett is paying out of pocket for Alzheimer's Disease medication (donepezil) that NICE has ruled (plausibly, in my opinion) doesn't make the cut under the current UK thresholds for cost-effectiveness. There's good evidence that this drug really is better than nothing, but only slightly. There are lots of drugs like this, and the costs of providing them do add up.

I used to believe that the savings from getting rid of ineffective care would be larger, but I'm growing less convinced with time. I should have put it on the list, but I don't think it's low-hanging fruit.

In a supermarket today I overheard an argument about the 'Obama death panels'.

This was in Seattle.

Even more amazing, it was in Wallingford.

I'm scared.

You know what I really hate about all this the most?

The fact that people are seriously worrying about "death panels" gives me legitimate reason to despise them. To believe with justification that they are stupid, paranoid ninnies. To know for a fact that "we," in the collective societal sense of "we" that doesn't include me, are fearful, gullible idiots who can reliably be counted on to Fall For It.

I don't like feeling that way.

Mark, #193, and meds. I'm taking a generic fosamax every other week because I'm also taking prednisone (temporarily, I hope, and tapering). Doctors know long-term high-dose prednisone makes your bones weaker and they think people in my situation should have the fosamax just in case. Now, I'm also taking a fairly large dose of vitamin D for much the same reason, and we can check that with a blood test. (Kaiser and I each paid $29.30 for four months worth of the generic fosamax because the $29.30 was what tipped me into the Plan D donut hole.) I suspect that if it wasn't so awful to take I might not mind so much.

Thomas, #194: There's a reasonable argument to be made that universal health care access would actually decrease both the frequency and the size of malpractice lawsuits. When you know that your long-term survival depends on being able to afford medical care, or medication of some type, for the rest of your life -- and that you're now completely uninsurable, and possibly unemployable as well -- getting a large settlement from a lawsuit is one of the few options available to you. Remove that pressure, and people who aren't just plain greedy would be more likely to settle for smaller amounts, or not to sue at all.

Mark @193: The article you linked to was interesting. Conscientious efforts to restrain costs, as described, remind me somewhat of the 'Prisoner's Dilemma', where someone figures it is in their benefit to break first from an accord.

In the 80's, Reagan highlighted in one of his State of the Union addresses the practice in Rochester NY of a community pool for healthcare (offering it as an example of a community effort that could be duplicated elsewhere). One of the large corporations that was a part of that of that pool was Kodak.

However, not long after Kodak decided it was to their advantage to seek the best deal they could get for themselves, and withdrew from this pool. This was done under the administration of a CEO who stated when he took his job, that he was there for the stockholders of Kodak, not the community of Rochester.

Lee @198

If there's a state-funded basic level of care, it's not just that you don't need the mega-settlement to pay for your future and so don't ask, the courts will take that into account when they set the amount. The restitution will drop, a lot. And many of the other problems of the US system, such as cost increases way above inflation, affect settlements, and will be eased by some reform models.

Here in the UK, with the NHS, people still get paid compensation. For instance, adapting your home for a wheelchair user. And this overlaps with the sort of extra support that charities give.

We still have medical charities, funding research, and specialised care (cancer patient nursing and hospices are the best-known), and new facilities. Before the NHS, that's how many hospitals were built. Local charity fund-raising paid for many NMR scanners, awkwardly expensive in the early days.

David Bell, #175: "Insurance Companies Want You DEAD!!!"

If the customers just stay healthy until they keel over and die, the insurance companies don't make much money. The financial incentives in the system favor maintaining people chronically ill & paying regularly for drugs and medical services. And that is exactly what we've got.

Radical reform would focus on providing financial incentives to keep people healthy and with a good quality of life.

Overuse of testing, especially testing in response to concerns about litigation, is also a good target, but I don't see how that can be reduced without a major chance in malpractice law, which would need to be accompanied by some sort of no-fault compensation system like the New Zealand model.

Yes. This is what I was trying (poorly) to express further up the thread--not that putting a cap on punitive damages would reduce our insurance costs significantly, but that the amount that you and I would end up paying for tests ordered purely to cover the doctor's butt might go down if the doctor wasn't always worrying about whether the next lawsuit would send his own insurance costs to the Moon.

A newpaper report on the recent brief provision of free medical care in LA

Several examples of people falling through the gaps in the US systems.

And a set of reputable figures comparing the US and the USA.

The guy organising it maybe gives an incorrect date, it wasn't until 1945 that things got rolling in Cabinet, although the Beveridge Report was published in 1942.

I shall let Nye Bevan speak for himself.

Genesis 6.4 may apply in this case, but your politicians seem barely human.

On the Truman national health insurance proposal: here and here.

Oh, yes. Physicians for a National Health Program.

Oh, yes. Physicians for a National Health Program.

Basic principles? Okay, I'll take a shot. I'm a PTA, so this is from a rehab-oriented perspective.

1. The system should not substitute expensive late-stage treatment for cheap early-stage treatment (for example: right now some people can get coverage for amputations made necessary by uncontrolled diabetes, but not for the visits and supplies necessary to prevent such a thing).

2. The emergency room should not be anyone's primary health care provider.

3. Rehabilitative services necessary to restore a patient's independence should be covered. Currently many people end up disabled for want of PT, OT or other care that would have been cheaper than the disability payments (not to mention lost productivity and tax revenue from those who had to quit work because they couldn't get proper rehab).

4. Rehabilitative services necessary to MAINTAIN a patient's independence should be covered. Let's say your kid has cerebral palsy and the physical therapist says he needs X treatment to increase his trunk strength so he can sit up in his wheelchair at school all day. As soon as he can sit up all day, PT is no longer covered. The kid grows a little. Now he can no longer sit up. Lather, rinse, repeat.

Mark @ #193: After reading that New Yorker article, my take-home lesson is this: next time a doctor recommends a test, a procedure or a referral, I'm going to look him in the eye and ask, "Do you get any money from that?" And if the answer is yes, I will say, "Then I want a second opinion from someone without a financial incentive."

BTW, the hospital my husband works at has had the problem of neurologists demanding payment for referring patients to the hospital.

It's really hard for me to see the downside of "never give the doctor a financial incentive that opposes the patient's best interest." And don't blame malpractice--did y'all note that because of Texas' malpractice law, there are practically zero malpractice suits in MacAllen?

Dave Bell@200:

If there's a state-funded basic level of care, it's not just that you don't need the mega-settlement to pay for your future and so don't ask, the courts will take that into account when they set the amount.

I don't think this will happen automatically (at least, not in the short to medium term). The economic damages component would be smaller if basic care were free, but the big reason why malpractice is so much more expensive here is "pain and suffering" and "punitive" damages. It would take legislation to have much impact on these.

It would also help if the courts had better ways of introducing non-partisan scientific and medical evidence -- in principle (in many states) the court can appoint its own experts, but the process isn't used that much.

Thomas @ 194, the assumption that universal coverage will actually and significantly lower costs is not unreasonable when you consider that the US is paying on the order of twice as much on a per capita basis for health care as the next dozen most expensive systems in the world and that we have worse outcomes in terms of things like lifespan, infant mortality and many other standard measures of success. If everybody else can do it cheaper and better by covering all of their citizens, it seems likely that we could make comparable advances if we're willing to learn from the way the rest of the industrialized world does it. Are we capable of taking the worst from everybody else's system while maintaining the worst of ours? Absolutely, but we'll really have to work for it.

Lila@208
And don't blame malpractice--did y'all note that because of Texas' malpractice law, there are practically zero malpractice suits in MacAllen?

Malpractice really is a problem, it's just not the only problem.

There's at least three reasons for over-testing
- financial incentives
- malpractice risk
- mission creep in testing.

The first two we have talked about. A nice example of the third is the test for Factor V Leiden, one of the most common genetic tests in adults.

Factor V Leiden is a genetic variant that increases clotting, and increases the risk of pulmonary embolism and deep vein thrombosis. The test is useful for explaining why these things happened. It is of no clinical use: it doesn't predict recurrence if you have already had a clot, and the risk if you haven't had one is still too low to make anticlotting treatment with rat poison worthwhile. The people who discovered this variant, at the Leiden University Medical Center, don't use the test except in research and don't recommend its use.

Despite the fact that it isn't useful for making any treatment decisions and is only very marginally useful for predictions, the test is recommended by several sets of expert guidelines. If you ask doctors why they order the test, it seems that the main reason is that they want explanations -- they want to understand why things happened.

There's a general bias in favor of screening nearly everywhere in medicine. It's hard to convince people, especially doctors, that even accurate screening may not be helpful. The way I put it in class is that screening is the opposite of treatment: it takes healthy people and makes them sick.

Kelly McCullough@210

the assumption that universal coverage will actually and significantly lower costs is not unreasonable when you consider that the US is paying on the order of twice as much on a per capita basis for health care as the next dozen most expensive systems in the world and that we have worse outcomes in terms of things like lifespan, infant mortality and many other standard measures of success.

I don't think universal coverage is enough. The comparison systems have single-payer health care or very strongly cost-regulated insurance systems.

I do think universal coverage will remove the outcome gap, a lot of which is due to the large minority of people in the US without any useful preventive care. Infant mortality, in particular, is a really strong marker of inequality because cheap care gets you most of the way from appalling to excellent infant mortality rates. That's why places like Cuba and Kerala do pretty well on infant mortality statistics despite very low expenditure.

On the other hand, I can't see why just providing coverage to everyone will reduce total costs. There will be some cost reduction from stopping people using ER as their primary point of care, and some of the preventive care is actually cost-saving in the long run, but that doesn't add up to a huge amount.

Without either use of government bargaining power (the way Medicare doesn't) or explicit reduction in services, people who currently have insurance will be getting as much care as they do now, and paying about as much for it, and people who don't currently have insurance will be getting more care than they do now, and someone will be paying for it.

That is, the outcome gap is because some people are getting very little health care, and the cost gap is because some people are getting a lot. Universal coverage will fix the former, but I don't see it fixing the latter.

Universal coverage is still a Good Thing, and it probably provides a step towards more government intervention in the health care market (also a Good Thing). That might eventually reduce costs.

Kelly, the New Yorker article on McAllen, TX, is linked up @ #193

The best care systems in the USA, and, however you define that, I'd put the Mayo Clinic in that class, can also be among the cheapest. We're talking Medicare, so it isn't about preventive medicine or an insurance company cherry-picking. And the price differences are so great that most of the extra health-care costs in the USA could be eliminated.

I'm beginning to wonder, a little, if some of the attitude described in the article, and blamed for the cost differences, has crept into my local GP practice. The NHS is knee deep in "targets", there are rewards and penalties for meeting and not-meeting the targets, and there are ways of organising things which manipulate the figures.

A simple example: you set a target for how long people wait for an appointment for a Doctor, so you don't make long-term appointments. Six months for the next check, but they don't make an appointment until within a month of the target date. Hey, look at how we're meeting the target and earning the bonus.

Thomas @211:

Peripherally to the thrust of your comment:

The people who discovered this variant, at the Leiden University Medical Center*, don't use the test except in research and don't recommend its use.

* Located in Leiden, the Netherlands...because not all medical research happens for profit in the US. Despite anti-reform claims to the contrary.

Abi @ 214: In fact. And the dirty little secret of Big Pharma is that their researchers are standing on the shoulders of giants, with most of the truly innovative rather than derivative work being done at universities with nonprofit foundation and government grant funding. (R&D in the pharma corporations is largely concerned with how to extend their patents these days.)

Thomas @ 212 wasn't that isn't possible to make things worse so much as that we'd really have to work at it. Since every other major system in the world controls costs better than we do on an order of two to one, any rational system for cost containment we could possibly adopt as a part of universal coverage is most likely to improve both cost and outcome.

An anecdote about my most recent experience with the Ontario health-care system...

Yesterday, late afternoon, while cleaning out the crap in my gutters left behind by the bunglers who redid my roof last autumn, I stepped on a piece of wood with a rusty nail. It went through the sole of my shoe and went about 5 mm into the arch of my foot. There were only a couple of drops of blood; the injury had completely stopped bleeding by the time I got my shoe off a few minutes later.

I dug out my immunization record, and found that my last tetanus shot was about nine years ago. I called the toll-free "Telehealth Ontario" number, where registered nurses are available 24/7 to give advice. Among other things, it's a triage system: is this something that I need to take to a doctor at all? Do I make an appointment with my family doctor, go to a walk-in clinic, go to Emergency? At the time I called, I was connected directly to a receptionist/screener, who (after I described the problem) told me that all of the nurses were on other calls; would I prefer to be put on hold or be called back, probably within 15 minutes to half an hour? I opted for the call-back. It came in a few minutes.

I described the problem in more detail to the nurse, who also asked for further information such as whether I was taking prescription medications or had any related health concerns. She advised me that although the tetanus shot is nominally effective for ten years, if there's a reason to suspect possible infection, they recommend an update after five years. She advised me to go to a clinic or to my family doctor, as long as I could get it done within 72 hours. She also advised on how to clean the puncture (5 minutes scrubbing with soap and water and a cloth) and protecting it (band-aid and antibiotic ointment).

This morning I called a nearby walk-in clinic to check on their hours and on the availability of the shot. No problem. I arrived around 11:15. The receptionist swiped my provincial health card and, because it was my first visit to that clinic, I spent about 5 minutes filling out a patient-information form. There were about 8 people there ahead of me. My turn came up a bit less than an hour later. I described the situation in detail to the doctor; she gave me the shot and confirmed the advice I'd gotten from the Telehealth nurse. She advised me to wait in the reception area for 15 minutes in case I had some kind of reaction to the shot, and updated my immunization record.

15 minutes later, I left.

And that's all there's going to be to deal with (unless, of course, I contract some other kind of infection). No more paperwork, no fees.

Joel @217: that's fantastic.

I had a tetanus booster a few years back, with a vaccine reaction (simple fever) that showed up about a week after. For four days I had to take ibuprofen and monitor my temperature, but it went away.

I had to pay a $10 copay for my last tetanus booster because it was a procedure given by a nurse. But I had an appointment, he called me in on time, and I waited for the 15 minutes to make sure nothing happened. I can tell you exactly when I had my last booster (12/10/2003) and all my other immunizations because I just looked it up on my online chart.

The problem with "incentive for healthier behavior" is that, at best, it's an incentive for whatever the people setting up the system think is a healthy behavior. You can wind up spending serious money encouraging people to do things that turn out to be useless or even harmful, like yo-yo dieting, or long periods of bed rest for back pain.

It could also easily be reframed not as rewards but as "we will punish you if you don't do this": e.g., not just coming up with financial incentives for short-term weight loss, but charging people extra if they maintain a stable weight that someone believes is "too fat," or refusing certain medications to people who don't undertake an approved exercise program or find it impossible to kick a nicotine addiction. Because if the goal is to pressure people into not smoking, many humans will find it right and proper to punish those who don't accept the incentive, or find it insufficient.

This would not be a new problem; that doesn't mean it's a good idea to keep building it into the system.

Vicki @ 220: The "we'll punish you if you don't do this" strikes me as a real problem. For example, what do you do if the medical professionals are pushing one care modality but the patient disagrees that it's the right choice? I had a bad foot injury a couple of years ago, and I'm pretty sure the Kaiser physical therapist came to consider me "non-compliant". But it wasn't that I was non-compliant, I was just complying with a different treatment plan because the treatments the PT was prescribing weren't helping and the other treatments (acupuncture and Egoscue therapy) were.

Similarly, medication for mental illness. Some people with depression choose not to take antidepressants — maybe they're trying to address it through nutrition and talk therapy, or through Zen meditation, or through any number of approaches. A "do it or be punished" approach could lead to a situation where a person with depression would be told "Either you take medication X, as the care path* dictates, or you get NO ASSISTANCE OR TREATMENT FOR YOUR DEPRESSION AT ALL because we're not paying for talk therapy or nutritional counseling or anything else. Either take the pill we give you or go away and sink into despair until you're ready to kill yourself."

*I hate the way that care paths wind up being like mandatory sentencing guidelines, with no room for discretion or flexibility on the part of the doctor.

#271 Joel

It may be impolitic of me to mention, however, you didn't note in your writeup that you're unemployed and have been for several months. In the USA that would mean that either the healthcare had been dropped, or that the person would be paying the much higher rates for COBRA....

Paula @ 222: In that respect my situation is a bit odd. Because I was laid off (rather than being fired for cause, having the company fold, etc.) my former employer was required to provide a severance package including continued "salary" and benefits for a period of time (1 week per year of employment). At this point, I'm beyond the legally-required minimum time, but because my former employer was/is trying to deal with an unpleasant situation as well as they could, they're providing the benefits for twice the time they're required to by law. So I've still got the health benefits covered for a few more weeks.

Which doesn't affect the tetanus shot, which didn't involve the company's health plan at all, but which was a useful thing when I had to have a filling replaced a week before the con.

Ezra Klein interviews Ezekiel Emanuel on rationing and euthensia.

Serge #373 :::

And now, Kaja & Phil Foglio's acceptance speech after winning a Hugo last week...
(I'm not sure why Agatha thinks mind-control worms were involved.)

From Agatha's point of view, why would anybody give an award to the people who make her life so surreal, dangerous, and difficult? Three. Times. A. Week.

Mind control worms, clearly. (mime control worms will probably show up in a future episode)

The Democrats may grow a spine yet. From tomorrow's NYT: Democrats Seem Set to Go It Alone on a Health Bill.

Top Democrats said Tuesday that their go-it-alone view was being shaped by what they saw as Republicans' purposely strident tone against health care legislation during this month's Congressional recess, as well as remarks by leading Republicans that current proposals were flawed beyond repair.

Rahm Emanuel, the White House chief of staff, said the heated opposition was evidence that Republicans had made a political calculation to draw a line against any health care changes, the latest in a string of major administration proposals that Republicans have opposed.

"The Republican leadership," Mr. Emanuel said, "has made a strategic decision that defeating President Obama's health care proposal is more important for their political goals than solving the health insurance problems that Americans face every day."

And another example of NHS vs USA:
In defence of the NHS: I'm glad I didn't break my leg in the US

abi @ 134: Thank you for writing that so clearly. It helped me decide what to write when I was contacting my senators and representative. (I didn't copy your words, but I was inspired by them.)

I don't know if anyone has posted this, but I found it interesting.

http://surgeonsblog.blogspot.com/2009/06/fee-for-service.html

In it, the doctor talks about how the way medicine is paid for and how that can affect treatments.

John @ 225: You sure you're in the right thread?

Summer Storms @ 230... Probably, but I like the idea of mime-control worms.

It'll be the zombie mimes that herald the apocalypse.

Quietly, of course.

Apparently the space-time continuum warped when I posted that, it should be on another thread. Woof.