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March 2, 2012

I have an entirely well-deserved tax deduction. You are a lazy welfare bum.
Posted by Patrick at 01:00 PM *

According to Mettler’s survey, 60 percent of those who benefit from the home-mortgage interest deduction didn’t think they had ever used a government social program. Fifty-three percent of those with student loans didn’t think they had used one. Among Social Security beneficiaries, 44 percent thought themselves unsullied by the touch of government, and among Medicare beneficiaries, 39 percent said the same. Twenty-seven percent of those in public housing answered in the negative, as did 25 percent of those on food stamps.
Funny stuff, and it’s tempting to simply observe that roughly a third of the population are nincompoops (a defensible approximation). But the research that Ezra Klein describes, further on in the post above, suggests that “policy design” is “an important determinant of whether people recognize they’re using a government program or not.” When you have to go to a counter in a government office building in order to apply for something, you know it’s a government social program. When it’s something like the the tax exclusion for employer-provided health care, it’s easier to believe that this is just how the universe works.

Design matters. Design, as it happens, currently makes it extraordinarily easy for better-off Americans to not notice that most of them are as much beneficiaries of “government handouts” as anyone else.* It’s hard to think this is entirely accidental.

* (Leaving aside, of course, all that social and technological infrastructure like the Internet and the highway system, all of which was brought into being by the pure flame of American entrepreneurialism.)

Comments on I have an entirely well-deserved tax deduction. You are a lazy welfare bum.:
#1 ::: Ken Houghton ::: (view all by) ::: March 02, 2012, 02:17 PM:

"all that social and technological infrastructure like the Internet and the highway system, all of which was brought into being by the pure flame of American entrepeneurialism"

Yep. Never let it even be suggested that Eisenhower waited 30 years for a chance to bring the French highway system to America, or that DARPA was anything but a Private Initiative.

VH1 Classic last night was running a documentary that declared that most of the "Hip Hop" artists who came up during the "crack epidemic" days run their rap careers based on the entrepreneurial methods of the crack dealers. (We can quibble whether re-creating a Maslovian pyramid as an org structure is entrepreneurial.) Waiting for Jamie Dimon to admit that he runs JPMChaseBear the same way.

#2 ::: Marty In Boise ::: (view all by) ::: March 02, 2012, 02:18 PM:

When an article on the same research ran on BoingBoing in 2011, the small-government types were very busy in the comments explaining that tax deductions and the like are not really government social programs, since they simply "allow us to keep more of our hard-earned money."

I think someone in another blog coined this the "No True Social Program" fallacy.

#3 ::: cgeye ::: (view all by) ::: March 02, 2012, 02:19 PM:

Tax cheaters are systemic and accepted predators on the food chain, so high up that their efforts, especially by corporations, are seen as a normal part of doing bizniz, glorified by their skilled accountants, lawyers and advisors all helping to Reign in Government... by bribing politicos as to block prosecution or the end of the torrent of corporate welfare.

Meanwhile, the mother going through the application process for food stamps is a cheat if she buys anything other than organic veggies (and, lentils! They're so easy and cheap to prepare!) -- and heaven help her if anyone in her charge is fat.... It's not the benefit, it's the built-in punishment and shame, that determines whether a government program is a handout.

#4 ::: Bruce Cohen (Speaker to Managers) ::: (view all by) ::: March 02, 2012, 02:46 PM:

And that picture proves that they know how to spell, too.

#5 ::: LMM ::: (view all by) ::: March 02, 2012, 03:06 PM:

the small-government types were very busy in the comments explaining that tax deductions and the like are not really government social programs, since they simply "allow us to keep more of our hard-earned money."

On a similar note, I've long insisted that the creation of Medicare, while necessary, was a massive mistake, ideologically speaking. If the government wanted to insure a single class of people, they should have insured children, not the elderly. Apart from any of the other politics involved, the dominant message of Medicare is that you've contributed enough to the system that you deserve government benefits. Paying for children's medical coverage tells them that the government has already given to you -- you deserve to give back to your country. [1]

tl;dr: Government programs need better PR.

[1] And, no, I strongly dislike how joining the military is largely construed as the only way to "give back to your country." I would make a strong argument that, say, becoming a schoolteacher is equally important for society, if not more so.

#6 ::: Lylassandra ::: (view all by) ::: March 02, 2012, 03:22 PM:

@1: If only he'd brought the Metro, too...

(Yes, I know some cities have it. I just wish we did here in San Diego.)

#7 ::: Lee ::: (view all by) ::: March 02, 2012, 03:55 PM:

Ken, #1: I must confess that I'm not intimately familiar with the business model used by crack dealers. Did the program go into any detail, or was it just the bald statement and moving right along now? Inquiring minds want to know!

#8 ::: Malaclypse ::: (view all by) ::: March 02, 2012, 04:22 PM:

Funny stuff, and it’s tempting to simply observe that roughly a third of the population are nincompoops (a defensible approximation).

I believe the number has been definitively shown to be 27%

#9 ::: Serge Broom ::: (view all by) ::: March 02, 2012, 04:27 PM:

Bruce Cohen @ 4...

"Dammit, Jim! I'm a protester, not a writer!"

#10 ::: Phyllis ::: (view all by) ::: March 02, 2012, 04:41 PM:

I had a co-worker in the 90's who said indignantly at lunch one day "Do you realize how much more money we'd have in our checks if they didn't take out taxes?" When I replied "We'd have none, because we're state employees and taxes pay our salaries.", she had no response.

#11 ::: Henning Makholm ::: (view all by) ::: March 02, 2012, 05:34 PM:

Terminology? The post seems to treat "government program" and "government social program" as synonyms, but it's not clear to me that they ought to be.

Consider: "I was in the army, and the government paid me a salary and bought the equipment I used, because the nation needs to be defended and it's not enough for that defense to consist only of the independently wealthy citizens who can equip and support themselves, like how it worked in the early Roman republic". That's certainly a government program, but I suppose we can agree that it's not a social program.

On the other hand consider: "I studied at the university, and the government paid me money to buy food and clothes and hired the professors who instructed me, because the nation needs highly educated citizens, and it's not enough only to have those who are rich enough to support themselves through their education and pay for tution, like how it (apparently) works in America". That's a government program too, and I suspect in your terminology it would be a social one too. I'm not so sure; it appears to me to be fairly isomorphic to the previous example in structure and motivation.

On the other-other hand: "I became sick and couldn't work anymore, and the government paid me money so I could keep eating and have a roof to sleep under, because the voters don't want to live in a society that lets its members die in the street due to poor rotten luck." That's an archetypical social program.

I think it is reasonable to distinguish between at least the following groups of public expenses, and not in particular a sign of nincompoopity to understand "social programs" to cover only the first of them:

1) Social programs: directly benefit people who are down on their luck (whether as individuals or by inheritance); benefit society at large in terms of better sleep at night, less fear of one's future for everyone, social coherence, reduction of misery in general, and common decency. (Typical example: unemployment benefits, health care).

2) Public-interest programs: These benefit society at large because they enable some people to do things society needs to have done, but which they couldn't do otherwise. Said people are the immediate beneficiaries but not ultimately the program isn't there for their personal sake. (Typical example: free education, student support and loans, subsidies for public transportation or fuel-efficient cars).

3) Voter bribery which has individual beneficiaries but where everybody would be better off if we could just agree to put a stop to everything, which would however be political suicide. (Typical example: favored tax treatment of owned rather than rented housing).

4) Public works, where the government pays individuals or businesses to do needful things for where it would be impractical, impossible or create undesirable incentives if money was raised by charging the immediate users directly. (Typical examples: roads, courts, libraries, basic research).

[I'm not claiming that the boundaries are sharp -- say, a case could be made for putting public transportation under 4 instead of 2. The point is just that not everything should be lumped into one heap).

#12 ::: Fragano Ledgister ::: (view all by) ::: March 02, 2012, 05:48 PM:

The fact that the tax system, and government programmes like Medicare, farm subsidies, defense spending, tend to benefit people who work, middle class people, and people who are in comfortable circumstances. Also that their effects are less immediately visible as transfer payments (except for Medicare), does tend to blind some people. I for, one, am grateful for the fact that I benefit from some of these policies. They make me better off than I might otherwise be.

#13 ::: Teresa Nielsen Hayden ::: (view all by) ::: March 02, 2012, 06:43 PM:

Marty in Boise @2:

When an article on the same research ran on BoingBoing in 2011, the small-government types were very busy in the comments explaining that tax deductions and the like are not really government social programs, since they simply "allow us to keep more of our hard-earned money."
They're wrong. The fraction that goes for taxes was never theirs. The entirety of their gross income was earned in a context that only exists because of taxes.

A few of the things taxes provide:

-- A country that hasn't seen foreign invaders since 1814, unless you're on a Pacific island, in which case it's happened once.

-- Police and fire departments and a vast range of other public safety personnel (highway patrol, harbor patrols, the Coast Guard, forest rangers, animal control, some EMTs and wilderness rescue, et cetera), plus the FBI and specialized labs, databases, and other resources, without which everything we do would be more dangerous and expensive, and many things we're accustomed to do would be impossible.

The courts, and the rest of the judiciary system at every level.

-- Schools, universities, libraries, educators' salaries, student grants, student loans, school lunches, funding for research, and innumerable other educational resources, without which we wouldn't have educated consumers, an educated workforce, or any kind of technological edge.

-- Water and power. There are a few places in the country where the local water or power systems owe nothing to government at any level, but there are damned few of them. If you live west of the Dry Line, you're definitely the beneficiary of government water programs.

-- The internet.

-- Roads, highways, bridges, dams, causeways, canals, locks, levees, harbor facilities, airports, and commuter rail lines.

-- Reasonably reliable currency, mail delivery, patents, and copyrights. All of which have serious problems; but you should see what happens when they aren't there.

-- Clean air, clean water, effective medicine, unadulterated food, safe consumer products, safe workplaces, advertisements that are merely misleading rather than outright lies, the Center for Disease Control, vaccination programs, many hospitals and clinics, Medicaid, Medicare, the VA.

-- Sewage and garbage disposal.

-- GPS, accurate weather forecasts and monitoring, severe weather alerts, tornado alerts, hurricane tracking, flood warnings, plus continuous study and refinement of our understanding of weather and climate. NCAR. NOAA.

-- Topological and geological surveys. Free maps thereof. Land boundary and ownership registration. Land use planning and regulation.

Every one of those "small government" types earns his money in a tax-dependent environment. The figure for "his" gross income is a fiction that's useful for accounting purposes. The fact that some portion of that gross income is going to go for taxes is as integral a part of the overall system as the road he uses to get to work and the currency he uses to pay for his coffee at Starbuck's.

The founders of our political system fought for a system where government undertakings, and the taxation that paid for them, were decided and voted on by their elected representatives, who were answerable to everyone's interests. They had enough contact with essentially lawless states to know that governmental expenses are necessary if you're going to have a prosperous, well-regulated country.

They also had something modern "small government" enthusiasts don't. That is: experience with countries like France during that period, where the nobility got a disproportionate share of the perks while paying next to no taxes. Unlike our guys, they weren't so focused on the threat posed to them by people lower down the ladder that they failed to notice that fairness and equality also protected them from the powerful guys farther up.

Funny thing, how they've lost track of that.

Bruce @4: Three out of six. Not a passing grade.

#14 ::: elise ::: (view all by) ::: March 02, 2012, 06:51 PM:

Henning Makholm @11: I'm startled that you didn't lead category 2 with public health as an example. It's not just about epidemics, though those certainly do get people's attention. And public health is why health care doesn't belong in your category 1; it belongs in category 2.

"No man is an island" is made pretty clear when looking at public health issues in books like Laurie Garrett's Betrayal of Trust: the Collapse of Global Public Health."

#15 ::: Teresa Nielsen Hayden ::: (view all by) ::: March 02, 2012, 06:53 PM:

Henning Makholm @11, they're all social programs. Affording ourselves decent bridges and a well-run court system is as much a social good as any other.

#16 ::: Henning Makholm ::: (view all by) ::: March 02, 2012, 07:21 PM:

elise @14 -- the examples are just what I could think up on short notice.

I put health care in group 1 because the touchstone in the classification I propose is "what would happen if the government didn't pay for it?". Group 1 is for things where the answer is "Most people wouldn't suffer any direct consequences most of the time, but an unlucky minority would have their lives utterly ruined". Group 2 is for when the answer is "The immediate recipients of the money would find some other way to get by, but the economy (or environment or whatever) would be a little worse for everyone all of the time".

The effect of no public health care is that the few people who are sick at any given time would be significantly worse off, but those who aren't sick at the time would not be directly affected. Therefore, health care naturally belongs in group 1.

Public health (by which I suppose we're speaking about generic prophylaxis such as food safety, pest and pollution control, health warnings and campaigns targeting the general population, epidemiology, screening programs, etc.) I would tend to put in group 4 -- inasmuch as we're paying professionals to do some specific task, not paying people in general to eat less saturated fats. However, things such as lower sales tax on vegetables if that food group is underrepresented in most people's diet, that would be in group 2.

Teresa @15 -- doesn't that make the word "social" vacuous? If all government spending is "social", then what communicative purpose would the word have?

#17 ::: Henning Makholm ::: (view all by) ::: March 02, 2012, 07:40 PM:

Further to Teresa: For example, in the phrase "social security", my impression is that "social" makes it mean something different from "government spending on security". A guard at the entrance to a military facility is there to provide "security", and he's paid by the government, but he's clearly not "social security".

But more in general, are we merely disagreeing about the meaning and use of "social" as a linguistic issue (in which case I should probably defer to the native speaker, though I'd be curious to learn why whatever semantics "social" has in "social security" cannot modify "government program" analogously), or do you contend that my attempt at a categorization is meaningless in principle?

#18 ::: James D. Macdonald ::: (view all by) ::: March 02, 2012, 07:41 PM:

#16 ::: Henning Makholm The effect of no public health care is that the few people who are sick at any given time would be significantly worse off, but those who aren't sick at the time would not be directly affected. Therefore, health care naturally belongs in group 1.

If I take the set of all people who have been sick, are sick, or will be sick ... I think that's 100% of the population.

#19 ::: Fragano Ledgister ::: (view all by) ::: March 02, 2012, 08:01 PM:

TNH #13:

"-- A country that hasn't seen foreign invaders since 1814, unless you're on a Pacific island, in which case it's happened once."

Not quite the case. Please note this:

Pancho Villa (en su camisa, en este caso)* definitely counts as a foreign invader, and New Mexico as part of the United States.

*Y eso no da risa.

#20 ::: Henning Makholm ::: (view all by) ::: March 02, 2012, 08:16 PM:

James @18: True. That's why I'm proposing not only to look at how dramatically the acute need for a benefit varies between different people over their whole lives, but how dramatically it varies between different people at different times.

That said, some people get sicker than other people -- or more relevantly: a small minority of people get illnesses for which there is an effective but expensive treatment. And those are the cases in which public health care matters -- when there is no treatment, it's just a tragedy, and when there is a cheap enough treatment we can all shoulder it ourselves. But when treatment is possible but expensive, that's when it a matter of life and death whether you're rich or poor or whether you have access to a health care system that will spend it on your behalf.

Another way to say the same thing is that the programs in my group 1 are basically risk sharing schemes. Most people will not need them most of the time -- but by sharing (through taxes) the cost of those who do need them, the risk is made bearable for everyone.

Group 2, meanwhile, is not about sharing the risk of individualized disasters, but about sharing the cumulative benefits of small outlays that need to be large in number before the begin to be beneficial to everyone rather than just an unpredictable group of random winers.

#21 ::: LMM ::: (view all by) ::: March 02, 2012, 08:21 PM:

The effect of no public health care is that the few people who are sick at any given time would be significantly worse off, but those who aren't sick at the time would not be directly affected. Therefore, health care naturally belongs in group 1.

This assumes that health care deals only with non-contageous events. I would argue that, while this argument *might* apply to cancer, it definitely doesn't apply to tuberculosis.

#22 ::: James D. Macdonald ::: (view all by) ::: March 02, 2012, 08:42 PM:

I would argue that, while this argument *might* apply to cancer, it definitely doesn't apply to tuberculosis.

It doesn't even apply to diabetes. Or hypertension. Or a whole list of other, very common, conditions.

The practical effect of "no health insurance" is "no health care." The practical effect of "no health care" is that small, easily and cheaply fixed problems require large, difficult and expensive solutions. And each one takes a productive member of society out of the workforce/taxpaying group.

Universal health care isn't a luxury: It's a human right.

#23 ::: P J Evans ::: (view all by) ::: March 02, 2012, 08:52 PM:

One of my grandfathers was in the National Guard and was called up to serve chasing after Pancho Villa. So, yeah, invader, if small scale. I believe Columbus, NM, is still not happy with him.

#24 ::: Rick York ::: (view all by) ::: March 02, 2012, 08:54 PM:

During the "debate" about the healthcare bills, in a town hall in Vancouver Washington, a woman who had to be at least 70 got up and said "I don't want the government managing my health care!"

Any bets on whether or not she has Medicare?

Since Proposition 13 in California, the Republicans have succeeded in persuading a large segment of American voters that they could have their cake and eat it too.

#25 ::: LMM ::: (view all by) ::: March 02, 2012, 08:56 PM:

The practical effect of "no health care" is that small, easily and cheaply fixed problems require large, difficult and expensive solutions. And each one takes a productive member of society out of the workforce/taxpaying group.

Oh, I definitely agree with you there. I just think that tuberculosis is a better example of the fact that paying for medical care (even for bums) is better than just letting people stay sick.

#26 ::: Bruce Cohen (Speaker to Managers) ::: (view all by) ::: March 02, 2012, 09:28 PM:

Jim Macdonald @ 22:

Universal health care isn't a luxury: It's a human right.

And it's also a necessary prerequisite for a well-functioning society (which the US, for example is not at the moment).

#27 ::: Avram ::: (view all by) ::: March 02, 2012, 09:32 PM:

I thought they were called "social programs" because they were transmitted sexually. (See also: social networks, Langdon Chart.)

#28 ::: Lee ::: (view all by) ::: March 02, 2012, 09:34 PM:

Henning, #11: When someone is loudly proclaiming that THEY have never taken a penny from government programs, then I think it is both reasonable and fair to point out all the ways that they have in fact done so. What you're saying here is a form of weasel-wording; you may not be using it as a way to ignore the government-paid benefits that you (if you are a US citizen) receive, but there are a hell of a lot of people who are doing exactly that.

In particular, your boundary between "social programs" and "public-interest programs" seems to be artificial and arbitrary. Individuals may benefit from student loan programs which enable them to get an education they couldn't otherwise afford, but the program is "not there for their personal sake"? Oh, please. And Social Security certainly enables a lot of people to have housing and food who would otherwise be unable to do so. You appear to be assigning programs to one category or the other depending on the social status of the primary beneficiaries thereof, which is exactly the problem under discussion.

and @16: Claiming that "most people wouldn't suffer any direct consequences most of the time" without access to health care IS weasel-wording. How many worker-hours are lost to illness among people who can't find a full-time job which would allow them to see the doctor? How many of those people LOSE their jobs because they couldn't be there for 3 days because they got sick? How many people catch what they've got because they were obliged to work while contagious if they wanted to keep their job? Hand-waving away indirect consequences is a standard right-wing talking point.

#29 ::: Thena ::: (view all by) ::: March 02, 2012, 09:49 PM:

@20 But when treatment is possible but expensive, that's when it a matter of life and death whether you're rich or poor or whether you have access to a health care system that will spend it on your behalf.

It seems to me that this is highly contingent upon what your threshold for "expensive" is, and the way the US currently does these things, pretty much all health care is expensive to somebody - the question is who pays.

I am fortunate enough to have insurance that covered my recent gallbladder surgery, which was about as routine as these things get - no overnight hospitalization, no complications, all good. I got the insurance statement of charges covered and the bill was approximately $10K - of which I paid about $500. If I'd had the same illness three years earlier, when I was uninsured (because my job at the time didn't offer coverage, and I wasn't yet married), I would have been responsible for the entire bill, barring some charitable intervention. Or ten times that, because I wouldn't have been at the doctor's office where I mentioned the annoying minor pain that led to the diagnosis and treatment of the problem before it became an acute medical emergency.

$10,000 USD isn't that much money in the great scheme of the universe, but it's still awfully close to half my gross annual income. So yeah, that qualifies as expensive by my understanding of the word.

That's the scale of cost-to-resources that plagues US healthcare. Jim is right (@22) when he says:

The practical effect of "no health insurance" is "no health care." The practical effect of "no health care" is that small, easily and cheaply fixed problems require large, difficult and expensive solutions.

I'm inclined therefore to classify health care under category 2 (shared benefit) rather than category 1 (distributed risk) although distributed risk is part of it, because the benefits go beyond distributing risk. I imagine that the distributed-risk component applies mostly to catastrophic illnesses and accidents that won't happen to most of us -- but at least in the US, basic routine health care is sufficiently expensive relative to the resources of average people that any accident or illness leads to calculation of medical vs financial risk: "Is this (potentially) a $1000.00 problem?" (rough estimate for the minimum cost of a trip to the emergency room for an uninsured person who falls through the "safety net" - when that $1000.00 is most of a month's after-tax income for a lower-wage worker.)

It's math like that which makes Jim's day job that much harder.

#30 ::: P J Evans ::: (view all by) ::: March 02, 2012, 10:11 PM:

Then there's the news stories about people who die because they can't afford treatment for things that are actually easy to fix, before the problem escalates to a major emergency.

#31 ::: Serge Broom ::: (view all by) ::: March 02, 2012, 10:17 PM:

Teresa @ 13... Your list reminds me of something Greg Bear recently said here, that Libertarians tend to forget the contributions that the rest of us make to that world they live in. Or words to that effet.

It also made me think of the People's Front of Judea, but that's another story. :-)

#32 ::: Lee ::: (view all by) ::: March 02, 2012, 10:44 PM:

Thena, #29: the distributed-risk component applies mostly to catastrophic illnesses and accidents that won't happen to most of us

I submit that the last part of this is inaccurate. If we live long enough, most of us will at some point or other suffer a catastrophic illness or a life-threatening accident. Is there anyone here who has not yet had either, and how old are you if so?

I had a life-threatening accident when I was 17 -- got T-boned by someone going about 60 MPH. If I hadn't been wearing my seatbelt, I'd be dead. If I hadn't gotten medical assistance quickly, I'd be dead -- I was bleeding out from a ruptured spleen. To date that's the only such incident, but I have trouble thinking of myself as a statistical outlier in this context.

#33 ::: OtterB ::: (view all by) ::: March 02, 2012, 11:07 PM:

Lee @28, I disagree that Henning's discussion of "social" vs. other kinds of government programs and the fact that people may have misunderstood "social" programs is weasel-wording.

I agree that it's important that people who think of themselves as taking nothing from the government recognize that most often they do.

But to my mind, it confuses the issue to conflate "I don't get any economic benefit or break from the government" with a possible misunderstanding of what's meant by "social programs."

If I'd been completing the survey, I would quite probably have equated "social programs" with what I think of as "safety net" programs. It doesn't mean I don't value the others. It's just that I wouldn't have thought they were intended to be included under that umbrella.

#34 ::: B. Durbin ::: (view all by) ::: March 03, 2012, 12:14 AM:

"west of the Dry Line"

This is a term I immediately understand and I want more specifics. The Dry Line is, what, roughly 100 miles west of the Mississippi? Or is there a more formal demarcation?

I've always lived west of the Dry Line, to the point where water running down a gutter when it's not raining is a horrifying sight to me. "What are you DOING?"

#35 ::: P J Evans ::: (view all by) ::: March 03, 2012, 12:17 AM:

The 'dry line' is about 100 west, if I understand it correctly.

#36 ::: Thomas ::: (view all by) ::: March 03, 2012, 12:41 AM:

B. Durbin: The 'Dry Line' runs north-south through Kansas and Texas -- 100 west sounds about right. If I recall correctly, it corresponds to the 20in average precipitation contour, which also (to some authorities) marks the edge of the Great Plains. West of the dry line, farming requires bringing water in from elsewhere.

#37 ::: eric ::: (view all by) ::: March 03, 2012, 12:53 AM:

So, by that standard, anyone who has qualified dividends or capital gains would also be a recipient of a government program. Also see the capital gains exemption on your primary house that you can take every 5 years. They're using social programs to prop up the wall street end of the economy.

Having done my taxes recently, it's not hard to see that there's a whole lot of social engineering that goes into them.

Having kids -- tax deduction. Putting your eyes out. Tax deduction. Running up huge uninsured health care bills -- tax deduction. Taking on a mortgage that's too big for you -- tax deduction. Making a bunch of money in long term capital gains -- Tax deduction. Giving money to wall street to put in your ira/401k. Tax deduction.

I've also done the numbers for a refi, and my mortgage tax deduction costs a hell of a lot for what I get. I get (roughly) a 8% rebate on the interest I pay. (YMMV, I'm married with kids, which tends to reduce such things. A single person with more money would get a bigger benefit due to smaller standard deductions.)

The other interesting thing that I found on my taxes is that long term gains and qualified
dividends have an ultra low rate in my tax bracket, either 0 or 5%. If I could (somehow) figure out how to make my living from a hedge fund, I wouldn't have to pay (fed) taxes at my current level.

On the other hand, If I wanted to bring in a little extra money by doing some consulting on the side, the marginal tax rate on that is fed marginal + 15%(ss, medicare + se tax) + state b+o taxes + local taxes. That's pretty discouraging to picking up a little on the side.

#38 ::: Tom Whitmore ::: (view all by) ::: March 03, 2012, 01:09 AM:

Lee @29 -- I've never had an illness that required hospitalization (though the pneumonia could have if not caught) and I haven't had an accident that required more than stitches (though several of those). And I've just turned 59. I too don't think of myself as that much of an outlier, but I know I've been very lucky in my health. I go to the doctor less frequently than I might, and I've been uninsured for a large portion of my life (probably more than half of my adult life). I am insured, at this point, though I don't have a really cushy plan.

I am grateful for my luck and hope that mentioning it does not cause the luck to change.

#39 ::: Bruce Cohen (Speaker to Managers) ::: (view all by) ::: March 03, 2012, 02:24 AM:

eric @ 37:

I think that's good evidence that the system of incentives in the US that's implemented in part by tax policy is perverse, in that it is designed to reward parasitic activities like financial speculation more than productive activities.

#40 ::: Bruce Cohen (Speaker to Managers) ::: (view all by) ::: March 03, 2012, 02:45 AM:

Lee @ 32:

Over the years I've seen a number of friends, acquaintances, and relatives die (of accident, violence, catastrophic illness, or complications of old age), and even more suffer serious physical, mental, emotional, and economic distress as the result of accidents or illness. Both my wife and I have had serious medical problems resulting in long-term restrictions on our life styles, and large financial outlays. In fact, we've had reasonably good insurance coverage most of our lives, and still have had to spend a great deal of money out-of-pocket.

So extrapolating from my experience and that of the people I've known, I'd say odds are damn good that a very large fraction of the population is going to have to deal with life-threatening occurrences at least once in their lives. Don't, by the bye, expect that those things only happen to old people. Two of my friends when I was a teenager were killed in motorcycle accidents, one of my college friends was permanently paralyzed in a car accident, and one of my high school classmates who was in grad school at the time was murdered late one night as he was getting some money at an ATM. The dice come up snake-eyes whenever they choose.

☤ When I filed my 2010 tax return last year, I itemized over $30,000 of out-of-pocket medical expenses. That was probably the worst year we've ever had, because we both had major procedures. But the only reason we could afford it was that we could draw down our retirement savings. That's what we have to live on for pretty much the rest of our lives, so spending it on medical expenses has the ironic effect of making our lives longer while reducing the time during which we'll have money to live on.

#41 ::: elise ::: (view all by) ::: March 03, 2012, 09:53 AM:

Lee @28: You appear to be assigning programs to one category or the other depending on the social status of the primary beneficiaries thereof, which is exactly the problem under discussion.

Exactly. Exactly exactly.

#42 ::: Lori Coulson ::: (view all by) ::: March 03, 2012, 10:37 AM:

Lee @32: I'm 56. No major illnesses, no life-threating accidents, no broken bones, and the only operations I've had were to remove wisdom teeth.

Chronic illness, yes: Fibromyalgia and hypertension. All treatable with drugs, none of which are incredibly expensive.*

My accidents have required a few stitches, Ace bandages and a walker, several weeks of physical therapy or visits to the chiropractor.

I KNOW I'm lucky -- and I'm hoping I haven't just jinxed myself!

*I've also had health insurance all but 1 year of my life.

#43 ::: Thena ::: (view all by) ::: March 03, 2012, 11:14 AM:

Lee @32 --

You are correct in that I omitted a parenthetical "at any particular point in time" with respect to catastrophic medical need - not saying that most of us won't have a life-threatening medical incident ever, but at any particular point in time most of us are not having one. The way I read Henning's comments earlier in the thread suggested to me that he (?) is somewhere in continental Europe, and while I assume that there's a general knowledge that the US health care system doesn't work the way European ones do, I'm also assuming that people who live in societies with functional health care systems may not immediately understand the implications of a broken system. My comment was intended to point out that in the US, you don't need to have one of the things you might think of as medically catastrophic (cancer, organ transplant, N-tuple bypass, major trauma, etc) to end up with financially catastrophic medical bills.

That having been clarified, I'm with Tom @38 and Lori @42 in not having had any major health issues yet (*) - part of why I freaked out so badly about the gallbladder surgery this winter was that it was the most serious medical thing I'd ever had happen. Had I ignored it, it could easily have gotten much worse and much more expensive.

I am also very lucky - both that I haven't had any catastrophic health issues yet (knock wood) and that the mid-grade problems I've uncovered recently didn't turn into emergencies during the decade-plus that I was uninsured.

(*) In retrospect, there were times when if I'd known I had asthma, I'd have realized I was having an attack, and ought to have gone to the ER (or at least taken meds for it.) But I wasn't diagnosed with that until last fall, and not knowing the underlying problem, I'd take take some cough syrup and sleep it off and be sick for a month. I have insurance now; the list price for my maintenance meds is about $350 a month of which I pay $40 out of pocket (under the current insurance contract, subject to change in July) plus the OTC stuff I take for allergies. Is being able to breathe worth $400 a month? Absolutely. Would I be able to afford it at my wage level if I didn't have insurance? That $400 would be most of a week's gross pay.... and it would still work out cheaper to pay almost quarter of my wages for medication than to pay for one hospital admission in a year. On the other hand, when I was single and living paycheck to paycheck, I didn't have $400 a month left over after rent, utilities and other overhead expenses.

When people talk about the financial impact of medical costs, I get the sense that mostly they're thinking of the Really Big Really Expensive things. But everything else all the way down is expensive too.

#44 ::: Bruce Cohen (Speaker to Managers) ::: (view all by) ::: March 03, 2012, 11:52 AM:

Thena @ 43:

One of the most common ways to get into financial trouble because of medical problems is Being Nibbled To Death By Ducks: Or, The Debt Of A Thousand Cuts. Especially as people get older, little medical problems start to add up, and start to interact with each other, requiring more, and more complex, treatments.

#45 ::: Thena ::: (view all by) ::: March 03, 2012, 12:02 PM:

Bruce @44

I'm 38 and looking at the last six months as baptism-by-fire into middle age, at least as far as health care is concerned. It's going to be interesting how this plays out with generational demographics: Gen X (into which cohort I fall) is entering the "early middle ages" and I can't back it up with hard statistics but I have the sense that people in my age bracket (at least within the US) are not doing as well financially as our parents' generation did when they were turning 40. Given that Gen Y and Millennials are struggling to get entry level work (largely because us X'ers won't get out of the entry level jobs until the Boomers retire) I really hope the system can be fixed before there's an even bigger crisis of people who can't afford preventative care.

#46 ::: Phyllis ::: (view all by) ::: March 03, 2012, 12:15 PM:

Regarding 'transfer payments' such as food stamps, what gets lost is the fact that the clients who receive the benefits aren't in fact the final beneficiary. They aren't hoarding them, they're using them at the grocery store to buy food.

There are a lot of grocery stores that would find themselves hurting if food stamp benefits went away.

#47 ::: P J Evans ::: (view all by) ::: March 03, 2012, 12:18 PM:

I'm considerably older than you, and I have the same feeling: not doing as well as parents at the same age, even with an approximately-equivalent income. And a future that doesn't look good, because the PTB seem to be trying to make us work until we drop dead.

#48 ::: Glaurung Quena ::: (view all by) ::: March 03, 2012, 12:27 PM:

Something the linked article doesn't touch on is how the US government does little to no PR for itself. I think that, rather than stupidity, may be part of why 1/4 of food stamp and public housing recipients in the linked study thought they hadn't benefited from any government programs.

I was born in the US but currently live in Canada. Up here, the Canadian government spends quite a bit of time and money letting people know what it's done for them lately -- subway posters, TV ads, letters in the mail, etc, all letting you know that this or that thing has been made possible by "the Government of Canada."

And it's almost always just that -- not this or that government agency, but rather "the government of Canada." On the rare occasions when it is an agency that IDs itself as responsible for something, they do so with a font and logo that is designed to match the federal government's logo, so the association is still there.

In short, up here, the government realizes that it is a brand, and it goes out of its way to make sure that that brand is associated in people's minds with the stuff the government does for them. Contrast this to the US, where for whatever reason (for Republicans, it's because they want people to think of the government as useless/evil because that furthers their agenda of goring it as much as possible for the short-term benefit of their wealthy corporate masters), the opposite is the case.

#49 ::: Mea ::: (view all by) ::: March 03, 2012, 12:48 PM:

I haven't noticed the catastrophic medical emergencies that didn't happen. My mom gave birth to me in a hospital, and didn't die or have her health compromised and she was healthy for MY birth because she used contraception to have spaced and planned pregnancies. I was vaccinated against a lot of nasty diseases as a child. Also remember taking anti-biotics on more than one occasion. I also got routine dental care and doctor checkups. I eat at restaurants inspected by the public health department and buy food regulated by a slew of entities, including organic products that reduce my body burden exposure to chemicals.

Oh, and I have never had or met anyone with pallegra (beri-beri) or other common illnesses of the 19th century caused by vitamin deficiencies because of fortified foods due to past public health campaigns.

So, I could say that I am healthy and thus far have never needed acute medical care for catastrophic illness, but That isn't a fair statement unless I also emphasize that I have dodged a lot of potential for catastrophic illness by having access to good medical care.

Thus, I put health care and public health into one category.

Folks in the USA that balk at "socialized medicine" are ignoring all the positive externalities that make it cheaper for us to cooperate. One reason American medicine is expensive is because it is too individual instead of being a social (ie cooperative) undertaking.

#50 ::: Fragano Ledgister ::: (view all by) ::: March 03, 2012, 01:01 PM:

PJ Evans #47: I have a very similar feeling.

#51 ::: Henning Makholm ::: (view all by) ::: March 03, 2012, 01:32 PM:

I'm somewhat confused by the replies.

It appears -- though nobody is saying it directly -- that many people assume that by classifying universal health care as a "safety net" type of program (thanks for that term, OtterB @33), I'm somehow implicitly arguing that it is less worthy of government funding, or a less desirable feature to include when designing a society.

I'm quite at a loss here -- what can I say to dispel that impression? I thought that by making "voter bribes" category 3 out of 4, it would be clear that there is absolutely no order of political desirability implied by the systematic.

On the contrary, there are very good arguments for government-provided universal health care. I hoped I had reproduced enough of them in my comments to make it clear to the reader that they convince me, but apparently not?

Back to the point, however, whether it's desirable or not does not inform which kind of program it is -- that would be a completely useless, teleological classification.

Health care is a "safety net" program because the actual costs of it are distributed unevenly in space and time, and the purpose of the program is to spread those costs among everybody at all times. The fact that everybody can expect to be sick sometime appears to me to be quite irrelevant to this. It is unacceptable to have X percent of the people miserable all the time due to lack of health care, and it is equally unacceptable to have everyone miserable for X percent of their lives due to lack of health care.

Lee @28: You appear to be assigning programs to one category or the other depending on the social status of the primary beneficiaries thereof,

I don't get this at all. If there's anything that's characteristic about ill health, it is that it hits people with no distinction given to their social status at all. Poor people sometimes get horribly sick, sometimes less horribly; rich people do too. They are all equally "primary" beneficiaries of universal health care.

We (here and in the following "we" means the government of Denmark, because I don't know what American governments provide) provide universal health care because nobody should have to suffer from a treatable illness that they can't afford treatment for themselves.

That's different, by the way, from programs targeting only poor people. We provide shelter for people who lose their homes because nobody should have to sleep under bridges. The primary beneficiaries of that are characterized by their social status.

Yet I'm classifying both as safety-net programs even though one targets particular social classes (inasmuch as "homeless people" constitute a social class, which is an interesting discussion for another time), whereas health care benefits every social group equally.

On the other hand, when we provide student loans and free universities, it's not because nobody should have to suffer being a plumber. We need plumbers, and there's nothing undignified about being one, but we also need enough people with university educations, and we wouldn't have that if we didn't subsidize them.

It's a distinction between motivations going "nobody should have to suffer such-and-such", and motivations going, "we must ensure that some, but not necessarily all, citizens do such-and-such". I have trouble seeing how making that distinction could be so controversial.

#52 ::: LMM ::: (view all by) ::: March 03, 2012, 02:41 PM:

@51: It appears -- though nobody is saying it directly -- that many people assume that by classifying universal health care as a "safety net" type of program (thanks for that term, OtterB @33), I'm somehow implicitly arguing that it is less worthy of government funding, or a less desirable feature to include when designing a society.

I think that part of the problem is that you opened #1 by specifying that it's intended to aid people who are "down on their luck" -- i.e. they primarily benefit poor people, not everyone.

#53 ::: Cynthia W. ::: (view all by) ::: March 03, 2012, 02:55 PM:

@Henning Makholm - #51 - I think this is where not understanding how a broken health care system works is causing a misunderstanding. In the US health care is a function of social class. If you're employed at a high-level job, you will have health care as part of your job. Generally speaking, the higher status, higher paying the job, the better the attached health care is likely to be. Blue collar, lower-paying jobs are less likely to have attached health care, and if they do, are likely to have poor coverage, or have large hunks of things uncovered. Medical crises may be no respecters of social status, but the financial outfall thereof differs dramatically.

Or to provide an illustration: there are two people in my life who developed hyperparathyroidism at about the same time. One is well into the upper class, and has excellent health coverage. Within weeks of the diagnosis, she had surgery at the Mayo Clinic (about 1500 miles from her home) with the best available surgeon. Recovery was quick and uneventful, and these days (about five years later) it has no impact on her daily life at all. The other is a free-lance math tutor, eking out a living student to student, and barely keeping herself housed and fed. (Anybody got a job for a Math Ph.D. who speaks five languages and is also a certified Cordon Bleu Chef? She's been looking for a couple years now.) She got her diagnosis by accident while she was taking advantage of a free physical provided for agreeing to be part of a medical study. She had some medication that the study physician gave her as samples, but that soon ran out. No health insurance. She can't afford routine treatment, let alone surgery. She used up what grace the local hospital was willing to give her when they wrote off the cost of surgery to set a broken wrist for her. Now she's beginning to see signs of osteoporosis. It's probable that she'll be dealing with the outfall of this for the rest of her life, even if she somehow got her surgery tomorrow.

#54 ::: elise ::: (view all by) ::: March 03, 2012, 03:50 PM:

Henning Makholm @51: I'm wondering if part of the reaction you're getting is because you're unknowingly wandering over some of hot-button terminology in the U.S. (Hey, say hello to Denmark for me please, by the way? I hope to visit again some day.)

I've been trying to put it into words unsuccessfully, and need to go grab a bus and get to a gathering in a few minutes, but I think it has something to do with how the whole fiction of individualism works over here, and why too many of us don't think in terms of, as you said, designing a society. A lot of people don't see themselves as part of a society at all; sometimes they locate themselves as the lost rightful heirs of the society that's gone astray (uh-oh, I think I've been reading TV Tropes too much again) or as targets of society. And some people see themselves as different things at different times. (Dunno. Maybe we all do.) What I'm trying to gesture at is something like this: we aren't used to thinking about we in expansive and acknowledging terms, in our national discourse. Or at least, we aren't doing it enough. Instead, there's a habit of thinking about Those People. The Ones Who Need Help. Which usually gets shaded over into Those People Who Are Deliberately Poor, Who Would Stop Being Poor If We Would Make It A Little Harder To Be Poor, Right? And it gets worse from there.

#55 ::: KayTei ::: (view all by) ::: March 03, 2012, 05:42 PM:

Cynthia @ 53

I can put that in to even starker terms for you. My mother and my aunt were both diagnosed with stage IV cancer, within a year of each other. My mother is insured and is still alive. My aunt was uninsured, and she wasn't even diagnosed until three days before she died.

There were other health differences between them, but they all boil down to having money and health insurance.

I unequivocally support universal health care and health care as a basic human right.

#56 ::: Mea ::: (view all by) ::: March 03, 2012, 07:43 PM:

Henning at 51: what Cynthia and Elise and said. I am very much reacting to the abysmal situation and level of discourse in the united states. Where rolling BACK health insurance coverage (ifnit is for women and involves reproductive health) is a major push of one of the two major parties. You, from the delightfully rational Danish perspective can rationally talk categories and know that those categories won't interfere with a basic understanding of the social contract. We are still trying to explain to bat-crazy selfish or badly educated fellow citizens that a social contract exists and is a good bloody thing to support.

It goes back to your question about why Americans put social in front of things like social security. The fact that health care is up there with missiles and a standing army is disputed here. And it is crazy-making and stressful to live in a country where each one of us is one job loss away from losing access to first world medical care. I am afraid to quit my job because it has rock solid health benefits (that are under attack because I work in the public sector).

KayTei: I am so very sorry about your Aunt. It is so deeply unfair. I hope your mother is doing good.

#57 ::: Vicki ::: (view all by) ::: March 03, 2012, 09:21 PM:

Henning: The explicit context of this discussion is American politics and opinion/belief. It's careless, at best, to define categories based on Denmark, not state "this is how things work in Denmark, which is different from what you're talking about but might be useful," and then be surprised when you get replies from Americans based on how things work in the United States.

Another point on who benefits from these programs: I recently verified that my pertussis vaccination is up to date (when I got that vaccine two years ago, I offhandedly asked my doctor for a tetanus booster, and didn't make a note of whether it was just that or DTaP). I didn't check because I'm worried about the effects of pertussis on myself. I checked because my trainer is not quite nine months pregnant (as in, she canceled a session Thursday because her midwife said she might be in labor by Friday), and she wants me to visit the baby. Pertussis wouldn't be a big deal for me, at 48, but it can be fatal in infancy.

The best Emilie can do on this is make sure that she, her husband, and their parents are vaccinated, and tell everyone else not to visit if they have a cough. That will probably be enough, but any random unvaccinated person wandering around the city is a risk to her, and to every other infant.

#59 ::: Bruce E. Durocher II ::: (view all by) ::: March 04, 2012, 12:05 AM:

Damn, damn, damnit! Bloody Chrome mislabeling the tabs with the next tab over so you end up cross-posting and looking like an idiot!


#60 ::: Cynthia W. ::: (view all by) ::: March 04, 2012, 12:18 AM:

KayTei@55 - damn that sucks. I'm very sorry about your aunt, and I hope your mother continues to do well.

One of the most frustrating things about the whole health care discussion for me, is that my mother (the insured person in my previous post) is very, very conservative, and very much against government-funded health care, because it might have a negative impact on her top-flight coverage. She seems to find it incomprehensible that I would find it acceptable for my mother (my own mother!) to get less than the very best - I.e. the ability to fly across the country to get the very best surgery from the very best surgeon, even for relatively routine surgeries - in return for allowing other people, even if they are my friends, to get healthcare at all. It just doesn't seem real to her that I know (and she has met) people who have wandered around with a broken wrist for a week before seeking treatment because they flat can't afford to get it fixed.

She seems to find these priorities of mine very selfish, which completely boggles my mind.

#61 ::: KayTei ::: (view all by) ::: March 04, 2012, 12:50 AM:

Mea @ 56, Cynthia @ 60

Thank you. My mother continues to dramatically exceed conventional expectations, which suits me just fine. :)

Cynthia, picking up your point regarding tradeoffs -- At the risk of telling you what you already know, I can't think of any solution which has been proposed that would result in your mother losing her access to enhanced levels of care. Even if we went to Medicare for All, I believe any such law would also have to provide for comprehensive supplemental insurance (such as Medicare beneficiaries have access to already), specifically to address concerns such as those. Congress-people like their perks -- anything that would diminish their ability to obtain the best healthcare money can buy is simply never going to make it to the table. I would go so far as to say she quite literally has nothing to lose, because the people who get help through this program still will not be able to afford her level of health care.

#62 ::: Lee ::: (view all by) ::: March 04, 2012, 01:49 AM:

The idea that health care is a zero-sum game, and thus that any improvement in its availability for the Lower Classes will necessarily take something away from ME! is endemic among the better-off in America. Nor is health care the only place where you see it, but that is one of the points at which the naked ugliness of it tends to be clearest.

#63 ::: janetl ::: (view all by) ::: March 04, 2012, 03:29 AM:

Lee @ 62: I encountered that in a relative who actually said out loud "But if more people get access to health care, how long will I have to wait to get an appointment?"

#64 ::: Pyre ::: (view all by) ::: March 04, 2012, 07:03 AM:

Confusing taxpaid with nontaxpaid programs....

Rush Limbaugh's three days of broadcast foul slanders against Sandra Fluke, followed by his website apology for "word choices," all argued on the premise that American taxpayers shouldn't pay for contraceptives.

But the policy at issue required only *private* insurance companies to pay for them, covering employees of religious organizations that had objections to paying for them.

Taxpayers didn't come into it at all, making Limbaugh's bloviations entirely irrelevant.

This, I suppose, is the "flip-side" idiocy from the type shown at top of thread.

#65 ::: Thena ::: (view all by) ::: March 04, 2012, 07:50 AM:

@62-63 (zero-sum health care)

I'm about to run off for the day, but at the risk of posting something incoherent and not being around to clarify for a few hours, another piece of the zero-sum mentality with respect particularly to health care but also to other societal goods (I'm thinking education particularly, I'm sure there are others) is that in some contexts there is genuinely not enough to go around. I live in a less-rural area of a fairly rural state (Maine) and it's been known for a long time that there simply aren't enough dentists and family doctors up here. A lot of the ones that are here have already got more custom than they can keep up with and are not taking new patients - sometimes with the exception that they'll take on a patient who is a family member of a patient they already have, which is how I got on with my current doctor. (I found my current dentist by calling all the dentists in the phone book until I found someone who was taking new patients at the time.) There are a lot of whys behind that - the cost of physician training is one; also the overhead costs of malpractice insurance and in this climate, fuel for heat and travel; furthermore, low rates of reimbursement from perpetually-underfunded government programs (Medicare, Medicaid, sCHIP, etc) make this patient base hard to cover, and patchy insurance coverage among the next economic tier of patients means the physician might not get paid at all. There's definitely a financial motivation for medical students to go into a lucrative specialty and settle in an upscale urban / suburban area than to go into general practice in a rural or inner-city environment.

So there's an element of truth to the fear that if there's already not enough to go around now, how much worse will the situation be if/when Everybody (read: Those People Over There, Who Do Not Deserve What I Have) has as much right to what I have as I do.

Darn, I had more to say, but I have to get off the internet and go sing this morning.

#66 ::: Rob Hansen ::: (view all by) ::: March 04, 2012, 08:29 AM:

A while back I was experiencing pain in my right elbow. I phoned my doctor's surgery and made an appointment for a couple of days later. On the day I went along, waited maybe five minutes in the very pleasant waiting room and was seen. The doc examined me, figured out it was a mild case of bursitis and gave me a prescription. He than chatted to me about my health in general, checked my records, and noticed it had been about 30 years since my last tetanus shot and, given my work situation, suggested it would be a good idea if I got a booster. Since the nurse was in that day I could have the booster then if I wanted.

"Yeah, I'm here anyway so why not?" I said.

Waited about another 20 minutes to see the nurse. She gave me the shot, took my blood pressure, weighed me, and also asked some more questions. I was home about 40 minutes after setting off, having stopped by the pharmacy to get the prescription filled, the cost for which was 3 or 4 pounds. No charge for the surgery visit or tetanus shot.

So far, I've never needed the NHS for anything major and hope matters stay that way. Not so Avedon. A few years earlier, she had major eye surgery which involved a stay in hospital, all at no charge to us.

GOP propaganda to the contrary, there are the 'horrors' of 'socialized' medicine in the UK for most of us.

#67 ::: Lila ::: (view all by) ::: March 04, 2012, 08:33 AM:

I can tell you one thing (having just spent the evening with 2 ER docs at a charity event): if/when everyone in this country has access to basic health care, your wait at the emergency room will get a LOT shorter! (This also applies to dental care; if you think that's a frivolous reason to visit the ER, well, there's always this story.)

Also I'd like to echo Thena's point on low reimbursement rates. Most of the docs in my area will not take new Medicare patients, and it's nearly impossible to find someone who will take an adult Medicaid patient. Moreover, for the past several years there's been a 20-something percent pay cut for Medicare services hovering over us; every time they put it off for a few more months, the percentage goes up. That's an ax waiting to fall, though it's currently on hold (again) till the end of 2012. This makes physicians even more reluctant to take on new Medicare patients.

#68 ::: Lila ::: (view all by) ::: March 04, 2012, 09:07 AM:

Link to story on Medicare physician pay cut that does not require signing up to view. Sorry about that!

#69 ::: David Harmon ::: (view all by) ::: March 04, 2012, 10:32 AM:

Thena #65: Except that that scarcity is itself the result of many years of government abuses -- notably the underfunding and backstabbing of Medicare.

#70 ::: Dave Bell ::: (view all by) ::: March 04, 2012, 12:05 PM:

Dental Care in the UK is in an in-between state of a high rate of private provision with the NHS limited. You can get emergency NHS care through a system with barely adequate capacity. Otherwise you have to be on the lists of a specific dentist, and you will be dropped if you don't have regular checks.

My father really ought to get new false teeth. At his age, he is reluctant to spend the money, and because he hasn't visited a dentist in a long time, he isn't on any list.

Which means the "emergency" system, and a local provider who has no nearby parking for any patients, not just the disabled.

(I am going to have to get a photo of the wheelchair access for the outpatient department of the local hospital.)

Anyone who wants to "save money" on healthcare is likely to end up killing people. And the admin costs never seem to fall, where a bit of efficiency would be possible. I've been "lost" by the hospital, moved from one ward to another, and the Police couldn't find me. They didn't like that, and I was left feeling they thought it was my fault.

Anyone remember that piece which suggested that the Mayo Clinic was spending less per patient than most places, partly because they didn't waste money on irrelevant tests?

#71 ::: Bruce Cohen (Speaker to Managers) ::: (view all by) ::: March 04, 2012, 12:35 PM:

Dave Bell @ 70:

Anyone who wants to "save money" on healthcare is likely to end up killing people.

And in the US the people who run the insurance companies are quite content with that. There are many instances of insurance companies stalling the approval of or the payment for procedures in the expectation that the patient will die before the lawyers run out of bullshit. The archetypal case (and there are far more of these sort than anybody has counted, I'm sure) is where an honest, and usually completely irrelevant, error on an application or medical history form is used as an excuse to cancel all coverage to someone who has just been diagnosed with a disorder requiring very expensive treatments that were covered by hir policy.

This isn't just bureaucratic misfeasance, it fits the definition of "depraved indifference to human life" quite well.

#72 ::: Lori Coulson ::: (view all by) ::: March 04, 2012, 01:17 PM:

Henning Makholm @51:

I'm getting the impression that you aren't aware that the term Social Security is an actual Federal Government program, with the agency known as the Social Security Administration to run it. SSA serves retirees, disabled individuals, and the widows and children of dead beneficiaries.

There ARE several socialized medicine programs in the USA: Medicare (everyone over 65 years of age), TRICARE (which active duty military members are covered under), and the Veterans Administration (which is run like Great Britain's NHS). There is also Medicaid and the State Childrens Health Insurance Program, which is part of the safety-net.

It's a patchwork quilt, and it has a lot of holes for people to fall through -- and I'm including the military and veterans in the category of folks who sometimes hit the holes.

#73 ::: P J Evans ::: (view all by) ::: March 04, 2012, 02:08 PM:

The other one is giving the insured person the go-ahead for treatment, and then refusing to cover it after treatment is underway, or after [frequently expensive] arrangements have been made for it.

#74 ::: Thena ::: (view all by) ::: March 04, 2012, 03:11 PM:

David Harmon @67 -- That's certainly part of it. The US health care system, such as it is, is a complex collection of interrelated problems that seems to me much like -- what's it called? That table game where you build a tower of blocks and when you run out of blocks you start pulling blocks out of the bottom of the tower to stack on the top, with the object of the game being to see how high you can build the tower without it collapsing under its own weight due to all the holes you've made in it...

To frame it in market-economics language, which isn't necessarily the preferred way to frame something like health care precisely because it's not a market commodity no matter how much Wall Street tries to make it one, we've got a situation with both restricted supply (care providers can't afford to do the work needed for the price offered due to low Medicare/Medicaid reimbursements; insufficient numbers of primary care providers being trained due to high overhead costs) and restricted demand (uninsured patients who can't afford care, insured patients whose insurance declines to pay for a particular procedure). Removing restrictions on demand is going to make the shortage of supply worse, unless that side of the situation also gets addressed. And that's not even touching the for-profit motivation of (nongovernmental) insurance companies and Big Pharma.

There is not a single easy fix to American health care, and unfortunately the American political system (also in need of serious overhaul, but that's another argument) does not deal well with things that cannot be fixed in three sound bites within the course of a single election cycle.

#75 ::: Debbie ::: (view all by) ::: March 04, 2012, 04:12 PM:

Dave Bell @ 70 -- was the article you were thinking about "The Cost Conundrum"?

#76 ::: Mary Aileen ::: (view all by) ::: March 04, 2012, 05:03 PM:

I have an entirely well-deserved tax deduction. You are a lazy welfare bum.

That calls out for a third element. "He is a tax cheat," maybe?

#77 ::: Dave Bell ::: (view all by) ::: March 04, 2012, 05:17 PM:

Debbie @75

That's the one.

#78 ::: Dave Bell ::: (view all by) ::: March 04, 2012, 05:19 PM:


I have an entirely well-deserved tax deduction.

You take professional advice to minimise your liability.

He is a lazy welfare bum.

#79 ::: KayTei ::: (view all by) ::: March 04, 2012, 05:29 PM:

Mary Aileen @ 76

"He is a victim of an oppressive socialist regime."

Though I admit, my first impulse was "He is entirely irrelevant to this discussion. Stop trying to use his actions to make yours look good."

#80 ::: David Harmon ::: (view all by) ::: March 04, 2012, 06:59 PM:

Thena #74: Which in turn feeds back to the sidebar (?) article about the modern "debt uber alles" mentality.... Some things need to be given, without reckoning the price.

#81 ::: chris ::: (view all by) ::: March 04, 2012, 09:43 PM:

I think that part of the problem is that you opened #1 by specifying that it's intended to aid people who are "down on their luck" -- i.e. they primarily benefit poor people, not everyone.

Well, if he's from Denmark, maybe that's not so surprising. Most civilized countries don't have quite as *persistent* a class system as we do. Being down on one's luck might be a temporary condition, there, rather than being a signifier of membership in an intergenerational system of recurring often-lifelong poverty and sometimes a coded way of talking about racial identity while pretending that's not what you're talking about.

Maybe that calls for another irregular conjugation:

I am down on my luck.
You lack marketable skills.
He is a worthless bum.

#82 ::: Thena ::: (view all by) ::: March 04, 2012, 10:18 PM:

David Harmon @80 -- On that point I think we are in violent agreement. :-)

Getting back to the OP, in the roundabout way to which we are accustomed, the unacknowledged US class structure ("We're all middle class here") both feeds and is fed by our cultural heritage of individualism and independence and the synergy between the two bears strange and miserable fruit.

My thoughts are not well organized at the moment, but where I am going with this is that it seems to me that the Us vs Them mentality is coming from the same psychological and sociological places as the unwillingness to acknowledge the stratification of our society: if we are all as equal as we imagine our so-called classless society to be, then Those People Over There must be Doin' It Wrong if they are not as successful as we are. Inequality of outcome appears fitting and proper in that context -- the difference between the conservative and liberal positions is that the former often resentfully declare that We Who Are Doin' It Right are being unfairly punished by systems that help them who are Doin' It Wrong, while the latter approach pan-societal hlepyness in their quest to Show Them How It's Properly Done. (I run into this in my church congregation entirely too often - earnest, kind, well-intentioned liberal people who want to fix other people's business. It's frustrating. I want so badly to scream, "Don't be hlepy! Listen first and then be useful, even if that means butting out!" But I digress.)

We (Americans) need to better acknowledge our invisible class structure or we aren't going to make any progress on any of the other stuff.

(I'm getting ranty, I'd better go to sleep before I do something stupid on the internet.)

#83 ::: Craig H ::: (view all by) ::: March 05, 2012, 02:18 PM:

Cynthia@53: No promises (really no promises, since I have nothing to do with hiring), but where does she live and can you get her to send me a resume?

I know people who can employ Cordon Bleu chefs, and I know people who can employ math Ph.D.s, and I know people who can employ polyglots. If she can program as well, the latter two categories are synergistic.


#84 ::: Craig H ::: (view all by) ::: March 05, 2012, 03:18 PM:

Thena@74: It's even worse than you think. At present, Medicare reimbursement rates for procedures are (effectively) set by a large panel of doctors. All of these doctors are specialists; not one is a Primary Care Physician. Medicare reimbursement rates are what insurance companies peg their reimbursement rates to.
Guess what has happened as a result? First, you get higher reimbursement for specialized procedures and lower reimbursement for primary care. Then you get hospitals and hospital-affiliated doctors pushing more testing because of higher reimbursement for those procedures. Then you get med students going towards specialties in droves because of higher debt loads and higher pay in those specialties. Then you get a deficit of PCPs, pushing more care from the (cheaper) PCPs onto the (expensive) specialists. And this has been going on for ~25 years.
This is, BTW, one of the things that ACTA tries to make an end-run around; the new panel is also one of the primary things the Republicans are fighting.

#85 ::: Jacque ::: (view all by) ::: March 05, 2012, 03:43 PM:

P J Evans @47: PTB seem to be trying to make us work until we drop dead.

I think that's generous. My impression is that the PTB think that they would prefer that we just FOAD, without all that troublesome stuff in between. (It doesn't seem to cross their minds that they need to somebody to grow their food and clean their teeth and suchlike.)

I have (had) a friend who seemed to delight in trying to pick arguments with me, based on some conception of me as a spherical liberal of uniform density. The last go-round we had, he allowed as how people were really responsible for their own healthcare. WRT nationalized health, he said, "You see people crossing the Canadian border to get healthcare. And it's all people coming here." It later occurred to me that I should have pointed out that those people could afford to do so. Back in the days when a week in the hospital cost $500, that was fine. But now—his thesis is all very well and good for people like him (living in a household with two professional incomes), but leaves me (who sometimes has health insurance, but haven't for much of my adult life) basically screwed. Hence the past tense of "friend." His wife was an ER doc. He should have damn well known better.

Henning Makholm: It's my vague understanding that the term "Social Security" refers to the security of the "society."

P J Evans @73: giving the insured person the go-ahead for treatment, and then refusing to cover it after treatment is underway

Another popular trick (I personally crossed paths with this one when I was doing temp work in '07.) is for the insurance company to blackmail a private company by telling the employer that their insurance premiums will go up NN% if they have to cover the employee who's been diagnosed with, say, stage IV cancer, thus resulting in the ill employee getting the sack.

#86 ::: Lee ::: (view all by) ::: March 05, 2012, 03:58 PM:

Jacque, #85: Your former friend was dead wrong. Everyone I know who lives in the US but is eligible for Canadian health care, and who lives close enough to the border to make it feasible, goes there instead. The difference is that there is an eligibility requirement in Canada. Here, the only eligibility requirement is lots of money.

#87 ::: Jacque ::: (view all by) ::: March 05, 2012, 06:25 PM:

Lee @86: Your former friend was dead wrong.

What!? Someone filtering the data to support their thesis!? Never happen! ;-)

#88 ::: Lenora Rose ::: (view all by) ::: March 05, 2012, 09:02 PM:

Lee & Jacque*:

Some Canadians do cross the border for treatment. For highly specialized treatments for which there is a large waiting list, or for treatments so unusual there are a handful of acknowledged experts worldwide, and they want THE best**, for things counted worth the expense (and sometimes even then there's private insurance).

Nobody does it for primary care, or (relatively) routine treatment. Or I'm sure someone does, because humans do nonsensical things, but it's not the smart way to bet.

* I always want to spell you Jacquie, the form I'm most used to. Apologies if the i ever does slip out.

** One of our admitted problems is specialists moving to the States because they can make more money. Or at least it has been. I don't have any concrete info as to whether the debates on what to do about this ever bore fruit.

#89 ::: Nancy C. Mittens ::: (view all by) ::: March 05, 2012, 09:10 PM:

I live in Buffalo, and have never noticed flocks of Canadians coming here for our superior (obviously, they must be, since they are American!) American doctors.

#90 ::: Steve C. ::: (view all by) ::: March 05, 2012, 09:14 PM:

Damn, I was just reading a piece yesterday on health care costs in the US, and how much higher they are than other nations, and the gist is that, big surprise, the prices are considerably higher. Can't find the link anymore, though.

One of the things that would help is transparency. If I were king of the forest, I'd make it a law that all pricing agreements between hospitals , doctor's groups, and other providers, and the respective insurance providers, would be made public. Without information, we're blind.

#91 ::: Linkmeister ::: (view all by) ::: March 05, 2012, 09:51 PM:

Steve C @ #90, I'll bet it's this post from Ezra Klein, showing prices for various medical procedures around the world. There's a link to the larger chart and the article from which it came embedded.

#92 ::: Lee ::: (view all by) ::: March 05, 2012, 10:15 PM:

Lenora Rose, #88: That was my point. Canadians who want to cross the border and get medical care here can do so freely, because the only prerequisite here is to have money. Americans, by and large, can't cross over for treatment in Canada because you have to be a Canadian citizen or be married to one to qualify -- and those who do qualify and can do so easily often do, even for primary care. But if you look at raw numbers, all you're going to see is Canadians coming over here. It's not "proof" of anything except that we don't have any citizenship-based qualifications.

#93 ::: Dave Luckett ::: (view all by) ::: March 05, 2012, 10:16 PM:

"He observed my shredded paper suit, my thrice turned overcoat and my toes sticking out of the end of my feet."

"Down on your luck?" he asked.

Dishonoured, The Goon Show.

#94 ::: Elliott Mason ::: (view all by) ::: March 05, 2012, 10:36 PM:

Steve C @90: It's worse than that. Pursuant to our gestation, we wished to find out the sticker shock for a couple of optional extras that our insurance wouldn't cover. I called the hospital.

"How much does it cost to get a laboring pool in the room, you know, an 'aquadural' pool?"
"That depends. Who's your insurance?"
"Doesn't matter, they won't cover it. How much will it cost us out of pocket?"
"I can't tell you how much it costs until I know which insurance we're billing it to ..."
"But you're not billing it to any insurance, they won't cover it!"
"I'm afraid we just don't have a retail price list, honey. We deal with insurance for things like this."

Insert me walking away from the phone fuming. For many hospital procedures, there is quite literally no way to know how much it will cost you until after it's been done to you -- not a very liquid market there, since you can't compare providers by price and quality to choose which one you will go with, beforehand ...

#95 ::: Steve C. ::: (view all by) ::: March 05, 2012, 10:55 PM:

Linkmeister @ 91 -

That's it exactly. Thanks!

Elliott Mason @ 94 -

I feel it. Definitely. If Wikileaks really wanted to lay down chaos on society, forget military secrets. Reveal pricing agreements.

If they don't want you to know it, it's because it would give them less of a hold. It's because it would give you an advantage. Fuck 'em.

#96 ::: Lee ::: (view all by) ::: March 06, 2012, 02:03 AM:

Elliott, #94: That sounds exactly like my last experience with new-car buying. Nobody would give me an actual PRICE unless I would commit to buying the car. Which is why I've bought only used cars, and not from dealers, since then.

Oh, and my last round of medical stuff that didn't come from my primary provider? The clinic could tell me how much THEY would charge me, and it wasn't unreasonable, but they couldn't tell me how much any of the OTHER departments involved (radiology, etc.) would charge me. That came as a nasty surprise a month or so later, and I won't be going to that clinic again for anything.

#97 ::: Cynthia W. ::: (view all by) ::: March 06, 2012, 08:23 AM:

@Craig H. 83 - She's in the NW corner of the US. Her programming skills are minimal, unfortunately, though she's considering working on that. She's not eager to move, but would consider it if a job was sufficiently good.

#98 ::: Craig H ::: (view all by) ::: March 06, 2012, 09:01 AM:

Dear Mods,

Could you please pass my email address along to Cynthia W.? Thanks.

#99 ::: Gerald Fnord ::: (view all by) ::: March 06, 2012, 10:05 AM:

The greatest subsidy of all? The use of State violence to back up unnatural 'property rights'.

#100 ::: abi ::: (view all by) ::: March 06, 2012, 02:10 PM:

Craig @98:


#101 ::: David Wald ::: (view all by) ::: March 06, 2012, 03:34 PM:

abi @100: Can I ask the same favor? What I'm thinking of may be a slightly longer shot than Craig's options, but we can figure that out in email.

#102 ::: abi ::: (view all by) ::: March 06, 2012, 03:50 PM:


#103 ::: Nancy C. Mittens ::: (view all by) ::: March 07, 2012, 06:16 PM:

[[Silently loves this community.]]

#104 ::: Andrew Wells ::: (view all by) ::: March 10, 2012, 10:44 AM:

I hestitate to join in, as I live 3,000 miles from North America; but I have much appreciated reading this discussion.

#105 ::: P J Evans ::: (view all by) ::: March 10, 2012, 11:48 AM:

The other day at work, our resident Uzbek came over with his tax returns, ready to mail, and the instructions he'd been given, and wanted to know about the one marked 'check payable to US Treasury'. I looked at the envelopes, and said 'this one' to the one marked IRS.

I guess it was the first time he'd had to pay them since he came.

#106 ::: Terry Karney ::: (view all by) ::: April 10, 2012, 04:47 PM:

Late, but regarding pricing: I had a kidney stone about seven years ago. It was billed to me at about 8,000 USD.

I was told that, had I possessed insurance, it would have been about half that. Insurers get "discounts". The only way for it to be a discount is to charge that rate to people who don't have insurance.

Which means, I suspect, the real costs are closer to what the insurers pay, and the uninsured are being soaked.

Which adds to the value of the, "unpaid medical bills" the poor are blamed for having; and reads as a loss on the hospitals' books.

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