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June 28, 2012

Health care decision roundup
Posted by Avram Grumer at 04:17 PM * 229 comments

For those who can’t wait for tonight’s Daily Show and Colbert Report, here’s the Internet on today’s big news story:

  • @Dr_Cop:
    DEWEY DEFEATS OBAMACARE
    (Context)
  • @MSignorile:
    Breaking: Conservatives planning to leave U.S., but can’t find wealthy Western democracy without universal health care. #hrc #scotus
  • @garyyounge:
    BREAKING NEWS: Fox News reports that Kenyan-born Supreme Court Justice John Roberts has converted to Islam
  • Rob Beschizza on BoingBoing:
    Supremes uphold Romneycare
  • The Onion:
    Republicans, Leukemia Team Up To Repeal Health Care Law (“While chronic leukemia was reportedly worried about how its association with the Republican Party would affect its public image…”)
    (Actually a few months old, but new to me.)
  • Pelosi & Boehner reaction shot (Update: Damn, it’s actually from yesterday.)

And just in case anyone wants some more serious coverage:

Comments on Health care decision roundup:
#1 ::: TexAnne ::: (view all by) ::: June 28, 2012, 04:45 PM:

What a relief. I went to bed last night convinced that they'd rule based on party affiliation, like they always do, and that therefore I'd be dead of asthma complications before I hit 50.

#2 ::: davidmanheim ::: (view all by) ::: June 28, 2012, 05:00 PM:

My take on the issue: Republicans spent the past several months pointing out that the economy was doing badly partially because of the uncertainty surrounding the legality of “Obamacare”. (For example, Representative Scott Tipton said the president’s health-care plan is creating “uncertainty.”)

The Supreme Court has now decided that the Regulation was mostly constitutional, which should have reduced the uncertainty. Of course, we now have further uncertainty about the regulation - Mitt Romney says he plans to repeal it, which means that this uncertainty will continue until the economy knows the outcome of the election in November. And that helps the Republicans; more uncertainty hurts the economy,and they get to blame Obama. So I guess that’s a smart move for them.

#3 ::: Rob Thornton ::: (view all by) ::: June 28, 2012, 05:17 PM:

Right now, I work for a federal contractor who is building the software infrastructure for part of the ACA. Most of us were expecting the worst so the good news was a complete and total stunner.

Result: Lots of excited office chatter and not much work was done today. :)

#4 ::: LMM ::: (view all by) ::: June 28, 2012, 05:27 PM:

@1: Same here -- I was pretty much convinced that it would fail. But I've found it's easier to be pleased than to be disappointed.

I'm stunned at the Roberts / Kennedy reversal, but there's circumstantial evidence that the Roberts decision was highly political and may have been reversed through pressure. (Wish I had the page which mentioned it.)

Mind you, it's really too early to closely analyze much of any of this.

#5 ::: Serge Broom ::: (view all by) ::: June 28, 2012, 05:30 PM:

TexAnne... therefore I'd be dead of asthma complications before I hit 50

They'd have been a lot of 'splaining to do.

#6 ::: Serge Broom ::: (view all by) ::: June 28, 2012, 05:32 PM:

My closest buddette at work is a Republican and she's happy that ObamaCare has been ruled constitutional.

#7 ::: Avram ::: (view all by) ::: June 28, 2012, 05:44 PM:

This decision wasn't actually the best possible outcome (though it might've been the best plausible outcome).

One distant possibility (that none of the justices seem to have favored) was that the Court would strike down the mandate while leaving the rest of the law intact. That would have likely led to either (1) the insurance companies desperately renegotiating with the government, this time with the insurance industry in the weak position; or (2) the destruction of the for-profit health insurance industry, leading to the establishment of some kind of single-payer system by necessity.

#8 ::: JM ::: (view all by) ::: June 28, 2012, 05:45 PM:

Hooray! Such great news, undimmed by the uncomfortable discussion with my conservative father this morning. How a man with an easily genius-level IQ can believe in death panels...

#9 ::: Serge Broom ::: (view all by) ::: June 28, 2012, 05:46 PM:

I was... ah... amused that Comcast's site referred to this as a 'victory' for Obama.
Yes, they actually used quotation marks.

#10 ::: Sisuile ::: (view all by) ::: June 28, 2012, 05:58 PM:

Thanks be to God
For my health,
For my healthcare,
And for knowing that I will not ruin one for the lack of the other.

This morning, my physical therapist suggested I get MRIs done. I told him we had to wait to schedule until I'd checked the news. If the decision had come down the another way, I couldn't have afforded the "pre-existing condition" that we might find.

#11 ::: Edmund Schweppe ::: (view all by) ::: June 28, 2012, 05:59 PM:

LMM @2:

there's circumstantial evidence that the Roberts decision was highly political and may have been reversed through pressure. (Wish I had the page which mentioned it.)

Was it http://www.volokh.com/2012/06/28/was-scalias-dissent-originally-a-majority-opinion/, perhaps? (That's where I first saw something along those lines.)

TexAnne @1: What Serge said.

#12 ::: Steve Downey ::: (view all by) ::: June 28, 2012, 06:01 PM:

LMM @ 2
Scalia's dissent has internal evidence that suggests that it was drafted as the opinion. Primarily where it refers to Ginsburg's concurring opinion as a dissent.

Brad DeLong has been collecting some of these:
DID NINO SCALIA FIRMLY THINK HE HAD HIS "CONSTITUTIONAL MOMENT", AND HIS MAJORITY?


MORE EVIDENCE THAT SCALIA'S DISSENT WAS ORIGINALLY WRITTEN TO BE THE OPINION OF THE COURT...


LAWRENCE SOLUM: EVIDENCE THAT THE VOTES SHIFTED AFTER CONFERENCE (INITIAL VOTE TO DECLARE MANDATE UNCONSTITUTIONAL)

#13 ::: Henning Makholm ::: (view all by) ::: June 28, 2012, 06:02 PM:

Can someone explain in small words to the oversigned confused European what the causes for the frenzied opposition to this law are? Not the legal/formal/philosophical basis, but the actual reason people would care enough to construct and maintain that basis.

I realize that this community mostly comprises supporters, but just therefore there might be a chance that perhaps a coherent explanation can be told without being drowned out by knee-jerky sloganism.

My own hypotheses, each with problems of its own:

1) The opponents are against the ACA because it's a poor substitute for actual universal health care. (This would make sense, but even with my limited exposure to U.S. news I can tell that's definitely not the wind that's blowing).

2) The opponents are evil, in the cartoonish sense of desiring other people to suffer for its own sake. (I don't believe such people exist in a statistically significant number. There are schoolyard bullies and serial killers and various things in between, but what they want is to be the direct, personal cause of suffering, not just to be one among millions who vote suffering into being).

3) The opponents are stupid: They think that everything that benefits the weak must necessarily harm the strong in equal measure, and they believe themselves to be among the strong. (Many people of all persuasions are individually stupid -- but the ringleaders of the opposition appear in general to be anything but).

4) The opponents are afraid that if too many poor get access to health care, there won't be enough of it to go around, so they themselves will end up lacking it. (Makes a certain amount of sense, except that people seem to be earnestly fighting tooth and claw for a right not to have any health cover. If you're determined never to use the system, why worry whether there's enough of it to go around?).

5) The opponents are against everything the government does on general principles (Very well, but that doesn't explain how this law in particular gets people to threaten to emigrate).

6) Poverty is caused by bad actions/choices, and if we design the inherent penalties for being poor out of the system, nobody would want to make the right choices in the first place. (Um, right. See (2), above).

I must have missed something. What's the straight story?

7?) Most of the opponents are just stupid. Their leaders, however, are ruthless demagogues who don't personally care either way but use the law as a banner to rally stupid voters/donors around because being the leader of sufficiently many stupids is a well-paying job. (It's not that bad, is it? Please tell me there's something else that makes sense).

#14 ::: Nicole J. LeBoeuf-Little ::: (view all by) ::: June 28, 2012, 06:07 PM:

JM @ 6:

Hooray! Such great news, undimmed by the uncomfortable discussion with my conservative father this morning. How a man with an easily genius-level IQ can believe in death panels...

Yeah, I got an email from my Dad which he'd sent to all his buddies too. I was spared, I think, by Thunderbird's "View plain text only" from seeing what was actually in the email. (I shot back a whole bunch of text and links from the Slactivist reaction.)

He's a pediatrician. He does good work in the New Orleans area. But he sees everything through the lens of how the insurance companies and the government together are screwing him over, failing to reimburse him for his health-preserving work for the very poor. I'm sure he's worried that this will just screw him over more.

It's a real concern -- there's a lot that's effed up about Medicaid and Medicare from the health provider's perspective. But, call me disloyal, but I'm more concerned that under the ACA, my friend can't be turned down for necessary treatment for her "pre-existing condition" of bipolar. Just for example.

I recall an argument with him, when he was watching the Money channel or whatever, and I was all, "Damn straight health care is a right, not a privilege," and he's all maddeningly patiently about "but how far does that go? If there were a cure for cancer tomorrow but it cost a million dollars, is that everyone's right?" And I'm all, "'If' can take a long walk off a short pier. We have people dying from effin' *tooth decay* today. Whose lives do you consider expendable for the sake of the economy? Your patients'? Mine? Your nephew's? Your partner's kids? Who? Write me an effin' list and don't forget to CC the named individuals."

I may have to send him the Onion's brilliant article. That should hit slightly closer to home -- his daughter is a leukemia survivor. Or maybe it won't; his daughter is also a woman, and he seems unmoved by the idea that if I were to have to switch providers mid pregnancy, I'd have risked being denied for a "pre-existing condition" in a pre-ACA USA. Just for example.

Have I mentioned my Mom seems to believe in the Fox News spectre of "death panels?" *facepalm* "We've already got 'death panels,' Ma! They're called 'Insurance companies that decide whether you can receive life-saving treatment!'" Arrrgh.

#15 ::: Nicole J. LeBoeuf-Little's been gnomed! ::: (view all by) ::: June 28, 2012, 06:08 PM:

I been gnomed! halp!

Prolly used a word-o-power. THey're strewn across this topic like little verbal whoopie-cushions.

#16 ::: Nicole J. LeBoeuf-Little ::: (view all by) ::: June 28, 2012, 06:13 PM:

Henning Makholm @ #11 ::: It appears from where I'm sitting to mostly be a combination of your 4, 5, and 6.

Republican spokesmen have been telling us, in precisely these words, that we need to accept that some of the poor will die of sickness, and that this is necessary to prevent bankrupting the country; and the rest of their rhetoric about the poor does seem to be colored by the "just world fallacy," that the poor clearly got to be poor because they were bad, lazy, good-for-nothing people. Poverty as punishment AND proof of guilt, if you will.

There's a good round-up of links to people making such statements here (Slacktivist again).

#17 ::: Nicole J. LeBoeuf-Little's been gnomed again! ::: (view all by) ::: June 28, 2012, 06:14 PM:

Both posts had links to da Slackmeister, but both posts were also about the ACA. So.

#18 ::: Lee ::: (view all by) ::: June 28, 2012, 06:35 PM:

Henning, #11: From where I sit, it appears to be a combination of your factors 3 and 4, with a dusting of 6 and a large cherry of old-fashioned racism on top. That's for the lower-level opposition. At the upper levels, it's more a case of "You're pushing us out from under the @$&%*# MONEY TREE!" on the part of the Medical Profits Complex and their boughten Congressmen.

#19 ::: Eduardo Ramirez ::: (view all by) ::: June 28, 2012, 06:38 PM:

@11

I'd say it's 8) The opponents are against anything that Obama or Democrats are for, and for anything they are against. Romney, for example, passed nearly the same law when he was governor of Massachusetts. But since this law was pushed by a democratic president, it is clearly the work of Karl Marx. Or possibly Satan.

#20 ::: Andrew T ::: (view all by) ::: June 28, 2012, 06:38 PM:

Henning Malcolm @11:

The most sensible explanation for Republican leadership's opposition to the Affordable Care Act is that it is a lever with which to move public opinion, which will help in the November 2012 elections.

Brad DeLong is good on this:

"What next for health care reform?" (written on June 27, with a "choose-your-own-adventure" flavour)

Why Republicans used to support and now oppose the individual health care mandate

Key quote from DeLong: "Certainly in private Republicans willing to talk about policy will admit that, yes, if Romney had won the 2008 election, nearly all the Republian politicians now condemning nationwide RomneyCare would be its biggest boosters."

So, a mix of your theories (5) and (7).

The fact that a large portion of the right-leaning electorate was shifted from "The individual mandate is a classic Conservative mechanism for personal responsibility" to "OMG SOCIALISMS START STOCKPILING AMMO" in less than 3 years is pretty depressing.

#21 ::: CLP ::: (view all by) ::: June 28, 2012, 06:49 PM:

Eduardo Ramirez @15: I agree that much of the opposition to the ACA, and to many of the president's other policies, is not based on principle but rather a desire to stymie the president at any cost.

That said, I do think there are conservatives who sincerely believe that the federal government does not have the constitutional authority to impose the individual mandate. I also think some conservatives sincerely believe that such policies properly belong in the state realm and not in the federal realm.

On this basis, it is possible to agree with the Massachusetts law and disagree with an analogous federal one, without being a hyprocrite. (However, I think Romney's positions are less about principle and more about political expediency.)

#22 ::: LMM ::: (view all by) ::: June 28, 2012, 06:53 PM:

@9: Yes. Was it actually linked to on the SCOTUS Live feed? Either way, IIRC, it seemed to have been hit by pretty heavy traffic when I looked at it earlier.

#23 ::: Henning Makholm ::: (view all by) ::: June 28, 2012, 06:56 PM:

Lee, #14: Forgive my ignorance, but how does that money tree actually work? Shouldn't the "Medical Profits Complex" you speak about be overjoyed with a law that requires everybody to become their customers?

Eduardo, #15: Very well, but still why? One doesn't go around opposing everything someone does just for the lulz. There must be some underlying reason.

#24 ::: GlendaP ::: (view all by) ::: June 28, 2012, 07:02 PM:

Henning@11

For the general public, your #3,4,6, along with:
8)No fair! I made sacrifices and worked hard for my health care. Now you're lettting people have it for nothing.
9)Obama is a Kenyan Muslim terrorist (aka scary black man), so anything he supports is EEEEVIL.

For the leadership:
10)Partisan politics
11)$$$$

#25 ::: MoltenBoron ::: (view all by) ::: June 28, 2012, 07:08 PM:

Henning Makholm, @11:

Making the most charitable case that I can to explain violent opposition to health care reform, my sense is that there's a lot of explanatory power in certain polling figures that show that, while most Americans feel that there's something wrong with America's health care system, most Americans are, themselves, quite pleased with the health care that they receive.

Thus, a lot of Americans are fearful that post-reform they will no longer receive the quality of healthcare that they currently receive. Fear that things will get worse overrides their hopefulness that things will get better. Mix this with general American anti-government sentiment and right-wing demagoguery ("this is the thin end of the wedge of socialism," etc.), and you get the sort of violent reaction that you're seeing today.

#26 ::: Michael I ::: (view all by) ::: June 28, 2012, 07:10 PM:

LMM@2, Steve Downey@10

For what it's worth, Josh Marshall speculated back on June 26 over at TPM that Scalia's tantrum after the immigration ruling might have been anger at a health care decision that didn't go his way.

#27 ::: Thomas B. ::: (view all by) ::: June 28, 2012, 07:29 PM:

Henning Makholm@18: The law also states that insurance companies must spend at least 85% of what they take in from premiums on healthcare, limiting overhead to 15%.

My impression is that Eduardo Ramirez@15 and CLP@16 are correct. Additionally, there is a generally-held belief among those who identify themselves as conservatives, that the ACA constitutes government interference in "the free market" and/or in people's lives - and it is a fundamental precept among those people that this is the root of most evil in the US. This is similar to a fundamentalist religious belief, in the sense that it is impossible to influence with evidence.

#28 ::: steve downey ::: (view all by) ::: June 28, 2012, 07:42 PM:

Healthy people largely think that their health care and insurance are good.

#29 ::: C. Wingate ::: (view all by) ::: June 28, 2012, 07:44 PM:

I'm not the only one who saw echoes of Marbury v. Madison in the decision.

#30 ::: Eduardo Ramirez ::: (view all by) ::: June 28, 2012, 07:47 PM:

Henning@18

I think it's because that is their plan for how you win elections. You paint the other other guy as wrong headed and and bad for the country and say that if you vote for me I'll save you from them. And you always stay on message.

I don't think they are wrong, either. I hear so many voices crying out about death panels, about Obama being a socialist (while all the real socialists I know complain about how Obamacare embraces for-profit hospitals and insurers), and how Obama hates America and is pro-terrorist even as he send ever more drones into Pakistan and Yemen at potentially greater cost to civilians and I think to myself that lying works. Repeat your lies and fabrications loud enough and long enough and you will convince enough people that you are right and should be the one in charge.

I should point out that I agree 100% with CLP @16. There are plenty of conservatives who oppose Obamacare because they genuinely believe free-markets and private enterprise would do a better job with out any government interference. Or that government telling people that they should buy insurance or be fined is an assault on their personal freedom. Or that it should be the prerogative of states to handle mandates and health care reform, not the federal government. But I think the Romney, the House leadership, and even the majority of Tea Party leaders (at least the ones that show up on Fox News) say that Obamacare is bad and wrong because they think that's the best way to get to 51% of the vote.

Someone once said, when asked about Arlen Spector true beliefs on an issue, that '[He's] in favor of winning the next election, and against some other person winning the election. And nothing else' (that's a paraphrase, btw. I couldn't find the exact text). I think the same can be said for many politicians opposed to the Obama bill.

#31 ::: Avram ::: (view all by) ::: June 28, 2012, 08:08 PM:

Steve Downey @10, hmm. CNN called the vote against the mandate based on the opening lines of Roberts' decision. Is it possible that Roberts changed his mind and rewrote the decision while he was reading it?!

(˙ʇou ʎןqɐqoɹd :ɹǝʍsuɐ)

#32 ::: Lee ::: (view all by) ::: June 28, 2012, 08:13 PM:

Henning, #18: Shouldn't the "Medical Profits Complex" you speak about be overjoyed with a law that requires everybody to become their customers?

No, because that "everybody" means EVERYBODY, which means that they can no longer cherry-pick for customers who are unlikely to require benefits. Two of the provisions are "no denying someone on the basis of pre-existing conditions" and "no dropping someone just because they had a large claim". Remember, from their POV, customers are a liability, not an asset -- their primary fiduciary responsibility is to deliver large dividends to their stockholders. Paying out claims cuts into their ability to do that.

Also, what Thomas says @22.

#33 ::: SamChevre ::: (view all by) ::: June 28, 2012, 08:41 PM:

Henning Malcolm @ 11

As a very-definitely-not-supporter of the ACA (although also a very-much-not-supporter-of-what-we-have-now), I'll try to answer usefully. I'll also link this discussion on SameFacts, where I lay out some of the reasons I see for opposition in more detail.

There are three potential sets of reasons that I see for opposition to the law.

One objection is current-position-based: a significant number of people see the law as making them relatively (and absolutely) worse-off. This includes people who currently have good insurance and expect to keep it (Medicare beneficiaries, some people with employer-provided healthcare), people who currently have cheaper insurance than the law allows (many of the self-employed who have high-deductible, heavily-underwritten plans), and people who earn more in the current system than in an alternative system (some care providers, insurers, etc.)

The second objection is healthcare-system-based: a significant number of people think it will make the healthcare system work more poorly, or at least not fix any of the actual problems. This includes people who are afraid that it will reduce the widespread availability of new treatments for diseases that are currently poorly treated (like the auto-immune disorders); people who don't think the cost-control mechanisms are likely to work well; people who think it will lead to more byzantine bureaucracy around getting paid for services provided; and so forth.

The third objection is around the structure and reach of the government. One side (basically, conservatives) sees the US system as one where some powers were delegated by consensus to the national government, and everything else belongs to the States, and it takes consensus to change that allocation of powers. This group has been losing for the past couple generations, and so is tended to be very easily infuriated when the national government takes over yet another area of State discretion.

For the record, I share objections 2 and 3.

#34 ::: Matthew Brown ::: (view all by) ::: June 28, 2012, 09:07 PM:

Personally I think the American healthcare system is one of the most broken in the world, and manages to collect all the disadvantages of a socialized system and all the disadvantages of a completely private system, with less of the advantages than one might hope and for a horrendous price for the level of service and care it provides.

The ACA is a patch on the existing system, and does not fix most of the fundamental issues with it. I would take a socialized scheme in a heartbeat over this. There are some aspects in which even the extreme LIbertarian solution would be better (at least, it would encourage greater cost-cutting to provide more affordable solutions).

However, I'll take the ACA over the unpatched system without much hesitation at all.

#35 ::: Diatryma ::: (view all by) ::: June 28, 2012, 10:24 PM:

Most of the people my boyfriend knows are furious; they don't want to have to buy health insurance. These are people in their twenties who have never had a job that provided insurance and don't want to have to pay for it.

Which is fair. That's what I did when I graduated. I looked at COBRA things and discovered it would be approximately rent to be insured, so I got on the Don't Get Hit by a Bus plan, and that's working out okay.

But mandated insurance, according to a calculator that may have been at the Washington Post, would be about five hundred dollars a year. I have spent almost that much this year on yeast infections.

No one likes the mandate. It's a way to get in the door for health care, though.

#36 ::: torrilin ::: (view all by) ::: June 28, 2012, 10:30 PM:

Healthy people largely think that their health care and insurance are good.

Lots of unhealthy people do too, even in the face of evidence that their health care provider is not providing care that meets with NIH baseline for their condition. See also, Megan McArdle's asthma, which she has insisted is properly treated. (I'm sure she's not the only public figure convinced her doctor is perfect... but I know asthma standards pretty well and I don't know other stuff at all mostly)

NIH baseline for asthma treatment is *less* strict than Britain's NHS standard of care. And the NHS manages to get most asthma patients to around standard, and they do it for a pittance compared to what we spend. It's pretty straightforward to terrify a British citizen with what US insurance gets billed for an asthma attack... and with how much extra care is deemed "necessary".

As far as I'm aware, for pretty much every chronic condition where there is good treatment, the US and Britain have the same kind of disparity of care. And a fairly large number of patients in the US will insist their health care is better anyway.

Folks who meet the diagnostic criteria for severe cases of their chronic disease generally have a different point of view. But even there, they're frequently aware of particularly tricky bits in their own disease, and they assume that of course the NHS would make it harder to get the care they need since it's expensive. For my sister (who is a serious, no questions severe asthmatic even as an adult, and has been hospitalized for asthma as an adult) the assumption is always that whoever is providing medical care is trying to make sure she can't get her medications, and trying to avoid doing basic testing to make sure she is responding correctly. For her whole adult life that's been the case. At this point, she's out of the habit of believing that doctors want to help.

#38 ::: P J Evans ::: (view all by) ::: June 28, 2012, 11:02 PM:

37
Depends on whether they want to lose again, since they don't seem to remember what happened the first time.

#39 ::: Emma in Sydney ::: (view all by) ::: June 28, 2012, 11:40 PM:

torrilin, that's awful about your sister. Those of us in countries with single payer healthcare (with optional add-on private insurance here in Australia) find these stories, as you say, terrifying. My son had three stays in hospital in his third year, till his asthma was stabilised, and under control, where it has remained. But every year or so, there's a flareup, requiring assessment, Prednisone and tweaking of his asthma plan. All of this, every last bit, cost me nothing other than the taxes I've paid. His medication costs us $30 every couple of months. We do not have private insurance, because I worked for one of those bloodsuckers (briefly, as a tech writer) and decided never to buy their product if I could avoid it. Luckily, I have that option.
I hope this victory is the first step to an equitable and single payer system in your country too.

#40 ::: TexAnne ::: (view all by) ::: June 28, 2012, 11:56 PM:

SamChevre, 33: Regarding your reason 3, I invite you to reread the very first post in this thread. I believe that my objections to dying from something treatable are more important than your feelings about states' rights.

#42 ::: Nicole J. LeBoeuf-Little ::: (view all by) ::: June 28, 2012, 11:58 PM:

...only minus the "been gnomed again" thingie in my name. Drat.

#43 ::: Lizzy L ::: (view all by) ::: June 29, 2012, 12:25 AM:

Diatryma at 35, this is interesting to me. Back in the day, when I moved to San Francisco, age 25, from Chicago, the first thing I did after finding a place to live was sign up for Kaiser Medical Insurance. I did this because I was training seriously in a martial art, and it was obvious that in any given class I could break a leg, or a tooth, or bang my head hard enough to suffer a concussion -- in fact, those are only three of the injuries I've taken to Kaiser ER over 40 years training. It cost just about nothing back then, though of course, it was significant, as my income was pretty low -- $35 a month, I think. I have no idea what it costs to insure an otherwise healthy 25 year old through Kaiser now: $200 monthly? More?

I guess the people your boyfriend knows don't do anything (MMA, soccer, racquetball, roller skating, paintball?) in which they might hurt themselves...?

#44 ::: Stefan Jones ::: (view all by) ::: June 29, 2012, 12:42 AM:

I had Kaiser via a former employer. I thought they were wonderful. When I had chest and arm pains, I got a encephalocardio whatever within a few hours, and a stress test the next week.*

Vaccinations were free, and could be had without appointment.

Occasionally Kaiser (who are building a big hospital just down the street) sends me "come back!" mail. Last I paid attention, the plans for a 50 year old male started at around $550 / month.

* My heart was fine; as near as they could figure, my left side was chronically stretched and strained with the help of my sturdy shepherd dog.

#45 ::: Another anon ::: (view all by) ::: June 29, 2012, 12:52 AM:

Posting more or less anonymously; I hope this is acceptable.

I have Crohn's disease, and on Saturday my doctor recommended that I should consider intravenous Remicade several times per year, which is very expensive. Luckily, I am 22 years old, and therefore it is covered by my parents' insurance for now (I don't know the specific terms).

I don't know whether this has changed my opinion on the ACA or not. I don't supposed it should. I was not convinced by the arguments in favor of the constitutionality of the mandate, but I have no particular legal knowledge. On the other hand, the ACA implements several other necessary reforms (due to my "pre-existing condition," I don't suppose I might even be able to get insurance, once I need to do so, without it). So should I "support" it or not? If I say "no, the ACA as it stands is not sufficient to reform American healthcare," am I lending support to those who oppose it for selfish or racist reasons? Is SamChevre@33 right to believe that the new system would not work as intended, for financial or bureaucratic reasons? (I don't know, and I don't know where to find a non-partisan analysis of the whole situation, or even if anyone can know at this point.)

For me, I think the answer to this question is "it doesn't really matter, because I can't do anything about it either way." I'm not going to vote for Romney because of his position on gay rights or environmental issues, and I'm not going to throw away my vote on a third party, so what choice do I have? Maybe this comment would be more appropriate for the Social Security thread, or at least the subthread regarding feelings-of-disenfranchisement-among-younger-people, but I've never even thought about retirement or SS, whereas health insurance is a more immediate issue. I feel like it's impossible for the average person (well, me, anyway) to even completely understand some issues, certainly not without doing quite a lot of reading - and the quality of information provided by the mainstream media is generally rather low, and often biased.

#46 ::: Bruce Cohen (Speaker to Managers) ::: (view all by) ::: June 29, 2012, 01:26 AM:

I'm on Medicare, and there's no question in my mind but that the ACA will improve my coverage, because it will fill in the "donut hole" in the prescription plan that W invented to screw us out of several thousand dollars a year in prescription costs. I wish it would do that all at once, but I'm willing to live until 2020 to see it filled in completely, a bit at a time, starting this year.

#47 ::: Lee ::: (view all by) ::: June 29, 2012, 01:35 AM:

TexAnne, #40: Quite. As a friend of ours said elseNet, if civil rights had been left up to the states we'd still have slavery in Alabama.

#48 ::: janetl ::: (view all by) ::: June 29, 2012, 01:41 AM:

I'm just so relieved. I thought I was on tenterhooks over the bill passing, but if it had been pulled away...Oh, my.

Of course it's not perfect. Nothing is. We'll be tweaking it, just as we tweak every program.

#49 ::: Josh Berkus ::: (view all by) ::: June 29, 2012, 02:20 AM:

Henning #13:

All of those to some degree, but you missed the big one:

$2.26 Trillion

Yes, really. The US spends more money on health care than any other country in the world. We're #1 in private spending, and #4 in government spending (ahead of most countries who provide full cradle-to-grave socialized medicine). We have the most inefficient, and therefore the most privately profitable, health care system in history.

And while there are a billion things a man wouldn't do for five dollars, there aren't five things a man wouldn't do for a billion dollars.

Insurance corporations, hospital corporations, device manufacturers, ambulance companies, medical schools ... they are raking it in free jackpot night at the casino in heaven. Any change to the system *has* to be bad for them, and they can afford to spend $millions to convince poor, undereducated Americans that health care regulation is somehow bad. And since the US media is for rent to the highest bidder, and our politicians are for sale (thanks to Citizens United), the billionaire health care corporations can do a *lot* of convincing.

#50 ::: Evan ::: (view all by) ::: June 29, 2012, 02:40 AM:

Henning @11: I wrote this comment (in a somewhat different form) in another thread elsewhere, but I think it bears a do-over here.

Here is the grand unified field theory of politics: In any significantly divisive political controversy, there is one potential outcome which will tend to increase or maintain a real or perceived difference in power and/or privilege between two interest groups (management/labor, male/female, white/minority, straight/gay, cis/trans, jock/nerd, whatever), and another outcome which will tend to reduce or mitigate that difference. The first of these is the position held by "conservatives"; the second is the one held by "liberals". There are no exceptions to this rule that I have ever found. Near as I can tell, this division has existed since republican forms of government have been around, with different words substituting for "conservatives" and "liberals". (Thomas Jefferson called them "aristocrats" and "democrats".)

The reason for this is that conservatives really just plain like hierarchy, and liberals don't. Conservatives, down deep, don't see inequality as an unfortunate fact of life but as an inherently reassuring thing; it tells you where you stand in the world. If some people are winners and some people are losers, and the winners get to enjoy extra privileges and the losers get punished, then the world makes sense in a very basic way. Conservative intuition says that it's not possible for anyone to win unless someone else loses.

(Importantly, most conservatives don't insist on being at the top of the hierarchy themselves. But they do insist on not being at the bottom, and they strongly prefer it if the person at the top is someone they can tribally identify with.)

Liberals, by contrast, tend to dislike hierarchical power structures and prefer egalitarianism. Liberal intuition says that nobody really wins unless everybody wins.

So. To the conservative psyche, the existing health care system in America prior to the ACA was a good thing, because it was an easy way to see who's a winner and who's a loser. If we change all that, if we just give good health care to the losers... then it's no longer so obvious that they are losers. This is Very Distressing! I mean, if all the Sneetches have stars on their bellies, how do you know who the best Sneetches are?

This is why they call health care "socialism" -- it equalizes privilege, and equalizing privilege is bad. They fought tooth-and-nail against Medicare for the same reason, forty-odd years back, but now they don't... and the reason why is that generations of people have grown up with the expectation that they'll have health care when they're old. Nobody thinks of that as a privilege reserved exclusively for winners anymore, and so the defenders of privilege aren't interested.

I predict that conservatives will eventually lose interest in the ACA too -- I give it ten or twelve years. When everybody's gotten used to the idea that responsible adults can just go out and buy health insurance for themselves, conservatives will move on to defending some other set of privileges against the socialistic encroachment of egalitarianism.

#51 ::: John Mark Ockerbloom ::: (view all by) ::: June 29, 2012, 06:17 AM:

Nice to see ACA held up in court. However, the circumstances of the ruling and other recent developments make me wonder how vulnerable it now is to repeal or gutting. Specifically:

-- The mandate is permitted if (as in the current bill) it's implemented in the form of a tax, but not in any other form. Does this mean that a simple majority in Congress is now enough to get rid of it? (I'm recalling the "reconciliation" discussion when the bill was going through Congress, when people were saying that tax and budget bills only required a majority, and were not subject to filibuster.)

-- Obama has recently directed that government agencies stop enforcing certain aspects of current immigration law, to prevent some people who largely grew up in the US from being deported. Even if you think that's a nice thing to do, doesn't that provide a clear precedent for a Republican president to gut healthcare reform by stopping enforcing the parts of it they don't like? (I'm assuming that's what Romney's referring to when he says he'll "repeal Obamacare" on his first day in office.)

#52 ::: Niall McAuley ::: (view all by) ::: June 29, 2012, 06:34 AM:

As Avram noted above, if the Republicans remove the mandate but leave the rest of the bill, the insurance industry will go broke. So removing the "tax" through reconciliation will not be popular with the folks who own the Republican Party unless they can get full repeal of the Act, which they need Democratic help to do.

#53 ::: LMM ::: (view all by) ::: June 29, 2012, 07:40 AM:

@50: Nobody thinks of that [Medicare] as a privilege reserved exclusively for winners anymore, and so the defenders of privilege aren't interested.

This should probably go in the other thread, but ... they may not think of it as a privilege for *winners* per se, but they don't think of it as a gift, either. It's something they've bought and paid for. That's why government health care for younger individuals is opposed, in part -- those people don't deserve it.

One of the problems with this mindset is that government benefits -- acceptable government benefits -- turn into things that one has paid for in the past rather than some sort of benefit that might induce some sort of future obligation. (Like, say, a higher tax rate once one has become successful. [1]) The only time that anyone talks about "paying our country back" is military service -- and even then that's a token gesture.

[1] Which may be crucial to the framing, come to think of it: as it stands, SS / Medicare is the only benefit that's framed in terms of a future reward for current taxes.

#54 ::: SamChevre ::: (view all by) ::: June 29, 2012, 08:35 AM:

another anon @ 45

For a fairly careful and not too partisan look at health care questions, I recommend The Incidental Economist; the series on What makes the US healthcare system so expensive? is particularly helpful.

#55 ::: C. Wingate ::: (view all by) ::: June 29, 2012, 09:36 AM:

re 50: Evan, it is in its way an attractive theory, but unfortunately it puts you in the class of people who like hierarchy. At least that's the way I see it.

The problem is neatly encapsulated by your misinterpretation of what they mean by socialism. They mean something precisely hierarchical: the sociocrats, through their governmental minions, telling everyone what to do all the time. And I don't think they are utterly incorrect in thinking that. Their identification of things as being socialist is (at the moment at least) typically wildly exaggerated, but I don't think that's an inaccurate characterization of it as a political type.

If you look at the stereotypical American conservative foot soldier, he is supposed to belong to a Protestant, conservative, evangelical church. These are about as anti-hierarchical as it is possible to get in Christianity. Conversely, the chief mainline, liberal Protestant groups are by and large full of hierarchical structure. The big fights in the latter are inevitably about whether the conservatives or the liberals control the hierarchy, which is why the conservative Anglican sects tend to have extremely weak political structures: they don't trust power, because power for them has been about forcing heterodoxy on the church.

It seems to me that there are two different impulses that give people an urge towards hierarchy. One is a belief in orderliness, and the other is a need for power structures. These often don't coincide, giving hierarchies that are disorderly and ineffectual (see under "Catholic Church"). There is a lot of strictly strategic use of power structures without regard to the conservative or liberal end to be achieved.

Also, Evan, I think you're giving yourself too much slack in ignoring the arguments they make. The conservatives I know don't think you describe; their general reaction is the perception of liberal, interventionist government as paternalistic, meddlesome, self-aggrandizing, and immune to being made competent. And sometimes, maybe a lot of the time, they have cause. I discovered the other day that within the next few days my wife will be breaking the law each morning when she pulls one of the cars out and parks it on the grass by the street; but if we obeyed the law, nobody would be able to get past us and the neighbor's car on the other side. And I'm never sure whether some of my yardwork or home repairs are illegal: I'm pretty sure I can replace my own toilets, but not whether I could replace my kitchen countertop without calling in an inspector. The countervailing issue, from my perspective, is that people being the sinners that they are, some degree of paternalism is necessary, and that furthermore, relying on the economy to keep wealthy/corporate power in check doesn't work, for a variety of reasons. So I'm very much in favor of business regulation, but I'm also sensitive to the tendency of regulators to become Nosy Parkers.

I don't think libertarianism is a viable political position (because they ignore the reality of power besides that of the government), but their hatred of power structures is a problem for the liberal self-portrait. I am all for the civil rights advances of the 1950s and '60s, but it has to be admitted that these were achieved through the manifest exercise of the governmental power hierarchy, and that egalitarianism, in practice, is something that has had to be forced on people. There is a tension in the American system between the urge to be left alone, which is recognized in the constitution, and the need to be policed and regulated, which is implicit in the need for government in the first place. There is a lot of dishonesty in conservative mouthpieces who often enough are, I would agree, arguing in service of corporate and wealthy power. But when you are arguing for governmental pushback, you are arguing for hierarchy.

All that said, it seems to me that all of this is rather removed from the reality of the act, at least as best I understand it. The conservative frothing over it is wildly at variance with reality.

#56 ::: Fragano Ledgister ::: (view all by) ::: June 29, 2012, 09:41 AM:

I would have preferred not a single-payer system but a national health service, but I'll take the Swiss-model system faute de mieux. It does a lot more than ensure that TexAnne won't die before she hits 50. It'll get rid of the Medicare doughnut hole that awaits me in less than a decade. It ensures that, if I change jobs, my preexisting conditions will not prevent me from gaining coverage.

What has become very clear, when we observe the approach taken by President Obama to decision-making, is that he emulates Muhammad Ali's rope-a-dope strategy. His opponents have, so far, all been dopes. There are worse people to imitate than the Greatest.

#57 ::: Craig ::: (view all by) ::: June 29, 2012, 10:17 AM:

Steve@12, Avram@31: Actually, I think that what happened was that Fox + CNN got leaked copies of the decision from before Roberts changed his mind. It explains how they both screwed it up.

#58 ::: Serge Broom ::: (view all by) ::: June 29, 2012, 10:18 AM:

Fragano @ 56... he emulates Muhammad Ali's rope-a-dope strategy

An interesting comparison because, not only has Obama admitted that he was born on Krypton, but I remember the cover of a 1960s comic featuring Muhammad Ali vs Superman.

#59 ::: Jim Macdonald ::: (view all by) ::: June 29, 2012, 10:33 AM:

The reason the Republicans have been fighting "Obamacare" is because, once people get to try it, they'll be naming their kids "Obama."

#60 ::: Victoria ::: (view all by) ::: June 29, 2012, 10:54 AM:

Henning Makholm @ 13

I think the real difference between ACA supporters and ACA opponents come down to one thing and one thing only: Have they ever had to live on a strict budget and made life-impacting decisions based on whether or not they could afford something like going to the doctor. (I call this living with the Budget Monster because poverty is so much more entertaining for me when I anthropomorphize it.) Most of the reactions you list are coming from the people who have lived in the upper middle class and higher income brackets all their life and they've never known a way of life where they didn't have insurance. It's kind of like breathing for them. They're afraid that giving affordable health care to all means they will have to accept a lower standard of living even though they can afford to buy better. Or they think they'll be asked to subsidize the people who can't pay for insurance now.

In my experience, any business in the US that offers health insurance also provides sick leave for their employees. That means that getting sick means they loose no money. Businesses that don't offer health insurance also do not have sick leave. If you don't work, you don't get paid... and if you don't get paid, you can't afford to go to the doctor because the doctor's offices ask to be paid at the time of the service with or without insurance. (And even with insurance co-pays --the stuff insurance doesn't cover-- the patient is left paying between 10% and 50% of the total bill.) Been there, lived like that, and nearly came down with pneumonia thanks to a nasty cold. I was raised poor even though I'm now in the lower middle class income bracket. You either toughed it out and got better or you didn't and coped. I toughed my way into a vicious case of bronchitis. The doctor told me I was literally 24 hours away from being diagnosed with pneumonia. Luckily I had enough saved that I could pay for an office visit, antibiotics and a few days of lost pay, but it meant giving something else up--the something I'd scraped and saved for. (The Budget Monster and a newer, more reliable car in a public transportationless city lost out to me deciding I wanted to feel better.)

Another example is my friend Crystal. She was raised and is still solidly middle middle class financially, but she has an idiosyncratic type of psoriasis. 99% of the standard medicines make her condition worse, not better. As a result, she's always the first to try out a new drug, and they're always very expensive because the drug companies recover their costs of research by charging high prices for the drug while they still have the patent on it. Her current prescription costs $238 for one pill and she has to take one pill a day, every day. (She and her doctor had to jump through hoops to get the insurance company to pay for the drug she's taking now.) Luckily, it works, so she's not one big walking sore. Unlike one of her past medicines, she doesn't have to get monthly liver biopsies to make sure the drug isn't slowly killing her in other ways. Each biopsy meant she spent 2 days a month taking sick leave in addition to the mandatory quarterly exams and blood tests which added up to another day and a half lost from work. Lucky for her, her employer offers good insurance and generous sick leave. Even with the sick leave, she's had to user her vacation time to do medical stuff. If Crystal ever lost her job, she'd be destitute and suffering horribly within six months.

I'm pretty sure that the ACA opponents have never had to make these kinds of decisions or live with the possibility of it. Your items 2-6 are the hysterical reaction of people faced with the Budget Monster for the first time. Your item 1 is from the people who've been goosed by the Budget Monster or felt its breath on the back of their neck.

As someone who has lived with, wrestled with and been bitten by the Budget Monster all her life... anything is better than nothing.

#61 ::: Theophylact ::: (view all by) ::: June 29, 2012, 11:05 AM:

Craig @ #57: Actually what I think happened was simple enough. I was following live blogging at scotusblog, and they first reported that the mandate had been struck down -- and then followed up almost immediately with the correction that it had been struck down under the Commerce Clause, but upheld as a valid exercise of the taxing power.

These guys are really sharp legal types, and even they were caught off guard. CNN and Fox? Not so much.

#62 ::: SamChevre ::: (view all by) ::: June 29, 2012, 11:09 AM:

Victoria @ 60

I think the real difference between ACA supporters and ACA opponents come down to one thing and one thing only: Have they ever had to live on a strict budget and made life-impacting decisions based on whether or not they could afford something like going to the doctor.

In my observation, this has not been true. It's the people who have something that just barely works now who are the most suspicious of the ACA--the well-paid middle class people I know are much more indifferent. (The inability to buy the cheap, high-deductible, heavily-underwritten plans really freaks a lot of the poverty-level self-employed out.)

#63 ::: Diatryma ::: (view all by) ::: June 29, 2012, 11:09 AM:

Lizzy L, most uninsured people I know (limited to me and the boyfriend's friends) just don't do risky things. I would have tried harder to be a roller derby official, but they strongly prefer you have insurance. Then again, when I had the Scary Stroke Migraine last year, instead of calling for anything medical, I went to bed.

I'm also of a generation that doesn't expect insurance to pay. Insurance is something you get so people don't say you're stupid for expecting health care without it. After a decade of saying they'd cover it, no problem, insurance backed out of my brother's major facial surgery because they suddenly decided it was cosmetic rather than preventative. My aunt and uncle were on the hook for a month of residential treatment because his work didn't pay their part of the premiums. A friend of mine was told that her insurance would be at least a hundred dollars a month cheaper than it actually is and that it would cover the medication she needs it to, and no, she's still paying out of pocket.

I think the mandate is a terrible compromise meant to placate the for-profit medical industry, but it moved the rest of the bill forward. Now if only I could find a job in Canada or the Netherlands (or the US, to be honest....)

#64 ::: Evan ::: (view all by) ::: June 29, 2012, 11:16 AM:

C. Wingate @50: Your idea that there are two different impulses toward hierarchy is an interesting one and I'll give it some thought. But I think you're missing the point that I'm talking about relative power and privilege between groups of people, and about divisive political issues rather than common annoyances.

Being annoyed about stupid zoning laws is neither a liberal nor a conservative thing; they bug all of us pretty much equally. But throughout history, liberals have split off from conservatives in a big way on issues like whether white people should get to own black people, whether women should get to vote, whether kids from rich white neighborhoods should share their nice schools with kids from poor less-white neighborhoods, whether gays should be allowed to live their lives without being bullied or beaten or discriminated against, whether it's good or bad for adult authority figures to hit kids, whether it's permissible for a woman who's had sex to make her own decisions about future parenthood, whether kids should be taught things about natural history that contradict the book of Genesis, whether it's okay to torture middle-eastern people on the suspicion that they're terrorists, etc... the big divisive issues always seem to come down to power and privilege, and whether out-groups get to have them, and how threatened existing in-groups feel when they do.

Liberals are okay with hierarchy when it's limited to the context of getting a job done, but they're not cool with privilege. You do what the foreman tells you, sure, but that doesn't make him better than you, and it doesn't follow that his kids should automatically get a better education than yours.

Not every person is 100% "liberal" or 100% "conservative" on every issue or in every context, but in a political conflict where there are identifiable liberal and conservative positions, this rule predicts which is which. I've been looking for an exception for more than ten years; I've never found one.

(A side note regarding your mention of evangelical churches: A church in which wives must submit to husbands and children to parents, in which "biblical authority" as interpreted by the church must not be questioned under any circumstances, and in which God is expected to reward the obedient elect but plans to eternally torture everyone else, is actually just about the most hierarchical church I can imagine. God > us > them. Very compatible with the conservative mindset as I see it.)

#65 ::: Serge Broom ::: (view all by) ::: June 29, 2012, 11:36 AM:

"But what about the cost? Put it this way: the budget office’s estimate of the cost over the next decade of Obamacare’s “coverage provisions” — basically, the subsidies needed to make insurance affordable for all — is about only a third of the cost of the tax cuts, overwhelmingly favoring the wealthy, that Mitt Romney is proposing over the same period."

So said Paul Krugman.

By the way, what hilarity did Stephen Colbert come up with? Maybe he suggested that, by making it illegal to turn people down for pre-existing conditions, we will encourage them to acquire pre-existing conditions.

#66 ::: LMM ::: (view all by) ::: June 29, 2012, 12:02 PM:

As a result, she's always the first to try out a new drug, and they're always very expensive because the drug companies recover their costs of research by charging high prices for the drug while they still have the patent on it.... If Crystal ever lost her job, she'd be destitute and suffering horribly within six months.

One of the *very* few gripes I have with the liberal framing of health care has to do with the use of "old" vs. "new" drugs -- the idea being that doctors who recommend drugs still under patent protection are doing so primarily because they're in the hands of Big Pharma. While there *are* cases of this, the side effect profiles of newer drugs are very likely to be far more tolerable than those of drugs that have gone generic. It's one thing if you're taking a drug for a temporary condition -- but when you're taking it for years, even minor differences in the side effect profiles can make the difference as to whether or not the drug is tolerable.

I recently had to go off the class of atypical antipsychotics completely -- after nearly a decade of *awesome* mental stability (for autism spectrum + mood disorder, there are *nothing* like them), I started getting extrapyramidal symptoms. All the atypicals to date carry a risk of EPS, but the older ones are far more likely to cause it. Switching from an older drug (Risperdone) to one of the newer ones gave me another three years or so before I couldn't tolerate it either.

Given the *extremely* low dose I was on (c.a. 5-10+ times lower than the usual dose), I've been told that my chances of getting EPS were minuscule on any of the atypicals -- apparently I was just *really* unlucky in that respect. But I still wonder if, had I jumped from Risperdone to the newer drugs as soon as they hit the market, I might still be able to tolerate them today. [1]

I've seen what I'm like without medication. I'd rather be dead than go off (some combination of effective) moodstablizers. And if I ever can't afford the drugs I need, I will be.

[1] What I'm on now works, but it isn't nearly as effective -- my social abilities have dropped (and I seriously wonder if that's the cause of various fallouts with coworkers) and it doesn't so much prevent mania as give me time to distance myself from trigger situations before they start. If an atypical-like drug ever comes out which doesn't carry the risk of EPS, I'm going on it the instant it comes out.

#67 ::: Bruce Cohen (Speaker to Managers) ::: (view all by) ::: June 29, 2012, 12:03 PM:

C. Wingate @ 55:

Their identification of things as being socialist is (at the moment at least) typically wildly exaggerated, but I don't think that's an inaccurate characterization of it as a political type.

As a life-long progressive socialist from a family consisting of socialists and self-made capitalist conservatives I have to disagree with that statement. It's a not-completely inaccurate characterization of a certain kind of socialist, and it doesn't fit other kinds at all. Trying to characterize all socialists as hierarchical is as incorrect as trying to characterize all conservatives as Tea Party wingnuts.

#68 ::: Emily H. ::: (view all by) ::: June 29, 2012, 12:21 PM:

My sister is quite anxious about the effects of health care. She's almost 30, "self-employed" in an industry where almost all the jobs are contract positions that don't offer health care, and while she makes more than the "400% of poverty level" cutoff for subsidies, she can't afford the $300 a month she's being quoted for even the highest-deductible catastrophic insurance plans -- plans that would have her pay $10,000 out-of-pocket before they started to pick up a cent.

I don't think she's seen a doctor in five years.

What scares her is the prospect of having to choose between a $300-a-month plan that would do nothing for her except in the case of a dire emergency, and paying $1000 a year just because she can't afford the $300-a-month plan.

The good thing is, even the cheapest plans that the ACA would permit are better than that high-deductible plan. The bad thing is... we have no idea how much they're going to cost when all is said and done.

I'm going to see if I can find that calculator that estimated $500 a year. Because that would make her feel a lot better about this whole thing. (We're both, incidentally, pro-ACA although we'd prefer single-payer. It's just that it's hard to be in that position and not worry about what it would mean for you personally.)

#69 ::: Victoria ::: (view all by) ::: June 29, 2012, 12:47 PM:

Henning Makholm @ 23

Budget Monsters. It's all about Budget Monsters and economies of scale.


The Budget Monsters for the too poor for insurance says "You can't afford insurance so the doctor's office will turn you away. Therefore wait until whatever you have becomes life threatening before you go to the ER because the ER can't turn you away. By law. If you can't pay that's too bad for the hospital. It sucks to be us. We have no money, but that's okay. Everybody expects us to be penny wise and pound foolish whether we are or not."

The doctors' Budget Monsters say, "This is a business not a charity! I have to pay off your education and overhead costs. My Sibling over in Insurance says I have to pay more and more every year in malpractice coverage. You can't afford to treat the uninsured!"

The hospitals' Budget Monsters say. "This is a for-profit business! We can't get all of the uninsured to pay for their costs, so we have to raise all the prices for all of our services so we can make up the difference with insured patients."

The insurance companies' Budget Monsters say, "The money pool is too low! Put a spending cap on each person so they can't use more than they've paid in now or will ever pay in over their lifetime. Each client must make me profit! The costs are rising! Pass on the increases to the customer. I need my money pool as full as possible so I can pay the claims and still have enough profit to pay my share holders."

The insured people get their bills from the hospitals, doctors, policy holder, and pharmacies and their Budget Monsters say "Higher costs mean less (or no) vacations, more bargain shopping for groceries and clothes and less stuff to give during the holidays. It looks like I'll get to mess around with your life some more."


Right now (and this stays in effect until the ACA gets implemented) all health care costs for the poor and insuranceless are currently subsidized by the insurance companies whether they will admit to it or not. And they're not admitting to it because every time the hospitals and doctors offices and pharmaceutical companies raise their prices to compensate for the people who can't pay, that cost gets passed on to the insured because insurance companies are in the business of collecting and maintaining money pools. Insurance companies in the US only make money if the drain on the money pool is less than the inflow. This normally isn't a problem because there are more healthy people than there are sick people*. So when the insurance company sees that its money pool is getting low due to bigger bills from hospitals, doctors and pharmacies, they raise the premiums so the private citizen and various sizes of businesses winds up paying a hidden insurance costs for the impoverished and working poor**.

What ACA proposes is to take the insurance companies' Budget Monsters and make them broaden their money pool inputs and outflows. By law, they would not be able to tell someone you can only use the insurance you yourself have paid for or you can only join if your part of pre-existing pool called "employee benefits***." They would also have to take on riskier clients - like the working poor at a rate based on current income rather than a number derived by actuaries based on health risks and a return on investment.

The ACA assumes that if the hospitals Budget Monsters know that all the people coming in the ER can guarantee payment through mandated health insurance, they will stop marking up analgesics and bandages by 400% and bring down other costs as well.

The driving idea behind ACA is that making everyone pay for insurance they can afford will put more money into the pool that pays the hospitals and doctors for treating the sick and injured. ACA is also working on the assumption that the USA has more well people than sick people.

In addition to all the patient, doctor, hospital, insurance roundy-round round robin fears about money and budgets are the pharmaceutical companies. Their Budget Monsters say "you have to pay off all your research costs, plus make profits while your medicine is still protected by patents. Once something goes off patent, all our money will be taken by the generic drug manufacturers." Part of the ACA address the length of patents and providing affordable meds to needy while the med in question is still in patent. (because every doctor I've seen and every pharmacist I've been to, always prescribes and dispenses generics where possible.)


------
*You just don't hear about them unless your employer is the self-insuring kind that makes a point of educating you about where your insurance comes from and the options you have available.^

** The working poor is defined, in this argument as someone who has an okay job with okay pay, but no benefits and resides in a city where the cost of living for basic shelter, food, utilities, and simple transportation is the same as their take home pay. Once the bills are paid, there is no money left over for frills like paying for unexpected illness, accidents, pregnancies, or basic preventative health care maintenance. (things like cable TV, internet, computers, movies, dining out and so on are not even in the realm of the possible.)

***Insurance not paid by the employer is so expensive only the wealthly (the infamous 1%) can for private insurance out of pocket and not have to sacrifice on their overall standard of living. If the upper middle class economy didn't have employer subsidized health care^^, their out of pocket expenses would put them near the poverty line.

^My day job switched to private insurance shortly after I started working here 10 years ago. They've explained every single time why they had to increase our contribution and backed it up with numbers and graphs that were clear and easily understood.

^^and for all the Chicken Littles that predict employers will stop providing this service, don't realize how many employees inquire about benefits packages during the job application process or interview. (one of the joys of sitting on hiring committees) Good employees demand and get good compensation or they leave.


#70 ::: Victoria ::: (view all by) ::: June 29, 2012, 01:10 PM:

#68 ::: Emily H. What scares her is the prospect of having to choose between a $300-a-month plan that would do nothing for her except in the case of a dire emergency, and paying $1000 a year just because she can't afford the $300-a-month plan.

The $1000/year plan works out to $83.33/month. The driving question is what will that $83.33/month pay for? and how does that coverage compare with the $300/month plan?

I'm not as up in arm about the ACA as the rest of the country. I won't be until I know how things will be implemented in real time and in the real world rather than political theory. But then, I'm used to my self-insuring employer telling me "here are your options for the next two years; pick the best plan that works for you. The drop dead date for decisions is just that. Make a decision or you live with the option you picked upon hire."

#71 ::: Emily H. ::: (view all by) ::: June 29, 2012, 01:23 PM:

The $1000/year plan works out to $83.33/month. The driving question is what will that $83.33/month pay for? and how does that coverage compare with the $300/month plan?

Sorry, I was unclear -- $1000/year is what she'd pay as a penalty for not having health insurance.

#72 ::: Leigh Kimmel ::: (view all by) ::: June 29, 2012, 01:24 PM:

Emily H @ 68

I'm self-employed (long history of not fitting well into standard dayjobs, resulting in sufficient black marks on my permanent record to be effectively unemployable, particularly in a down economy), and I'm also very worried about the probability that my current health insurance will be too cheap to qualify under the mandate -- and we're able to afford it only because when my husband retired, he got something similar to a HSA, but which can only be used to reimburse premiums. If we have to go up to a plan that costs three or four times as much per month, that money will run out that much faster -- but if we don't come up with that money, we get dinged every year simply because we don't have the money to buy the health insurance they consider adequate.

To me it seems like just a case of people assuming that your resources automatically expand to accommodate whatever they impose on you. Like the people who keep plopping additional tasks and responsibilities onto my plate, as though my day grows extra hours at need.

Very sore point for me at the moment. Like the use of "it's your responsibility" to excuse themselves from looking at whether the person can reasonably accomplish what they've been made responsible for.

#73 ::: Howard Bannister ::: (view all by) ::: June 29, 2012, 01:31 PM:
The $1000/year plan works out to $83.33/month. The driving question is what will that $83.33/month pay for? and how does that coverage compare with the $300/month plan?

...that 83.33/month penalty goes into the pool of providing better health care for people who fall in the gap.

Remember, Medicaid expansions, sliding scales, government assistance for low-income folks? That's a piece of this too.

(not nearly as good as a single-payer system... grr... argh)

That may or may not help Emily H.'s friend. Part of the whole 'watered down' problem is that there will be people left behind.

(also, that penalty is income-controlled--no more than 2.5% of income--if you're making less than 40,000 a year it would be less than that)

#74 ::: Lee ::: (view all by) ::: June 29, 2012, 01:42 PM:

Victoria, #69: I need my money pool as full as possible so I can pay the claims and still have enough profit to pay my share holders.

That bit in bold is the root of the trouble. When insurance companies were allowed to offer stock, the money pool stopped being about covering claims and overhead and started being about profits for shareholders, and the customers became liabilities rather than assets. Unfortunately, there's no easy fix for this, although the ACA's 85-15% provision is a step in the right direction.

#75 ::: Howard Bannister ::: (view all by) ::: June 29, 2012, 02:27 PM:

I feel the need to drop this link here.

Crony-Keynesianism.

The key definition: "doing policies whose logic calls for government spending, but take the form instead of incentives to favored private-sector interests.

From a macro point of view, even crony Keynesianism is better than continued destructive austerity. But we should be aware how basically strange it is, and how subject to abuse."

He's speaking about British government. But it applies very well to the health care stuff here.

#76 ::: Caroline ::: (view all by) ::: June 29, 2012, 02:46 PM:

Emily H. @ 68: The best datapoint I can think of right now is the monthly premium for insurance on the Massachusetts exchange -- because RomneyCare.

If you go to the MA exchange website, you can browse health plans available to MA residents. It will ask you for a zip code; I just entered 02138 (Cambridge, MA) in order to get in and have a look. (Obviously, you can't actually buy said insurance unless you are a Masschusetts resident.)

For someone 30 years old (as I am), the lowest-cost quote under RomneyCare is $233/month. That plan has a $2000 deductible and a $5000 out of pocket annual maximum for individuals. Already a heck of a lot better than $300/month for a $10k deductible plan.

I'm trying to dig up specific information on income levels and the 2014 penalty, and government premium subsidies. This guide from Kaiser says "Premium subsidies will be available for individuals and families with incomes between 133 percent and 400 percent of the poverty level, or $14,404 to $43,320 for individuals and $29,326 to $88,200 for a family of four."

Ooooh, here is a premium subsidy calculator, also from Kaiser. (It requests income in 2014 dollars. Hell if I know how to estimate that. But it will also accept income as percentage of poverty level; you could compute that for the present day.)

#77 ::: torrilin ::: (view all by) ::: June 29, 2012, 02:50 PM:

Insurance not paid by the employer is so expensive only the wealthly (the infamous 1%) can for private insurance out of pocket and not have to sacrifice on their overall standard of living. If the upper middle class economy didn't have employer subsidized health care^^, their out of pocket expenses would put them near the poverty line.

Even if you've got insurance... one sick kid puts you near the poverty line. See also, my sister.

At one point (loooooong before President Clinton attempted health care "reform") my parents' insurance audited us. Turns out they'd refused to cover enough different bits of basic asthma treatment that were supposed to be covered that my parents were due about $3000 in 1980s dollars. In 2012 dollars, that's closer to $10 000. At the time, my dad's salary was in the $50 000 range.

From tracking the bills, my mom knows that every single year the insurance refused to pay about the same amount. Some years she managed to get a bit more covered stuff actually covered, others a bit less. But year in, year out, our insurance skimped on paying.

This is a common and routine thing to run into when someone has a chronic illness.

A lot of people act like lifetime coverage caps are some sort of new thing too. My mom and sister started running into attempts to cap their treatment in the late 1980s. Sometimes, you can appeal the cap. Mostly, we ended up paying out of pocket.

#78 ::: Caroline ::: (view all by) ::: June 29, 2012, 02:57 PM:

The calculator I linked in my previous comment makes the following assumption: "The premiums are illustrative examples in 2014 dollars derived from estimates of average premiums for 2016 from the Congressional Budget Office. For a 40 year old single adult, the premium for a silver plan is assumed to be $4,500 for a plan with a 70% actuarial value." (That's $4500 per year, not per month.) That premium is adjusted downwards for someone under 40, upwards for someone over 40.

A "silver" plan (as in the Massachusetts exchange) is the mid-range plan; there would be "bronze" plans available for lower premiums. The MA bronze plan premiums look to be about 30% lower than the MA silver plan premiums.

I think that information can give you a rough estimate of what sort of premium costs you might be looking at in 2014 (and what subsidies might be available to you in 2014) to buy insurance that will keep you from paying the penalty.

#80 ::: C. Wingate ::: (view all by) ::: June 29, 2012, 03:08 PM:

re 64: Evan, you say that "Liberals are okay with hierarchy when it's limited to the context of getting a job done": well, yeah, but that means you're OK with hierarchy, and that you are subject to the temptations having it affords. If you are in a position to put your opinions about creationism or segregation or gender roles or whatever into practice, then you are one of the privileged, and near the top of the social hierarchy; and I gather that you are unwilling to relinquish this, because that would allow the people you look down upon as being conservatives to gain those positions in your stead. And in this discussion this is manifested in you saying how conservatives think. Why should I take you as an authority on that? The conservatives I know do not outwardly think as you say they do, so why shouldn't I interpret your explanation as a rationalization for attaining and maintaining liberal control of power structures?

#81 ::: Avram ::: (view all by) ::: June 29, 2012, 03:36 PM:

C Wingate @55, you're confusing hierarchy with managerialism.

In a hierarchical society, the upper classes have privileges that the lower class lacks. In the case of health care, the upper class gets good care, and the lower class get crappy overpriced care, or get none.

The phenomenon you're talking about, where a set of bureaucrats decide upon best practices which then have to be followed by everybody, is a kind of hierarchy in that there's a group that issues orders, but it's not the kind of privilege-preserving hierarchy that Evan is talking about, unless the practices establish or perpetuate some kind of privilege.

#82 ::: SamChevre ::: (view all by) ::: June 29, 2012, 03:41 PM:

I'm with C. Wingate here: if one group can decide what another group has to do, they are both in a hierarchy and in a privileged position.

#83 ::: Henning Makholm ::: (view all by) ::: June 29, 2012, 03:46 PM:

Thanks to everyone who responded to my query (now #13). It was an interesting read, and I feel at least somewhat enlightened. I will forgo further attempts to engage with the responses individually, though. Given the infrequency of my visits here, that would quickly become tedious.

(Thanks even to those respondents who apparently thought I need a new last name -- but no thanks).

#84 ::: SamChevre ::: (view all by) ::: June 29, 2012, 03:50 PM:

I apologize to both Henning Makholm and Howard Bannister for getting their last names wrong.

#85 ::: Avram ::: (view all by) ::: June 29, 2012, 03:53 PM:

C Wingate @80: If you are in a position to put your opinions about creationism or segregation or gender roles or whatever into practice, then you are one of the privileged, and near the top of the social hierarchy

No, you're not.

Evan is describing conservatives as people who desire a society stratified according to social class (and maybe race and/or religion --- those things have historically been tangled up with social class).

You're describing liberals as desire a society in which people temporarily occupying a certain professional position have a certain degree of political power.

Social class is generally attached to a person, while political power (in a democratic republic) is attached to an office.

SamChevre @82: if one group can decide what another group has to do, they are both in a hierarchy and in a privileged position

A hierarchy, yes. A social hierarchy, no.

And they're not in a privileged position if they're subject to the same laws as everyone else. (Which Congress and the President are not, so there is a valid liberal argument to be made here about political power as practiced in the US today, but it's not the argument C Wingate is making.)

#86 ::: SamChevre ::: (view all by) ::: June 29, 2012, 04:05 PM:

Avram @ 85

And they're not in a privileged position if they're subject to the same laws as everyone else.

I think this fails the "the rich as well as the poor are forbidden from sleeping under bridges" / "ye bind heavy burdens upon men ..., and you yourselves will not lift them with one of your fingers" test.

In actual fact, the policies proposed are congenial to the people with power (they require them to do nothing they would not do anyway, and/or affect institutions that aren't important to them), and uncongenial to people without power. And those policies can't be changed by voting, can't be opted out of, and agreeing with them is required to get a policy-making position.

That looks like a self-perpetuating hierarchy with privilege to me.

#87 ::: Howard Bannister ::: (view all by) ::: June 29, 2012, 04:05 PM:

@84: I don't have much ego invested in the correctness of my nym, since it's so blatantly not mine; so it's very easy for me to accept that apology. But thank you.

#88 ::: SamChevre ::: (view all by) ::: June 29, 2012, 04:07 PM:

Avram @ 85

And they're not in a privileged position if they're subject to the same laws as everyone else.

I think this fails the "the rich as well as the poor are forbidden from sleeping under bridges" / "ye bind heavy burdens upon men ..., and you yourselves will not lift them with one of your fingers" test.

In actual fact, the policies proposed are congenial to the people with power (they require them to do nothing they would not do anyway, and/or affect institutions that aren't important to them), and uncongenial to people without power. And those policies can't be changed by voting, can't be opted out of, and agreeing with them is required to get a policy-making position.

That looks like a self-perpetuating hierarchy with privilege to me.

#89 ::: albatross ::: (view all by) ::: June 29, 2012, 04:24 PM:

Evan's model of what conservatives believe does a remarkably bad job of describing conservatives I personally know, or whose opinions or ideas I read. I think it is often true that conservative policies have the effect of making whatever groups is doing well now better off, but that's neither the goal (in general) nor anything like a constant. Nor does his model seem to me to describe liberals especially well.

#90 ::: Avram ::: (view all by) ::: June 29, 2012, 04:49 PM:

SamChevre @86: In actual fact, the policies proposed are congenial to the people with power [...] and uncongenial to people without power.

Which policies are you talking about? C Wingate mentioned "creationism or segregation or gender roles or whatever". Do you think the Civil Rights Act of 1964 did nothing for people without power? Do you think it perpetuated the power of Lyndon Johnson and the Democratic party? Seriously?

He also mentioned something having to do with moving his car, but I know nothing about the details of that, and it's clearly a local issue, not a federal one.

#91 ::: SamChevre ::: (view all by) ::: June 29, 2012, 05:20 PM:

C Wingate mentioned "creationism or segregation or gender roles or whatever".

Those work fine, although I might choose other examples; in all cases, anyone that you might describe as part of the national establishment elite is in favor of current policies, and a lot of people who are NOT part of that elite (and are generally poorer, less educated, and in generally lower in the hierarchy) would rather strongly prefer different policies.

This is not to say that everyone who is benefitted, or favors these ideas, is part of the national elite.

1) Yes, my definition of elite is circular. I'm not sure how to get away from defining elite in terms of who gets to have their ideas enforced on others, and so implicitly defining the elite's ideas as those ideas that are enforced on others.

#92 ::: Avram ::: (view all by) ::: June 29, 2012, 06:19 PM:

SamChevre @91, does it make no difference what those policies are?

Assume the existence of Hypothetical Proposed Policy A, which would benefit a large group of poor people at the expense of a small group of rich people, and Hypothetical Proposed Policy B, which would benefit a small group of rich people at the expense of a large group of poor people. Are you saying that those two policies are equally describable as perpetuating the power of the elite, because they can only be put into effect by a political establishment?

#93 ::: Leah Miller ::: (view all by) ::: June 29, 2012, 06:29 PM:

I think people attribute the problems of price directly to the insurance industry a little too much... and I don't just say that because I'm from Connecticut, insurance-industry-land-USA. Insurance companies tend to have much smaller margins than a lot of other companies. A lot of what they do is really, incredibly, nigh-unforgivably awful, but they aren't running away cackling with huge sums of money because of it. At least, I haven't gotten that impression from reading I've been doing recently.

This WaPo blog post was very interesting. It's about how prices are radically different in the US vs other countries. An MRI in France costs around $280, whereas it costs around $1,080 in the US. The same devices are being used, the same procedures - just, in the US, it costs a lot more. Because of reasons. I had an MRI recently and the bill was over $2,000. It got sent directly to me because of insurance issues, which have hopefully been sorted out by now.

The balance between the price of research and the cost of health care is really scary to look at, and I think that's something a lot of people don't want to touch. The problem is that the pharmas are making the vast majority of their profits here, so in a lot of ways the US is subsidizing research that benefits everyone. Which isn't... bad in and of itself, but has caused a lot of incredibly bad things to happen.

#94 ::: Leah Miller has been gnomed ::: (view all by) ::: June 29, 2012, 06:31 PM:

For uncertain reasons. I suspect that's happening a lot in this thread, with all the mentions of common things that are spammed.

#95 ::: Fragano Ledgister ::: (view all by) ::: June 29, 2012, 06:56 PM:

Bruce Cohen (Speaker to Managers) #67: I am in the middle of a project on the democratic ideas of a socialist leader whom I knew. To say that he was hierarchical or believed in hierarchy would have been to traduce him. Justice and equality were synonyms in his vocabulary.

#96 ::: Victoria ::: (view all by) ::: June 29, 2012, 07:23 PM:

Lee @ 74

The quickest way to get around that? Have a bunch of small and medium sized businesses set up their own self-insurance co-op and then start pricing health insurance with the intent to negotiate premiums.

My self-insured employer has enough employees to be able to negotiate with Blue Cross and Blue Shield - one of the more expensive providers of health insurance out there. At least it was when I went around pricing it around 15 years ago for the small business owner that employed me at the time. BCBS was also the most widely accepted insurance policy at the time and looks like it still is today, based on the number of options I have to pick from when it comes to health care at home and while I travel. ("good" insurance is accepted by most doctors in every state. "bad" insurance isn't.)

This is possible for one very important reasons. In addition to having a lot of people to insure, my current employer has annual health fairs where employees are given free blood work, their BMI is calculated, and everyone gets counseled* once they've run gamut of stations. Attendance at said fairs are optional, but I get less taken out of my pay check in annual withholdings if I participate.

Here's how it works. When I plug those test result numbers into my employer's health insurance questionnaire (again voluntarily) and answer a handful of lifestyle questions, (proof that I participated), I only pay half of what I would if I didn't participate in the aforementioned faire. In short, my employer is paying me to do preventative maintenance (frex: having an annual checkup lowers my share of the premium.) A calculator shows me how my inputs change my health rating.

My employer takes the questionnaire info and then goes to BCBS's actuaries and tells them, "I have proof that my employees are good risks. Lower my premium." The end result? My share of my health insurance premium is only $35 a month and I took the most expensive option with the broadest coverage because my family on both sides has a history of expensive chronic illnesses.

----
* I look like I should be very high risk, but I'm actually low risk. I love the expression on the counselor's faces when they read my tabulation sheet at the end and try to deploy their canned lecture. Their perplexed frustration makes my day every single time. It's hard for them to get the "keep up the good work" out because they want to scold me for looking like a heart attack waiting to happen.

#97 ::: SamChevre ::: (view all by) ::: June 29, 2012, 09:10 PM:

Avram @ 92

Assume the existence of Hypothetical Proposed Policy A, which would benefit a large group of poor people at the expense of a small group of rich people, and Hypothetical Proposed Policy B, which would benefit a small group of rich people at the expense of a large group of poor people. Are you saying that those two policies are equally describable as perpetuating the power of the elite, because they can only be put into effect by a political establishment?

No, but I think that example is more confusing than helpful. Let me try a different example, and see if I can clarify.

Assume the existence of powerful group A (e.g, the wealthy), powerful group B (e.g., the Catholic hierarchy), and powerful group C (e.g., federal judges), as well as large but not-powerful group Z (e.g, citizens without a college degree).

Assume further that for some reason the decision to be made is a "here's-what-you-get" decision for everyone. (Avoiding that dynamic is my main focus.) If, regardless of what the other 3 groups want, one of groups A-C always gets what it wants, that group is an elite. It's the "no-one else can win on any grounds" that makes it a privileged elite.

#98 ::: Avram ::: (view all by) ::: June 29, 2012, 10:55 PM:

SamChevre @97, I'm not really seeing how any of that ties in to the earlier discussion.

#99 ::: Kip W ::: (view all by) ::: June 30, 2012, 11:45 AM:

Favorite comment from some thread somewhere about irate conservatives moving to Canada because of the decision:

"I'm sick and tired of this heat. I'm moving to Ethiopia!"

#100 ::: jnh ::: (view all by) ::: June 30, 2012, 12:19 PM:

another anon @ 45:

I have Crohn's disease, and on Saturday my doctor recommended that I should consider intravenous Remicade several times per year, which is very expensive. Luckily, I am 22 years old, and therefore it is covered by my parents' insurance for now (I don't know the specific terms).

You are able to be covered by your parents' insurance until age 26 due to the Affordable Care Act. That part became effective "for health care years beginning on or after September 23, 2010"

#101 ::: heresiarch ::: (view all by) ::: June 30, 2012, 02:48 PM:

C. Wingate @ 55: "it is in its way an attractive theory, but unfortunately it puts you in the class of people who like hierarchy."

That's like saying that endorsing surgery puts you in the class of people who like scalpels. There's a distinction between liking something for its own sake and liking it for the ends to which it can be turned.

It's true that liberals are happy to use power, large-scale governmental power, to annihilate the little tyrannies of the authoritarian church, the racist community, the sexist workplace, or the classist university. That power is assembled and applied through a hierarchy, it is true. But their use of it has nothing to do with an abstracted affection for the hierarchy itself, but with a specific affection for the end to which it has been turned: the liberation of the individual from intimate oppression.

There's an undeniable tension there, between the ends and the means. It's something that has to be solved for every time: is the governmental force necessary to correct this injustice greater or less than the force of the injustice itself? It is not, however, indicative of "liking hierarchy."

#102 ::: heresiarch ::: (view all by) ::: June 30, 2012, 02:58 PM:

Diatryma @ 63: "I think the mandate is a terrible compromise meant to placate the for-profit medical industry, but it moved the rest of the bill forward."

This is true, and it isn't. Keeping the private medical insurance system intact and not replacing it entirely was a huge compromise with the for-profit medical industry, but given that choice the mandate is a necessary and vital component of the new system. It is a necessary complement to the requirement that companies accept anyone, no matter their pre-existing conditions: once people are certain that they can get insurance whenever they need it, there's no reason to waste money on it until you actually do need it. Since insurance works by spreading the expenses of ill people over the whole healthy population, if healthy people stopped participating the whole thing would collapse in a spiral of ever-increasing fees and ever-shrinking enrollment.

In fact, something mandate-like--requiring everyone to participate--would be equally necessary for a single-payer system.

#103 ::: Lee ::: (view all by) ::: June 30, 2012, 03:23 PM:

heresiarch, #102: My understanding is that single-payer systems are funded by a tax that everyone has to pay -- which is to say that you're absolutely right, and also that Roberts is correct in linking the mandate to taxation. We've moved closer to a single-payer type of structure, only we're doing it weirdly and with an extra (unnecessary) layer of interference in the middle.

#104 ::: Lenny Bailes ::: (view all by) ::: June 30, 2012, 05:42 PM:

According to Ruth Bader Ginsburg in Patrick's Sidelight, "Roberts’s analysis was “rigid,” “crabbed,” and “stunningly retrogressive,” [that] it “finds no home in the text of the Constitution or our decisions” and made “scant sense.”

My first thought on reading about the decision was that if Roberts wanted to declare the Mandate unconstitutional under the Commerce Clause, it must mean there are a number of useful things the government might be able to do under that clause that Roberts wished to get rid of.

Thank you for that Sidenote, Patrick. Roberts has always had a bad smell to him, from the time Bush appointed him to the District of Columbia Circuit Court to gain a ruling that circumvented William Hamden's right to a trial by jury.

Roberts followed instructions and was subsequently rewarded with the Supreme Court appointment.

#105 ::: Torrilin ::: (view all by) ::: June 30, 2012, 05:55 PM:

just, in the US, it costs a lot more. Because of reasons.

Nope. Not just because.

In the UK, the MRI machine is owned by Her Majesty's government. In the US, it's often owned by a radiologist or group of radiologists. It might also be owned by a health insurance company, a hospital or a university.

While the UK's government budget is smaller than the US's, and by a lot... it's still FAR better funded than a radiologist. Or a hospital. Or even a university. This means the UK can take advantage of economies of scale. Instead of buying their MRI machines retail, and each radiologist gets frequent visits from company sales reps trying to convince them of a new machine... They can ask for bids and buy standardized equipment. This produces a large savings. Same principle as a fleet of rental cars really.

Buying in bulk saves at the time of purchase, and it tends to save in maintenance over the item's lifetime. Plus if you *know* one item has long term advantages (perhaps less maintenance needed) you can factor that in.

Now you'll recall (or perhaps you don't) that fairly recently there was a scandal that quite a lot of MRI patients in the US got radiation sickness from having an MRI. (given the radiation dose necessary for radiation sickness vs the dose necessary for an MRI, even one patient is too many) Why were a lot more than one patient affected? Because the machines were designed in odd and unusual ways. No safety cutoffs for starters.

The faulty machines sold relatively well in the US, but they did not do well elsewhere. So now the manufacturers have to allot extra money to their pay off the patients budget. But just for the US. That counts as increased costs in the US medical system.

Going beyond equipment... in the US, radiologists get paid per procedure. The more ways you can break "an MRI" up into different bits and convince an insurance company that it's legitimate, the more money you make. This means that you as a radiologist *want* very badly to come up with new billable procedures to help pay off your phenomenally expensive investment in an MRI machine.

And remember, the radiologist who owns her own MRI machine? She's self employed most likely, with all the extra tax hits and generalized hassle that involves. Including her own health insurance costs :P.

In short, our medical system is not expensive "just because". It's expensive because it's designed to take as many steps as possible, and for those steps to be billed at the highest rate possible.

That means when my sister has an asthma attack, checking her breathing with a stethoscope is billed separately from checking her blood oxygen levels, and separately from doing a spirometry test, and under some kinds of insurance they've even figured out how to get peak flow tests billed separately. They're not all billed as one number "examined patient" or "office visit". In quite a number of cheaper health care systems, doctors get paid bonuses if a horribly expensive chronic patient has fewer attacks. In the US? The doctor is effectively getting a bonus every time she has an attack... and at least one of her doctors has tried to take advantage of this by refusing to write prescriptions for her. That cost about 4 office visits to the insurance company that employed the doctor, and a month's worth of work to her employer.

#106 ::: Lee ::: (view all by) ::: June 30, 2012, 06:02 PM:

In the US? The doctor is effectively getting a bonus every time she has an attack... and at least one of her doctors has tried to take advantage of this by refusing to write prescriptions for her.

THAT merits a complaint filed with your state's Medical Board of Examiners. I wonder how many other patients he's doing it to?

#107 ::: Trey ::: (view all by) ::: June 30, 2012, 06:23 PM:

Torrilin, at 105, don't you mean CT scans?

And as someone who works in health IT and is learning more about coding than I ever wanted, your statement is very true.

#108 ::: Paula Lieberman ::: (view all by) ::: June 30, 2012, 08:27 PM:

John Roberts, Chief Weasel! That ruling of his, is an amazing weasel!!!! Bis handlers might be having shitfits--or maybe not... (I'm at Concertino, sitting in the audience at a concert... )

#109 ::: Benjamin Wolfe ::: (view all by) ::: June 30, 2012, 08:27 PM:

Now you'll recall (or perhaps you don't) that fairly recently there was a scandal that quite a lot of MRI patients in the US got radiation sickness from having an MRI. (given the radiation dose necessary for radiation sickness vs the dose necessary for an MRI, even one patient is too many) Why were a lot more than one patient affected? Because the machines were designed in odd and unusual ways. No safety cutoffs for starters.

Ok, having spent a couple of years running my friends through lots of MRI scans for vision research, it seems like Torrilin is confusing MRI scanners for CT scanners... I'm assuming the incident that is being referred to (or, at least the one that comes to mind off the top of my head) is the issues with a set of CT scanners (maybe VA owned?), which are X-Ray devices. MRIs are magnetic resonance devices - they don't use ionizing radiation, they use magnetic excitation, and as such cannot give a patient radiation sickness (or, for that matter, any dose of radiation). The worst thing that can happen with an MRI (aside from it attracting metal objects as a result of the field) is dizzyness/nausea from moving in/out of the field or from certain cranial sequences.

#110 ::: chris ::: (view all by) ::: June 30, 2012, 10:51 PM:

It's true that liberals are happy to use power, large-scale governmental power, to annihilate the little tyrannies of the authoritarian church, the racist community, the sexist workplace, or the classist university. That power is assembled and applied through a hierarchy, it is true. But their use of it has nothing to do with an abstracted affection for the hierarchy itself, but with a specific affection for the end to which it has been turned: the liberation of the individual from intimate oppression.

I agree, but... this is just the kind of complex, nuanced position that so many conservatives just refuse to believe in. Not just "refuse to agree with" -- they don't even believe anyone else could believe it either. How could anyone possibly live with such a contradictory set of beliefs? Surely that must be a sham to cover up liberals' REAL agenda of bigger government for its own sake. Because that's the only agenda simple enough for someone to actually commit to.

You either want smaller government and lower taxes, or you want bigger government and higher taxes. You're either with us, or with the terrorists.

The more I think about conservatism, the more I think that *refusal to accept complexity* is its root cause. If you have to see everything in black and white, the whole rest of their worldview follows. Multiculturalism is a mask for being on the other side of the race war because race war is inevitable -- surely nobody could be in favor of two races at once. Men should be men and women should be women and people who are uncomfortable with that kind of rigidity should be made to conform, with as much force as necessary. Good people are good and bad people are bad and there's nothing you can do with bad people but keep them in cages where they can't hurt anyone. Etc.

Or am I oversimplifying in my view of people who oversimplify everything?

#111 ::: John M. Burt ::: (view all by) ::: June 30, 2012, 11:45 PM:

Avram @31, how do you get text to do that? Is it called "ROT 180"?

#112 ::: David Goldfarb ::: (view all by) ::: July 01, 2012, 12:20 AM:

John M. Burt: check out fliptext.org.

#113 ::: KayTei ::: (view all by) ::: July 01, 2012, 01:56 AM:

chris @ 110

That's true only if you conflate conservativism with the extreme conservative movement in modern America. There was a time, within living memory, when the difference between conservatives and liberals really did come down to moderate differences in philosophy and extent. There are still people around who identify as conservatives, who nevertheless feel uncomfortable with the excesses of certain segments of the Republican base.

#114 ::: Lee ::: (view all by) ::: July 01, 2012, 02:22 AM:

I've been having an e-mail discussion in which it was mentioned that the Founding Fathers designed our system on the assumption that anyone who was elected to office would have an interest in working for the benefit of the country as a whole*, and what's happening now is that this assumption no longer holds.

What I want to know is, how did we get from there to here? As far back as the 80s ISTR that Democrats and Republicans did manage to work together. When did that change? Was it just with the stolen election in 2000, or was it with Clinton, or was it happening before that?


* And thus would be able to work with, and compromise with, other people whose philosophies differed about how best this should be accomplished, because they were both working toward the same basic outcome.

#115 ::: abi ::: (view all by) ::: July 01, 2012, 03:20 AM:

You know, I think we're going to draw this low-resolution othering of people we don't like to a close. I haven't seen any universal statements about conservatives or conservatism in this thread that would withstand two minutes in the presence of actual conservatives I know, and I know relatively few of them. The liberal stuff is no better, but at least it's being said in the presence of liberals themselves and can be compared to reality.

This kind of cartoony description of the people of The Other Stripe does us, and our civic discourse, no end of harm. We comfort ourselves that we know what we don't, and therefore quiet our curiosity before we find out anything that might transform our own views of issues, of each other, and of the tasks that lie before us.

Smarter/wiser/more joyful, folks. Try to make us at least one of the three, or abandon at preview.

#116 ::: Serge Broom ::: (view all by) ::: July 01, 2012, 10:10 AM:

Abi @ 115... Smarter/wiser/more joyful

Going back to the original tone of the thread, I wish to reiterate my joy that TexAnne's asthma won't get the better of her. One alternative to death would be to transplant her brain into a RoboCop body, but metal mitts might interfere with her knitting's necessary dexterity.

#117 ::: Michael I ::: (view all by) ::: July 01, 2012, 10:42 AM:

Serge Broom@116 Robocop body

Plus then she won't have time for knitting, because she'll have to focus on fighting crime...

I suppose she could always knit while she patrols...

#118 ::: Serge Broom ::: (view all by) ::: July 01, 2012, 12:52 PM:

Michael I... she could always knit while she patrols...

TexAnne *will* be back in "Dragknit"

#119 ::: Fragano Ledgister ::: (view all by) ::: July 01, 2012, 01:22 PM:

Serge Broom #118:

Delivering purls of wisdom along with the arrests?

#120 ::: KayTei ::: (view all by) ::: July 01, 2012, 01:48 PM:

Abi @ 115

Sorry, I agree, that was awkward and isn't even what I meant. I don't know why I didn't catch it.

#121 ::: David Harmon ::: (view all by) ::: July 01, 2012, 02:48 PM:

Lee #114: My understanding is that neo-conservativism (small relation to actual conservativism) was spawned in 60s-70s, at a think-tank called People For a New American Century (PNAC), which trained most of the Watergate crowd (who later returned under Bush and Shrub, and had been active on the sidelines in the meantime). I'm not sure where Obama-style "neo-liberalism" came from in those terms, but it's certainly drifted well away from what I consider true liberalism.

Also, regarding "conservative" vs. "liberal", and the descriptions' non-resemblance to anyone in reach, it's worth remembering that at the moment, both parties have been hijacked by their "neo-" dopplegangers. While "neo-liberals" and "neo-conservatives" may differ on social issues and preferred styles of war, they're both solidly in line with plutocracy, corporatism ("privatization"), and imperialism. (We've seen links posted here discussing this before.)

#122 ::: abi ::: (view all by) ::: July 01, 2012, 03:13 PM:

KayTei@120:

Actually, it was your comment cutting through the fog that made me realize it was time for moderatorial intervention, not because it was wrong, but because it made me realize that even it wasn't likely to get us back onto a workable line of discourse.

David Harmon @121:

Just for the record, talking about the neo-conservative and neo-liberal intellectual and political movements, with particular reference to the think-tanks and pundits who express their ideals, is fine. I'm even willing to see occasional "neo-conservatives/neo-liberals are..." statements, mostly because I know very few people who are emotionally attached to those subclasses of the larger movements.

Just...tread carefully. Continue, as you do there, to shed light as opposed to adding heat.

Thanks.

#123 ::: Chris W. ::: (view all by) ::: July 01, 2012, 04:04 PM:

David @121:

Neo-Liberalism (or the "New Democrats" as they used to be called) draws a direct line from the Democratic Leadership Council, which was founded in 1985 in response to the landslide defeat of Mondale, and has for much of its history served as an important part of the policy establishment around the Clintons.

It's also worth mentioning that the Tea Party movement which seems at the forefront of so much of the insanity in the Republican Party is in many ways a specific reaction against the PNAC neo-conservative crowd. The tea partiers like the Bush administration establishment types about as much as the Occupy folks like the mainstream Democratic types.

#124 ::: Serge Broom ::: (view all by) ::: July 01, 2012, 04:33 PM:

Fragano @ 119... "Just the flax, Ma'am."

#125 ::: David Harmon ::: (view all by) ::: July 01, 2012, 04:47 PM:

Chris W. #123: So, on both sides, we've got think-tank crews having taken over the parties, each with populist revolts¹ in their own ranks. You couldn't make this stuff up....

¹ I'm granting the Tea Party that in origin, even if they have since been (as I believe) suborned.

#126 ::: P J Evans ::: (view all by) ::: July 01, 2012, 05:24 PM:

123
And the progressive/liberal wing of the Democratic Party really doesn't like the DLC centrists, who have voted with the GOP many times.

#127 ::: Howard Bannister ::: (view all by) ::: July 02, 2012, 10:16 AM:

@abi, 115


You know, I think we're going to draw this low-resolution othering of people we don't like to a close. I haven't seen any universal statements about conservatives or conservatism in this thread that would withstand two minutes in the presence of actual conservatives I know, and I know relatively few of them. The liberal stuff is no better, but at least it's being said in the presence of liberals themselves and can be compared to reality.

One of the things that keeps me rigorously defensive* about political discussions is that inevitably whatever sweeping statements I make about conservatives has to somehow include my own mother. Ergo, any statements like 'corrupt paymasters and their simpering puppets' is, um, well... Some days I'd like to just say that, but I don't think I ever can say that.

Because, you know, mummy.

Which is a long and roundabout way of saying thanks.

* I was going to say rigorously honest, but that's not so at all.

#128 ::: Serge Broom ::: (view all by) ::: July 02, 2012, 11:00 AM:

Howard Bannister @ 127... "The Mummy" was a silly bit of fun, but it also had Rachel Weisz and Patricia Velasquez in its cast.

#129 ::: Howard Bannister ::: (view all by) ::: July 02, 2012, 01:04 PM:

Serge Broom @ 128

...I would happily call Rachel Weisz mummy in any number of situations. Brendan Fraser too, come to think of it.

Um. Well. Time to polish off the DVDs, methinks.

#130 ::: SamChevre ::: (view all by) ::: July 02, 2012, 01:11 PM:

abi @ 115

Thank you!

I will comment further on why over on the "Guidelines for Discourse" thread.

Now, over to health-care:

Victoria @ 96

... start pricing health insurance with the intent to negotiate premiums... "I have proof that my employees are good risks. Lower my premium."

That works, but it doesn't fix the underlying problem.

Here's the underlying problem with health care funding[1]. Health care costs are very unevenly distributed, and predictable health-care costs are (probably) even more unevenly distributed. Somewhere around 80% of people could finance their own health-care costs; it's figuring out how to fund the costs of the top 10% that is a thorny public-policy problem. (Demonstrating that your employees, or you, are in the cheap category is what the whole system Victoria describes, or current underwriting, does.)

1)The underlying problem in addition to the very high costs overall, which have gotten some useful discussion and which I linked a more thorough analysis upthread.

#131 ::: Victoria ::: (view all by) ::: July 02, 2012, 03:14 PM:

#130 ::: SamChevre
Somewhere around 80% of people could finance their own health-care costs; it's figuring out how to fund the costs of the top 10% that is a thorny public-policy problem.

Let me rephrase myself. "I have proof that most of my employees are good risks. The ones who aren't, are covered by the ones who are. Lower my premium."

It all comes down to lies, damn lies and statistics. The insurance companies can argue that "we get more bad risks that good risks" because they have a self-selecting set of clients -- all with either health issues or a high risk of getting health issues. If not required, the healthy don't buy insurance until they need it, hence the "health tax." There are two thoughts on this. 1) You may not need it now, but you will need it later. Pay up. 2) Preventive medicine isn't as exciting as emergency surgery, but it is cheaper in the long run because you find the big things and stop them while they're still small and cheap to fix.

FWIW, I'm employed by the state of Kansas in one of the state universities. Kathleen Sebelius set up our current insurance plan after she became governor. I started on the job in '98. Looking back over my records, before Sebelius, we only had health fairs when it was time for the state to re-negotiate insurance. (Health, auto, & property -- I'm peripherally involved in the property insurance negotiations.) Post Sebelius... we have annual health fairs and it saves the state enough money that we're still following her plan after she left office. She was a Democratic governor in a solidly Republican state so I think it says a lot about how good her health cost management plan is. Her political opponents in the state have kept her plan in place after she left office.

As for implementing this plan on a nation-wide scale? There's already a start - county health fairs. Kansas is lousy with them. It's far cheaper to get the standard preventative health care workup from them than going to a doctor's office. The economy of scale kicks in. The county contracts with a lab and all the participants have to do is fill out a SASE, pay $30 and wait two to four weeks for the results to come by mail. No appointment required, people are taken on a first come, first served basis.

Modify the form a bit, make allowances for those that can't afford the $30 fee, and the currently existing county health fair report can be used during tax time to report heath status for insurance cost maintenance purposes.

#132 ::: Jeremy Leader ::: (view all by) ::: July 02, 2012, 03:53 PM:

Regarding Leah Miller's comment at #93 about US MRI costs vs. French (or anywhere else sensible) MRI costs:

Keep in mind that in the US system, the prices on the invoice are not only broken down into ridiculously small pieces in order to maximize each participant's payoff (except of course the patient's), they're also completely fictional. My impression is that no insurance company pays 100% of the listed fee for anything; sometimes they don't even pay 25%. Also, knowledgeable uninsured patients negotiate a "cash price" which, while probably higher than what insurance pays, is probably a lot less than the list price. The price on the invoice is a lot like the sticker price on a used car; it's a starting point for negotiations.

That Incidental Economist series that Sam Chevre linked to at #54 was rather depressing in a way. The US is paying way more than everyone else for health care, even *after* correcting for the fact that we are (on average) wealthier than just about everyone else. The trouble is, there's no one obvious place where all the money's going. It seems like we've constructed this incredibly over-elaborate system, and every piece leaks some money. There's no one easily plugged hole, just a huge labyrinth of dripping pipes.

#133 ::: abi ::: (view all by) ::: July 02, 2012, 04:08 PM:

Jeremy Leader @132:

I know one place the money goes: salaries.

I gather from my American relatives that every doctor's office has at least (at LEAST) one person whose full-time job it is to argue with insurance companies.

Insurance companies are employing people to argue back.

You can argue that the insurance company's person is paid from cost savings (maybe), but the doctor's office one is paid from overheads, charged to the insurance companies as part of the market rate for care.

This is, of course, the kind of efficiency that free markets encourage, as opposed to the bloated bureaucracies of the public sector.

Ow. I just sprained my tongue and bruised my cheek.

#134 ::: Serge Broom ::: (view all by) ::: July 02, 2012, 04:29 PM:

Abi @ 133...

The invisible tongue of the free market?

#135 ::: Serge Broom ::: (view all by) ::: July 02, 2012, 04:34 PM:

(I think the above didn't come out quite right.)

#136 ::: Xopher HalfTongue ::: (view all by) ::: July 02, 2012, 04:47 PM:

Uhhh. Yeah.

#138 ::: Xopher HalfTongue ::: (view all by) ::: July 02, 2012, 04:56 PM:

It's OK, Serge.

#139 ::: Lee ::: (view all by) ::: July 02, 2012, 06:38 PM:

Question: Will the ACA make it easier for companies to hire (or continue to employ) people with expensive pre-existing or chronic health conditions?

Context: A previous health-care discussion here a couple of years back, in which someone recounted their personal horror story with insurance companies and a cancer survivor. The company's insurance provider raised their premium by some unghodly (and unpayable) amount because of the existence of the cancer survivor on the payroll. If they let that one person go, of course, the raise would be rescinded. The company's owner, appalled, went looking elsewhere, and every other company gave the same response: they'd be happy to bid for the company's insurance plan... as soon as the cancer survivor was off the payroll. Until then, so sorry.

Is the ACA going to prevent this type of shenanigans?

#140 ::: LMM ::: (view all by) ::: July 02, 2012, 06:48 PM:

@131: "I have proof that most of my employees are good risks. The ones who aren't, are covered by the ones who are. Lower my premium."

And what if they aren't?

What if (say) two employees have come down with cancer? Or if only one has a serious enough medical crisis that the employees who are good risks aren't really covering them, or if the company is skewed in favor of older workers? Hell, what about *family* coverage?

The health insurance offered by the school district my cousin works for is great -- but it's incredibly expensive, because the costs of a few (post-tenure) teachers with unavoidable but serious medical issues drives up the price of insurance for everyone. (She tried going off of it onto a self-insured plan once, just to save money.) I have other family members who are in similar situations.

Health fairs are all good and well. Paying for preventative care and well check-ups are a good idea. But needing to guarantee that most people are good risks means that (once again) employers will be selecting for the healthy over the sick -- and, for that matter, the employees who have a choice will be picking companies that have fewer sick people.

#141 ::: Tracy Lunquist ::: (view all by) ::: July 02, 2012, 06:52 PM:

There are two things troubling me about the health care issue. One is very practical and the other very philosophical.

The first is that I have not yet had much luck determining how likely it is that my current health insurance (a high deductible catastrophic type plan) will either be acceptable under the new law or be replaceable with something that costs a similar amount.

The second is a message/attitude I see more than I'd like, wherein certain groups or speakers imply that being poor is a choice. What worries me is that this attitude appears to have gotten a solid foothold in a segment of the poor and conservative population, with the outcome that some conservatives of modest means have concluded that their poverty is something they have brought on themselves and that they deserve. I certainly don't think that whining, blaming or abdicating personal responsibility are appropriate, but I'm a little alarmed that the "personal responsibility" message has gotten such a firm foothold that even the people most harmed by the systemic inequalities of the current situation will so readily and staunchly defend it. "handouts" and "entitlements" are bad in this population, even when they would be the ones receiving them.

It seems to me that this is dangerous. If the people in power can effectively persuade others that they deserve whatever they are currently getting, how far can that be taken?

#142 ::: David Harmon ::: (view all by) ::: July 03, 2012, 06:35 AM:

Tracy Lunquist #141: Stockholm syndrome has been a major player in national politics at least since abolition.

#143 ::: SamChevre ::: (view all by) ::: July 03, 2012, 08:38 AM:

Tracy Lunquist @ 141

On "poverty as a choice", can you give me an example?

Because I know that my wife and I have made several choices that we knew would make us have much less money, and I maintain that those were choices, and were good choices that were right for us--but I'm not sure if that's what you are talking about.

#144 ::: SamChevre has been gnomed ::: (view all by) ::: July 03, 2012, 08:42 AM:

On criteria mysterious and arcane,
excluding URL's

#145 ::: Howard Bannister ::: (view all by) ::: July 03, 2012, 08:51 AM:

Tracy @ 141:

Your point 1: Yeah, you may be screwed. There are sliding scales and stuff like that, but folks right on the brink, with income not quite low enough to get government help and not quite high enough to afford health insurance? SCREWED.

Rassem frassem Republican plan with a coat of whitewash....

Point 2: You're spot on. The people in power have been busy persuading people that they got where they are by the almighty power of BOOTSTRAPS, when most of them come from wealth and money. Donald Trump? Went bankrupt six or seven times, as I recall. I don't know if I could rebuild from going bankrupt once. But he had connections and family that I don't have, and for him that's just a hiccup on the road to success.

But ignore that! He's won at business, so clearly he has virtue, and poor people do not!! Pay no attention to the system of privilege behind the curtain!

#146 ::: Howard Bannister ::: (view all by) ::: July 03, 2012, 09:52 AM:

Further reading:

Another Digby link.

Basically, there's two pieces to making sure folks aren't put in a vise by the mandate. One, tax credits for those up higher. Two, expanding Medicaid to protect the working poor.

Well, what happens if States don't accept the Medicaid expansion?

The mandate crushes the working poor, of course.

Naturally, Republican governors are pledging not to accept the Medicaid expansion.

#147 ::: abi ::: (view all by) ::: July 03, 2012, 10:13 AM:

SamChevre @143:

If you're not aware of the strong strain of American discourse that the poor are only poor because they made bad choices...well, I think you have some reading to do before you are likely to be able to participate meaningfully in any further discussion here. Try Googling poor "own fault" and get reading.

Agree or disagree with it, it's a known line of thought. I'm sufficiently surprised that you don't recognize it that I'm having a hard time extending the level of trust and charity to your query that I try to extend to all commenters here, even ones who have already got under my skin with their recent commenting style.

Ahem.

#148 ::: SamChevre ::: (view all by) ::: July 03, 2012, 10:18 AM:

my 143/abi @ 147

Sorry; my request was obviously unclear.

What I'm looking for is examples of poor conservatives saying their own poverty is their own fault, NOT the extremely-common comments by relatively wealthy people that the poverty of those other people is their own fault.

#149 ::: abi ::: (view all by) ::: July 03, 2012, 10:26 AM:

SamChevre @148:

Here's a Tumblr for you. Pick your own examples.

#150 ::: Elliott Mason ::: (view all by) ::: July 03, 2012, 11:29 AM:

For those who, like me, had to google it, "We are the 53%" is referring to the 53% of Americans who make enough money to not be exempted from paying income tax.

There's a particularly telling personal narrative in the photo on top of this story:

I've lived below the poverty line. My wife and I decided in 1996 that we were sick of poverty. We went back to school. We earned degrees. We got jobs. No one handed that to us. We earned it. We did it. I didn't go through all that struggle while raising 5 children so that I could support lazy ass people who want nothing but government handouts. You want to "occupy" something? Occupy a job and start contributing. I AM THE 53%.

I'd love to know how two parents below the poverty line, with children in the household, managed to attend enough college to get degrees? How was there money? Pell Grants? Community college (which are paid for substantially, at least in my city, by state and local property taxes)?

My nasty suspicious mind sniffs potential benefit-usage there (and a strong whiff of pulling the ladder up after themselves), unless someone's grandma died and they paid the tuition with that ...

#151 ::: Elliott Mason got gnomed ::: (view all by) ::: July 03, 2012, 11:32 AM:

I was talking about things relating to abi's Tumblr link, which seems to contain an awful lot of people who are struggling working poor but claim to be middle class ... odd blindness their on their part.

#152 ::: Lee ::: (view all by) ::: July 03, 2012, 11:59 AM:

abi, #149: Wow, that's really sad. The idea that things could be better -- that they shouldn't have to work 60 hours a week and be paid for 40, or work 3 jobs just to make ends meet, or spend the rest of their lives paying off student debt -- just isn't on the table for those people. That's just the way things are, and it will never change, and if you think it could be different you're a starry-eyed liberal idiot.

I suspect this ties in with the Republican strategy of making "hope" -- not just the word, but the concept itself -- a thing to be mocked. There's also an element of sunk-cost fallacy in there; if you've invested a lot of your self-image in "beating the odds thru your own hard work" and then someone else comes along and changes the odds, what does that say about all the time and effort you put in working within the system?

#153 ::: Serge Broom ::: (view all by) ::: July 03, 2012, 12:03 PM:

"Don't forget that most men with nothing would rather protect the possibility of becoming rich than face the reality of being poor."
- Dickinson in '1776'

#154 ::: LMM ::: (view all by) ::: July 03, 2012, 01:41 PM:

@152: That's just the way things are, and it will never change, and if you think it could be different you're a starry-eyed liberal idiot.

There's a more kind explanation (although I doubt it applies to everyone). Admitting that society and external forces limit your choices -- and, to a large extent, control your destiny -- means at least temporarily abandoning the possibility of personal success. If the system is rigged, then you too could do everything right and still fail. And if you can't change the system -- well, you may very well be screwed.

It's victim blaming, of course, but it's a kind of self-protection, because it promises that you won't meet the fate of others. One of the most obvious examples here are cases of sexual assault: She *shouldn't* have gone to the bar alone, or walked alone at night, or done half a dozen other things wrong -- because, if assault isn't the result of violating a rule, then it could happen to you, too.

In the absence of a real movement that promises social change -- in the absence of hope for a better future -- such a belief makes a lot of sense, *particularly* when you're young. (When you're older, if the system is rigged, it explains why you haven't succeeded or barriers you've faced in the past. When you're younger, all it does is tell you that you won't succeed.) And the organized left -- such as it is -- has spent the past three decades *far* more focused on social issues than it has on class. (See What's the Matter with Kansas?, among others.) It's also easy to buy into when you don't happen to agree with the people who want to change the system on other issues (e.g., if you're socially conservative).

There's a strong similarity here with social models for discrimination. I've known several successful African-Americans who have convinced themselves that what people see as racism today is all about class. (Hell, I'm guilty of it myself. Completely buying into the social model of disability when it comes to autism means that, if I work at it and start advocating for change, I have a chance of being completely accepted socially, say, three or four decades from now. It *also* means that I can't really increase my chances of getting laid in *this* decade. See also: diets vs. fat acceptance. [*])

It's a vicious circle, of course: the less hope there is, the more people will embrace victim-blaming, which in turn will reduce the possibility of change. That goes doubly so when the system is completely entrenched. (Where does one begin with financial reform, particularly if one buys the li(n)es about the rich being "job creators" and taxes diminishing personal wealth?)

(Sorry if this is rambling: my cats have decided that I need to wake up with them before sunrise, so I've not gotten much sleep recently.)

[*] I think it's possible to partially blame the system (e.g. yes, one can lose weight, but it'd be nice if it weren't always necessary; yes, it's possible to succeed even if you're quite poor, but it'd be great if it weren't as difficult), but it's pretty difficult to form a movement around such nuanced positions.

#155 ::: Lee ::: (view all by) ::: July 03, 2012, 01:50 PM:

LMM, #154: Another piece of it is that the Great American Mythos doesn't allow for either luck or connections. Person A has done better than Person B not because they were in the right place at the right time, or because they knew someone who could give them a break, but purely because of personal merit. Therefore if you don't succeed, it must be entirely your own fault -- and if you think otherwise, then you're a starry-eyed liberal idiot who wants something for nothing.

#156 ::: OtterB ::: (view all by) ::: July 03, 2012, 02:05 PM:

abi, Sam Chevre, Elliott Mason, Lee, and others on poverty etc.

There are intertwining threads in this argument, and I think John Scalzi did a good job of separating them in this piece from 2007 on getting out of poverty

Thread 1 is that people are expected to work to improve themselves and their situation.

Thread 2 is that work is necessary but not sufficient.

Along with the work is needed a certain level of support and/or luck. One can get support from one's family, from government programs, from non-profit organizations, from friends and neighbors, from scholarship funds. Luck is ... by definition fairly random. I believe that chance favors the prepared mind, but I also believe that people can be subject to catastrophic illness, injury, loss of transportation, etc., through no fault of their own.

There are two points of action. One is helping those currently caught in poverty to get out. Loan them a ladder to help them out of the hole. (Don't stand on the edge and shout down, "Try harder!"). The other point of action is trying to manage the system better so that the holes are shallower and fewer people are caught in them to begin with.

#157 ::: SamChevre ::: (view all by) ::: July 03, 2012, 03:23 PM:

OtterB @ 156

Thanks!

That link, and its indispensable companion Being Poor, are two of the most accurate pieces I've read on poverty.

(I will read the Tumblr, but probably tomorrow--I can't get tumblr at work.)

#158 ::: albatross ::: (view all by) ::: July 03, 2012, 04:19 PM:

abi:

That thread seems to mostly be about one particular thread of the "choosing to be poor" meme: People who make better decisions (work harder, stay in school, stay out of trouble with the law, don't become a drunk or drug addict, don't get pregnant when you can't care for a baby yet) overall do better than those who make worse decisions. The people in that thread are saying they made good decisions at some personal cost and ought not to have to pay to support people who made bad decisions and took the benefits up front.

Now, the basic idea here is correct. Better decisions tend to give better outcomes, which is why parents spend a lot of time trying to get our kids to understand what kinds of decisions are liable to really mess them up (like getting involved in serious crime, getting addicted to alcohol or drugs, getting pregnant at 16, etc). There is no question that a lot of people who are in poverty or in very hard circumstances of one kind of another really did make awful decisions, often of the "eat cake today, defer broccolli till tomorrow" form.

In bumper-sticker-slogan or talk-radio-blowhard form, this loses the rest of the picture, though[0]. There is a huge amount of noise in the system. Some people made perfectly reasonable decisions and then got screwed over by bad luck or big economic changes or illness or something. Most successful people pulled our[1] share of boneheaded stunts, which generally didn't blow up in our faces as they might have. Many of us screwed up in various ways and were bailed out by family or friends.

That said, there are a hell of a lot of people who made awful decisions, and now are paying a price for it. And it *is* unjust that people who made better but harder decisions get stuck with the bill for them. That may be the best we can do (I think you reach diminishing returns very quickly on trying to make sure the beneficiaries of your poverty programs are sufficiently deserving, or even needy enough), but you can believe that while not pretending the injustice doesn't exist[2].

[0] ISTM that a lot of political argument involves responding to talking points from the other side's least thoughtful and loudest members. It's worth remembering that the people who get access to media megaphones are almost never actually the deep thinkers of any political movement, and in fact are often in the business of generating outrage.

[1] I guess I'm successful, if you don't look at our extremely meager retirement savings and our outstanding debt.

[2] And, in the mode of not going into bumper sticker slogan land, I'll point out that you can recognize that injustice while not being blind to the many other kinds of injustice in the world, ranging from uneven luck to uneven starting positions to uneven genetic inheritances.

#159 ::: Lee ::: (view all by) ::: July 03, 2012, 04:32 PM:

Somebody over on DailyKos provides a stellar example of how language framing works, and manages to convert his conservative, Fox-News-watching co-worker into a health-care supporter.

The basic technique: accept, for the moment, one of the right-wing arguments (which, like many such arguments, is true as long as you only look at the surface), and then show how the ACA is going to address that particular issue.

In this case, the argument is "making freeloaders who don't have insurance and run up MY medical costs pay their fair share". The people who are susceptible to that argument don't give a shit about the deeper causes behind "people who don't have insurance" (cf. "if they're poor, it's their own damn fault"), but explaining that the ACA is going to make those people GET insurance (never mind the details -- again, that's not important) opens up a crack in the otherwise-impenetrable armor. It's their own magic words, used back against them.

#160 ::: albatross ::: (view all by) ::: July 03, 2012, 04:42 PM:

Another part of the "chosing to be poor" meme involves the idea that for some poor people on various kinds of assistance, their lives are better on assistance than they are on a job. Again, there's a real, live injustice here--I go to work every day, while someone else lives off my taxes. And again, it's damned easy to turn that into the kind of slogan that loses all nuance and stops further thought instead of encouraging it--think "cadilac-driving, steak-eating welfare queens."

Thinking about it a bit, you sometimes see some realization of why this might happen. This Megan McArdle post is one example from the right end of the spectrum--if you're poor and getting some kind of assistance, you are often facing a huge effective marginal tax rate--increase your income a few thousand dollars a year, and you can actually *lose* money. (A linked paper from the post points out that it is also almost impossible for anyone to know their effective marginal tax rate, without some significant computer skills and detailed knowledge of the rules of all the programs.)

And of course, there's a lot more than incentives going on. Social pressure, examples you see growing up, the need to help your friends and family vs the ability of your friends and family to help you, all have a big impact on what you do. Most of us who grew up middle class went to college largely because we were expected to and our friends were doing it, regardless of any economic incentives. Extended unemployment is very hard on people who have the expectation that they should be working. Both of these probably lead to some amount of people going to college or taking jobs even when these things aren't good economic decisions.

I guess the point of all this is that behind the bumper-sticker slogan level of these memes, there are real issues. And it's very easy to respond to the bumper sticker slogan, and deny or ignore or miss the real stuff.

#161 ::: OtterB ::: (view all by) ::: July 03, 2012, 04:55 PM:

albatross @160, as I understand it there can also be - ironically - health insurance issues. Get a job that makes too much money for you to be covered on Medicaid, but doesn't offer insurance? Have a pre-existing condition? Some of this should get better with the ACA, but I don't have a clear idea of how it will play out.

Child care is the other biggie, of course.

#162 ::: Tracy Lunquist ::: (view all by) ::: July 03, 2012, 05:11 PM:

Lee @155, yes. That. Because of course anyone with a degree and a little relevant experience can send a cover letter and resume in response to a want ad and get a job, right?

(miraculously, that happened to me once. But I think they were so desperate they'd have hired anyone who could fog a mirror and actually answered the ad.)

In my experience (that one weird exception notwithstanding), nobody gets a job without some kind of connection, whether it's through networking or some other mechanism having very little to do with merit.

abi-- thanks for the tumblr link. I tend to be intuitive (I know because I know) and not always as rigorous as I should be. I appreciate the backup. I had forgotten, Elliott, about the specifics of the "53%" as well, although that is probably exactly the source of the rhetoric that led me to my impressions as expressed above. So thanks for that as well.

The myth of the meritocracy is right at the heart of the problem that is bothering me. That, and the giant gaping hole that a poor person's bootstraps have to stretch across, between the "150% of poverty" cutoff of many social programs and enough income to actually live on. America appears to have it in for the people who are trying to span that gap. Am I imagining that?

#163 ::: Tracy Lunquist ::: (view all by) ::: July 03, 2012, 05:14 PM:

Or is it that one party or another has it in for that group? Or is it that the Starry eyed liberals want to help those folks and the big mean conservatives either specifically want to keep them down, or deeply need for them not to actually exist because they are bad for the message?

#164 ::: Lee ::: (view all by) ::: July 03, 2012, 05:35 PM:

albatross, #160: if you're poor and getting some kind of assistance, you are often facing a huge effective marginal tax rate -- increase your income a few thousand dollars a year, and you can actually *lose* money

Yes. I have a friend who used to be in the field of family law, and she said it was amazing how many of her clients fit this basic description:

Married right out of high school (or, sometimes, while still in high school), had a kid or two or three, hubby dumped them for a newer, prettier model -- and is behind or nonexistent on child support. Now they're single moms with kids to support, who have never worked (because they stayed home with the kids like you're supposed to) and don't have any salable skills. The best job they can get is something clerical that pays minimum wage or a bit more. The cheapest apartment they can get goes for 65% of their monthly take-home pay from that job.

At this point, they have three options:

1) Get a job, and be in negative numbers on the budget from the get-go, and have their kids taken away from them for neglect because they can't feed or clothe them;

2) Get two or three jobs, however much it takes to actually have a working budget, and have the kids get taken away for neglect because they're never home;

3) Go on welfare and food stamps, and get subsidized housing and medical care for the kids, and be able to stay home and take care of them like you're supposed to, and be told that you're a leech on the flank of Society.

Doesn't say anything nice about the society that sets up this sort of trap, does it?

#165 ::: David Harmon ::: (view all by) ::: July 03, 2012, 05:59 PM:

Tracy Lunquist #163: A little more complex: The Democrats want their votes, and the Republicans want to use them as alternating, a punching bag and a spare set of Designated Bad People.

#166 ::: GlendaP ::: (view all by) ::: July 03, 2012, 06:16 PM:

The definition of the poverty line used in the US is seriously broken.

http://prospect.org/article/mismeasuring-poverty

Short version: Calculate the cost of food required for a household to subsist in a short-term emergency*. Assume food is about one-third** of a typical household budget, so multiply the food cost by three. Set that as the official poverty line.

*Not adequate long-term nutrition.

**Reasonable 50 years ago when the measure was first devised. Today it's closer to one-eighth.

(Sorry, for some reason I can't get the proper link format to work.)

#167 ::: Howard Bannister ::: (view all by) ::: July 05, 2012, 09:35 AM:

@albatross, 158:

And that basic construction--I made the right choices of not getting into crime--of course leaves out a pretty big reason people are sucked into a life of crime.

Because they can't get a job.

Because they can't get an education.

In my life I had to struggle and sweat to get the breaks I got, and I barely got through. And, as John Scalzi put it, I basically rolled all twenties in character design.

But that kind of view doesn't work well with the bootstraps narrative. Dig ditches!

#168 ::: albatross ::: (view all by) ::: July 05, 2012, 11:27 AM:

Howard,

The great majority of people in poverty do not become criminals. And crime levels vary enormously during times where there aren't big changes in the amount of poverty. And much of the crime engaged in by some subset of poor people has little to do with making a living in a hard world, and a lot to do with being addicted to drugs or alcohol, or just having bad judgment and getting into a fight. So while there's a correlation and probably some crime is economically motivated in the long-term sense of no options (rather than the short-term sense of he has a wallet and I want what's in it), I don't think it explains much.

My understanding is that one important correlation between economic well-being and crime, though, is simple availability. Young men commit most of the crime in the world (at least the lowbrow[0] stuff--there aren't many 17 year old dropouts padding defense contracts or forging document in foreclosure cases, but muggings and smash-and-grab burglaries are well within the reach of those guys). Young men who are in school, at work, or in the army tend to commit a whole lot less crime, all else equal because they're otherwise engaged.

It would be interesting to me to see research on whether there are situations where people do face strong economic incentives to go into crime. I gather this isn't usually the case in a straightforward sense--most lowbrow crime pays very little and involves a big risk of jail time or death or serious injury. (Being a small-time drug dealer or a mugger are both incredibly shitty ways of making a living.) But I think a lot of lowbrow crime looks good to someone with little experience and not much sense, who can see how they get the money today but not how likely they are to go to jail tomorrow[1]. Also, our ever-increasing class of people in unpayable[2] debt have a strong incentive to work off-the-books, to avoid the ability of a court or creditor to get hold of the money. The more off-the-books work is criminal (not just by virtue of working off the books, but because you're being paid to do something illegal), the more we're creating an incentive for crime by having those unrepayable debts.

[0] By lowbrow crime, I don't mean that the perps are always stupid, though I gather a lot of them are, but rather that this is crime that is accessible even to people at the bottom, who don't have a lot of great prospects anywhere.

[1] I know of a horrible and tragic case like this, in a small town. A recently-fired employee of a local restaurant got the bright idea of robbing his former employer at closing time. He brought a gun, murdered the guy, netted probably a couple thousand dollars tops, and was in police custody within a couple days. He'll be in prison till he is an old man, and rightly so, but this strikes me as an example of both lack of morals and bad judgment leading to a crime that was both evil and stupid.

[2] I gather it's not all that uncommon for guys with no skills and a prison record to have two or three child support judgments against them. High paying jobs for dropouts with a GED from their stay in prison are kinda thin on the ground, and I think up to 50% of their wages can be taken for back child support, so this is a class of men whose effective minimum wage is half of the legal minimum wage, and whose effective marginal tax rate is higher than your cardiologist's marginal tax rate..

#169 ::: abi ::: (view all by) ::: July 05, 2012, 11:54 AM:

albatross @168:

The only nit I would pick with your analysis is in this bit:

And much of the crime engaged in by some subset of poor people has little to do with making a living in a hard world, and a lot to do with being addicted to drugs or alcohol, or just having bad judgment and getting into a fight.

I've had a number of family members and family friends over the years who have been addicted to, or have abused (as opposed to occasionally and controllably used) drugs and/or alcohol.

In almost every single case, those people were quite clearly self-medicating, either for specific neurological conditions for which they could not afford—or could not find*—appropriate medical treatments, or for profound long-term depression. (Most of the drug use was for the former; all of the alcohol and some of the drugs was for the latter.)

The incidence of untreated neurological conditions and depression is frequently higher among the poor. This is particularly the case in the US, for the reasons that cause this thread to exist.

Of course, there is still drug and alcohol abuse among the insured, and among the properly treated (these groups are not identical). But there's a whole whack of it that would go away if, for instance, a currently uninsured (and probably undiagnosed) person with ADHD could get a more appropriate stimulant than meth.

-----
* If you're homeless and not connecting too well (because of your neurological condition), it's a lot harder to make all of the testing and evaluation appointments necessary to optimize your medication regime.

#170 ::: albatross ::: (view all by) ::: July 05, 2012, 12:14 PM:

abi:

Yeah, that seems right. Though causality goes both ways: having either a drug/alcohol problem or an untreated/ineffectively treated mental illness is a pretty good way to lose your job and wreck your credit and burn your bridges with family and friends who might otherwise help you out, leading you into poverty. A police record for drug possession probably isn't going to help with getting a new job, either. It's not hard to see how this can be self-sustaining--no money = no treatment for depression = drinking more to self-medicate = losing your job for coming to work with liquor on your breath once too often = no money.

Charles Murray has been pushing the idea that the people on the bottom tend to have worse habits in the sense of 50s morality--more kids out of wedlock, more divorces, more crime, etc. I haven't read his book on this yet, so maybe he addresses this there (he hasn't in the essays I've seen on the subject), but it seems obvious to me that causality here runs in three directions:

More stability in your life makes it easier to stay in school, keep a stable job, do better. (For one example, in a stable marriage, one partner can do something like spend a few years going to school while the other partner supports her.)

A better life makes it easier to keep that other stability going. Wealth doesn't always make you happier, but you're under a lot less stress, all else equal, when you have a stable income and a roof over your head and health insurance and a little money in the bank. It sure seems like that should help with the stable marriage.

A common cause can drive both of these. For example, alcoholism, drug addiction, or mental illness can screw up your marriage and your career at the same time. Being raised with middle-class values can help you keep a job and can make you unwilling to have kids before you're married, say.

#171 ::: albatross gnomed ::: (view all by) ::: July 05, 2012, 12:15 PM:

The gnomes aren't bad, exactly, it's just that they had a rough childhood and bad role models. They're depraved on account of they're deprived.

#172 ::: KayTei ::: (view all by) ::: July 05, 2012, 12:28 PM:

albatross @ 168

It is only a rational decision to adhere to the social contract, if you can expect doing so to benefit you. I suspect that much of what you are describing as short-sightedness can be attributed to people who have learned from experience that the system is stacked against them and the odds are that no matter how hard they work, they will probably never significantly improve their lot in life. However socially undesirable such criminal activity may be, it is not particularly irrational.

The difference between the two groups of kids you're describing, from my perspective, looks like you have one group of kids who believe they can change their future and are engaged in activities likely to result in that sort of improvement, and a second group of kids who don't believe that and don't have access to those activities.

#173 ::: Lee ::: (view all by) ::: July 05, 2012, 02:10 PM:

KayTei, #172: Good point. It's really, really hard for someone who's never had to face poverty -- or who has not faced it without the benefits conferred by a privileged upbringing -- to understand that their well-meaning advice just doesn't work for a lot of people, and that the reason it doesn't is that the system is rigged to keep it from working for those people.

In this regard, encouraging people from the lower socioeconomic classes to apply middle-class morality is no better than encouraging them to accept their lot on earth in exchange for a better life in Heaven; it's a cheap and illusory cop-out. But it's harder for the non-poor to grasp that, because for them, those things would work.

#174 ::: Ginger ::: (view all by) ::: July 05, 2012, 02:46 PM:

My Ex's siblings are a good example of the trap that people face. She got herself out of the small town by applying herself at school, and working her way through all her degrees, because her parents could not spare any financial aid, nor could they give her any pertinent advice (which left her somewhat bitter); her sister who chose a career as a waitress has ended up with bad health, no benefits, and no savings; the other sister married someone who did have a lengthy career as a Federal GS-level employee, but she's trapped in her marriage because she is barely employable herself, and has multiple health issues.

My Ex has tried to point out alternatives to her sisters, but they literally cannot see the utility in making changes. They grew up without any real ambition or hope for change, as that was taught to them at home and at school; they are as trapped within as they are without. Even basic computer skills, or keyboarding/typing, seem worthless to them. They show the outward appearance of middle-class citizens, but behave as if they were lower-class and make their decisions accordingly. It's frustrating to see.

People without any hope for a better future will never change themselves; they need help from the outside world if anything is to improve. Why should they shop for a new car, which is expensive, when they can buy a crap used car for cheap? Yes, the used car breaks down often, putting jobs in jeopardy, and they have to spend money getting it in shape repeatedly, but they don't see that as part of the price. Eating expensive healthy foods doesn't stack up against eating cheap highly processed food that lead to increased ill-health, but they don't see that.

A conversation I had last night reminds me that some families do better at encouraging their children to strive, to do better -- in many cases, immigrants and first-generation Americans embody this, but not always -- and I feel this is an essential part of the problem as well as the resolution.

When my son wants to quit school now, and become a cook, I point out that he'll spend long hours washing dishes in someone's hot kitchen, and be trapped in a cycle of poverty. His birth grandmother, on the other hand, would think his idea had merit. You can see the contrast between their family, and mine; my parents were the first generation to finish college, but they were completely supported by their families, and by New York City public schools, which allowed them to attend high-ranked high schools and City College -- tuition-free.

One of my responsibilities to him is to encourage his education -- academic as well as technical -- so he will not be yet another generation of lost "middle class" struggling to get by. It's really a responsibility that our society has to all of us, because when the least of us can exist without a harsh struggle for survival, then the rest of us can expect continued improvement in our lives as well. It's not trickle-down, it's a rising tide that lifts us all.

#175 ::: David Harmon ::: (view all by) ::: July 05, 2012, 02:54 PM:

Albatross #168, adding to KayTei #172: It's also not "being stupid" about the chances of going to jail for a mugging, if you are likely to be jailed anyway, for Failing to Cringe, or Existing While Black, or Wearing a Hoodie.

Also, that guy you mention in your footnote sounds more like a classic "snapped under stress". And remembering that part of poverty is poor support networks....

It's critical to remember that poverty is not only not inherent to the people, it's not even something that's imposed on them individually -- if anyone you might call for help is going to be as poor as you, that's a problem in its own right. I've got a neighbor or two who superficially matches my circumstances -- diagnosis, disability, un- or barely-employed. But I'm richer broke than they are flush, because I've got family to fall back on -- not to mention education and the credentials that go with it.

#176 ::: heresiarch ::: (view all by) ::: July 05, 2012, 03:19 PM:

KayTei @ 172: "It is only a rational decision to adhere to the social contract, if you can expect doing so to benefit you. I suspect that much of what you are describing as short-sightedness can be attributed to people who have learned from experience that the system is stacked against them and the odds are that no matter how hard they work, they will probably never significantly improve their lot in life. However socially undesirable such criminal activity may be, it is not particularly irrational."

Amen. Someone in poverty has two broadly-defined paths. One is to buckle down, work hard, submit to the system, take its abuses, gradually accumulate the skills, connections, and cash necessary to transition to the middle class. This means forsaking any chance of joy for the next decade or four* in the hope of a big payoff down the road. The other option is to maximize joy in the here and now: skip work to hang with friends, blow your cash on drugs, parties and tattoos (i.e. things that are difficult to repo) instead of saving it, ignore paying your debts, and snatch every moment of joy you can from an overall fairly shitty life you're not even trying to escape.

Which of these actually maximizes joy and minimizes suffering over the long-term depends on how reliably successful the pursuit of middle-class life is, and how much joy can be wrung from a life of poverty. It's staggering how easy it is to be knocked off the "virtuous" path: you can save for years and years, and one time the dice come up snake eyes--your car is totaled, you develop a chronic illness, a child is hospitalized; the list goes on--and everything you've painstakingly built is gone. On the other hand, being poor really is consistently awful: settling for the level of happiness that can be wrung from constant debt and insecurity is settling for not much happiness at all. But I'm not willing to grant that there is an obviously superior choice here--not in the general case, and certainly not in the here and now of post-collapse America.

* Perhaps forsaking it altogether, in the hopes that your children might have it.

#177 ::: Caroline ::: (view all by) ::: July 05, 2012, 03:43 PM:

Ginger @ 174:

Both of those examples seem to me to be habits born not of failure to think long-term, but being financially unable to invest more money now to reduce costs later. Sure, a newer car will be more reliable. But if you've only got $1000 to spend, your choices are a crap car or no car. Sure, more expensive healthier food will cause you to spend less time sick. But if you've only got $10 for groceries this week, your choices are eat ramen or go hungry.

When you live in a constant triage situation, long-term planning is not a skill you tend to learn.

(I think this may have been what you were saying.)

My father works with young men about to be, or recently, released from prison. A lot of what he does is teaching them long-term planning skills for life and money -- the kind of thing that he taught me just by example when I was growing up. These guys are interested in changing their lives, but the strategies they learned to deal with their previous lives (not to mention prison) can be actively harmful in a different context. The skills and strategies my dad teaches -- how to use a bank account, how to build credit, how to get a loan, how to plan your grocery shopping, how to apply to community college and deal with financial aid, etc. -- were just not part of their world growing up, and they're not things they can just learn by osmosis.

It's the same way that Mitt Romney and John Kerry, for example, learned very different strategies, skills, and assumptions about life and money than I did. I simply didn't grow up in a world where venture capital happened or anyone ran companies. In my world you made money by working a 9-5 job at an established company, where if you did a good job you'd get raises and promotions. When I went to a science/tech entrepreneurship workshop a few years ago, I realized I have absolutely no clue how to pitch a business to investors, no idea where to even begin -- but a lot of the people there acted as though the process were obvious and they were just there to refine the details. They'd already learned the basics, probably from their family and friends' parents.

So I can likewise imagine coming from a world where a steady 9-5 office job at a living wage just doesn't happen and you never learn the basics of how to navigate that world.

#178 ::: SamChevre ::: (view all by) ::: July 05, 2012, 03:51 PM:

Comments 172-176 seem to assume heresiarch's statement Which of these actually maximizes joy and minimizes suffering over the long-term depends on how reliably successful the pursuit of middle-class life is...

That has very much not been my observation. People with stable relationships, living with their children, who don't drink to the point that they regret the decisions they made while drunk the next day--they seem to be much more satisfied with their lives even when they are equally poor. (This would be my observation of both the people on the bus, and of the peopel I grew up with--and both demographics skew poor quite strongly.)

#179 ::: albatross ::: (view all by) ::: July 05, 2012, 04:05 PM:

I think there are three threads of argument here:

a. Crime (or other stuff that looks like bad decisions to me) may be good decidions from the perspective of someone poor.

b. Crime (or other stuff that seems like bad decisions to me) may seem sensible to many poor people, for reasons of culture, limited experiences, low expectations, etc.

c. Crime (or other stuff that seems wrong to me) may be morally acceptable or pardonable for poor people, on the theory that the social contract is only worth following if you're not getting screwed over by it.

For (a), I am sure the landscape of good and bad decisions looks different to me than to someone poor with few prospects. However, I'm pretty damned sure that lowbrow crime does not actually pay very well. I've read the claim that bottom-tier drug dealers in Chicago routinely sponge off their mom/girlfriends, because they don't make enough to live on unless they rise up the chain a few places. I've also read the claim that most low-level crime pays very poorly when you factor in time spent in prison. Since most poor blacks don't get involved in serious crime, and don't go to prison, presumably this isn't an idea that's entirely foreign to the experience of people on the bottom. Do most parents of poor black kids encourage them to get involved in drugs and gangs, or to stay away from that stuff?

I suspect that other somewhat common things among poor people, like dropping out of school, getting pregnant/getting their girlfriend pregnant when they're not ready to settle down and raise kids, and borrowing money from payday lenders, are all actually bad decisions that look appealing to someone without much experience or example to draw on and maybe some bad judgment.

For (b), this seems extremely likely. One reason to want universal public education of some kind is to offer kids from poor or dysfunctional families some alternative ideas about how to live, and some tools for doing so.

For (c), I don't really buy the social contract view of morality, for a variety of reasons. People who start mugging, robbing, raping, or killing their neighbors are doing evil, mostly to people who are just as much on the bottom as they are, but it wouldn't be any more right if they terrorized rich white oil billionaires and their wives, rather than single mothers in housing projects or little old ladies living on squat. (The cops come when the oil billionaires call, so mostly the lowbrow criminals rob the little old ladies and single moms.)

#180 ::: abi ::: (view all by) ::: July 05, 2012, 04:22 PM:

SamChevre @178:

But those same people may spend money that they might have saved: buying a better TV, eating brand-name food or going on vacation rather than putting every penny aside for their children's college funds. (Nor, for the record, do I blame them for these choices. But there are plenty of pundits who have, and do.)

Short-term versus long-term thinking is not always incompatible with stable relationships and sobriety. Heresiarch's examples of drugs and tattoos are not the only ways that people who have internalized the idea that there's no point planning for the long term trade the certainty of present comfort for the prospect of future advancement.

#181 ::: Howard Bannister ::: (view all by) ::: July 05, 2012, 04:26 PM:

Just to follow up on my post at 146: if States don't accept the Medicaid expansion, who gets the shaft?

A handy chart.

That's from Ezra Klein's Wonkblog.

#182 ::: Howard Bannister gnomed ::: (view all by) ::: July 05, 2012, 04:29 PM:

For linking to a chart, and then the blog post that I shamelessly stole the chart from.

Well. Links. Addiction.

#183 ::: SamChevre ::: (view all by) ::: July 05, 2012, 04:42 PM:

abi @ 180

And those choices to consume rather than save are choices that I can see as reasonable, and as not having much to do with mental health or criminality. I'm arguing that a lot of the really bad choices don't even succeed in maximizing joy in the next 24 hours, and avoiding those choices can make people much better off.

Also, Doug Muder's Parable of the Maze.

Still others were placed in the maze with no map and no promise. Some were told that there was no feast. Some were told that there was a feast, but that the maze did not lead to it. Some were told that the maze had once led to a feast, but that the way had since been blocked up. Of these less favored ones, many ran randomly from place to place, and though a few of these stumbled out of the maze, most eventually collapsed from exhaustion and stayed where they had fallen. Many others decided to break down the walls of the maze, and beat on them with all of their might. But in the end, they were the ones who were broken, and they stayed where they had fallen. And many others watched the running and beating and falling, and they said to themselves, 'This is pointless. I will stay where I was placed and not waste my effort.'

#184 ::: Avram ::: (view all by) ::: July 05, 2012, 05:49 PM:

albatross @179: c. Crime (or other stuff that seems wrong to me) may be morally acceptable or pardonable for poor people, on the theory that the social contract is only worth following if you're not getting screwed over by it.

I'm not seeing that thread of argument here.

What I am seeing is an understanding of causality, a notion that people who make what are being dismissed here as "bad decisions" aren't doing it just for the sheer joy of making bad decisions. There's more going on than that.

(More later, but I'm'a go out and make a mildly bad, but delicious, decision of my own. And also get more toilet paper.)

#185 ::: heresiarch ::: (view all by) ::: July 05, 2012, 07:07 PM:

SamChevre @ 178: "That has very much not been my observation. People with stable relationships, living with their children, who don't drink to the point that they regret the decisions they made while drunk the next day--they seem to be much more satisfied with their lives even when they are equally poor."

I am concerned that you moved so easily from has tattoos, throws parties, and does drugs to has no stable relationships, doesn't know their children, and abuses drugs, as if having a tattoo renders one incapable of monogamy, as if use equals abuse. I see nothing mutually exclusive between your list and mine, and am surprised that you seem to.

albatross @ 179:

If we're going to talk about crimes, let's distinguish between actual crimes and criminalized poverty. I do admire your uncompromising stance against mugging and murder, even when it's the poor against the poor. But debating the legitimacy of the stigma of underclass crime as if the average criminal act of a person in poverty is armed theft is laughable. Smoking pot. Doing heroin. Being insufficiently submissive to authority. Breaking curfew. Being homeless. Not paying one's debts. These, far more than violent crime, are the characteristic criminal acts of the underclass, the decisions which demonstrate their lack of sufficient moral fiber, for which they are written off as incorrigible, as born parasites. In short: criminality isn't the easy analogue for immorality that you'd like it to be.

I'm not suggesting that knocking over liquor stores is a smart move, that every decision poor people make reflects a cunning and flawless rationality. I'm suggesting that applying the moral worldview based on the assumption that long-term investments usually pay off more than short-term reflects the conditions of middle-class life more than they reflect a truism about the universe. I am suggesting that the assumptions about what is a wise decision is very different when your networth is as likely to be negative as positive--that banking it in the form of some joy now is often wiser than hoping to reap more joy from it tomorrow.

There's a common assumption that the virtuous, working poor who model middle-class behavior, saving money and economizing today, are the ones who have it figured out and are on a path to success. Or maybe they're just engaging in a modern American cargo cult, imitating uselessly the forms of middle-class life in the hopes someday it will arrive. Until we abandon the assumption that middle-class economic reflexes are valid under conditions of poverty, we can't even tell what is and isn't a bad decision.

#186 ::: Avram ::: (view all by) ::: July 05, 2012, 07:33 PM:

OK, back. Forgot what I was gonna say, though. There was something about how social conservatives want to centralize moral decision-making in way that contradicts the lessons of Austrian-school economics, but then I went out shopping and tried to sing Kipling's "In the Neolithic Age" to the tune of Queen's "'39" (it almost works!), and lost it.

#187 ::: elise ::: (view all by) ::: July 05, 2012, 08:14 PM:

heresiarch @185:

Being insufficiently submissive to authority. Well put. And that charge is often bundled with the other ones you mention.

There's a common assumption that the virtuous, working poor who model middle-class behavior, saving money and economizing today, are the ones who have it figured out and are on a path to success. Or maybe they're just engaging in a modern American cargo cult, imitating uselessly the forms of middle-class life in the hopes someday it will arrive. Until we abandon the assumption that middle-class economic reflexes are valid under conditions of poverty, we can't even tell what is and isn't a bad decision.

THANK YOU. Yes.

#188 ::: Lee ::: (view all by) ::: July 05, 2012, 09:49 PM:

SamChevre, #183: Thank you for that link! It makes exactly the point we've been arguing here -- that what's obvious to someone outside the situation may be far less so to the person trapped inside it.

Avram, #186: I think it works pretty well. You have to do it verse-verse-chorus style, and some of the lines have extra syllables, but that's what eighth notes are for. :-) Take the 5th verse in each section as representing the chorus of the Queen song, and then it goes very nicely as ABAB-chorus, ABAB-chorus.

#189 ::: C. Wingate ::: (view all by) ::: July 05, 2012, 10:07 PM:

re 185: The thing is, though, that probably for every person who evaluates their life and makes a decision to not bother with the middle class rat race, there's probably ten whose impulsiveness and other character flaws make that decision for them. I am at the junction of several families which straddle the line between middle class success and failure; and by and large, the difference between the successes and the failures is the presence or absence of just the kind of flaws I'm talking about. It's not an assumption about the middle-class virtues, not for me; it's something I can observe about me.

#190 ::: KayTei ::: (view all by) ::: July 05, 2012, 11:51 PM:

C. Wingate @ 189

How many of those kids would be receiving treatment for ADHD, or depression, or some other such thing, if they had been born into a middle class family with adequate insurance and the money to fund regular copayments?

I feel like these are not single-layer problems. It can be true that some kids are dumber than others. It can still also be true that an upper-middle class kid who smokes pot, or sets off pipe bombs in his neighbor's field, or aims bottle rockets through his neighbor's window, will still get away with more than an equally stupid kid from the lower class, who does the things available to him that require equal levels of stupidity. I don't see the first as something that justifies the second.

Sam @ 178
"Comments 172-176 seem to assume heresiarch's statement 'Which of these actually maximizes joy and minimizes suffering over the long-term depends on how reliably successful the pursuit of middle-class life is...'"

Not mine. I've been pretty clear in my other posts on this site that I have extremely limited sympathy for people who commit crimes and expect to get away with them unjudged. But I'm very aware that the causes of crime are not just "bad people doing bad things." Crime doesn't occur randomly in a vaccuum, it occurs as a generally predictable part of the social ecosystem, which can be studied and understood. In part, that means that if we want to reduce our levels of inner city crime, we would do well to examine how we can improve inner city paths to prosperity.

#191 ::: abi ::: (view all by) ::: July 06, 2012, 04:03 AM:

KayTei @190:
I feel like these are not single-layer problems. It can be true that some kids are dumber than others. It can still also be true that an upper-middle class kid who smokes pot, or sets off pipe bombs in his neighbor's field, or aims bottle rockets through his neighbor's window, will still get away with more than an equally stupid kid from the lower class, who does the things available to him that require equal levels of stupidity. I don't see the first as something that justifies the second.

Amen. I spent the latter part of my upbringing in a firmly upper-middle class (or lower-upper class) town, and I saw plenty of people whose "impulsiveness and other character flaws" would have gotten them locked up, or otherwise ruined their chances, had they been black and in East Oakland rather than white and in Piedmont.

I know how many kids in my high school class had babies (1). And I have a reasonable idea how many of them were sexually active, and I know what teenagers are like about contraception. Fill in the gap...

I knew kids who shoplifted, drove under the influence (we lost a classmate every couple of years to drunk driving, but no one got locked up for DUI). I dated the local "bad boy" for a while, the one who had been the go-to guy for a cherry bomb or a firecracker—and the suggestions for how to use 'em—when we were kids. (He did end up getting sent to reform school. For otherwise consensual underage sex with the daughter of the wrong person*.)

Bad boy was last heard of going to law school. Those drunken, sex-obssessed kids are now respectable adults and members of the Establishment: doctors, lawyers, politicians, techies, professionals of all stripes.

There are a lot of poor people who don't do everything right. But there are a lot of rich people who don't either. And they seem to make out OK anyway. Some of 'em even break entire banks or manipulate key economic indicators, yet seem to be able to keep a roof over their heads and a sports car in the garage anyway.

A system where some people have to be saints and may yet not rise, while others can be sinners and never fall, is not a system where sanctity really matters. It just isn't.

----
* not me, for the record

#192 ::: C. Wingate ::: (view all by) ::: July 06, 2012, 07:41 AM:

re 190: I don't think we disagree as much as I sense you might like to believe.

#193 ::: Elliott Mason ::: (view all by) ::: July 06, 2012, 09:34 AM:

abi @191: A system where some people have to be saints and may yet not rise, while others can be sinners and never fall, is not a system where sanctity really matters. It just isn't.

I just wanted to look at this some more. QFT, as we say on another board of mine.

#194 ::: abi ::: (view all by) ::: July 06, 2012, 09:40 AM:

C Wingate @192:
I don't think we disagree as much as I sense you might like to believe.

(emphasis added)

WTF?

#195 ::: Patrick Nielsen Hayden ::: (view all by) ::: July 06, 2012, 09:51 AM:

I don't think I had the same breakfast as I sense C. Wingate believes I did.

I don't have the same opinion about MIDDLEMARCH as I sense C. Wingate might prefer to think I do.

I don't support Stannis Baratheon's quest for the Iron Throne as much as I sense C. Wingate would like to imply.

Hey, this is fun! Everyone can play!

#196 ::: albatross ::: (view all by) ::: July 06, 2012, 12:28 PM:

Sane conservative commentary on the healthcare law

In our media/social/political environment, where the loudest and craziest folks on the right get the megaphones and the sane and smart ones are mostly afraid to contradict them for fear of losing their cushy think-tank jobs, it's important to highlight where people on the other side are actually talking sense.

#197 ::: heresiarch ::: (view all by) ::: July 06, 2012, 12:28 PM:

C. Wingate @ 189: "The thing is, though, that probably for every person who evaluates their life and makes a decision to not bother with the middle class rat race, there's probably ten whose impulsiveness and other character flaws make that decision for them."

You're in their heads, and know precisely what drives them?

The value judgement implicit in the distance between "evaluating one's life" and giving in to "impulse" is precisely what I'm challenging. We tend to assume that people making middle-class decisions are doing it for analytical, thoughtful reasons and that people making "poor" decisions are acting impulsively. Why? Isn't it just as possible that someone is saving money and working hard because that's what they find psychologically satisfying and offers them a false sense of security and self-worth? Isn't it possible that the person who blew off work to smoke weed with her friends is making a perfectly rational decision to maximize her life-long happiness?

"I am at the junction of several families which straddle the line between middle class success and failure; and by and large, the difference between the successes and the failures is the presence or absence of just the kind of flaws I'm talking about."

Now you're assuming that reaching the middle-class is synonymous with success--that anyone who doesn't make it into the middle class has "failed." This fits right into the narrative about character flaws: why there's a staggering correlation between people who don't prioritize getting to work on time and people who don't make it into the middle class! Clearly it's their "impulsive" lack of self-discipline that lead to their "failure" to achieve middle-class status. But it's all tautological: they are flaws because they lead to failure, and failures because they're produced by flaws. If you don't go to work regularly because you don't care about getting into the middle class, how is it a "flaw" or a "failure?"

In the same way that we criminalize poor behavior, we pathologize poor psychology. It's oppositional defiant disorder, not a sensible response to a world where authority figures are typically trying to get you to do things against your best interest. It's lack of self-discipline, not a recognition that work is designed to take as much as possible while offering as little as possible in return. Certainly these things can be pathological: so can obeying instructions too ardently and working too hard. Strangely, the neuroses those excesses produce aren't nearly so worrying.

Do poor people do stupid things for bad reasons? Yes. Do they do it a higher rates than middle-class people? Not so you'd notice. Is it the reason they are poor? No.

KayTei @ 190: "I've been pretty clear in my other posts on this site that I have extremely limited sympathy for people who commit crimes and expect to get away with them unjudged."

Criminality isn't what I was discussing--it's not even what SamChevre said I was discussing.

#198 ::: Jim Macdonald ::: (view all by) ::: July 06, 2012, 12:40 PM:

PNH #195

Stannis Baratheon indeed! Daenerys Targaryen is the only one of the whole bally lot with a legitimate claim to the Iron Throne.

#199 ::: C. Wingate ::: (view all by) ::: July 06, 2012, 12:43 PM:

For your information, I had a glass of milk and a couple of the four-day-old doughnuts out of the refrigerator, which happen to be just about the only food in the house because everything else is rotten from the power failure and we've been afraid to buy anything much for fear it will fail again. Tonight we get to throw everything out and start restocking. Meanwhile my sleep is thrown off from the power failures and the anxiety over paying for the repairs and the tree removal on top of all the other deferred maintenance I've been trying to make some progress on so we can finally refinance, and hoping that my car doesn't quit running completely (cannot find the time to get it to the shop, afraid we can't afford the repairs and the work on the house at the same time).

I don't have an opinion on Middlemarch because I haven't read it.

#200 ::: abi ::: (view all by) ::: July 06, 2012, 12:55 PM:

C Wingate @199:

It sounds like a stressful situation. Sympathy and best wishes for improvement.

One day, when you're a little less stressed, let's talk about the nature and structure of apologies.

#201 ::: SamChevre ::: (view all by) ::: July 06, 2012, 01:22 PM:

heresiarch @ 197

The value judgement implicit in the distance between "evaluating one's life" and giving in to "impulse" is precisely what I'm challenging.

Correct: and it's precisely what I am insisting is an important distinction.

Here's the best distinction I can come up with: if you routinely are unhappy about the decisions you made last night, or last weekend, AND you continue to do those things whenever the opportunity presents, THEN you have a problem with acting on impulse.

Sure--you can have very different ideas about what would be a good life than I, and sure, it can make sense for you to do things that I wouldn't in pursuit of those different goals. But that's mostly not what I hear about when I ride the bus, or talk to my more dysfunctional neighbors; mostly, what I hear about is doing things that seemed like a good idea at the time, that have ended badly the past 15 times, and that the conventional wisdom of the past several millennia has held to be a bad idea.

The fact that the rich have always been able to be "..careless people...[who smash] up things and creatures and then [retreat] back into ...their vast carelessness... and let other people clean up the mess they [have] made," is not, in my opinion, something that anyone else ought to be encouraged or assisted to emulate.

#202 ::: SamChevre has been gnomed ::: (view all by) ::: July 06, 2012, 01:23 PM:

Probably for using square brackets...

#203 ::: Jeremy Leader ::: (view all by) ::: July 06, 2012, 01:32 PM:

Wow, Albatross @196, I'm going to go a bit "no true Scotsman" here, and ask if you really think Conor Friedersdorf is a conservative. He seems to consider himself one, but perhaps more importantly, do other conservatives consider him a conservative?

Of his 7 bullet points of things he thought were more important than repealing the individual mandate, I (a self-identified liberal) agreed completely with 6, and on one I thought "Eh, maybe, but is that really a big problem? If so, it's certainly not a high priority to me." A very different reaction than I usually have to the writings of conservative pundits. Usually I find myself thinking "yes, that would make sense in some alternate universe where X and Y didn't exist, and our biggest problem was Z."

#204 ::: C. Wingate ::: (view all by) ::: July 06, 2012, 01:41 PM:

heresiarch, there is no point in telling me I don't know what's in their heads when you have spent half this thread telling me what's in their heads. For that matter, you just told me what's in my head. It seems to me that the kind of analysis you're putting forth authorizes, by parallel, my suppositions on the behavior of people I have observed.

#205 ::: abi ::: (view all by) ::: July 06, 2012, 01:47 PM:

A couple of general statements for everyone's consideration at this juncture:

People rarely do what they do for only one reason. Ever.

These are contexts where more than one seemingly contradictory thing can be true at the same time.

#206 ::: Serge Broom ::: (view all by) ::: July 06, 2012, 01:53 PM:

"Don't lose your head."

Freddy Mercury in 1986's 'Highlander', the movie that to this day TexAnne still insists has no sequel.

:-)

#207 ::: abi ::: (view all by) ::: July 06, 2012, 02:01 PM:

Serge @206:
'Highlander', the movie that to this day TexAnne still insists has no sequel.

It totally does. 'Highlander 3'.

...

What? Why are you looking at me like that?

#208 ::: heresiarch ::: (view all by) ::: July 06, 2012, 02:47 PM:

SamChevre @ 202: "Correct: and it's precisely what I am insisting is an important distinction. Here's the best distinction I can come up with: if you routinely are unhappy about the decisions you made last night, or last weekend, AND you continue to do those things whenever the opportunity presents, THEN you have a problem with acting on impulse."

And I am saying I don't think that word means what you think it means. In my experience, the routinely-made decision that most often makes people unhappy is going to work. I know plenty of people who are animated in their careers and lives by a hypertrophied sense of guilt and obligation, that drives them puppet-like to great success and zero joy. Where does that put a link between dysfunction and poverty? The poor impulse control theory of poverty is no more than a just-so story that explains only the surface of poverty, not the substance.

C. Wingate @ 204: "heresiarch, there is no point in telling me I don't know what's in their heads when you have spent half this thread telling me what's in their heads. For that matter, you just told me what's in my head. It seems to me that the kind of analysis you're putting forth authorizes, by parallel, my suppositions on the behavior of people I have observed."

If you believe that I have been putting forth in this thread a positive argument about what is going on in poor people's heads then I have written unclearly. The argument I have been making in this thread is this: standard narratives about what behaviors lead into and out of poverty, what lead into and out of happiness in poverty, are wrong. It treats as universals assumptions about what strategies are successful, what goals are worthwhile, that are only valid under middle-class economic conditions.

In the service of this negative argument--that we don't know what we think we know--I've made weak arguments about how decisions typically regarded as irrational might actually be rational; about how characteristics typically associated with poverty are actually evident through out the class spectrum; that poverty is criminalized as often as the poor act criminally. The purpose of these arguments is not to assert that the poor are never irrational, crazy, or criminal, but to counter the argument that they are always, archetypically so; that these are essential characteristics of the class. A singular, categorical view of poverty is precisely what I am arguing against.

#209 ::: Avram ::: (view all by) ::: July 06, 2012, 03:05 PM:

Jeremy Leader @203, according to an interview cited on his Wikipedia page, "Friedersdorf [...] has right-leaning views but [...] does not consider himself to be a doctrinal conservative or a member of the conservative movement." He used to be an intern for Andrew Sullivan, who himself identifies as a conservative, but has a somewhat complicated relationship with conservatism as a movement. I'd say it's a complicated thing.

It's pretty clear that the article Albatross linked to is aimed at that particular branch of the population that typically calls itself something like "small-government conservative", and uses rhetoric designed to appeal to that branch.

#210 ::: Lee ::: (view all by) ::: July 06, 2012, 04:39 PM:

heresiarch, #197: Somewhere I've got a button which sums this up very nicely:

Why should I spend my life doing work I hate to get money I don't need to buy stuff I don't want to impress people I can't stand?

Some people, of all social classes, decide to opt out of the rat race. They figure out how to make enough money that they're not suffering, and beyond that they don't care about the trappings of middle-class success. They are, without exception, labeled "failures" by people whose only measure of success is how much you look like the TV-show, cookie-cutter model.

What I tend to consider more important is, does this person say they want to have the trappings of middle-class success? Are they unhappy because no matter what they do, they can't seem to get any further up the ladder? Then it may be worth looking at what they're doing... but only with heresiarch's caveat in place, that aping the mannerisms of the middle class may only be cargo-cult behavior if you're poor.

#211 ::: KayTei ::: (view all by) ::: July 06, 2012, 04:56 PM:

heresiarch @ 197

Sorry, that was a bit of a 90 degree turn, wasn't it? I've been a bit distracted recently, and the chain connecting those two concepts was crystal clear to me inside my head... :D

It connects up, because I think that criminality - which is, I think, one of the forms of poor decision-making we (and particularly I) have been discussing - is always a bad choice. I think it's one of those things that never ends well, even when you think you're getting away with it. So I can, on the one hand, believe completely consistently that criminality will never result in increased happiness, and on the other hand, believe equally consistently that it is still a rational choice for people who don't hold my viewpoint about the nature of crime. And that is directly related to my previous posts, and it is why the quote I was responding to is an inaccurate reading of my post.

#212 ::: albatross ::: (view all by) ::: July 06, 2012, 11:32 PM:

Jeremy/Avram:

I think Connor Friesdoerf is somewhere on the libertarian end of conservative, or the conservative end of libertarian. He has made whaf seem to me to be pretty sensible comments and critiques of both Obama and the Republicans for the last couple years. I haven't seen any in-depth reporting or analysis from him, though.

And again, it's damned important to find sensible people who aren't on your team, and hear what they have to say. The alternative is allowing your mental picture of peope who disagree with you to become Rush Limbaugh or some such idiot. That's just another way to make yourself dumber.

The megaphones on the right are overwhelmingly in the possession of people who will never add anything meaningful to any discussion. The people who are smart and do think deeply seem to me to mostly be unwilling to criticize the blowhards, though maybe that s common and I miss it because those guys don't get the megaphones. That makes it really important to find and understand people on the right who aren't blowhards or fools, and who aren't afraid to call the blowhards out.

#213 ::: Lee ::: (view all by) ::: July 07, 2012, 01:27 AM:

albatross, #212: That seems to fit. I looked at the article, and the only point I disagreed with him on was pure Libertoonian nonsense:

Countless thousands are prevented from entering into the profession of their choosing -- hair-braider, interior designer, lawyer -- due to onerous professional licensing requirements, despite zero evidence of their efficacy.

First off, that last clause is presented with zero evidence of its truth -- because I say so, nothing to see here, move along.

Secondly, DAMN STRAIGHT I want some sort of gatekeeping on the person I entrust with my legal problems! Asking an unlicensed "lawyer" to draw up your will is like... asking someone with only self-published books to ghost-write your story, without being able to view samples of their work. You might get lucky and it would be someone like Amanda Hocking or Henry Melton, but the odds are overwhelming that you'd end up with somebody more like the ones who get made fun of on Amazon. (Or somebody like my father, who thought he and a will-writing software package could do better than a lawyer, and I'm still paying for that both figuratively AND literally.)

And yeah, I want the person who dyes and/or cuts my hair to have had some training too. Bad haircuts are a pain even though they grow out, and an unskilled dye job can do physical damage -- those are some pretty strong chemicals.

#214 ::: Avram ::: (view all by) ::: July 07, 2012, 02:22 AM:

Lee @213, how much gatekeeping do you need?

Right now, becoming a lawyer in the US generally involves getting a 4-year college degree in some arbitrary field, followed by 3 years of law school. This means that in order to become a lawyer, you need to be able to afford seven years of expensive schooling.

Several famous lawyers of the 18th and 19th centuries would've been trapped on the wrong side of that gate. Abe Lincoln never went to law school. Neither did supreme court chief justices John Jay, John Marshall, Roger Taney, and Salmon Chase. Clarence Darrow only attended law school for a year.

And haircuts? One of my dormmates in college used to make pocket money by giving haircuts in the bathroom; one of my roommates was a repeat customer. Should she have gotten a license first?

Should there be a blogger's license? We've all seen how much influence blogs can have over the political process --- maybe there should be a law requiring people to spend a few hundred bucks getting a piece of paper vouching for their honesty, integrity, and ability to use blockquote tags.

#215 ::: P J Evans ::: (view all by) ::: July 07, 2012, 10:08 AM:

214
Avram, the gatekeeping mechanism for lawyers is the bar exam, not the schooling. It's their version of getting a license to practice.

#216 ::: David Harmon ::: (view all by) ::: July 07, 2012, 11:08 AM:

Lee, Avram: The thing is, when you get down to hairdressers, plumbers, and such, there gets to be a really fuzzy line between licensing to assure competence, and simply limiting the competition.

Even with lawyers and doctors, the professional exams are set up to match the educational gauntlets provided by the universities, and those educational burdens are so expensive as to distort the economics of their professions.

Teaching holds a middle ground here, in that they're trying to maintain professional status, but running against the issue that "anyone can stand at the front of a classroom and talk"... and the differences provided by actual training are not only poorly-understood, but contentious in their own right. (E.g., "What conflict resolution, kids fight all the time...", let alone the sex-ed and evolution battles.)

#217 ::: joann ::: (view all by) ::: July 07, 2012, 11:59 AM:

PJ Evans #215:

Things have changed a touch from 120 years ago, when not only did my grandfather become a lawyer without going to law school, he also apparently did not go to college. The bar exam was, as near as I can tell, a viva voce in front of all the local judges, after a protracted period of "reading law" at nights and on weekends. (IOW, gatekeeping was done by the local people most concerned.)

#218 ::: P J Evans ::: (view all by) ::: July 07, 2012, 12:13 PM:

217
I understand that some states allow you to take the bar exam after 'reading law' with a practicing lawyer. It's an honored tradition - Lincoln read law. (In California, the bar exam takes two days.)

#219 ::: Avram ::: (view all by) ::: July 07, 2012, 01:56 PM:

PJ Evans @215, except in some states, the schooling is a mandated prerequisite for taking the bar exam. I'm about 90% sure that if we had Friedersdorf here, he'd say that it's the expensive educational requirement he was talking about in the case of lawyers, not the bar exam, mostly because I've heard other people with similar politics to his talk about this in the past.

#220 ::: Elliott Mason ::: (view all by) ::: July 07, 2012, 03:08 PM:

Here in Chicago, the 'hair braider' part he talks about is a going political issue, hard-fought on both sides.

There is a largish and growing from-Africa-recently population in certain areas of the city (some specifically as refugees; others economic migrants doing the Right Legal Way). The women of these groups have certain hair-care expectations and styling desires, and generally prefer to pay a skilled professional to do their monthly/whatever maintenance and infrastructure, rather than trying to do it at home with their auntie or whatever.

They generally, when asked, say they dislike the way the "American" (their word) salons deal with their hair, and think they both offer too few braided/twisted styles and that the service offered is sub-par. So some trained hair-braiders with decades of experience who have also immigrated, set up small businesses advertising "African Hair Braiding And Styles" in the window (otherwise, from the outside, the shops aren't terribly visually different than the other small black-owned salons in the area; some also offer relaxing).

The local salons are screaming about it, partly because in order to set up, THEY had to go get a cosmetology license, which has a couple of years of schooling and a lot of training in things like inspecting people's scalps for cancer and other conditions (while you're up there), colorant, perm, and relaxer chemistry, and goodness-knows what-all else.

The "African" salons don't see why they should throw away money and time on a cosmetology license when what they're doing is a shampoo-and-braid, the which they have been doing for 30 years now, and are more than a little insulted at the thought that the "American" salon-owners see them as ignorant, untrained amateurs trying to muscle in and deceive a loyal customer-base.

Um, yeah. So there's a lot of fighting about it, sending delegations to their alderman, talking to their state reps trying to get (or prevent) state-wide laws passed ...

Meanwhile, almost all the reputable, established tattoo-and-piercing shops in greater Chicagoland really, really want the state to pass a licencing-test requirement in THEIR profession, because they're constantly cleaning up behind the efforts of their less-reputable 'peers', and some seriously negative health outcomes can come from slipshod piercing/inking. That could be viewed as acting as a 'gatekeeper' to keep people out of their business, but most of those same shops are happy to apprentice anyone wanting to learn the craft; they don't feel there's any real limit on their business by having more providers available.

#221 ::: Jeremy Leader ::: (view all by) ::: July 08, 2012, 03:13 AM:

Yeah, the "gatekeeping" point was the one I had the "eh" reaction to. I see value to both sides of the argument; there are potentially serious public health aspects to hairdressing, for example (a young relative stayed home from first grade yesterday due to head lice). I'm a computer programmer, and I've watched discussions for the last 30 years of whether we should be licensed. I know several licensed civil engineers; you can't sign off on blueprints (indicating their soundness and safety), or advertise your services as an "engineer" if you're not licensed. Just today, I saw an item in the LA Times about a controversial new requirement for pet groomers to be licensed.

#222 ::: Bruce Cohen (Speaker to Managers) ::: (view all by) ::: July 08, 2012, 03:02 PM:

Here's an analogy that may illuminate the issue of the validity and success of different life strategies. In discussing biological reproduction strategies1 biologists identify 2 general strategies: K-selection (produce a few offspring, but put large amounts of the parents' resources into each, gambling that most offspring will survive and reproduce) and r-selection (produce many offspring, putting small amounts of resources into each, gambling that some will survive and reproduce).

You can't directly compare the two strategies and say which one is better in general; their success depends on the nature of the organism involved and the environment in which it lives. Squid, for instance, typically use r-selection and have been successful with it, while humans use K-selection and arguably have been extremely successful. On the other hand, humans in the past, and those in undeveloped areas have often used a strategy that was more like r-selection than the current most common strategy in developed areas; the difference in part is due to the improvement in infant and child mortality. If the resources available to a parent don't allow for a strategy that's the most like K-selection possible to the organism, then something closer to r-selection is the most viable choice.

The choice of strategy for organisms other than human is not a conscious choice, and for most humans it isn't necessarily conscious either. Does it have a moral component? IMHO not in the same way many commenters in this thread have assigned a moral component to the question of long-term versus short-term choices. It might be instructive to discuss in what ways these two kinds of choice differ, and how those differences affect the nature of their morality.

1. Let's limit the discussion to the more complex eukaryotes so as not to get into digressions about horizontal transmission of traits, and the nature of species, and all the other issues that single cell and colony organisms raise.

#223 ::: JFW Richards ::: (view all by) ::: July 09, 2012, 11:41 AM:

Highlander, there should be only one.

#224 ::: Jeremy Leader ::: (view all by) ::: July 09, 2012, 01:05 PM:

So today I saw an article on the front page of one of the WSJ's inner sections about health care reform. I haven't read the whole thing yet, but the first few paragraphs seem to be expressing amazement at the shocking idea that relatively few people get most of the benefit from health insurance. I think I'm detecting a subtext that this is fundamentally wrong somehow.

I'm almost speechless; this is supposed to be the US's premier daily business newspaper, and their reporters and editors don't understand the basic purpose of insurance? That everyone pays in, and the unlucky few who experience catastrophic problems get their expenses covered by the collected funds?

#225 ::: Jeremy Leader ::: (view all by) ::: July 09, 2012, 01:07 PM:

Oh, and the other thing the WSJ finds shocking is that people who require extremely expensive medical care often don't survive it.

#226 ::: fidelio ::: (view all by) ::: July 09, 2012, 04:30 PM:

Whether in its editorials or in its articles reflecting political issues, it is the WSJ's firm policy to remain loftily unaware of how the 99% lives. It is remotely possible I am doing them staff of this publication a disservice, but what comes out in its pages on these matters firmly reflects the preferred worldview of the ownership, even if it means ignoring the issue of inconvenient facts, which tend to have, as we all have heard, a certain bias which the Murdoch clan finds distressing to contemplate.

Amazingly, what they report on individual businesses is not generally contaminated by this attitude, so I can only conclude that where making (or losing) money via investments is concerned, facts, inconvenient or otherwise, are preferred.

#227 ::: Lee ::: (view all by) ::: July 09, 2012, 04:45 PM:

Elliott, #220: A good point; this is a nuanced issue, which is exactly what was missing from Friedersdorf's blanket condemnation of licensing. I find that sort of throwing-the-baby-out-with-the-bathwater absolutely typical of what I call "toon economics". (Which relates to real-world economics in exactly the same way that toon physics relates to real-world physics.)

#228 ::: Bruce Cohen (Speaker to Managers) ::: (view all by) ::: July 09, 2012, 05:33 PM:

fidelio @ 226:

Your point is borne out by the identity of the owner of the WSJ: Rupert Murdoch.

#229 ::: Tracy Lunquist ::: (view all by) ::: July 09, 2012, 09:52 PM:

@223 -- where's the "like" button?

@224, well, yes, but I think by now many of us have come around to the understanding that health "insurance" isn't really like other kinds of insurance. The system is way too convoluted for that notion to apply. If you don't have homeowner's insurance and your house burns down, you lose; end of story. If you don't have health insurance and you go to the emergency room, you WILL be seen and your critical needs will be met. If you do have homeowners insurance, it probably doesn't cover routine fire safety checks or lab tests for the presence of "sick building syndrome", but your health insurance covers just such preventive sorts of stuff. Unless it doesn't. And if it does, there's a good chance your premiums far exceed the price you would pay for such care if you just paid cash for those appointments and carried a high-deductible "catastrophic" policy. If you go to the doc/hospital/pharmacy and are able to pay for your care, you will be overcharged to subsidize the uninsured regardless of what insurance coverage you yourself have. You can have more than one form of health insurance coverage, and if you do, there will be a fearsome battle among your insurers, each seeking to avoid paying for your care based on the fact of the other's existence. Some people get health insurance from the government and some don't. Some get health care from the government and some don't. Some get government health coverage and end up paying more than they would if they were just paying cash (for a glimpse into the seventh circle of hell, read up on "Medicaid Share of Cost"). I would cheerfully pay into a system so simple that I was just betting some money that I wouldn't get sick.

Here in Volusia County, Florida, some of our homeless folks provoke the local constabulary to arrest them, exactly so that they WILL go to jail. Jail, after all, is four walls and a roof, and three meals a day. Jail time as a negative on the crime income balance sheet works only if you're actually worse off in jail. We also have some folks who use the emergency room as their primary care provider, and a few of them have in fact been to the emergency room 20 or more times in a year. Cost to the taxpayers tends to run $1000 per visit and up, so that's a trend worth reversing.

As to decision making, I think the discourse here has traveled in a favorable direction, away from speculating about how poor people make decisions and toward acknowledging that people make decisions using the same strategies regardless of their socioeconomic status.

The idea that a poor person might make a choice that leads to a quicker form of gratification vs. saving up for a longer-term goal is a fine idea as far as it goes, but the person I know whom I see make those choices most often is single, mid-40s, white, and making roughly $45K a year. The repeated decision that makes that person miserable is the decision to go to work every day, but more importantly, said person is operating from a very firm belief that zie is *stuck* where zie is. There's plenty of data that supports hir belief, but as you all know, you can make data tell any story you want. To me, the critical issue here is that everyone, regardless of any characteristic of themselves you would care to name, social, racial, economic, intellect or otherwise, acts from a set of assumptions about the world that they have been forming since birth. If that set of assumptions includes "I can't change my circumstances," the facts will agreeably pile on in support of that belief. Same holds for any other assumption. 80% of everything we do happens below the conscious level, and that keeps us all from going insane. But a huge chunk of the 80% is the fabulous designer collection of self-limiting beliefs we all hold, and unless and until we can get a good look at those and rewrite our personal scripts, nothing that matters is going to change.

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