Yep it's clueless, heartless and pointless other than as yet another piece in Bush's class war against the poor.

And from the way it sounds, he wants us who have company-sponsored health insurance to pay taxes on it to pay for low income insurance. Right now they are talking about only charging 'gold plated insurance' but I would bet money they'd apply to all eventually to avoid 'discrimination.' Against his rich buddies.

I may be misinterpreting, but it doesn't sound good. Then again, do any of his proposals?

And he wants the companies to be discouraged from providing high-quality health-care plans to employees by limiting the deductibility to the companies of the cost of those benefits.

All part of your Ownership Society.

It's even worse than that.

According to the news coverage I read, he apparently wants to "fund" this, by treating employer-paid premiums for a better than average health insurance plan as taxable income. Those are currently not considered income and are non-taxable. So he's going to "level the playing field" by trying to drag down everyone who has employer-provided health coverage towards the level of the uninsured.

Is Shrub going to do something to make health insurance actually cover everyone who wants it (as in 'you can't be turned down for anything except fraud')? Because if that doesn't change, the problem will still be there.

Not to mention that even people who can afford the astronomical premium and/or deduction are being turned down by private insurers for such expensive and life-threatening maladies as heartburn (acid reflux), athsma, ear infections and allergies.

If I were a theist, I'd thank the gods every day for my new union job with benefits; otherwise my easily maintained thyroid condition ($10 for a generic scrip, even without insurance) and my garden-variety fatness (see aforementioned thyroid condition; BP, cholesterol and blood sugar all just peachy) would surely keep me from insurance, and I'd never be able to pay the hugely inflated costs on the bill for anything beyond a strep test.

"I warn you not to be ordinary - I warn you not to be young - I warn you not to fall ill - I warn you not to get old."

I loved Webb's response, but it would have been nice to see him slam Bush's health insurance nonsense as the third prong of his devastating attack. I tend to think he actually should have lead with the mismanagement of the war, followed up with the spiel about the robber baron CEOs and disappearing middle class, and finished up with health care as a prime aspect of the second one.

"The tax break's nice, Mr. President, but I think Rep. Conyers actually has a better idea... one that would actually insure *all* of those forty-six million and bring down costs for *all* of us."

I may be misinterpreting, but it doesn't sound good. Then again, do any of his proposals?

Sometimes they do, but only when the proposals are presented with few details. It's then a question of whether or not you believe this administration will get the details right.

Tennessee's replacement for Medicaid, Tenncare, has not been the perfect medical-coverage plan for the otherwise-uninsured; there have been problems with the administration of the plan, and not all of the providers who signed up for it handled their end of the work honestly and well.
However, from my viewpoint in the bowels of the welfare system, I've seen the difference it made for the people enrolled in that program to get real, ongoing care from doctor's office and regular clinics, instead of showing up in hospital emergency rooms when things were too bad to ignore any longer.
There are numberless conditions that can be reduced to minor inconveniences, "better keep and eye on that"s, or eliminated altogether with consistent monitoring and treatment. Even larger public facilities can send people to their outpatient services centers, and get necessary monitoring and diagnostic tests for them, instead of dealing with them as crisis customers in the emergency room. Some of these people were unable to work at all, or to work consistently because the constant interruptions from illness made any but the most patient of employers unable to tolerate their frequent absences due to illness.
People who don't have regular medical care aren't just at risk of severe illness and death, they're often unable to support themselves and their families. It's an issue like education--people who lack basic skills aren't likely to be able to work either, and people who lack the basics of healthcare are in the same boat.
For the people out there who aren't moved by the arguments of decency and compassion, consider this: it's a workforce infrastructure issue. It's good business planning, not a free ride for losers. If you want people up on their feet and leaving their homes to work (and support themselves, pay taxes, spend money as American consumers, etc.) you need to keep them healthy.
There is a myriad of health problems that need just a bit of attention to keep them on the "controlled, not a disabling condition" side of the line--it starts with high blood pressure and diabetes, and goes on and on--asthma, rheumatoid arthritis, gall bladder disease, and so on. Putting people into the maze-trap of "You could have insurance if you worked, but you're not working, you bum, so you can just suffer" is not only morally corrupt, it's stupid.

You're absolutely right, Jim. My family does not have health insurance, and a tax deduction would mean absolutely nothing to us.

It sucks. We can't afford even the state sponsored program (at close to 5 grand a year, that's nearly 1/5 of our family income) yet we make too much to qualify for assistance.

So again, we, who work our butts off, get thrown a life line that isn't tethered to anything at the other end.

Part of the secret agenda is undoubtedly to punish those nasty people whose unions have not been broken or permanently crippled, and who thus have "gold-plated" healthcare plans. (The corporate executives who scam the laws to use corporate status to give themselves tax-free health care will take the deduction instead.)

Shrub and his allies always like deduction-based tax incentives, not just because they are most valuable to the richest taxpayers, but also because they annoy the middle classes by making taxes more complicated, thus adding to the ranks of those who would fall for a Simplified/Flat Tax scam (again, most valuable to the richest Americans).

Why would Bush invoke anything other than "tax cuts" and "market forces" to resolve an issue? Those and "the end of big government" are the "Best of all Possible Worlds" of metaphysico-theologo-conserva-nigology. Voltair pretty much ended the novel with Candide's observations on garden management, but I can't believe that they caused Panglos to shut up and pick up a hoe.

The analogy breaks down in that we can't just stick a back cover on history and start working on a new book where Panglos does not appear.

"Orange Mike" Lowrey @ 12

Ah, that's why they pull these 'we're going to 'help' you by making you miserable' stunts.
That's what they did with the 'tax breaks for hybrids': they put it on a form for businesses, then made it impossible for the average person to figure out the instructions. I quit at that point: the tax break would have been nice, but -!

Not directly about the Bush proposal, just about having health care or not. I had health care over the weekend (which I regard as an exciting event), and I thought about contrasts.

A few years ago, I sprained an ankle really, really badly. I wasn't sure if I'd actually broken it or not, but with no insurance there wasn't much to be done about it. I have a high pain tolerance, so I wrapped it tightly and wore high-top shoes and slowly limped my way to work - I couldn't afford to park at work, and if I didn't go to work, I didn't get paid. So I walked, and altered my gait to accommodate the ankle. When I had to dance - and I was performing a few days later - I wrapped it up more and danced through the pain.

After a few weeks I managed to make a quiet connection with someone who knew someone who could sneak me into x-ray before it opened for a free shot of the ankle. They sneaked me in, did the x-ray quickly, and bundled me out the door, film in hand, no records kept. (This would be harder now that the whole system is computerized.)

I called to find out how much it would cost to see an orthopedist. $200. After three months, I had saved up the money and duly took my film and my ankle in. The orthopedist was helpful - it definitely wasn't broken, though he said I'd have been better off breaking it, overall. He recommended several months of physical therapy; when I explained my lack of insurance, he gave me an 8" wide rubber band and a quick lesson on do-it-yourself PT. They tried to bill me for $400. I went through an appeals process and got the bill reduced to the $200 I'd been quoted.

The ankle healed up to about 90% after several months; it's still noticeably weaker than the other. I had a long bout of severe plantar fascitis, probably caused in part by the adjustment to my gait I made so I could walk on the ankle. I read up on PF on the internet and designed a set of exercises for myself which eventually took care of it.

Flash forward to the present and what I suspect Bush would call my gold-plated employer-provided insurance:

Friday night I slammed my right index finger in a door. I didn't think I'd broken it, so I iced it and bandaged the gash. It was purple and swollen and throbbing. By Saturday morning it was agonizing, and I thought I could feel something clicking when I bent the finger (as much as I could with the swelling). I was also having trouble with everything from unlocking my door to tying my shoes to typing - the ongoing pain I could deal with, but the sudden blitz of agony whenever I bumped the finger was a problem. Taking painkillers for an injury goes against all my instincts, but this was becoming a problem.

Going to the doctor is still not an automatic response for me, but sometime around the coliseum implosion, it occurred to me that I had insurance now and could actually do something about this. So in I went to Urgent Care at my HMO. I was examined, x-rayed, and given a lecture about how nutrient blood vessels look on x-rays, which I wasn't terribly focused on once they said "not broken". I didn't have to pay anything. I went home for more ice and to finally take some painkillers. Then I sat in bed all day nursing my finger, thinking about what I went through with my ankle, and wanting to cry.

Oh, and I'm finally getting belated PT for the ankle, too. And for my knee. And I've had two biopsies (no cancer, hurrah.) One of my co-workers calls our health plan the "death plan" because she considers it so bad.

She just has nooooo idea.

This is one of the best-thought-out sallies in the War on the Underclass I think I've ever seen. What better way to refocus the anger of middle-class, unionized, health-insured workers from the general incompetence of the Screwups-In-Chief to those damn no-good lazy uninsured folk who are going to make them have to pay taxes on their health benefits?

Well done, Mr. Rove, sir. Well done. *restrained applause*

The implicit message in Bush's plan is that people too poor or sick or in crisis to have health insurance ought to have the decency to die and decrease the surplus population.

I doubt even the combined efforts of the Ghosts of Christmas Past, Present, and Yet-to-Come would have any effect on him at this point.

Susan... Your finger adventures bring back fond memories. I have good health coverage, but it took days after slamming the car door onto my finger's tip before I decided that maybe I should have it looked at. Luckily, there was no fracture and most of the pain was from fluid buildup under the nail, which was taken care by the doc's puncturing said nail, which eventually completely fell off then was replaced by an all-new one.

I live in Hawai'i, where state law requires employers to provide full-time employees with approved health insurance. When I've worked full-time, that's meant getting good health insurance. I'm currently working 6 days/week at two part-time jobs, and not making enough money to buy my own health insurance. Phooey. I do get sliding scale at the local clinic, at least. On the other hand, you can have insurance and have it suck - I know a woman who found a lump in her breast and had her insurance co. inform her that the plan has a $1000 deductible and then will cover only 40% of the cost after the deductible. Worse still, she found the lump in December, and the insurance "resets" at the end of the year, so if she'd gotten the lump checked in December and required additional care in January (as she found it right before Christmas, highly likely), she'd have to start over with the deductible on January 1st.

I haven't been underinsured for many a year, but right after I graduated from college, I was first unemployed and then working for a store that didn't do insurance. The real lifesaver was an outfit called People's Community Clinic, which offered free or no-quite-free treatment based on income. They got me through two serious sinus infections and two years of the Pill at very low cost, before I went back to school. Now, in an effort to give back, we donate to them yearly.

The rest of Bush's health-care proposals include a pile of unfunded mandates for the states, and yet another attempt to limit the ability of people who've been harmed by malpractice to be compensated. This last has nothing whatever to do with the either the cost or availabilty of health care ... it's just part of the plan to protect the rich from the consequences of their actions.

The Bush proposal on health insurance contains only two elements: (1) Screw the poor, (2)soak the middle class.

(1) In essence, this is a way to end what's left of Medicaid by claiming that the new tax deduction puts private insurance 'within reach' of the poor, and it screws a lot of the working poor who can only afford what W calls a 'basic' plan (i.e., almost as bad as not having any).

(2) People with 'gold-plated' plans (i.e., plans that leave you with some of your money) are going to have to pay taxes on them. Watch how happy that makes the middle class.

I knew I made the right choice by not watching his latest lie, cheat, and steal session.

I hate that man. I feel queasy whenever I see a shot of him.

I'd like to see the answer that an insurance company would give on an application (with honest, straight-up responses) for Bush. You'd have to use a fake name on it, of course, but at his age and with his history, would he be accepted or would he be stuck with high-risk-pool insurance?

Xopher - Yup. I know I'm not the only person that can say this is the first State of the Union address they've deliberately missed. I was glad to miss it. I read the transcript, but at least I didn't have to hear him blather on.

Heard the first few minutes of the SOTU address, because I was in the car and my presets were all news stations.

Fortunately, Shrub the Lesser was still in the preliminary blather phase when I got to my destination, the local pet hospital.

Spent the rest of the speech's time slot holding my dog down on a table and popping biscuits in her mouth while 400 ml of canine hemo-juice was collected for use by other patients.

Got out in time for the response, which was pretty good.

Let's see...last year our premiums doubled. The in-office and pharmacy co-pays also went up. And now they want to tax our premiums?

I know this is a laid-back group, but the words that passed my lips when I read about this are not fit to print here.

Kevin Drum quotes Paul Krugman's and Jonathan Cohn's analyses of the plan. Short form: it stinks.

Krugman:

In particular, healthy high-income people would be encouraged to drop out of employment-based plans, leaving behind a sicker risk pool, driving up rates, and pushing employer-based care in the direction of an adverse selection death spiral.

Cohn:

in encouraging the demise of employer-sponsored insurance, the administration had no plans to create a suitable alternative in its place. After all, a lot of people are going to have a hard time finding insurance in the individual market. Not only do costs run higher there, because the administrative overhead is higher, but insurers offer coverage and adjust premiums based on health condition--to the point where people with preexisting medical problems simply can't get decent coverage at all.

Brad DeLong finds Krugman amplifying in space his column wouldn't allow, as well as other commentary. (Top two or three posts.)

My Kaiser Permanente insurance premium went up $120 a month more this year from last year's number -- I hit one of those dandy age brackets, and insurance for just me now costs nearly $500 a month. Plus copays and fees for drs appointments, lab tests, drugs, PT, etc. Nevertheless, I consider myself to be one of the fortunate ones, because at least I have insurance.

Bush's plan is a total scam. Paul Krugman tore it apart January 22 in the Times in a column titled "Gold-Plated Indifference."

2 more years of this.

Wow. That's a total let them eat cake moment there. "Hey, guys, this thing you can't afford anyway, hey, I'll let you have a tax deduction so you can use THAT money on your health care."

Hell, I have a pretty good job and pretty good insurance considering the rest of the US....and there are times when I am still left debating, Do I spend this money now on physical therapy and medication? Or do I just try and suck it up because my savings are being depleted slowly? A lot of people make far less than I do, and support more dependents--I have none--and make due by putting off their own needs for far too long. I see people walking around on broken legs on a regular basis. People not quite in their right minds, wandering around aimlessly outside the local mental health clinic. Bush's tax deduction will do diddly squat for all them--they don't even have money for new clothes or shelter. And for the people that do have just enough money, he's still squeezing blood from stones. When I was jobless, I went without health care merely because it was a choice between paying money in case something horrible happened, and keeping on top of a small avalanche of bills. I chose the bills--I'm not debt free, but I'm in a better position if I had chosen health care. HOWEVER, had anything happened to me, I would have screwed six ways til Tuesday--so that was a gamble on my part.

In any case, tax deductions just won't work in the current system. Over at the blogs Dooce and Blurbomat, you can read Dooce and her husband's struggles to get insured after they both became self-employed. She was denied coverage because she'd been successfully treated for post-partum depression, he was denied coverage because he'd had a successful operation on his cornea, I think, and their daughter was denied coverage because she'd had two MRIs to determine that despite some slow starts she was in fact completely healthy. They are finally on a plan, I think, but for a while it looked like nobody would take their family on. Tax deductions do a little to soften the financial blow in those cases but they still have to find somebody willing to take them on.

Er.....little note on my post at 31 in the second paragraph, last sentence: That is meant to be "would have been screwed six ways til Tuesday" NOT plain "screwed six ways til Tuesday." My bad. There is definitely a difference. :)

The best way to fund universal health care is by drastic cuts in all executive salaries, stock options, and other Gilded Age benefits. Win-win.

When Bush presents a plan, I now assume that the framing narrative, assumptions, definitions- the real plan he wants to push- are hidden within the more newscatchy discussion points.

$7500 for an individual is "gold plated"*? This frame pushes the hidden idea that individuals can get good but not great plans for less than $7500, and therefore what are folks whining about.

Except I know that in California, $9000 is what you'd pay for the "if everyone else rejects you" high risk, 20% copay plan. One of my best friends pays this: she's in her early 30s**. And the 20% copay is on medical retail / rack rates, so that the $4000 paid for a $20,000 3 day hospital visit is a profit to the hospital... good insurance would negotiate the price down to $12k or $15k.

And if you're a Canadian or EU reader not used to the US system, I know you're reading this with horror and confusion. Agreed. I'm writing this with horror. I can't explain it.

* For an employee plan, which is different from individual plan. Granted, a $7500 plan at a large corporation could be gold plated, but most people don't work at large corporations. Prices for small company plans track prices for individual plans.

** In comparison I'm several years older than her, and have had a individual plan for 5 years. I pay $3900/year, with low copays ($20 per visit, $100 for the ER). I protect it like mad- if I only could pay one bill, I'd pay health insurance.

Well, apparently John McCain was deeply impressed by the Shrub's speech...

As another data point...for a period of time about a year ago I had to pay for individual health coverage-- my school coverage ran out and I didn't have insurance through my job. At the time I was healthy, under 30 (though not by much), with 2 perscription medications (birth control and an SSRI), and seeing a therapist for an anxiety disorder. I consider(ed) myself lucky to even be eligible.

I was paying ~$400 a month, which was, at the time, essentially a week's salary for me-- I was temping at the time, which is not exactly a job with a lot of security. I also live(d) in an expensive city. However, I was (and am) lucky to have other resources, such as family and a fiance (now husband) who were able to help support me. If I had been living on my own, trying to pay for health care and student loans and rent and etc., I'm not sure I would have been able to make my salary stretch that far. I know people in similar situations who have looked at that equation and come to the decision not to have health care-- not because they didn't want it, but, as Mr. MacDonald says, because they cannot afford it.

I kind of plan to stay in grad school as long as I can, because for someone my age, I get amazing insurance. I had friends as an undergrad who were staring at med school and realizing that they couldn't get sick because they couldn't afford insurance on top of everything else. I am very much on top of the grad-student heap, in terms of living conditions and benefits.
And then I look at my two-teacher family, at risk for just about everything, and wish that school districts could afford to help us afford everything.

Bush might do okay for insurance, but Laura had a skin cancer removed recently, so she could probably not get coverage.

I understand the thing they're trying to do here. The idea is that tying health insurance to a job is nuts (true), and that part of the historical reason it's tied to your job is because of tax policy--you don't get to deduct your private insurance premiums, but your employer does.

But the bigger issue with health insurance is the whole selection and cost-shifting thing. If a health insurance company takes clients freely, it gets adverse selection problems--healthier people don't need insurance, especially very good insurance. (This is an issue with high-deductable health insurance, too--healthy people are much better off with a cheap policy with a $10K deductable than with an expensive one that covers everything with a $20 copay; the same coverage isn't so great for a 50 year old diabetic.) By binding the insurance to the job, it gets a certain randomization of its applicant pool, with a skew toward healthy enough to work people.

My uninformed take on this is that there are a couple broad models that work other places:

a. Require everyone to carry some level of insurance; the basic insurance is regulated in terms of rates, and poor people are subsidized.

b. Have a single-payer scheme (perhaps with a parallel private scheme).

Either of these can provide decent care. I'm more comfortable with some variant of (b), or at least with a minimally decent parallel private health care system, so that if the centralized system is a disaster, it's not impossible to get decent care.

For a whole bunch of reasons, the current system is broken, apparently beyond repair. Everyone in the whole medical industry seems to spend more energy with cost-shifting games than with treating patients. Hospital bills are intentionally incomprehensible, and a major stay at a hospital seems to routinely involve getting double billed for stuff. (It's an accident, of course. It's just bad luck that the accident is always in their favor.) Doctors and pharmacies spend huge amounts of time and energy satsifying paperwork requirements to get reembursed. Nursing homes and hospitals play ping-pong with very old, very sick patients, since the cost of caring for them is not reembursed by Medicare. Insurance companies apparently reject some fraction of legitimate claims by default, since many times nobody re-files them. And on and on.

Nitpick: I'm more comfortable with some variant of (a)--that is, private insurance chosen from a menu of available plans, but everyone has to carry coverage. I've seen that work well at the state and federal government level. Subsidize the poorest peoples' insurance, but make everyone carry it.

One effect of this is that we can get rid of the emergency rooms as free clinics of last resort thing we are doing now.

There would be some problems doing this will illegal immigrants. (But there's a huge problem with 10M+ people here illegally, for reasons that have very little to do with anything other than the "illegal" part.)

albatross @38,

If you're self-employed filing a Schedule C you now do get to fully deduct your health insurance premiums. It had been at 70%, but that changed to full deductability in tax year 2005 (I think. If I'm wrong, so is TurboTax. Please don't advise the IRS).

And what about those of us with expensive "preexisting conditions"? I notice that merely making it more tax-deductible doesn't do a durned thing for eligibility...

How do you "incorporate under your business" if you are self-employed and wish to deduct your health insurance costs from your federal income tax? Last year I searched the IRS site for some information about this process, but they were not helpful, and nobody else I Google seems to understand it.

I Google "business license" and find sites where you have to pay upwards of $175 for a license, but some of these sites look dodgy.

Like religion and bellicosity, class warfare is one of the things the W. Bush administration returns to, over and over again. The question comes up as to who in the Administration and its advisers are active class warriors--people who are working to establish a class system (or, if you prefer, vastly intensify pre-existing class distinctions) in the USA? Any thoughts?

Randolph @ 43

I'd start with Cheney or his wonderful colleagues. They're the same neocons who brought us 'trickle down economics', and you'll recall how well that worked. They're insane, by the definition of 'doing the same thing and expecting different results'.

Even if GWB were trying to do good, he's as effective as Jack Skellington as Santa Claus.

The NHS is looking really good about now....I know its waiting lists are miles long and there are patients stacked in the corridors because there aren't enough beds, but resident in this country has to walk around on a possibly broken ankle. (What happens in the USA if you're in labour with no health insurance? 'Sorry, the baby's just going to have to go back again?'

That would be 'no resident'.

#44:

They're insane, by the definition of 'doing the same thing and expecting different results'.

You're not giving them enough credit. "Trickle down economics" does work . . . for them.

It's the fools several rungs down the economic ladder who believe that crap who are insane.

Stefan, I'd call that 'pour up economics'. It works for them, temporarily. At some point the peasants show up with the pitchforks and torches, though, and it gets much more interesting for those on top.

Cat at #46: My understanding (and I am not an expert) is that if you are uninsured and have a true health crisis (labor, open wound, etc.), there are usually local hospitals that will treat you for the condition and receive payment from the state or the federal government. This, of course, leads to the problem of people not treating problems until they become truly emergent, as referenced by others upthread (such as fidelio reference in #10 to problems that are "too bad to ignore"). If you've ever watched ER when the Caring Doctor/Nurse tells the Impoverished Patient, "This is County, we have to treat you"? That's what they're referring to.

Another issue with the Bush Plan to Re-Break Health Care is that one aspect of it entails removing these subsidies-- which are, for some people, literally the only way they can receive health care-- and using the funds as an incentive for states to provide affordable health care for all their citizens. Which...well, again, if it were done well and competently, could be a useful and helpful reallocation of funds. I personally, however, have no faith that it would be done competently by the current crew, and I have visions of illegal immigrants (for example) dying for lack of emergent care, because they aren't legal citizens of any state so they aren't insured, and the mechanism isn't there anymore for them to go to a hospital if they are truly ill.

Aack! That should be "fidelio's reference" in the first graf. And in the second graf, I meant that the federal government would "[use] the funds as an incentive for states to provide affordable health insurance for all their citizens."

I'll slink away now.

Any plan that leaves out illegal immigrants is broken before it ever starts. It may sound temptingly simple to demand that they get no or reduced medical care... but that comes right up against the reality that infectious diseases are not good about respecting class lines.

So say a state denies medical care to its large population of illegal immigrants... and then bird flu finally gets around to getting super-infectious. It starts out as a typical case of flu, too -- can you imagine the pandemic that results if you don't get people (regardless of their legal status) treated early and promptly?

The only reasonable course is universal free health care. Anything else is garbage and should be rejected, with mockery, the moment it's proposed.

#53: That sounds good, except, TANSTAAFL. Short of enslaving doctors (and nurses, and manufacturers of medical supplies and equipment, and...), there's no *free* health care; somebody works for it which means somebody pays for it. Who?

I do think it's reasonable that nobody should be refused treatment for a potentially life-threatening condition, a communicable condition or any preventive treatment on financial grounds, ever, and that *someone* should be picking up the tab for people with those sorts of conditions if they can't afford to pay the bills themselves. The first out of simple human decency and the latter two because 28.4g of prevention is worth 453.6g of cure.

But how far do you take this? Free dentistry? Orthodontics? Reconstructive surgery? Extensive (and expensive) treatments with a small but non-zero chance of success? Ditto, but for a condition that isn't life threatening even when untreated? And what about treatments that are arguably elective, like fertility treatments?

We can't provide everyone in the country with the level of medical care currently enjoyed by Bill Gates. There aren't enough hospitals, doctors, medicines and medical equipment. This is the fundamental problem of economics: how to allocate limited resources to needs/wants (the distinction is not always clear) too big to be completely covered.

That being said, I don't trust Bush to know which end of the syringe goes into the patient, so I'm not surprised his plan is terrible. But the problem is by no means a simple one and I'm not convinced that slogan-slinging is helpful.

Sara (42):

There's a pretty good layperson's guide to the pros and cons of "self incorporation" called Inc. Yourself; virtually any public library will have a copy of it. It's useful to read once, but not worth buying... and you really need to find a fairly recent edition, so don't rely on used book stores.

One caution: Keep in mind that any copyrightable work that you do through and for the corporation (or LLC if you go that route) will be work for hire, and will have a flat 95-year term of copyright protection (instead of life plus 70 years) and, perhaps more importantly, will not have any termination/revocation rights under § 203. Inc. Yourself wasn't written with producers of intellectual property in mind.

None of which, of course, gets to the root of the problem with the shrubbery health "plan."

Connie @52 and all,

Adding to your comment about illegal immigrants, and covering how the uninsured use the ER, I recommend this LATimes article. Multiply these sorts of expenses by 46 million uninsured, and that's a huge percentage of the total costs of healthcare.

In short: MH is an illegal immigrant with a regular job and without health insurance. Side effects from his cirrhosis require regular treatment to keep them under control, but he only gets treatment when his health is so bad he had to go to the ER...

" At each ER visit, he waited from five to 10 hours, received immediate treatment and left with no long-term plan for follow-up care. So his condition worsened, making more ER visits necessary.

" Hospital officials estimate that in the first four months of 2006 alone, Hernandez's ER visits and hospitalizations cost taxpayers $37,500."

LA County started a pilot program to guide uninsured people out of the ER and into clinics. A caseworker worked closely with MH to cover every aspect of helping MH use clinics instead of the ER.

" By now, MH has stopped going to the ER. His stomach is slowly becoming smaller. A specialist has determined that he doesn't need a transplant.

" The cost of his care over the last seven months has been cut almost in half, to $19,500, COPE officials estimate"

I just want to take a second to thank Uncle Jim and the Nielsen Haydens (and anyone else who posts here that I'm missing-- the lj feed doesn't name the poster) for continuing to keep up with and post about important issues like this.

The bilge that's been spewing out of the whitehouse for the past six years literally makes me ill. I have to keep up with current events because of my major, but even then, there are days that I don't want to touch or discuss the news because of how utterly powerless it makes me feel. That quote about the power of a small, dedicated group of people's capacity to change the world has taken on a terrifying dimension since Bush took office. I'm so sick of being angry and afraid that it's hard to resist the urge to bury my head in the sand and just ignore it all.

Thank you guys for not doing that. Thank you for being willing to say 'hey, this is stupid bull****;' even when you know it's going to mean dealing with idiots, trolls, and trawling idiots. Even if it doesn't seem like blogging about this sort of thing makes a direct difference, it does make an indirect one. It's helped to give at least one person the hope to not give up entirely on this country and leave it to the fundies.

That said: Tax cuts? WTf'nH?

...Yeah, let's tax the middle class in order to pay for health care for other parts of the middle class instead of asking the rich to pick up the tab for the poor. That sounds fair, right? After all, if our dear leader is any indication, the rich always have each other's back. Why shouldn't the middle class follow their example? It'll kill the poor? Feh! If they're going to die, they should go ahead and do it. It will decrease the surplus population.

...Worst. President. Ever.

Ok, that might be an exaggeration. It's possible than Andrew Jackson was worse. I wouldn't put money on it, but it's possible.

For the uninsured, things like active labor, traumatic amputations, MVA injuries, and the like are covered under a (federal? CA state? I've honestly never looked it up) law known as the Emergency Medical Treatment And Labor Act, or EMTALA; what it boils down to is that someone who presents with something like that must be treated, regardless of insurance or ability to pay, and in theory the government will then reimburse the hospital for some portion of the cost of treatment. As an example of how well that theory's working out, I'd like to point to the ~100 positions announced cut last week by the hospital system I work for. Interestingly, at the mid-size urban hospital I work at one day out of ten (I verify timecards for a couple of departments once a pay period, and spend the rest of the time at a semi-rural small hospital in the same system,) the half-a-dozen large signs explaining, in various languages, how EMTALA works are posted on the wall of the bridge connecting one of the outlying office buildings to the main hospital tower. Smaller signs, I believe in English and Spanish only, are posted on a side wall in the ER entrance where you might notice them if you were wandering around bored long enough; they might also be posted somewhere in the main entrance lobby, but I've certainly never found them.

Another part of my job includes coding all the ER visits at the smaller facility; in just the last 18 months I've seen a definite upswing in the number of people using our ER as their primary medical provider -- most of them either uninsured or blatantly underinsured, and more than a few of them already delinquent in their accounts. I don't see any signs of that going away any time soon.

Chris @54, Jim @53

"Universal free health care" is easier to say than "Universal low-barrier-to-visits health care with signaling mechanisms for the relative costs of treatment."

Chris-
When everyone has insurance, the total cost to society of health care goes down. Far fewer people's illnesses progress to where the most expensive treatments are needed. Check out the LATimes article linked above: $1.6 billion in uncompensated care costs for LA County alone*.

But even if you do have insurance, in today's system you can easily "make" yourself uninsurable by having ordinary health problems. As someone else said upstream, Laura Bush couldn't get health insurance if she applied, because she's had skin cancer.

And on dentistry-- there's now strong, strong evidence that bad teeth lead to heart attacks and other non-dental health problems. Try to imagine a society that accepted skin wounds elsewhere on the body that were equivalent to gingivitis. We have this odd blindspot about dental health, as if the mouthbone is disconnected from the bodybone. Weird.

Jim-
Health care shouldn't be free in that people need to account for the relative costs of visits. For example, I recall that Ontario (Canada) had a problem when clinics and the ER were identical in price: people overused the ER.

But quite possibly all the system needs is coupon books, where an ordinary doctors visit cost $1 and 20 coupons, and an ER visit cost $20 and 100 coupons.

* part of the problem is that the uninsured face the highest rates. They can't negotiate prices down to anywhere near what insured people pay. As an example, I have a friend who was temporarily unisured betwen jobs. During this time he was hit in the face (accidentally walked between two people starting a fight).

The blow broke several bones in his nose and his cheekbone. $10,000. He negotiated down to $8000 by putting it on his credit card, and then paid it off quickly once employed again. But he only could do this because he had $8k of credit available and he knew he'd be able to pay it off quickly.

Bex (#58), EMTALA is a federal mandate. But there are some whopping holes. Your condition has to be life- or limb-threatening and an emergency. So when I see an uninsured patient with a retinal detachment, it's not covered. Because it's not an emergency, and it won't kill you. You'll just go blind.

And I've also seen 24 year-old type 1 diabetics who go slowly blind because they can't get treatment...until they are legally bind, and then they can. What a beautiful system.

I'm in favor of universal coverage, even though I know it will mean a big cut in my salary.

ted_curtis (#60): I'm not saying it's a comprehensive system by any means -- but Cat, upthread, had asked about the unfortunately-not-hypothetical uninsured pregnant woman scenario -- and EMTALA does cover that. Kind of. At a reimbursement rate that drives up the prices for everything and everyone else.

Of course, even that coverage, limited though it is, does no good for the people who aren't aware that they have even that much access -- and the signs aren't exactly up where they're visible to all. I'd guess that less than 10%, if that, of the people we treat under EMTALA would ever be in a situation where they'd be in that particular area of the hospital at all, never mind having the leisure time and presence of mind to actually read through the sign, and I work for a Catholic hospital system whose publically stated values include "Compassion in Christ" and "Advocacy for the Poor." What do they do with the signs in a for-profit hospital, hide them in the broom closet?

People would rather not go to the doctor's office, they'd rather not go to a clinic, they'd rather not go to an ER. Even if the cost is low or none. I see the fears of people abusing the system for frivolous ends being like the fears of Welfare Queens.

Listen: every industrialized country in the world except ours has universal health care. What's the matter with us?

I'd say free, right the way down to annual physicals, with triaging to see where the resources go. Pay for it out of tax funds. Raise taxes for all to fund healthcare for all. Heck, pull out of Iraq and use that same money to fund health care, with cash left over.

This proposal of Bush's is shameful. Particularly given that there are lots of real-world examples, up and running, all over the Western world of functioning government-run health programs. Pick one, put it in place, and move on to the next problem.

In the summer of '05 i developed an odd pain-I thought it might be kidney stones. I worked for a small company that did not offer insurance,so ignored it for a while. A day and a half later,I couldn't stand it and went to the ER. I was only able to do this because I knew that I could make payments because of that hospital's policy, and that if it was really bad, AHCCS (Arizona's medicare} would probably help. It turned out to be something severe,. AHCCS isn't perfect,but as I have been left with a chronic condition which requires meds-I don't know what I would have done. I really miss the days when I did work for a large company and had no worries.

#62Heck, pull out of Iraq and use that same money to fund health care, with cash left over.

Iraq HAS public health care. Currently, their hospitals are battle zones, but that's one of the things we're sending our military to defend in Iraq.

Yet somehow we're too poor to establish it here at home.

#59 - I'm not a fan of a coupon system; you wind up with a cap on the health care you have access to. I suspect that most of what you need is *exposure* to the cost, but no direct responsibility to pay it. One of the failings I see in Canada's healthcare system (I'm Canadian, living in Canada) is that the treatment really does look free. That turns out to have an obvious effect where people over(ab)-use the system, and a perverse effect where responsible people with relatively minor ailments under-use the system in order to save the system money, while letting their problems become more expensive.
If instead we just mailed out an itemized list of expenses due to a visit, I'm certain that some abusers would see their drain on the system (not all, some - I do believe most people are decent and prefer to do the right thing), while others could more closely value the cost of preventative vs. emergent care.

Double-checking my statement in #40 about the percentage of deductibility of health insurance premiums allowable by the IRS, I find this in IRS Pub. 535:
Self-Employed Health Insurance Deduction

You may be able to deduct 100% of the amount paid for medical and dental insurance and qualified long-term care insurance for you, your spouse, and your dependents if you are one of the following.

A self-employed individual with a net profit reported on Schedule C, C-EZ, or F.

A partner with net earnings from self-employment reported on Schedule K-1 (Form 1065), box 14, code A.

A shareholder owning more than 2% of the outstanding stock of an S corporation with wages from the corporation reported on Form W-2.

The insurance plan must be established under your business. You may be allowed this deduction whether you paid the premiums yourself or your partnership or S corporation paid them and you included the premium amounts in your gross income. Take the deduction on line 29 of Form 1040.

So if your income exceeded your expenses while self-employed (which, if you work out of your home, it surely does), you can deduct 100% of health insurance premiums.

Paul @65

The "coupons" could be something handed out by the thousands. There just has to be some mechanism for people to feel that ERs are worth more than ordinary doctors visits.

The Ontario system made a mistake by not having any signaling method- as you say, treatment looks free. While treatment can be free, people need to know that actually expensive services- a fully stocked ER is one- are actually expensive services.

How do you educate people about this? Something like a ticket book seems easy.

Pepsi-Cola Co. ran a sweepstakes called the Pepsi Challenge for a few years. The top prize (never paid) was supposed to be $1 billion. Of course, in the small print, it turned out to be much less, although still an unimaginably huge sum.

I still daydream now and then about what I would do with a literal billion dollars. I would like to establish two accounts modeled after the Alaska Permanent Fund: one to subsidize a midwifery practice* and one to provide free health insurance to all residents of my home borough. For fewer than 20,000 people including the illegals, that would only take about, oh, half of my prize money.

*I could rant at length about the way the Powers That Be in my state "kept midwifery legal" on one hand and loaded midwives down with so many costs of doing business on the other that rural areas no longer have midwives; also on the absurdity of treating an uncomplicated childbirth as a medical situation and putting a laboring woman in a hospital for it. But it's late, I'm tired, and I've already digressed enough.

Mr. Macdonald at #62 said, "Heck, pull out of Iraq and use that same money to fund health care, with cash left over."

THIS is what makes me so angry about all this. Or, you know, it's one of the many things, but it's the one that's battled its way to the top of my head right now.

If we just prioritized our spending, free health care for all would be easily affordable. Between reducing military spending to a sensible level and instituting some kind of maximum wage (what Earl Cooley III was talking about at #33), all this crap and more would pay for itself. Hell, if we fixed our tax system so that, say, rich people actually paid taxes, it would pay for itself.

A billion dollars wouldn't be enough to buy any of the unambiguous European micronations that are monarchies (and thus, the only ones that could theoretically be purchased). Hmmm, on second thought, I wonder if Queen Elizabeth II would be open to the idea of selling Tuvalu... That would have the advantage of giving me control over the coveted .tv domain name system.

Jenny Islander... I still daydream now and then about what I would do with a literal billion dollars.

I'd immediately move back to the San Francisco Bay Area, and then would have a party where everybody who posts here would be flown in - trolls not included.

Okay, I get a tax deduction (or rather, an exemption to an increased Medicare levy) through having private healthcare. However, I'm in Australia, where we have a functional (if not perfect) public health system, which allows for people who don't have private health care to get ill and have it dealt with by the nice doctors and soforth, without needing the state of their wallets checked beforehand. If I didn't have private healthcare, I'd be paying an extra 10% in taxes, to help fund Medicare. I only *get* the tax exemption if I remain on full private health cover (ie covering all hospital expenses) for the full financial year.

It appears to work over here. Certainly it means if I want to get my tonsils removed, I have two options: I can wait on the Medicare waiting list until there's a hospital bed available in one of the major public hospitals; or I can talk to my health fund, ask them which private hospital they'd recommend, and see whether there's a surgeon available to work there. If I wait for the Medicare bed, I won't have to pay a cent. If I get it done privately, I'll see the theatre some time before my fifties (I'm currently 35).

It's as Fidelio pointed out (#10) - Having a reasonably comprehensive public health system actually benefits everyone. It benefits the people who are on marginal incomes, because they don't have to wait until it's an emergency to get to see a doctor. They can get the small stuff treated *before* it becomes life-threatening, or before it becomes disabling, and thus put themselves in a position where they have a few more options. Having the private tier running alongside things also helps, because it means that those who have the money for it can use the private system, and leave the public system available for those who need it (or at least, that's how it works in theory - in practice, a lot of those with private health insurance tend to only use it when they have to).

Now, in my case, I broke a bone in my ankle year before last - I stumbled on some steps coming out of a bookshop while I was on a visit to see my parents. I got picked up by an ambulance and taken to the major hospital in the area (about five blocks away, a journey which wound up costing $500). Once at the hospital, I was taken into emergency, given some painkillers, had x-rays taken, got plastered up, given crutches and sent on my way within about 2 hours (which wasn't bad - the usual turnaround time people expected in that hospital was about 3 hours). I also had a followup visit the following week to the relevant outpatients clinic, where I had another x-ray done, and a further cast provided. What did I have to pay? Well, in the end, I didn't have to pay a cent, because my full hospital and ancilliary cover with my health fund included ambulance cover. So the health fund picked up the bill for the ambos, and I returned the crutches to the nearest large public hospital in the city I was living in.

Oh, and I pay about $45 (Australian) a fortnight for this.

[Might I mention that in Western Australia (where I live now) we're in the middle of a resources boom, and we need people who can do *anything* - but particularly people who are willing to wait tables, or answer phones?]

Oh, and Chris (#54) - Universal health care is what we have here in .au, and it's fairly low cost as well. If you are on a low income, you can apply for a health care concession card, which means you're not expected to pay anything over the Medicare rate on your health care. You get subsidised prescriptions through the Pharmaceutical Benefits Scheme (actually, all Australians get that, but for those with health care cards, it comes out even cheaper) and you get lower safety net thresholds for monetary outlay for health care (about $300 per annum, as compared to about $1500 for those who aren't on a concession). Again, dentistry (particularly for children) is often covered under Medicare - I have about eight fillings, and all of those were through the school dentists while I was in primary school. My grandmother (who is on a social security pension) has false teeth supplied by the government, and while I'm not certain, I think her hearing aids were subsidised too.

The doctors and the nurses who work in the public hospitals are paid by the government. Private hospitals charge fees that cover the cost of staff and facilities. At the moment, there's a shortage of nurses here, too (mainly because nurses have been expected over the years to do more and more for less and less of an effective wage - the law of the peasant's donkey applies). Most people who graduate from Australian universities as nurses tend to discover very rapidly that they can get better money working elsewhere (either a different country, or in many cases a different industry).

James MacDonald @62:

Listen: every industrialized country in the world except ours has universal health care.

Sadly, no. The Netherlands has universal healthcare in as much as the insurance people cannot refuse anyone for basic insurance, but that only cost basic medical assistance I'm afraid: doctors visits, hospital care, specialised medical care, but not glasses or dental work...

Still, without our insurance my partner's medical troubles (chronical medical condition) would've been very very expensive indeed...

Did you see this recent direct comparison of Canadian and US healthcare?

I think when you have figures showing everything pretty much the same for the two countries until the introduction of proper healthcare in Canada and then Canada shooting ahead in everything except costs, there isn't really any argument left for individually funded healthcare -- even before you get to all the anecdotal stories about people doing without treatment they need.

When we were living in Toronto, my wife had a mole on her neck she was concerned might be cancerous. If I remember correctly, she had to go thru a couple of specialists before someone took it off. When we moved to the Bay Area, she started worrying about a mole on my neck, so I went to Kaiser: the person (not even a specialist) who looked at it asked if I cared about getting a tiny scar, and then removed it on the spot. I always wondered about the different approaches.

It is a myth to assert that universal single-payer health coverage would be too expensive. We have the most technologically advanced medical system in the world-- which already enjoys substantial governmental subsidization-- but access to it is limited in weird and almost arbitrary ways. The fix will not be particularly popular with many practitioners, but needs to happen. Subsidize medical education in exchange for a service commitment to free public medical service-- eliminating the medical profession's reliance on the argument that the "free market" is its due, owning to the cost of training. Expand the VA system to include all comers. And let anyone who wants to opt out -- providers or patients-- do so.

I don't know a single doctor who won't tell you that health care is a "right". The problem is that the compensation infrastructures that we have in place now consume a substantial component of medical overhead. That has to change, and universal single-payer is the way to do it. All we want is the same healthcare that every member of Congress enjoys. Is that so much?

#61 Bex:

I've noticed three big effects of the requirement that emergency rooms must treat anyone:

a. Emergency rooms are usually packed, especially at night. This uses up the scarce resource of available doctors and nurses to treat things that were inevitable emergencies like broken bones and heart attacks, so that they can treat sick people who should have just seen a doctor a few days earlier, but couldn't afford it.

b. Lots of after-hours clinics have opened (it seems like they've proliferated in the last few years) so that if you aren't having a life-threatening emergency and you have insurance or money, you can see a doctor without waiting six hours in a crowded ER full of sick and injured people.

c. New hospitals are being built which are explicitly not including an emergency room, since this avoids the requirement to run a free overnight clinic.

There are surely others I'm not noticing. It's clearly a good idea for ERs to treat emergencies without waiting for a credit check, but the way this works out in most places I've lived is a disaster.

Connie H. at #52 -- If you have an illegal immigrant presenting symptoms of Avian Flu at an ER, it's going to be too late to prevent a pandemic.

Common garden-variety influenza kills people every year* -- the bad thing about Avian Flu is that it's got the potential to behave like a virgin-field epidemic.

In the last couple of months we've had two local High Schools report two ACTIVE cases of Tuberculosis, which meant the entire school population had to be tested (or retested) for the disease. There's been no news as to the results of those tests.

This is a disease we had supposedly beaten, but it's showing an up-swing, and the odds are good that the carriers were illegal immigrants.

With universal health care we'd have the chance of stopping an epidemic before it takes hold -- I think our current system can and will get a lot of people killed by something that could have been prevented.

*Ok, yes most of those are due to secondary infections, but if the victim hadn't caught the flu they might not have died.

Barack Obama and John Edwards have both come out strongly in favor of universal health care; it is one of Hillary Clinton's long term concerns. I am not a single issue voter -- I care deeply about war and diplomacy and about energy policy/response to global climate change -- but at this early stage, I know which candidates I am inclined to favor.

Very good point. I think a tax break in this case is not going to be of much help to people with very low income.

First, a quick gimmee.... I don't think anyone will have any trouble imagining what my homeless/street clients think about the usefulness of a tax cut to improve their access to health care...

Someone upthread talked about the lack of awareness among the target groups of the availability of current assistance programs. This is SO true. Here in Minnesota there is still a network of general assistance medical programs, but our asswipe of a Gov does everything he can to not only keep word of them from getting to the streets, but also is making it harder and harder for the average person to navigate the bureaucracy of getting signed up.

In mid-2005, the Doc I work with started an aggressive program of signing his drop-in clinic patients on to the general assistance plans. Our funding was drying up (Thank you, AGAIN, Gov Pawlenty, you moronic twit) and we were faced with closing. We don't bill our patients for any services, but due to his efforts, a couple hundred street people are now signed up and eligable for real care in a regular clinic, we have received about 50k in state reimbursement (and will be staying open at least another year), and the taxpayers have been saved well over a million dollars in ER visits.

I have to imagine that this scenario could be played out in most states and large cities. What we have been doing, within the existing system, can WORK... It only makes sense to expand it to a national scope.

James (#53 & #62) is absolutely correct. Any system that is not based on universal free coverage for EVERYONE will never work. On the other hand, we have now shown that a system where the billing is transparent to the user, with no out of pocket expenses for the user, can work even with the hosed-up aid programs we currently limp by on. Think how much better it could be with a unified, national program...

Serge @ 71: one of our annual rituals is returning to the city that will always be Home (Santa Cruz) for New Year's Eve at our best friends' house. While there, we go with them to make our once-yearly purchase of lottery tickets, with the understanding that should any of us actually win, the first order of business would be buying us a house across the street from them.

Despite the apparent karmic deservingness of this quest, we've so far proved unable to match more than a single winning number at a time...

Anyway, I thoroughly understand the draw of the Nor-Cal coast and the heartache of being unable to afford to ever live there again.

#59: part of the problem is that the uninsured face the highest rates. They can't negotiate prices down to anywhere near what insured people pay.

Despite my libertarian (small l) leanings, I think this kind of price fixing should probably be illegal. It's a conspiracy between provider and insurer to stick the uninsured guy with the bill - i.e. force him to subsidize the insured. Because of the oligopsony power of insurers, the providers don't realistically have the option to tell them to bug off, so they get strongarmed into it.

Single payer of any kind would moot the whole issue, though.

As an example, I have a friend who was temporarily unisured betwen jobs. During this time he was hit in the face (accidentally walked between two people starting a fight).

The blow broke several bones in his nose and his cheekbone. $10,000. He negotiated down to $8000 by putting it on his credit card, and then paid it off quickly once employed again. But he only could do this because he had $8k of credit available and he knew he'd be able to pay it off quickly.

IANAL, but this sounds like a pretty solid lawsuit - your friend was injured and had medical bills as a direct result of someone else committing a crime (assault and battery). In the presence of witnesses, even. Personal-injury plaintiffs' lawyers live for that sort of thing, don't they?

Admittedly, that might be slow to pay off, and he might have trouble borrowing against the outcome of the lawsuit even with the lawyer's opinion that he has an excellent case, but even aside from insurance there's no reason he should be paying those particular health care bills in the first place.

More commentary on this dead-on-arrival Bush plan.

Serge at #75: that may not be a private/public difference. Some years back I had a bleeding mole, and took myself off to my UK National Health Service doctor -- who agreed with me that it was almost certainly not dangerous but needed to be biopsied just in case, and told me to make an appointment for the in-house minor surgery clinic later in the week. They took the whole thing off and sent it away to the lab -- if the result had come back positive I'd have been in an oncologist's office the next week, but as it was, it was all handled by my own doctor.

Julia Jones... That's basically what happened with me at Kaiser.

Man, I am so glad I moved here.

Serge & Julia, I had shown some odd moles to my immediately ex-primary at Kaiser and she said nothing was wrong with them. More recently I saw a dermatologist for another reason and asked her for a full-body scan and she took off two of the moles I'd worried about. Both were negative, fortunately, but it sure made me happy I have the new primary.

avedon @ 87: ditto.

"The peasants have no bread."
"Let them eat gateaux."

==============

It continues to astonish me that the media coverage of healthcare mostly ignores, "just what are the bases of 16% of the US Gross National Product going to healthcare and the percentage of GNP going to healthcare continuing to increasing, anyway?

Why aren't they "following the money trail" to see just where that 16% of the GNP is going, to whom, how, why, where... such as the multi-thousand dollar service visits by GE personnel to change out an illumination light on a panel on a piece of medical equipment, which light is mostly cosmetic to make it easier to see something--not a strict necessity, and the change change a minute or two and the bulb is maybe a dollar or two if that in value, but GE is going to charge thousands of dollars for the service call, and prohibits any other organization from doing servicing--that example showed up in the Wall Street Journal a decade or two ago.

What else, oh, hospital administrator salaries, in the high hundreds of thousands of dollars, while nurse pay ad work conditions had eroded in value to where there was a nurse shortage, nurses decided other careers offered more pay and/or less stress.

What else? Oh, modern medicine can't cure everything... trying doesn't mean successful. Microcephalic infants are not going to suddenly grow a brain. Fetal alchohol syndrome babies start off life with major disadvantages and congenital health and adjustment problems. Low birth weight babies carried by females lacking in nutrition and well baby and mother care during pregnancy, are incredibly high expenses for treatment in Newborn Infant Care Units--most of the expense and medical issues could have been prevented with a few dollars per day to effectively to provide better maternal nutrition and with periodic checkups, and/or with more clues on the part of the person with the pregnancy and society regarding family planning and pregnancy and lifestyle issues to minimize unwanted and/or problem pregnancies. (I;ve had the opinion that various drugs should be legal and substances added to reduce fertility substantially and the probability of a pregnancy occurring if taking such drugs. What one does to one's own body is one thing, inflicting babies abused and damaged by parental drug abuse from before conception through to the horrific tales of women taking illegal pharmaceutical to speed up delivery or taking unregulated street drugs while nursing that got from their bodies into breastfeeding children, is quite another.

The news media focuses on healthcare premiums and costs to those paying for health insurance, it doesn't look at where that money -goes- within n insurance company, through auditors and paying for auditors, though to purchase goods and services which are very heavily promoted and which can yield very high profits to stockholders, management, business associated, etc.

Where's the balance sheet for the society, how much of other people's lives get taken up providing what types of medical services to whom when, for what, how long, and why?

A wrinkle in the universal health care idea that dosen't seem to have come up yet: unhealthy lifestyle choices. IOW, when getting sick or injured is your own fault, should you still expect society to foot the bill?

Atheist Ethicist has an interesting post about this.

There are of course lots of people who get sick or injured in ways they have nothing to do with. But there are also a lot of smokers, unhealthy eaters, people with dangerous hobbies, etc., and when those *voluntary* health risks are added to the risk pool they increase costs for everyone. (Neglecting preventive care and checkups could even be viewed in the same light.)

And then you get into even more disturbing grey areas: pregnancy, for example, almost always results from a voluntary act, and has substantial associated health care costs. Who should pay for them? Does the right to medical care include the right to society-subsidized pregnancies? As many as you want? Yet to neglect medical care for pregnancy neglects the (potential) child, possibly causing even more long-term costs. And if reproductive decisions are generally made for non-economic reasons (which seems likely), economic or financial "incentives" one way or the other would have little or no effect anyway.

Yes, universal healthcare for people who make poor life decisions too. This isn't hard. Unless someone wants to suggest that high infant mortality is a good thing? How could anyone who spent one second thinking about it call prenatal care a "grey area"?

albatross (#77): It's not the uninsured who come into my ER for hangovers, head colds and forearm contusions. It is the uninsured who come in with life-threatening complications from diabetes or infected lacerations that should have been cleaned and stitched ten days ago, because they were hoping it would heal on its own. Without some kind of educational campaign about what is and isn't appropriate use of the ER, removing what little there is in the way of "requirement to treat" laws won't do much about overcrowding caused by the former, but it'll result in a lot more and worse of the latter.

James:

I think bypass surgery for the guy who smokes two packs a day might be more what Chris has in mind. There's going to be rationing of some kind in any medical system. There is a question of how we want that rationing done, and whether a moral assessment of the worthiness of the patient, or the preventability of the illness or injury should be part of that.

Any bad thing that can happen to you and has some component of bad decisions or choice involved runs into this problem. Think of the issues with welfare, unemployment insurance, disability benefits, etc. Part of having a safety net is that you sometimes spend resources saving people from bad outcomes they partly caused. There doesn't seem to be any solution for that.

Albatros (#94): the problem is we do have rationing right now -- those who have insurance get care, and those who are uninsured don't. I really can't see how any medically or societally based rationing would be worse. And it could be a lot better.

I've wondered, do countries with socialized medicine have required medical care, or do people who have free access automatically do what's best for them (for example, prenatal care)?

Edward Oleander, thank you for your post at #81. I'm sure it was a lot of work for you and the doc, but you made the system work a little bit more the way it is supposed to, you saved Minnesotans a lot of money, and who knows how much pain and grief you prevented. It's so simple, but what a difference it made. It gives me hope.

Edward @ #81 - I totally agree about Pawlenty. The sooner we see him gone the better. I lost my favorite job because of his cuts.

One more comment on health care. In addition to educating people when and how to use the ER, Urgent Care and the like, there are other possibilities. Blue Cross of Minnesota has a nurse line that has been very helpful in sorting out whether I need to see a doctor, or go to the ER, or just self treat at home. Several times, this has saved me the co-pay for an office visit when all the doctor could do advise rest and liquids, and got me to the ER when it was possible I had a detached retina (I didn't.) The nurse line operates 6 am to 11 pm or something like that. Staffed by well-trained experienced people, this sort of program can save time, money and grief for everyone.

chris

A wrinkle in the universal health care idea that dosen't seem to have come up yet: unhealthy lifestyle choices. IOW, when getting sick or injured is your own fault, should you still expect society to foot the bill?

was it libertarians whose most soul-wracking pain is the thought that someone, somewhere is getting something good they don't deserve? someone said something like that at making light earlier, one of the smart people, & i'm sure i'm getting it all wrong.

as much as it might make one feel good to wield health care as a weapon, even to enforce the most glowing morality, it's much better for us as a society to not try it. in my opinion.

as much as one might like to punish women for having sex, denying them prenatal care will do no good to anybody. i'm sorry. even if they're meth-injecting chain-smoking illegal immigrant lesbians, or whatever one's particular bugaboo is.

punishing smokers won't make things fair, either, cause rich smokers will still get top-of-the-line medical care. & really, we all know that in the vast majority of cases, wealth is not the result of having made all & only the best choices in life.

making case-by-case choices of who gets what health care, also in my opinion, would not be saving a systen of universal health care any money.

When I hear people talking about how we ought to deny care to people who get sick or injured because it's "their own fault", I want to interrogate them about the choices they've made in their own lives. So, you've never chosen the donut instead of the whole-grain bagel? You've never had an alcoholic drink? You've worn your seatbelt every. single. time. you've EVER ridden in a vehicle? You read the emergency procedures card every time the flight attendants go over it at the beginning of the flight? You always take the stairs instead of the elevators? You're getting the recommended amounts of calcium and vitamin D and fiber in your diet? You've brushed your teeth right after every single meal you've ever eaten, as well as flossed? You've never said, "Oh, I know I shouldn't, but they taste so good!" while reaching for a fat- and sugar-laden treat? You've never gone skiing, or bicycling, or swimming, or done anything else where if you got hurt it would be "your own fault"? If all that's true, then maybe you're entitled to tell other people how stupid they are for the choices they've made, and how much they deserve to suffer for them.

But if you've EVER made a "bad choice", I think you've got no standing to lecture others about theirs.

ted_curtis @95
I've wondered, do countries with socialized medicine have required medical care, or do people who have free access automatically do what's best for them (for example, prenatal care)?

Huh? As if socialised medicine somehow reduces the requirement for patient consent?

What happens here in the UK is that I go to my general practitioner when I need medical care. If I need tests, or treatments that s/he can't provide, I get a referral to whoever can. Sometimes that involves waiting, sometimes it doesn't.

The only difference is that I pay for it in my taxes rather than at the reception desk or to the insurance company. I suspect I pay less to boot.

Overall, I see the NHS as providing better care for the poor at the expense of the quality of care for the middle class. Everyone gets shared wards (4 to a room after childbirth, for instance). That's better than the uninsured get in the US, but worse than the professional classes would get in the UK. It is, however, a perfectly acceptable standard of care.

The middle class people who don't like it get private insurance. But I am content.

Kathryn @ 59: I think you're answering the right question with your suggestion of coupon books for medical care. As someone else mentioned, the fundamental problem of economics is allocation of resources. The idea here, as I understand it, is to make people aware of the actual cost of providing various kinds of care, to help them make better decisions.

But you know what? We already have coupons for health care. They're called dollars. And as we've been discussing throughout this thread, the system isn't working very well.

Superficially, the coupon books sound like an improvement. They couldn't be used for anything besides health care, so people wouldn't be faced with the choice of spending their money for other urgent needs instead of for health insurance and medical care. But if we actually tried this, I'm sure people would find ways to buy and sell the coupons, and we'd be back where we started.

So I think this is on the track of the right answer, but hasn't gotten all the way there yet.

Who will make the decisions? That's what I want to know about any proposed plan. And I'll give anyone else's proposals just as much scrutiny as Bush's.

It's not enough for the new system to be different than the current one. It has to be *better.*

Framing the question is important. At its roots this topic goes well beyond medical care and insurance. The same people who absolutely can't afford insurance also have trouble paying their heating bills or buying nutritious food or any number of other necessities. This isn't just a health care problem and a food problem and a heating oil problem -- it's a poverty problem.

(Yes, I know it's not a simple matter of poverty causing all the other problems. There are feedback loops; as someone already mentioned, people who are sick a lot have trouble holding down a job.)

So Bush addressed the question in the terms in which it was asked rather than getting at the root of the problem. People complain that medical insurance costs too much, so he trots out a plan where some of the people who can already get insurance might find it a little more affordable.

Meanwhile, I am wondering if he has any thoughts about how to help the poor.

I wonder the same question that Chris @ 91 asks: When the decisions are made about how to allocate our resources, will society take the so-called lifestyle choices into account?

When I say this, I'm not hoping it will happen. I'm fearing that we will attempt to do it and make an awful mess of it.

Lexica 99:

Sometimes, people take voluntary risks for reasons that seem good to them. Some people ride motorcycles or horses, or like to swim in the ocean, or go mountain climbing, or eat six donuts for breakfast every morning. Letting them make those choices is a pretty fundamental part of freedom.

But then there's a legitimate issue about why everyone else has to pay for their voluntary risks. If you ride a motorcycle, why do I have to pay for your hospital bill when you get hurt? If you decide to go mountain climbing, why should I get stuck with the bill for mounting a massive rescue operation if things don't go well?

More fundamentally, if I have to pay some of the costs of your choices, I'm likely to want to have some say in them. This is the stated logic behind things like seatbelt and helmet laws. (I think it's pretty bad logic in both cases, but that's the usual argument for these laws.) The more I'm expected to pay for the costs of your actions, the more legitimate is my desire to tell you what you can and can't do.

I can understand why people might be loath to subsidize medical care for people who go bungee jumping or rock climbing or whatnot; but really, if you go rock climbing and something goes wrong and you need health care, the pain is punishment enough.

(Two years ago I rode my bike into a curb, smashed my elbow, and had to pay two thousand for it due to an insurance snafu, on a grad student salary; the pain was far, far more disincentive than the money.)

One more comment on health care. In addition to educating people when and how to use the ER, Urgent Care and the like, there are other possibilities. Blue Cross of Minnesota has a nurse line that has been very helpful in sorting out whether I need to see a doctor, or go to the ER, or just self treat at home. Several times, this has saved me the co-pay for an office visit when all the doctor could do advise rest and liquids, and got me to the ER when it was possible I had a detached retina (I didn't.) The nurse line operates 6 am to 11 pm or something like that. Staffed by well-trained experienced people, this sort of program can save time, money and grief for everyone.

Yes! My hospital network has an after-hours line that's staffed by nurses 24/7. It's absolutely free to all callers. It saved me a doctor visit when my youngest daughter had terrible diaper rash and another when my oldest had a worrisome fever. Both times it turned out that I could solve the problem without even going to the store for something.

Allen@103: Bush addressed \a/ question. How many people think the problem is the price of health insurance, rather than the health insurance industry per se?

Kaiser has an advice nurse line 24/7 and they have my chart for the last few years on the computer screen in front of them. (Kaiser is not going back and scanning all the old records in, they're just summarizing them on a history page.)

At this point, I'm pretty good at figuring out what's wrong myself, though.

#108 Chip:

Surely the price and availability of health insurance are major issues. If it were $50/month and everyone could get it, there wouldn't be millions of uninsured people out there, and businesses and employees wouldn't be being squeezed on health care expenses every year.

My experience with health insurance companies is mostly good, with one exception for Aetna carried as a COBRA plan. Helpful hint #1: Even if the law says they have to do business with you, if they would rather not do business with you, they can be pretty unhelpful. Helpful hint #2: When you let them know you're complaining to the state attorney general and the COBRA compliance office at the Dept. of Labor, they suddenly find themselves able to be helpful again.

Lexica @ 99: If that's all true, I say you STILL don't get to penalize others for their lifestyles. Why? Because you're worrying all the time, and that kills you faster! Oy vey!

#112 makes the spammeter's needle move

Just how much health care could we pay for in the US if doctor's offices and hospitals didn't have to pay the staff to keep track of billing for dozens, if not hundreds, of insurance companies? Plus the travesty of "for profit" health care. How do you save money by adding whole categories of expenses such as advertising and dividends to shareholders?

Our health care dollars would go a lot farther if they all could be spent on health care, rather than on the complex administration of a thousand competing insurance companies. Which would, of course, mean some sort of single payer.

Ursula L @ 113

Not just the number of insurance companies, but the paperwork isn't standardized in any way; every company has its own set of paperwork. (The doctors and hospitals are unhappy with that in itself.)

albatross @ 110: look at what I was answering, and note that you're answered (for my purposes) by 113-4, and beyond that by the fact that the health insurance industry is a profit-making operation in itself; dump them and suddenly you have enough money for single-payer.

Of course, that also puts a fair number of clerks (here, not just in overseas call centers) out of work; damfino how they would be absorbed. Certainly the government wouldn't need all of them -- it takes a lot fewer people to process check requests than to hassle practitioners -- but that hasn't been an obstacle to various other job-cutting measures, so it's not an obstacle they can claim significance for.

The WashPost's Allan Sloan's column today takes a look at what the proposed health deductions will do to retirement. Folks with low income might find their Social Security cut in half with this proposal.