Good news and bad news last night, as the House passed health care reform.
The good news is: the House passed health care reform. The work isn’t completely done yet, of course. The House had already passed a heath care bill, months ago, but this isn’t it; last night they passed the Senate’s version of the Bill, which had some glaring flaws. Under ordinary circumstances the House and Senate would get together and hammer out a compromise between their two bills. But in the meantime Republicans picked up an extra Senate seat in Massachusetts after Teddy Kennedy died, and they had promised to filibuster the compromise package. (Because, after all, what courageous moral stand could be worth invoking arcane parliamentary procedures more than the fight to prevent millions of people from getting health insurance, especially if that was the life’s goal of the Senator whose death allowed you to improve from having twenty fewer votes than the opposition to only having eighteen fewer votes?)
So Obama will sign the Senate bill that the House just approved, and then the Senate will consider a reconciliation bill also passed by the House last night. Under even-more-arcane procedures, the reconciliation measure can be passed without threat of filibuster. It requires only “majority vote,” a quaint notion in this highly baroque age.
It’s not an especially huge bill, whatever you may have heard, but it will have an impact. Here is a list of the major impacts, and an interactive graphic to figure out how you will be affected. The most important features seem to be:
- Establish health insurance exchanges, and provide subsidies for people below four times the poverty line.
- Guarantee insurance for people with pre-existing conditions, and eliminate “rescissions” that take away insurance from people who get sick.
- Push business to provide insurance for their employees, and self-employed individuals to buy insurance for themselves.
- Close the “donut hole” in the existing Medicare payout structure.
- Implement cost controls (mostly through slowing the growth of Medicare spending), thereby lowering the budget deficit by $130 billion over the first ten years, and by another $1 trillion over the next ten years.
Overall, it’s a relatively incremental bill, placing bandages over some of the more egregious wounds in the current system, while leaving in place the essential structure through which we funnel billions of dollars to middlemen while paying far more for medical care per person than any other country without getting better results. For 90% of Americans, coverage and insurance will continue as before. Basically, this brings us a little closer to where Western Europe was a century ago.
Still, a tremendous political accomplishment — maybe not from the perspective of what we were hoping for when Democrats took control of both houses of Congress and the Presidency in 2008, but certainly from the perspective of the last couple of months, when it often seemed like we weren’t going to get anything at all. More than anyone, credit for the accomplishment goes to Nancy Pelosi, who didn’t give up when things looked grim. From now on she won’t simply be known as the first female Speaker of the House, but one of the most effective leaders in its history. Here she is marching to the Capitol yesterday, arms linked with civil-rights pioneer Representative John Lewis from Georgia, carrying the gavel that was used when Medicare was passed in 1965. An historic moment.
Which brings us to the bad news. One of the reasons why Pelosi was marching with Lewis was to demonstrate support a day after this man who had marched at Selma was repeatedly called “nigger” by protesters outside the Capitol. Ugly by itself, but worse in context: it’s becoming harder and harder to have a meaningful debate in this country without participating in a race to the rhetorical bottom.
There exist reasonable arguments against health-care reform; not arguments I agree with, but ones that at least make superficial sense. It costs money to provide insurance for the uninsured, and someone will have to pay. Asking healthy people to buy insurance will be a burden to them. There will be less extra money floating around if we cut down on unnecessary costs, which might impede the pace of medical innovation. (I didn’t say they were great arguments, just that they made superficial sense.) But these aren’t the arguments that are actually made most frequently. Instead we hear that the Democrats are abandoning the principles of representative democracy by passing legislation while they control both legislative houses and the executive; or that liberals won’t stop until they have swept away the last vestiges of personal choice in American life; or that the government wants to decide when to kill granny. Right-wing bloggers nod with approval at the idea that people are stocking up on guns, preparing for fighting in the streets. The race to find the most scary and overheated characterization of a pretty benign state of affairs is a fierce one.
The most depressing aspect of the situation is not the existence of crazy fringe elements — those will always be with us, on both sides of any issue — but of the reinforcing dynamic between the fringe and the supposedly respectable parts of the Republican party. It’s been clear for a while to most people (outside the White House, anyway) that Republicans in Congress made a clear choice that their own self-interests are served by preventing Democrats from passing any meaningful legislation, whatever that might mean for the good of the country. Speeches during House “debate” last night consistently played to the worst aspects of the protesting mob. One Congressman shouted “baby killer!” at Democrat Bart Stupak, who is staunchly anti-abortion, as he spoke to support the bill. [Update: it was Randy Neugebauer (R-Tex.).] Two protesters inside the House chamber were arrested for being disruptive — and “several Republican lawmakers stood up and cheered during the interruption.”
Lest you think this is simply concern-trolling from a liberal telling conservatives to be less intrusive, note that conservative commentators like David Frum are making the same point: the rhetoric has gotten out of hand, and it’s not good for anybody, except maybe the “conservative entertainment industry.”
I’ve been on a soapbox for months now about the harm that our overheated talk is doing to us. Yes it mobilizes supporters – but by mobilizing them with hysterical accusations and pseudo-information, overheated talk has made it impossible for representatives to represent and elected leaders to lead. The real leaders are on TV and radio, and they have very different imperatives from people in government. Talk radio thrives on confrontation and recrimination. When Rush Limbaugh said that he wanted President Obama to fail, he was intelligently explaining his own interests. What he omitted to say – but what is equally true – is that he also wants Republicans to fail. If Republicans succeed – if they govern successfully in office and negotiate attractive compromises out of office – Rush’s listeners get less angry. And if they are less angry, they listen to the radio less, and hear fewer ads for Sleepnumber beds.
I’m not sure what the end game is — whether it’s possible to step back to a more reasonable dialogue. Disagreement is good, and it’s important to have an active and engaged opposition party, no matter who the majority party might be. But whipping up hysteria at the cost of working together constructively isn’t in anyone’s interests. Obama campaigned on a message of hope and change and bipartisan togetherness, and I think that was a sincere message on his part; but it certainly hasn’t come to pass, and there doesn’t seem to be any indication that it will.
Aren’t schools in america publicly funded? Does Jeff think that is also wrong?
As tempting as it might be, this really isn’t the place to debate the fundamental principles of libertarianism. But if you want to talk about health care, go for it.
Jeff: “I claim it is wrong to take by force the fruits of one person’s labor and redistribute them to someone else, no matter how noble the ends.” Spoken like a true libertarian. Well, here are a few things the “fruits of your labor” support: public schools, community colleges, state universities, police protection, fire departments, trash collection, recycling, water, sewer, parks and recreation, libraries, museums, road construction and repair, traffic safety, mail delivery, Social Security, Medicare, Medicaid, Homeland Security, FEMA, TSA, FAA, FDA, EPS, OSHA, SEC, FDIC, Federal Reserve, Army, Navy, Marines, Air Force, Coast Guard, National Guard, FBI, CIA, NIH,CDC,NSF. Etc. Exactly which services do you wish the “fruits of your labor” not go to someone else?
SteveN
We have nearly a million bankruptcies a year -families with health insurance which did not cover costs. Someone asked a Swiss how many medical bankruptcies they had. he said “none- that would be immoral”
Sean,
There is historical precedent for hyperpartisanship whipped by outrageous rhetoric. Look no further than the bowels — then the Terror — of the French revolution, what happened between the Jacobins and the Girondists. Suggest Simon Schama’s “Citizens” if you haven’t already read it. What happened then is one possible outcome. Self-immolation followed by the rise of an imperial Consulate (Bonaparte) and years of war — self-destruction turned outwards into military aggression.
– g
Sean —
“Asking healthy people to buy insurance will be a burden to them.”
I think that’s the whole point of insurance — that you divvy up the risks among a group of people because “one never knows” who is going to get sick. And these group of people include healthy people.
Jeff, here’s another way to look at it. When people buy health insurance right now, the healthy people are redistributing their wealth to the unhealthy people. I’ve been to a doctor about three times in my life (I get annual checkups by nurse-practitioners at work), and have never had anything worse than a broken nose. If I get run over by a truck tomorrow, all the money I spent on premiums was redistributed elsewhere. Yet I buy insurance because I don’t know that I will never need it.
A lot of my money went to insurance company personnel who aren’t doctors or nurses. What’s wrong with eliminating the insurance company middlemen, and all insuring each other, through some non-profit, central organization, like, say, the government?
I realize that’s not what we got in the current bill – because, and forgive me if I’m wrong, people like you derailed all attempts to put in a public option. (If you do support a public option, I apologize.)
Anyway, I didn’t get my public option, but the numbers I’ve seen, from studies by the Kaiser Foundation, the CBO, and elsewhere, convince me that what I did get is way better than nothing.
@ Scott B
I’m sure an educated debate is a waste of time. But here we go…
The CBO score is meaningless at this point. The CBO follows very strict and well understood rules in scoring a bill. We will most likely not see the cost savings promised and this legislation will not reduce the deficit.
From the CBO:
“Those longer-term calculations reflect an assumption that the provisions of the reconciliation proposal and H.R. 3590 are enacted and remain unchanged throughout the next two decades, which is often not the case for major legislation. For example, the sustainable growth rate mechanism governing Medicare’s payments to physicians has frequently been modified (either through legislation or administrative action) to avoid reductions in those payments, and legislation to do so again is currently under consideration by the Congress.”
http://www.cbo.gov/ftpdocs/113xx/doc11379/Manager%27sAmendmenttoReconciliationProposal.pdf
The well publicized “Doc Fix” is an example of cost cutting in Medicare that never materialized. Doctor reimbursement was supposed to be decreased to make Medicare more financially sound, but every few years Congress returns to the issue and overturns the cuts to Doctors. It’s expected to cost $200 billion over the next 10 years. There is a similar example in this bill too. See Section 1202 of the House reconciliation.
http://docs.house.gov/rules/hr4872/111_hr4872_amndsub.pdf
In 2013 and 2014, primary care physicians seeing Medicaid patients will get payment equal to Medicare patients. Medicaid usually reimburses doctors and hospitals less than Medicare because payment is determined by states. Since states share the cost of Medicaid with the government, it’s in their interest to keep Medicaid reimbursements down.
What do you think will happen in 2015? Will the federal government allow doctor reimbursement to drop back down to Medicaid levels or will this create a new “Doc Fix?”
The CBO scored this as only $8 billion in new spending because it only lasts two years. But this is a cost that I expect to last indefinitely. And this bill expands Medicaid eligibility to 15 million additional Americans when the meat of this bill kicks on in 2014.
This is ONE example of awful accounting and manipulation in this bill. I will continue, if the readers here will concede that this is a serious problem and we have been deceived by the Democratic leadership.
All the Republican shrieking about this was completely over the top. By the end they sounded like Bucky Katt (http://comics.com/get_fuzzy), spouting inflammatory words (“totalitarian!”) without the slightest regard for what they mean. I have a hard time believing these are elected officials from a serious political party.
Jeff’s quote
I claim it is wrong to take by force the fruits of one person’s labor and redistribute them to someone else, no matter how noble the ends. I guess that makes me an uncivilized idiot.
This is theology, and brooks no argument, and makes no sense. it is specially ironic in a cosmologist’s blog. Imagine cosmology without government backing.
Readers of this blog might be interested to know that when Canada passed health care legislation, much the same overheated rhetoric and absurd predictions of calamity were made. None of those predictions came true and the people who voiced them sound parochial, silly and partisan in retrospect.
For the organized political parties, continuing to oppose what clearly was an overwhelming success, became political hemlock. So they switched positions of course. That’s politics!
Sean’s request in #27 means that any responses I might make are out of place here.
” It costs money to provide insurance for the uninsured, and someone will have to pay.”
No kidding. Never mind, I’m sure that that fabulously wealthy guy, Someone Else, will pick up the tab.
You all seem to have a lot more trust in the federal government than I do. When I see the spiraling costs of Medicare, Medicaid, Social Security, the US Postal Service, and expanded health care in Massachusetts and Tennessee, I lose all faith in any of the cost estimates that I hear. Everyone loves entitlements until they bankrupt the country.
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No kidding. Never mind, I’m sure that that fabulously wealthy guy, Someone Else, will pick up the tab.
I would be happy to contribute.
You all seem to have a lot more trust in the federal government than I do.
The Federal Government is staffed by people, not space aliens. Some do a good job, some not so good. But insurance companies are staffed by people also. Good luck to us all.
The point is, how much are you personally willing to contribute when it takes a toll on your own family.
Imagine you are taking care of your family, it’s needs and also your neighbor’s family. While that may be morally or philosophically attractive, that losses luster as your family is hurt by the loss of income.
Too many Grasshoppers and not enough Ants. Soon we’ll have the ruling elite and the rest designated workers. Maybe we can all join the ruling elite.
At the last physics conference I attended, a physics professor from Canada, in response to my noting that people who exercise a lot seem to always have to go to the hospital, complained about their health system. A tendon snapped near his elbow and a muscle came loose. When he went to the hospital they required him to talk to his “primary health care provider”, rather than go directly to the obvious specialist because Canada’s health care reform has resulted in a shortage of doctors (official Canadian gov. link) Then he would be put on a waiting list; by the time he would be operated on his arm would be permanently impaired.
In addition, he discovered something that those of us who have worked in the ultrascan industry already knew; Canada’s “MSP” system has no available modern doppler based ultrascan equipment <a href="http://www.canadadiagnostic.com/A5_AboutCDC.phpinstead you have to pay private companies like this one. He had received better care in the Philippines.
He was so dissatisfied with Canada that he asked his department for a 1 year sabbatical so he could take a job in the Caribbean, (I forget where, was it the Dominican Republic) where he expected to receive better care than Canada.
Fortunately, some of his former students worked at the hospital and recognized his name. They pulled strings and he was operated on the next morning. The situation reminded him of his experience in the former Soviet block. Yes, adequate (not good) health care remains for people who have connections, but the system runs as badly as any other system run by the government.
I know people who’ve had wonderful experience with European health care. But I live close to the Canadian border and people regularly come across the border to obtain access to real health care. I know the Canadian system is atrocious.
I am very impressed and surprised with this blog entry — a physicist making a political statement, but also one that is highly informative and well-composed. I had no idea any of things were happening just a couple of miles away from my sorry existence.
Rejoinders:
This bill reduced health costs. Other bills in the future may increase health costs again. That is true of all deficit-reduction bills (they could all be overturned in the future), and is no reason not to vote for such bills.
The additional cost of insuring the uninsured comes to about 5 cents on the health-care dollar. At that level I have no us-vs.-them moral quandry. (Note: the uninsured actually do get some of the most expensive kind of health care – emergency care – right now.)
I have seen more anecdata from Canadians (including a brother who lives in Canada) extolling the Canadian system than otherwise.; and it is a fact that they live longer for less per-capita cost than us, just like the rest of the developed world.
If people want to get rich quick, they spend four years of college taking courses like “Physics for Poets”, then become investment bankers. My nephew the doctor was never happier than when he was in the Navy, working in a clinic, getting paid a salary and never caring whether his patients had health insurance or not. (He left med school free of debt – the Navy paid his way in exchange for a tour of duty. He got to fly in the back seat of jets, too.) His practice employs more people just to handle insurance forms than doctors and nurses.
The bill could have been a whole lot better. I personally blame that mostly on Republican obstructionism. A life-long independent, I voted about 40% Republican and 60% Democratic 30 years ago. These days, as poor as many Democrat politicians are, I have difficulty voting for a Republican for dog-catcher (knowing that they voted for GWB twice).
Hello Braemar,
Thank you for responding to my previous post (#41). You said,
“The point is, how much are you personally willing to contribute when it takes a toll on your own family.”
You posit a hypothetical that does not apply to me. As Yogi Berra might have said, “If things were different, they’d be different.” Notice that I made no claim that anyone else would or should be happy to contribute, merely that I would be. I respect the fact that each person has his or her own unique circumstances.
Imagine you are taking care of your family, it’s needs and also your neighbor’s family.
You nailed me this time. I do take care of another person, who is not related to me.
While that may be morally or philosophically attractive,…
Man does not live by philosophy and morals alone. This may be tough for you to understand, but I very much enjoy helping this person. I think many (most?) of us feel something similar at times. Watch a mother with her child, watch two lovers, watch two friends.
Too many Grasshoppers and not enough Ants.
Most of us don’t ultimately aspire to be Ants. I would never disparage Anthood – if you are an Ant, I say be a proud Ant, perhaps even a great Ant. I enjoy a balanced life. I am lucky in that I enjoy my work, but I also like to relax and have fun.
When I was a kid growing up, many people in the neighborhood had antique-looking cast iron plaques mounted as decorations to the fronts of their houses. It was explained to us in school that these had originally been fire company logo markers: artifacts of a bygone age when people contracted individually with private fire companies, and each fire company would only douse a fire in your house if you had their marker out front. We were told that, back in that benighted era “a fire truck would go right past your house, even if it was burning, if you didn’t have their marker!” in a tone indicating that this was an uncivilized practice; and that we, now with public fire companies, were rightly proud to be better than that.
I look forward to a time, maybe within my lifetime, when schoolchildren will be taught that the bygone age when sick people couldn’t always see a doctor was an uncivilized time, and they should be proud to be better than that.
@ JimV
Jim V wrote:
“This bill reduced health costs. Other bills in the future may increase health costs again. That is true of all deficit-reduction bills (they could all be overturned in the future), and is no reason not to vote for such bills.”
This bill is not about reducing costs. Republicans already proposed doing this piecemeal. If the Democrats had identified ways of cutting costs in Medicare, why not make that a standalone bill and reinvest the savings in the unfunded Medicare liability we already have?
At its heart, this bill is a new entitlement program. It’s scored by the CBO as a net deficit reducer because of tax hikes and Medicare cuts. We have seen examples in our past where promised Medicare cuts never materialized (Doc Fix). And I outlined one example in post #33 why the CBO probably underestimates future spending.
The claim of deficit reduction is misleading. And in his interview with Bret Baier, President Obama said, “…if they vote against, then they’re going to be voting against health care reform and they’re going to be voting in favor of the status quo.”
This was never our only feasible course of action for health reform. A no vote is not a vote for the status quo. We don’t have to push for a Western European form of socialized medicine to improve health care and health insurance. This legislation will most likely increase the deficit. And this process and its result has been an unmitigated disaster.
And so back to Brian137,
To the heart of the question:
Where is the tipping point, the point where you will not give up any more of yours to help another because you will not be able save yourself?
I heard this tonight and I feel it is probably close to the center of this matter:
Democrats see this as a moral issue and Republicans as an economic one. Ultimately well meaning help ends when you are in danger of doing great harm to yourself or others you care for.
If this care plan saves money, (and I can not see how it can in this form) the Democrats will be proved correct. And if this costs money the country may fall into a bankruptcy from which it will not recover.
Others believe, with me, that there are better ways to solve this problem.
What have we learned from Oregon and Massachusetts?
Time will tell us about this next experiment, if we have enough left.
So, let’s see. We either move towards one of a number of systems that cover all citizens, are far cheaper, and (overall) have equal and sometimes even better outcomes than the US system, or…. what?
We continue to tweak a system that is already failing millions of Americans, is rapidly pricing itself out of range of millions more, and continues to lock millions of workers into jobs, and forces millions of others to leave other jobs they like to find ones with decent and affordable health insurance. And all of this has never been successfully tried in any other country on the planet.