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The Health Care Bill Sucks--and What to Do About It

khin's picture

Crossposted on Firedoglake

The public option was always a fig leaf. Thus, its demise will not really change the fundamental nature of the health care bill, in my opinion. It merely pushes the bill a small step further down the road. I'd argue that a more important issue is the funding, which is changed in the Senate bill from a progressive income tax on the wealthy to taxes on high-end insurance plans and on insurers and providers. These taxes may well be regressive.

According to the CBO, the effects of this bill on overall premiums will be a negligible 1% increase overall. They may be wrong, but that seems hard to predict for sure.

On the other hand, the benefits of the bill are clearly progressive. Medicaid is offered to low-income people and in the exchanges the subsidies benefit the middle and lower middle class.

With that off-the-cuff look, I'd say the overall effects of the final bill are tending towards positive. Yes, it will do nothing to change the overall structure of the system. Yes, costs will continue to spiral out of control in an unsustainable manner. But will the bill make the situation worse? It's hard to see how.

Then there is the question of political calculus. There's the cost-benefit analysis of whether the Democrats have more to lose by jettisoning the current bill or else by passing an unpopular bill. There's also another question that may be getting short shrift: how much the Democrats winning or losing actually impacts what most of us really care about, namely progressive change. These are tough and subjective questions.

I don't know the answers, but at least we can outline what the answers depend on. The first answer depends on the public reaction after the bill is passed. If the public hates the bill and wants it reversed, the Democrats will suffer. In Massachusetts the public reaction has been positive several years on, but right now nationally the bill is unpopular.

The second answer depends on the existence of a viable political alternative to corporate Democrats that isn't the Republicans. In other words, say the Democrats somehow lose politically from this. Either they lose because they pass the bill and the public hates it, or they fail to pass it and the public punishes them for weakness. Is the opposition likely to be Republican or leftist?

My view about this bill is similar to the view that David Himmelstein expressed earlier this year. When asked about how Congresspeople should vote, he said they should abstain. He did not say oppose. I don't think we should waste effort attacking Congresspeople strictly for voting "yes" to this bill. I think whether to vote for or against this bill is an issue that reasonable people can disagree about because the logic depends on matters of political calculus that are hard to understand and predict. I certainly don't think we should attack politicians like Anthony Weiner or Bernie Sanders for their choice here.

"But," you're saying, "somebody has to pay. We didn't get into this mess through the actions of reasonable people. We got into it because of corrupt sellouts and hacks." True. But we need to discern the best place to focus our efforts. The truth is that the story of sellouts and hacks began far before the final vote on this bill. It began far before, in fact, the so-called public option and Medicare buy-in were jettisoned in favor of the demands of Lieberman and Nelson. The story begins with the fact that most Democrats--meaning most, i.e., a majority that does not just include Blue Dogs but rather the actual center of gravity of the party, are beholden to the moneyed interests of insurers and especially providers on this issue. Even in the more democratic House, a mere 90 or so representatives out of 250 Democrats favor Medicare for All. In the Senate, the domination of money is nearly complete, with maybe three or four people in favor. This is in a country where two-thirds of the population may well favor Medicare for All given sufficient information about the topic. (See Kip Sullivan's recent must-read piece.) The problem is not some "tail" of the Democratic Party, as certain apologists and misinformed people sometimes say, with Robert Kuttner for example coming to mind on the recent Bill Moyers Journal. The problem is at least two-thirds of the elected officials in the party.

If "we" is progressive activists, then by the principle that tending to one's own house is one's first and foremost responsibility, our first concern should be to truly come to grips with this. In the end we can hardly blame anyone else for the abject state of affairs of health reform if we are still accepting the absurdities pushed by certain so-called "progressive" figures. Howard Dean comes to mind: he is now angrily calling for the demise of the Senate bill and fulfilling his usual role of superficial progressive hero, even while he denounced single payer from the start and said that anyone attempting it would "pay an enormous price at the polls" because "you can't take choice away from Americans."

The founders of the major progressive blogs are deeply compromised right now. Markos Moulitsas is behaving like the clown and hack he typically does, which is entirely predictable given that his blog is quite explicitly "not a liberal blog" and is officially wedded to the current Democratic Party. No one with any intellectual honesty could wed themselves to that beast (not that Moulitsas makes much pretense of having any). Chris Bowers, Mike Lux and similar "progressives" provide a more intellectual but ultimately just as vacuous perspective. Firedoglake is hardly immune either with its sponsorship of slinkerwink the public option propagandist over at Daily Kos, of "Public Option Please," and so on. The only blogs I know of that actually align on health care with the interests of the general unwashed masses (contrast to educated bloggers) are Corrente and ZBlogs.

So yes, let's make somebody pay--but let's make it count. The first order of business of bloggers needs to be changing the blogosphere. The problem is that this is not really a matter of blogging, rather it's about supporting blogs that are actually progressive and even of forming new blogs. We should cut down the legitimacy of faux-progressives by leaving their blogs as much as possible, whether they're Kos-like clowns or Bowers-like intellectuals. I refuse to post on Daily Kos or Open Left, and only post on Firedoglake because of the great community here, not because of its editorial activities. I stick around on TPMCafe probably due solely at this point to Dean Baker. I strongly suggest that everyone crosspost all their work at Corrente. ZBlogs is even better but without enough responses to be a viable community at present. We should work on that.

Corrente is obviously not as large an operation as Firedoglake, let alone King Kos. It clearly needs software as well as fiscal help. That also goes for ZBlogs, not to mention as yet uncreated blogs. The blogosphere at present is not structured democratically, but for the most part is dominated by opportunists who happen to have the expertise in software and management on their side. If we're going to democratize it then progressives need to capture the technical and managerial expertise. I myself am a computer science major and might try to lend a hand if my personal life ever allows the time, which at the moment it doesn't.

Progressives in general need to understand that the Democratic Party is at least two-thirds rotten. Democratic leaders are not idealists, they are power players who are simply acting in their own self-interest. Chuck Schumer for example is a brilliant politician in one of the most Democratic states in the country, yet he certainly is no Medicare for All advocate and hence has sold out a majority of the US population, not to mention the even larger majority that must exist in New York. None of this bothers him in the slightest because he's dedicated not to progressive ideals but to getting elected by the widest margin possible. The interests of Democrats and of the public are not always or in fact even mostly the same. They just happen to be superior to the Republicans.

Finally, we need to get better organizations. is now calling for the demise of the Senate bill in a fashion reminiscent of Moulitsas, Dean, and other fakers. A far better organization is Progressive Democrats of America, which is actually economically progressive, unlike Moveon which was founded by wealthy entrepreneurs in classic liberal elite style.

It goes without saying that Health Care for America Now is simply a shill to the Democratic establishment and explicitly rejects the idea of meaningful opposition. It is perhaps with them more than anyone that we should place our blame for the disaster that is this bill. After all it is rather easy for politicians to resist a mass movement when there are groups like HCAN working to distract from any movement because it's "infeasible." We put our faith this time around in an organization that explicitly favors politics and "process" over policy and populism. It's time to buck up and realize that no win is possible without a fight. Let's get behind Healthcare-NOW! and Progressive Democrats of America.

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madamab's picture
Submitted by madamab on

Your recommendations about the blogosphere are good too.

I am incredulous that you think the bill shouldn't be killed, though. No, the overall effect will not be positive if you're poor or a woman. Please read any of Lambert or DCBlogger's posts for more details, but in general, the overall effect will be that poor people will have to buy insurance they can't afford, and poor women's right to control their own bodies will be severely compromised. Meanwhile, there is no cap on how expensive insurance can become.

This bill is punitive towards the people who need help the most, and deeply misogynist as well. As a liberal woman, I could never in good conscience support such a travesty.

okanogen's picture
Submitted by okanogen on

I know links are annoying to some people, but really, I have no idea how to verify your opinions since I don't know where you got your facts. You put forth a lot of presumed facts with no back up. Not a single link!

Just as one example, where do you get the evidence that "the benefits are clearly progressive"? That is a supposition that you would have to support with linky goodness and evidence. Especially around these here parts.

Submitted by lambert on

I would rather have 10 blogs, cross-linked, with 10K readership apiece, than 1 blog with 100K; diversity is linked to survival, and a very few huge blogs present better targets than a more distributed system.* (That's why the OFB targeted Kos, which is, after all, about the size of a cable station, and that's why they were successful: it's a monoculture.) "Hail Hydra! Immortal Hydra! We shall never be destroyed! Cut off one limb and two more shall take its place!"

We shouldn't fool ourselves that personality issues cause the problem; if any one of us had first mover advantage and got a little access, the same thing might have happened to us, and one of us C listers might have been tapped as the next David Broder ("There but for the grace of ....").

How to herd the cats? Not sure. Some ideas.... One is to refuse access entirely. Turn that into an advantage -- like Consumer Reports refusing advertising. I mean, who wants the Rs? And if 2/3s of the Ds are lost, that means 3/3s of the Ds know the score, right? Let them figure it out. They're the pros. A second is to share troll lists. If I've got some IPs I've blocked, why shouldn't I share them with my friends? A third is could be editorial policies subscribed and adhered to (big focus here). A fourth is common principles (like Violet's?). I think we should also try to draw a firm line, old-fashioned though it may be, between the news department and the editorial department. In other words, we need to be quite clear that we don't make shit up. With our famously free press in the shape that it is, there is an obvious opportunity there for us.

So, in short form, what I'm thinking about is a self-moderating network of C list blogs. We know that such an architecture impacted the discourse 2003-2006, so why not build on success?

NOTE * Why not 100K blogs with 1K? Intuitively, I'm not sure that's sustainable; 10K is large enough to support a community. I'd be happy to be proved wrong. Basic idea though, is to flatten the power curve.

letsgetitdone's picture
Submitted by letsgetitdone on

A distributed system is also much more effective in coming up with innovations and is much more adaptive than a hierarchical system according to complex adaptive systems theory.

Valhalla's picture
Submitted by Valhalla on

It's also much more likely to create the conditions necessary for "emergent leadership" that lets and Lambert were talking about the other day.

Which is pretty much what you said, but I wanted to throw that link in there.

letsgetitdone's picture
Submitted by letsgetitdone on

It's good to see you here. I agree with much of what you say above, but not about voting for this bill. Here are some reasons why we need to kill this bill.

1) What the bill does immediately (2010 - 2014) doesn't materially address the primary consequences of lack of insurance: fatalities, bankruptcies, and foreclosures. Therefore, the bill is a lie because it doesn't get people care in the short run at an affordable price and protect them from financial ruin. This alone is a compelling reason to vote against this bill.

2) The bill doesn't address the problem of insurance cost increases at all in the immediate period. We can predict that in the four years from now until 2014, we will see insurance premium increases from 50 -75% or more. This alone is insupportable since it will increase the average annual cost of family coverage from the current 13,375 to roughly $20,000 - 24,000. This is another compelling reason to defeat the bill.

3) The bill sells out a woman's reproductive choice. This is not something progressives should ever agree to, since it is a core principle of progressivism.

4) After 2014 the bill tries to force people to buy unaffordable and also crappy insurance from private insurers. The subsidies are not high enough to make insurance affordable except in the judgment of legislators who are all well off and have no understanding of middle class family budgets, and the subsidies don't do anything about the remaining high out of pocket costs people can expect.

5) After 2014 the bill will not cover 30 million additional people. The subsidies are not indexed to rising insurance costs, and therefore insurance even with subsidies will become increasingly unaffordable. In my view it's doubtful that more than 15 million will be covered, and those people won't be protected from bankruptcies and foreclosures because out of pocket costs will be great enough to drive middle class people into bankruptcies. Since US population will be increasing over time, we can expect the total number of uninsured to grow over time, so even after 2014 and taking into account the 15 million additional people covered, we will still be looking at 35 million uncovered, and 35,000 fatalities per year due to lack of insurance.

6) After 2014, it won't be possible to enforce the mandate. The IRS isn't really a very effective collector. It collects only a very small percentage of debts each year now. If there is widespread non-compliance with the mandates, the IRS won't be able to enforce them. In one way that's good. However, the IRS presence will be a constant irritant to people, and in addition, widespread non-compliance will increase the widespread disrespect and cynicism we already see with respect to our laws and their enforcement.

7) The bill does nothing to stop or decrease the share of GDP being spent on health care. It's now about 17.5%, if GDP averages 3% growth over the next four years, which may not be the case if we have a double-dip recession, we're looking at health care costs outrunning GDP growth by probably about 7% per year. By 2014, health care expenditures could be about 22-23% of our economy, while other nations are still at 12% or so. This will make the US much more uncompetitive in international markets than we are now.

8) in addition to all these reasons, one of the more compelling ones is the political damage that passing this bill will do to the larger political context. In the short run, it makes it much more difficult to pursue real solutions to health insurance reforms because the political elites will moan about how hard they worked to pass this bill, and about how everyone should wait around until 2014 to see how it will work. In the longer run, the inflation in premium costs, the waiting period of four years while costs increase, and the actual experience of the system beginning in 2014, will all persuade people that it's useless to expect Government to help people with their problems. This bill is potentially a killer for progressive politics, if we let the Administration push us into the obvious wait-and-see posture with respect to it that they expect from us.

In brief, we need to work as hard as we can to defeat this bill, and if we can't convince any Senators to kill it, then we have to come out the box in January breathing fire about how bad it is, and how much it needs to be repealed before the elections of 2010, and replaced with enhanced Medicare for All.

Submitted by [Please enter a... (not verified) on

Also, the CBO estimates that the cost for individual plans will go up 10 - 13%. (Of course, Wellpoint and Blue Cross estimate that some will triple.)

The whole reason people have tried to spin this so that it seems like it will be less expensive for people is because 57% of the people participating in the "exchanges" will be getting subsidies to pay for their insurance. So, we foist the cost onto the tax payer, and then act as if it goes away.

The entire bill is jammed full with garbage. It cuts Medicare by $483B. It was just tweaked to allow for coverage caps determined by insurance companies so long as they are not "unreasonable." "Have $80,000 worth of bills this year? Sorry, that's beyond your cap." They're stepping on the ability to import cheap drugs. There are also a slew of other taxes associated with it, and apparently it will virtually eliminate HSA's, which seem to be a good idea.

Also, the majority of MA citizens do not think their health plan is doing a good job:

Twenty-six percent (26%) of Massachusetts voters say their state’s health care reform effort has been a success. A new Rasmussen Reports telephone survey in the state finds that 37% say the reform effort has been a failure, while another 37% are not sure.

nihil obstet's picture
Submitted by nihil obstet on

The other issue that I would add is the enforcement of requirements on the insurance companies. I keep reading about what insurance companies can and can't do, but I don't see anything about how they'll be made to do it.

Now, you walk into a doctor's office. First bit of paperwork includes signing a statement that you acknowledge that you are responsible for any charges that the insurance company doesn't pay. (I regard this as sheer financial intimidation and generally hand it back unsigned; I would guess that people less accustomed to dealing with forms just sign what they're told.)

In my experience, anything beyond routine check-ups will produce several denied claims -- that pathology analysis that the surgeon ordered while you were out cold on the table turns out to be "unnecessary", and the doctor's office thinks you didn't pay the co-pay for the follow-up visit, and four-syllable procedure during the follow-up isn't covered, and . . . . When my mother was undergoing treatment for cancer, my parents would drive up to insurance company headquarters once a year with denied claims and walk out with a substantial check because it turns out, surprise, that the claims had been mistakenly denied. They could stay with me, who live about 30 miles from the headquarters; otherwise they'd be looking at hotel bills. On my own stuff, I spend untold hours filing appeals, copying cancelled checks, contacting the state Attorney General's consumer affairs division. This is employer provided insurance. The HR people say they're not involved; the individual has to deal directly with the insurance company.

If you're less accustomed to dealing with paperwork, the insurance company pays less and you pay more than the contract calls for. This is especially true when your time and energy is consumed by your poor health. I always reach a point where I just figure continuing the fight isn't worth the remaining money that they should have paid.

What enforcement mechanism in this bill prevents the insurance company from taking premiums and throwing up obstacles to care?

letsgetitdone's picture
Submitted by letsgetitdone on

Politics penetrates the Government, and these days the Government won't enforce the law against anybody but poor people. The regulations in this bill are a joke because there are no enforcement mechanisms.

Submitted by hipparchia on

In the short run, it makes it much more difficult to pursue real solutions to health insurance reforms because the political elites will moan about how hard they worked to pass this bill, and about how everyone should wait around until 2014 to see how it will work.

this strikes me as a much more likely scenario than the one where killing this bill will result in no more working on health care for another 15 or 20 years.

letsgetitdone's picture
Submitted by letsgetitdone on

But neither of those things is what's going to happen. What will happen is whether this bill passes or not, the Dems will have to pass something else to fix it by next Summer, or they will die at the polls in the Fall.

khin's picture
Submitted by khin on

If we’ve determined that we can probably get a better bill with reconciliation, and that is what we mean by “kill the bill,” then I do not have a problem. Maybe what we want to do is pass a leaner bill, one that only includes a Medicaid expansion and a Medicare buy-in and that simply does not address the private sector. As far as my fairly meager understanding of Senate procedure goes, that is possible.

I found the debate between Nate Silver and Jon Walker about using reconciliation to be informative. Nate Silver argues that if a bill were passed using reconciliation, senators like Ben Nelson and Joseph Lieberman would very likely vote against the remaining provisions out of spite at having been snubbed in the process. However, it now occurs to me that maybe it doesn’t matter. In other words, suppose they do kill the other portions of the bill. So what? The provisions I am most attached to as a progressive are the very ones that could be passed through reconciliation. If the other provisions go down, maybe they can wait anyway.

The big question for me is how likely we are to actually get a leaner and better bill through reconciliation. A big sign we might get it is that the consequences of passing no bill for the Democrats after six months of debate are, at least in my intuitive estimation, likely worse than passing even a flawed bill. Therefore, being self-interested, if they are somehow blocked from a successful comprehensive bill, they will at least pass a smaller bill. However, against this we do have to balance the fact that Harry Reid would have to make enemies with the most conservative members of the Democratic Party by doing so, and also this debate has gone on for six months and there is a limit to how much time can be devoted to one issue. But upon consideration I am starting to come around to the idea that this is actually doable. That’s not because I think this bill is literally worse than nothing, which seems difficult to justify given the sources and recipients of funding. Rather it’s because it seems hard to imagine Obama and Reid just giving up, passing nothing, and embracing a Clinton ‘94 redux.

I don’t think your statements above show that this bill is worse than nothing. For example, it’s true that the best provisions of this bill don’t kick in until 2014, but neither does doing nothing. Also, I don’t see any evidence for saying that health expenditures could be 22-23% of our economy by 2014. That is far beyond any projections I’ve seen.

Anyway, regardless of whether this bill does pass, we need to fight first and foremost for a Medicare for All system and go through the process of soul-searching that I described above. The bar for determining whether a person or group is progressive on health care reform should not be whether they favor a mere Medicare buy-in for those aged 55 to 64 who cannot find other insurance, or a “public option” that is not actually an option for most. The population supports better than that and there’s no excuse for demanding anything less. We should not be supporting groups, blogs, or others who claim to be progressive and refuse to do so. That also means jettisoning any poison alliance with the Democratic Party. Those who ally with the present mostly-rotten Democratic Party are simply suck-ups to power.

That’s really the central point I want to make here. Regardless of what happens in the next few days and weeks, far more significant are the failures that brought us to this disheveled state in the first place. We wouldn’t be in this asinine position if we hadn’t put our trust in the Democratic Party, in associated lapdogs like Moulitsas, Bowers, and Dean, and in organizations like HCAN and Moveon. If “we,” meaning progressives, had dumped these sorry people and organizations and supported independent ones like Corrente, ZBlogs, Kucinich, Healthcare-NOW! and PDA with equal fervor, this would not have happened.

Submitted by hipparchia on

yes, we could possibly get something mildly progressive out of a bill if it went to reconciliation, since only those things that affect federal spending are considered. medicare and to some extent medicaid would qualify, and yes, the private insurance mess would most likely be left as is [not that i'd cry over that].

madamab's picture
Submitted by madamab on

I don’t think your statements above show that this bill is worse than nothing. For example, it’s true that the best provisions of this bill don’t kick in until 2014, but neither does doing nothing.

This bill will block access to abortion for millions of women. Is that good, or bad? Is that better, or worse, than doing nothing?

Sorry but WTF. WTF. WTF. What does it take to get through this fucking wall of denial?

With all due respect, get your head out of the process and recognize that these policies have real fucking consequences for women.

Jesus fucking Christ.

letsgetitdone's picture
Submitted by letsgetitdone on

I think we're in pretty close agreement. But a couple of comments on this statement:

"I don’t think your statements above show that this bill is worse than nothing. For example, it’s true that the best provisions of this bill don’t kick in until 2014, but neither does doing nothing. . . . "

I think my statements above show that the bill does much positive harm before 2014, and plenty of harm after that as well. I'm neither claiming that it's worse than nothing, nor suggesting that we have nothing. The choice between this bill and nothing is a false choice. What I am saying is that if we kill this bill we are much more likely to get something better in the short run, while if we vote for it we are much less likely to get something better in the short run.

You also said:

"Also, I don’t see any evidence for saying that health expenditures could be 22-23% of our economy by 2014. That is far beyond any projections I’ve seen."

Compute the projections yourself. Private sector medical costs are increasing by about 10% per year right now, while the GDP forecast is what, about 3%. Medical costs are about 17.5% of the economy in 2009. GDP is about 14.3 trillion and Medical expenditures are 2.5 Trillion. If you thing any of these estimates are wrong, then use your own.

Finally I didn't read Nate's debate with Jon. But here's my recent piece on reconciliation, which also suggests that once we go through reconciliation, we don't much care if they don't want the regulatory bill, because if they defeat that, we'll defeat their exchange and then the stuff passed in reconciliation will destroy them.

DCblogger's picture
Submitted by DCblogger on

3) The bill sells out a woman's reproductive choice. This is not something progressives should ever agree to, since it is a core principle of progressivism.

women are 55% of the population. Legislation that injures the health of women is neither health, nor care, nor reform.

bendjamin's picture
Submitted by bendjamin on

Obama set a 2012 timeline.

The New Deal wasn't enacted in one bill. Something as complicated as health care reform is going to take several bills over many years. The Senate bill is a first step. It's a very big first step.

We have a bill now. If you kill this, the Democratic Party will not pick up health insurance reform again for 20 years.

Or, you can pass this bill and try to improve upon it in 2011.

Democracy requires compromise. And if you refuse to compromise, you will never get anything.