• Put your money where your mouth is

    About a year ago, after Sen. Brown won election in Massachusetts, and it seemed like health care reform would die, I began to despair at the glee I saw in many who opposed the bill. I wrote a post entitled, “This is not a game“:

    This isn’t a game; it never was. Like it or not, the problems in the United States health care system are real. I have cared for children who have — literally — died because of bad insurance or no insurance. I have personally known people who have lost everything because of a medical tragedy. And I swear to you, these illnesses involve children who were not lazy or shiftless or deserving of these problems in any way.

    I’m not declaring that you have to support health care reform as it’s currently being proposed. I’m also not saying that if you oppose reform then you are somehow to blame for misfortune or death.

    But I have to tell you, the glee I’m seeing at its potential failure is unsettling.

    This isn’t a game. Real people’s health and lives are at stake. The long term fiscal stability of the United States is on the line. We may not choose to reform the health care system this week, but it must be done.

    If you oppose this reform, and I know many people who do, then you have to come up with another plan. Not only that, but you have to come up with a realistic way of getting that plan accomplished. I don’t know nearly as many people who meet those criteria.

    I’m watching election returns in Massachusetts and reading bloggers who are simply giddy about what’s going on. Unfortunately, most seem to be excited not for what a Scott Brown victory means in terms of a policy agenda, but for what it means for potentially stopping an opposing agenda.

    I’m watching people partying about the potential death of health care reform.

    I’ve always been prepared for this bill to fail. There have been many times I’ve not been thrilled with it. And I would continue to stoke my opposition if I saw anyone else proposing a viable alternative. They’re not.

    But I’ve not prepared myself for the absolute delight some people seem to be taking in killing this bill.

    It’s a year later, and I have to tell you, the despair I’m feeling is pretty similar. Your glee is not endearing.

    I get that many of you don’t like the PPACA. As I’ve said over and over, it’s not my ideal way to reform the health care system, either. But I accepted it because it was clear to me that I wasn’t going to get anything better. I watched the Democrats sacrifice a single-payer system in order to placate the Republicans. Then went the public option. The exchanges were whittled down. And implementation was pushed back to 2014 to meet an arbitrary number of $1 trillion over a decade (as if that had some meaning).

    I can accept that. As I also said last year, wishing won’t make it 60.

    What I want now is the same as what I wanted then – a better health care system. I don’t sense a lot of that coming from many of you. You want the PPACA gone. You want those who passed it to lose. You want to win.

    I say this because I see many of you so absolutely crazed by the individual mandate. It’s as if this is akin to “taxation without representation”. You believe this is the first step on the slippery slope to fascism.


    If that’s the case, where is the simple proposal to lose the mandate? I know you’d have no trouble getting every Republican behind that bill. I bet you’d even get a fair number of Democrats. Heck, Senator Obama was opposed to it. So if you really, really hate the mandate so much, go ahead and lose it. I no longer care.

    As I’ve said before, the mandate is there to protect the private insurance industry. It’s so people don’t game the system and then buy insurance only when they need it. If people do that, there’s adverse selection, and rates go up. You see it in New York, which has a lot of regulation, but no mandate. You’ll piss off the insurance companies, and possibly endanger their long term survival, but go ahead.  If the mandate so offends you, so be it.

    But I’ve seen no one propose that.  Why not?  I suspect it’s because you’re really not as offended by the mandate, as you are by the PPACA.  If that’s the case, then yes – I call you a hypocrite. You’re begging for judicial activism. You’re asking the courts to do what you cannot do through Congress. And even then, losing the PPACA would likely need reconciliation and a new President, and many of you called that evil last year, too. You’re recognizing that you can’t get what you want through the usual legislative pathway, and looking for a shortcut to achieve your goals without a majority.

    And you’re going about it in a pretty cynical manner. You’re using words like “tyranny” and “fascism” and “liberty” for political means. It’s rhetoric, and personally I think it’s harmful.

    But prove me wrong. If the mandate so offends you, call on your representatives to support a bill to remove it right now. It’s not like there aren’t other means to achieve the same incentives. Here’s one.

    So there’s the challenge. Support a fix to the mandate right now. If you won’t, then you obviously aren’t that concerned about “liberty”. You’re willing to risk the mandate standing if the courts don’t go your way.

    Unless… your real goal is a return to the status quo before reform, and your “anger” at the mandate is really a tool to achieve that. If that’s the case, don’t expect me to engage you much. It’s hard to negotiate with people who won’t be honest.

    UPDATE: Comments on this post have been closed.

    • –“What I want now is the same as what I wanted then – a better health care system. I don’t sense a lot of that coming from many of you. You want the PPACA gone. You want those who passed it to lose. You want to win.”

      The “my goals are noble and pure while the goals of others are cynical and self-serving” line of argument is not really very helpful. Many people oppose PPACA because they think it will make the health care system worse in the long-run. They believe that the personal tragedies that you wish to prevent would be even greater with a post-PPACA health care system. Reasonable people can disagree on that point of course, but there is little to be gained from just calling people who disagree dishonest and disingenuous.

      If one believes we’re worse off with PPACA, and there are legitimate concerns about the constitutionality of the mandate, of course one would embrace the mandate as the most effective means to defeat the bill. And what’s more, a federal mandate to purchase insurance would indeed be a pretty dramatic expansion of federal power. I’m not calling it tyranny or fascism or any other inflammatory words, but it is certainly unprecedented and very arguably beyond the constitutional limits of the federal government to do so.

      We already do some social engineering through the tax code with mortgage interest, etc, but none of these really comparable because you’re not being ordered to do something. The mandate could have been structured similarly, and the constitutional concerns would be moot, but the Democrats didn’t do that because of their own politically cynical motives.

      It comes down one rather simple fact: the Democrats screwed up by creating the bill with what may be an unconstitutional component. Opponents of this particular bill would rather have a completely different approach to reform, and so they’ll use this Democrat screw-up to try and accomplish that.

      –“If that’s the case, then yes – I call you a hypocrite. You’re begging for judicial activism.”

      And this is just wrong. Using the court system to decide if the federal government has the constitutional power to force you to buy something is not judicial activism. It is asking the judicial system to do exactly what it is supposed to do. Since when is asking the judicial system to determine if a law is constitutional “judicial activism”?

      –” You’re asking the courts to do what you cannot do through Congress.”

      And you’re asking Congress to do something the constitution may not allow, and hoping the judicial system that was designed to prevent that very thing will just keep quiet on the matter. There is a much bigger issue here than just health reform. How far does the power of the federal government go? What are the limits of what they can force you to do?

      –“And you’re going about it in a pretty cynical manner. You’re using words like “tyranny” and “fascism” and “liberty” for political means. It’s rhetoric, and personally I think it’s harmful.”

      No less rhetorical or harmful than the heartstring-tugging arguments about children dying for lack of healthcare.

    • So, then, AB, how do you explain the fact that the mandate was a Republican idea? Orrin Hatch insisted on it during the Clinton attempt, along with a dozen of his Republican colleagues. It was the only way they’d even begin to think about backing a reform plan then.

      But put the mandate in the hands of Obama, and suddenly Republicans forget that it was their idea to begin with. That’s hypocrisy. Republicans have latched onto killing PPACA because with it, they believe they’ll kill Obama’s chances of a second term. They latched onto it because their party was dead in the water after the 2008, and becoming the party of ‘no’ was a way to revive it.

      Where have the Republican health plans been? They’ve simply re-heated failed ideas of the past. Nothing new, nothing inventive, nothing that really addresses the problems within the system, just the same old tripe about the market magically fixing everything.

      On January 21, 2008, the Republicans sacrificed policy on the altar of politics, and that’s why they oppose PPACA.

    • AB,

      I’m not going around in circles on this. If what I say doesn’t apply to you, don’t take it as such. If you believe you’re working towards a better health care system, go forth and do good.

      I fail to see how taxing everyone and then giving people who buy houses a big deduction is any different than taxing people and then giving people who buy insurance a credit. One does not “force” you to buy insurance any more than the other “forces” you to buy a house. Do or don’t. Get the money back or don’t.

      I’m not a partisan, I and I have called out the Democrats for going penalty instead of tax. I’ve called them out for delaying implementation to meet an arbitrary budget goal. I’ve called them out for weakening the exchanges and denying better options.

      I don’t call people who disagree with PPACA “dishonest and disingenuous”. I call people who had no problem with a mandate two years ago, or even when the debate was heavy, but NOW call it tyranny disingenuous. I call them hypocrites. I’ve been blogging for some time, and I can tell you, few commenters said then what they say now. Very few.

      I believe that many of those who fight the mandate fight it just because it’s a tool to try and potentially destroy the law. That’s politics, not policy, and don’t conflate the two. If that wasn’t the case, they could work with Democrats to rid the law of the mandate.

      Where are the calls for that?

      P.S. I think using heartstring tugging arguments (which I very rarely do) is far less dangerous to our discourse than whipping people up into a furor using words like “tyranny” and “fascism”. If you can’t see the difference, so be it.

    • HomecareNurse, please don’t interpret my comment as endorsing the Republicans or suggesting they have great ideas on health reform. I don’t know why I should be expected to defend Republicans because I disagree with Democrats on health reform. Yes, they’ve been hypocritical and dishonest throughout the process.

      I think that PPACA is a bad bill, that doesn’t mean I endorse the views of everyone else who dislikes the bill. And Republican hypocrisy is irrelevant to the issue of whether it is constitutional for the federal government to force you to buy health insurance.

    • –“I fail to see how taxing everyone and then giving people who buy houses a big deduction is any different than taxing people and then giving people who buy insurance a credit.”

      It’s not different. But that’s not what PPACA does. They could have done it that way, and then I agree that there would not be constitutional challenges to the bill. Would Republicans still oppose it and be trying to find ways to repeal it? Of course they would.

      I’m not disagreeing with you that some people are using the mandate as a wedge to get rid of the whole bill, even if they believe that a mandate implemented in the way you describe would be fine. But your whole premise of “work with the Democrats to fix the mandate” assumes that opponents of the bill ought to just give in and accept PPACA with modifications rather then getting rid of it. Others see this as a chance to repeal what we believe is bad legislation. That’s not politics, that’s realizing that the Democrats messed up and it gave you another chance to get rid of what you believe is a bad bill.

    • AB, Why is it a problem to revise the current bill & make modifications to improve it? This is not a bill affecting only peoples finances, it literally is a life & death situation for thousands of Americans. Unfortunately some are declaring the mandate unconstitutional & using this political argument to repeal it, although President Reagan’s Solicitor General Charles Fried expressed today in testimony during a Senate hearing his personal assessment that he is “quite sure that the health care mandate is constitutional.”. This is not an abstract discussion we can continue while thousands literally die or lose everything they have because they have the misfortune to become ill. Middle class people need to educate themselves & learn what will happen to them if they lose their employer supplied health insurance or get priced out of the private pay insurance market due to illness. How much will Cobra coverage cost you, how much will the high risk pool insurance cost you? What will you do if you need chemotherapy which costs $6000 a dose? Without insurance you pay up front- very few hospitals or clinics or testing centers will bill you. People are under the mistaken idea that if you are uninsured & can’t afford treatment it will be given to you. Wrong. Only if you qualify for Medicaid or county health services & if you have a job making anything above minimum wage or own anything, you won’t qualify. Yes you can go to an ER, but you will be billed & hounded for the astronomical rates they charge, & there are no provisions for follow up care. It is a disgrace we have allowed our health care system to devolve into it’s current state. We have the best, most incredible medical care available in this country- if you can afford it. I know- I am still alive after being diagnosed w/ stage 3 breast cancer at age 38. I thankfully had very good insurance at the time & thought dealing w/insurance companies was a nightmare until I lost the insurance due to my premiums being tripled in a 24 month period. Now I know what a horrible nightmare it is to navigate the system with no insurance. It is time to stop arguing & realize we must fix our health care system. In a country so rich in resources & intellect, it is inconceivable that thousands of people go without proper healthcare.

    • Tina, the amount of revisions needed to make PPACA what I and many others would find an acceptable bill would be practically a complete rewrite. That’s not to say every single aspect of PPACA is bad, but there are fundamental differences between this bill and what we believe should be the guiding principles of reform.

      –“it literally is a life & death situation for thousands of Americans”

      If one believes that PPACA will make our health system worse in the long run, then it is also a life and death situation for those who will suffer under an even more broken system. It is not at all helpful to portray people who disagree with you as being indifferent to the plight of the medically needy.

      –“President Reagan’s Solicitor General Charles Fried expressed today in testimony during a Senate hearing his personal assessment that he is “quite sure that the health care mandate is constitutional.”.”

      Well I guess that settles that then. His personal opinion is that it is constitutional, and he worked for Ronald Reagan. That’s typically how we decide laws are constitutional, we ask law professors who once worked in the Justice Department for a Republican president.

    • AB, My example of Pres. Reagan’s appointee was just one example of a legal expert who agrees the bill is constitutional. It does appear the issue will be settled in the Supreme Court.
      Could you explain how you think the bill will make things worse? I do not mean to imply anyone who disagrees is indifferent to the plight of the medically needy, I do question if you or anyone you know well has ever had to deal with a serious medical condition without insurance. I have been a social worker & thought I was aware of the difficulties of navigating the health care system, but when it happened to me I was shocked at the price of tests & prescriptions & therapies. I just strongly feel we can no longer sit back & talk about fixing things. We have to make changes, and if that means starting down the wrong path & then having to correct course ( as with the 1099 issue in the current bill), well, at least we are moving & working on the issue.

    • It will make things worse by further entrenching the employer-based system, continuing to add to the expensive coverage mandates (not the individual mandate, the rules of what must be covered by an insurance plan) that force people to buy more insurance then they need, adding tens of millions more people to Medicaid which is in my opinion a failing system, and using flawed and ineffective methods like minimum loss ratio requirements to try and control the cost of insurance which will likely put many smaller insurers out of business. Those are just a few examples.

      I think what many people don’t realize when they bemoan the status quo is just how many of the problems with the status quo are either not changing or being made worse by PPACA.

      Changing the health care system is hard, and inertia is strong. Doing something just to do it and planning to fix it later is not prudent in my opinion. It’s interesting you use the 1099 issue as an example, because that actually has nothing to do with the health care system, it was just one of the sources of funding the Democrats found to pay for a coverage expansion. Then they realized it was a very ineffective way to raise funds and had to abandon it. It’s not an example of something they changed and then fixed to make it better, it’s an example of how difficult it is to find a way to pay for a dramatic expansion of coverage.

    • I’m not surprised, we passively allowed medicine to slip from a profession of caring to a business of service delivery and now the most well (health) insured elected representatives have taken the challenge to reform a dysfunctional system that denies access, provides questionable quality and is unaffordable and turned it into a massive legal/political game of chicken. The saddest part is that the players seem to want to keep this game going until 2012 or beyond.

      Reform (regardless of ideological bent) will always be a work in progress, mostly progress based on trial and error. What I don’t understand is if Republicans have a better/different/cheaper/easier/prettier way to accomplish the objectives of slowing the rate of health care cost growth, getting folks more reasonable access to care, and continuing to improve the quality of care, they don’t draft legislation, debate it, and then vote to substitute these changes for what they don’t like in the Affordable Care Act.

      The problem I have with repealing the ACA is that without knowing what’s to replace it, I’m worried we just declare political victory and return to the status quo which all reasonable persons agree is unsustainable. I believe our elected representative have sold their souls for the sake of the game and not for the well being of their citizens. But they have excellent health coverage so what do they have to worry about.

    • AB,

      You keep saying how awful the PPACA is. Why? Do you think people with pre-existing conditions should be denied insurance? Do you think the current ‘donut hole’ for Medicare part D coverage should continue? Do you agree with insurance company decisions to deny coverage when someone gets sick? Did you think that insurance company that halted breast cancer treatment for that woman because she had a zit was reasonable?

      If you don’t support the PPACA, fine. If you can’t come up with a reason why, I’ll suggest it’s because a) you don’t like Democrats generally or b) you think the POTUS should be an old white man

      or c) you agree with the Republican Health Plan as explained by former Rep. Alan Grayson: Don’t get sick, and if you do, die quickly.

      Yes, I think that’s an offensive comment, too. Prove me wrong.

    • AB: “It will make things worse by further entrenching the employer-based system…”

      The reason that the employer-based system is so entrenched is that people who currently get insurance through their employers don’t want to lose that insurance unless they are convinced that they can obtain equal or better coverage in some other way. The ACA creates health care exchanges which are intended to allow individuals to buy their own health insurance at reasonable prices. Once these are set up, assuming they work as projected, then it may become more politically feasible to move away from an employer-based system. The ACA doesn’t further entrench the current employer-based system; it makes people less dependent on employment for health insurance.

      AC: “using flawed and ineffective methods like minimum loss ratio requirements to try and control the cost of insurance which will likely put many smaller insurers out of business.”

      My preferred approach was the public option. But, given that Republicans think it would be unfair to expect private insurance companies to function as efficiently as a government program, it still makes sense to place some limits on insurance company overhead, and a loss ratio requirement seems like a pretty straightforward way to do that. To the extent that smaller insurance companies are less efficient than large ones, yes, this will hurt small insurance companies. The cost of health care is a real problem, and addressing requires a certain amount of intolerance of inefficiency. I do realize that regulations sometimes cause problems which are hard to foresee, which is why if it were up to me the bill would rely on competition (the public option) rather than regulation (the loss ratio requirement).

    • Sarafina, I don’t know why you feel the need to attack me personally simply because I disagree with you on the proper direction of health care reform. I’ve already laid out some reasons why I am not in favor of PPACA.

      –“b) you think the POTUS should be an old white man”

      You hit the nail on the head! I’m a self-hating black man, so I hate the fact that we have a black president!

      This is why people ought to take a deep breath before commenting and think of how little you know about someone from reading a couple of their comments. That person you call a Nazi just might be Jewish.

    • Kenneth, I strongly disagree that it does not entrench the employer-based system. There are new tax credits for small employers offering insurance, above and beyond the the tax subsidy we already get for employment-based insurance. Once credits like this are in place it’s hard to get rid of them because it is functionally a tax increase on small business. Good luck with that! There are also penalties for certain classes of employers who don’t offer coverage. The exchanges are not enough to move away from the current employer-dependent system as long as there is unequal tax treatment.

      —“given that Republicans think it would be unfair to expect private insurance companies to function as efficiently as a government program”

      Honest concern about the public option is not about efficiency (I say honest concern because I’m quite sure there are people who have given weak and/or disingenuous arguments in opposition to the public option, I do not side with or wish to defend them). It is about a level playing field. Will the public option be required to meet the same solvency requirements of a private company? Will the public option be required to price products in an actuarially sound manner and get the rates approved by insurance regulators? Will the public option be required to negotiate its own network agreements and reimbursement or will it simply dictate reimbursement levels to providers?

    • AB,

      Nice shuffling. You managed to avoid a substantive response completely. Obviously, if you can’t respond, it shows you’ve got nothing. Have fun kicking your dog.

      And yes, I know internet comments are just pixels on a screen. You choose be destructive, without useful suggestions.

      Also, you seem to think ‘the government’ should just wave a magic wand and make things perfect (for you). Here’s a fact – there are no wands. Societal change, which health care reform is, is a process that takes time.

    • Sarafina, in my comment on February 3rd at 13:33 I already listed a few specifics on why I do not like PPACA. Obviously you haven’t read what I’ve already said, instead choosing to argue with the caricature of me you’ve created in your head.

      If you’d like to have an adult discussion on the merits and weaknesses of the bill I’m game. If you choose to just ignore my points and call names like a child I’ll have to respectfully decline.