What Would a Health Reform Deal Look Like?

A central claim of my book Balancing the Budget is a Progressive Priority is that slowing the rate of health care cost inflation is a necessary, but not a sufficient condition to our ever achieving a sustainable budget down the road (it will also take a tax increase). Further, it will be virtually impossible to take the very hard steps to address health care cost inflation without both political parties coming up with a set of health care reform strategies that we will actually try, and which make both sides responsible for seeing to the hard work this will take. Health reform is far more difficult than Social Security reform (in a technical sense), for example, because mailing checks is much easier than purchasing health care. We will never be done with health reform and there will be many mid course corrections.

Even though we don’t know what all the steps will be, we desperately need to take some initial ones, and we will soon know what the Supreme Court will say about the ACA. This will be a landmark decision that will have profound political and policy consequences, but in one sense, regardless of what the Supremes say, the next step is to identify a bipartisan way forward on health reform (stop laughing; we have to do it).

Central to my book is a set of health reform policies that I claim represent the type of deal that would emerge if the two sides actually negotiated with one another. For such a deal to emerge, it would take both sides being clear about what their primary interest was in health policy. For Progressives, universal coverage has always been the holy grail and dream deferred, not just of health policy, but really of all social policy. As I noted in this debate with Jim Capretta, I don’t think Conservatives have an interest that is so clear and heartfelt as universal coverage is for Progressives, but if I had to take a stab, I would claim that it is their belief that people don’t have enough “skin in the game.” As an aside, this makes little sense to me, and when I look at empirical data on cost sharing with my more conservative friends, we see different things. In a similar way, when I say that I think the lack of a predictable, universal health insurance coverage scheme is an existential mark against our nation, they don’t get my degree of feeling.

Accepting such differences is an important step, because reaching a deal will mean abiding with one other to reach a compromise.

The essence of the deal I suggest in the book is this:

  • Universal catastrophic coverage implemented through Medicare, with gap insurance available to persons wanting it (no mandate!) via state based exchanges
  • With a massive deductible (I suggest $10,000/persons; $15,000/family to maintain a key role for private insurance; far larger out of pocket exposure than Bronze level cover in the ACA)

There are many legitimate ‘yeah buts’ that both sides will have, and I am not even getting into the other parts of the health policy deal I propose, and that are detailed in the book, in this post. However, a compromise health reform deal will have to capture the ‘big idea’ for both sides. I think step one of such a deal will look something like this if we ever manage to do it. And if we don’t, we will never again have a sustainable budget.

Author: Don Taylor

Don Taylor is an Associate Professor of Public Policy at Duke University, where his teaching and research focuses on health policy, with a focus on Medicare generally, and on hospice and palliative care, specifically. He increasingly works at the intersection of health policy and the federal budget. Past research topics have included health workforce and the economics of smoking. He began blogging in June 2009 and wrote columns on health reform for the Raleigh, (N.C.) News and Observer. He blogged at The Incidental Economist from March 2011 to March 2012. He is the author of a book, Balancing the Budget is a Progressive Priority that will be published by Springer in May 2012.

49 thoughts on “What Would a Health Reform Deal Look Like?”

  1. My question to you would be this: what makes you think that today’s “conservatives” have even a shred of interest in reaching any sort of a deal with the progressives/liberals that they so consistently demonize and lie about? Obamacare began its existence as a “conservative” solution to the problems you outline – and yet just how many Republicans will even admit that fact? Surely the clearest thing in all of the godforsaken mess that is the Beltway is that “conservatives” conserve nothing except the interests of their wealthy corporate paymasters – and that they will pay very little price for this because the media are either inept, cowardly or simply bought and paid for, and the true believers will get their news from such reliable sources as Breitbart “News” and RedState in any case? What makes you believe that any of this can change?

    I might also point out that the GOP is currently busily trying to renege on the rather unimpressive deal they made last year on matters fiscal. Why would anyone imagine that they will not immediately renege on any healthcare deal as soon as Fox/the teabaggers start howling and threatening another purge?

    1. More than one Conservative has said that bipartisanship means that Democrats accept Republican policies.

      But then when they do, the Conservatives abandon those policies.

      1. Somehow, I haven’t noticed any area of life where the federal government has increased the discretion of state governments, or reduced total non-military spending.

        If “bi-partisanship” means “everyone gets some of what they want”, those of us arguing for a smaller and more limited federal government haven’t seen any of it on offer.

        1. Why do you want smaller / more limited federal govt? What goal or purpose do you have for wanting that?
          Because smaller government just for the sake of smaller govt. is an odd goal. I suspect you want it for another reason.
          The compromise is to ensure THOSE needs and desires are met. Let’s not confuse means and goals.

  2. @NickT
    when you put it that way it seems quite hopeless. You have convinced me to leave work early and retreat to beer… We actually will have to do something, the question is whether it will take a crisis of some sorts to drive it. Regardless of what the supremes do, progressives really do have to keep the pressure on insisting that conservatives provide their way ahead on health reform.

    1. You speak as if leaving work early and cracking a beer were a bad thing!

      Joking aside, I wish I could see some reason to feel hopeful – but the GOP has made it abundantly clear that it wants more partisanship, more ignorance, more fake Christianity, more misogyny, more attacks on education, more hatred of women, more voter suppression – regardless of the cost to America’s finances, its social cohesion, or its long-term future. The only outcome that I can see is that “conservatives” will bring on utter calamity in order to appease their bizarre base – unless progressives stop their own trivial fights, organize, fight back and find some way to bring America back from the abyss into which deep-fried Southern stupidity wishes to plunge us all. My own guess is that by 2020 the GOP will have brought about an entirely avoidable disaster, just because they couldn’t get their own reactionary-Bolshevik way.

    2. I would like to make a deal with the Republicans.
      And a PONY!

      In reality, we have to make the ACA work, and make it work better. The Republicans can come along if they want – they had a chance to work on this in the last decade, controlling the main pillars of government, and did diddly.

      1. @NickT
        a little league baseball game plus beer have done me well tonight. I wouldn’t pick the post-2010 GOP as a negotiating party, but there is not any choice. Hopefully it wont take a disaster….maybe a self inflicted one via debt ceiling round 2.

      2. @MobiusKlein
        it is a great point that from 2000-06 Rs did nothing to address insurance expansions and address health care costs. They have shown themselves to be expert at arguing against things, but can’t seem to muster the practical ability to be for anything in the health sphere.

    3. I have to side with Nick T, at least as regards GOP politicians.

      I like to think there is a significant chunk of the GOP party itself that is *not* insane, and which realizes that healthcare is not a real market. But this is just because I want to believe it, it’s not based on any evidence I can see.

    4. Don, what we’re saying is that you’re the butt of that old joke where the economist on the desert island says ‘assume a can opener’. Right now all good paths lead to the castration of the right, and nothing good will get done until then.

  3. Don,

    This might be achievable. Maybe. But it’s a travesty of the progressive ideal (as I understand it, anyway): put a $10- $15K deductible in place and leave total costs where they are and we will have many more people effectively uninsured. Yeah, they’re covered if they are run over by a truck (figurative or literal), but they will avoid routine care.

    If you want to do this, you’ll have to convince progressives that you’ve got a way of stuffing the genie back into the bottle. Pregnant women need to get in for prenatal care early and then as needed by their Ob. Babies need to be seen for well-baby checks and vaccinations. If our health care finance system was less f***ed up, perhaps we could change the vax schedule and take a couple of arrows out of Jenny McCarthy’s quiver. These are the things that lead to better population outcomes.

    I tend to agree with Nick: there is no reason whatever to believe that Boehner, McConnell and Co are capable of taking, “Yes” for an answer. As you note, they have no clearly defined interests. You can’t negotiate with someone who can’t figure out what their interests are. My wife is a former paralegal who worked in domestic relations for years. She told me once, “Men have a terrible time signing the divorce complaint, but once they do it’s a done deal. Signing the final agreement is easy for them. Women have an easy time signing the complaint, but it’s very difficult for them to sign the final agreement.” She explained the difference in terms of finality — but equally, I think, is the matter of understanding self-interest in the process. When someone’s primary perceived interest is using negotiations to beat up on the other side, you can’t negotiate with them, because they can’t take “Yes” as an answer. They will invent an entirely new line of objections and try to change things already agreed to, because they don’t want the negotiations to end.

    1. I’d have to say that you can’t negotiate with someone who doesn’t see it as being in his interest to negotiate – which, by all accounts, is where the GOP stands today. I think Boehner et al have clearly defined interests – as GOP politicians tending to an increasingly extreme and irrational base. What’s much less clear is that their interests and those of the USA coincide at any significant point or set of points, even though the base (and, quite possibly Boehner Inc) have managed to convince themselves that their interests and those of the country are identical. This seems to me the logical outcome of an ideology based on hatred of any sort of community, any sort of functional system of civil liberties and any idea of science trumping mythology. What the GOP offers is a politics of entitlement and self-indulgence masquerading as a politics of rugged individualism. Ultimately, you can’t negotiate with a spoiled child and, if you try, you shouldn’t expect any “deal” to last, because the spoiled child sees itself as a victim of intolerable tyranny when it doesn’t get its own way. From the spoiled brat’s perspective, the right and proper thing to do is to break the “imposed” deal as soon as possible, regardless of the real-world consequences.

    2. @Dennis
      In the book I note you cover prenatal first dollar, and other similar care. I think it would be preferable to have universal cata as opposed to continued movement in and out of insurance coverage, but of course that is a value judgement, and it really depends on the counterfactual–what else are we likely to be able to get. A few side benes: (1) you would have to deal with issue of what price is used in the gap for those choosing no gap insurance (and low income could have premium paid for gap cover). This could have positive impact on transparency of prices. (2) you would reduce cost shifting, but not rid it (some would make bad choices and then not be able to pay, etc.). There are real effects of cost shifting that could be expected to drop, but I suspect there is a large ‘rhetorical effect’ of uninsured cost shifting whereby all providers will say to insurers ‘we need more due to cost shifting.’

      I believe having a guaranteed route to even very catastrophic insurance would be a step ahead.

  4. We have had argumentum ad infinitum in re: how to pay health care costs, but paying the cost is only one leg of a four-legged chair. The “Health Care Crisis” is about (a) the quality of our care, (b) the delivery of our care, (c) the high cost of our care, and (d) how to pay the costs. Note that two of those four issues are medical, one (high cost) is medical-related, and one — the one that’s gotten 99% of the attention — is the single one totally unrelated to the practice of medicine. If we can’t even get a handle on the payment/insurance system, it’s a grim outlook for addressing the other three areas in my lifetime.

    1. @Ken Rhodes
      Coverage, cost and quality (errors and provision of correct care) are inter-related problems that all need to be addressed. If we could get coverage straight there could be more effort put toward the others….of course it is not linear and all need to be addressed at once.

      1. If you read Nortin Hadler’s (MD) books you will quickly see that a huge portion of so called health costs are actually for over treatment, treatment that is more harmful than beneficial. We could provide universal coverage for all by spending less, with better outcomes, by providing full, first dollar coverage for effective preventive care and treatment and refusing to pay for any treatments not significantly better than placebos in double blind clinical trials. When you look at the statistics on how little progress we’ve made in actually improving longevity for cancer victims and how little benefit we get from all the heart bypasses, you realize that there is an ocean of money available for better uses, uses that would help us move out of the basement in terms of our being pretty much a third world country in health outcomes.

  5. I agree that a compromise on “skin in the game” might (only might) get Republicans to the table, or even to an agreement. But the skin has to be sliding scale. $10,000 for an individual would be more than half of many people’s annual pay. %15,000 for a family would lead many families to an endless round of unpaid bills and harassment by predatory bill collection agencies. Or are you talking about those levels of out-of-pocket only for those whose income exceed some benchmark?

    1. @EB
      I have in mind an income level below which persons would have full cover provided, and likely a income based premium support approach similar to ACA. You could get the same actuarial outcome via having the deductible differ by income, or the amount of premium support do so. The biggest difference is that having standard deductible and differ premium support by income would give private insurance a larger role.

  6. Who paid for Dick Cheney’s heart transplant? I will bet $1000 against a donut that it was not Dick Cheney. That is where the problem is. Those that have get. Those that don’t die. Your congress, senate, Supreme Joke and President have life time medical coverage. Why should they care about someone else?

  7. I disagree that the failure of some such deal will inevitably lead to unsustainable budgets. The alternative is that the structure of US government changes to become more parliamentarian allowing the party in power to implement its agenda without input from the other side.

    You may think such a transformation is impossible. But how likely is it compared to Republican capitulation?

    1. @Tom Scirotino
      In one sense if we had a parliamentarian system, at least there would be a “winner” who could implement policy. I don’t think I agree with you, because without some sort of health reform, the default in (1) health care and (2) taxes given politics of how hard it is to cut military spending leads me to worry lots that we will eventually hit a debt driven crisis (not there now, don’t know exactly how much constitutes one,etc…..but the antidote has just about got to include profound health reform, and the Rs don’t really have any coherent plans. In that sense they actually need a deal more than Dems do….we have bazillion health reform plans in ye old back pocket.

      1. “and the Rs don’t really have any coherent plans. In that sense they actually need a deal more than Dems do….we have bazillion health reform plans in ye old back pocket.”

        Yes, they have coherent plans – aim for a negative-sum game, since they’ll profit.

        And the g-dd-mn plans don’t matter for squat, unless and until the GOP leadership has an incentive to actually agree to something other than Gotterdammerung.

        Don, I’m going to be harsh here. You’re writing like a strawman of an ivory tower academic, who smells the smoke of his city burning outside of his tower, and thinks ‘great! BBQ for supper!’. And in addition you are writing like it’s 1999, and you have no idea of how this millennium has started.

        The only thing that you’ve avoided is the back-stabbing of the typical centrist liberal (‘both sides do it’, ‘we can’t try to hard to win, or their fee-fees will be hurt’).

        1. I’m sorry for being harsh, but the whole tone of this policy discussion is surreal. I recently saw some Monty Python skit of this British tourist in the USSR, who didn’t quite seem to realize why the line of guys with rifles was pointing at him, while an officer was barking commands in Russian. That’s what this reminds me of.

  8. Don,

    I like your idea — it’s a huge step in the economically-sound direction and completely side-steps the current Supreme Court skirmish while offering important concessions to both sides of the political debate. Secondary insurance to cover the high deductible for those who can’t afford to bank it themselves would be cheap due to the payout cap. With catastrophic care out of the way routine health-care coverage would be less expensive. Others have raised the valid point that Progressives will remain concerned about the preventative health care needs of the poor, but those needs can (and are) dealt with in other economically-sound ways and nothing in your plan precludes those sort of measures being taken independently. Still, it’s important to be wary of the ways in which removing catastrophic care from actuarial considerations will incentivize insurance companies against preventative coverage. I have not yet read your book but from my reading of your posts here I get the impression that you’ve likely considered these factors and more.

    On the other hand it seems a rather large correction from our current course, and the US economy is a big ship to steer. And I can just imagine the “death-panel” talk we can expect to hear about a proposal to have the government fund catastrophic care. You’ve got your work cut out for you. I admire your ambition. Good luck!

    1. @Freeman
      a key part of your post and something I don’t really know is what would the optimal construction of a catastrophic plan be if that is what you were trying to build. A few key questions. (1) what is covered after the gap. It has to everything/very expansive to truly be catastrophic insurance, so you still need some type of regulation. (2) How is the price set for care in the gap? Impose Medicare fees? providers negotiate with patients seems a nightmare to me. (3) The cost level of the deductible and what incentives are created if the coverage is for $10,000 but all above that is to Medicare. You could have different deductible by age band as well; the cata policy for <35 year old would be quite cheap. I talk about some of this in the book, but I am not an actuary...the book really has ideas and not a plan in the sense that is has been scored, etc. Meant as a part of the conversation/trying to get one started as opposed to a claim to have it all worked out.

  9. I don’t see why a compromise to the right of ACA will do anything much about health care costs. The more socialist the system, the cheaper it is (holding quality constant): UK < France < Germany < Switzerland < USA. So if you think US health care is too expensive, and its quality should not be lowered, your only long-term option is more socialism. The conservative solution is to lower the quality of health care for the poor and working class. These visions are not compatible and the difference can't be split.

    Me, I think I'd go with class warfare: the aim forced on American progressives is to crush the conservative movement, raze its its foundations, and sow salt on the ruins. Delenda est Carthago. (The difference with Cato is that Carthage didn’t start the Third Punic War.) Then again, I’m not American and don’t have the problem of having to think of these people as fellow-citizens. I would have the same attitude to neo-fascist European parties like the BNP or Front National.

    1. James Wimberly: “Me, I think I’d go with class warfare: the aim forced on American progressives is to crush the conservative movement, raze its its foundations, and sow salt on the ruins. Delenda est Carthago.”

      I agree. It’s pretty clear now that not only are we in class warfare, but that there is no possibility of a reasonable surrender. Whatever we give up becomes the baseline for tomorrow’s war against the peons not having actually starved to death.

      I would add ‘Chicago delenda est’, ‘Harvard delenda est’ and ‘George Mason delenda est’, for obvious reasons.

  10. I think the conservative concern (focusing here on conservatism, and libertarianism, NOT on the current Republican Party) is some mixture of the following points:

    1) Disrupting the current arrangements where, from a patient perspective, they work well. (These are the concerns about access to your current doctor/hospital/medication: this concern is important among Medicare recipients and people with good employer-based coverage.)
    2) Disrupting the current arrangements where from a business perspective, they are profitable. (This includes health insurers, but is most importantly the concern of the professional groups–especially doctors, among doctors the higher-paid specialists and pharmaceutical manufacturers.)

    Note that these two provide the money, and the grassroots, and tend to work synergistically. The talking points often come from the below concerns, but that’s not the primary concern.)

    3) Reducing the incentives to discover, commercialize, and adopt effective treatments. Some portion of the growth in medical costs is because we genuinely have better and more effective treatments. As “new stuff” has a less entrenched constituency than “existing stuff”, there a reasonable fear that the new stuff gets squeezed out when the choices get difficult. (This is especially important to people with currently-poorly-treated conditions.)
    4) Control of the health-care system giving the government greater leverage to pressure social issues other than health-care. (This is important to groups who disagree with the national elite consensus, but have strong popular or local support: think the contraception mandate battle. Historically, think the hospital desegregation driven by Medicare).
    5) Control of the health-care system giving the central government more ability to pressure the States. (The battle over expanding Medicaid, and over Texas’ attempt to not fund abortion providers, are examples here.)
    6) Questioning the dynamic sustainability of a cost-control/spending trade-off. At any one time, a cost-benefit trade-off can be made; it will tend to become entrenched over time, and to become simultaneously outdated. (How do you find out about and commercialize new treatments if introducing them is not immediately cost-effective?)

    My proposal would be the following:

    First, set up an expert panel to do a cost-effectiveness of treatment ranking. Just that: nothing else.
    Secondly, have a group that takes the cost-effectiveness of treatment ranking, and calculates a 10% of GDP level; that defines a “basic health-care benefit”. (10% of GDP is intended to be 2/3 of current spending,a nd can be adjusted to keep it at 2/3 over time.)

    Insurers must sell to all comers, a basic benefit package; any supplemental insurance must go to a designated higher-on-the-list position. They can set the price however they want, and have any deductible they want.

    If anyone who is insured’s health-care spending on basic health benefits (premium and deductible) is over 10% of household income, they get a 100% rebate for the excess except if the deductible is over 10% of household income, in which case only 50% of the deductible over 10% of income is refunded. (This makes the cost manageable for any income level, while discouraging overly high deductibles.)

    An insurer can have a “new policy fee” up to 1 year’s premium (or difference in premium) for someone who was previously uninsured, or insured at a higher deductible. This is NOT included in rebatable health spending. (This makes going without coverage and buying when you get sick possible, but costly.)

    Anyone who gets a rebate 3 years successively may be assigned to a government-specified insurer. (This is to prevent system-gaming by insurers–getting someone who has a chronic illness, and bill-padding systematically.)

    Medical providers can give no more than a 20% discount from listed price to any insurer. (This is to enable price-shopping.)

    Supplemental policies are available with no regulation, but no portion of the premium is tax-deductible.

    This replaces Medicare and Medicaid.

    1. Who exactly are the conservatives and libertarians who have these concerns you have outlined – and yet don’t belong to the Republican party? Not to be unkind or anything, but it sounds as if they and Andrew Sullivan would fit quite comfortably into one armchair.

      1. I’m thinking of the blog commentary I’ve read, people I’ve talked to, and so on; I’m not saying they are not members of the Republican Party: I’m saying that the concerns of, say, Andrew Sullivan, or Megan McArdle, or others who identify as conservative ro libertarian, are quite different than those of, say, Boehner.

        1. Oddly, people who bring in $250,000/year+ and work for employers with good solid health care plans, as well as people with $100 million+ of family wealth in the bank, tend to have these “concerns”.


    2. @SamChevre
      Lots of good points here….fading….back tomorrow. Three things. First, it is possible to imagine systems working that are more or less progressive/conservative, the really hard part is transitioning to a new system. Second, Martin Feldstein proposed a universal catastrophic insurance (federally guaranteed) in oct 2009 http://www.aei.org/article/health/healthcare-reform/a-better-way-to-health-reform/ He would have deductible vary by percentage of family income (15%) which is a reasonable way to define the catastrophic amount if that is what you are after. His idea actually has a ‘federal health care credit card’ which would provide a means to finance care, though it would still be a debt that could ruin credit, etc. It is surprising to me that a conservative would want the executive branch mechanisms required to implement his plan, and I would prefer to just use Medicare for the catastrophic vehicle. However, if we could agree to cover everyone and only guarantee catastrophic cover (with certain care first dollar, paying attention to the poor) we should be able to work out a deal.

      You have lots of other interesting ideas that I will think over. thx

      1. “Martin Feldstein proposed a universal catastrophic insurance (federally guaranteed) in oct 2009 http://www.aei.org/article/health/healthcare-reform/a-better-way-to-health-reform/

        Let’s see – an economist on the Greenspan Commission to Loot Social Security writes an ‘article’ which is published by a pack of frauds whose #1 priority is to destroy Social Security.

        I don’t mean to be harsh here, but you’re getting to Kahnish levels of credibility.

      2. I’m familiar with the universal catastrophic plan, and think it has some advantages (easier to understand being one), but several significant disadvantages. (I do think that a deductible varying by family income is vastly better than a fixed deductible.)

        1) It focuses on the less-common catastrophes. There are two sorts of “catastrophes” in the current system; the first is the classic “get hit by a bus” catastrophes–unpredictable, time-limited, very-high-cost medical care. The more common sort, though, is manageable chronic illness–diabetes, MS, etc–where you end up spending $20K every year forever. THe Feldstein plan does little for those cases.

        2) These’s no private actor to provide pricing pressure for any type of catastrophic care.

        3) There seems to be no cost transparency required of providers, which makes shopping for care very difficult. (It’s not a panacea, but the examples of Lasik, sterilization reversal, and cosmetic surgery make it clear that shopping can contribute to controlling cost and improving experience.)

  11. One person who might conceivably be receptive to your “deal” is Anthony Kennedy, who in oral argument over the mandate expressed distress at its scope while acknowledging that the young and healthy and older and sicker were yoked in one health/insurance market. Marty Lederman has suggested that Kennedy might either uphold the mandate in a narrow ruling or narrow it further by limiting it to catastrophic coverage:

    “Moreover, even if Randy and Mike Carvin were correct, and the preventive care coverage could not be justified under my proposed, or any other, limited holding, that would only mean that the Court should declare invalid those subsections of section 18022(b) that go beyond coverage for catastrophic care and other services that are government-guaranteed. Such an excision would likely have, at most, only a marginal impact on the cost of insurance premiums, since it is of course catastrophic and longterm care–the services the state and federal governments guarantee–that account for the lion’s share of uncompensated health care costs, and of the cost of health insurance.” full post at http://bit.ly/HYlzq1

    Moreover, justices’ questions in oral argument suggested that they may be unaware of the extent to which the ACA already limits the mandate, e.g., by allowing those under 30 or showing financial hardship to buy catastrophic coverage in the strict sense, and providing as the cheapest option to everyone else the bronze plan which by some definitions itself offers merely catastrophic coverage. More here http://bit.ly/LUaVmM

    1. @xpostfactoid
      thanks for the links. Many don’t understand that ACA has a Bronze catastrophic level….not as big as the numbers I threw out but different levels. There is a link in the post to a document on this.

  12. Perhaps the more fundamental question is, what does the end-state United States look like to the Republican Party? As recently as 2006 it was possible to speak of behind the scenes managers who ran the party while the hard right wing made noise on the hustings, but at this point it is clear that that hard radical right IS the Republican Party and will be driving it for the foreseeable future. If we get a Republican sweep in November (Presidency, Senate, House), what will they do? I absolutely cannot see any replacement for Obamacare being on the table, but I can easily see massive heavy rollback of not only FDR but Teddy Roosevelt’s reforms and a direct, purposeful return to the Gilded Age (+ some radical fundamental religiousity enacted into law).


  13. Kudo’s to Sam for actually making a strong (and largely correct) analysis of what R’s / conservatives are thinking about this subject, and incorporating some of those concepts in his suggested solutions. To be fair, I am not sure about signing on to those solutions until I give them more thought and understand them better. However, both Sam and Don are on a productive track here. For one thing they use the term “insurance” correctly. Bill paying, as in comprehensive plans, is not insurance, it’s administration. I recognize the iomportance of non-catastrophic medical services like check-ups and pre-natal care, but insurance per se is effective only when the loss is one that we need to share – i.e. catastrophic. High deductible, major medical plans are insurance. Comprehensive medical plans are not.

    So hats off to Sam and Don for actually trying to engage the other side productively (as opposed to the class war mongering neanderthals who constitute most of the readership here). You will find folks on my side who want to solve this as much as you do, even though our objectives may not quite coincide (for some of the reasons Sam listed). Frankly, Don has it right. Medicare/medicaid as currently constituted is economically unsustainable, and PPACA only makes things worse.

    1. I’d be slightly more convinced, Comrade Redwave, if there was any sign that any significant faction in the GOP shared or cared about these issues. As it is, in the real world all your party has offered in terms of healthcare reform, since the time of Clinton, has been obstruction, falsehood and a series of shrieking lunacies about such things as death-panels and socialism. When it comes to neanderthals – well, one party accepts science and evolution, while the GOP bumbles through fantasies about how Jesus walked with dinosaurs and how the government much be kept out of “their” Medicare, while demanding the right to force a grossly invasive sexual probe on American women. You are the ones with a nominee who is now desperately disavowing his one constructive piece of legislation in Massachusetts, aren’t you? You are the ones with a base that howls insults at a serving member of the military just because he is gay, aren’t you? You are the ones seeking to restrict access to the ballot in defiance of the Constitution whenever you can get away with it,aren’t you? You are the ones who claim to love liberty and in practice accept dictation from ALEC and whatever the latest Koch brothers’ front group might be – aren’t you? You are the party that has, over the last 40 years, practiced demonization of any group of fellow-Americans that might disagree with you, aren’t you? Women, gays, people who don’t live in hicksville, the poor, Hispanics, African-Americans, liberals – what a catalog of hatreds you have accumulated! So spare us the hypocrisy about class-warfare and neanderthals, Comrade Redwave. We know precisely who you are and what you lust for – and it ain’t democracy, ain’t freedom and ain’t American.

    2. A bunch of reasonable folks who would have preferred a sensible negotiated solution to the healthcare problem have ended up at “GOP delenda est” for a REASON, Redwave. That being that the GOP has displayed itself utterly uninterested in such a solution. You may want to solve the problem. The party you apparently support *does not*

      1. OK, great. Was any “sensible negotiated solution” propsed that took my #4 and #5 as legitimate and tried to ensure that they were not fulfilled? As I recall, the only such attempt, on one specific issue, was the Stupak Amendment, which I don’t recall great Democratic enthusiasm for.

        1. Did your proposals #4 and #5 include safeguards to ensure that clerics of a specific branch of a specific religion would not have direct control over the bodies, reproductive choices, and health of women? When you have those safeguards worked out, and the “submitted women” wing of your party under firm control, let us know.


  14. As so many people have pointed out, the notion of “skin in the game” as currently consituted is privileged, pernicious garbage. Is there a way that we could make it not so, perhaps by limiting the deductible-eligible items to conditions where we actually want to reduce use of resources? No deductible for injury-related treatment, or for illnesses that require time off work. Certainly deductibles for treatment of erectile dysfunction…

  15. “As so many people have pointed out, the notion of “skin in the game” as currently consituted is privileged, pernicious garbage. ”

    ‘Skin in the game’ means ‘afflict the afflicted, comfort the comfortable’.

    1. Skin in the game means poor deaf kids don’t get hearing aids or implants.
      Skin in the game means poor kids with cancer die.

      I’ll talk skin in the game when medical services are priced by the income of the recipient.

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