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Drew Bittner

Excellent post, Jeff. Tony Isabella is trying to link it on FB but it's not working for some reason...
all best, Drew

Robert Heinlein

Wow. You are one deluded and sick minded individual.

There is no proof, anywhere, that 45000 Americans have died in any year because they couldn't get health insurance. None. It is a lie, made up by bleeding heart liberals who think that they should spend other people's money.

Under Obamacare, the derogatory term that correctly describes this disaster of legislation, anyone could have their existing health insurance yanked because of a pre-existing condtion. Anyone. It's in there. But then, you didn't read the entire Bill did you? You just looked at the talking points from other bleeding hearts and leeches like yourself who were preaching what you wanted to hear.

Seniors will always have the "donut hole" because that is part of how medicare was set up. By liberal democrats. They have to get additional private coverage, just like they always have, to make up the difference. Or pay it out of their own pockets. Your comment anent them falling back into the "donut hole" is nothing but pure hokum.

Small businesses will not be forced to provide health insurance for their employees. So the tax break won't be necessary, as they won't have already paid the money out of pocket up front.

"People under 26 could be kicked off their parents' policies." No. People between 21 and 26 could. And they should be. At that age they are supposed to be adults. I'm all for helping the helpless, just not the clueless. Or the lazy.

You mention that the Bill's provisions do not come into effect immediately. Just so. So nothing is lost by repealing it now, before any more damage can be done. What's that? You say you don't know about the damage already done? Health insurance rates are up across the board. Everyone is paying more. Right now. That's damage. And it's unfair to the hard working Americans whose lives didn't change and had this foisted upon them.

"The long-term financial impact of it is a cut in the deficit of more than a trillion dollars." Wrong. That's an estimated projection based on the aging baby boomers continuing to get older and stay alive longer. The older you get, the more medical care you need. That is a fact of life. It has nothing to do with compassion, or health insurance, or medical coverage, or Obamacare. The deficit will swell under this Bill, as Congress is forced to come up with more and more money to pay the doctors and nurses and pharmaceutical companies for their products and services to the elderly. Forced. To. Pay.

You are probably one of those idiots who has never looked at an EOB after visiting the doctor. EOB stands for explanation of benefits. Go read one, there are plenty on the internet. See that part where it says what the doctor wanted to charge? See the smaller number next to it saying what the insurance company negotiated as the reduced rate that is actually paid? Do the math. Without them doing this, on your behalf, you would always have to pay what the doctor wanted you to pay. Can't pay, or don't want to? Fine. There are plenty of people waiting in line who are willing to pay. Who do you think will get served first? The ones who pay!

"Insurance companies will be able to deny coverage to those most at need." No. You are confusing medical coverage with medical insurance. Those most at need have existing conditions. They don't need insurance companies, they need doctors. Insurance is for those who are at risk, that "pesky" thing you call living, who might at some future date need help covering a medical bill because of a future condition that may arise. Medical care, which is what people with preexisting conditons need, needs to be paid for. That's what medical coverage is for. You seem to confuse health insurance with medical coverage. Regularly. Learn the difference.

Death panels exist. Yep. Always have. Organ transplant waiting lists exist. Who do you think makes the list? Who do you think orders it? By what priority? Need? No! The guys with the most money are at the front of those lists. Baseball players, actors, wealthy businessmen. The ones at the bottom of the list? They die. The guys making the list know this. They are the death panel. There are many death panels.

"hat's two real Americans who have really died, in the past few weeks, because the Arizona government decided to interfere with arrangements people had made with their doctors." How is the state of Arizona's transplant program for peopel without insurance in any way part of an agreement between these people and their doctor(s)? If the doctor had a matching organ, then they had it. The people who voluntarily choose to become organ donors don't need someone else's permission to do so. The only thing missing here is how the doctor gets paid for his work. If they were this close to death, that was also the last thing on the mind of those 2 patients. Your comment makes no sense at all.

"The emergency rooms will continue to fill up with the uninsured, and every taxpayer will be on the hook for their care." Yes, and under Obamacare who would be on the hook for their care? Every taxpayer! But the money would be routed through a massive government organization first. This is not a change, it's just wasteful.

"Who cares about the vast majority of us, and who cares only about the wealthiest one percent?" I do. As do most conservative Republicans. It's the vile, evil and hateful liberal Democrats that only care about the wealthiest one percent. Oh, that's not 'care' as in 'love' -- no no! That's 'care' as in "how can we take their money from them because we know how to spend it better than they do." Vile. Evil. Hateful. Liberal. Democrats. If they aren't in control of your money, something must be wrong!

Yes, the act is largely symbolic. And fortunately for the world, BHO will be voted out of office in 2 years. He'll be lucky to survive his own parties nomination process, with a serious challenge from Hillary Clinton. You remember her, the one who originally brought health care into the public forum?

Overpopulation is the biggest problem facing the world today. You, in particular, are part of the problem. You actually want to keep the dregs of society alive and leeching off the rest of us longer. You want them consuming limited resources, like fresh water, so there will be less for those of us who do contribute to society. You produce nothing, and then decry the happy state of those of us who do. Worse yet, you probably consider yourself to be an artist or some other such bullshit.

And if you think this is harsh, dig your head out of your ass. It isn't. It's the reality you refuse to face.

Jeff Mariotte

Actually, I think I can recognize the deluded and sick-minded individual by a) his or her hiding behind the name of a dead author instead of putting his or her own name on this ignorant diatribe, and b) writing such an ignorant diatribe. I don't have time at the moment to respond point by point, because I'm busy earning a living. But just to address your very first point, about the 45,000 dead Americans, that's a statistic from a study conducted at Harvard University Medical School and Cambridge Health Alliance, by the American Journal of Public Health. It's not a number that somebody just made up.


A second point, just because I'm feeling generous--yes, here in Arizona, people who have had organs lined up, after their doctors have told them they need the organs, have seen the funding for those transplants disappear. When that happens the organ is reassigned. So far, in the past several weeks, two of these people have died. Because a private insurance industry that recognizes that the easiest path to profits is offering insurance to those who need it least and denying those who need it most, and the state's Medicaid safety net that was supposed to catch people who can't get insurance was yanked away. I suppose to you those unwell people are dregs who ought to die. I wonder if you'd feel different if one of those "dregs" was a loved one of yours.

Talk about sick...

Jeff Mariotte

Thanks, Drew.  Not sure what the FB issue is...

Jeff Mariotte

P.S.: I noticed in the news today that the CBO--you know, the group that both parties in Congress rely on for nonpartisan budget projections--has raised the projected cost of repealing health insurance reform to $230 billion in the first decade. It gets more significant after that. I wonder whose figures are more accurate and honest, the CBO's or Mr. Heinlein's...?

James Corelli

Unlike the commenter above, I'm not going to go ad hominem on you or traffic in conspiracy theories ('death panels', etc.). But to claim that the last year's HCR Bill aka 'Obamacare' is an unalloyed social good is a dangerous and misguided assertion.

No sane person would argue that the current status quo w/r/t health care, health insurance, etc. is anything to brag about. There are serious flaws, inefficiencies, and even inequities that need to be addressed. But for every problem (preexisting conditions as a bar to coverage, the 'donut hole', etc.) HCR/Obamacare solves it creates two or more. Some examples:

1)HCR/Obamacare will create a giant new entitlement program with unsustainable costs. The oft-cited CBO figures that assert that the HCR bill will reduce costs are misleading to the point of being deliberately deceptive. The CBO does not have the authority to critique the scenarios it is asked to assess for plausibility or even possibility -- and the figures the liberal intelligentsia fed it are the sort of rosy pie-in-the-sky musings that have already been invalidated by the slowness of the current economic recovery. It would be as if one asked the CBO if they could afford to by a brand new Ferrari, and when the answer was no then asked 'But could I buy one if I won the lottery?'. The answer would be yes, but only because the CBO's narrowly defined operational parameters prevent them from telling the questioner that the chances of them doing so are infinitesimally small.

That's the sort of dubious accounting that's been done here. Obamacare will not reduce the already massive burdens of entitlement spending, it will add to them significantly. If you and other HCR/Obamacare boosters want to argue that it's the right thing to do anyway, fine. That's at least line of argumentation on which reasonable people can disagree -- but do so in good faith and with numbers that are at least marginally believable.

2)Though HCR/Obamacare will indeed move many of the currently uninsured out of ERs across the country, it will do so by overwhelming a Primary Care system that is already stretched to the breaking point. Primary Care Physicians are already in extremely short supply. Try changing cities/jobs and finding a PCP practice that your new employer/HMO will accept, it's very difficult now and will be exponentially more difficult (if not impossible for many patients) once the 35-40 million uninsured flood into doctor's offices nationwide.

This was the single biggest lie Obama & co. were peddling w/r/t the HCR bill: "If you like your current insurance, you can keep it and nothing will change for you." Nothing could be farther than the truth. The hardworking already-insured, will have to compete with 35-40 million new patients for appointments, treatments, and hospital beds. It will be much harder to get a doctor, harder to see a doctor in a timely manner, and harder to get treatment for serious medical issues in time to make a difference. Eventually, Primary Care medicine as we know it will have to be largely deprofessionalized to cope with the overload. The new gatekeepers of this brave new Obamacare world will be overworked nurses and nurse practitioners, with less training and medical knowledge to make accurate assessments. At least some people who would be able to get critical medical intervention in time under the current system will die or suffer serious physical debilitation due to increased diagnostic errors and longer wait times.

This, IMHO, is a grave injustice. I think an argument can be made that more should be done to help those outside the bounds of our current health care system, but their gains should not come at the expense of the hardworking men and women that have played by the rules and payed into the system all these years, and that's exactly what will happen. And I've yet to hear any lawmaker or policy wonk propose a solution to the PCP shortage, a shortage most experts project will only worsen as greater meddling by government bureaucrats and the HMO counterparts make the profession less and less desirable, especially as compared to lucrative medical specialty practices.

3)Back to costs, the massive budgetary drain will only increase in the likely event that the Supreme Court shoots down the 'individual mandate' portion of the Obamacare 'reforms'. Forcing every citizen to buy a product regardless of circumstance seems to be a clear cut case of legislative overreach, and the current, conservative-leaning Supreme Court is likely to deem individual mandates unconstitutional, even by the historically lax standards of the 'interstate commerce' clause.

With mandates likely to be off the table at some point, there are only two plausible scenarios, both of which are highly undesirable:

-A public option is created, sending economic shockwaves throughout the entire heathcare field (resulting in job losses and substantial economic and market instability, slowing if not reversing our tenuous economic recovery) and requirung an even more bloated bureaucracy and budget to sustain it, increasing the deficit exponentially unless massive tax increases are made across all socioeconomic lines.

-Private HMOs, now mandated to enroll people who are poor insurance risks, but without a pool of new healthy customers to balance them out, manage their increased risks the only way they can: Massive increases in EVERYBODY's premiums.

(And even if the SC were to affirm individual mandates, there will also be a high price to pay down the road. The precedent of forcing the citizenry at large to buy a particular type of product without exception will have been carved in stone, and all manner of predatory actors will be all too happy to step up and exploit it.)

It's true that some form of heathcare reform is needed and that the current system is inefficient and unsustainable. But Obamacare will make things markedly worse, not better, for most Americans -- especially those who have insurance already. It too much to extend benefits, little to nothing to control costs (much less decrease them), and will inevitably result in a wholesale degradation of the standard of care for those already in the system.

It is also worth noting that the Obama-Pelosi regime's agenda of placing the USA on a path towards Western European-style socialism (with it's higher tax rates, higher structural unemployment, and massive government entitlements) runs counter to overarching international trends. In an age where Greece, Ireland, Germany, and most recently the U.K. have determined that the European Welfare State model is hopelessly outmoded and are implementing (or being forced to implement) budgetary austerity in order to stay economically viable, liberal policymakers here are running in the other direction, creating massive new bureaucracies and entitlements that we cannot afford. Liberals often deride conservatives for their 'American Exceptionalism', but here they appear the ones who believe our country to be exempt from the rules mathematics and the laws of supply and demand.

As you note, with Obama in the White House and Dems still clinging to control of the Senate, wholesale repeal simply won't happen. However, there is a chance that the GOP majority in the house will be able to reform and/or defang some of Obamacares more pernicious components, and I wish them luck in doing so.

Would it be nice to improve access to helathcare to the uninsured and indigent? Certainly. Should it be done? Probably. But can it be done in the scale and manner prescribed by Obamacare? Only with disastrous and far-reaching consequences. The benefits are not worth the costs, and, hopefully, the electorate will realize this and demand intervention before Obamacare's most damaging components come online.

Agy Wilson

Now I'm going to conflate something Mr. Mariotte, because frankly I'm finally scared. What some of the skinny I've heard is the states with their new-found "rights" are going to be given the right to go bankrupt. As has been seen often, I believe the dazzle-em-with-bs crowd likes to also use dead of night, sleight-of-hand to get odious measures passed. Whether it was the much contested Intellectual Properties bill to things like expanding martial law power for the government. I live in Maine, we have one of the lowest living wages (I can attest to that one), and a high proportion of un- or under- insured (I can attest to that one as well, as not only are my husband and I self-employed, he's a small business owner, I'm a writer/illustrator and the entire family has pre-existing conditions)that just shooed in a teaparty governor (look for fireworks there, he famously had said he would tell Obama to go to hell) as well as a Republican controlled congress for the first time in decades. So while this bill will get the hooplah watch for some manuevering to really screw things up.

Jeff Mariotte

Thanks for your comments, James, and your tone. I'm always happy to see respectful disagreement with my views here--what I don't like is name-calling from behind the screen of anonymity.

I disagree with a few of your fundamental premises, and agree with others. I don't see anything socialistic about the agenda of Obama and Pelosi (which, to begin with, aren't necessarily the same agenda--Obama has never been as liberal as Pelosi). In the case of health care, legislation that guarantees the continued existence and profitability of the private sector health insurance business hardly seems like socialism. The health insurers get millions of new customers--some of whom will cost them more, others of whom will be healthy and ideally balance out the unhealthy.

I doubt you've been reading this blog throughout the health care discussion. If you had, you'd know I never said this bill was perfect. It isn't. I think it's several steps in the right direction, but it'll need a lot of fine tuning along the way. Most big social legislation does.

What it did, however, was move the whole discussion to the forefront of the national consciousness, and successfully overcome the opposition of the well funded health insurance industry for the first time. That's an accomplishment of note.

To me, the health care insurance industry has become little more than a racket. I've worked at a variety of different jobs, and been a self-employed freelancer. Before the bill passed, I was always at risk of losing my doctor and/or insurance company. Companies I worked for, even big ones like Warner Bros., could at any time decide to switch health insurance from one provider to another. As you say, the PCPs who work with this insurer might not work with that one, and vice versa. I've had doctors yanked out from under me. I've had insurance companies refuse to cover the costs of expensive medications that doctors prescribed for me. I've had insurance that barely covered anything. And I haven't even been one of those unfortunates with a preexisting condition serious enough to cause a company to decline me, or to pull my insurance because it looked like I might get sick enough to actually need it. Nor have I been one of the many people forced into bankruptcy by huge medical bills. But I have had to lie awake at night sometimes worrying about that.

Any industry that profits most when it collects high premiums and finds excuses not to pay for treatments is a broken industry, but that is exactly what this industry so often does. It needs regulation, it needs government intervention. Under the health care bill, doctors will be paid to help people stay healthy. That's good for the entire country. It'll keep people from using emergency rooms for non-emergency care. That's good for all of us.

You might be right about the Supreme Court and the individual mandate, but there might be other ways around that. We don't have to buy auto insurance--but we have to if we want to own a car. I'm uncomfortable with the idea that the government can force us all to buy a product offered by private industry...but I'm also uncomfortable with the private health insurance industry as it is, and I recognize that other countries with other systems achieve much better health results than we do, with our broken system.

If the Republicans had been serious about health insurance reform, they had plenty of opportunity during the lead-up to the bill to participate. They were in all the committee meetings, they were "negotiating," but in bad faith, with no intention of actually voting for anything, regardless of how many of their ideas were implemented, for the purely political reason that they didn't want Obama to achieve a legislative victory. Their best idea seemed to be offering consumers the chance to buy insurance from companies located in some state that had low enough regulatory standards that the policies would come cheap--but, like those low-rate auto insurance companies, the protection would be as minimal as the rates.

Since the summer of 2009, have they actually come up with workable solutions that will bring millions of Americans into the system, keep prices down, encourage good health, and help small businesses? Or, as seems far more likely, are they simply trying to kill the bill in order to put us all, once again, at the mercy of a health insurance industry that is all about private profit, not public health?

Jeff Mariotte

Agy, I've been watching the situation in Maine with something like Stephen King-induced horror. Your new governor sounds like a real gem--much like ours here in AZ, which is also a pretty low-wage state. I'm employed full-time, with benefits, for the first time in years, because I've also been freelancing (by choice). But in the current economy, with freelance opportunities drying up and even marginal health insurance premiums skyrocketing (yes, before the health insurance bill), I took a "real" job.

Yes, we need to keep a close eye on the new tea-infused governors and state legislatures. Our state legislature is frankly dysfunctional to the point of insanity, and that was before the 2010 election. The new US congress is frightening, but state legislatures around the country are downright terrifying.

J Corelli

Thanks, Jeff. I came to this blog entry via a link at Tony Isabella's board, so you're right to suspect I haven't read your earlier thoughts on the subject. If your support of the HCR package has been more nuanced than the rah-rah advocacy I've seen elsewhere, that's all to the good.

Some comments on your comments:

"I don't see anything socialistic about the agenda of Obama and Pelosi."
I'll concede that the 'Obama-Pelose regime' phrasing I employed in the paragraph in which I argued that the Dems seem to be interested in moving America in the direction of a welfare state democracy (a la the economic model that's begun to fail in most of Western Europe) doesn't do justice to the ideological differences between the President and former Speaker.

On balance, I do think Obama is a moderate -- a fundamentally smart and decent man capable of negotiating and compromising in good faith. If he'd had a better Congress to work with, a better bill might have emerged last year's national debate.

My issues with him specifically are twofold. The first is this: After launching the debate on HCR, he then largely left the crafting of the legislation itself to the House Democrats, and effort that was spearheaded by ultra-liberals like Pelosi.

IMHO, Pelosi can accurately be labeled a socialist. Her far-left ideology is out of step with the vast majority of Americans in both parties, and I have no doubt she'd gleefully transform the USA into a Denmark-style socialist democracy (complete with vast and unchecked entitlement regimes, government taxation of just under 50 cents on each dollar earned by individuals, and structural unemployment of 12-15%) if she could.

(Please note that I'm not using 'socialist' as some sort of dog-whistle for 'communist' here. I definitely think Pelosi is the former, but not the latter -- and Obama, in my estimation, is neither.)

Obama made efforts to negotiate with GOP lawmakers in good faith. Pelosi and her cohorts did not. They knew they had the votes in the house to ramrod through whatever boondoggle her caucus (and *just* her caucus) could agree on and, ultimately, that's pretty much what they did. That's more or less been her style of management since the Dems seized control of both houses in 2006. She's a zealot and a partisan, who displays nothing but contempt for those who disagree with her radical agenda -- and not just those in the opposing party, she's used her powers as speaker to compromise and marginalize more centrist voices in the Democratic caucus too. Her oft-quoted line soundbite from 2010, "Let's pass this bill so we can read it," neatly encapsulates her extreme arrogance and the extent of the bad faith with which she was operating throughout the HCR process.

If not for more moderate actors in the Senate on both sides of the aisle, the HCR bill would have been an even bigger debacle than it eventually became.

"What it did, however, was move the whole discussion to the forefront of the national consciousness, and successfully overcome the opposition of the well funded health insurance industry for the first time. That's an accomplishment of note."

I could agree with this, if not for the timing. This is my second complaint about Obama: His stubborn insistence in placing HCR at the top of the legislative agenda, regardless of the country's lack of fiscal health.

When the economy is taking (the unemployment rate where I live is still hovering around 12%), deficit spending has spiraled to frankly ludicrous proportions (through the actions of both Republicans and Democrats), and the burden by existing entitlements like Social Security and Medicare (neither of which will survive the mass retirement of the Baby Boom generation without serious reductions, I'm in my mid/late 30s and don't expect that either SS or Medicare will be anywhere near being solvent or viable by the time I reach retirement age) is already unsustainable -- creating another, potentially even larger, entitlement we can't afford is a bad, bad idea. People need to be put back to work, the size of the existing government needs to be reduced, and deficits need to be slashed before undertaking a reform on the scale of the HCR bill would be a reasonable idea.

As it is, this sort of unreasonable spending makes investors, both foreign and domestic, less and less certain that the large amounts of our currency they hold will be worth anything down the line. If we keep spending like a banana republic, our currency will eventually be valuated like the coin of those proverbial realms, triggering an economic crisis that will make the last 2-3 years seem like a pleasant daydream.

"To me, the health care insurance industry has become little more than a racket. I've worked at a variety of different jobs, and been a self-employed freelancer. Before the bill passed, I was always at risk of losing my doctor and/or insurance company."

Here, I sympathize completely. The existing healthcare system is a raw deal for the self-employed, to such an extent that I think it actually retards entrepreneurship and innovation. Though I've never made a living solely via freelancing, I have stayed at jobs longer than I've wanted to because I was reluctant to lose my benefits, change doctors, etc.

See, I do have a pre-existing condition. It's well controlled (to the point of affecting my daily life little to not at all) via medication, but it does require annual monitoring in order to prevent it from becoming something potentially life threatening. Despite that, my healthcare expenses still pretty low, and don't make me a bad risk from a provider standpoint, but the 'inability to deny coverage based on pre-existing conditions' component of the Obamacare package could conceivably do me some good.

Still, in the context of my own self-interest, a sober look at my potential costs and benefits sets me against the Obamacare 'reforms' as they currently stand. My condition is 'monitored' via outpatient procedure roughly once a year, but if I have a 'flare-up' of increased pain, my timetable changes and I will need to go in earlier to make sure nothing has gone seriously wrong. With 35-40 million people flooding into the mainstream of the healthcare system without a proportional increase in the number of doctors necessary to treat them, my ability to get this more immediate sort of intervention will decrease significantly. Best case scenario, I spend weeks (perhaps months) more in pain, without sleep, and my ability to work and provide for myself suffers significantly. Worst case scenario, I am diagnosed with a terminal illness with my chances of survival decreased exponentially by a late diagnosis.

It's possible that Obamacare could save me money at some point down the road. But given the choice between being able to access treatment that could potentially bankrupt me, and being able to afford treatment, but but not being able to access it in time to save my life, I would choose (and vote for) the former.

That's why I'm skeptical of the argument that the allegedly less 'broken' healthcare systems of countries like Canada, the U.K., etc. are truly superior to ours. If you can't access treatment in time to make a difference, does it truly matter how much it costs? I recall a scandal that concerned Britain's National Health Service a few years back. It was an epidemic of blindness, there was a surgery available that could arrest the deterioration before the afflicted lost their eyesight entirely, but the long wait time for it resulted in most patients going irrevocably blind before they could receive treatment.

Is that truly a better and more just system than our current one? Really?

"Under the health care bill, doctors will be paid to help people stay healthy."

Here I must also respectfully disagree. Most doctors will tell you they are underpaid by the government already. HCR/Obamacare does nothing to mitigate this, and will likely make matters worse. While I agree with you that the GOP did not do enough to argue and introduce affirmative solutions of their own, two areas in which they did advance some ideas (and were unceremoniously shot down by Pelosi and co.) were tort reform (such as punitive damage caps) and other adjustments to the prohibitively expensive malpractice insurance doctors are forced to maintain. I don't disagree with the notion that the health insurance lobby has too much influence over both political parties, particularly the GOP, but the collusion between the Dems and the equally powerful (and sleazy) trial lawyers lobby did the nation no favors here.

Primary care medicine is already the most taxing, labor intensive and least lucrative (and therefore the least popular, there aren't enough PCPs to meet current demand, let alone the 35-40 million new patients Obamacare will bring into the system) form of medicine to practice, and under the auspices of the current HCR bill it will become even more so. Most medical school graduates will become specialists, leaving the PC practice of the future to be staffed by mediocre physicians and overworked nurses and NPs, who will be forced into making assessments beyond the scope of their knowledge and training. In addition, they will face fiscal pressure both from HMOs and the government to run fewer diagnostic tests in order to save money at the system-wide level. Serious conditions will be improperly diagnosed and people will suffer. Some, whose maladies would likely have been caught under the current status quo, will even die.

No steps have been taken to address this at the policy level. Nothing has been done to create incentives for new doctors to pursue PC medicine or to address the impending shortfall in any way. And what few measures have been included in the HCR omnibus to control costs are all on the demand side ('doctors should ask for fewer tests') rather than the supply side ('tests should be cheaper') -- which will serve to degrade the quality of care even as it is extended to more and more people.

Perhaps some of these problems can be fine-tuned as the portions of the bill are enacted, but at this point, I rather doubt it. We'd need to have more PC physicians in the educational pipeline already to manage the massive impending influx of patients, and we don't. The slim Dem majority in the Senate will likely block any attempts to add tort reform to the mix, and all the theoretical savings advocates of the bill postulate are predicated on gains to be brought about through more preventative treatment, which may or may not materialize to the rather optimistic extent the bill requires to be viable from a budgetary standpoint. And if the individual mandate is shot down, costs will increase exponentially throughout the system.

Some people will be helped by these changes, but just as many (if not more) will be hurt -- some significantly so. Health care reform is needed, but a party-line vote orchestrated by the ideological left of the Democratic caucus when our country is struggling to pay the costs of a bloated and inefficient state during the most serious economic downturn was emphatically not the way to do it. It was the wrong time for this, and the wrong way to go about it. I only hope that both parties can come together and salvage the healthcare system before it tanks irrevocably.

Thanks for responding to my comments in such a polite and thoughtful way. I've been an admirer of your work since your tenure at Wildstorm, and wish you continued success and, in keeping with the theme of this conversation, good health in the future.

Jeff Mariotte

I'm sorry to hear about your pre-existing condition, James, and wish you the greatest success in coping with it. I have high cholesterol, which so far hasn't manifested itself in any serious heart problems--and I've never had an insurance company willing to pay for Lipitor, which is the statin that's most effective for me (at about $90 a month, cheap compared to many other prescription drugs).

In terms of other countries' health care systems, you might want to take a look at France's, which offers universal coverage, no long waits, and a mixture of a public/private mechanism that might work (in a tailored fashion) in the US. People with chronic conditions like diabetes, cancer, and critical surgeries like bypasses pay nothing. The very poor pay nothing. Everybody else pays up front and is reimbursed 75-80%. Employers pay in, people pay in, and the government (via taxpayers) picks up those w
ho can't afford to pay in. The state pays for medical school, so doctors aren't saddled with crippling student loans, and malpractice insurance costs far less there. Patients can choose their doctors and choose between public and private hospitals. I'm not saying it's perfect, but it's been rated the best in the world by the WHO, and health costs account for only 10.7% of its GDP, while we pay 16% of ours for lesser results. Here's a piece from Business Week on their system:

As for our current system, under the new law, as I said, I don't think it's perfect. But I do think it's a vast improvement. I disagree with some of your financial projections--I think controlling health care costs, emphasizing wellness and preventive care (as this law does, making preventive care visits free for Medicare patients, for instance, and providing for greater reimbursement for preventative care and patie
nt-centered primary care. Small businesses are already lining up to take advantage of the small business tax credit, and covering employees at a far greater rate than they ever had--which, as you point out, spurs entrepreneurship and innovation. Ending annual lifetime caps and pre-existing condition exclusions and shrinking the "donut hole" and working to reduce waste in Medicare are all good ideas. Forcing insurance companies to spend their premium dollars on medical care rather than taking enormous profits, paying huge executive salaries, and enriching stockholders is a mixed blessing--that's probably where the law borders on socialism--but on the other hand, if they are really in business to provide health insurance and not simply to steal money from us, it's what they should be voluntarily doing anyway. If the health insurance market was truly a free market--if you could choose your own health insurance policy rather than (as in most cases now) having it chosen for you b
y your employer, that's the kind of company most of us would look for. Spending money researching what works and what doesn't is a good idea, with benefits for job growth, medical innovation, and public health, and actually can have an appreciable impact on controlling costs and demand (tests can be cheaper and doctors can order fewer of them if we have a better idea of what's efficient and cost-effective).

Economist David Cutler has a new study out claiming that repealing the bill now would cost us 250,000-400,000 jobs annually, because rising health care costs result in offsets in employment--companies that see their health care going up respond by not hiring, hiring more part-timers, or even layoffs to control those costs. I suspect his numbers are somewhat inflated, but I believe that letting our system go on as it has been is bad for the economy as a whole--that we can't let the cost of health care as a percentage of GDP continue to go up. Here'
s his report:

Yes, we need more doctors, especially PCPs. The new law encourages that by providing bonuses and student loan help for people who go into primary care medicine, but we could do more. And there are plenty of doctors and medical students out there who support the new health care law (and plenty, too, who want to see it go further, like the members of Physicians for a National Health Program who want single-payer). Anything that eliminates paperwork and allows doctors and medical staff to focus on patient care seems like a plus. I agree that malpractice costs are a big problem, and that should be limited (and we should, as a rule, get over our overly-litigious ways, but that's another topic).

I'm not as opposed to certain socialistic elements as you seem to be. I think Social Security, Medicare, and the VA are good programs that can be shored u
p with minimal tinkering around the margins, and can remain viable well into the future. And while I'm also worried about us becoming a banana republic, I think what's pushing us in that direction is income inequality, with the rich controlling ever more of the national treasury, a shrinking middle class, and a growing population of the poor (which costs taxpayers ever more for safety net programs). All of that is bad for a country that needs good public schools and robust college enrollment, which feed the entrepreneurship and innovation that grow the economy.

We don't live in a country where an absolute free-market approach covers all the angles. Perhaps the existence of Social Security, for instance, has exacerbated that situation--making people feel like they don't have to take care of Grandma's expenses, because she has Social Security. But on the flip side, we can't know that for certain--what we can know is that Grandma doesn't have to choose
between medication and dinner, because Social Security and Medicare help her out, and by enabling her to retire, opened up a job for a younger worker.

I worked for a start-up publisher, WildStorm, which became big and successful, hiring dozens of people (and providing health insurance and other benefits for them). That had a spillover effect down the line--those people bought homes and cars and groceries, and we published products that retailers around the country sold, enabling them to do the same, etc. That's how small business creates jobs. When we were bought out by a big business, I was, for the first time in my life, eligible for a pension (although I had a 401K as well). But after 5 years I got the chance to join a different start-up, helping it grow big and profitable and hire dozens, etc. So my total pension, at retirement, will be about $200 a month. My 401K is no great shakes, either. As a freelance writer, I can of course write for as lon
g as I'm able, and maybe sell books (and maybe not, there are no guarantees in this game) and contribute down the line to the economy of publishers and booksellers. And there's always the outside chance of a big success, movie sales, bestseller lists and all that, but that's a long shot. (I could also be hit by a truck tomorrow...) So I expect that Social Security and Medicare will be very helpful in my future. Now, certainly I could have kept working for Warner Bros (at least until they shut down WildStorm last month), and increased my pension--but in the greater scheme, my helping to grow yet another big successful company offered more economic advantage to society as a whole, I believe.

Obviously we're not going to agree on everything. I maintain that we're better off keeping the AHCA and tweaking it into something more useful and applicable to the realities we face as a nation, and as individuals. If we repeal, we're back to square one. And consi
dering it took something like 70 years to get what we got, with both Republicans and Democrats trying to do something, I'd rather build on an imperfect start than start over from scratch.

Good health to you, too, and thanks for taking part in the discussion.

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