alexandraerin | Written on the road: matters of definition.

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to your health

Written on the road: matters of definition.

Whenever liberal judges or politicians bring up the state of justice overseas in discussing the laws here, a certain segment of the far right tends to go into a tizzy.

"New World Order!" they say.

"One World Government!" they say.

Pish, I say.

We're just taking stock of the world and our place in it. If we happen to notice that we're engaging in a practice that only countries Bush 43 identified as members of an "Axis of Evil", we wonder about the company we're keeping, you know?

We're not interested in giving up our sovereignty. We're interested in using it... using it to better ourselves as a nation, to form a "more perfect Union"... more perfect today than it was yesterday, we hope, and possibly even better still tomorrow.

And at its heart, that's what this health care debate is about: how we define ourselves as a people, how we define ourselves as a nation.

Is it enough to be a free people and a powerful nation? Does it not matter what we do with our power and freedom?

Is it enough that America is great?

My thought is that greatness is okay, so far as it goes, but it's better to be great and good than the alternative.

Those who are against reform say that there's an effort underway to change America, to redefine what America is and take it away from our roots and traditional values.

Folks, that's going to happen anyway. It's happening anyway.

A shining beacon on the hill? Not when we lag behind every other developed nation in how we treat our citizens.

A Christian nation? Not with how we do unto the least of us... and I don't know exactly who shall know us by our works, but probably not anyone we'd want to be seen with.

The land of opportunity? Face it, we've had a mixed record on that one. Unavoidable, really... if success doesn't bring rewards then "opportunity" is worthless, but if the rewards are meaningful then the rich hold advantages over the poor that carry across generations, resulting in unequal opportunities.

But even if we've never been perfect in an area, we can still do better or worse and right now we're doing much worse than we should be. The rising cost of health care shackles people to jobs by making a lot of traditional opportunities... entrepreneurship and education, for instance... too risky for the rewards.

The land of the free and the home of the brave? It's hard to be brave when you have to choose between food, rent, and medicine. It's impossible to be free when your choice is death from untreated but preventable conditions or a lifetime of onerous debt.

America is redefining itself by degrees. Like a satellite in a decaying orbit, the great and soaring dream of the world's first Democratic Republic will come crashing down if we're too afraid to make some necessary course corrections. We will become a third world country with scattered pockets here and there of breathtaking privilege. Within one hundred years, we may not be one nation indivisible, but two nations divided: a permanent underclass of workers who find that both the simple necessities of life and the opportunities for advancement are rigidly controlled and rationed in order to keep them in bondage, and an upper class that pats itself on the back and congratulates itself on having "made it" while exhorting the teeming masses to pull themselves up by their bootstraps.

(Hopefully somebody among the underclass will be educated enough to appreciate the irony when the ruling class identify themselves as John Galt and claim the millions whose labor supports them are parasites and looters.)

And you know what? Eventually I think the underclass will pull themselves up... and it will be ugly. When our descendants some centuries hence read about "The American Revolution", they won't be reading about George Washington and Thomas Jefferson. They will be reading about something that would make the Bolsheviks blush and Robespierre go "Oh, my."

Because that's what it would take to upend a social order that entrenched in a nation so large, so great, and so powerful.

And with that, the redefining of America will be complete.

Call this speculation. Call this hyperbole. Call it a bit of fiction dreamed up by a purveyor of the same.

But don't be afraid to look at the path we're on and see where it's leading... not where you want it to lead, not where you think it should lead, but where it actually is leading: the gap between the rich and poor... the increasing barriers to opportunity... the almost pathological gutting and cutting of any tool we give ourselves to use our collective might and wealth and freedom to help our fellow citizens.

Making access to our leading edge health care system a public concern, a national concern isn't so much about "redefining America" as it is about examining our existing definitions and seeing how we measure up.

I think we can do better. I write this without irony: we can put a man on the moon. We can split the atom. We wrapped a continent in bands of iron and a world in bands of information.

Anybody who says we can't provide health care is underestimating us. Anybody who says we shouldn't... well, with as much respect as I can muster, I disagree with their definition of America.

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What about the millions of people for whom the only two options are Public Option health insurance... or NO health insurance? What solution would you advise?

This is not a problem that you can just wave a magic wand at and suddenly have cheap insurance for anyone that wants it.

I do NOT think our current system is perfect. That said, I do not believe that scrapping a system that works for 250 million people so that 12-40 million (depending on the source) is the right idea. If you're truly interested, in alternatives, I suggest you check out heritage.org or any other reputable conservative group.

Short version is portability...allow insurance policies to be sold across state boarders; tort reform...cap damage suits for medical malpractice/frivilous lawsuits; encourage hsa/msa plans for catastrophic care; and most importantly, EDUCATE THE PUBLIC. It's amazing how little people know about how to utilize their coverage in the most efficient and economical ways possible.

That said, I do not believe that scrapping a system that works for 250 million people so that 12-40 million (depending on the source) is the right idea.

300 - 250 = 50. Just sayin'. And this assumes that the system 'works for' anyone with insurance, which it doesn't.

Then there's the whole 'scrap' thing - I wish to hell we'd scrap it and move on, but I don't see any serious proposals to do so. So I object to your framing of the current weaksauce reform proposals as 'scrapping' the current system.

Short version is portability...allow insurance policies to be sold across state boarders

I love that you're anti-big-government, and probably (though I may assume too much here) pro-states-rights, but actively promoting a plan that undermines individual state sovereignty! Loves it!

tort reform...cap damage suits for medical malpractice/frivilous lawsuits

This implied categorization of all or nearly all medical malpractice suits as frivolous is offensive. Ever get hurt by a doctor? Ever get hurt by one who told you that your poor surgical outcome (note: initial surgical outcome, immediately apparent) was because you were lazy, fat, and stupid, and not because he fucked up? Ever try to scrape together a few thousand dollars for a lawyer, and for medical experts to testify on your behalf, so you even have a shot at winning a case?

If you have, I can't see how you buy into this framing.

encourage hsa/msa plans for catastrophic care

Do you understand what this actually means, in practice? Go on, explain how you think this plays out in real life.

and most importantly, EDUCATE THE PUBLIC. It's amazing how little people know about how to utilize their coverage in the most efficient and economical ways possible.

Oh please. Every doctor I go to has one or more specialist staff members whose sole job duty is to figure out how on earth to get the insurance company to pay for what the doctor deems medically necessary. If it were reasonable to expect the average person to be able to figure this out, there would not be schools devoted to training these people, or a strong employment demand for anyone with a few years' successful experience.

***300 - 250 = 50. Just sayin'. And this assumes that the system 'works for' anyone with insurance, which it doesn't.

Fine. 250 and 50. Not that important to the overall discussion. If the system doesn't work for you why pay for it?

***I love that you're anti-big-government, and probably (though I may assume too much here) pro-states-rights, but actively promoting a plan that undermines individual state sovereignty! Loves it!

So we should continue to allow insurance companies to have monopolies in their respective states so they can charge whatever they want with no competition? Alright. I'll mark you down for keeping insurance out of reach for low income people.

***This implied categorization of all or nearly all medical malpractice suits as frivolous is offensive. Ever get hurt by a doctor? Ever get hurt by one who told you that your poor surgical outcome (note: initial surgical outcome, immediately apparent) was because you were lazy, fat, and stupid, and not because he fucked up? Ever try to scrape together a few thousand dollars for a lawyer, and for medical experts to testify on your behalf, so you even have a shot at winning a case?

I made no such implication. Legitimate and non-legitimate lawsuits need to be capped, not just in the medical field, but everywhere. This is just one area that would particularly benefit. Doctors and hospitals pay more for malpractice insurance because the risk is so high it is often more than their own six figure salary. Would you think it is a problem if your insurance cost more than your paycheck? I think you would.

***Do you understand what this actually means, in practice? Go on, explain how you think this plays out in real life.

I have an HSA account for my wife and 21 month old child. I'm quite happy with it. Lord forbid one of us ever has a large medical claim, the maximum I pay for the entire year for all doctor visits, related to that claim or not is $6,000. How many people with traditional plans have tens of thousands of dollars in hospital bills they owe? And that is the family cap. The cap for single people is $3,000.

***Do you have a family doctor? If not, then no reason to read further. If you do, how did you go about finding that doctor? Did you shop around to different doctor's offices in your area to see who had the best rates, the best customer service? Did you look into where they refer their patients for testing they can't do in house? Is that place the cheapest in the area? Do the doctors at that practice believe in remedies involving life choices or prescriptions? Do they take time to explain your options to you or do you have to ask about alternatives? (you should ask anyway by the way) How willing are they to work with you on bills, treatments, etc? If you didn't find your doctor that way, you might as well be buying a used car from a discount lot without running the VIN to check its history...you have no idea what you're getting.

As I understand it, a HSA is a health savings account; i.e., a place where you can stick X dollars or N% of your paycheck away tax-free to save against unexpected/unpredictable medical expenses.

They are darned handy, in certain situations.

However, they are not silver bullets.

Actually, they sort of are... insofar as they embody the idea that people who have silver are less likely to be killed by the monster under discussion.

HSAs are paired with high-deductible health plans. What you tout as a feature ("I only have to pay a maximum of $3,000 a year in medical expenses!") is a bug for most people ("I have health insurance, but I have to spend $3,000 out of pocket to cover the deductible before anything is covered.")

To them, the HSA is a much-chewed over bone they're being thrown: if you can scrape up some money every paycheck in addition to the premiums you're already paying, then you have some tax-free earnings you can throw down the gaping black hole of the massive deductible.

If.

The system that works for you is still broken in general.

Edit: I'll add that in cases where people encounter horrifically high expenses, a high deductible plan beats the alternative of a plan where everything is paid for up to a certain amount and then it's out of pocket... but the situation where these are the only two choices? It's an intolerable one.

If you have the income to sock away in an HSA and you're able to swallow $3,000 a year out of pocket then the one plan is clearly superior to the other, but for many other people it's a choice of "Do I want to make my bad situation worse now or risk making it catastrophically worse later?"

We can and should be offering more choices than that.

Edited 2009-09-15 15:04 (UTC)

The premiums are much lower for HSAs. In a lot of cases, even if you hit that max out of pocket, you end up spending less than you would with a traditional plan over the course of the year. Many people do not ever come close to that max out of pocket, or if they do, it is generally a one-two year timetable. I'll admit it does require more effort to manage. As for expense, I chose to sock away the difference between my old insurance premium and my new premium in the HSA which was about $40 a week. There was no change in my take home pay, except that I had that $40 a week that was going into an account for me to use on my medical expenses. It earns interest, and if God willing, I'm healthy until retirement, I can withdraw what I put in as income just like a 401(k) or IRA. I call that a win.

Yes, you can call that a win... you who don't have any compelling use for that $40. The system works for you. Other people, though, look at the difference in premiums and they think, "Good, because I need that money now for [food/clothes/child care expenses/halfway decent pre-school program for my kids]."

And then they get in a situation where they need medical care and the evil fucking pricks who designed the system that works so well for you sneer down at them for making poor financial decisions and not being able to plan for the future.

To put it in simple terms, what you are saying is, "I can afford healthcare so the system is fine."

Edited 2009-09-15 15:58 (UTC)

By the way, I had such a plan at most of my corporate jobs and they did work well for my needs. At the time, I wholeheartedly supported nationalized health care. In other words, this isn't sour grapes on my part... it's a simple recognition that rather than being a solution to the problem of the Have/Have-Not divide this system works to reinforce it.

"Portability" would lead to the same situation we have in the credit card industry, where every company flocks to the one or two states that really want to boost their economy by catering to an industry's needs with overly generous regulations. Our founders would likely consider today's credit card lenders to be usurious. I shudder to think of an insurance industry unregulated by the federal government and only regulated by the lowest common denominator among the several states.

When we speak of ideology, what I am emphatically not is an anarchist, because anarchy is the most direct route to tyranny. Getting the government out of anything and allowing "the market" to solve it is an appeal to anarchy. The government is us... you, I, all of us, acting collectively. Our republican system allows us to put checks on that collective action so that it's not sheer mob rule, so that 99 people can't always lynch the 100th and call it democracy. It's not perfect in execution, but it beats the alternative.

Our insurance system "works" (for a certain value of working for hundreds of millions of people), but the more those people learned to leverage their coverage... the less it would work for them. Because the more service people are squeezing out of a profit driven system, the less profits there will be. I'm not as somebody said on a previous post accusing the insurance companies of "cheating"... I'm not even saying they're bad... but the profit motive is driving them in the wrong direction for them to be helping millions of Americans and for what I think our health system needs to do, given my definition of America.

I pray to God this doesn't end with the political elite just doing what they need to stay elected, because that would mean giving into the fearmongering that's been promulgated around the 250 million at the expense of the rest of America. We have 2, 4, and 6 year election cycles for our federal elected offices.

It takes a remarkably principled politician to act to protect all Americans when there's a clear majority/minority divide and the fearmongering talking heads of the far right (who go on each other's shows to deny that they have a voice in the media, and their idiot viewers mindlessly ape it) have got segments of the majority fired up against the minority, which is what we have here.

I don't want the government out of our health care because I don't want myself and my interests out of our health care. That's what our government is. We had an election about this time last year. One of the major points of contention between the two candidates was their health care plans. We the people made our choice clear.

The problem is that in the time since then, President Obama made the classic liberal mistake of allowing the opposition to shape the debate, taking a hands off and low-key approach in the name of compromise and bipartisanship. In the silence, the loudest and most emotionally overwrought voices of the Republican/Conservative bases came in and they changed the landscape, for the worse. Now we're going to have an uphill battle to get a better system than we have now, and we may end up with a worse one (i.e., if the only thing left with any teeth in it after all the "compromise" is a penalty for the uninsured).

I agree with pretty much all of that actually. What I don't understand is that if the people made their choice, and the Democrats have enough seats to do anything they want, why can they not get it done? The minority party doesn't even have enough votes to block them. They need Democrats to cross the isle to do that. So the people who made their choice (and the politicians that represent them to an extent) are either having second thoughts, or were duped into making that choice.

Ideologically, I think we have a lot more common ground than not. We just disagree about how to get there. I apologize if I ruffled any feathers. I vastly prefer calm constructive debate than the alternative. I'll leave you to your regularly scheduled blogging. :)

So the people who made their choice (and the politicians that represent them to an extent) are either having second thoughts, or were duped into making that choice.

There's a pretty glaring omission in the possibilities you have enumerated there, isn't there? I'll fix it for you.

So the people who made their choice (and the politicians that represent them to an extent) are either having second thoughts, or were duped into making that choice, or are being duped now.

The problem is that President Obama faces a loud and well-organized and loud (and also loud) segment of opposition that seeks to cast him as a power-mad despot. You may recall that when he was first elected, he had a different attitude: "I won. I'll check you on that because I won." then he has shown these past few months, at least up until his speech before the joint session.

His problem was... and again, I say that this is a classic liberal mistake... that he cared too much about the rhetoric of the other side. Despotism is so anathema to liberalism that even the appearance of it disquiets and upsets us. He backed off. He let the other side shape the public debate. This may very well prove to be the biggest mistake of his presidency. Time will tell if it's an insurmountable one.

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Written on the road: matters of definition.

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