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Bobo In Fantasyland

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If Paul Ryan wants to strip health care from millions of people to help pay for massive upper-class tax cuts, David Brooks’s job as he conceives of it is to defend him. As you would expect, his collection of implausible abstractions, random anecdotes, and complaints that Ken Arrow isn’t really hip anymore in defense of the proposition that markets in health care work fail to mention — let alone grapple with — the fact that every other liberal democracy 1)has less “market-driven” health care and 2)provides universal coverage for considerably less money.

But, really, you could just stop right here:

They’re probably going to agree to cover everybody Obama covered

Sure. And Julian Assange was indifferent about the outcome of the 2016 elections. But it gets better:

The Republicans are going to try to introduce more normal market incentives into the process. They are probably going to rely on refundable tax credits and health savings accounts so everybody can afford to shop for their own insurance and care.

Whoa, whoa, wait, what?

everybody can afford to shop

This is truly a masterpiece of bullshit. Your standard-issue hack would merely handwave about how Paul Ryan’s health savings accounts and massively underfunded leper colonies high-risk pools would magically cover as many people as the ACA. But Brooks preemptively praises Paul Ryan for giving consumers the opportunity “to shop” for health care. And, indeed, pretty much anybody will be able to go on the internets and look at some plans that meet the exacting standards South Dakota or Delaware have established for insurance quality. Now, whether you can buy any of these plans, or whether they would actually provide you meaningful access to health care if you did…that’s another question. But, hey, David Brooks once saw an ad for relatively cheap laser eye surgery once so I’m sure the market will be able to sort all of this out! You’ll probably be able to cancer treatments at the Applebee’s salad bar.

Needless to say, the freedom to shop is the merging Republican party line — the favored euphemism is “universal access.” RyanCare, in its majestic equality, will allow the rich and poor alike the theoretical opportunity to shop for health insurance plans. And when the result is millions of people being stripped of their health insurance and millions more getting much worse insurance, don’t worry — Ryan fluffers like Brooks and Cillizza will be just fine.

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  • Sure. Anybody can afford to shop. They just can’t afford to buy.

    Is it worth pointing out that although Bobo can write this today, it will not come true? Will that matter?

    • AlanInSF

      I’m certainly no health care policy wonk, but is it not the case that an out-of-state insurance plan, while it might re-imburse some of your expenses, would treat all your local providers as “out of network” and not re-imburse anywhere near full cost?

      • malraux

        The not insane theory is that having a pool of members in Louisiana and Mississippi would give a stronger negotiating stance to a company negotiating with doctors/hospital systems, plus efficiencies of only having one plan rather than two.

        In practice, the savings aren’t worth it. Also the ACA allows for interstate compacts to sell across state lines; no one is interested.

        • AlanInSF

          The cool thing is when you have a medical emergency, you’ll be able to call a call center in the Philippines.

  • jim, some guy in iowa

    someone else (Tom Till?) said this in comments to the earlier thread, but it’s time to give up the idea someone like Brooks is bullshitting. He’s lying. He knows damn well when people are up against it in a crisis they don’t have the time or knowledge to go “shopping” for care as if they were shopping for a new car. Brooks and the rest are lying when they pretend they believe the republican plan is anything other than “root, hog, or die”

    • Junipermo

      I think there’s a possibility that Brooks is just profoundly stupid. Or, maybe has his blinders crazy-glued to his face and thus will never be able to see what ought to be obvious to anyone with a room temperature IQ. Or, like so many others on the Gooper side of the aisle, he may just be a garden-variety sociopath.

      I don’t know. I make it a point to never read Brooks.

      • Steve LaBonne

        I’ve read, and heard on NPR, just enough (one needs to be careful not to absorb a neurotoxic dose) to know that, like Paul Ryan, he is a profoundly stupid guy. Edited to add: this of course is perfectly compatible with also being a liar and a sociopath.

      • ASV

        If Trump is a poor person’s idea of a rich person, Brooks is a dumb person’s idea of a smart person (not that he is the only pundit that fits this description).

    • Saskexpat

      Actually shopping for care in many situations is impossible. I needed an outpatient surgery from a specialist. I chose the specialist, but had to have the surgery at a hospital where he has privileges, and use an anesthesiologist chosen by the specialist (and hospital). I got 3 bills (specialist, hospital, and anesthesiologist) but only could realistically “shop” for the specialist.
      I don’t know what kind of fantasy land these assholes live in, but in my reality, I have never seen any upfront pricing for necessary medical services provided, other than for routine office visits and notices of cash discounts.

      • howard

        we’re back to the basic unsuitability of markets to deliver health care effectively. your first instinct when you slip and fall and feel like you’ve broken something is not to write an rfp for ambulance, diagnostic, and treatment services and get 3 bids while you’re lying there….

  • howard

    brooks is welcome to point to the either theoretical or real-world market scenario in which a third party takes on unlimited liabilities for a fixed price from anyone who wants to buy it.

    he will, of course, be unable to do so.

    markets are good for many things: providing access to health care isn’t one of them and never will be.

  • JKTH

    Gee, if only the Democrats had relied on refundable tax credits instead of forcing socialism and death panels down our throats.

  • BobOso

    “Hey how much is that basic health care plan?”
    “Um sir, if you have to ask…”

  • There are times that I think Bobo is an idiot, and times that I think he just likes to prey on them.

    • N__B

      Not mutually exclusive.

  • Incontinentia Buttocks

    People — some people at least — want to shop for medical care. Does any actual human being want to shop for health insurance?

    • Junipermo

      Really? I’d think it was the opposite.

      Years ago when I had a corporate job that provided my insurance I had to pick from three or four options. I didn’t do a huge amount of research, but did read a bit about each plan, whether you could see doctors out of network, etc. This was during the annual open enrollment period when you had a few weeks to decide. So, within the confines of what my job offered, I did my shopping. Plus, the whole ACA model is predicated on people doing some shopping on either their state or the federal exchange.

      Medical care, on the other hand, is something that you don’t necessarily have time to plan for. You get sick, your kid breaks an arm, whatever, you go to your doctor and do whatever she tells you to do to get better, especially if it’s a serious problem.

      • AlanInSF

        Absent the ACA marketplaces with their clarity and guarantees, no one wanted to, or was capable of, shopping for health insurance — or, more accurately, not capable of selecting one that they could be confident would meet their needs. So of course the marketplaces and the standards must be abolished, so people will have no clue whatsoever and will be ripe for serious plucking.

      • Aaron Morrow

        Really? I’d think it was the opposite.

        Most people would want to spend less to no time choosing health insurance. It’s hard! Too many options that don’t quite match up! Speaking as someone who is reasonably good at math, calculating the likely cost of health insurance, with different levels of co-pays, deductibles, premiums, OOP costs is a pain in the ass.

        Most people I talk to want to focus on shopping for health care; either they focus on a particular doctor, or they have a type of health care need that they made covered. Even when people have to shop for health insurance, they end up shopping for health care.

      • GeorgeBurnsWasRight

        You like to chose from health insurance plans. I like model railroading in a minor scale. I’m not sure which of us is less common among Americans.

        I used to handle employee benefits, and our mostly professional employees loathed both choosing a health insurance plan and selecting where to put their pension contributions. A lot of them begged me to make their decisions for them.

    • I think most people just want their shit taken care of with minimum heartache when they’re sick, and not have to worry what the current free market rate for heart surgery is on a given day as they’re riding in the ambulance so they know which hospital they can afford to go to.

  • ΧΤΠΔ

    Also worth shitting on: Fuck the Fucking New York Times’ interview with Thiel.

    • trollhattan

      That Thiel and MoDo were able to sit together in a (doubtless lavish) room without instantly summoning a comet is further proof the universe just doesn’t give a shit.

  • Denverite

    some plans that meet the exacting standards South Dakota or Delaware have established for insurance quality

    You’re thinking too small. Why even bother selling worthless cheap insurance when you can sell expensive insurance, loot all of the premiums, and then just declare insolvency when the plan runs out of money to pay claims. Which would all be totally doable if an enterprising state decided just to eliminate its admitted asset requirements.

    • I eagerly await being able to purchase insurance through Amazon Prime, and having a heart transplant delivered by a robot drone whenever I need it.

      • GeorgeBurnsWasRight

        Only possible if you’ve signed up for Prime.

  • President Putinfluffer

    Everyone knows desperately sick people are much easier marks.

    All across this great nation my supporters are just chomping at the bit ready to steal everything not nailed down. Mr. Brooks is simply pointing out that bogus insurance policies will once again be a money maker.

    Desperate People make for massive profits.

  • kped

    Health savings accounts are great if you have extra money you can put away to save…but for people who are struggling, they’re borderline useless.

    • Junipermo

      They’re just tax shelters for affluent people, dressed up as a way to pay for health care. But they won’t work for most people, especially if they are already or become chronically ill.

      • Denverite

        This isn’t really true. The contribution limits are such that they’re pretty small potatoes for rich people. Even at the highest brackets, you’re only going to save $2000 or so in taxes if you max it out. That’s nothing for rich people.

        HSAs are basically a good mechanism for upper middle class people with significant family medical expenditures in a year to get a $1500 tax credit.

        • Rob in CT

          Yeah, it’s an upper middle class goodie, not an uber-rich goodie.

          Still, the point stands: it’s useless for like 85% of the population.

          • Denverite

            This isn’t 100% true either. Some employers fund HSAs (or, less generously, match contributions), which is probably the best of all worlds (because you have no risk but you get to keep the money if you don’t have health care costs).

            And even for non-funded plans, there’s a tax benefit for anyone who pays federal income taxes and has or can get access to an amount equal to medical costs paid the previous year prior to filing taxes. Even if you have to borrow it, you can funnel that amount through the HSA and the tax savings normally will be a good bit more than two weeks of interest.

            • ColBatGuano

              Doesn’t this require itemizing deductions? So, not useful for 70% of the country?

              • Denverite

                I think you can claim an HSA deduction even if you don’t itemize. It’s essentially nonincome.

          • nixnutz

            I don’t know about the percentages but it has obvious benefits for anyone who spends a significant and predictable amount on prescriptions. And in fact saving $20 or 30 a month seems like more of a benefit for those nearer the bottom.

        • GeorgeBurnsWasRight

          That’s nothing for rich people.

          While far from universal, you’d be amazed at how much of a tightwad many wealthy people are, and for many of them who are conservatives they’d do almost anything to save a few tax dollars from going to the government which they hate.

    • altofront

      As a way of providing health insurance, I think they’re pretty much useless for everyone. Even if there were no restraints on contributions, no one would ever put as much aside as medical care might actually cost. That’s why we have insurance companies, who can calculate these probabilities to a fare-thee-well.

      • Denverite

        This misunderstands how HSAs work. You can only get one if you have a HDHP. The theory is that the HSA contribution limit hits right where the deductible is met so you’re paying the high deductible with tax-free dollars (in practice, there usually is some gap going in either way, but it’s normally pretty close). HSAs were never meant to cover medical costs in excess of a HDHP deductible.

        • President Putinfluffer

          Isn’t it great how banks can also make money off of sick people?

          A Savings Account to pay your Health Insurance deductible.

          Pure genius.

          • Denverite

            Yeah, and they usually charge like $30 a year, so there is definitely something to this. I’d suspect you can probably link an HSA to your existing bank and savings account which might qualify you for no fees depending on balances, but I haven’t figured outhow to do that.

            • Solar System Wolf

              I’m a self-employed person who gets health insurance through the Colorado exchange, which Sen. Gardner is busy trying to get rid of. I also have a small HSA that I use for my copays, prescriptions, etc. I get it through State Farm, which carries all my other insurances as well so there’s no fee on the account.

          • Origami Isopod

            Great handle.

        • Murc

          I was once covered under a very idiosyncratic plan where we had an HDHP and an HSA, but the company put a couple hundred bucks into the HSA every quarter, and matched our own contributions up to it up to three hundred dollars in a year. So by contributing three hundred a year to it, I would end up with 1400 dollars in it by end-of-year, on a plan with a 2500 dollar annual deductible.

          That wasn’t really a bad deal, especially since it rolled over year-to-year, but it was SUPREMELY odd. I’ve never been on a plan quite like before or since. I have to wonder how the accounting worked out to make that more worthwhile for the company than a traditional PPO.

          • D.N. Nation

            I’ve been on this exact sort of plan with employer match over the course of two jobs for the past 8 years or so. It works for me, though I am young-ish (though soon not to be young-ish) and healthy (knock on so much wood). For example: I still haven’t drained the money out of my HSA from my old job that I stopped adding to in 2012.

            e: I’d rather have single-payer of course, and there by the grace of God go I.

    • AlanInSF

      Retirement is a much more probable, and certainly more conceivable, eventuality than a health crisis, so we can look at how well most Americans save for retirement and be certain they’d fund their health savings accounts even worse.

      • Linnaeus

        Retirement? What’s that?

        • David Hunt

          It’s something rich people do. Also people who haven’t had their defined benefit plans destroyed yet.

  • Linnaeus

    What if I can’t save enough in my health savings account to cover the health care that I need?

    • howard

      then you, my friend are of no interest to the republican party (and in fact, by their lights, are a failure as a human being).

    • President Putinfluffer

      Start a Health Insurance company young man!

    • FlipYrWhig

      Work harder, I mean, obviously. :/

    • Linnaeus

      You are all correct. Silly me!

    • Snarki, child of Loki

      Then you need to get signed up for the “GOP 2nd Amendment Catastrophic Coverage Plan”.

      When you get that “catastrophe diagnosis”, withdraw all the money in your health savings account, buy insanely powerful firearms and huge amounts of ammo, and go looking for GOPers.

      You’ll be just as dead at the end, but the journey will be quicker, less painful, and VASTLY more satisfying.

      • GeorgeBurnsWasRight

        Reminds me of the punch line in a Harlan Ellison story that the guy in the story had decided that if it was true that every man’s death diminished him, it was time for him to do some diminishing back.

    • tsam

      What if I can’t save enough in my health savings account to cover the health care that I need?

      Try being more white and wealthy.

      • Linnaeus

        Not sure which one would be more difficult at this point.

        • AlanInSF

          Try to die at home. We can’t have people dying in the streets.

    • D.N. Nation

      Buy more money, stupid.

    • Aaron Morrow

      “Reverend Morrison, in your policy… in your policy… here we are. It states quite clearly that no claim you make will be paid.”

      “Oh dear.”

      “You see, you unfortunately plumped for our ‘Neverpay’ policy, which, you know, if you never claim is very worthwhile, but you had to claim, and, well, there it is.”

  • FlipYrWhig

    The Republicans are going to try to introduce more normal market incentives into the process. They are probably going to rely on refundable tax credits and health savings accounts so everybody can afford to shop for their own insurance and care.

    Maybe the Republican alternative to Obamacare can have a “web site” where people can “comparison shop” for different “plans.” And maybe they can offer “discounts” based on “income.”

    • It’ll be called “Amazon Prime”

      • Jameson Quinn

        Unfortunately, “prime” refers to the only time of life when it will be affordable.

  • Uneekness

    This is my personal dead horse, so I will continue to beat it as long as I want – but there will be very little political cost to doing this. For the same reason that very little political benefit accrued to Obama and the Dems for enacting it in the first place. With insurance, the benefits are abstract, and the costs are upfront. You have a lot of people who know they are paying something (even a little) for something that cost again (not always a little) when they use it and is still confusing because it is mere an extension of our shitty profit-drive insurance/medical care system as a whole.

    Sure, they’ll wish they had it when they get sick, but they’re used to dealing with that in the past, and they manage. It’s the same reason that a lot of poor people get the minimum car insurance they can when licensing a vehicle and then drop it soon after. Nobody thinks they’re going to get into a wreck, and that $30/mo sure is useful in the here and now for food or a cell phone bill.

    Add to it the GOP media will go to he ends of the earth to promote the stories of happy, former Obamacare people now getting ‘better’ insurance from the glorious, newly freed healthcare ‘market’. Some will actually be true (30 yr-old with no health problems in his past) and some will merely sound better until they try to use it (48 yr-old single mother with two dependents and a minor condition that will enable recession when they get breast cancer…) And if you don’t think that this media blitz on top of the existing feelings about the ACA won’t work, well, just look at how many ‘not crazy’ friends in your FB feed describe the ACA as failing or troubled or saw Hillary as ‘flawed’, etc., etc…the GOP is very vewry good at setting the narrative.

    • I think this goes back the the argument of why Obama didn’t start with fighting for single payer and settling for a public option, instead of starting his bargaining pitch where he did already in the middle and then being pulled to the right of that.

      • Uneekness

        Agreed. Although, considering how much a lot of people (like me!) actually believed in Obama’s kinda centrist, we-can-overcome-this-partisanship rhetoric, starting out with the plan that had been the GOP fallback position on healthcare seemed smart at the time. I may have thought the GOP would still be reluctant to come meet Obama at the 50 yard line, but I never thought they’d both tear the goalpost out and run with them out to the county line AND claim that Obama wasn’t meeting them halfway. Nor did I think they’d be so well-rewarded for the same strategy. And more personally, as a person who has had his bank account dinged yet ultimately saved by our flawed medical insurance based system, I also felt that more people would see it as a pure benefit, warts and all. My biggest concern was the delay to 2014 for things to kick in. And I still think had they ignored those who had pushed that start date for the deficit optics, it would be rooted enough now that there wouldn’t have been the will to get rid of it. But all the Very Serious TV Talkers claimed with Absolute Certainaity that every American voter Cared Deeply About the Deficit, so…

        I know that the congressional Dems of 2008 were fighting the previous war in regards to their approach to the ACA at the time, and that the overall coalition was looser and more diverse politically than it is likely to be in any future Dem majority. But hopefully the lesson will be crystal clear: seal out all beltway jabbering and ignore the crocodile tears of the GOP and just get the right program put in place the first time.

        • Rob in CT

          You speak for me as well. That’s exactly how I thought too, and how my thinking has changed.

        • Murc

          starting out with the plan that had been the GOP fallback position on healthcare

          This is flatly and categorically untrue.

          • Uneekness

            Sure, technically the GOP position had always been to insert their head in the sand. Inasmuch as they had a talking point for the Sunday Showz, about how to fix healthcare, or what they would do to fix it, it was always this.

            • Aaron Morrow

              Maybe Nixon was for expanding Medicaid one time when Democrats were pushing for national health care, cite omitted of course, but that damn well hasn’t been the GOP fallback position on health care for forty years.

            • Murc

              Inasmuch as they had a talking point for the Sunday Showz, about how to fix healthcare, or what they would do to fix it, it was always this.

              No, it wasn’t.

              Both the initial ask and what actually passed were both loads better than anything the GOP has proposed, seriously or not, since Nixon. And going back forty years is a hell of a leap.

              • Uneekness

                The Democrats took back the White House in 1992 due in part to what had been a period of rapid cost increases in the midst of broader economic doldrums. Clinton explicitly campaigned on tackling health care costs. The GOP response was varied, with the most substantial bill coming from Chaffee. And yes, it was attacked by the right-wing of the GOP, but the themes it was built on (insurance ‘reform’, coverage portability, subsidies/tax credits in one form or another) flow through the campaign platforms of Dole ’96, Bush ’00, and McCain ’08.

                So sure, there was never an ‘official’ GOP position on health reform beyond hand-waving “gov’t bad/free market good” argle bargle. But whenever they were pressed on what the outlines of a real policy might look like, over the 15 years pre-Obama, this is what it would look like.

                • Murc

                  The GOP response was varied, with the most substantial bill coming from Chaffee.

                  And Chaffees proposal was significantly worse than Obama’s initial ACA ask and also worse than what was actually passed!

                  I mean… you’re making my points for me.

                • Uneekness

                  Points…in what game, exactly? Again, the reason for staking out a subsidized insurance market plan in 2009 is that it really was a compromise position – one that included lots of things that Democrats wanted and lots of things Republicans had at least tipped their hat at being acceptable in many, many public forums. It was literally a huge symbol of what Obama had run his entire campaign on.

                  Remember, even as the backlash against BillandHillaryCare was building in 1994, the GOP still floated multiple actual plans – they went into the hopper as actual bills. It would not surprise me if the Obama administration at the time thought that there would at least be a back and forth, substantive negotiation over the final form of the bill with the at least a handful of GOP members if they themselves took the first step. Nobody – nobody – in the spring of 2009 would’ve thought that the entire GOP would stay in lockstep NO mode AND that it would be a phenominally successful electoral strategy for them

                • Murc

                  Points…in what game, exactly?

                  Points as in “you have made the factual points I am attempting to make and that you are ostensibly arguing against for me, which seems odd.”

                  Again, the reason for staking out a subsidized insurance market plan in 2009 is that it really was a compromise position

                  No. The reason for staking out that plan is because no plan further to the left than that would have passed.

                  It would not surprise me if the Obama administration at the time thought that there would at least be a back and forth, substantive negotiation over the final form of the bill with the at least a handful of GOP members if they themselves took the first step. Nobody – nobody – in the spring of 2009 would’ve thought that the entire GOP would stay in lockstep NO mode AND that it would be a phenominally successful electoral strategy for them

                  This is true, but it has no actual bearing whatsoever on whether Obama’s initial ask was “the GOP fallback plan” as you claimed it was.

                  It was not. You were wrong.

                • Uneekness

                  I sense some retconning going on by you. The intellectual energy of the left between 1993 and 2008 was always in favor of far more expansive, government-centric ideas that broke us from the employer-based model once and for all. The ACA from the start was a rejection of a “democratz only club!” approach to crafting the bill. Starting with a ‘market-based’ approach was a sop to the Republicans, very generous subsidies and a medicaid expansion was a sop to the Democrats. The thinking was that with the big election win and (nominal, if not full procedural) control of the legislative branch, the GOP would see it for the good faith negotiating step that it was and at least some GOP members would participate in developing the final bill. It was VERY important to the Obama team in early 2009 to be seen working across the aisle, and everything about the last 30 years in DC suggested that at least a handful of Senators and House members would join them.

                  Had they known of the epic political sea change about to wash over them, and decided to just work with Democrats on the bill, we’d have gotten a far more robust bill, and Lieberman would be crowing about how he saved America from the perils of single-payer by agreeing to the compromise of Medicare for all. But that’s not how the world looked in 2008. And to argue that a medical insurance expansion wasn’t the argument being used by Republican politician and think tankers as a “well, if i HAD to fix healthcare” default position in the salons and TV studios of Washington DC between 1994 and 2008 is just dumb.

                • Scott Lemieux

                  1)where’s the Medicaid expansion in the Chafee plan?
                  2)that aside, touting a bill written by a guy who supported a national firearm ban as representative of Republican health care policy is a fucking joke.
                  3)the idea that Lieberman would have supported a robust public option if Obmama had only started with an ask everybody knew had insubstantial support in Congress is an idiot’s idea of how negotiating works.

                • DamnYankees

                  3)the idea that Lieberman would have supported a robust public option if Obmama had only started with an ask everybody knew had insubstantial support in Congress is an idiot’s idea of how negotiating works.

                  This is actually one place where I think the counterfactual worked. Did Lieberman actually oppose the public option on the merits? Or did he take that position because he wanted to be the guy who had the leverage and stood has ground and got something “reasonable” to show he isn’t an ideologue?

                  If the former, I agree with you. But if the latter, then starting farther left, and letting Lieberman extract something else, might have worked.

                  That all said, this wouldn’t have worked anyways, since Lieberman was hardly the biggest issue here. But vis-a-vis Lieberman himself, I see the argument.

                • Murc

                  The intellectual energy of the left between 1993 and 2008 was always in favor of far more expansive, government-centric ideas that broke us from the employer-based model once and for all.

                  Yeah, and we’ve never had the votes for it.

                  The ACA from the start was a rejection of a “democratz only club!” approach to crafting the bill.

                  No, it was not. It was a recognition of the fact that nothing more robust had a chance in hell of passing. All it took was one Democratic Senator to want bipartisan cover and to demand he get to spend months trying to get it, or one Democratic Senator deciding that he had no truck with all this crazy socialism and would, regrettably, have to “represent faithfully the people of his state, who are not in favor of this” to torpedo the whole thing.

                  Starting with a ‘market-based’ approach was a sop to the Republicans

                  No, it was a sop to the Democrats who would not have voted for anything else.

                  The thinking was that with the big election win and (nominal, if not full procedural) control of the legislative branch, the GOP would see it for the good faith negotiating step that it was and at least some GOP members would participate in developing the final bill.

                  This is true, but also not relevant to what you tried to argue, which is that the ACA in the form it was initially proposed was “the GOP fallback plan.” It was not.

                  Had they known of the epic political sea change about to wash over them, and decided to just work with Democrats on the bill, we’d have gotten a far more robust bill,

                  No. We would not have. Lieberman would have torpedoed anything more robust. If not him, Bayh. If not him, Nelson. If not any of them, Max Baucus would have pitched a fit about Obama not letting him spend six months massaging Charles Grassley’s balls and refused to work with the White House.

                  And to argue that a medical insurance expansion wasn’t the argument being used by Republican politician and think tankers as a “well, if i HAD to fix healthcare” default position in the salons and TV studios of Washington DC between 1994 and 2008 is just dumb.

                  “Medical insurance expansion” covers a multitude of sins. Not everything that falls into that bucket is remotely identical to everything else that does.

                • Uneekness

                  Holy shitsnacks, the pushback on this point is silly.

                  1) OF COURSE the Chaffee bill isn’t IDENTICAL to the ACA. I didn’t say it was. But back during a time when the DC press asking “what’s you’re alternative idea then?” actually could cause politicians to act, it was a real bill, with 20 co-sponsors, actually deposited into the hopper. And it laid out the core idea of strong-arming the existing insurance market to serve the public interest. As the GOP wanted to draw a distinction between a “free market” solution and the big gubmint librul Hillary Clinton plan, this is what got the most traction on the right. It was not universally taken as a position, but Beltway Washington certainly saw it as the sophisticated GOP position of the moderates in the party. Meanwhile, the left laughed and dismissed it as unworkable and a giveaway to the insurance companies that were already viewed as rapacious by the general public.

                  The whole reason Hillary and Obama campaigned on this idea by 2008 is BECAUSE it had taken hold as an acceptable ‘middle ground’. (Hillary’s 2008 campaign always prefaced health plans talks with “there are no new gov’t agencies or bureaucracies created…” yada yada) Clinton and Obama both ran centrist campaigns in 2008. Certainly neither expected to have a filibuster-proof majority in the Senate at any point in their first two years. At that point the only Dems they were trying to convince of anything were the Russ Feingold fans (no BernieBros yet, brah!) that their plans weren’t complete sellouts.

                  So to the whole IT WAS THE MOST LIBERAL PLAN THAT COULD HAVE PASSED, well, yes, considering that it was designed to pass WITH REPUBLICAN SUPPORT. Again, if they had known there was going to be fanatical GOP opposition (starting with slow-walking everything from day one) PLUS a brief window of 60 Senators PLUS Kennedy dying at a critical moment, then yes, I believe a stronger bill would’ve been run through the House and a bill would’ve passed the Senate that looks similar to the existing ACA and the real work would’ve been done in the conference committee behind closed doors. For all the talk that there were a multitude of Senators who could’ve been the one to fuck things up, none of them did. And when Lieberman did blow up the compromise that allowed the limited Medicare buy-in at the end of 2009, it came as a surprise. Would he have the gumption to do it in early July 2009, with a vote taken shortly after liberal hero Al Franken is seated and before the Koch brothers had spun up the astroturf operation at the congressional town hall meetings? Maybe! But not for certain! We do know that all of the other squishes didn’t squish the limited buy in, so there is more than a fighting chance this plays out differently had the Obama administration known that htey needed to capitalize on this narrow opportunity

                  As it was, Obama and the dems in general always seemed just behind what was actually happening. Like being told to prepare a tap dance for a dance recital, then getting there and finding out you’re being judged on your tango. Then leaving to prepare a tango when you come back they tell you, no, we are doing a waltz. Ad infinitum. Not their fault, from the way Dems and Republicans appeared to embrace the Obama campaign and his huge victory less than a year prior, it was easy to think the GOP was making a huge mistake, would ultimately pay at the polls and both Dems and Republicans would continue to improve the law in the future.

                  But again, it is just silly to say that the ACA wasn’t developed with an eye towards meeting Republicans part way on the matter, specifically via the expansion of the existing healthcare insurance market. I mean, for the love of baby jeebus, Mitt Romney’s centrist run in 2008 was predicated on getting credit for having solved healthcare in a GOP-friendly way.

                • Murc

                  Holy shitsnacks, the pushback on this point is silly.

                  1) OF COURSE the Chaffee bill isn’t IDENTICAL to the ACA. I didn’t say it was.

                  Neither did I. You explicitly said that Obama’s initial ask on the ACA was “the GOP fallback.” It was not. Not even remotely. It wasn’t identical, nor was it equivalent. The only thing it had in common was that, broadly speaking, they embraced the same mechanism. This in no way makes them equivalent; it is like saying the Democrats and the Republicans fiscal policies are equivalent because they both involve taxes and spending.

                  So to the whole IT WAS THE MOST LIBERAL PLAN THAT COULD HAVE PASSED, well, yes, considering that it was designed to pass WITH REPUBLICAN SUPPORT.

                  No. It wasn’t. And the proof of that is that it didn’t pass with Republican support.

                  Again, if they had known there was going to be fanatical GOP opposition (starting with slow-walking everything from day one) PLUS a brief window of 60 Senators PLUS Kennedy dying at a critical moment, then yes, I believe a stronger bill would’ve been run through the House and a bill would’ve passed the Senate that looks similar to the existing ACA and the real work would’ve been done in the conference committee behind closed doors.

                  This is astounding. This is basically saying “if they had eschewed trying to get Republican support… the Senate would have passed something similar to what we got!”

                  Thank you for admitting you were wrong on the matter.

                  For all the talk that there were a multitude of Senators who could’ve been the one to fuck things up, none of them did.

                  Yes, because their demands were met.

                  And when Lieberman did blow up the compromise that allowed the limited Medicare buy-in at the end of 2009, it came as a surprise.

                  Not to anyone paying attention, it didn’t.

                  We do know that all of the other squishes didn’t squish the limited buy in

                  It only requires one.

                  But again, it is just silly to say that the ACA wasn’t developed with an eye towards meeting Republicans part way on the matter, specifically via the expansion of the existing healthcare insurance market.

                  It was designed that way because the Democratic votes to do a more left-wing plan didn’t exist.

                  They did not. Period. The Democratic votes were not there.

              • Uneekness

                You know what would be an enlightening experience for you, Murc? Go back and read the contemporary reporting on the ACA as it slogged it’s way through the day to day process Each day. As it happened. You don’t think there was a huge shock when Lieberman bolted on the limited expansion of Medeicare after he’d been part of the negotiations to include it?

                Lieberman Reverses Position on Medicare Expansion

                Updated: 7:36 p.m.Sen. Joe Lieberman (ID-Conn.) formally notified Senate Majority Leader Harry Reid (D-Nev.) on Sunday afternoon that he would filibuster the health care reform bill if it includes a Medicare “buy-in— provision. Lieberman’s position came as a surprise to Reid, considering the self-described Independent Democrat was among the first people Reid spoke to about the Medicare provision when it was discussed by a Democratic group of centrists and liberals attempting to craft a compromise that could secure the votes of all 60 Members of the Democratic Conference. At the time, Lieberman “voiced support for the plan, according to a Senate Democratic leadership aide. Lieberman spokesman Marshall Wittmann strongly disputed the leadership aide’s account. “The suggestion by an anonymous ‘aide’ that Senator Lieberman ever supported the Medicare buy in proposal is absolutely and totally false. The fact that the ‘aide’ won’t identify him/herself is a testimony that they are telling a deliberate falsehood or he/she is completely confused, Wittmann said. One Lieberman aide said the Senator notified Reid on Friday that he had “problems with the Medicare provisions. This is the second time that Lieberman has threatened to filibuster a final health care measure over a provision that is key to securing the votes of liberals. Lieberman first indicated his intentions on CBS’ “Face the Nation program Sunday morning. Lieberman’s stance means that Reid either has to abandon a recently crafted compromise between liberals and centrists or will have to secure the vote of moderate Sen. Olympia Snowe (R-Maine) and possibly Sen. Susan Collins (R-Maine) in order to find the 60 votes that he needs to overcome a GOP-led filibuster.

                It’s…pretty easy to google stories like it, by the way. (oh, look, its the New York TImes: WASHINGTON — In a surprise setback for Democratic leaders, Senator Joseph I. Lieberman, independent of Connecticut, said on Sunday that he would vote against the health care legislation in its current form. The bill’s supporters had said earlier that they thought they had secured Mr. Lieberman’s agreement to go along with a compromise they worked out to overcome an impasse within the Democratic Party...)

                Bernie Sanders was adamant – ADAMANT, I tell you! that he would torpedo that same vote if the plan DIDN’T include a the Medicare buy-in just three days earlier. Ben Nelson got his Cornhusker kickback as a condition of signing on – yet he still voted for the bill after it was removed in the end. Lieberman, under an altered set of negotiating circumstances, was not necessarily immovable. Slight tweaks to the offset those cost might have brought him around even

                Which comes back to the goddamn point. They never started with a “what’s the most liberal bill that can pass WITH ONLY DEMOCRATS.” Maybe it wouldn’t have looked a whole lot different if they had. Maybe! But when you consider that in the end they were stuck trying to work with a bill that was initially built by Max Baucus to appeal in some way to Charles Grassley, then it becomes obvious that it was a bill that WOULD HOPEFULLY GARNER SOME GOP SUPPORT, BUT THEN THEY WERE STUCK WITH IT.

                It’s like a basketball team having its star players all get get food poisoning the morning before a game – if the scrubs that are left win, the coach doesn’t insist that it was his plan to play those scrubs all along, because DUR THEY WON SO THEY WERE THE BEST PLAYERS ON THIS TEAM. It just means the team made the best of the situation with what it had at the opening tip. To extend the metaphor, if the star players were sick for a long period and it dropped the team from having home court advantage throughout the playoffs, then Hooray! Made the playoff, but also, damn, we could be in a much stronger position if we’d been playing with our best players all along.

                This whole insistence that the ACA is just the ONLY AND BESTEST POSSIBLE HEALTH CARE BILL THAT COULD’VE EVER HAPPENED THEN AND THERE IS NO WAY THAT A SINGLE THING ABOUT IT COULD EVAH BE BETTAH AT THAT TIME! is a weird obsession around these parts.

      • Mayur

        Holy Joe Lieberman wasn’t going to allow for single-payer, and neither were Baucus or Nelson.

        Even with all 40 Republicans (god, I miss those days!) against him, Obama couldn’t get Medicare for All past his OWN PARTY. That was the problem.

        • FlipYrWhig

          Look at the Democrats in the Senate when the whole thing was going on. Lieberman was an obvious problem. Baucus, Ben Nelson, Blanche Lincoln, Mary Landrieu were high-profile wafflers. Then there were the people who’d pipe up with various criticisms at various points of the process: Pryor, Carper, Bayh, Webb, Conrad, Dorgan. Then there were the people who stayed quiet but who we know aren’t exactly rock-solid progressives in the first place: Begich, McCaskill, Tester, Bill Nelson, Specter, Tim Johnson, Warner. That’s 18 people not even including other heterodox sorts like Casey, Bennet, Wyden, and Feinstein. That’s a lot of people with a lot of power.

          • Rob in CT

            Right. The question is, is our Democrats learning?

            We need Dems who might be inclined to be centrist to understand how the partisan environment has changed. In short, we need them radicalized. Not necessarily in the sense that they magically turn into Sanders clones (rather unlikely, that). I mean more partisanship, which would keep the caucus together when push comes to shove.

            • Uneekness

              Based on Schumer’s actions since the new congress was sworn in, I’m cautiously hopeful…

              But just to be certain, I say a little prayer/mantra every morning before I start my car and flip on NPR:

              “voters don’t actually reward bipartisanship…voters don’t actually reward bipartisanship…voters don’t actually reward bipartisanship…”

            • FlipYrWhig

              It’s never been clear to me how many centrist Democrats are moderate because they think it’s the way to get reelected (“s/he is practical and reasonable unlike the rest of that crazy party!”) vs. those who are because they actually believe in limiting the social-welfare state a/k/a Big Government. Unfortunately for us I think most of them believe it.

          • DamnYankees

            Wow. Now that you list out those names, I’m even more impressed the ACA passed in the first place. I can’t imagine a single one of them voting for it now. Maybe Warner.

            • Scott Lemieux

              The question is not how Obama and Reid weren’t able to get a public option. The question is how the hell they were able to get anything out of that group of hacks.

        • Joe Bob the III

          Not just single payer. Lierberman’s vote was conditional on axing the public option.

          • Scott Lemieux

            And then opposing an alternative he had long supported literally for the sole purpose of pissing liberals off. But, sure, he totally would have voted for a public option if Obama held a press conference with the 3 senators who supported single-payer and threatened to bring it to a vote.

      • FlipYrWhig

        Which goes back to the argument of how at least half the Democrats in the Senate didn’t want the final plan to be any further left than it was and were willing to blow up the whole thing to prevent it and had the leverage to do it and would kneecap the entire Obama presidency if they had.

        • FlipYrWhig

          Perhaps “at least half” is an overstatement, but by my quick headcount above, “at least a third” would be a defensible claim.

          • Scott Lemieux

            And when each and every senator has a de facto veto, that’s plenty.

    • Murc

      It’s the same reason that a lot of poor people get the minimum car insurance they can when licensing a vehicle and then drop it soon after.

      You… you can’t do that. They’ll suspend your license and refuse to renew your registration. You won’t even be able to get your car inspected.

      • Jameson Quinn

        maybe in some states?

        • Uneekness

          Very common in Kansas. You show up once a year to renew. As long as it is current at that moment, you are good to go. No car inspection at all. (Currently driving a car with a giant crack in the windshield myself…but I do have insurance)

      • FlipYrWhig

        Lots of uninsured drivers out there whose cars still work even without the proper paperwork in the glovebox.

        • Murc

          Yeah, and eventually they’re gonna get pulled over and end up in some really deep shit.

          Maybe it is different in other states, but here in New York if you don’t have the right color inspection sticker in your window, the cops will be ALL OVER YOU. (The stickers rotate color every year specifically to enable a cop to tell if you’re driving with an uninspected vehicle from a distance.) And driving around with an invalid registration sticker on your windshield is an offense in itself. And you can’t get your car registered without being current on the inspection. And if your insurance or registration lapses the state will automatically yank your license.

          They cops won’t write you a ticket. They’ll BOOK you. Aggravated unlicensed operation of a vehicle is no laughing matter.

          I guess other states are different?

          • FlipYrWhig

            I think a lot of people judge their likelihood of getting spotted by cops on any given day is low, so they’ll just roll the dice because dammit they have to get to work.

          • Uneekness

            You can get (in Kansas at least) month to month car insurance. And in the late night commercials, they specifically use terms like “state minimum coverage’. You go to pay your yearly car tag fees, the check to make sure you don’t have anything disqualifying, and then check to make sure you have coverage at that moment, and give you the sticker. (Goes on your plate here.) If that coverage lapses a week later, it doesn’t matter. The only time you will get in trouble in the next year is if you are pulled over for something else. Even then, if you don’t have proof of current insurance, you will be issued a citation – one that a secretary down at the courthouse can remove instantly if you go down there prior to the court date and show that you had coverage. If you don’t do that (and don’t show up for your court date) the process of punishing you begins – but can still be a loooong time before anything real happens.

            • GeorgeBurnsWasRight

              I think most states work that way.

              With the internet, I imagine most states could set up a mandatory reporting system where insurance companies would have to report who had insurance on a vehicle nearly real-time.

              That this doesn’t happen is part of the general move to reduce enforcement of laws relating to operating autos. It’s pretty obvious to me that the police enforcement of speeding laws is far less than it used to be. And done properly, this is a money-maker for governments, so clearly there’s other factors at work.

          • David Hunt

            Caveat: I’m white and the vast majority of people I know are white.

            I’m in Texas and no one is worried about getting arrested for driving while their car isn’t improperly insured. I have a friend who went several years without inspecting his car or renewing the registration. He knew he’d get ticketed if caught, but he most drove at night…

            He wasn’t worried about anything more dire than a traffic ticket and that’s my impression of how things work here overall.

            • Murc

              I’m in Texas and no one is worried about getting arrested for driving while their car isn’t improperly insured.

              Huh.

              Thing is, nobody up here would be much worried about just that… but driving uninsured quickly leads to driving while unregistered and unlicensed.

              And that’s not a citation up here. That’s an actual misdemeanor.

          • Scott Lemieux

            Not only that, in New York if your insurance expires for a day you have to either turn in your plates for several weeks or pay a substantial daily fine.

      • rea

        It is a misdemeanor here in Michigan, but nevertheless common

      • Just_Dropping_By

        You… you can’t do that. They’ll suspend your license and refuse to renew your registration. You won’t even be able to get your car inspected.

        Your faith in humanity is astounding, Murc.

        • Murc

          I generally assume people don’t want to pay thousands of dollars in fines and go to prison unless they have literally no other options.

          Sometimes they don’t, but otherwise…

    • GeorgeBurnsWasRight

      There’s the other consequence which will impact more people, but most of them won’t be able to make the connection.

      Ending the ACA will cause the closing of numerous hospitals, many in low-population areas, which were thrown a lifeline with the ACA because it meant that they were going to get paid for treating a higher percentage of their patients than before.

      • Uneekness

        The hospitals in all the rural areas of this very red state made a big show to the legislature and the Governor that they needed the Medicaid expansion to stay afloat when said Governor and legislature first turned it down. Said Governor and legislature told said hospitals were lying, and it they weren’t, then to suck it up (well, they may have said to become more efficient, but who’s to say.) Two years later, after the Governor and legislature won bigly in the off-year election, same hospitals come back, minus the many that had closed down, and asked again for he Governor and legislature to please take the free money. Again told to go eff themselves. In the fall elections, legislature lost a handful of incumbents – almost none of them in the rural areas where the hospitals are closing.

        We are truly through the looking glass. Twenty seven years ago, behavior far less egregious was punished by a Democratic takeover of the legislature and Governorship. These things used to be possible. But things are just different now. We have to find a way to win no matter what, and once in power, wield it without hesitation.

  • Alex.S

    https://abetterhealthcareplan.com/

    House Republicans have a plan to get there

    Our Congress is fighting for us: lowering costs, providing more control and more choices to pick a plan that meets our needs, not a plan that Washington mandates.

    That is literally all of the text on Paul Ryan’s Obamacare replacement plan.

    Note that it doesn’t include “covers more people” or even “covers the same number of people”.

    • D.N. Nation

      not a plan that Washington mandates.

      Mandating is for ladyparts, of course.

      • N__B

        But not ladypart hats.

    • AlanInSF

      See? Sound health-care policy for a nation of 330 million people doesn’t take 2700 pages.

      • Solar System Wolf

        Medicare for All would take about a page.

    • wjts

      Note that it doesn’t include “covers more people” or even “covers the same number of people”.

      Or indeed “cover anyone at all”.

  • Bitter Scribe

    Did Brooks also address Medicare as a vouchers program? As in, “Here’s $1,500 for the year. Now go shop for health insurance. That might cover you for almost a month.”

    • ColBatGuano

      I’m sure my 91 year old father will enjoying shopping for health insurance.

      • Scott Lemieux

        I suspect he will envy Russell Wilson when the Rams kill him on the field next year.

        • ColBatGuano

          Wade Phillips to the Rams. Unless the Seahawks line shows some massive improvement, I suspect they may have to call the game in the 3rd quarter because there are no more QB’s left.

          • Scott Lemieux

            If the Seahawks signed Tebow just to play the two games against the Rams I wouldn’t object.

  • Brooks’s example of aviation is exactly contrary to his intended point. Yes, we entrust our lives to airliners, but we are actually entrusting our lives to a complex system that involves the airline and the FAA and the regulations that bind them together.

    Flying is a lot like health care. There is wildly asymmetric information. Most pax don’t know how airplanes work, don’t know how they should be maintained, don’t know what operations are safe and unsafe. Furthermore, even if they did know, the actual state of the aircraft and crew are unknown. It’s not like they’ll let me take a screwdriver and a flashlight and conduct my own walk-around before I board.

    What makes aviation work are regulations that put the airplane and crew in a state where the passengers know a minimum level of safety is assured.

    I mean, file under duh.

    Does Brooks really want to fly on an unregulated airline constrained by its reputational risk alone? WTF?

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