To Those Arguing that this is not Real Health Care Reform

Ezra has a short post answering the question of a self-employed, single mother with income of around $38,000 per year about the impact of health care reform legislation on her situation.  Basically, once health care reform fully kicks in, she will be able to purchase insurance for herself and her children for about $1,500 a year, or approximately $125 per month.  Under the Patient Protection and Affordable Care Act, the bill passed yesterday, she will be guaranteed a subsidy that is worth at least $9,300 a year.  (My figures differ a bit from Ezra's, who indicates the subsidy is worth over $11,000 -- I am not sure if he is calculating in the value of being in a purchasing pool.)

Either way though, this legislation makes purchasing health insurance coverage highly affordable to someone of very modest means.  (On the open market of today, such insurance would likely cost at least half of her take home pay.)

A concerted effort needs to be undertaken to answer just such questions of people of modest means.  I am sure that many such people have no idea what this legislation likely means to them.  My only concern is that they won't get this benefit until 2014.  It would be nice to be able to accelerate this package -- like maybe to 2012.

Comments

[Corvus9]

Right. The belay was basically for the purpose of budgeting numbers, and making the look like it "cost" less. Once it becomes obvious what the reforms are that are coming, it might be politically possible, by harnessing public impatience, to move up the date.

So, date of implementation, public option, reconciliation fixes, national exchanges...

I actually have a feeling we are in for a lot of changes to this law before it actually kicks in. None of those changes will be repeal.

[John]

Maybe a future bill could speed up implementation of the exchanges and premium subsidies. Now that the basic bill is passed, it might be to the advantage of moderate Republicans to help improvements through the Senate.

[Sir Charles]

John,

Oh I wish. But really you're looking at Brown, Snowe and Collins -- not exactly the profiles in courage set. I don't think there is anyone else who is remotely gettable. And the Republicans tend to enforce party discipline pretty ruthlessly.

[Corvus9]

I don't think John is necessarily wrong. The pair from Maine are, after all, from Maine, and contributing to something that speeds up something that is popular, and already a done deal, after the immediate insanity dies down, might not be out of the realm of possibility for them. The seem to both have a bit of a free-hand to burnish their Centrist credentials from time to time.

[oddjob]

I believe Brown is a waste of time on this matter. His whole campaign was based around opposing HCR. In just three years he'll be facing re-election in a state that for the most part will probably be hostile to him since Obama will most likely be running for re-election (barring an unforeseen political catastrophe), and will probably do pretty well in Mass. If he were to reverse course on it by voting for an improvement of its implementation I think he'd lose face among the Mass. locals who voted for him.

He'd look like just another garden variety hack. I already think he is that, but those who voted for him would probably be considerably less than impressed to see him voting for a measure they elected him to oppose.

[oddjob]

(If Brown were to reverse course......)

[Corvus9]

I wouldn't be to sure of that, oddjob. Brown only won because he was running against a truly horrible candidate. Like Alan Keyes in Illinois level bad. Presumably, whoever runs against him next time won't be such a joke, and he won't be able to sit upon a pile of resentment aimed at Democrats for not getting things done.

But his political position is still basically impossible. If he doesn't do anything to soften his policy stances, there is no way he can win a second general in Mass., especially against a candidate on Obama's coattails. But if he does soften his stances, he loses his major base of support. The needle he has to thread is even smaller than the one Specter was facing, and Specter couldn't thread that one. And Specter is a much smarter politician than Brown (I assume).

(I don't think this means Brown will switch, by the way. Even if he wanted to, I am not sure the dems would even take him. They have to just know they could get someone better in three years, and after all, this is the motherfucker who won Ted Kennedy's seat on a promise to kill Ted's life's work. No way anyone in the Senate, or the White House, have any warm feelings for him. I doubt a party switch could even guarantee him institutional support in the primary.)

[John]

I don't know what to expect from Brown, but the pair from Maine are gettable on at least some issues. So they may be willing to support popular changes, like speeding up the exchanges or improving subsidies for middle class families. I know that Republicans enforce party discipline better than Democrats, but they have to be careful about that – would they really want to risk losing Snowe or Collins through a defection? As for Brown, he has to win re-election in a deep blue state in an unfavorable year and probably against a better candidate than Coakley. He'll need to show some signs of moderation if he wants to keep the seat.

[Sir Charles]

John,

I think Brown is in an impossible position. You may be right about him -- he may actually moderate a bit in a desperate fight for survival. But in a presidential election where the turnout will be high (and at a time when the economy will presumably be appreciably better) and ambitious Dems have been waiting to knife him, I don't see how he survives.

Collins is surprisingly conservative at her core. Snowe is gutless. I think getting them is going to be pretty difficult on these party line votes.

[Corvus9]

That's why it will come down to constituent pressure. Snowe and Collins will only defeat if they think they need to for political survival, or if the vote in some way is dependent on abortion, since they are both pro-choice. Otherwise, no.

I actually am somewhat curious what Brown's plans are, since he must be aware of the political obstacles in his way.

Does anyone think he will vote for the reconciliation bill? Like as a, "I don't support healthcare, but if it's passed, at least get rid of the Cornhusker kickback" type of thing.

[T.R. Donoghue]

Atrios had some utterly ridiculous nonsense up today about how this isn't the reform that he voted for. Apparently Atrios had a Magical Senate Pony that he was hiding from the rest of this entire time.

I lost a lot of respect for Prof. Black today after reading that nonsense. It's time for the Jane Hamsher's and Duncan Black's to grow the fuck up and look beyond their own narrow world view.

Sweet Jesus, these people act like the most important thing at stake here is their feelings.

[Sir Charles]

Hey T.R. -- how're you doing buddy?

I have a really hard time attacking the cerulean cherub. He was my gateway drug into the blogosphere, the voice I latched onto in those dark days in 2003 and I retain a certain slavish loyalty.

That aside, I think in large part he is vexed not so much by this particular episode but by the fact that he has been prescient with respect to both the policy and politics of 1) the stimulus; 2) the bank bailout; and 3) the mortgage crisis. He was an advocate of what I would describe as pragmatic left populism where he correctly saw the scope of the crisis and the unemployment that would stem from it -- including the fact that the cutbacks by state and municipal governments would create a crater that the stimulus could barely fill. He understood from the start that cramdown was the only way to start getting the mortgage crisis past -- and he understood the bad politics of Geithner and Summers being perceived as primarily concerned with the interests of banks rather than consumers.

Now, I think it is debatable that some of these things could have been accomplished. I think the stimulus was probably about as big as it could have been, although Obama might have been able to use the bully pulpit to leverage more direct spending. Durbin pushed cramdown and couldn't get it through -- would more White House support have made the difference? Again, hard to say, but this would have been worth a shot. And I think there is not a one of us on this blog who would not have advocated kicking the banksters in the balls a bit -- that the Dems ended up owning this crisis politically is beyond galling.

Having said all that, I think it is time for Atrios to accept the fact that the health care bill as passed is still a pretty good and substantial piece of legislation -- the biggest and most progressive that has been passed in 45 years in this country. Sometimes we should just declare victory and smile. This is one of those times.

[oddjob]

I wouldn't be to sure of that, oddjob. Brown only won because he was running against a truly horrible candidate. Like Alan Keyes in Illinois level bad.

Ummmmmmm.................

You don't live in Mass., do you?

I do.

I voted for Coakley in the primary, and I like to think I'm sufficiently independent of either party to recognize a nutjob caricature when I'm presented with one.............

[oddjob]

Thanks for playing.

Try again next time.

[oddjob]

I think Brown is in an impossible position. You may be right about him -- he may actually moderate a bit in a desperate fight for survival. But in a presidential election where the turnout will be high (and at a time when the economy will presumably be appreciably better) and ambitious Dems have been waiting to knife him, I don't see how he survives.

YES!

[oddjob]

And all you have to do is listen to Brown for a few minutes (or less) to realize he doesn't have a future unless he not only switches parties, but disavows every stance he campaigned upon this time around. But if he does that, how does he maintain his credibility (when he isn't intelligent enough to square that circle, and he's not)?

[Corvus9]

Hey, I'm not saying Coakley is as crazy as Keyes, or even that she was bad on the issues, or even that it was a bad idea to vote for her. If I did live in Mass, I would have voted for her too. I just meant in terms of campaigning. Anyone who blows a—what was it? 15 point lead? 25 point lead?—at such a critical time, deserves to have their campaigning skills insulted as extremely as possible. And, as I am from Illinois, when I think of horrible, horrible candidates, Keyes was the first person who sprang to mind.

And I understand it must sting to hear that she is that bad from someone out of state, after you acted to select her and all but, well, she pooh-poohed shaking voters' hands. On the record. To a reporter. That makes you an objectively bad candidate. Sorry, oddjob, but Dem primary voters really screwed up in selecting her.

[oddjob]

Okay, I grant you that. Yes, she campaigned really, really poorly. She definitely comes across as the kid in class who did all the homework, and knew all the answers, but hadn't a clue as to how to get along with everyone.

[ballgame]

I remain agnostic as to whether this bill truly represents a stride forward for progressive health care in this country. It certainly appears to be a stride forward for the health insurance industry (as I alluded to in my earlier comment and as Greenwald clearly demonstrates).

If I were to be totally uncouth, I'd say it appears to let the upper class profit by pitting the middle class against the poor. I'm glad a large segment of the poor will be able to get lower cost (to them) coverage, along with the tentative steps at reigning in 'coverage denial' through rescission or pre-existing conditions. I sure as hell don't like the political implications of having the middle class essentially bribe the rich to cover the poor … this does not seem like a politically propitious paradigm for our side.

As for what the bill actually will do, it might be enlightening to read about what the results would have been for the Sicko patients under this bill alongside Ezra's scenario (h/t masslib over at Ian's).

[Corvus9]

I fail to see how a bill which, starting on the first day of next year, forces the insurance industry to spend 85% of the money they take in from premiums on actual medical care, leaving only 15% for all administrative costs and profit, to the point that if they are not spending sufficiently on medical care, they must return any remaining money to their customers in the form of rebates, as a giveaway to the insurance industry. This bill cripples their ability to increase profits.

[ballgame]

I would assume it does that primarily through increased volume ($1 trillion more in revenue in eight years), Corvus9. (I suspect creative accounting which maximizes the percent of expenditures which will fall under the 'medical care' category will also be a factor.) The mandated increase in customer base might create a scenario where insurers' profit margins per dollar of revenue may decrease while their net profits accrued will go up.

And can I just point out how fundamentally ass-backwards this government-mandated adminstration/profit percentage is? One of the prime virtues of having a private enterprise-dominated industry is the tremendous incentive for a private company to hold down costs in order to maximize the owners' share of profits. Competition operates to hold down prices. The knock against government is it lacks these structural mechanisms.

Of course, the knock against private enterprise is that it can enrich the undeserving.

It seems to me a government-sanctioned monopoly — which is what the health care system will be for many Americans — will end up with worst of both: there won't be much of an incentive to hold down costs (except insofar as the relative amount of money going to admin vs. profit — I suspect we're not about to enter the era of excellence in customer service in the health insurance industry), and there won't be much of an incentive to hold down prices either.

So if I'm a health insurance company about to enter into negotiations with a network of hospitals and providers — a thoroughly neglected aspect of the health care debate AFAICT — why won't my attitude be, "Just charge us what you think is fair"? Indeed, isn't my incentive to maximize what hospitals charge me, enabling me to take my fixed cut out of a larger pie? (Not that the paragons of moral virtue who run health insurance companies would ever think like that.)

BTW, This American Life did some excellent programs about the provider side of the health care industry (here and here.)

Also, while Sir Charles made good points that health insurance companies may not be unusually exposed to commercial real estate problems, hospitals are involved in the potential leveraged buyout credit crunch … so a lot of the money we pay to health insurance companies will be ending up rescuing institutions whose financial assets were used to enrich LBO firms at the institutions' (and ultimately our) expense.

[Crissa]

I keep wondering why people say Coakley was 'foisted' when she ran in a Primary. If she really wasn't wanted at that point, wouldn't she have lost the Primary?

[Sir Charles]

Crissa,

I believe the use of a word like "foists" regarding Coakly, who has been a well respected public servant who overwhelmingly won her primary against pretty respectable competition is a classic case of buyer's remorse.

Having said that, she ran a complacent and clueless campaign, totally missing the shift in the zeitgeist that was ongoing. The shocking absence of polling being just one example of a sloppy and lazy cmapaign.

ballgame,

The "Sicko" site is just not terribly enlightening. I can't figure out why they think these servcies would be denied or why they were denied -- was the treatment experimental for instance. And I don't know what level of out of pocket obligations the author believes would have bankrupted her. These are capped under the bill, a huge improvement over the current state of affairs.

As for collusion between insurers and providers to allow prices to rise, I can't see it happening. What's in it for the insurer? If the insurers can't deliver discounts to group customers, you will see employers either opt to self-insure or simply drop out of the employer provided market. At that point you will have individuals getting their coverage on the exchanges where there will be significant competition. The provider that can deliver the best premiums will be the winner.

I've had a fair amount of delaing with the insurers as providers of group networks for health care discounts. Although their fees are too high for my tastes, they generally can deliver substantial discounts from hospitals and providers in return for providing a volume of patients. Trust me, the providers hate them.

I don't think there are that many hospitals (as a percentage) that are parts of LBOs. This law, however, will be a tremendous plus to those hospitals that are providing a large amount of uncompensated care.

I don't understand your claim that the bill pits the poor against the middle class. The bill provides subsidies for people who are solidly middle calass -- indeed, the focus of the legislation is really on the uninsured middle class. The poor are already covered under Medicaid.

[oddjob]

I keep wondering why people say Coakley was 'foisted' when she ran in a Primary. If she really wasn't wanted at that point, wouldn't she have lost the Primary?

Yes. She was in no way "foisted" upon the Mass. electorate.

[Corvus9]

Crissa, is this "foisted" complaint directed at me, or is it a general complaint spun off from the topic of this thread? Because I read back through posts, and even ran a search on this page, and at no point did I use the word foist. In fact, at one point I even said "Dem primary voters really screwed up in selecting her." So we are in agreement on that. Coakley was not foisted on anyone. She just sucked and Dem voters should have known better.

Sir Charles, thank you for responding to ballgame, because I don't really feel like wasting any time arguing with someone that incoherent.

[oddjob]

(Corvus, the other candidates weren't better.)

[Sir Charles]

Corvus,

It's what I do babe.

[big bad wolf]

oddjob, not better substantively or not better as candidates

[oddjob]

Substantively they were largely the same. There were damn few ways in which they were meaningfully different when it came to policy questions.

As candidates, my perception was that Coakley was the straightest arrow (too straight as it turned out). The second strongest candidate was Michael Capuano, but as I've said before, I wasn't willing to vote for yet another Massachusetts hack.

[big bad wolf]

i must say, as a massachusetts hack in exile, that i always am suspicious of the straight arrows

[Corvus9]

Considering Our Beloved Speaker is the daughter of a machine pol, I am starting to see great benefits to hackery.

[big bad wolf]

hack tends to be pejorative these days, but it need not be. hacks are never great, but they get the assigned job done. no one aspires to be a hack; many of us end up there. in my middle years, i think there are worse destinations.

[Corvus9]

Yep. Burris is a hack, but my mom (still living in Illinois) kind of likes him. His people are always really polite on the phone and he responds to constituent requests, and always votes the right way without making a stink. Not everyone can be a leader, not even elected officials.

[big bad wolf]

i think that is right. i also think that most people who get elected have a fair number of skills, though daring and innovation are not usually included. properly directed by gifted leaders, these folks are very useful, and far preferable to the prima donnas that the senate hothouse can give life to (hi, joe)

[Sir Charles]

I guess I have a certain affinity for hackery too. It's in the genes. We Massachusetts Irish are always a little suspicious of the goo goos -- they're so -- well -- protestant. Especially the goddamned Greeks -- see e.g. Dukakis and Tsongas.

I will post on this later, but who the fuck should be at the local bookstore tonight but Tim O'Brien celebrating the 20th anniversary of the publication of "The Things They Carried." I've got a signed copy kids!

Anyway, on the way out, who was coming in but Mark Shields. In my best Boston Irish way, I said Hihowareyou! And he said "how are you?" And my wife said "does he know you?" And I said of course not -- but he recognizes our kindred genetic bullshit.

[big bad wolf]

ah, those particular greeks, good folks though they were in almost all respects, became waspish in their lecturing, an aspirational failing of many right-thinking liberals.

signed copy. i'm envious. was he wearing a sox cap?

[Corvus9]

Shit. What a fortuitous circumstance be that!

It's things like that that convince me there must be gods at work on the universe. If nothing else, at least a couple of tricksters.

[oddjob]

But then you get a state house full of them and people get so sick of them they go & elect a Republican for senator...................

[Corvus9]

I think people get more sick of people like Lieberman and Nelson who think they are leaders than people like, I don't know, the guys you never hear about who vote with all the bills. No one is pissed at the guys you never hear about (I mean, I can't name all 59 democratic senators. Can you?), and those are the hacks.

Also, as a Chicagoland area native, Daley. At the low levels, Hackery can sometimes produce some pretty effective governance (at least if you live in a place where snow removal is a large issue).

[big bad wolf]

from deep in the heart, i'd say that a state house full of democratic hacks is infinitely (i'd mean that literally if i could grasp infinity; i can't so it will have to metaphorical) preferable to a state house full of republican ones. though with the latter you never have textbooks that might alert you to the problem.

[oddjob]

That may be so bbw, but we both know it's no accident that a plurality of Massachusetts voters deliberately choose to be a member of no political party.

[oddjob]

(And now that I think about it, both the vote for Brown & also the primary vote for Coakley were votes by the people of Massachusetts to reject the state's political mainstream.)

[Corvus9]

In what way was a vote for Coakley a vote to reject the state's political mainstream?

[big bad wolf]

withdrawing to "independent" status does not necessarily constitute a statement of principle. it may not be an accident, but that doesn't necessarily mean that it is a thought-out response, or a socially and politically efficacious one. and it may leave one more susceptible to scott brown like claims of independence through naysaying, a susceptibility that undermines the claim of independence.

[oddjob]

Coakley is a woman, and has only ever been a prosecutor. The mainstream is defined by the legislature, and it's a nearly total boys'-only treehouse. Capuano revels in that environment.

[oddjob]

It may not be a thought out response, but it's almost certainly a visceral one.

[Corvus9]

I figured that was what you were going for, but I felt it better to ask than to assume.

And I think this assumed response speaks to the usefulness of hacks, and of accepting hacks.

You have basically state that, in large part, Coakley got the nomination because she was a woman. But she was also an objectively terrible candidate (once again: pooh-poohed shaking voters hands). So, this means the pursuit of a non-hack lead to electoral defeat. I mean, do you think Capuano would have lost to Brown in the general?

There is probably also a broader point to be made about how identity politics can be beneficial in a broad sense, but can be harmful in individual situations, and thus also harmful to the larger public good.

[oddjob]

But she was also an objectively terrible candidate (once again: pooh-poohed shaking voters hands).

There was no way to realize that during the primary campaign. That happened after the fact.

[oddjob]

She had never behaved like that in her previous elections. She figured because this was a special election with so little time involved that focusing on stomping the pavement was a mistake. As it turned out she followed that strategy so resolutely it made her look like she couldn't be bothered. She'd stomped the pavement in other elections. If I had realized she was going to make that mistake I would have reconsidered my vote, but I had no way to know that ahead of time.

[oddjob]

You make it seem like it was a simple decision, but you are evaluating after the fact, and you don't live in this state.