Editore"s Note
Tilting at Windmills

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July 12, 2007
By: Kevin Drum

OVER STATED....Ezra Klein has a piece in the current issue of the Washington Monthly about (surprise!) universal healthcare. But this one's a little different. Massachusetts recently passed a universal healthcare law and California is seriously thinking about one, and this has provided liberals with the hope that maybe by starting at the state level they can eventually build a consensus for a full-blown national healthcare system. But Ezra suggests this is a fool's errand:

The idea of giving universal health care a little more time in the laboratories of democracy may sound tempting to certain cautious, bipartisanship-loving Beltway observers. But letting states continue to take the lead would be disastrous, for one very simple reason: providing health care for all citizens is one of those tasks, like national defense, that the states are simply unequipped to manage on their own. The history of state health reform initiatives (and there's quite a history) is a tale of false hopes and great disappointments....Universal care advocates must be realistic about that, and think hard about how to convert the energy in the states into a national solution before the current crop of novel experiments fail — because fail they almost certainly will.

The rest of the piece explains what happened when Washington, Hawaii, Tennessee, and Oregon tried implementing universal healthcare plans in the early 90s (they all fizzled) and suggests that this failure is inherent in anything done at the state level.

This strikes me as correct. The Massachusetts and California plans are politically helpful because they're the brainchildren of Republican governors, which makes it harder for Republicans to demonize the concept itself. The danger, though, is that failures do nothing but set back the cause, and the problems with state level plans are unfortunately pretty numerous. For starters, they're almost inevitably cut back during recessions when costs grow (because more people are out of work) and state finances are strapped (because tax receipts are lower) — and the cutbacks usually provoke a death spiral that's irreversible. State plans also attract the chronically ill in disproportionate numbers, a version of adverse selection that prompts death spirals every bit as effectively as recessions. Finally, most states don't have the clout to make the necessary regulations work. Insurers can simply pick up their ball and go elsewhere — and they do.

None of these problems affect a national program. The federal government can run deficits during recessions; there's no adverse selection because the entire country comprises the risk pool; and insurers have no choice but to play by the rules. There's nowhere else for them to run off to.

The state programs currently underway or under consideration might provide useful data points for a future federal program. But the odds are heavily stacked against genuine success. Caveat emptor.

Kevin Drum 1:32 AM Permalink | Trackbacks | Comments (58)

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Comments

We have a universal system for national health care. It's called Medicare. We need to do three simple things:

1) Put everyone on Medicare.
2) Negotiate with drug companies.
3) Control costs by controlling the salaries of physicians. That's where the money is in health care - physician salaries. We set salaries at 5 times the national median income.

I work in the field, but am not a physician.

Posted by: POed Lib on July 12, 2007 at 1:39 AM | PERMALINK

Yes, but that don't matter anyway. until you decouple insurance,legislators, and the AMA nothing is going to work anyway! Get your head out of your ass and have a look around. The improtant thing is to realize you are dealing with a criminal conspiricy of long standing. Once you get that you MAY be able to make some progress.

Posted by: jay boilswater on July 12, 2007 at 1:43 AM | PERMALINK

One of the things not discussed in Ezra's article is how state size impacts the viability of universal health coverage. Washington, Hawaii, Tennessee, and Oregon together have about half the population of California. This goes a long way towards generating the large risk pool you need to really have a viable statewide health plan, and minimizes how much the system is disturbed by adverse selection.

Massachusetts doesn't have this advantage, but with better than 10% of the nation's population, California could very effectively be a health care system unto itself.

Posted by: Imaginary on July 12, 2007 at 2:02 AM | PERMALINK

I'm not completely sure that bringing up universal healthcare, now, before the next election, is the optimal strategy. It would be a big change, and as it is now, democrats could sit back and win the next election with large margins, based purely on the fact that they're not republicans.

Making this an issue in the election might cost a few seats in Congress somewhere. And it might be especially bad if Hillary is the nominee.

OTOH, is keeping this low profile, then just pushing it through after the election, with less of a mandate the right thing either?

Posted by: luci on July 12, 2007 at 2:10 AM | PERMALINK

Sorry to disagree, Luci but I think Universal Health care is a big winning issue for the Democrats, if someone steps up to the plate. (I know Kucinich already has....)

People are wanting big change and this is an area that we all know personally is pretty sucky. No need to try and stealth the issue in. The bigger, the bolder, the better - get rid of private insurance companies, take the best from the world's other systems.

Posted by: Lee Stranahan on July 12, 2007 at 2:18 AM | PERMALINK

The Massachusetts and California plans are politically helpful because they're the brainchildren of Republican governors, which makes it harder for Republicans to demonize the concept itself.

Welcome back from outer space, brother Drum. A few things have changed while you were away.

Posted by: Quaker in a Basement on July 12, 2007 at 3:09 AM | PERMALINK

There is nothing in the Hawaii, Oregon and Tennessee failures which is not applicable on a Federal scale.

But Kevin just sticks his head in the sand.

Posted by: am on July 12, 2007 at 4:21 AM | PERMALINK

The problem with state plans is that they lock people to the states. If you want the insurance, you cannot move to another state.
Note that this is the same problem employer-based plans have. Why should the need for insurance be a mobility-inhibitor?

Posted by: focus on July 12, 2007 at 4:29 AM | PERMALINK

"...maybe by starting at the state level they can eventually build a consensus for a full-blown national healthcare system..."

don't I recall polls show around 70% of RVs support universal health care? the consensus is there already, except inside the beltway. of course there *are* a few little details to iron out.

oregon, according to ezra:

"In 2002, Governor John Kitzhaber decided to push Oregon closer to full coverage. However, the state was undergoing an economic downturn, and had no extra revenues to spare."

kitzhaber was dealing with a gop majority in the house, where revenue bills originate. it wasn't so much that the revenues couldn't have been found as the gop (taxes are evil is their mantra) refused to allow it. for quite a while there the gop would go (illegally as I recall) into closed caucus, hammer out all the details on bills with no democrats present, and then emerge when they had the votes among themselves to pass them. basically the democrats in the legislature might just as well have stayed home. because of kitzhaber's adroit use of the veto the gop were not able to gut everything in the state, but of course vetos don't pass bills. the gop controlled the house from 1990 to 2006 when they were resoundingly thumped, losing 4 seats and control of the agenda.

so the oregon gop did their part and the federal government helped out by reducing medicaid support to the states, a double whammy.

oregon also has a unique tax law perfectly designed to screw things up as the economy goes up and down. the "kicker" as it is called, requires the state to refund taxes collected in excess of 2% above PROJECTED revenue. that means if the economy has a surprising upturn the state has to give back the money, but of course there is no negative kicker so when something like the dotcom meltdown happens they have no rainy day fund and no automatic tax increase. maybe you know an economist who called state revenues a year ahead within 2% every year from 1998 to 2004? I doubt it. unfortunately there is absolutely nothing in oregon more sacred than the kicker, thank you irrational voters.

Posted by: supersaurus on July 12, 2007 at 7:12 AM | PERMALINK

This is not hard to understand. "Universal" does not equal "in some states."

Posted by: jayackroyd on July 12, 2007 at 7:21 AM | PERMALINK

The reason Canada has universal healthcare is that Saskatchewan, one of the poorest provinces, established a provincial single-payer plan that covered all residents in the province. The plan had to survive a doctors' strike (and did, as doctors from other provinces came in by busloads to help out), but after that its benefits became obvious even to the establishment parties at the federal level. It still took special circumstances (a vulnerable federal government needing a crowd-pleaser) to get to the national plan Canada now has, but we probably wouldn't have it yet if Saskatchewan had not taken the lead.

Posted by: inukjuak on July 12, 2007 at 7:46 AM | PERMALINK

supersaurus gets it. Any sort of program is going to suffer at the hands of a political party that wants to destroy it. That's why for universal health care to happen, just like in other countries, it has to become a political third rail.

And I think for that to happen a political party needs to run basically solely on the topic, so the voters can very clearly show that, and not have an election chalked up to the multitude of other things.

Posted by: Karmakin on July 12, 2007 at 7:49 AM | PERMALINK

Maybe I'm overly discouraged, but even with the current enthusiasm for the issue, I don't think the politicians will let us have Universal Single-Payer health care for everyone until something over 100 million people lose their health insurance. Which I think will happen.

Until then, it's just not going to matter to them.

Posted by: katiebird on July 12, 2007 at 8:03 AM | PERMALINK

As long as healthcare is a private industry, there will always be abuses to the system. Private firms need to worry about profit, which governments aren't even supposed to have. Private firms thus have incentives to screw people over in a way the federal government never wll.

Kamarkin, once universal healthcare is in place, and people have experienced it's benefits, it will become what you desire. That's why Republicans fought it so hard in the 90's. They know it would seriously damage their party.

Posted by: soullite on July 12, 2007 at 8:13 AM | PERMALINK

Huh? Massachusetts has universal coverage, now that Mitt's "brainchild" has been implemented?

WTF are you talking about?
Universal coverage? You keep using that word - I don't think it means what you think it means.

There's no universal coverage in this Commonwealth.
There IS, however, a legal requirement that all residents over age 18 have some form of health insurance coverage. The Commonwealth of Massachusetts isn't providing it - just penalizing you come tax-time if you haven't taken it upon yourself to go out and sign up for a health insurance plan of some sort.
Let's be very clear on that, 'cause it matters.

A number of health insurers have come up with a number of lower-cost, minimal coverage plans that individuals can enroll in, to avoid being penalized. I suspect that a few companies not previously in the business have also decided to test the waters.
This may be a step towards universal coverage, but there are a lot of people who will opt to take the loss of the state personal tax exemption over joining one of those plans. That pesky cost-benefit analysis thing - it's amazing how many of the rabble understand the concept and apply it in situations like this, even if they can't tell you that it's what they used to make the decision.

So, regardless of the legal requirement to get coverage, there will most certainly NOT be universal coverage in the Commonwealth of Massachusetts for the foreseeable future.

Don't get me wrong - in the absence of genuine single payer universal health insurance coverage, I think this is a good step. Mostly because some sizable percentage of the currently un-insured will now have some form of health insurance coverage. And various insurers are now competing to provide them which will hopefully lower consumer costs generally, AND take some of the burden of treating the previously uninsured off of the purses of our hospitals, which are hemorrhaging money whilst treating the un-insured.

But it's a "better than nothing" situation.
We'll see how it plays out, and I'm glad we in Massachusetts have taken some steps to somehow get coverage to the uninsured. They will be under-insured moving forward, for the most part, but like I said, it's better than nothing.

Posted by: kenga on July 12, 2007 at 8:40 AM | PERMALINK

focus: "The problem with state plans is that they lock people to the states. If you want the insurance, you cannot move to another state."

...yep. And vice versa, if an individual wants insurance, but doesn't live in a state that provides it, he or she has a powerful incentive to move to one that does. Plus states that don't provide insurance, at some point, have a powerful incentive to free-load. Let other states pick up the tab.

Minnesotans saw something happen with welfare that I think is illustrative. Originally, MN had generous welfare payments. Word got out nationally, however, and people began to move to MN to take advantage of that generosity. Costs went up. The state tried to establish a residency requirement, to restrict welfare payments to those who had lived in the state for at least a year. The Supreme court found that residency requirement unconstitutional. People could start collecting welfare benefits the day after crossing the border into MN. In response, welfare benefits began to be slashed.

Analogously, with health care, one predicts that costs will rise more rapidly than forecast because demand will increase as people without healthcare will move to states that provide it.

Some problems can only be addressed at the Federal level. Either everyone is in the game, or the game will be rigged to fail.

Posted by: PTate in FR on July 12, 2007 at 8:41 AM | PERMALINK

In the mid-90s, medicare reimbursement rules were changed to make penalties for fraud more draconian. Fraud was redefined to include up-charges (higher pay DRGs) as well as the more prosaic form, which can be seen in the Iraqi security forces, where the doc/hospital/rehab et al charged for people they didn't treat.
To think that the profit motive doesn't or won't exist in a single payor system is as naive as believing the profit system is the root cause of evil in healthcare. Any reimbursement system can be and, given human nature, will be gamed. There will still be jobs for auditors.

Posted by: TJM on July 12, 2007 at 8:49 AM | PERMALINK

The thing I don't get about the universal healthcare discussion is that it usually doesn't address the intelligence, power, and resolution of the opposition.

It's like we're saying that it would sure be cool to grab that flag from that post over there, but we're forgetting about the guys hiding inbetween with the fully automatic paintball guns.

Intelligent argument won't go too far if the other side own the talking heads. And Kevin's right. The state programs are just going to be the arguments that spread seeds of doubt in pre-election and/or pre-senate vote editorials. The fact that they come from Romney and Schwarzenegger makes me think that this is at least partially the point (probably at the political adviser level) in the first place.

Universal health care probably has to start with a public campaign to cull or retrain the HMO CEOs and other health care system employees who make out like bandits in the current system.

Posted by: B on July 12, 2007 at 8:52 AM | PERMALINK

If I was cynical I'd suspect that the Mass system is designed to fail so that Mitt can run against it. I mean, when you're running as a conservative as former governor of a famously liberal state, you need something.

I hereby mandate that every Mass. resident over the age of 18 has must have a good job.

Posted by: thersites on July 12, 2007 at 8:57 AM | PERMALINK

Health care is a state issue, and should be left at the state level so its failures can be observed by other states who are more sensible than CA and MA. That is the only sensible course of action.

Posted by: Al on July 12, 2007 at 8:57 AM | PERMALINK

Health care is a state issue, and should be left at the state level so its failures can be observed by other states who are more sensible than CA and MA. That is the only sensible course of action.

Posted by: Al on July 12, 2007 at 8:58 AM | PERMALINK

Kenga is right for the most part. But despite the "universal health care" name, the people who benefit by the plan the most are the insurance companies, who were big Romney supporters, not the people who are forced to buy a low cost plan that provides skimpy coverage for the poorest, but puts a lot of the money that the poor spend into the bank for the insurance companies.

Posted by: Big Ed on July 12, 2007 at 9:00 AM | PERMALINK

has must have

No more posting before morning coffee!

Posted by: thersites on July 12, 2007 at 9:00 AM | PERMALINK

The main problem with all the state plans is that they try to work within the confines of the current "competing private insurers" paradigm. As Paul Krugman has pointed out repeatedly, that system does not work because all the incentives lead to denying people coverage, adverse selection, vast private bureaucracies to support cost-shifting, etc.

Posted by: Dennis Doubleday on July 12, 2007 at 9:08 AM | PERMALINK

Kevin: "The rest of the piece explains what happened when Washington, Hawaii, Tennessee, and Oregon tried implementing universal healthcare plans in the early 90s (they all fizzled) ..."

Excuse me, but that's simply wrong.

Hawaii first pioneered the concept of employer-based universal health coverage back in the early 1970s, and thanks to exceptionally high overall employment rates was quite successful for nearly 30 years at maintaining 97%-plus coverage of island residents.

That number has since declined to a little above 90%, and is showing signs of stress because employers and employees alike are burdened by escalating insurance and medical costs, as are most everyone else across the nation. But it most certainly hasn't "fizzled", and is still far better than the other 49 states' respective health-care policies. In fact, Massachusetts modeled its much-ballyhooed plan on ours, and California is looking to do the same.

All that being said, Ezra Klein is right to urge a national solution to this rapidly approaching national crisis.

Posted by: Donald from Hawaii on July 12, 2007 at 9:11 AM | PERMALINK

...Selfish right-wingers will still complain about how illegal aliens fill our hospitals and our schools and ruin our neighborhoods and use it as excuses to not manage day-labour and medical care.

I wonder what they'd think if they ended up at a hospital without an insurance card, and were turned away as 'illegal aliens'.

But yeah, the plan in Oregon (the only one I have experience with) basically got pared down to not covering anything, like every other HMO plan. Not to mention the right-wingers whinging about how they shouldn't care for unpopular diagnosis.

Posted by: Crissa on July 12, 2007 at 9:11 AM | PERMALINK

..yep. And vice versa, if an individual wants insurance, but doesn't live in a state that provides it, he or she has a powerful incentive to move to one that does. Plus states that don't provide insurance, at some point, have a powerful incentive to free-load. Let other states pick up the tab.

All true. OTOH, at least one car maker has located in Canada because of the health insurance. Such advantage could work between states.

Posted by: snicker-snack on July 12, 2007 at 9:35 AM | PERMALINK

The problem with state plans is that they lock people to the states. If you want the insurance, you cannot move to another state.

Yeah, it would have been nice if, when my mom was ill with cancer, she had been able to come here for at least a good part of her treatment-- it's a much larger city with more services & a top research hospital, her kids who live here have white-collar jobs with more flexibility & leave time than our blue-collar relatives back home, and so on. But there was no way to get any coverage for her if she moved after the diagnosis, so we spent months driving 700 miles round trip every second or third weekend to take care of the problems that no one in her immediate environment seemed to notice.

This isn't only a problem with Medicaid, either; private insurers are completely different operations in different states, so even if you could theoretically transfer your BC/BS from one state to another, there are plenty of opportunities for them to drop significant portions of your coverage in the process.

Posted by: latts on July 12, 2007 at 9:45 AM | PERMALINK

Ah, Kevin.

Congratulations. You were almost right for a change.

It is correct that universal health care would not work at the state level, but you are wrong in that it will also not work at the federal level.

Just look at other countries, if you doubt that. In the rest of the world as a whole, health outcomes are far inferior to the US, while there is more regulation and socialization of health care. In some countries the avg lifespan is not even into the 50's. They take in more taxes and force people into substandard hospitals.

Even Europe, which is held up as a success story by the liberals, is an embarassment. They piggy back off our R&D spending, and get their drugs from us for cheap. You have to wait months, perhaps years, just for hip replacement surgery.

Posted by: egbert on July 12, 2007 at 9:59 AM | PERMALINK

You have to wait months, perhaps years, just for hip replacement surgery.

Indeed, the need for all that waiting... one of the reasons they have to live so long I guess.

(and hats off to one of my two favorite parodies)

Posted by: snicker-snack on July 12, 2007 at 10:13 AM | PERMALINK

There's no universal coverage in this Commonwealth. There IS, however, a legal requirement that all residents over age 18 have some form of health insurance coverage. The Commonwealth of Massachusetts isn't providing it - just penalizing you come tax-time if you haven't taken it upon yourself to go out and sign up for a health insurance plan of some sort.

This gets to the heart of my deep problem with some of the "universal" health care proposals being bandied about, including even, I gather, that of John Edwards.

Here's the problematic scenario. You are living paycheck to paycheck. You have no savings. Suddenly, you lose your job. You go on unemployment, at less than half your previous salary. But your mortgage still needs to be paid, and, say, college tuition for your kids is still due. On top of everything else, now you have to pay well over $1,000 a month for family medical insurance.

What do you do? Your expenses are already more than you can cover WITHOUT the additional burden of paying all your medical insurance out of pocket. Even if you get some kind of break under the "universal" plan because you're unemployed, the formulas are very unforgiving, as such government formulas always are, and you still can't come close to affording to pay for the mortgage AND tuition AND the medical insurance.

So what do you do? As much as you hate to, you drop the medical insurance and take your chances -- you can't lose the house or pull the kids out of college.

And what does the "universal" plan do for you? It PENALIZES you at tax time for not having medical insurance!

This consequence strikes me as insane. If people could explain how it might never come about, I'm all ears. But I've never heard an explanation that gets around this outcome.

Which is exactly why Medicare for All seems to me to be the ONLY program worth fighting for. Under Medicare for All, you are ALWAYS guaranteed access to health care because the money is paid into the system by all ONLY when they are employed, and as withholding on the paycheck. When you're unemployed, your burdens don't get any great, and you can receive medical care as needed.

Posted by: frankly0 on July 12, 2007 at 10:29 AM | PERMALINK

I lived in France for 13 years, and egbert doesn't know what he's talking about. I have never met an American critic of the French healthcare system that has actually lived in France. All the critics use anecdotal evidence to bolster their opinions. Here are some figures for him. American drug companies spend more on marketing than on R&D. The money for universal health care is already there, in the form of profits to insurance companies, accounting and collection agencies, and pharmaceutical companies.
Yes, these people need jobs, but their paychecks should not come out of my medical bills.

Posted by: gaston44 on July 12, 2007 at 10:37 AM | PERMALINK

eggie: In the rest of the world as a whole, health outcomes are far inferior to the US...In some countries the avg lifespan is not even into the 50's.

That's a dumb comparison, even for a mock conserva-troll. Smarter fake trolls, please.


Posted by: grape_crush on July 12, 2007 at 10:39 AM | PERMALINK

"State plans also attract the chronically ill in disproportionate numbers..."

I'm astonished to see PA concede that government largess attracts clients in need of its services that would not otherwise be present to take advantage. For my entire adult life I've heard liberals dispute, for example, that Wisconson's generous welfare benefits attract deadbeats from Chicago, or our asinine family reunification priorities in the immigration law attract disabled Mexicans looking for a nursing home, etc.

Posted by: minion on July 12, 2007 at 10:43 AM | PERMALINK

OT post:

To WM - Please drop the "Susie for President" ad. Her face is very annoying as is her denim jacket.

Thank you.

Posted by: forsythe on July 12, 2007 at 11:03 AM | PERMALINK

What if several states banded together, say the New England States or the Gulf Coast States?

.

Posted by: agave on July 12, 2007 at 11:04 AM | PERMALINK

"as is her denim jacket."

??

Posted by: agave on July 12, 2007 at 11:06 AM | PERMALINK

Huh? Massachusetts has universal coverage, now that Mitt's "brainchild" has been implemented?

WTF are you talking about?
Universal coverage? You keep using that word - I don't think it means what you think it means.

Exactly. If the police come by, hold a gun to my head, and make me buy a pony (preferably from a pony farm belonging to the cop's brother-in-law).... Woo hoo! I get a free pony!

Actually Mass. amazingly came up with a program worse than the status quo. I'm a freelancer, and getting away from the Mass. insurance debacle was a major reason why I moved out of there.

Posted by: Equal Opportunity Cynic on July 12, 2007 at 11:21 AM | PERMALINK

We have national defense care. We need national health care. The problem is that there are practically no leaders who can communicate the need in a way the electorace can understand and, much worse, there are few leaders who have not been co-opted into the trillion dollar/year revenue that the medical industry generates. I expect a mandatory requirement to purchase health insurance from a private provider, who will not provide much, will be the bipartisan solution.

Posted by: Brojo on July 12, 2007 at 11:36 AM | PERMALINK

E.O.Cynic,

How is that any different than a Dem politician telling you some rich guy somewhere is going to be taxed to pay for your pony...do you honestly think you're not going to pay for it in the end? But you do illustrate Kevin's point about state plans vs. federal plans.

Posted by: minion on July 12, 2007 at 11:41 AM | PERMALINK
The Massachusetts and California plans are politically helpful because they're the brainchildren of Republican governors, which makes it harder for Republicans to demonize the concept itself.

This is, at best, misleading in the case of California (there isn't just the Governor's plan, and AFAICT of the plans out there, the Governor's plan doesn't have a whole lot of support, so say that "the" California plan is the brainchild of a Republican governor is not all that accurate), and, Republicans, especially outside of the state in question, can easily demonize broad concepts even where a couple of Republican governors have put forward or implemented plans that are based on those concepts, and, anyone, Republican efforts to derail universal healthcare proposals have never focussed on attacking the broad concept of universal access, but instead attacking details (often false or distorted details) of the implementation, so even if there was a barrier to them criticizing the broad idea of universal access, it wouldn't have any substantial political effect.

Further, if Ezra is correct and state proposals are doomed to failure, any state plan implemented (whether recommended by a Republican or not) enables, when it ultimately fails, Republican attacks on the broad concept, rather than inhibiting it. Plenty of Democrats supported the Iraq war at the outset, but in its revealed abject failure and with the public response to that failure, its very easy for Democrats to oppose it now—likewise if state universal healthcare plans fail, even if some Republicans initially supported them.

Posted by: cmdicely on July 12, 2007 at 11:55 AM | PERMALINK

If Americans want genuine universal healthcare, which every other advanced industrial economy in the world provides for its' citizens, they have to stop hoping for insurers, HMOs, state based systems or employer funded schemes to provide any substantive part of the solution.

Insurers & HMOs are the quite useless profit-making middle men between consumers & providers of an absolutely essential service. Ethical employers & ambitious state governments might be more altruistic as gatekeepers of healthcare, but such systems unnecessarily, if unintentionally, deter benefited residents/employees from geographical & occupational mobility which are part of their fundamental rights as citizens. Equally, state & employer-based systems are enormously inefficient & expensive solutions to an essential service that is inherently national & intrinsically governmental in its' provision (at least according to every other advanced economy in the world.)

The near-absolute privatisation & speculative commodification (through insurance & HMOs), of American healthcare has produced the most expensive & by far worst overall system in the world in terms of outcomes, access, value & equity. The US already has among the best hospitals, specialists, technology in the world & yet tens of millions of its' citizens can't remotely afford it & even those who are exorbitantly insured run the very real risk of complete financial ruin/curtailment of care should any major illness or injury befall them or their family. Above & beyond anything else, that's just an incredibly cruel & unfair way for the wealthiest nation on earth to care for its' most vulnerable citizens at times of greatest need & hardship. It's disatrous enough for a person or their family member to suffer major injury or be diagnosed with a serious illness. To pile on the extra likelihood of bankruptcy/abbreviated treatment is to, quite literally, add insult to injury.

Americans already pay for & have long deserved a much, much better system of healthcare. Here in Australia our, admittedly imperfect, mix of subsidized pharmaceuticals, universal & private coverage ensures world class healthcare for all at a fraction of the price (per capita & % GDP) that people at every strata of the US economy pay. Cut out the obscenely profiteering middlemen & demand far better - not just for yourselves & your family, but for the sickest, neediest & most vulnerable members of your community.

Posted by: DanJoaquinOz on July 12, 2007 at 12:01 PM | PERMALINK

Republicans sure as hell can and DO demonize these plans, at least the California one: Haven't you heard? Schwartzenegger is no longer considered a "real" republican.

This is another reason that the Republican party chooses "pretty faces" well-known actors and such, like Fred Thompson, and Ronald Reagan. (and George W Bush - ) they can capitalize on the name-recognition, but ultimately, the chosen candidate is a sock-puppet, and, if they fail, or screw up, if they try to strike out on their own, or stray from the party line, they can be instantly branded as the lightweight they actually are. (we've already seen some of this on GW Bush from the right).

The problem with state-based plans, is that for example, people from states like Arizona will flood into California for the free health care (just as they do from Mexico). This causes a lot of other economic problems, beyond simply abusing welfare infrastructure. If it's not Universal, then it's not Universal.

And don't get me started on how inadequate California's plan is. It won't protect me from the abuses of the health insurance industry. In fact, it REQUIRES everyone to buy health insurance. How would you like to own a business where everyone was required by law to purchase your goods and services? You could pretty much charge whatever the fuck you want. The insurance industry already does that now. This program will not help the consumer, in this regard.

Posted by: osama_been_forgotten on July 12, 2007 at 12:04 PM | PERMALINK

Oh, and did I forget to mention?;
Michael Moore is FAT!

http://hosted.ap.org/dynamic/stories/A/AR_HUCKABEE_MOORE_AROL-?SITE=ARMOU&SECTION=STATE&TEMPLATE=DEFAULT

Posted by: osama_been_forgotten on July 12, 2007 at 12:06 PM | PERMALINK

the maas and cal healthcare initiatives are mislabelled as universal healthcare

is there a reason to accept that label and not challenge it

do you agree that these plans are they are consistent with the idea of universal healthcare


do you agree that they are worthy reprenstatives of the concept of "universal healthcare"

if politicians of a certain stripe, major league owners and the media started calling "proposed refineries in arizona a clean fuel producer" would you let the claim go unchallenged?

why not investigate the impetus behind thwaw mislabelled "universal healthcare initiatives?

i suspect you will find that they might more be more accurately labelled "health insurance company laboratory experiments"

republican governors using the "cache" of universal healthcare to promote insurance company "consumer health care initiatives"

using the power of the state to coerce uninusred
people to purchase the high-deductible, low coverage insurance policies that the insurance industry is promoting

"mandatory insurance"

like driving a car

you have to have insurance

it is "illegal" to to drive without insurance

implied threat

if you have a crisis and need help, it may be denied

expressing opinions is good

doing resarch informs and enriches opinion

Posted by: jamzo on July 12, 2007 at 12:09 PM | PERMALINK

Another factor working against the success of mandatory insurance programs in states like Massachusetts and California is the growing concentration of the insurance industry:

In most states, the AMA concludes, the idea of choice among competing insurance providers is a myth. The study showed that in each of 43 states, a small group of insurers exerts such market dominance as to merit the Justice Department "highly concentrated" market methodology for assessing potential anti-trust action. In 166 of 294 metropolitan areas surveyed, a single insurer controls over half the preferred provider network and HMO underwriting. In North Dakota, for example, Blue Shield owns 90% of the market. It's no wonder that Jim Rohack, an AMA trustee, concluded "This problem is widespread across the country, and it needs to be looked at."

That's especially the case if other states are serious about adopting the Massachusetts model. Without a choice of providers, mandatory insurance plans have no mechanism to help states rein in costs for their taxpayers-turned-health care subscribers. The insurers growing market power means they can dictate both coverage terms and prices. 400 mergers in the past decade have helped fuel out-of-control health care costs, which rose at a double-digit clip from 2001 to 2004, three to four times the overall rate of inflation. The implications for middle class resident on their own in the health care marketplace are worrisome, to put it mildly.

For more background, see:
"Health Care Monopolies and the Massachusetts Model."

Posted by: Angry on July 12, 2007 at 12:39 PM | PERMALINK

The only good health care plan in California is the one re-introduced by my state senator, Sheila Kuehl. It's being re-introduced because the Republican governor, the fake health care and the fake global warming doofus, vetoed it before.

Posted by: Mike on July 12, 2007 at 2:21 PM | PERMALINK

Kevin,

Maybe I am missing something, but as far as I can tell the only difference between a federal health plan and a state health plan is that the feds can finance theirs with deficit spending.

Am I missing something? If this is the only material difference, how does that say anything at all about whether Government-Owned-and-Operated health care can deliver better or cheaper healthcare than either a private system or a mixed public and private system?

Posted by: DBL on July 12, 2007 at 4:33 PM | PERMALINK

POed liberal - I like your suggestion to put all doctors on government salaries and pay them like postal workers (or, to be fair, maybe a little bit more). That way we can end up just like Great Britain, which has to import jihadists to serve as docs in the NHS because English boys and girls have better things to do with their time.

Posted by: DBL on July 12, 2007 at 4:36 PM | PERMALINK
Maybe I am missing something, but as far as I can tell the only difference between a federal health plan and a state health plan is that the feds can finance theirs with deficit spending.

You are apparently missing differences of scale, and the fact that feds, unlike the states, can legally control admissions and therefore eligibility for a "universal" program.

You are also missing that that some of the things that need to be regulated to implement a universal system are elements of interstate commerce where the state runs into limits by federal regulation or Commerce Clause reservation of power to the federal government, limits that don't impede a federal program.

You are probably missing more differences, as well.

Posted by: cmdicely on July 12, 2007 at 5:18 PM | PERMALINK

Exlpain why the same logic does not apply to all of North America. After all, if Massachusetts cannot do it alone, then is that not proof of the long denial of progressives that 58% of Mexican women travel El Norte to give birth.

Posted by: Mtt on July 12, 2007 at 7:03 PM | PERMALINK

That way we can end up just like Great Britain, which has to import jihadists to serve as docs in the NHS because English boys and girls have better things to do with their time.

Fears of a total wack-job. Seriously, with thoughts like that I'd suggest a visit to the psychiatrist. You're not a healthy man.

Posted by: snicker-snack on July 12, 2007 at 8:56 PM | PERMALINK

Disclosure: I am named after Tommy Douglas, and I was born 3 days before the Saskatchewan doctor's strike in Lansing, MI.
From Wikipedia:
Douglas's number one concern was the creation of Medicare. In the summer of 1962, Saskatchewan became the centre of a hard-fought struggle between the provincial government, the North American medical establishment, and the province's physicians, who brought things to a halt with a doctors' strike. The doctors believed their best interests were not being met and feared a significant loss of income as well as government interference in medical care decisions even though Douglas agreed that his government would pay the going rate for service that doctors charged. The medical establishment claimed that Douglas would import foreign doctors to make his plan work and used racist images to try to scare the public.[citation needed] Their defenders have also argued that private or government medical insurance plans covered 60 to 63 per cent of the Saskatchewan population before Medicare legislation was introduced.[citation needed]

An often forgotten political fact is that though Douglas is widely hailed as the father of Medicare, he had retired from his position as Saskatchewan's premier, turned over this job in 1961 to Woodrow Lloyd and took the leadership of the federal New Democratic Party.

The Saskatchewan program was finally launched by his successor, Woodrow Lloyd, in 1962. The success of the province's public health care program was not lost on the federal government. Another Saskatchewan politician, newly elected Prime Minister John Diefenbaker, decreed in 1958 that any province seeking to introduce a hospital plan would receive 50 cents on the dollar from the federal government. In 1962, Diefenbaker appointed Justice Emmett Hall�also of Saskatchewan, a noted jurist and Supreme Court Justice�to Chair a Royal Commission on the national health system. In 1964, Justice Hall recommended the nationwide adoption of Saskatchewan's model of public health insurance. In 1966, the Liberal minority government of Lester B. Pearson created such a program, with the federal government paying 50% of the costs and the provinces the other half.

Posted by: doug r on July 13, 2007 at 10:11 AM | PERMALINK

Snicker - Snack,

My understanding is that about 40% of the new docs in GB are imported, most of them from third world nations. Why is it that GB, a modern, industrial nation with a pretty good educational system, can't train enough docs to fill the needs of the NHS? What's your explanation? Mine is that the salaries and working conditions for NHS doctors are insufficient to attract sufficient numbers of the best and brightest English boys and girls. Do you have some other explanation?

Posted by: DBL on July 13, 2007 at 11:14 AM | PERMALINK

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