Tuesday, February 14, 2017

Some Good News from Washington

First, Michael Flynn is out as National Security Adviser. I always thought he was the most dangerous member of Trump's administration, combining a combative militarism with a weak relationship to the facts. His two hand-picked deputies are also said to be on the way out. Of course his replacement may turn out to be bad, too, but it will be hard to find anyone as dangerous as Flynn.

That Flynn fell because he lied about unauthorized back-channel talks with the Putin regime is also gratifying; it's nice to know that there are limits to how much schmoozing with dictators Trump will tolerate.

Second, Republicans in Congress are backpedaling hard from Obamacare repeal. Some are openly talking about "repair" instead of "repeal," and many others are insisting that a new plan be in place before the Affordable Care Act is undone. Let's hope they step up here and do some serious work on a new plan. The ACA is far from a perfect law and there are other ways to do what it does, some of which might work better. People who know Paul Ryan say he is a serious policy guy, and now is his chance to prove it. Honestly right now it looks like nothing will happen at all this year.

13 comments:

aunteater said...

ACA... Lord, have mercy. I had a glimmer of hope when it looked like they were going to repeal it. Why do so bloody many people think that this monster is a good idea? We are trying to raise a family of four on an income of almost $15k (I just did our taxes, so I know!). AND WE DON'T EFFING QUALIFY FOR MEDICAID BECAUSE WE HAVE TOO MUCH MONEY. We have lived with less, mooched off family resources, done whatever we could to minimize expenses-- we buy in bulk, we never, ever eat out, I cook every single meal from scratch, we buy all our bread from the overbake sale rack at Walmart, I use the clothesline like it's part of my religion. All our clothes come from thrift/consignment stores (except our underwear, which frankly is looking a little threadbare, but hey nobody else sees it). The soles of my husband's shoes are wearing out, and I'm trying to figure out if we can re-sole them instead of buying new ones, since the uppers still look ok with some polish. We have done all this so that we can stay within our income (we just barely scrape in under it) and then bank our EIC tax credit so that we have a cushion in savings for emergencies, and maybe, someday, enough to install a used trailer on an empty lot owned by my parents-- so that we can grow some of our own food (not possible in our current living situation). So that's our life. Not quite $15k a year, barely staying in our income, and you know what the ACA "subsidized" plan system offers us? Best we can get there is insurance that doesn't cover ANYTHING until we've met a deductible of $5k, and for that privilege we can pay $600 a month. SIX HUNDRED A MONTH. Do you know what that means on an income of not-quite $15k?? It means "insurance" would cost us half our income. HALF OUR INCOME. And not even kick in until we've used up all our savings paying the deductible. Why on earth would anyone do that? I mean, a major medical expense would ruin us financially, but so would getting insurance, so... no help there. And did I mention we don't qualify for Medicaid? Because if you're trying to have an emergency fund and scrape together enough cash for a used trailer, YOU'RE NOT POOR ENOUGH. Too much savings. But if, on the same income, we blew all our savings on a nicer car (our current model has latches that don't work, some scrapes and dings, and 270,000+ miles on it, but by golly it's paid for!), and gave up on ever trying to claw our way out of this hole, we could qualify for Medicaid! Woohoo! Well, sort of. I'm told, by people who've run that gauntlet, that there's a wait list, and that you may never get to the top of it if you're not the right color. And no, we're not the right color.

The ACA doesn't need fixing. The ACA needs to be scrapped, along with the entire insurance-industrial complex. If there is any legislation that would help with the current medical-cost crisis, it's this: Pass a law that forbids employers from offering health insurance. Divorce it from employment. Force comfortable middle-class people to shop around and foot the whole bill themselves. You'd see the price of insurance, medication, and every medical procedure, plummet. Plus a bonus reduction in the deployment of unnecessary drugs and procedures, and suddenly, hourly employers would be able to offer full-time jobs again!

G. Verloren said...

Oh the irony.

Most of the problems people have with the Affordable Care Act exist solely because of GOP obstructionism, and are the direct results of changes and revisions made to the law by the Republicans before they would allow it to be enacted. It was originally going to be a much better system, but partisan politics forced Democrats to make ugly compromise after ugly compromise and water the act down enough that conservatives would agree to sign off on it.

Why would the Republicans go out of their way to purposefully make the act worse? Leverage and political blackmail. "We are going to do everything we possibly can to block and sabotage this bill at every step of the process - but we just might change our minds if you let us have our way with certain other bills..."

And now after going to all that effort to cripple the ACA and introduce all of those problems to it, they turn around and lie through their teeth to shift the blame, saying "See how many problems this law written by the Democrats has? None of those would exist if we Republicans had been given a say on the matter!"

And people believe them. That's the incredible thing.

G. Verloren said...

But here's the real kicker in regards to specifically medical insurance.

See, car insurance has a lot of flexibility involved. There's a lot you can do to lower your premiums. If you drive more safely, you pay less. If you drive a less expensive car, you pay less. And if you really want to, you can choose to not drive a car at all, and then you pay nothing.

But medical insurance? Doesn't work that way. You can get rid of a car that is expensive to insure, but you can't get rid of your body. You're stuck with what you have. If you are born with a congenital heart defect, tough shit - you're now permanently more expensive to insure, because that's how the economics play out.

And that's not fucking fair. Driving a car is a luxury. But living your life is a basic human right. What gives anyone the right to say "If you want to receive medical care, you have to pay twice as much money as the other guy, because you drew the short stray in life"? You already have to deal with your own naturally poor health to begin with!

And even for self-inflicted harm to your health, what right does anyone have to judge? Things like smoking and excessive drinking are tragic, but they overwhelmingly afflict the poor and vulnerable, who are driven to drink and to smoke in the first place by the stresses of being poor. Rich people who have plenty of free time to exercise or relax, who can afford good food and comfortable lifestyles, who enjoy all the little privileges of wealth and status aren't the sort of people who feel compelled to unwind every day after work with a six pack of beer and a dozen cigarettes. And yet they cost less to insure!

The only fair solution is to make medical care a basic right for everyone. When you get sick, you should just go to a doctor and get treated, and not have to pay anything, and the cost should be made up in taxes.

Because this is a basic societal good we're talking about here. This is a fundamental part of a fair and just society, and the fact that we handle medicine in this country this way is monstrously unjust.

We don't force people to "shop around" for police protection, and then charge poor people higher rates because they're statistically more likely than the rich to be victimized by crime. Instead we pay taxes to the government, and those taxes pay for the protection we receive from the police, and everyone receives equal protection regardless of how much of a risk they would otherwise be to insure against crime.

Access to medicine must be made to work the same way. Human dignity depends on it.

aunteater said...

Verloren: There is no right to someone else's labor, which is what you are proposing when you say "the only fair solution is to make medical care a basic right for everyone".

If I have a right to medical care at the expense of others, what else do I have a right to make you pay for? Is there any natural limit? Who decides? Do I have to trust that you know what I need better than I know? I think I need ten acres of fertile land with a well, septic, and good fences. Human dignity depends on it. Are you going to buy it for me? Social goods are not the same as rights. Stop polluting the language by pretending they are.

What you may have missed in that first comment is that while we are cash-poor and things are tight, we don't actually WANT to be on Medicaid (and I don't see any meaningful distinction between socialized care and Medicaid). We want to be able to work 40 or more hours a week so that we can earn enough to live on and save a little. It would certainly give our human dignity a boost. But we can't do that because someone decided those greedy employers must be made to provide benefits. Which means nobody can get a full time job anymore, down here in the hourly employment world. Your progressive compassion is killing us.

"Oh, but that was a Republican conspiracy!" you shout, "employers should have been made to provide benefits to their part-time employees, too!". And then we wouldn't have been able to get part-time work, either. Because then it is cheaper for an employer of any large-ish size to suddenly discover that even their most menial jobs require a graduate degree and special technical licensing, and oh, dear! Nobody qualified is applying! Worker shortage! So now they can justifiably import their entire workforce from Bangalore, where college degrees are cheaper. Shall we then solve this problem by denying work visas or severely limiting immigration? Isn't that racist?

Why do so many people think that the only possible choice is between our bloated, broken, inscrutible, byzantine shambles of a medical system, and socialized medicine?

My son needed an ultrasound last year:
1) In the current system, we were out of pocket for the expense, but we couldn't find out how much it cost until we were actually AT the appointment. So we had to go to the appointment and decide right there at the front desk if we could afford this or not. Because insurance=opacity, and screws everything up. And then they still sent us a bill for it in the mail, because cash payment is so rare it breaks their computer system. It cost us about $180, because of common non-competition agreements that the county makes with the local hospital to limit the number and type of independent non-hospital medical facilities, and because they have to pay so much extra staff to navigate the billing. Could be worse. I've lived places where the agreements were tighter, you'd HAVE to go to the hospital for it, and it would cost hundreds of dollars.

2)In a socialized system, we'd still be on a waiting list for the procedure, if it were authorized at all.

3)In the South American city where we used to live, we'd have gone to the ultrasound place, checked the price on the signboard outside the office, paid the $30 and had it done without all the weird drama, by someone who was friendly and good at her job.

aunteater said...

Incidentally, the stresses of being poor have not yet driven us to drink, smoke, or do drugs. We didn't even have any abortions or out-of-wedlock babies. Maybe we should give it a few more years?

David said...

@aunteater

I can't claim to have a solution to health care, and I distrust those who claim that any one solution is obvious or clear. But your claim that "there is no right to someone else's labor" when that labor is "at the expense of others" (or at the collective expense, as would be the case with socialized medicine) is clearly false as far as present American society is concerned. As presently constituted, American citizens clearly have the legal right to expect the labor at public expense of judges, police, firefighters, elected officials, civil servants, the military, and many more. The question with socialized medicine is simply the question of what the parameters of a right to another's labor at public expense are going to be. Are we going to treat doctors like police officers in this sense? That may or may not be a good idea. But our society has already accepted the idea of a right to another's labor at public expense in principle. Of course, you also have the right to question that, and might do so, especially if you self-identify as a libertarian or an anarchist. But if so, 1) the issues we would be debating would be much larger and more profound even than socialized medicine and 2) you would probably have to accept that yours would be a small minority position that is most unlikely to be adopted anytime soon--less likely even than socialized medicine--and discussion of it would be mostly of philosophical rather than practical or political interest.

aunteater said...

@David. No. None of those things are rights. Those are all public goods. I am not arguing that those things are bad, or should not be. I am pleading for linguistic clarity in talking about them: calling them rights is inaccurate and misleading. I think Medicaid is a good thing, and should continue-- and my family has needed and used it in the past. It's a public good, not a right. My local fire department is fantastic, but if my town goes bust, the fire department goes away. My rights don't.

Rights have to do with what the government isn't allowed to do to me, not what the government is required to provide for me. I have the right to keep and bear arms. That doesn't mean the government has to buy me a rifle.

But when you describe access to medical care (or police, or firefighters, or judges, or military, etc.) as a "right", that's not what you mean. If access to medical care were a right it would simply mean congress couldn't make laws against you getting medical care. Which might be nice in terms of knocking down rent-seeking medical professional associations, allowing access to medical marijuana and alternative treatments, telling drug companies where to shove it, and that sort of thing. I might support a right to access medical services if that's what was commonly meant by it. But that's irrelevant when it comes to actually providing health care to people. Then you're talking about a public good, or public service. Be precise. Be honest. Use correct words.

No, I don't identify as libertarian or anarchist. I've just lived, and used medical services, outside the US, and I know that it doesn't have to be this awful. Yes, I'm one of those dreadful, old-fashioned pedants who still cares about the difference between "compliment" and "complement", and "effect" and "affect." Don't hate me.

John said...

As a general note about this discussion: I have noticed that it seems to be very difficult to get "welfare" in America. I have had two friends who were desperately poor at a point in their lives, one because he was recovering from brain surgery and the other because she ran out on her abusive husband. Both found that even though they could not afford to feed their children, they did not qualify for help from the government. The experience of my friend who left her husband turned her best friend into something of a Republican; she said, "I always supported that stuff partly because I thought it would be there for me if I needed it, and to see that [our friend] couldn't get any help made me so mad I'm not sure I can support any of it."

Plus there is all the paperwork; have you seen the bureaucracy involved in getting yourself declared disabled?

Which makes me wonder about how this all works. If it is true as claimed here that you can have a family on a poverty-level income and not qualify for Medicaid, how does anyone qualify? I thought the law extended Medicaid to people up to 1 1/2 times the poverty level.

I have a pretty good theoretical understanding of how things like food stamps and the ACA are supposed to work, but I guess I don't understand very well how they actually work in practice.

On the other point, I agree with David that in practice we think we already have the right to use other people's labor in lots of ways. There is not rigorous way to distinguish between "public goods" and private benefits. Extreme libertarians are right about that. I think all talk of "rights" is a distraction. There is only the political question of how much we want to tax ourselves, and how we want to spend the money.

David said...

@aunteater

I take your point, and given the definitions you use, what you're saying is inarguable. However, most words are in fact polysemous, even in legal practice. Thus, while it's true that if my town goes bust, the fire dept will go away, in practice as a resident of this town I have a right to the fire dept's services as long as that dept exists, and if they refused to help me, I would have a case that they had violated my rights as a citizen. That is, right does not only mean an inalienable right, but a kind a claim, including on other people. In the same vein, we speak of a person's right to an inheritance, their property rights, their rights under a contract, etc.

In any case, the way you seemed to be speaking in your original post about "right" seemed to have less to do with semantic carefulness and more with rejecting socialized medicine in principle. You certainly did NOT seem to be saying that your only objection to socialized medicine would be the idea of having a "right" to medical care, and that you'd be just fine if medical care were deemed a public service.

aunteater said...

John, I'm not sure about your friend, but it sounds like a case where she might not qualify until she's officially divorced-- until then, her husband's income may count against her. There are people who get legally divorced (but stay together, on the downlow) because it's the only way they can qualify for state benefits they desperately need-- it makes them separate households, on paper. In our case, we qualify on income but there's also an asset test, and we have too much money saved up to qualify. Those numbers vary by what state you live in. If we were less honest, the smart thing to do would be to hide our cash assets and then apply for assistance. For better or worse, we were raised better than that. We don't cheat.

aunteater said...

David, sorry for the confusion. I'm against both universal socialized medicine AND fuzzy language.

I gave birth to my first child, and had all the associated prenatal care, in South America, in a far less regulated and subsidized medical environment (note I am not claiming it was some kind of unregulated anarchist paradise). The system was far from perfect (the poor have hardly any access at all to medical care, for monetary and also some really hairy geographical reasons. And the C-section rate is over 90% in a lot of the private clinicas.). But if you know what you want, you can get it for a decent price. It was possible there to be an informed consumer without being stonewalled by the medical establishment.

We were only going to be there for 3 months, originally, but faced with the prospect of going back to the US uninsured, with a "pre-existing" pregnancy, we ran the numbers and found it was substantially cheaper to renew our visas, rent a tiny apartment, stay another six months in the country, and have the baby there. All prenatal and childbirth expenses together cost us $1,500 plus a few lab tests (not enough to push it over $2k by a long shot). If I'd needed an emergency C-section, that was also well within our budget. It would have been another $1,500. I loved my doctora, and we had half-hour-minimum prenatal visits where she talked to me and answered my questions and generally treated me like a human being. The maternity hospital (do they even have those here?) was pleasant. The lab techs who drew my blood were very, very good. They never had to stick me twice, or wiggle the needle around in my arm, even the one time I was severely dehydrated (in the US, they tell me I have difficult veins and act like it's my fault they suck at their jobs).

In the states, the most basic discout-rate rural hospital we had access to would have cost more than $6k to have a baby, assuming no complications. Prenatal care and lab tests would have been a bundle extra. A childbirth emergency would have left us in staggering medical debt-- c-sections can run over $20K easily. That $1500 for a C-section back in the hogar maternidad would have included a week of inpatient recovery.

I realize that some of that difference is exchange-rate voodoo, but not all of it. And I see no reason we can't have some of that competitive, cash-based, less-regulated medical service here. At the very least, dealing with doctors would be less stressful without the crazy bureacracy. And it would likely be friendlier, cheaper, and better.

aunteater said...

--I'd like to add that my interactions with the medical profession in the states have ranged from brusque and dismissive down through rude and unhelpful all the way to abusive and harmful. They are universally unpleasant. My interactions with doctors, hospital staff, lab techs, and medical clerks outside of the country were always pleasant and reassuring, even though my Spanish is terrible, and I was always stumbling through like an idiot. I cannot emphasize enough how stark that difference is. Why can't we have that here?

leif said...

we *should* have that here. i agree. four doctors in my extended family have informed me that part of the blame for this falls on suits and the ridiculous cost of malpractice insurance. that cost is passed on to consumers. they aren't happy about it, but if they wish to continue helping people (and they *want* to help people, otherwise who would willingly do what they do), they play the game.