March 28, 2017

"The Democrats will make a deal with me on healthcare as soon as ObamaCare folds — not long. Do not worry, we are in very good shape!"

Tweets Trump.

Depends on the meaning of "very good shape." About to collapse... great.

That tweet was right after "The Republican House Freedom Caucus was able to snatch defeat from the jaws of victory. After so many bad years they were ready for a win!"

Sometimes losing is winning.

Make me think of the old Bob Dylan quote: "She knows there’s no success like failure/And that failure’s no success at all."

183 comments:

Tom said...

The House Freedom Caucus did the right thing.

The GOP needed to look at the first 2 years of Trumps presidency as revolutionary and time sensitive. And, since Congress rarely does anything in an election year, it's really only one year of opportunity. They're wasting time when these bills should have been worked out long ago.

Unknown said...

Yep, and sometimes LOSING is well, LOSING.

"Nobody knows the SYSTEM BETTER than ME. That's why ONLY I CAN FIX IT"
Donald Trump, 2016

Trump #SAD #INCOMPETENT #LOSER

Chuck said...

Trump is going to make a deal with Democrats?

What about a deal with Republicans?

When, and how, is Trump going to learn enough about healthcare reform to make any deals, with anybody?

I'm actually curious to see what it looks like, to have Trump dealing with Democrats. They will want something; Trump will want something. (I don't expect that Trump actually has any principles; what he might want is just a deal. Any deal. But what will the Democrats want? What will Trump need to give to them?

Kevin said...

"Gloria Clemente: [to Billy] Sometimes when you win, you really lose, and sometimes when you lose, you really win, and sometimes when you win or lose, you actually tie, and sometimes when you tie, you actually win or lose. Winning or losing is all one organic mechanism, from which one extracts what one needs."

Mike Sylwester said...

Ann, less than a year from now you will be embarrassed that you did not write one post critical of Bob Dylan while he was being awarded the Nobel Prize in 2016.

robother said...

"She's an artist, she don't look back."

Amadeus 48 said...

I don't think Trump is on the right track here. He should shut up about this. Tweeting this stuff out makes it less likely that there will be a deal with either the Dems (except on their terms) or the Freedom Caucus if and when Obamacare collapses. Of course, Donald (maybe we should do single payer) Trump could be OK with a deal on Dem terms.

Obamacare killed the Democrats and now it is coming for the Republicans.

Chuck said...

Tom said...
The House Freedom Caucus did the right thing.

The GOP needed to look at the first 2 years of Trumps presidency as revolutionary and time sensitive. And, since Congress rarely does anything in an election year, it's really only one year of opportunity. They're wasting time when these bills should have been worked out long ago.


Okay; so what you want is a bill, and revolutionary health care reform, that would please the Freedom Caucus. It would slash federal spending, shut down the ACA exchanges, and leave lots of people without insurance coverage and without means to purchase coverage in the near term. Okay; I don't wish to argue the merits or even the 2018 politics of something like that.

What I want to know is how you get something like that into law, through the Senate.

(The answer of course is that you don't; and what you do is put it into the Senate and let the Dems filibuster it, and then blame them. That would have been smart politics. Charles Krauthammer recommended that course; and he didn't understand any other option, other than that Paul Ryan honestly and earnestly wanted to get a bill that could pass on reconciliation in the Senate. So shame on Ryan for acting as an honest broker and as someone who actually wanted to get something accomplished.)

AprilApple said...

uh - no they won't.

Amadeus 48 said...

I'm with Chuck on this one.

Inga said...

The NHS is true single payer socialized healthcare. Doctors, hospitals, caregivers are all government employees. Why not continue to keep our system but expand Medicare, making it a Public Option? The infrastructure is already in place. People pay premiums for Medicare, it's basically insurance. People still buy private insurance to supplement Medicare as they will only cover 80%. Why not allow everyone to buy into Medicare? The pool will be massive, driving down healthcare costs. Healthcare providers remain private or public entities. Base premiums on income perhaps. We can do better than Obamacare and don't need to go down the road of true socialized medicine. Who knows, maybe Trump would be in favor of such healthcare, as he hinted at during the campaign.

Ann Althouse said...

LOL Mike Sylvester & robother

Nonapod said...

I kind of doubt that the Democrats will ever make a deal with Trump. It's just not in their interest.

Ultimately the Dems want one thing: Single Payer. As a new entitlement that sets an expectation before falling completely apart, Obamacare has always been the Camel's nose for full government healthcare. Everyone knows this. Right now it's like watching a car crash in slow motion while everyone's debating about what color of the car should be repainted.

Inga said...

I posted my above comment in the obese boy builder thread in which the NHS comes up. There is already a Medicare for All Bill that's been around for several years now. If Trump is willing to listen to people who can explain it to him, it would be a step in the right direction.

MikeR said...

"So shame on Ryan for acting as an honest broker and as someone who actually wanted to get something accomplished." Uh, no. "Actually getting something accomplished" is only worthwhile if the "something" is better than the alternative. The first alternative - try to get what you want and get it blocked - is much better. ACA is falling to pieces all on its own; there may be no more exchanges next year, or the premium increases may be astounding (they are already). Get the Democrats to agree on completely removing the regulations in return for keeping protection for those who can't afford health care.
Ryan's plan would have made the problems permanent.

bagoh20 said...

"Okay; so what you want is a bill, and revolutionary health care reform, that would please the Freedom Caucus. It would slash federal spending, shut down the ACA exchanges, and leave lots of people without insurance coverage and without means to purchase coverage in the near term."

Yes, becuase just as before the ACA, having coverage is not the same as having access. Everybody gets treatment they need. There are lots of ways to improve the old system. Nearly all of them would cost less, and work better than the ACA did. You design it with maximum freedom and maximum transparency of pricing and competition.

You at least put such a thing up for vote, so that we know who to blame or credit if it works, fails, or never passes. What was offered would have changed little, fixed nothing, and left everyone still arguing over who should be blamed for the inevitable failure of it if passed. What was offered was cowardice, lack of faith in Americans and the free market. It was designed to protect politicians from criticism by doing just enough to claim credit for doing something, while not doing anything that would shift the blame from the ACA and the Democrats. It wasn't about health care. It was about politics.

Amadeus 48 said...

Inga--the economics of Medicare are really bad. Senior, retired Americans are heavily subsidized by younger, working Americans. If Medicare becomes the health care payment system for all Americans, Medicare premiums will have to go to the sky. Medical care professionals' incomes will have to shrink (doctors, nurses and other care-givers--compare pay in the NHS). We have the system in place that we have. It is going to be impossible to squeeze it into an NHS model.

WisRich said...

Looks like some Republican Senators agree:


Tweet from Erica Werner:
Cornyn says flatly that health care will not be attempted again via reconciliation. "It's
clear it needs to be done on a bipartisan basis."

wendybar said...

The bill sucked. It didn't cut costs. Do you REALLY trust them to pass 2 other parts??? Seriously?? Those were the parts with "all the good stuff" Why not pass the "good stuff" first?? The Freedom Caucus did the right thing, because Obamacare still stands, and is going to fall. If they passed this bill, they owned it...and we would be saying President Warren in 2018. Take the time to get the right bill...why rush it in 60days???

Hagar said...

I kind of doubt that the Democrats will ever make a deal with Trump. It's just not in their interest.

Quite so. But the insurace companies are losing real money by the billions and billions and they may have some words with the Democrats as to what is in their interest.

bagoh20 said...

So we still have the ACA, it's still gonna fail, and it was passed with zero Republican support using outright admitted lies to get it passed despite numerous warnings about exactly what is now failing. Yet, the Dems will try to blame the Republicans for it's failure. That will be much harder without this bill passing. Sometimes it takes being pushed into a corner with no escape to get people to see their options clearly.

Inga said...

OK, live and learn. The U.K. isn't technocally sngle payer. The French system uses a Public Option with supplemental private insurance, a little bit like Medicare for All it appears.

"Single-payer healthcare is a system in which the state, rather than private insurers, pays for healthcare costs.[1] Single-payer systems may contract for healthcare services from private organizations (as is the case in Canada) or may own and employ healthcare resources and personnel (as is the case in the United Kingdom).

The term "single-payer" thus describes the funding mechanism, referring to healthcare financed by a single public body from a single fund, not the type of delivery or for whom physicians work. The British system is technically not single-payer, as it consists of a number of financially and legally autonomous trusts and private health insurance options are also allowed. Only Canada and Taiwan have true single-payer systems.[2]

The actual funding of a "single-payer" system comes from all or a portion of the covered population. In contrast multipayer healthcare uses a mixed public-private system."

Health care in France
Everyone is covered by the French national health insurance scheme, known as "Assurance Maladie", but more than 90% of its residents have private, supplemental insurance, known as "complémentaire santé", which is either provided by their employer or purchased on the market."

Kevin said...

Trump was unfairly handicapped because Republicans insisted on knowing what was in the bill before voting for it.

In that respect, it was much, much more difficult for Trump than Obama and he was right to be surprised by this inequity.

Chuck said...

MikeR said...
...
Ryan's plan would have made the problems permanent.


So why did Trump invest himself in Ryan's plan? Ryan's plan must have been consistent, in Trump's own mind, with whatever his grand plan is, for the future of American healthcare.

I dunno; maybe I am being unfair to you, MikeR. Are you someone who, like me, thinks that Trump is a bit of a laughable ignoramus on healthcare? Incapable of anything beyond spouting Fox News Channel-level platitudes about "Obamacare," and not possessing any intellect, nor any principles, on the subject of health care beyond the crassest of low-level political appeal?


Inga said...

Amadeus,

What do you think of the French system? Michael K is an expert on the French system and is on record as being in favor of it.

Kevin said...

Health care in America
Everyone is covered by the American national health insurance scheme, known as "go to the local ER or free clinic", but most of its residents have private, supplemental insurance, known as "health insurance", which is either provided by their employer or purchased on the market. In recent years, those who chose not to purchase "health insurance" were required to pay a fine to the government, called "Obamacare".

Inga said...

Funding HR 676: The Expanded and Improved Medicare for All Act How we can afford a national single-payer health plan.

The Expanded and Improved Medicare for All Act, HR 676, introduced into the 113th Congress by Rep. John Conyers Jr. and 37 initial co-sponsors, would establish a single authority responsible for paying for medically necessary health care for all residents of the United States.

Under the single-payer system created by HR 676, the U.S. could save an estimated $592 billion annually by slashing the administrative waste associated with the private insurance industry ($476 billion) and reducing pharmaceutical prices to European levels ($116 billion). In 2014, the savings would be enough to cover all 44 million uninsured and upgrade benefits for everyone else. No other plan can achieve this magnitude of savings on health care.

Specifically, the savings from a single-payer plan would be more than enough to fund $343 billion in improvements to the health system such as expanded coverage, improved benefits, enhanced reimbursement of providers serving indigent patients, and the elimination of co-payments and deductibles in 2014. The savings would also fund $51 billion in transition costs such as retraining displaced workers and phasing out investor- owned, for-profit delivery systems.

Health care financing in the U.S. is regressive, weighing heaviest on the poor, the working class, and the sick. With the progressive financing plan outlined for HR 676 (below), 95% of all U.S. households would save money."

Chuck said...

bagoh20 said...
So we still have the ACA, it's still gonna fail, and it was passed with zero Republican support using outright admitted lies to get it passed despite numerous warnings about exactly what is now failing. Yet, the Dems will try to blame the Republicans for it's failure. That will be much harder without this bill passing. Sometimes it takes being pushed into a corner with no escape to get people to see their options clearly.


I expect that the ACA will NOT fail suddenly and dramatically. I expect that it will encounter a gradually increasing number of difficulties that will be easy to put into understandable human terms that the media can portray simply and convincingly. A case here, and a case there, and a thousand people up there, and five thousand people down there, with serious problems that could be fixed by legislative patches; and be assured that Democrats will propose those patches. And they'll say that EVERY big legislative change (Medicare, Social Security, Homeland Security, Internal Revenue) that we've ever done needed alteration and patching along the way.

I am not advocating the Dems' position here; I am suggesting to you how it is likely to play out.

MikeR said...

"Are you someone who, like me, thinks that Trump is a bit of a laughable ignoramus on healthcare?" We all are. There are no good solutions. My hope is that most Trump supporters have just realized that, and will shrug their shoulders and try the next thing.

dreams said...

"Depends on the meaning of "very good shape." About to collapse... great."

The crybaby Dems will eventually make a deal but in the meantime they'll need a lot of Depends, as in adult underwear.

PB said...

The only way to get bipartisan agreement is to completely blow Obamacare out of the water, no matter what it takes, even eliminating legislature filibuster. After all ist's merely a Senate rule.

bagoh20 said...

"Are you someone who, like me, thinks that Trump is a bit of a laughable ignoramus on healthcare?"

He's not the only one.

I doubt anyone understands heath care well enough to design a top down centralized system for 330 million very diverse people. The ACA should be proof of that since it was designed by the expert geniuses in health care and it failed spectacularly right from the start and is quickly headed for total collapse. Even with that experience behind them, you know what those experts would do now with that information. Probably the same thing all over again. It's not a failure of expertise. It's a failure of imagination and ideology.

Chuck said...

Kevin said...
Health care in America
Everyone is covered by the American national health insurance scheme, known as "go to the local ER or free clinic", but most of its residents have private, supplemental insurance, known as "health insurance", which is either provided by their employer or purchased on the market. In recent years, those who chose not to purchase "health insurance" were required to pay a fine to the government, called "Obamacare".


If you go to an ER, they have to treat you under EMTALA. And then, you get a bill for that treatment. The bill will be enormous. Thousands of dollars for an ordinary visit. Hundreds of thousands for a complicated admission. And you will get a bill for that. ALL of it. And if you don't pay, you will be into collections. And then, bankruptcy.

If you consider that "coverage," that is okay; but it is "coverage" for a poor underclass that has no hope or ambition to escape the underclass.

For everyone else, who does not consider a personal bankruptcy to b normal, it is not "coverage."

Brando said...

Better off with that lousy bill crashing--sometimes when the right, left and middle are all against something, it's a bad deal. Had it passed, it would have been a policy disaster and political disaster for the GOP.

What I don't get is why Trump backed it at all--he was well positioned to come out against it, as he had cover from both the right and the middle to do so. Did he feel he owed Ryan somehow? Even if he did, he still could have said "please try again, but I can't support this".

As for Ryan, I get that he felt the need to pass something that he could call Obamacare repeal, but he had better options to do so--delayed repeal, passing the buck down to the states, or even floating a few different bills through committees and letting everyone mull over them throughout the year while they worked on other priorities (it's not like it magically had to pass right away--sure it makes it look like they sat on their hands for seven years, but that's clear either way--and better to pass good policy and take longer doing it than rushing crap through).

Still, the only thing worse than backing this flop would have been if they actually passed this.

Michael K said...

Why not continue to keep our system but expand Medicare, making it a Public Option?

"How do you go bankrupt ? Slowly, then suddenly"

Hemingway.

Inga, you still have not read those posts I linked to before. There are multiple French funds. The big was for white collar workers.

Hospitals are both public funded, two thirds of them, and private, about half nonprofit but some for-profit. Everyone who is employed in France must join the Securite Sociale and must contribute to the system which has four branches; sickness and maternity, death benefits, invalidity insurance (disability), work accidents, old age and family. It is interesting that Britain, with its unitary NHS, also has a separate workers compensation health system like that in the US. The unions were unwilling to give up this fiefdom when the NHS was founded. We can expect similar resistance from unions to reforms that involved union health plans. France has successfully integrated them.

The entire system is called Natonal Health Insurance, or NHI. The largest system, covering 80% of the population, is Caisse Nationale d’Assurance Maladie des Travailleurs Salaries (CNAMTS), which includes all salaried workers and their families.


Please read the rest before describing it as "single payer." It is funded from payroll deductions.

Because Socialism has hurt France badly, there is now a large tax funded system.

A new (2000) social security tax (Contribution Social Generalisee – CSG) was introduced to relieve some of the burden on employment taxes. Supplementary insurance (analagous to our Medi-Gap policies) is provided by three types of organizations. Provident societies (like fraternal organizations), mutual funds (which provided all health insurance prior to 1945), and commercial insurers. There is a great variety of such plans, some group plans tied to professions for example. They provide a small fraction of hospital care but about 10 to 15% of ambulatory expenses, including drugs. This has allowed the French to avoid rationing as those who can afford it, prefer to pay the premiums. In 2001, 87% of the population had such insurance.

The basic principle of French healthcare is avance de frais, or payment directly from patient to doctor.


Please read more before stating things as though I supported them.

Germany has a series of "sickness funds" that everyone must contribute to. The NHS is tax funded and rationing is getting worse and worse.

Inga said...

"HR 676 (Section 211, Appendix 2) specifies a financing plan for single-payer that includes:
• Maintainingcurrentfederalfinancingforhealthcare
• Increasingpersonalincometaxesonthetop5%ofincomeearners
• Instituting a modest tax on unearned income
• Instituting a modest and progressive tax on payroll, self-employment
• Instituting a small tax on stock and bond transactions
The following progressive financing plan would meet the specifications of HR 676:
• Existingsourcesoffederalrevenuesforhealthcare
• Tax of 0.5% on stock trades and 0.01% tax per year to maturity on transactions in bonds, swaps, and trades
• 6% high-income surtax (applies to households with incomes > $225,000)
• 6% tax on unearned income from capital gains, dividends, interest, profits, and rents
• 6% payroll tax on top 60% of income earners (applies to incomes over $53,000, tax paid by employers)
• 3% payroll tax on the bottom 40% of income earners(appliestoincomesunder$53,000,taxpaidbyemployers)

HR 676 would also establish a system for future cost control using proven-effective methods such as negotiated fees, global budgets, and capital planning. Over time, reduced health cost inflation over the next decade (“bending the cost curve”) would save $1.8 trillion, making comprehensive health benefits sustainable for future generations."

Chuck said...

bagoh20 said...
...
... It's a failure of imagination and ideology.

And so what is Mr. Trump's "ideology"? If he had any imagination and ideology on health care reform, I sure don't know what it might be.

Brando said...

"I expect that the ACA will NOT fail suddenly and dramatically."

I agree--it has problems, and these problems vary by state, so what we'd more likely see is collapsing of some exchanges, premium increases in others, and more people dropping off coverage. But if GOP thinks they won't get blamed for this, they shouldn't be so sure--voters tend to blame whoever is holding the bag when government screws something up. Doesn't matter if it's fair or not.

damikesc said...

Trump is going to make a deal with Democrats?

What about a deal with Republicans?


Don't disagree, but in reality, Ryan looks like he doesn't know what he's doing.

As Instapundit has asked --- why aren't there bills ALREADY READY TO GO for the big things? Ryan and company knew they were coming. Why was the health care debacle not already drafted and got feedback from all of the possible critics on the Right? Why isn't a tax bill already drafted? Bills on regulations?

These are things that a party that REALLY wanted to tackle these things would've already had done.

I'm actually curious to see what it looks like, to have Trump dealing with Democrats. They will want something; Trump will want something. (I don't expect that Trump actually has any principles; what he might want is just a deal. Any deal. But what will the Democrats want? What will Trump need to give to them?

He's already mentioned possible "gun safety" laws (that'll kill him electorally in a way he doesn't want to fathom) and a few other Leftie pipe dreams.

Okay; so what you want is a bill, and revolutionary health care reform, that would please the Freedom Caucus. It would slash federal spending, shut down the ACA exchanges, and leave lots of people without insurance coverage and without means to purchase coverage in the near term. Okay; I don't wish to argue the merits or even the 2018 politics of something like that.

What I want to know is how you get something like that into law, through the Senate.


Pass it and blast Senate Dems if they obstruct. Pass what you can through reconciliation. Why not a simple "Repeal everything by 2018 or 2019", giving time for people to come up with options? Why not simply say "Well, we'll allow sales across state lines" and "we will not force any insurance policy to cover anything", allowing people to pick and choose what is important to them?

The Freedom Caucus are the most consistent group out there. People are mad they said "no", but many times, the best deal is the one you do not do.

(The answer of course is that you don't; and what you do is put it into the Senate and let the Dems filibuster it, and then blame them. That would have been smart politics. Charles Krauthammer recommended that course; and he didn't understand any other option, other than that Paul Ryan honestly and earnestly wanted to get a bill that could pass on reconciliation in the Senate. So shame on Ryan for acting as an honest broker and as someone who actually wanted to get something accomplished.)

...except he crafted a bill that couldn't even pass his own House. Why not submit those numerous repeal bills that seemed to have no problem passing in the past? Why not do this, quietly, in December --- meeting the Freedom Caucus and the liberal Republicans and hash something out then?

Why not allow everyone to buy into Medicare?

Outside of it bankrupting us, you mean?

I dunno; maybe I am being unfair to you, MikeR. Are you someone who, like me, thinks that Trump is a bit of a laughable ignoramus on healthcare? Incapable of anything beyond spouting Fox News Channel-level platitudes about "Obamacare," and not possessing any intellect, nor any principles, on the subject of health care beyond the crassest of low-level political appeal?


Trump is.

Problem: Paul Ryan is no more educated on it, clearly.

You had tremendous faith that the Republican establishment would craft a good bill.

We saw the shit sandwich they crafted.

Michael K said...

If you consider that "coverage," that is okay; but it is "coverage" for a poor underclass that has no hope or ambition to escape the underclass.

The "poor underclass" if they are citizens, will be enrolled in Medicaid AFTER admission. I spent 25 years caring for such patients.

The real burden on ERs are illegals. That's why the Democrats want to provide Medicaid for them, which is what Obamacare really is.

Inga said...

I didn't describe the French System as Single Payer, Michael. A lot of people are confusing the term "single payer", it's being misused all the time in describing certain countries Heathcare systems.

Kevin said...

"would establish a single authority responsible for paying for medically necessary health care for all residents of the United States."

So the problem is right there in the first sentence. Once you get a single payer, it determines what's medically necessary.

My philosophy is to never let my health be someone else's budget line item. You either believe real competition, with the ability for innovators to capture profits as a reward for innovating, will drive prices down, access up, and medical technology forward. Or you believe the only way to cut costs and provide access is to collectively bargain "profits" out of the system, giving people little incentive to find efficiencies or invest in new technologies.

We can have one system or the other, so we should choose wisely.

Chuck said...

Brando said...
...
What I don't get is why Trump backed it at all--he was well positioned to come out against it, as he had cover from both the right and the middle to do so. Did he feel he owed Ryan somehow? Even if he did, he still could have said "please try again, but I can't support this".

Great question as usual.

My notion -- I hope and expect that you agree, for whatever it's worth -- is that Trump never, ever had any sort of idea for a plan of his own. And that doing something, anything now was the imperative. Like doing an executive order that tipped its cap to a "shutdown of Muslims entering the United States until our representatives can figure out what the hell is going on." And like starting to draw up contracts for construction of a Mexican wall. Very little of substance; just messaging to the base.

See, Brando; your question is the right one, but only if we presume that Trump cared about healthcare reform. He doesn't. He cares about winning news cycles.

damikesc said...

• Tax of 0.5% on stock trades and 0.01% tax per year to maturity on transactions in bonds, swaps, and trades

I bet that'll do great for the retirement funds for older folks who cannot make up the losses.

• 6% high-income surtax (applies to households with incomes > $225,000)

A tax of 100% of all income wouldn't cover the costs. This is pissing in the wind.

• 6% tax on unearned income from capital gains, dividends, interest, profits, and rents

Boy, that'll help with the economy and housing. So, we'll have even less housing than we have now and more companies downsizing. I bet the math isn't factoring that in.

• 6% payroll tax on top 60% of income earners (applies to incomes over $53,000, tax paid by employers)

Raise taxes on people already struggling? That is some good empathy there. "Yeah, I know you are struggling to make it and have no real option for savings...but you're still too greedy, fucker!"

• 3% payroll tax on the bottom 40% of income earners(appliestoincomesunder$53,000,taxpaidbyemployers)

Advocating raising taxes on the poor?

Seriously?

While they should have some skin in the game, this is a viciously nasty tax hike that will DEVASTATE the far less fortunate.

HR 676 would also establish a system for future cost control using proven-effective methods such as negotiated fees, global budgets, and capital planning. Over time, reduced health cost inflation over the next decade (“bending the cost curve”) would save $1.8 trillion, making comprehensive health benefits sustainable for future generations."

Obamacare was supposed to bend the cost curve. It didn't seem to do that too well. Why expect better performance here?

veni vidi vici said...

What Trump did/is doing to the GOP is to denude it of the illusion of Congressional leadership.

Ryan is shown to be astonishingly ineffective as a "leader", with McConnell soon to follow (watch him "nice-guy" out of going with the "Reid Rule"/elimination of the filibuster, as Gorsuch's nomination goes down in flames).

Either that, or he's illuminating the commitment of the GOPe to neutering his administration's ability to govern, in the name of, well, no one out across the fruited plain quite knows, exactly...

Those "principled" Republicans, always making the perfect the enemy of the good, and playing a remarkably short game given the time they've spent in the wilderness to get back to full power in government.

Michael K said...

I didn't describe the French System as Single Payer, Michael.

"The French system uses a Public Option with supplemental private insurance, a little bit like Medicare for All it appears."

That sounds like comparing it to single payer to me, Inga.

bagoh20 said...

"And so what is Mr. Trump's "ideology"? If he had any imagination and ideology on health care reform, I sure don't know what it might be."

I don't care about Trump, or the damned politics of it all. That's the problem. Everyone is concerned about who wins or loses politically. That's why the federal government should get the hell out it, and why nothing they do will work. All they can do to help is pass laws that provide transparency, choice, and competition, which I do think is part of Trump's ideology. He just doesn't have the courage to make such a bold move, but I think he could sell it.

Michael K said...

Either that, or he's illuminating the commitment of the GOPe to neutering his administration's ability to govern, in the name of, well, no one out across the fruited plain quite knows, exactly...

I worry that this is it but what does he expect as stage II? The Koch brothers are behind Ryan, I think, not Walker as the lefties always said.

Chuck said...

Michael K said...
...
The "poor underclass" if they are citizens, will be enrolled in Medicaid AFTER admission. I spent 25 years caring for such patients.


Oh, that is such an excellent, and true, point. You are correct. But they will be enrolled in Medicaid only after they have been triaged in the ER and have gone through their appendectomy, or gall bladder removal, or their coronary artery bypass graft, or their dilatation and curettage... and still face bankruptcy, as a newly-enrolled Medicaid patient who will have coverage starting the following month.

Inga said...

I said "a little bit" Michael.

Kevin said...

"HR 676 would also establish a system for future cost control using proven-effective methods such as negotiated fees, global budgets, and capital planning. Over time, reduced health cost inflation over the next decade (“bending the cost curve”) would save $1.8 trillion, making comprehensive health benefits sustainable for future generations."

Hey I've heard this before.... Wait! (snaps fingers) Obamacare!

traditionalguy said...

The art of the deal requires Trump to convince the big donor owned Congress critters that he will walk away from their big donor's list of corrupt inserts in Legislation. He will be no easier for them to handle than Obama was.

In Congress both GOP and Dems are proudly owned by big donors. And DJT is in a Total War with the big donors.



Chuck said...

bagoh20 said...
...
I don't care about Trump, or the damned politics of it all. That's the problem. Everyone is concerned about who wins or loses politically. That's why the federal government should get the hell out it, and why nothing they do will work. All they can do to help is pass laws that provide transparency, choice, and competition, which I do think is part of Trump's ideology. He just doesn't have the courage to make such a bold move, but I think he could sell it.

So where was Trump, in writing and selling that bill?!?


Michael K said...

future cost control using proven-effective methods such as negotiated fees, global budgets, and capital planning.

Mean while why not read this ?

Urban planning, as we once knew it, is over. The current urban revival happened with no master plan and no national urban policy framework, mostly through the “invisible hand” of market forces. An amalgam of development approvals, incentives, and exactions has arisen in the past several decades, largely in place of planning, to harness this private initiative to serve public policy goals. Imagine Boston and other recent urban plans acknowledge this change. These plans express an attitude toward growth, rather than fostering the illusion that cities can or should just decree what’s going to happen where.

"Urban Planning" has shown how useless "proven effective methods" are in trying to run a big system like health care.

Lyndon Johnson and Joe Califano, whose wife voted for Trump and was screamed at by Schumer, decided the way to fix health care costs was to flood the market with doctors. The class size at my medical school tripled after I graduated.

That worked well.

damikesc said...

Chuck, the Republicans have said they wanted that for years. No reason to not have expect them to actually propose a bill to do that.

This is a Paul Ryan failure.

Chuck said...

traditionalguy said...
...
In Congress both GOP and Dems are proudly owned by big donors. And DJT is in a Total War with the big donors.


Apart, that is, from the ones who aren't already in his cabinet?

You wanna know who are, by far, the biggest and most politically active super-donors in the state of Michigan? It's Dick and Betsy DeVos.

The funny thing is, while the DeVoses are GOP super-donors, they were never really on board with Trump in his campaign. Trump was effectively their last choice.

Here is a WaPo story on the donors in Trump's cabinet. I do think the DeVos numbers are a bit misleading, only because I know them so well. The DeVoses have donated much, much, much more than is indicated. (More, that is, to conservative causes that don't need to do any FEC reporting.) But little if any of it went to Trump.

https://www.washingtonpost.com/news/post-politics/wp/2016/12/09/the-six-donors-trump-appointed-to-his-administration-gave-almost-12-million-with-their-families-to-his-campaign-and-the-party/?utm_term=.25661376b176


Inga said...

. guide to the French Healthcare System.

"Healthcare in France also requires mandatory health insurance.
The French healthcare system covers both public and private hospitals, doctors and other medical specialists who provide French healthcare to every resident in France regardless of age, income or status. This makes the French health caresystem highly accessible, even for foreigners.

Additionally, the majority of French healthcare costs are covered by the state via a public French healthcare insurance scheme. It is compulsory for residents in France to register with a French health insurer, as well as register with a doctor in France and go through this doctor for most treatments in order to be properly reimbursed by the French healthcare system.

This guide explains everything you need to know about accessing the French healthcare system:"

Sammy Finkelman said...

By being in "very good shape" Trump is referring to the prospects of amending Obamacare by the close of his first term at the latest.

The "we" here is the Administration or opponents of Obamacare.

Michael K said...

Chuck, your point is lost on me. Betsy DeVos is well known as an education reformer and that is why the Democrats hate her.

She and her husband did NOT donate to Trump but he picked her for Ed. Why is that a bad thing ?

The people he has picked for his cabinet seem to me to be good government types who have all the money they want and now want to try to make the country work. Why is that a bad thing ?

Do you prefer people like Ryan who have never held a real job ?

Nonapod said...

As far as I can tell, there’s never been any honest and realistic discussion about how to deal with the real problem with our entire system of healthcare: excessive liability.

When it comes to actual “healthcare”, we have the best in the world. The thing that’s always been the problem is the cost. And why is healthcare so expensive? Because every last person and entity involved in every aspect of healthcare is insured against everyone else. Every last doctor, nurse, anesthesiologist, medical technician, administrative person, hospital and/or clinic, medical equipment manufacturer and supplier, pharmaceutical producer and supplier, not to mention all the patients is/are insured. All this insurance drives costs every up, up, up along every step of the process to the point that it becomes ridiculous.

I’m not advocating this or saying it’s even a remotely good idea, but just as a hypothetical exercise, imagine a world with zero liability. How much would a basic visit to the doctor cost in such a world? How much do you think a routine surgery would actually cost versus what it costs today?

Nobody wants anything bad to happen ever... except for lawyers I guess, who are sort of like parasitic organisms feeding off fear and anger. And most lawmakers are lawyers, they’re part of that same community. For this and other reasons I doubt we’ll ever get any serious tort reform or anything else that could potentially reduce out of control liability. There’s just too much money to be made off that problem and not enough people who even seem to recognize that it's even a problem.

Which is why I believe eventually we’ll end up with socialized healthcare in one form or another. Nobody will ever properly explain this problem to regular voters in a convincing way. And it's too big and complex to address in a simple way, unless you're going to do something extreme like make certain types of non-catastrophic insurance illegal or something, which is a bridge too far for most voters. So Obamacare will collapse and costs will continue to explode, and nobody will deal with the real underlying problem ever.

Inga said...

"The French healthcare system: how it works

The healthcare system in France is funded partially by obligatory social security contributions (sécurité sociale), which are usually deducted from your salary. In 2016 employees paid around 8 percent in total, while employers paid around 13 percent of salary towards health costs. The French healthcare system is also partially funded by the government and the patient, too, pays a small contribution to their healthcare costs.

The remainder of your charge must be paid for either by the patient or through any supplementary private health insurance. This is why many people take out top-up health insurance (l'assurance complémentaire santé) often organised by a 'mutual society' (mutelle), or insurance provider. When you take out one of these policies, note that some may not cover certain sports and they may not offer immediate cover either. There are also other small charges that must be paid for by the patient, for example, a EUR 1 out-of-pocket charge per GP visit."

bagoh20 said...

"So where was Trump, in writing and selling that bill?!?"

Nowhere. Like I said, no courage, no imagination, unless he wants the ACA to fail openly so he can do something dramatically different, but even if he ends up doing that, I don't really think that was his plan. The swamp is sucking him in, and trying to make him concerned about getting things passed regardless of their merit, about looking effective and all that crap, rather than making real change. I don't know if he'll continue to sink that way, I hope not. He's doing a lot of the right things in other areas, but healthcare may be just too radioactive for any man to provide real courageous leadership until it goes down in flames. It gets much easier then when nobody can say that it was you who screwed it up.

Michael K said...

As of 2016, a new French healthcare system for foreigners known as the Protection Universelle Maladie (PUMA) allows all residents in France – working or not – to have access to French healthcare after three months of residence.
By the end of 2017, doctors and certain medical personnel will not be allowed to charge upfront payments – essentially meaning 'free' doctor visits – but instead will be paid directly by the government or health insurer, unlike now where patients typically pay cash upfront and claim a reimbursement later.


This is the Socialist government changing a successful system. I do not believe this will work.

Sort of like choosing "Medicare for All" as a new system.

Bankruptcy follows. I still think the system that worked well since 1945 is a model for us. That change is not.

Part of it may be the flood of British expats who have been signing up and refusing to go back to Britain for care. They stressed the CMU program. They had not contributed to Securitie Sociale.

Chuck said...

Michael K said...
Chuck, your point is lost on me. Betsy DeVos is well known as an education reformer and that is why the Democrats hate her.

She and her husband did NOT donate to Trump but he picked her for Ed. Why is that a bad thing ?

The people he has picked for his cabinet seem to me to be good government types who have all the money they want and now want to try to make the country work. Why is that a bad thing ?

Do you prefer people like Ryan who have never held a real job ?


Michael, my point was in response to the bottom-feeder notion that Trump is in a "Total War" with the donor class. I think that is a marketing pablum, for Candidate Trump. And it has no real meaning.

And it should have no meaning. Betsy DeVos was one of my favorite cabinet nominations. I love her in that role. She was a superb Michigan GOP Chairwoman. Not merely a donor; a competent manager with a spine of steel. And with much more highly-developed political principles and instincts, than Trump.

No, Michael; you once again have misread me completely. I am not complaining about any undue influence in the Trump campaign. No; what I am doing is ridiculing the Trumpkins who claim that their man is a fighter against the donor class, whatever that is.

The Trumpkins were laughing at how a bunch of people in Washington who never had private sector jobs, were so incompetent. And now, the political scientists are laughing at how ill-prepared the businessman Trump is for his current office.

Sammy Finkelman said...

Inga said...3/28/17, 9:16 AM

Why not continue to keep our system but expand Medicare, making it a Public Option? The infrastructure is already in place. People pay premiums for Medicare, it's basically insurance. People still buy private insurance to supplement Medicare as they will only cover 80%. Why not allow everyone to buy into Medicare?

The problem with single payer is that there is no pressure on proces, and ultimately costs get to be more than the government will tolerate, and then there is centrally dorected cost cutting, and also there is no counterpressure on quality, so that for instance, hospitals will even minimize the number of times bedpans are emptied, as happens in Japan when someone isn't paying extra.

The advantage of single payer is that you neither have people uncovered, nor forced to pay any money except through the tax system.

Expanding Medicare does risk a deterioration in quality.




traditionalguy said...

Hey Chuck. The Art of leadership uses the Big Donors who are willing for DJT to use them. It is like using Werner VonBraun to build the rockets. That may deeply embarrass you, but fortunately DJT is not embarrassed by silly people going oh,woo, woo.

Brando said...

"Don't disagree, but in reality, Ryan looks like he doesn't know what he's doing."

If we apply the "third dimensional chess rule"--which Althouse uses to find secret genius in everything Trump does, as her friend Andrew Sullivan found secret genius in everything Obama did--maybe Paul Ryan pulled off a brilliant coup by looking like he has no idea what he's doing. Success!

"See, Brando; your question is the right one, but only if we presume that Trump cared about healthcare reform. He doesn't. He cares about winning news cycles."

But Chuck, even in that case, wouldn't he win far more news cycles by coming out against the plan? Once it was clear there was significant opposition in the GOP ranks--apparently within days after it was announced--he could have turned on it. Would have been a win-win. But getting on board is like climbing onto the Titanic while it is in the middle of sinking.

"This is a Paul Ryan failure."

It absolutely was. Seven years, constantly passing Obamacare repeal bills, and now they made it clear that they only liked the idea of repeal when they knew Obama would veto it. Not that we thought they were particularly serious at the time, but this just exposes it. Ridiculous unforced error.

Rusty said...

Inga said...
"The NHS is true single payer socialized healthcare. Doctors, hospitals, caregivers are all government employees. Why not continue to keep our system but expand Medicare, making it a Public Option? The infrastructure is already in place. People pay premiums for Medicare, it's basically insurance. People still buy private insurance to supplement Medicare as they will only cover 80%. Why not allow everyone to buy into Medicare? The pool will be massive, driving down healthcare costs. Healthcare providers remain private or public entities. Base premiums on income perhaps. We can do better than Obamacare and don't need to go down the road of true socialized medicine. Who knows, maybe Trump would be in favor of such healthcare, as he hinted at during the campaign."

Finally. Something you said that nearly makes sense. Except that when you have a single payer with a nearly unlimited amount of money-at least for awhile- what do you think that is going to do to prices and coverage?
Hint; It's the same thing that's happening in GB, Canada and France.

Brando said...

Any thoughts on the Singapore health system? Publicly covered catastrophic coverage only, with some subsidy for the poorest, and individuals can use private insurance to add onto that, and HSAs to fill the rest.

Amy said...

I don't scare easily, but the concept of waiting until it 'explodes' is terrifying to me as a healthcare consumer and Obamacare participant. Has anyone said what 'explodes' means in specific terms? Does it mean the premiums will continue to rise even higher until ...what? Premiums are crazy now.
I hate the politicizing of this whole issue, which truly/directly affects people's lives. This is not just about numbers.
I don't know or care who is to blame. What I DO know is that this is one of the key reasons Trump was elected (if not THE single reason). To try once, fail and then walk away and let it gets more and more terrible is not leadership.

Lyle Sanford, RMT said...
This comment has been removed by the author.
Matthew Sablan said...

"Publicly covered catastrophic coverage only, with some subsidy for the poorest, and individuals can use private insurance to add onto that, and HSAs to fill the rest."

-- That sounds like an ideal compromise, but both sides may think they're still giving away the store.

Lyle Sanford, RMT said...

yeah, but "she's got everything she needs".

(previous delete due to misremembering the quote - of a song I sing all the time!)

Chuck said...

Brando;

Quick response... yes, even operating under my presumption that Trump only cares about winning news cycles (and I still think I am right about that) and not about any real healthcare reform, last week was a loss for Trump. I never meant to suggest that it was in any way a win for him.

It was a loss, no matter what he Tweets in the next week. He signed on, to the Ryan effort. He was supposed to be "The Closer."

Had the bill passed, we would have been treated to a month-long celebration of Trump's incomparable sales ability, the likes of which Washington has never seen. Trump brilliance. Trump winning. Ryan's name would barely have gotten any mention.


Matthew Sablan said...

[Note: I'm not saying an ideal system, but rather, an ideal compromise that would be workable without turning into political football/lightning rod every election cycle. At least until the gradual increase that all "subsidy for the poorest" and "publicly covered" costs natural have in politics until we reach this problem again in 40-50 years.]

Bob Boyd said...

Trump's still negotiating.

Michael K said...

Which is why I believe eventually we’ll end up with socialized healthcare in one form or another. Nobody will ever properly explain this problem to regular voters in a convincing way.

I think we could end up with expanded Medicaid and real insurance for the rest. The medical would bifurcate into two, one a cash system with catastrophic insurance, the other a welfare -like program for the poor and those with pre-existing conditions.

The Medicaid could be block granted to states so blue states could fatten the benefits but have to pay for them, not the feds.

The fallacy has always been the determination by Democrats, who have been the ruling party since 1932, to provide a "single tier" program for everyone regardless of ability to pay. Johnson promised "Mainstream care" for everyone. Medicaid starved the big city teaching hospitals that used to provide good, "lean" care for the poor. I saw it happen as Medicaid was passed in 1965 when I was third year medical student. Medicaid "Mills" proliferated. Fraud became the standard.

Kevin said...

"Has anyone said what 'explodes' means in specific terms?"

Knowing the press, they will begin broadcasting the meme that Trump wants all medical facilities to literally turn into flaming hunks of expanding and then collapsing debris. And if even one fails to do so, they will gleefully report he "lied".

veni vidi vici said...

The feds should repurpose one of the several existing government health care schemes already in existence to be a catastrophic-care insurance vehicle for citizens and legal residents, while liberalizing the private insurance market to remove the problematic aspects the ACA imposed on it.

This is similar to Inga's description of the French system, which is itself what I grew up with in Ontario, where we had OHIP, the provincially-administered national care that provided principally catastrophic care, and my family had Blue Cross for day-to-day stuff like doctor's visits and the like.

The problem is, our representatives all fancy themselves Great Men of History when what they ought to do is focus on solving the problems on the scale they exist. Small-ball is okay, especially at the federal level. Republicans who preach the limited-government gospel, of all people, ought to understand this, yet the GOP as manifest in DC consistently fouls its own ideological nest with dumb moves and half-measures that only annoy and frustrate the voting base.

Bring on the dealz. My guess is cutting the system back to catastrophic universal care, with a liberated private market as described above, is where Trump has been aiming since before the election, and it would be a big win for everyone. Except Paul Ryan, who has yet to change his trousers.

Brando said...

"I don't scare easily, but the concept of waiting until it 'explodes' is terrifying to me as a healthcare consumer and Obamacare participant."

Not just that, but any major disruption in the health care markets is likely to affect those of us not on the exchanges.

"-- That sounds like an ideal compromise, but both sides may think they're still giving away the store."

Sadly that's true. At this point it's hard to imagine anything that can get bipartisan support, outside of "celebrate flag day" resolutions.

Sammy Finkelman said...

The solution is give everybody a refundable tax credit of fixed dollar value, probably the same for everyone, possibly funded by a consumption tax, maybe a partial carbon tax, which some liberals might like. (nobody should be fooled into thinking its doing anything virtuous)

I would tweak it further by having some money expire after a year and the rest after two years, [so that that it really does cost a person nothing, but at the same time there is price resistance] with several ways to salvage it however, including medical gift cards (issuance of which would be limited or insured) or by donating it to cover somebody else’s bills.

This first tax credit could only be used any medical expenses, except insurance premiums. This could be kept track of by credit card billing codes, which are established (there might need to special rules to prevent to many other things from migrating under that) and, in places like drug stores, by paying for things now tax exempt in states that exempt medical expenses from sales tax, policed by bar codes. Computers are now well established enough to do this. This is all run through a special HSA account.

I would also have a second tax credit, which could enable anybody to buy catastrophic care, which some people wouldn't get.

All policies have the same premium for everyone who buys any particular policy regardless of pre-existing conditions, but not the same deductible. All indivdual rating would be done through the dedutible, which could even be as high as $1 million a year.

To make buying and price comparison easier at least 10 (and maybe each one in 2 or 3 versions) standard medical insurance policies would be established and listed on an exchange, although they wouldn’t have to be bought through it, and people could buy non-standard ones too. But the majority would, if this works well, be these standard policies that books and web sites could be written about.

Sammy Finkelman said...

The next level above the fixed amount everyone gets is the doughnut hole. This could be filled by savings, including savings in an HSA, contributions from others, regular credit card debt, special low interest medical credit cards, borrowing from the IRS (up to let’s say $3,000 a year) and cashing out or borrowing from Social Security. The cash out or borrowing should not affect any current payments coming from Social Security (making this most actuarialy sound for people below age 60 or 62) and the government should expect to lose some money on the last. Some people may never work again.

The next level is what is after the standard deductible. An insurance company may raise the deductible because of pre-existing conditions, but it may not raise the premium or co-pays or anything. There needs to be some incentive to set it right. The goal is to insure the unknown, and pay for the known by means other than “insurance.”

An insurance company would be either obliged or allowed to reinsure it the high risk (the level between the standard deductible and the high deductible till you reach the level at which catastrophic kicks in.)

The premium for the re-insurance is paid for by the government, except that the original insurance company pays the full amount of the premium plus 5% or whatever figure works best, minus whatever claims it does not have to pay that do not reach the standard deductible.

In other words, let’s say the deductible is $6,000, creating a doughnut hole between $1,500 and $7,500, (everybody gets the first $1,500, deposited in their HSA #1) but the standard deductible for that policy is let's say, $1,500, and expenses come in at $2,500, of which the insurance company pays $1,000 [2,500 - 1,500] – the insurance company gets back the $500 although it still loses the premium plus 5%.

The re-insurance is packaged in tranches, and the the re-insurance company gets the right to attempt to negotiate lower prices, but the patient must agree to anything. This needs a little work.

Under this system it doesn't matter who signs up to a policy, whether they are healthy or not.

Matthew Sablan said...

Also: Honestly? I'm kind of OK with every 40~50 years revisiting major legislation like Social Security or entitlement reforms or the like to see if they're still relevant or need to be updated. So, even if it is just "peace in the healthcare crisis in our time," that's not so bad.

Inga said...

French Health Care: The government participates in setting fair prices for health care, therefore not as expensive as in other countries.

An informative video, only 6 minutes long.

Sammy Finkelman said...

The level after that is catastrophic. There needs to be complete freedom to choose doctors, combined with it mattering, at least psychologically, what the bill is, plus avoidance of surprise billing and freedom to transfer medical records so that no provider traps anyone, plus uninsured people get charged close to the least amount not the highest [say, at the 15th percentile], except maybe for foreign visitors who specially came for treatment.

No family policies are needed – everyone is covered individually.

TreeJoe said...

I see the tweet as smart - he's ensuring that Democrats continue to own Obamacare and putting some burden on their shoulders to admit that it's failing as a cost containment model.

The republicans embarrassed themselves trying to ram through this fix-nothing bill on a partisan vote with no time for editing - exactly what the democrats did with Obamacare.

This should be done in a bipartisan manner or not at all.

Matthew Sablan said...

At work, so can't watch the video, but the title seems odd. The French government being able to get pricing right for medical care would surprise me, as governments have had problem predicting what things should cost since before the Romans. Are there any other things that might be helping to keep French costs low, besides government fiat?

Kevin said...

"At this point it's hard to imagine anything that can get bipartisan support, outside of "celebrate flag day" resolutions."

Are you kidding? That flag was designed and sewn by a white, cisgendered, stay at home mom, who supported terrorists in the process of overthrowing the lawful government.

Certainly there is enough principled opposition to mount an effective filibuster while raising money from the right interest groups.

Sammy Finkelman said...

While I’m doing this, I would abolish Medicaid, except maybe to have some governmental entity pay for (that is, fill) the doughnut whole. I would abolish applications and have that all done done automatically entirely based on whether or not someone owed income tax or, if you want, had bank deposits over a certain amount – but all this may not be necessary, as Social Security can handle it just like with people slightly over the current Medicaid limit.

Since people on Medicaid may eventually work, and this whole change is designed to eliminate the disincentive to work, or to train anyone to work, or find them a job, a portion of their future Social Security benefits can still be used as collateral.

As for people currenly insured by an employer, or where an employer charges an arbitrary price, they get the out of pocket tax credit, and the second tax credit minus whatever value their insurance is assessed at, with the rest, if any, being deposited into teh second (insurance) HSA. This needs work. Somebody needs to evaluate the value.

Also everyone gets to deduct the first dollar of medical expenses spent out of poket, above the tax credit from income, provided that the money is first deposited in an HSA, [after which the money is locked in and can’t be spent for anything but medical expenses] and if someone paid cash, they can adjust that within 90 days by having their HSA re-imburse them.

Since all medical expenses are deductible for income, there is no need to worry about inequality in taxation between those getting their coverage paid for by an employer and those who are not.

Also - encourage concierge medicine where a person pays ageneral practioner per year. This shold be moretahn affordable from the amount in the first HSA. Medoical practices can be reformed so as to cut dwn on the number of doctor;s visoits, many of which are just to update and check measurements or to renew prescritions, and really to get paid. They would be replaced by visiting nrses who wold report anomalies, telephone consulations and when visits occured tey would last loger and not be the same amountof time for every patient.

Also unscheduled vists would be favord over scheduled ones - just the opposite of Obamacare.

damikesc said...

It absolutely was. Seven years, constantly passing Obamacare repeal bills, and now they made it clear that they only liked the idea of repeal when they knew Obama would veto it. Not that we thought they were particularly serious at the time, but this just exposes it. Ridiculous unforced error.

It also has me, seriously, in a state of concern for the House. When your supporters realize that you lied to them for years, they won't usually be forgiving. The odds of the GOP holding the House, while still solid, are a lot less solid than they were a month ago.

Had the bill passed, we would have been treated to a month-long celebration of Trump's incomparable sales ability, the likes of which Washington has never seen. Trump brilliance. Trump winning. Ryan's name would barely have gotten any mention.

The bill, very likely, would've died in the Senate for the same reason it died in the House. Paul was already a guaranteed no. Two more wouldn't have been that difficult. Trump dodged a bullet by its failure.

Brando said...

"Had the bill passed, we would have been treated to a month-long celebration of Trump's incomparable sales ability, the likes of which Washington has never seen. Trump brilliance. Trump winning. Ryan's name would barely have gotten any mention."

Well, that's true--him taking up a bill that was in trouble and shepherding it through would have made him look like a big dealmaker. I could see how once he committed he felt the need for the "victory". But then, if the policy was terrible--which I think amazingly was something both the Freedom Caucus and the Dems agreed on, albeit for different reasons--it would have done far greater damage to the GOP (and Trump, by buying into this) than its failure did. Freedom Caucus saved the GOP from itself, in a way.

"I think we could end up with expanded Medicaid and real insurance for the rest. The medical would bifurcate into two, one a cash system with catastrophic insurance, the other a welfare -like program for the poor and those with pre-existing conditions."

I don't oppose a basic safety net, which wouldn't be "great" coverage and benefits but would at least be something, and where better options became available the more people are able and willing to pay. Of course, the elephant in the room is that our demand for health care is so great compared to our supply that prices are steadily rising beyond inflation. Without addressing that, any "coverage" will get stingier over time.

Michael K said...

the political scientists are laughing at how ill-prepared the businessman Trump is for his current office.

The "political scientists" have been showing us how not to run the government for 70 years.

Now, you sound like a Democrat.

The problem with a Singapore system, like Switzerland, is scaling such a system up is very chancy. You might as well use Chile as a model but it is still small.

I liked France because it is the biggest country in Europe with a system that could be adopted. Germany is also good but Germans are different.

Matthew Sablan said...

On "political scientists": I wish I had a link for "death of the experts" or whatever that Instapundit column was called.

Michael K said...

Are there any other things that might be helping to keep French costs low, besides government fiat?

The free market did that for 60 years but the Socialists don't believe in free markets.

This new approach will fail. Too bad. Why not adopt the Venezuela model and get it over with ?

Sammy Finkelman said...

Matthew Sablan said...3/28/17, 10:42 AM

The French government being able to get pricing right for medical care would surprise me,

Who says they get prices right?

Probably what they do is they fix prices, pay doctors less and get away with it because they have a big market share, and in eneral piggyback on the prices in the United States.

All over the world, medical standards probably piggyback on those in the United states of America.

Are there any other things that might be helping to keep French costs low, besides government fiat?

I would assume there is nothing else. The question is, what keep services available?


Chuck said...

So, Brando; your essential point seems to be that it was a bad bill all along and something that would have haunted the GOP. I'm not so sure it ever would have passed the Senate. I presume that it wouldn't.

No matter what, you won't get an argument from me on whether the bill was good or bad.

But again, the "bad bill" as you see it, was something that Trump endorsed and that Trump worked to get passed, in Trump's own blundering, incompetent, unserious way.

Brando said...

"Are you kidding? That flag was designed and sewn by a white, cisgendered, stay at home mom, who supported terrorists in the process of overthrowing the lawful government."

That's it, to the pitchforks!

"It also has me, seriously, in a state of concern for the House. When your supporters realize that you lied to them for years, they won't usually be forgiving. The odds of the GOP holding the House, while still solid, are a lot less solid than they were a month ago."

I agree--had they used the past seven years working up something that they could sell, and then starting fighting for it now (without an artificial deadline, but hopefully passing it by year's end) it would have shown GOP voters that they were serious about this and had a plan to replace ACA with something better. This can't do much for midterm turnout.

The old excuse was "give us control, we'll undo Obamacare!" then it was "we just have the House, but Harry Reid keeps blocking it!" then it was "ok, we have House and Senate, but damn that Obama!" and finally it's "well, let's just toss this mess out, and if we don't pass it within 60 days, we're dropping it from our agenda for the forseeable future!"

Chuck said...

Bob Boyd said...
Trump's still negotiating.


Toward what?

veni vidi vici said...

"Trump's still negotiating."


"Toward what?"


-- Toward Gomorrah, of course. Note the slouch.

Matthew Sablan said...

That sounds like the Yes Prime Minister's 4-starge policy:

"In stage one we say nothing is going to happen. Stage two, we say something may be about to happen, but we should do nothing about it. In stage three, we say that maybe we should do something about it, but there's nothing we *can* do. Stage four, we say maybe there was something we could have done, but it's too late now."

Sammy Finkelman said...

@veni vidi vici said @10:37 AM

Prices ave now escalated to the point where unsusbsidized catastrophic health insurance is not affordable and doesn't make sense for most people. Something like a $4,000 a year premium and a $12,000 deductible for a family I read.

Thorley Winston said...

"So where was Trump, in writing and selling that bill?!?"

Good question, the primary obstacle to health care reform is that Republicans have only a two seat majority in the Senate which means that if Democrats are united and three or more Republicans defect, they can block anything that Republicans try to do. There were four Republican Senators who said publicly that they wouldn’t support undoing the Medicaid expansion (and that’s not including Susan Collins who is usually a good candidate for crossing over). If Republicans are trying to get a bill through to minimize the collateral damage caused by Obamacare while putting us on the path to a free market as Ryan seems to do, what they can actually accomplish towards those ends is going to be limited by what McConnell can get through the Senate. If you want a better bill in the House, then you need to have support for it in the Senate. I would have liked to have seen President Trump put those vaunted negotiating skills to good use either in wearing down the Republican defectors or picking off a few vulnerable Democrats or both.

Michael K said...

encourage concierge medicine where a person pays a general practioner per year. This shold be moretahn affordable from the amount in the first HSA. Medoical practices can be reformed

Cash practice, "concierge" is a term used by those opposed to the idea, usually include all services needed under a global monthly charge. E-mail and telephone visits are common. The barrier is insurance which demands "discounts" from inflated "retail charges" that are illusory but which ban cash practice for the lower price. That is the biggest problem with HSAs. Doctors who sign contracts with insurance companies are barred from charging lower fees. The same with Medicare. It is illegal to offer someone medical care at prices less than those set by Medicare, which then discounts them by 80 to 90%.

Brando said...

"So, Brando; your essential point seems to be that it was a bad bill all along and something that would have haunted the GOP. I'm not so sure it ever would have passed the Senate. I presume that it wouldn't."

I doubt it would have passed the Senate either--certainly not if it couldn't pass the House. Though (in terms of "least bad" options) GOP is better off it never going to a vote in the House than to have it pass the House and fail in the Senate, because then House members are on record with their votes, and anyone whose arm was twisted would have to defend that vote.

"But again, the "bad bill" as you see it, was something that Trump endorsed and that Trump worked to get passed, in Trump's own blundering, incompetent, unserious way."

Yeah, Trump's "help" on the bill was of dubious value, considering he wasn't making any substantive defenses of the bill (e.g., explaining how various provisions would be better for consumers, the deficit, etc.) and stuck to threats of political disaster if it didn't pass (when it would be even worse if it did pass). This likely didn't increase his influence among Congressional Republicans. But why he got into this in the first place is where I'm at a loss. I can only imagine it was part of some deal with Ryan?

R.J. Chatt said...

My sense of what Trump said was that getting this Republican "failure" out of the way Democrats will have to come to the table to solve the problem once it becomes a catastrophe. So everything is in motion. He's giving us all a heads up so no one will be shocked or surprised when Obamacare become unaffordable and useless.

The only way there will be a compromised solution will be for the moderate middles from both the Republicans and Democrats to come together. The extremes will never bridge the gap. Trump wanted to and expected that he would be able to bring people together, but he can't force them, so he has to wait. Right now the parties are dug in and are useless but it's not Trump's fault the parties are what they are.

What Trump wants is a business mindset applied to the problem where rational decisions are made based on what works. Is that an ideology? No, it's the opposite. It's more like good management.

The Democrats (Bernie Sanders types) are set on bringing in socialism and frankly all you have to do is look at countries that have already tried socialized medicine, the UK, France, China, and they all failed, so why bother trying it here? Israel has developed a complex system of private and public programs to cover a very diverse population, which is worth a look. They've realized the biggest challenge in providing universal healthcare is the shortage of doctors and nurses. That's true here as well.

Inga said...

@Matthew Sablan,

"The government has two responsibilities in this system:

The Ministry of Health directly negotiates prices of medicine with the manufacturers, based on the average price of sale observed in neighbouring countries. A board of doctors and experts decides if the medicine provides a valuable enough medical benefit to be reimbursed (note that most medicine is reimbursed, including homeopathy). In parallel, the government fixes the reimbursement rate for medical services. Doctors choose to be in Sector 1 and adhere to the negotiated fees, to Sector 2 and be allowed to charge higher fees within reason ("tact and mesure") or Sector 3 and have no fee limits (a very small percentage of physicians, and their patients have reduced reimbursements). The social security system will only reimburse at the pre-set rate. These tariffs are set annually through negotiation with doctors' representative organization."

https://en.m.wikipedia.org/wiki/Health_care_in_France

Hagar said...

Has anyone said what 'explodes' means in specific terms?

Trump blows the language again. The term is "implodes," i.e. the insurance companies fold and refuse to offer medical insurance on any terms - leave the business - which I do not think Congress can stop them from doing.

Brando said...

"If you want a better bill in the House, then you need to have support for it in the Senate. I would have liked to have seen President Trump put those vaunted negotiating skills to good use either in wearing down the Republican defectors or picking off a few vulnerable Democrats or both."

One thing I've seen in a lot of criticism of both Trump and Obama's negotiating skills is a lot of emphasis on "schmoozing" and "building relationships" and while those things are good, they miss the point that Senators and Congressman can only be moved by appeals to their political interest. A pizza party is no substitute for having something they can win votes with.

There were a lot of things in this bill that angered moderates and conservatives, and mollifying either of those groups entirely probably still wouldn't have been enough to get passage (particularly with Dems not on board). And the polling on the bill was awful--around 17%. On the other hand, if they'd taken the time to work out something that could get enough buy in from both sides, sell it to the public, and work out the kinks, they may have had something later in the year that could have passed. And if it didn't, at least it would have looked like a good faith effort, not some "toss this out, schmooze, and start blaming everyone for its failure" tactic that helped nobody.

Chuck said...

My quote: Had the bill passed, we would have been treated to a month-long celebration of Trump's incomparable sales ability, the likes of which Washington has never seen. Trump brilliance. Trump winning. Ryan's name would barely have gotten any mention.

damikesc responded: The bill, very likely, would've died in the Senate for the same reason it died in the House. Paul was already a guaranteed no. Two more wouldn't have been that difficult. Trump dodged a bullet by its failure.

And; I agree. It became a likely failure in the Senate. Rand Paul, Tom Cotton, Susan Collins and Dean Heller had all basically announced opposition. There may have been others. Or(!) the opposition of these Republicans might have been negotiated away, if the bill built momentum somehow. And that, I suggest, is a possibility. A possibility along the lines of Trump being the "possible" GOP nominee a year ago. An unimaginable possibility at the time.

But again, if Trump dodged a bullet by the failure of this bill, then what the heck is Trump doing in Washington? What's he there for?

AprilApple said...

The Ministry of Health

Yikes that's creepy.

Michael K said...

But why he got into this in the first place is where I'm at a loss. I can only imagine it was part of some deal with Ryan?

When do presidents get into the weeds on legislation ? Lyndon Johnson did because he had been a Senator for decades. Who else ?

I think Trump thought Ryan knew what he was doing. He didn't. Trump now knows that.

Health care policy is extremely complicated mainly because it is written by tax lawyers. It's all about offsetting incentives and taxes.

Inga's single payer is less complicated but it always fails wherever it is tried. Canada now has private clinics because the supreme court in Canada said "Access to a waiting list is not access to health care."

Hagar said...

Inga most certainly is dreaming when she speaks of improved efficiency with the Government in charge of the whole works!

And with the NHS, the issues are not only costs and rationing of care, but also that the medical staffs come under Government union work rules, the patients are treated as cattle and there is nothing they can do about it since it is the Government itself they are up against.

Brando said...

"My sense of what Trump said was that getting this Republican "failure" out of the way Democrats will have to come to the table to solve the problem once it becomes a catastrophe."

Just a hunch, but based on the Dems' reactions in the past few weeks I don't see them saying "well, ACA failed on its own, maybe we should work with the GOP to fix this". They're already pre-blaming Trump for not adequately funding the exchanges or advertising them--if (when) they fail, they're going to blame him and the GOP for this.

One caveat though is if the Dems take back Congress and Trump triangulates with them then. But I don't see them doing that so long as they're in the minority.

Chuck said...

Hagar said...
Has anyone said what 'explodes' means in specific terms?

Trump blows the language again. The term is "implodes," i.e. the insurance companies fold and refuse to offer medical insurance on any terms - leave the business - which I do not think Congress can stop them from doing.


Has our friendly genius hypnotist Scott Adams weighed in on this? I'm not so sure that "implodes" is in the Trump vocabulary. Implodes is too wonky for Trump, right? Too much like other Washington policy geeks, right?

Trump, as usual, wants a John Wayne word; a Jerry Bruckheimer word. "Explodes." Because it is clear, even when it isn't useful or a good word at all, to describe what he means.


Michael K said...

a lot of criticism of both Trump and Obama's negotiating skills is a lot of emphasis on "schmoozing" and "building relationships"

Democrats complained bitterly, if quietly, about Obama's disinterest in meeting with them. Trump has had far more personal contact with Congress people than Obama had in 8 years.

Even NPR noticed.

Brando said...

"But again, if Trump dodged a bullet by the failure of this bill, then what the heck is Trump doing in Washington? What's he there for?"

I get the sense that Trump's deal with Washington is to be a cheerleader/marketer of sorts, and that he will sign whatever Ryan puts in front of him.

"When do presidents get into the weeds on legislation ?"

Presidents don't have to get into the weeds--usually they just propose something and Congress works it out. But in that case all Trump had to say was "let's see what hits my desk, then I'll make a decision on the final version." Sort of "lead from behind" but not inappropriate from a president's standpoint.

Chuck said...

Brando said...
...
Just a hunch, but based on the Dems' reactions in the past few weeks I don't see them saying "well, ACA failed on its own, maybe we should work with the GOP to fix this". They're already pre-blaming Trump for not adequately funding the exchanges or advertising them--if (when) they fail, they're going to blame him and the GOP for this.


You can take that to the bank. The blood bank. This will absolutely happen; in richer detail than Brando had space to describe.


Sammy Finkelman said...

Tweet from Erica Werner:

Cornyn says flatly that health care will not be attempted again via reconciliation. "It's clear it needs to be done on a bipartisan basis."

Actually that probably won't be possible, either.

Making a deal with Democrats as a whole won’t work (unless maybe he can get Senator Charles Schumer to agree, which just maybe is possible) because he’ll lose the majority of the Republicans. Trump would probably have to practically let the Democrats write the bill to get a deal, and that wouldn’t work.

He has to split the Democrats.

Probably very formally, not like the old 1950s/1960s Southern Democrat-Republican coalition, because the Democratic Party has become too tightly held together.

It is not necessary, or even desireable, for them to switch parties, and they can’t for a variety of reasons, including immigration/amnesty/sanctuary cities, abortion, hostility of their constitutents toward Trump as a person, and the Russian factor.

Another possibility is for that deal to make a deal to get close to happening – and then they can make a deal with the Democratic leadership to at least allow free votes with no pressure.

But if not, Trump, and Paul Ryan, will have to make a deal with what will have to practically become a separate caucus, (not necessarily, or likely, of the most conservative Democrats) and that includes offering them sub-committee chairmanships, maybe even a committee chairmanship or two, like in the New York State Senate, which they should study more.

Campaign finance reform of the sort that makes candidates more independent amd makes it easier to raise money for campaigns might be the glue to get this thing going. (It could something like dollar for dollar unconditional advance tax credits for campiagn contributions, perhaps limited in dollar amount, and limited to people who can also vote for the candidate. Although limiting this to people who can vote for a candidate, might create trouble in poorer districts. If it’s refundable, maybe it can work there too somewhat.)

And they would also agree to try to get state Republican parties, to treat them as Republicans when it comes to reapportionment, in Congressional distrcting after the 2020 election. Although since that’s only after the 2020 election, that one is hard to promise, but they can gain the support of other House Republcan members in their state, and can at least help with fundraising, especially if the Demoratic campaign committees threaten to cut them off.





Hagar said...

Maybe "what Trump is in Washington for" is to provoke a collapse in medical insurance that will convince a sufficient majority in Congress that trying to provide universal health care through the insurance industry is a blind alley - can't be done.

Sammy Finkelman said...

Donald Trump should really get former LBJ aide, and 1970s HEW Secretary Joe Califano involved in writing the bill, and he can bring along some Democrats.

Inga said...
This comment has been removed by the author.
Sammy Finkelman said...

Joe Califano was involved in writing the Medicare bill (that also, unoricedm created Medicaid)

Of course the math didn't work out quite as expected.

Chuck said...

Hagar said...
Maybe "what Trump is in Washington for" is to provoke a collapse in medical insurance that will convince a sufficient majority in Congress that trying to provide universal health care through the insurance industry is a blind alley - can't be done.

I missed that announcement from Trump-Pence 2016.

Sammy Finkelman said...

@Brando,

I think it would have been best to have the vote take place in the house, without trying to pass it. Untwist any arms, and have it fail by a big margin. People would know then who stood where, at least as far where the Republican members of the House are concerned, and that would later help in putting together a coalition.

Inga said...

Blogger Hagar said...
"Inga most certainly is dreaming when she speaks of improved efficiency with the Government in charge of the whole works!"

Hagar, instead of dismissing out of hand that the government can't do a good job with healthcare, compare what the French have and what we have. The French healthcare system is a hybrid of public/ private. I think they're doing healthcare far better than we are. Why can't the US do it? Are the French smarter than us?

Hagar said...

That is a very low bar, and the term used probably should be "less inefficiently" anyway.

Also, I suspect that all the European systems are behind the times, i.e., they were designed back when people mostly lived where they were born and largely knew each other, which is no longer the case - even without the influx from the Middle East and North Africa.

The United States is a quite different proposition and always have been.

damikesc said...

And; I agree. It became a likely failure in the Senate. Rand Paul, Tom Cotton, Susan Collins and Dean Heller had all basically announced opposition. There may have been others. Or(!) the opposition of these Republicans might have been negotiated away, if the bill built momentum somehow. And that, I suggest, is a possibility. A possibility along the lines of Trump being the "possible" GOP nominee a year ago. An unimaginable possibility at the time.

Could it have been negotiated away? To win over them, it would've required a rather significant change. Now, had that change happened, it might have passed easily. It was a really, really bad bill. Rand Paul's input would've done nothing but improve it (and, again, Ryan REALLY should've already had input from the assorted factions before this thing even began). As it was written, it wouldn't pass. Rand isn't one to back down on much.

But again, if Trump dodged a bullet by the failure of this bill, then what the heck is Trump doing in Washington? What's he there for?

All I have are theories. But few Presidents make any semblance of sense. Obama sure as hell didn't. Bush Jr really didn't. Clinton did occasionally.

Hagar said...

If Trump & Co. has neglected to inform Chuck of their plans for whatever, they do not exist?

Qwinn said...

Inga, so you think a health system that is less bad than its neighbors with a population of 66 million in a country roughly the size of Pennsylvania transfers easily to 350 million people in a country larger than Europe?

Sure. What could possibly go wrong?

If it's so awesome, why haven't lefties implemented it in one of their solid blue states, you know, to show us all how its done? At least the population size and geography would be more in line.

Brando said...

"I missed that announcement from Trump-Pence 2016."

Particularly as it's just as likely to create a majority in Congress pushing for single payer.

"I think it would have been best to have the vote take place in the house, without trying to pass it. Untwist any arms, and have it fail by a big margin. People would know then who stood where, at least as far where the Republican members of the House are concerned, and that would later help in putting together a coalition."

Wouldn't they achieve the same by doing unofficial whip counts? Part of the problem with putting it up to a vote without intending to pass it is a lot of members would be on record supporting something unpopular which wasn't going to pass anyway.

Inga said...

Quinn, well I guess you're stuck with Obamcare then.

Hagar said...

Because a welfare state is incompatible with open borders, and the United States has always had open borders internally. Indeed, the Constitution says so.

Michael K said...

But in that case all Trump had to say was "let's see what hits my desk, then I'll make a decision on the final version." Sort of "lead from behind" but not inappropriate from a president's standpoint.

No, I think the proper role is to say to the leadership, "I can sign a bill that does this, this and this."

That is leadership setting the agenda. I still say the easiest way to cut the Gordian knot is to just make Obamacare optional and let conventional insurance and HSAs return. Cash practice would be encouraged for the HSAs by outlawing contracts that don't allow discounting by providers. That is free market thinking. Medicaid is the base of Obamacare and block granting Medicaid to states would let them experiment with their own money.

@Inga The French healthcare system is a hybrid of public/ private. I think they're doing healthcare far better than we are. Why can't the US do it? Are the French smarter than us?

No, until very recently, the French were more practical. They use nuclear power for 80% of electricity generation, for example.

Socialists are not practical, hence the new rules about "free care" in France. It will wreck their system.


Bob Boyd said...

"Toward what?"

What we have seen so far just strikes me as off somehow. I know, I know, but bear with me.
The Republicans have been saying for 7 years that their number one priority is to repeal Obamacare. Why the big rush? Why no time and effort to sell the bill? I hate to see the Freedom Caucus guys vilified. They're the only ones who didn't break their promise or betray their constituents.
If Ryancare is, big picture, better than outright repeal and starting over, then Ryan, Trump, the Party ought to go out there and explain to voters how and why. You can't expect the Freedom Caucus guys to fall on their swords and lose their seats for Ryan or Trump. Especially if Ryan and Trump won't get out there and try to help them. The Freedom Caucus' constituents were probably some of Trump's most ardent supporters. Now they're the bad guys? It doesn't make sense. Ryan isn't dumb. Trump isn't dumb. They had to know an about face on repeal would put a lot of Congressmen in a serious bind back home.

I don't know. Maybe it's just a clusterfuck. Or maybe they're playing a longer game. It's all speculation down here in the comments.

Either way, I don't think this is the end of any effort to repeal and replace Obamacare.

Chuck said...

Hagar said...
If Trump & Co. has neglected to inform Chuck of their plans for whatever, they do not exist?


Oh, Trump hasn't been short on claims and trashtalk about healthcare! Right???

Trump was planning on something great, that covered everybody even if it cost him Republican votes. And government was going to pay. But the rest of the system was going to cost less, with no more big premium increases, and no massive deductibles and co-insurances, and simpler, and with better care.

That was Trump. Nobody but Trump made such blandly incredible and overwrought promises.


Hagar said...

Ivanka may know what Trump thinks, but even she has to figure it out without being told.

Hagar said...

and Ivanka is not telling either.

pacwest said...

Trump proved that the "chicken in every pot" style of campaign still works. Unfortunately there will always be too many pots and not enough chickens. I say grow your own damn chickens. The Freedom Caucus did what they were elected to do.

It was always a question of whether Trump's business style of management would translate to governing. Early indicators look like not so much.

Watching comments here and elsewhere it looks like the Dems won on healthcare. Very few are talking about repeal of ACA as a standalone now. More entitlements seem to be a given. What happened to the personal responsibility argument?

khesanh0802 said...

Will someone please tell me what the goals/objectives of the American health care system should be. Isn't that a big part of our problem? We really don't agree amongst ourselves what we are trying to accomplish in the area of healthcare. I think the major reason for this is that it is too big a part of the economy and it effects people in different areas entirely differently. We had a pretty good state by state system of health insurance coverage with high risk pools , etc. until we blew it up to try to insure some truly unknown number of uninsured, They were uninsured for so many reasons that no central planner could determine how to get them insured. Should our goal be to make sure that the poor are insured? If so, we can probably deal with that. Should our goal be to ensure that everyone will be insured (whether they like it or not)? We can probably do that. Can we accomplish any goal without breaking the bank?

Chuck and I have agreed that the only way to establish a consensus around any goal - no matter what it turns out to be - is to make the level of pain/cost to not achieve that goal very high. We have not, collectively, reached that point yet, but I agree with those that think that it is not far off.

Bob Boyd said...

"Nobody but Trump made such blandly incredible and overwrought promises."

You forgot about Obama.

Michael K said...

One more response to Inga who really thinks that government is really better than the free market at planning big projects.

Here is an example of why that is not true.

The free market always does a better job than government.

A small group of U.S. oil producers has been trying to exploit advances in DNA science to wring more crude from shale rock, as the domestic energy industry keeps pushing relentlessly to cut costs and compete with the world's top exporters.

Shale producers have slashed production costs as much as 50 percent over two years, waging a price war with the Organization of the Petroleum Exporting Countries (OPEC).

Now, U.S. shale producers can compete in a $50-per-barrel oil market, and about a dozen shale companies are seeking to cut costs further by analyzing DNA samples extracted from oil wells to identify promising spots to drill.

The technique involves testing DNA extracts from microbes found in rock samples and comparing them to DNA extracted from oil. Similarities or differences can pinpoint areas with the biggest potential. The process can help cut the time needed to begin pumping, shaving production costs as much as 10 percent, said Ajay Kshatriya, chief executive and co-founder of Biota Technology, the company that developed this application of DNA science for use in oilfields.


This is NOT government funded research. This is Adam Smith's "Invisible hand" at work.

Remember when Obama dismissed Sarah Palin saying, "We can't drill our way out of this."?

Michael K said...

And Inga, isn't this a better thread than snarky comments with no arguments ?

Inga said...

Yes indeed MichaelK and I'm so happy none of you were snarky!

Sebastian said...

"Why can't the US do it? Are the French smarter than us?" When it comes to running a central government, yes. Which involves tradeoffs. In the U.S., any government scheme turns into a racket before long. You need real competition to keep people honest.

Not only are the French smarter, they also have a fairly honest left--people who actually take responsibility and don't want to ruin the system just for political gain like the second-rate prog scum we have here. Doesn't mean their system works better overall. Again, trade-offs.

I wouldn't mind living under the French system here, if only to take healthcare off the political table for a good long while. But it's unlikely. Getting from here to there is hard. And with Dem progs no deal will stick--they'll start messing up the system and moving the goalposts as soon as the ink is dry.

My name goes here. said...

"What I want to know is how you get something like that into law, through the Senate."

It's called the Conference Committee.

The house passes a bill. The Senate can pass a bill. Then there is a conference committee that hammers out the differences between the two bills. The conference committee is the place where the final bill is written and then voted upon in each chamber.

There is a School House Rock video that explains this.

Sebastian said...

Of course, strictly speaking, Obamacare has already "folded." Major elements of the law (remember CLASS?) simply couldn't be, and weren't, implemented. The major goals couldn't be, and weren't achieved.

pacwest said...

"Yes indeed MichaelK and I'm so happy none of you were snarky!"

That was a joke, right?

Nonapod said...

Will someone please tell me what the goals/objectives of the American health care system should be. Isn't that a big part of our problem? We really don't agree amongst ourselves what we are trying to accomplish in the area of healthcare.

Obviously, the goal is universal infinitely great healthcare for no cost to anyone ever. But unfortunately since we don't yet live in a fantastical utopia that is curated by a godlike superintelligent AI, we have to compromise and settle for something less.

The goal should be to lower costs across the board as much as possible. And to do that you have to first identify why costs are so high in the first place. As I stated above, my (and many others) argument is that costs are high due to excessive liability. So how do you address out of control liability?

Hagar said...

OK. So Congress get together and pass a "bi-partisan" bill.
Then what?

Remember the old trope of "What if they gave a war and nobody came?"

Michael K said...

The goal should be to lower costs across the board as much as possible. And to do that you have to first identify why costs are so high in the first place.

Price = zero, demand = infinity.

It's that simple. The French system works, although it looks like the Socialists will screw that up, because the patients paid first and were allowed to choose to pay more for better quality.

Costs were also reduced because medical school is free and does not require a college education. That may affect quality but the option to pay more for perceived quality allows more choice.

There are other innovations. Catastrophic diseases are handled outside the usual insurance system.

Doctors who accepted the lower payment were rewarded with pensions and paid vacations.

D. B. Light said...

According to Dick Morris, Trump has already killed Obamacare -- it's dead Jim. https://www.facebook.com/search/top/?q=dick%20morris%20

Michael K said...

A very good piece by Tom Coburn on health care reform.

the solution for what really ails American health care isn’t better insurance—it’s competition. Insurers, hospitals, and even pharmacies keep consolidating, using their market power to grow their profit margins and lobby lawmakers to keep competitors at bay with regulations.

State and federal mandates hamstring competition in the name of protecting consumers and providing charity care, but they don’t do either job particularly well.


Yes.

Kevin said...

"But again, if Trump dodged a bullet by the failure of this bill, then what the heck is Trump doing in Washington? What's he there for?"

Showing the fecklessness of the GOPe that can't repeal and replace after seven years, and the otherworldliness of the Dems who can't stop themselves from filibustering Gorsuch.

On those two counts alone I think he's doing just fine.

Earnest Prole said...

Apparently Trump is unaware that all House legislation passes through the House Speaker; he can't simply cut a deal with House Democrats and expect a vote. How much of Trump's presidency will be consumed before he learns what is taught to college freshmen in American Government 101?

Kevin said...

"Yes indeed MichaelK and I'm so happy none of you were snarky!"

Today's snark is of the happy-go-lucky kind.

Michael K said...

"How much of Trump's presidency will be consumed before he learns what is taught to college freshmen in American Government 101?"

This is worthy of chuck or Inga.

Do you really think college freshmen learn anything of use ?

He got elected because he was NOT a politician. You seem to prefer them.

Hagar said...

. . .the solution for what really ails American health care isn’t better insurance—it’s competition. Insurers, hospitals, and even pharmacies keep consolidating, using their market power to grow their profit margins and lobby lawmakers to keep competitors at bay with regulations.

That is what has to happen if you try to do it with legislation.
You wnat competition and innovation, you have to cut them loose and let them fend for themselves.

Inga said...

"How much of Trump's presidency will be consumed before he learns what is taught to college freshmen in American Government 101?"

"This is worthy of chuck or Inga"

Why is this gratuitous insult necessary Michael K? I thought you weren't going to go there anymore, I guess I should've known better. Don't expect others to abide by rules you don't abide by.

Brando said...

"No, I think the proper role is to say to the leadership, "I can sign a bill that does this, this and this.""

I agree that would be preferable, but if you truly don't want to stick your neck out, you don't have to do that much--simply say you'll evaluate what they provide.

"Watching comments here and elsewhere it looks like the Dems won on healthcare. Very few are talking about repeal of ACA as a standalone now. More entitlements seem to be a given. What happened to the personal responsibility argument?"

I think we lost that argument several entitlements ago.

damikesc said...

I feared that Romney losing in 12 insured Obamacare goes nowhere unless it dies.

Static Ping said...

Arguing the Medicare is the model of the future of health care is rather a strange argument, given it is financially unsound. I suppose it is a better choice than Medicaid which is basically bankrupt now.

If you want single payer, you are basically declaring for medical rationing. The government gets to decide who lives and who dies based on funding and politics, as it has happened in every other country that does this including the UK and including Canada, with the added bonus of the corruption and incompetence that is endemic in government bureaucracies. If you though that insurance companies can be heartless, wait until you get to enjoy government bureaucrats. Please do not pretend that this is compassionate.

320Busdriver said...

"Chuck and I have agreed that the only way to establish a consensus around any goal - no matter what it turns out to be - is to make the level of pain/cost to not achieve that goal very high. We have not, collectively, reached that point yet, but I agree with those that think that it is not far off."

It would seem that we should expect that reforming the HC system priority would be to prevent that part of the budget from completely sinking us in terms of debt/gdp. At least I read somewhere that this was the impetus for Obamacare. In the end this idea was completely lost, surprise surprise. If the long term budget outlook from the CBO is to be believed we are going to get ^*&^#@. Maybe it's fake news, but if we continue to spend 3X what everyone pays in to Medicare during their lifetime it can't end well.

Chuck said...

Michael K said...
"How much of Trump's presidency will be consumed before he learns what is taught to college freshmen in American Government 101?"

This is worthy of chuck or Inga.

Do you really think college freshmen learn anything of use ?

He got elected because he was NOT a politician. You seem to prefer them.

Well, Michael, a housecat is not a politician. But wouldn't be a good president. Dennis Rodman is not a politician. Prolly wouldn't be a good president. Lena Dunham, is not a politician, at least not a professional politician. Wouldn't be a good president. Ditto Jesse Ventura; Arnold Schwarzenegger; Sonny Bono, all of whom were not politicians before they were elected.

Donald Trump -- I gather -- was elected because he was supposed to be a highly successful businessman, a great communicator, a talented and plainspoken messaging professional. And most of all, THE great negotiator of our time.

But it turns out that he's not only an overrated negotiator; he doesn't even show much interest in the substance of what he's negotiating.

Chuck said...

My name goes here. said...
"What I want to know is how you get something like that into law, through the Senate."
It's called the Conference Committee.
The house passes a bill. The Senate can pass a bill. Then there is a conference committee that hammers out the differences between the two bills. The conference committee is the place where the final bill is written and then voted upon in each chamber.
There is a School House Rock video that explains this.


Don't skip over that part that I have bolded. How does "the Senate pass a bill" that the 48 Democrats/others want to filibuster? It stops then and there. Unless it is a reconciliation bill, needing only a simple majority in which case the subject matter(s) of reconciliation bills are limited.

And just because I am that kind of guy, I did a little search for an appropriate response to your shot that there is "a School House Rock video that explains this."

There is an NPR video on YouTube that explains how Senate filibusters effectively show that "School House Rock is a lie."

http://www.npr.org/sections/money/2012/12/11/166993494/episode-422-schoolhouse-rock-is-a-lie-or-how-the-filibuster-ate-Washington

Suck on it.

Known Unknown said...

"French healthcare system is also partially funded by the government "

With their own special government money? Hilarious. Where does the government get those funds?

The government doesn't have any money. It has some of mine and some of yours. And a fuck ton IOUs because they've proven time and time again that they have no clue how fiscal responsibility works. What makes anyone think their approach to health INSURANCE—not health care—would be any better?

Earnest Prole said...

He got elected because he was NOT a politician. You seem to prefer them.

On the contrary, the great strength of American business is that bottom-line results matter and bullshit gets called out fairly quickly. With that as our standard, it’s essential to call out Trump’s utter and dismal failure in his initial legislative venture. If Trump is as advertised he’ll learn from his mistakes (“fast failure”) and master how laws are created. Otherwise he’ll be the White Obama, signing worthless executive orders for the remainder of his term.

Brando said...

"It would seem that we should expect that reforming the HC system priority would be to prevent that part of the budget from completely sinking us in terms of debt/gdp. At least I read somewhere that this was the impetus for Obamacare. In the end this idea was completely lost, surprise surprise. If the long term budget outlook from the CBO is to be believed we are going to get ^*&^#@. Maybe it's fake news, but if we continue to spend 3X what everyone pays in to Medicare during their lifetime it can't end well."

That's the problem with subsidies without increasing supply--you just drive up demand and price. We saw that with education costs, why would health care be any different?

A large part of the Obamacare argument was that it was deficit neutral because it would be funded by the Medicare tax increase, the Cadillac tax, the individual mandate penalties and Medicare cuts (sold as not harming recipients, of course, just reducing provider reimbursements, but this obviously does harm recipients by making their business less attractive to providers). Some of this was never implemented (Cadillac tax and medicare cuts delayed repeatedly), some is difficult to really enforce (the mandate penalties) and the medicare tax increase only affects a small portion of taxpayers who can usually structure their incomes to avoid paying it. So it's a mystery to me where that money is coming from if the Treasury doesn't increase its outlays.

Any plan is going to require tradeoffs, it's just a question of what tradeoffs are tolerable. Problem is there's been enough BS sold on each side telling voters that they can have it all.

Brando said...

Part of the issue here is the general public wants to treat health insurance as something that is not actually "insurance"--and I can't blame them, as this is the legacy of how health coverage has been provided for decades. When we think of say car insurance, we think of coverage that we never plan to use, but is there in case of freak events as a fail-safe--so you get in a bad accident, you have money coming to you to pay those damages.

But with health care, people want more than simply catastrophic coverage--they want "low deductables" because they want this coverage to cover frequent doctor visits, medications, etc.--and in cases like that a low deductible simply means you're financing that through higher premiums. It's coverage of a sort, but it's very different from how we treat other types of insurance, and so of course it becomes more expensive and because we're not paying most costs directly there's not enough accountability for price and keeping costs down.

Add to that other odd features of the industry--like not knowing what your out of pocket will be until the services are rendered and your provider and insurance tussle it out, so you could owe a few hundred and you could owe several thousand, and no one can give you a straight answer ahead of time--and this whole system needs major reform. It's not easy, and requires those hard tradeoffs, but the current system is incredibly inefficient and can be disastrous.

Michael K said...

he's not only an overrated negotiator; he doesn't even show much interest in the substance of what he's negotiating.

Chuck is the resident expert on Trump.

How did you make your first billion, if you don't mind my asking?

Here's a little something for Inga.

"Our work shows that up to 40% of patients diagnosed with high-risk or locally advanced prostate cancer may not be receiving the best available treatments in combination with hormonal therapy," commented lead author, Arun Sujenthiran, MBBS, MD, from the Royal College of Surgeons, England.

Mr Sujenthiran (surgeons in England are addressed as "Mr" or "Ms" rather than "Dr") presented the new findings here at the European Association of Urology (EAU) 2017 Congress.

Locally advanced prostate cancer is treated in several ways, and long-term studies have shown that radical treatments that aim to destroy all cancer tissues (and include radiotherapy and surgery) can improve survival compared with the use of hormonal treatment on its own, he explained. Hormonal treatment, such as androgen deprivation therapy, helps to slow the growth of the cancer but doesn't usually result in complete eradication of the prostate cancer, he added.


The NHS is not good for your health if you are male and have prostate cancer.

Inga said...

Known Unkown, well duh. No one was implying that it isn't taxes that fund the government.

Hagar said...

With Obama/Ryancare everybody is looking to get something for free, which cannot happen, and furthermore they want Congress to cnstruct this marvelous perpetual motion machine so that it will go of itself forever and ever. Also not going to happen.

The best thing might be to cut the VA facilities loose from the military - except those which deal with actual combat wounds, which should be the Pentagon's responsibility anyway - and turn them over to the states with some sort of suitable arrangements for means tested medical services for the indigent, and then let the great mass of the people, the medical professions, and the insurance industry find their own equilibriums with government - Federal, State, and local - only monitoring for fraud and other such duties that rationally belongs with the governments.

Achilles said...

You all are focused on arguing about which system is better. That's moot. The free market outperforms government in everything it is allowed to. So what. Three things that will help this discussion along a lot:

1. The government owns health care. It is not changing. Republicans and Democrats agree. If you are looking for something else plan accordingly. My suggestion is to start talking rich libertarians/conservatives into founding government free health coops in other countries and preparing for a British style government rationed system in the US.

2. Technology is going to make all of this moot within our lifetimes. But we may have to house the AI Driven Auto surgeons in other countries out of reach of the shitheads like Chuck Schumer, Barrack Obama, and Paul Ryan. See #1 above.

3. Budgets. GDP. Taxation. Employment rate. It is all garbage at this point. We have been printing borrowing about 40% of our government spending for 20 years and they wont even let us audit the fed and find out the real numbers. "Unemployment" is a joke number. The government isn't even pretending to tell you the truth. File your taxes and apply for federal benefits as honestly as the government files their numbers.

Achilles said...

Inga said...
Known Unkown, well duh. No one was implying that it isn't taxes that fund the government.

I am.

Peter said...


Buying prescription drugs is like going to a grocery store where the can of beans I want is not priced; I'll find out what it costs when I get to the checkout. And if I have an EBT card it might cost 89 cents (of which I'll pay nothing), but if I have employer-provided food insurance it'll be $2.59 (and I'll have to pay all of it if I havent met the deductible, or 52 cents if I have, or zero if I've hit my annual max-out-of-pocket limit). And if I have no insurance at all? Well, that'll be $21.50 please.

But food stores don't work like this. At the food store the price is marked on the shelf (or on the item) where I can easily see it and it's the same no matter how I pay for it. Of course, it might be more or less expensive at another store, but, if another store has better prices and/or better service I'm likely to discover that, and go there instead.


Buying a big-ticket item such as a car or house is more work than buying a can of beans, as I'll probably pay too much if I just take the first price offered by the seller. But if cars or houses were sold as big-ticket medical services are sold, there would be no asking price at all, nor description of what I was buying, but just a bare take-it-or-leave-it legal "agreement" in which I must agree to pay whatever was charged for whatever the seller chose to provide or I'd be refused service.

And then people wonder why market forces don't work to improve the quality and reduce the cost of medical goods and services?

Why can't prescription drugs be sold much as canned beans are, where merchants may charge whatever they please but everyone pays the same, and prices are conspicuously posted (because, although it may be legal in some places not to post prices, few shoppers would put up with that).

Selling big-ticket medical services can't work like selling houses or cars because by the time I need the service my need may be such that I'm in no position to negotiate. Nonetheless, I could sign up for services offered by a medical organization (offering either fee-per-service, or HMO-like annual prix fixe) if I knew how their prices and quality compared with those offered by others.

Why must the price (and often quality) of medical goods and services be opaque, why must everyone pay a different price for the same goods, why can't markets in medical goods and services be made to work much as other markets do?

Hagar said...

You don't understand much what government-industry "partnership" is all about, do you?

Unknown said...

Mitch McConnell today "We have the existing (ACA aka Obamacare) law in place and we'll just have to see how that works out."

Trump #SAD #INCOMPETENT #LOSER

n.n said...

The first step to health care reform is education reform.

The first step to medical industry reform is to repeal Obamacare and other anti-capitalist practices that artificially inflate prices.

Michael K said...

"Why must the price (and often quality) of medical goods and services be opaque,"

Because Medicare (Politicians) and insurance companies promised us free care. They don't want us to know the price and physicians are not allowed to compete on price.

Except of course on things that insurance doesn't cover like LASIK and plastic surgery.

Ever wonder why those have gotten cheaper ?

320Busdriver said...

This hospital president makes a lot of sense as to why the HC system does not work. It's just as others have described above. Predatory pricing. No transparency.

Sign his petition here

If he is wrong I would love for someone to explain to me why.

Earnest Prole said...

Except of course on things that insurance doesn't cover like LASIK and plastic surgery. Ever wonder why those have gotten cheaper?

Zactly.

Earnest Prole said...

Toward Gomorrah, of course. Note the slouch.

It’s Towards Gomorrah you philistine.

Danno said...

Bob Boyd said...Either way, I don't think this is the end of any effort to repeal and replace Obamacare.

My thought this failed attempt will get Congress people to start thinking about seeing the 2018 rate increase proposals, insurers that drop from the private/exchange market, etc., that will start unfolding in a month or two. This may amp up the pressure to find solutions that include bipartisan support.

damikesc said...

Because Medicare (Politicians) and insurance companies promised us free care. They don't want us to know the price and physicians are not allowed to compete on price.

The price also varies based on other things.

My doctor, for example, charges a MUCH lower rate for a visit if somebody has no insurance (he argues that the paperwork required for insurance is absurd and avoiding that is always a positive) than if they have insurance. No doubt part of it is due to the absurd paperwork insurance requires...but the rest is likely due to the likelihood of higher payment from insurance than from a pure out-of-pocket customer.