What about the very real possibility that it will be politically impossible to come up with enough money to cover everyone? What's the fallback? I think liberals will need an answer to this.

That's certainly true. I think the general fallback is Cover The Kids, but I think that's actually a weak response. I'll have more on this soon.

What about the very real possibility that it will be politically impossible to come up with enough money to cover everyone?

Not sure that is the right question. The current system already creates a massive burden on the economy and a big part of that burden is created by public costs created by having so many uninsured. Proposed systems which leave many uninsured or which leave many illnesses uninsured will not help with that burden. One way or another, we are going to pay. It seems to me that the real question is not how can we afford it, its how can we afford not to reform the system in a way which offers universal coverage.

Freeing people to leave deadend jobs and take greater economic risks would significantly boost tax revenues. Universal coverage is the greatest single mechanism to increase worker productivity since the information age.

Is there a troll network that always arrives first?

Let's review the bidding:
1) The US currently spends twice as much per capita on health care as nations that get demonstrably better outcomes.
2) Depending on definitions, somewhere between 10 and 20 percent of the population is without health-care coverage.

This implies that we can cover everyone only if we spend no more than about 170% of the per-capita costs of other nations...

In a way, Ponnuru's article is useful because it's a reductio ad absurdum of the current health care system. Everybody recognizes at some level that private, individually-paid insurance is a stupid way to organize the delivery of care, but it takes Ponnuru's single-minded focus on getting people insured regardless of the amount or quality of care that insurance delivers to make the contradiction inescapable.

this would enable more than 20 million more Americans to get insurance,"

If you're running 30% overhead with private insurance, and, say 3%=5% insurance with Medicare, wouldn't the same money that insures 20 million Americans under the first plan and something like 24 million Americans under the second?

We cover 3-4 million fewer because of an ideological preference for private insurance? To protect shareholders of existing firms? Why exactly do we need the private insurers again? Efficiency? Innovation?

Ezra, you should spend more time taking your fellow bloggers to task for their stoopid. You're quite good at it.

What about the very real possibility that it will be politically impossible to come up with enough money to cover everyone?

It might prove politically impossible to pass genuine 99.9% universal health care, but in reality it won't be because of money. Repeat after me: deficits are a blessing right now, and we ought be very, very careful about reducing federal borrowing too quickly, lest we suffer a repeat of 1937-1938. Yes, of course, eventually we'll have to tackle the debt-as-a-percentage-of-GDP issue, but we can cross that bridge when we come to it, after all Americans have meaningful, robust, federally-guaranteed insurance coverage.

This implies that we can cover everyone only if we spend no more than about 170% of the per-capita costs of other nations...

No, it really doesn't imply that. People who think we could cover an additional 45 million people AND reduce costs AND maintain the same level of coverage for people who already have it are living in a fantasy world.

What about the very real possibility that it will be politically impossible to come up with enough money to cover everyone? What's the fallback? I think liberals will need an answer to this.

If it's politicly impossible to insure everybody this year we're doomed. Not as a party or a political movement, but as a nation.

Right now health costs are 17 cents of every dollar we spend. Our competitors spend 8-9 cents. That isn't good. It's a major reason Germany and Japan's auto companies are surviving the market downturn so much better than GM.

A huge part of our problem is that we make it very difficult for everybody to get health care. Sick in Americawas pretty flawed, but it presented an excellent example. A 31-year-old-woman had Lupus. She was on Tennessee MediCare, but then there were budget cuts and she got thrown off. Eventually her condition caught up with her and an ER was forced to spend almost $1,000,000 to try to keep her alive. It didn't work.

The government of Tennessee saved money by doing this. But the health system lost nearly $1,000,000.

Most of these stories don't end in death and a net loss for the health system in the high six-figures. Poor diabetics routinely skimp on Insulin (cost: $35 a vial) and end up in an ER (cost: way more than $35).

No, it really doesn't imply that. People who think we could cover an additional 45 million people AND reduce costs AND maintain the same level of coverage for people who already have it are living in a fantasy world.

I doubt we can do all three. But I'll tell you one thing: without universal coverage our costs sill continue to increase at double-digit rates, increasing the number of uninsured, and reducing the amount of coverage for those who remain.

If it's politicly impossible to insure everybody this year we're doomed. Not as a party or a political movement, but as a nation.

This is the kind of absurd statement that gets advocates of universal health care a bad name.

Right now health costs are 17 cents of every dollar we spend. Our competitors spend 8-9 cents. That isn't good. It's a major reason Germany and Japan's auto companies are surviving the market downturn so much better than GM.

Er, if health care costs make labor in the U.S. so uncompetitive, why do Japanese and German automakers keep building factories in the U.S. and hiring U.S. workers to build their cars?

Observer writes:
Universal coverage is the greatest single mechanism to increase worker productivity since the information age.

Hah ... where you come from, maybe. But for the rest of the industrialized world, the information age came long after universal coverage.

Unfortunately, that 80 percent figure you cite (without documentation) represents the number of Americans who want "free" health insurance and delude themselves into thinking that Obamian health care reform means no-cost health care. Nice illusion.

"Why exactly do we need the private insurers again? Efficiency? Innovation?"

That's a question I want a real answer to. What service do health insurers actually offer? How do they improve healthcare? They stand between the public and healthcare. They perform administrative functions involving the movement of money, but they don't provide healthcare.

Nothing they do improves healthcare in any way whatsoever. They render no useful service but demand a lot of money.

Health is different than owning a car or insuring a house or business. EVERYONE, at some point, will need some form of healthcare, it's just a question of how much, while a majority of individuals DON'T take out of other forms of insurance what they put in, which is why there ends up being a profit.

The first part of the insurance equation makes sense: pooling money so that no one person is confronted with losses that are so high they can't withstand them. It is one step removed from the direct pay for service that once existed. Our current system is about 20 steps removed and benefits a whole lot of people other than the person needing medical services.

The debate should be about how we can best pool our money to provide services for all with the least possible interference between people and medical care.

What about the very real possibility that it will be politically impossible to come up with enough money to cover everyone? What's the fallback? I think liberals will need an answer to this.

I got an answer: add it to the fucking deficit.

I have no health insurance. I've lost my job. I have a chronic and potentially fatal health condition. Plus, who knows? I might get cancer, too.

Meanwhile, over the last decade, I've watched the federal government operate on the BOAT principle: break off another trillion.

Tax cuts for the rich? No problem. Add a trillion to the deficit.

War in Iraq? No problem. Add a couple trillion to the deficit.

Bank bailouts? No problem. Add another trillion to the deficit.

Until fucking five minutes ago, they'd could always find a trillion to spend, whether they had the revenue or not.

Now we need, what, about a trillion over ten years to do universal, affordable health care, to reduce my MORTALITY RISK, and we don't have all the revenue.

Oh, but NOW adding $50B a year to the deficit is out of the question?

No, no, no, no, fuck that. Nobody's using my fucking funeral as a platform to prove their "fiscal moderation." Bullshit. We are spending that money.

If our Senators are too queasy to find make the revenue side happen, well, tough shit, Evan Bayh, it adds to the deficit until we do make the revenue side happen. You are not going to win a hand job from David Broder over my dead body.

And another thing: I could give less of a shit whether it passes under regular order or through reconciliation. Robert Byrd can suck my dick.

@ Paula: thanks for focusing in on the key question! "What service do health insurers actually offer?"

As I see it, the primary and overwhelming purpose of health insurers (including public ones) to exist is risk pooling. Healthcare represents a cost that varies wildly from person to person over a lifetime, and there are few good ways to predict who will be expensive to care for, and who will be cheap. Very few, even among the rich, can afford the highest potential costs they might face, after all. Yet many people have very low healthcare costs for years, and if they die suddenly, may cost almost nothing to care for. In order to avoid a random lottery of bankruptcy and denied care, we pool the risk by having everyone, more or less, pay the average cost of healthcare for people like themselves -- which is signifcant, but not that high.

A side-effect of such pooling is that the pooler, whether public or private, gets to hold large amounts of money over time, taking in average cost premiums, and paying out wildly varying costs, over the years. This pooling creates the second function that private insurers do: they invest the money that they pool. Ideally, the returns on the investment helps keep up with inflation, and even to reduce premiums for everyone. In a world that was both capitalist and fair (or tightly regulated), private insurance might consistently outperform public insurance because of the investment income. (Of course, if the money is put into shorts on naked CDSs on sub-prime mortgages, aka AIG, then this benefit will not apply, hence the need for regulation).

My point here: the benefits of risk-pooling seem obvious and undisputed, and it's clear that this benefit is optimized if everyone shares in it. If not, the infamous adverse selection/cherry-picking dynamic kicks in, with low-risk patients like young men skipping insurance in a gamble that they won't get sick, and insurers trying every possible means to avoid insuring people who might be at a higher risk. The absence of low-risk patients raises average costs, meaning that more people have an incentive to gamble. And cherry-picking means that those who need insurance most can't get it.

I'm thus utterly puzzled by Ponnuru's claim that universal coverage is not an economically rational goal. Although he engages in various head-fakes that Ezra can no doubt dismantle, the underlying point remains: Ponnuru thinks some people don't need insurance, but he doesn't answer the question: what happens when these people arrive at a hospital needing treatment? The alternatives seem to be:
(a) lacking insurance, they are left to die. If that's his position, I wish he'd spell it out.
(b) someone else will in fact pay for the treatment. In this case, we DO in fact have universal coverage, but flawed post-hoc universal coverage, and coverage for which the individual bleeding on the hospital floor in fact DID NOT PAY FOR. Whether it's the hospital that pays for (and raises rates for everyone), the government (which raises taxes), or any other conceivable payer, the net effect is the same, only LESS efficient than universal risk-pooling in the first place.

Thanks for responding to my point PQuincy!

What grates is that we are in a situation where we are forced to pay money for service that may or may not be given when we need it, or risk disaster if we can't/won't pay that money.

Our entire society suffers from this constant lack of security; lots of money gets wasted; people get trapped into jobs they hate purely to hang on to health insurance (such as it is) and every day around the nation horrible situations occur where people are denied or have to go through extended hassles to get coverage, and on and on.

The simple fact is that we CAN afford universal coverage, and if we had a single risk pool mechanism and didn't have to waste any money on marketing, high salaried execs and a bunch of staff who's purpose is to find ways to refuse coverage, we could do it as cheaply as is possible.

Our government burns through massive sums of money every day. If we as a society agreed that funding a pool to provide all of us healthcare was a priority, the money could be allocated. The debate should be about the best, most far-reaching and efficient way to create, run and sustain a risk pool for the nation. As part of that we would have to decide what other programs should be merged/reduced/cut, and/or what levels of taxes should be raised, to accomplish it.

I've argued with conservatives about this issue before and you know how I bring them to a standstill? I ask them if they really believe that the GREATEST COUNTRY ON EARTH is unable to come up with a solution to this problem. THIS IS AMERICA! You're telling me WE CAN'T DO BETTER THAN FRANCE! THAN CANADA! THAN SWEDEN! It's very satisfying to watch them become tongue-tied, then silent. (I think very highly, by the way, of all of those countries. I just put the argument in terms conservatives respond to.)

Why, Ezra, do you entertain the Ramesh Ponnurus of the world seriously?

Ponnuru is not being serious about the issue. He's applying high-minded freemarket rhetoric to a situation that is not a problem to him or to his peers. And this is not a minor point: I get the vague impression that Ponnuru sees all who deviate from his "norm" as somehow inferior in character or lacking in personal initiative. We're not underinsured or uninsured, we're "unprepared"; we're not unfortunate, we've exercised poor judgment; and so forth.

Honestly, there's no need to treat Ponnuru and his flat-earthers as though they've given serious thought to the issue. They've started with an intractable proposition: That private, for profit health insurance is good enough for them, and, therefore, good enough for the rest of America. Everything else devoted to discussion about the issue is just to reverse-engineer a rationale that makes it look like they're standing up for the little guy, the working man, the stay-at-home mom, etc.

Er, if health care costs make labor in the U.S. so uncompetitive, why do Japanese and German automakers keep building factories in the U.S. and hiring U.S. workers to build their cars?

Because import tariffs on cars (2.5%), steel, parts, etc , related fees, and the cost of transport would do far more to reduce profit margins than than the cost of providing health care insurance. You didn't know that?! Sheesh@

Until we see the advocates of socialized medicine walking the walk, and accepting for themselves what they prescribe for others, no one should go along with it. Kennedy is a case in point. Days after the diagnosis, he had flown in experts from all over the country. Within days he had brain surgery from a top neurosurgeon. He is throwing millions at a cure for himself, despite his advanced age. How much better would it have been had he given some of these resources to a younger person with a brain tumor. But no, all the wealth to save himself, now in his late seventies. But it's his money, you object. Just so.

"Ezra, you should spend more time taking your fellow bloggers to task for their stoopid. You're quite good at it."

As a conservative who only reads liberal blogs because the conservative ones suck, the last thing the liberal blogosphere needs is more taking conservatives to task for their stupidity. Although this sort of thing is way more useful than Glenn Beck-bashing, or Jonah Goldberg-bashing for that matter, or Amity Shales bashing. I understand that liberals get off in some strange way on being reminded that there are a lot of insanely dumb conservative talk show hosts and writers out there, but I've never gotten the point.

Ezra,

Why do you hate the concept of research so much? Every time you blog healthcare you manage to say something to completely stupid one is forced to wonder if you graduated high school let alone UCLA.

Ignore the childish and disingenuous way you frame the debate you can’t even stick basic facts.

“policies in Florida don't have to cover maternity stays”

www.dol.gov/ebsa/pdf/CAGNewborns.pdf

The Newborns’ and Mothers’ Health Protection Act (the Newborns’ Act)
provides protections for mothers and their newborn children relating to the
length of their hospital stays following childbirth.

Group health plans that are subject to the Newborns’ Act may not restrict
benefits for a hospital stay in connection with childbirth to less than 48 hours
following a vaginal delivery or 96 hours following a delivery by cesarean section.

However, the attending provider may decide, after consulting with the mother, to
discharge the mother and/or her newborn child earlier.

Please explain how repealing state mandates like massage therapy or acupuncture also invalidates the Federal Newborn Act. For every beneficial mandate are you claiming there are not 1-2 equally worthless mandates born of special interest?

Why do you ignore his two specific examples;

“Every provider group with a lobbyist, from massage therapists to fertility specialists, would want in. The result would be expensive insurance policies and costly government subsidies to help people buy them.”

Are you afraid on any honest debate regarding mandated massages and octo-moms?

Just to pile on the Ezra is a joke dump truck;

“for a typical family that moves from group to individual coverage, therefore, the move to nongroup insurance will raise premiums for an identical policy by more than $2,000 per year."

That is odd considering I have NEVER seen a study claiming group insurance is cheaper then individual, on the contrary individual premiums are far cheaper then group. What you might be trying to say not knowing better is the premium paid directly by the family would increase $2000. That would be the difference between what a family with individual coverage pays in premium and what they pay in co-premium under a group plan. You seem to be leaving out the little detail of the 4-5000 in premium saved by the employer, most analysis assume a portion if not most would be returned to the employee in the form of higher wages since increased premium cost has depressed wages.

“But by the close of his op-ed, we're in a space where insurers could still discriminate based on pre-existing conditions,”

Before I accuse you of making and abusing strawmen please reference where he advocates the repeal of HIPAA.

How brave of you Ezra and your fellow progressives to fight the good fight so every American can have a Unicorn. The fact that like affordable, comprehensive universal health insurance for all they don’t exist, that doesn’t detract you a bit. Shame on those conservatives and their small dreams of giving them a horse instead, you know something possible that actually exist outside your policy papers and imagination.

How bout you balance Medicare and Medicaid first, make a factual argument for a change, then ask to take over the rest of the system. Your healthcare writing is analogous to universal healthcare, we need to stop rewarding poor work and failure.

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Sarah

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Nate:

You are an idiot. The link you provided summarizing the Newborn's Act says state law applies to anyone on an HMO or anyone not an a self-insured employer plan. It looks like state law still is the only protection for a lot of people.

That, however, is only a small issue. You are a bigger idiot on the bigger issue. The only purpose of allowing interstate insurance policies is to create a race to the bottom, at the end of which one state requires insurance companies to cover nearly nothing and no insurance companies exist any of the other 49 states.

Nate:

You are an idiot. The link you provided summarizing the Newborn's Act says state law applies to anyone on an HMO or anyone not an a self-insured employer plan. It looks like state law still is the only protection for a lot of people.

That, however, is only a small issue. You are a bigger idiot on the bigger issue. The only purpose of allowing interstate insurance policies is to create a race to the bottom, at the end of which one state requires insurance companies to cover nearly nothing and no insurance companies exist any of the other 49 states.

When Klein goes on his riff about lifting restrictions on interstate insurance coverage, he totally misses the point. He opines that if consumers were permitted to select their providers from a state other than their own, we would be faced with the terror of "policies in Idaho don't have to cover mammograms and policies in Georgia don't have to cover bone marrow transplants," etc. Yes, people in Georgia would not be mandated to pay for bone marrow transplant coverage if they don't want it. 39 other states manage without such a mandate, and they don't seem to be on the precipice of armageddon. Lifting these restrictions would allow consumers to shop around for the coverage they want at the price they want, and drive down premiums. The only people it would hurt would be special interests and insurance companies. Now, Klein isn't defending those, is he?

ODB wow you are clueless. Before you go throwing around big terms like idiot maybe you should have a clue what your talking about.

in 99% of the cases Federal Law applies to EVERYONE and EVERY type of plan. States may pass stricter laws that lay on top of federal law but federal law is always the floor.

On a rare occassion Congress will offer exemptions to ERISA and federal law but they are seldom and far between.

In summary, you sir are a moron. How does someone so stupid get the balls to call out someone who obviously knows more then you and everyone you ever meet on the subject?

"You are a bigger idiot on the bigger issue. The only purpose of allowing interstate insurance policies is to create a race to the bottom, at the end of which one state requires insurance companies to cover nearly nothing and no insurance companies exist any of the other 49 states."

So you have never heard of ERISA apparently? It's only the federal law that exempts all state laws that covers around 50%+ of those with group coverage. Instead of being a race to the bottom ERISA plans, around for 25 years, are the most efficent in the country.

Your comment is a clear example of someone that is to stupid to know when they should keep their mouth shut.