It’s time to evaluate where health care reform stands at this point.
Guaranteed Issue: The best thing about the bill is unquestionably the fact that insurers have to issue policies to anyone who can pay. No one can be denied coverage, no matter what pre-existing conditions they have. This is a big deal. While it can help people of any age, it is most important to older people, who are more likely to have pre-existing conditions. This also helps people who are stuck with very expensive insurance because they have pre-existing conditions and if they cancel their insurance wouldn’t be able to get new insurance.
Individual Mandates and cost sharing: An individual mandate forces people to buy insurance whether they want to or not. Insurance works better when everyone is covered and in the same risk pool. It also shares costs throughout the population. Individual mandates seem unfair, but they are generally instituted as part of changes to the system which reduce overall costs significantly. For example, relatively speaking, Canadian GDP/capita costs were reduced by one third compared to what they would have risen to otherwise during the ten years after changing from a US style system to single payer.
If there is no cost reduction due to systematic changes in the system, however, all that an individual mandate does is share costs through the entire population and direct profits to private insurers and medical providers of various kinds by giving them a captive consumer based, forced by government mandate to buy their services.
People who don’t have insurance right now are primarily younger people or those who feel they can’t afford it. What individual mandates will do, then, is subsidize older people’s insurance costs and the price of guaranteed issue, which is very costly since it forces insurers to cover people who are very likely to get sick. The people who subsidize this are, generally speaking younger and poorer.
If subsidies were adequate, then in fact, it would be the government subsidizing the costs, through progressive income tax and corporate taxes. However, since the subsidies in the various bills do not cover the full cost, poorer and younger people will subsidize older people. Since many of those people didn’t buy insurance because they are right on the edge financially already it means that some of them will go without food, not be able to pay tuition, or lose their homes as a result. Many people are already on the edge already, this is one more burden for them.
No Robust Public Option: A robust public option is one that is large enough and with enough pricing power to force down costs, and one which is available to everyone. At this point, the public option will likely have between 5 to 9 million enrollees (the CBO says 6 million, but we’ll be generous). As such it will be smaller than most private insurers and will not have pricing power. If it were linked to Medicare and could use Medicare’s clout, it could reduce costs, but the Medicare +5 amendment, which would have had it paying providers at Medicare rates +5% was defeated.
The Congressional Budget Office has stated that the public option insurance plan premiums will be higher than equicalent private plans. This is likely because of denial of care issues, insurer cherry-picking and lack of clout mean it won’t be able keep reimbursement rates low relative to private insurers who have more customers and thus more pricing clout with doctors, hospitals and other providers. If the public option costs more than equivalent private plans, it goes without saying that it will not reduce costs.
Reduces Practical Access to Abortion: The Stupak amendment, passed Saturday evening, makes it illegal for any plan offered on the exchanges to finance abortions. Any woman who wants abortion access, after being forced to buy insurance that doesn’t include it, will have to buy it elsewhere. The practical result of this is a reduction in access to abortions. This, of course, primarily affects young, childbearing age women though their family members, boyfriends and so on will likewise be effected.
The Bottom Line: Who’s Getting What, and Who’s Paying
This bill does not contain a robust public option which will contain costs. It will give guaranteed issue and force cost sharing through an individual mandate. Older people will disproportionately benefit, and the people who will disproportionately pay are younger poorer people, and especially younger women, the poorer ones of whom will lose practical access to abortions.
For a long time I’ve read that the bright red line for many progressives was a robust public option. None of the bills, including the House bill, have a robust public option. In addition, the Stupak amendment removes practical access to abortions for many women.
It appears that the bright red line was not a robust public option. The bright red line was, and is, guaranteed issue. As long as a bill has guaranteed issue (in exchange for which insurance companies insist on an indvidual mandate, aka, cost sharing and forced customers) any other sacrifice is acceptable.
This health care “reform”, if passed in this form or worse, which it will be if it is passed at all, will blow apart eventually, because it will not contain costs or ‘bend the cost curve” and the US economy simply cannot indefinitely afford health care costs wich rise faster than inflation or wages. But for as long as it lasts, it will help some people at the cost of other, generally younger and poorer people.
If progressives really meant that a robust public option was their minimum requirement, when Medicare +5 failed they would have gone into opposition. They didn’t, therefore it wasn’t their minimum requirement. It remains to be seen if enough progressives really will vote against a final bill which still contains the Stupak amendment. Given progressives failure to live up to their threats to pull support if no robust public option was in the bill, I am forced to suspect that if Stupak is in the final bill, the final bill will pass.
The last couple weeks have been very revealing as to what various people, including politicians, progressive bloggers and activists, are really willing to fight for, and what their bottom line really is.
I would suggest that if progressives ever want their threats to be taken seriously by anyone again they go into opposition against this bill until such a time as it both has a robust public option and the Stupak amendment is out. Failure to do so will show that their threats were always hollow, that they are willing to sell out child-bearing age women, and that they prioritize the interests of older people over younger and poorer people.
In negotiation against a good negotiator, you get the minimum you are willing to settle for. Progressives have shown that their minimum is not a robust public option. It may not even be practical abortion access. They will not get a robust public option if they will not oppose the bill over it, and if they won’t oppose the final bill over the Stupak amendment, that too will most likely remain.
Obama and the Democratic leadership’s bottom line is they must pass some bill called “health care reform”. Unless you threaten to take away their bottom line, they will take away anything that isn’t progressives bottom line – and that includes practical abortion access, and a robust public option.
The measure of terrorism's success
The Tiller family has announced that it is closing Dr. Tiller’s clinic. The terrorists have won, and that assassination has succeeded in doing what it was meant to do. I’m sure the murderer is very happy tonight.
The bottom line on right wing terrorism against abortion rights is that it’s succeeding and has been for some time. Take a good hard look at the chart at the top and try and tell me otherwise. And when it comes to late term abortions, well, Tiller was one of the very few who still provided the service. According to Tiller, speaking in March before his assassination, he was one of only three doctors left in the US doing such abortions. Now there are two. If those numbers are right, one third of all abortion doctors doing these abortions were just killed.
In the aftermath of Tiller’s death, I heard a lot of progressives talking about how the anti-abortion folks were losing. The bottom line is that they’re winning. It is harder to get abortions than it was 5 years ago, or 10 years ago, or 25 years ago. Abortion access peaked in 1982 and has been declining ever since. Consider that the US population has increased by approximately 30% since 1982. At the same time the number of providers has dropped by over a third.
Now, most types of abortion violence had been in a slow, long term decline (the exception is burglary) so there’s certainly some reason for optimism. At the same time I strongly suspect that anti-abortion violence will rise, along with other types of right wing terrorism, during Obama’s administration.
The larger point is simpler. It’s harder to get an abortion than it has ever been since Roe vs. Wade, because there are just less doctors who perform abortions. Until more doctors step up and start providing abortions, especially late term abortions, this will continue. It’s hard to blame doctors for not being willing to provide abortions. Not only could you be killed for doing so, your family will be stalked and perhaps harmed, your clinic will be burglarized, you will be subject to constant legal harassment and your life will, in general, be made a living hell along with the lives of your family, friends and associates.
It’s a lot to ask of someone. But this comes back to the truth of rights. You have no rights that people aren’t willing to suffer and die for. Rights that someone won’t put their life on the line for will be taken away by people who are willing to resort to intimidation, violence and to push for laws which take those rights away.
So the questions, then are these:
1) Where are the doctors who are willing to risk their lives, the lives of their families, and to endure constant harassment to ensure that women keep this right, not just in theory, but in practice?
2) Where are the mass of people who will provide money, aid, and physical protection to the doctors who put their lives on the line? Yes, they exist even now, but obviously there aren’t enough of them, because the number of abortion providers keeps going down.
Is this a right you’re willing to risk your life to keep? If enough people don’t answer that question yes, then you will continue to lose it.
The abortion rights debate looks different for people old enough to remember the days of back alley abortions.Case in point: the other day my my father brought up American politics, since he’s knows it’s my job to follow it (and since we don’t much agree on Canadian politics.) He’s a conservative guy, votes for the Conservative party routinely, likes to call himself “the last Victorian” though he really isn’t. Still, he’s no liberal and he’s pushing 80.
I filled him in on Sarah Palin, in particular, and mentioned she was against all abortion except if the mother’s life is at risk.
His voice turned incredulous and he said, “Don’t people remember what it was like when abortion was illegal? Women with coathangers up their….” His voice trailed off.
After a few moments he continued again, now angry. “How can these people be so stupid? Don’t they know what it was like? All the women who died?”
All I could really say was this: “People don’t learn from other people’s mistakes. Only their own. The generation that remembers what it was like, your generation, is mostly gone. The younger folks, they don’t remember, they don’t know. They don’t understand how bad it was, how many women died, how horrible it was. They weren’t there, and for some reason they won’t listen to those few who were. Those who remember. Those who know.”
The thing that saddens me the most about humanity, that worries me the most, is this shocking inability to understand anything unless they’ve experienced it themself. Wisdom is learning from other people’s mistakes.
It seems like every good thing that was done by older generations is being undone, step by step, by fools who weren’t there, don’t remember, and can’t learn. They stripped the protections meant to stop mass bank failures and a new depression and they keep trying to make sure that women will die in droves by getting rid of the right to safe, legal abortion.
So no, Dad, they don’t remember. If people like Palin and McCain have their way, the horrors you remember from your youth will start happening again. The battles your generation fought, the victories you handed to us, your children and grandchildren, we will squander and have to earn yet again.
And if we do fail to hold onto what you gave us, a lot of women will die because of our stupidity.
(Originally posted Sept. 15th, 2008. It seems worth re-posting today.)
Dr. Tiller, whose Wichita clinic performed late term abortions, was shot dead in front of his church today. A lot of the focus is going to be on right wing terrorism, and the culture of hate created by folks who call abortion murder, setting up the justification for these sorts of murders.
Tiller was one of only three doctors in the US who performed these sorts of abortions. That’s not because they’re illegal, it’s because the level of physical and legal harassment they and their staffs face is horrific, and it never, ever ends. It takes a very brave man or woman, and one who has decided to dedicate their life to the cause, to put up with constant threats, vandalism, legal harassment and the very real possibility of being murdered.
Tiller was incredibly brave and dedicated to do what he did. It’s highly unlikely that anyone will step up to replace him.
A theoretical right which cannot be practically accessed is not really a right. The right to abortion, both late and early term, has been under constant assault for decades. Unless other doctors step up, and start providing for that right (and even early term abortions are hard to get in many States) then what happened today is, in fact, a tragic loss for the right for women to be able to have abortions when they need.
In the meantime, I mourn Dr. Tiller. People as brave and dedicated as he was are so rare, that, well, there were only three of them in the entire United States. A lot of women will suffer, and yes, die, because he was murdered today.
Rest in peace Doctor Tiller. Hopefully someone will pick up the torch which fell from your hand today.
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