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Old 07-15-2009, 08:35 AM   #61
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Please don't let the conservatives in congress scare you into thinking that the status-quo is just fine. If you agree with that, you'll just be pushing the problem down the road to a later time just as we're doing with social security.
Sorry, forgot to comment on this. Let me paraphrase you:

Please don't let the liberals in congress scare you into thinking that this is a real solution. If you agree with them, you may just be making the problem worse, and push that bigger problem down the road to a later time just as we're doing with social security and Medicare.

We all need more time to review the pros/cons of this bill. Based on recent legislation I've seen, I'll start out skeptical. If it does not address some root cause problems, it will just be expensive, ineffective window dressing. But to add on to a previous statement, if Congress gets the impression that 51% of the people can be convinced there is a pony in there for them - it will pass.....

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Old 07-15-2009, 09:42 AM   #62
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I wish the government would do something important, like make a law saying I could fly, or see through objects. That would be great. I guess no one wonders how the setting of premium caps that are below the cost of providing the service for 95% of people can co-exist with the statement that this thing somehow won't result in a big increase in taxes and also won't result in reduced quality of care. Right, it's al possible due to "increased efficiency"--the very thing for which the government is most famous. I can already see the efficiency and simplicity of these conflicting premium formulae.
Heh, I kind of got that feeling too as I was reading the summaries. Grandiose promises for sure. My feeling is that these grand promises will be horse traded away if necessary and pork will be added to get the necessary number of votes to pass.

Some particular language that seems unbelievable is that the public insurance is going to be self supporting financially, yet affordable somehow. The plan makes it look like premiums will be whatever they are, and will vary based on geographic area (much like private ins today). Then if you fall within the income limits, you will get a credit somehow (voucher? tax credit? reduced premium directly from the public plan option?) that will be handled through existing public welfare offices at the local/state level.

So my premium may be $10000 a year for a family, but the income limits might make it only $4000 a year.

I think they are saying it will be funded from 1/2 trillion in cost reduction/efficiency and better delivery of service and 1/2 trillion from jacking the taxes up on folks making many hundreds of thousands and really jacking them up on folks making $1 million or more with an extra 5.4% tax (bringing the total fed tax rate to the highest bracket folks to 45% after the Bush tax cuts expire).

My hope is that they don't screw this up too bad.
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Old 07-15-2009, 09:44 AM   #63
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Sorry, forgot to comment on this. Let me paraphrase you:

Please don't let the liberals in congress scare you into thinking that this is a real solution. If you agree with them, you may just be making the problem worse, and push that bigger problem down the road to a later time just as we're doing with social security and Medicare.

We all need more time to review the pros/cons of this bill. Based on recent legislation I've seen, I'll start out skeptical. If it does not address some root cause problems, it will just be expensive, ineffective window dressing. But to add on to a previous statement, if Congress gets the impression that 51% of the people can be convinced there is a pony in there for them - it will pass.....

-ERD50
If the liberals really wanted to freak out the conservatives they'd be pushing for a single payer system similar to Canada's system. They know that would never pass, so they're trying to come up with something in between that and what we currently have. I actually believe that the best fix for the system is a single payer system. Under a single payer system some people would get better care while others would get worse care...nothing is perfect. But everyone would be covered.

The main point that I was trying to make when I mentioned the conservative scare tactics is that I believe something must be done to fix this. I didn't see the Bush administration trying to do anything about health care. At least the Obama administration is trying. Nobody knows if the liberal's plan will actually make things better or worse but at least they're trying. I just don't think the status quo can go on for much longer. If the conservatives have some better ideas other than just leaving the system alone, I'd like to hear them...maybe their solution would be better.
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Old 07-15-2009, 10:04 AM   #64
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... I actually believe that the best fix for the system is a single payer system. Under a single payer system some people would get better care while others would get worse care...nothing is perfect. But everyone would be covered.

I don't agree that single payer would be "the best fix". But regardless, single payer is *not* the only way to have everyone covered.

In IL, everyone who drives is required to have car ins. Yet, we don't go to our state for car ins, we have a choice of many privately run car ins companies. And they have to compete for my business. That is a much better system than "single payer", IMO.


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... believe something must be done to fix this. ... At least ... is trying. Nobody knows if the ... plan will actually make things better or worse but at least they're trying.

Sorry, I' just don't accept the "I don't know if it will be better or worse, but we are trying" line at all. That's is what the Doctors told George Washington as they applied more leeches (yes, I know, leeches may actually be beneficial in some cases, but not in most cases they were used for at the time), "hey, we got to do *something*". That thinking got us ethanol from corn, and a host of other things we would be better off without.

I agree with you on one point - I'd like to see a decent plan offered up to compare to this one. I don't know, is it out there but has not got the attention, since... geez, I'm trying hard to avoid the partisan politics and labels here, but if a bill can't carry the majority in Congress, it just isn't going to get much attention.

Are there any good proposals?

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Old 07-15-2009, 10:55 AM   #65
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The house proposal could be really good news for ER types. The low to moderate income folks are supposed to have their premiums capped at between 1.5% of income for those around poverty level and 11% of income for those making 400% the poverty level. So without knowing the tiers in between, lets say they require 5% of $40,000 income for a family of 2. $2000 a year in premiums.

They also specify that the age based premiums can't vary more than a 2 to 1 ratio. So presumably a 21 year old may pay $2000 a year and the 64 year old may pay $4000 a year. Presumably these are also capped by the income maximums too.

This is all based on the assumption that there will be no asset test for premium discounts based on low to moderate income status.

If this works out the way it is looking like it might, then my $10,000 line item for retirement health insurance may have just shrunk a lot.
That's interesting. I'm wondering what the difference in the details will be between a 10,000/year high deductible with HSA and and one of these 4,000/year plans, though. I'm pretty sure the 6,000/year difference didn't entirely go to executive compensation (unless you're with United Healthcare, of course).

Something has to give somewhere. There's going to be a subsidy hidden in there, and/or some severe limits on what care is permitted.
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Old 07-15-2009, 11:47 AM   #66
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Yep. Whatever changes we make to the health care/health insurance situation, one thing that needs to happen is the decoupling of employer and health insurance. This goes in the opposite direction and, for that reason, I think it's a mistake.

This is something I have to agree with.... I do not have 'choice'... well, I do, but not really... I can choose to accept the insurance plan my company has... or decline... there are not options as we are a small small company....

If I did decline... and went to get my own, the cost for an individual policy is high and I do not think 'pre tax'... so I get screwed there...

So if we are stuck with a bad plan, how does this new 'fix' to the system help me out any It does not, only cost me more....
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Old 07-15-2009, 11:54 AM   #67
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I find it quite laughable when the health insurance companies complain that a government health insurance plan would drive them out of business. The only thing it would do would bring their profits down to a more reasonable level. .
I find it laughable that people will say this is a 'level playing field'....

IF the gvmt had a true option that was level, then there should be NO cost to the taxpayers as the premiums would cover all the costs.... but that is not what I see... I see money going to this idea... why? Because they want to be the single payer of services... then they control it all..

Now, I am not saying that insurance companies are 'good'.... just that some of the rhetoric is just wrong...
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Old 07-15-2009, 12:01 PM   #68
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I have insurance through the Minnesota risk pool, which is there for otherwise uninsurable people. The premiums are set between 110% and 125% of market price of similar plans. Premiums cover roughly 50% of the cost of the program. The rest of the cost is financed by a tax on insurance companies.

Just a point of information.
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Old 07-15-2009, 12:19 PM   #69
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That's interesting. I'm wondering what the difference in the details will be between a 10,000/year high deductible with HSA and and one of these 4,000/year plans, though. I'm pretty sure the 6,000/year difference didn't entirely go to executive compensation (unless you're with United Healthcare, of course).

Something has to give somewhere. There's going to be a subsidy hidden in there, and/or some severe limits on what care is permitted.
If your high deductible plan can continue to exist in the future, the $4000 public plan may cover more stuff with less out of pocket maximums. So far they are saying there will be minimum requirements that must be met for coverage by the public plan and ultimately the employers too. No word on required coverage for completely private plans. I'm assuming the out of pocket max they are talking about will be less than $10,000.

The $6000/yr differential you are referring to will be made up for by direct taxpayer subsidies. So some new or modified existing govt agency will issue credits on behalf of low and moderate income people to pay into the public plan. The public plan itself will be self supporting they say, but it will undoubtedly receive lots of taxpayer subsidies via the credits to keep the premiums below a certain level for low to moderate income taxpayers.
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Old 07-15-2009, 12:23 PM   #70
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I have insurance through the Minnesota risk pool, which is there for otherwise uninsurable people. The premiums are set between 110% and 125% of market price of similar plans. Premiums cover roughly 50% of the cost of the program. The rest of the cost is financed by a tax on insurance companies.

Just a point of information.
If I understand you correctly, what Minnesota has effectively done (through a bit of clever sleight of hand) is to have increased the size of the pool (a good thing in many ways), and spread the risk and payments across that larger pool.

This higher risk pool is getting a discount, and that discount is paid by the lower risk group (the tax on the ins co will be passed on to those customers).

I still like the idea of mandating coverage for everybody, then everybody pays a fairer share. That high risk pool is sort of self-generating high risk participants - even at the relative bargain of 125% a normal policy, healthy people will try to avoid it if they can. So you end up with higher risk people in the pool.

Given the current mess, this might be a net positive, but I don't think it is enough, and it might give the false sense that there is some overall bargain here ("The rest of the cost is financed by a tax on insurance companies"), that makes it sound like "that guy behind the tree" is paying for it, which could just extend the problems.

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Old 07-15-2009, 12:30 PM   #71
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This is something I have to agree with.... I do not have 'choice'... well, I do, but not really... I can choose to accept the insurance plan my company has... or decline... there are not options as we are a small small company....

If I did decline... and went to get my own, the cost for an individual policy is high and I do not think 'pre tax'... so I get screwed there...

So if we are stuck with a bad plan, how does this new 'fix' to the system help me out any It does not, only cost me more....
It will be "interesting" to see what impacts this legislation has on all of our employer provided health insurance plans. The legislation suggests that eventually employers will have to provide coverage that conforms to some minimum standards in regards to covered services, out of pocket maxes, no lifetime maxes, etc.

Right now I have a $2400 high deductible plan through DW's employer that costs us around $300 per year (yes year) and it is paid pre-tax, so it costs us closer to $200 after tax. It would be bad news if that policy is deemed substandard and we are required to either pay a lot more, or go w/ the public plan. As you have noted, taxation of health ins. is a crazy thing that will skew decisions in an inefficient manner. It may be cheaper after tax considerations to pay for a crappier more expensive employer provided plan pre-tax than a possibly better cheaper public plan using after tax dollars.

I think leveling the playing field with respect to taxation of health insurance premiums would go a long way towards "fairness" in the healthcare field. Ie - either tax employer provided health ins benefits (even if only the amounts above a certain threshold) or allow an above the line tax deduction for health ins. premiums up to a certain threshold. Maybe the threshold of the public plan premiums.

I haven't seen any details behind the cost calculations for this bill, but it is clear they are funding a huge part of this by massive tax increases on the wealthy. And I don't know how accurately they have modeled the second order effects of the legislation, such as all the people that decide to quit working to get better/cheaper healthcare or drop their employer provided plan for the cheaper public plan (for which they get subsidies).
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Old 07-15-2009, 01:20 PM   #72
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If I understand you correctly, what Minnesota has effectively done (through a bit of clever sleight of hand) is to have increased the size of the pool (a good thing in many ways), and spread the risk and payments across that larger pool.

This higher risk pool is getting a discount, and that discount is paid by the lower risk group (the tax on the ins co will be passed on to those customers).

I still like the idea of mandating coverage for everybody, then everybody pays a fairer share. That high risk pool is sort of self-generating high risk participants - even at the relative bargain of 125% a normal policy, healthy people will try to avoid it if they can. So you end up with higher risk people in the pool.

Given the current mess, this might be a net positive, but I don't think it is enough, and it might give the false sense that there is some overall bargain here ("The rest of the cost is financed by a tax on insurance companies"), that makes it sound like "that guy behind the tree" is paying for it, which could just extend the problems.

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Well, of course the other insureds are paying for it. I don't have a problem with that. They could very well end up in the pool someday themselves.

I gave the data point not so much as to suggest a solution but to give an idea of cost for a group that is going to be higher than average in cost. Yet spreading that cost around doesn't make insurance unaffordable in Minnesota. Minnesota has long had the highest number of insureds of any state. It has the risk pool. It has Minnesota Care for people who can't afford the pool and pay a sliding scale fee. It has (soon to be had) broader medicaid coverage than most other states. If you wanted insurance, you could get insurance. Yet Minnesota did not break the bank in doing this and we wouldn't have to on a federal level either. Our only problem is a governor who wants to cut, cut and cut anything to do with the poor.

Minnesota is also known for its general lower cost of health care, with even the Mayo clinic having a good reputation for lower cost yet its good outcomes.
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Old 07-15-2009, 03:20 PM   #73
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Right now I have a $2400 high deductible plan through DW's employer that costs us around $300 per year (yes year) and it is paid pre-tax, so it costs us closer to $200 after tax.
WOW.... now I could live with that plan....

My company pays 100% for the employees, but nothing for family... so I pay about $600 per month for the wife and kids... and we have a $4,000 deductible plan... but our company will pay for most of the deductible as long as only two people have high costs in a year (the plan family deduct is $12K, the company will only pay $7K)...
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Old 07-15-2009, 03:29 PM   #74
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Well, of course the other insureds are paying for it. I don't have a problem with that. They could very well end up in the pool someday themselves.

I gave the data point not so much as to suggest a solution but to give an idea of cost for a group that is going to be higher than average in cost. Yet spreading that cost around doesn't make insurance unaffordable in Minnesota. Minnesota has long had the highest number of insureds of any state. It has the risk pool. It has Minnesota Care for people who can't afford the pool and pay a sliding scale fee. It has (soon to be had) broader medicaid coverage than most other states. If you wanted insurance, you could get insurance. Yet Minnesota did not break the bank in doing this and we wouldn't have to on a federal level either. Our only problem is a governor who wants to cut, cut and cut anything to do with the poor.

Minnesota is also known for its general lower cost of health care, with even the Mayo clinic having a good reputation for lower cost yet its good outcomes.
Your last statements are what I think is the problem... all I see is the payment side... who has to have insurance, who gets to pay more... what the plan has to have, the deductibles.... but none of that addresses the COSTS of providing healthcare... from an accounting prospective, this is the 'income' side... yes, we will get more income in the system which might mean the amount of 'income' coming from my specific plan will go down.... but I still will go to the same doctor, get the same tests, get the same results... which means the 'cost' side is the same.... I do not call this 'health care reform'.... but welfare for the poor (which seems to include a good part of the middle class)....
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Old 07-15-2009, 03:37 PM   #75
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I do not call this 'health care reform'.... but welfare for the poor (which seems to include a good part of the middle class)....
That's the key. This is welfare for primarily low income and to a limited extent middle income folks. This proposal will guarantee insurance to all at SOME price, and to the low and middle income folks at a limited price. Welfare = full price premium - limited price premium
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Old 07-15-2009, 04:16 PM   #76
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I gave the data point not so much as to suggest a solution but to give an idea of cost for a group that is going to be higher than average in cost. Yet spreading that cost around doesn't make insurance unaffordable in Minnesota.
OK, it is interesting that the high risk pool doesn't seem to cost all that much more to insure. By keeping costs reasonable for people, they are more likely to just get the insurance rather than try to game the system and wait until they are sick, and that lowers the total "riskiness" of that pool.

I think it all points back to the basics, we need to get everyone in a program to avoid the selection issues (on both sides), and we need to control costs, while giving people some reasonable choice and say in some matters (some of which they may need to pay for).

Am I interpreting this correctly? If the premiums are ~ 110% of "similar plans" (I assume you mean what a large employer would be charged per employee), and the premiums cover ~50% of the cost, that means the true cost is ~ 220% of "similar plans", a little more than double. Which isn't bad, esp if you just cannot get ins.

So essentially, Minnesota is "forcing" the ins cos to cast a wider net, take in more risk and spread the costs across the group (which is what ins is all about). The downside is maybe to the mega corp that negotiated a good rate, maybe because steadily employed people are healthier on average, or they have health clubs, etc... they are going to pay more.

Maybe that is what we need, but like others it is bothering me that this seems to be nothing but cost shifting, rather than tangible efforts to reduce costs. I keep hearing we have the highest costs for health care in the US and not always better outcomes, we should be able to find places to cut. What's next - when I buy a new car, there will be a 10% fee to help pay for a car for some person that just can't afford it? Hey, it's only 10%, and it will help someone.... I guess I just get tired of the "you have so we will take it" as the *first* line of response. Did they say they are going to pay for this from taxes from the top 1%? So 1% are going to pay their health care, and then pay the gap for another 99 people on top of that?

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Old 07-15-2009, 04:20 PM   #77
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Your last statements are what I think is the problem... all I see is the payment side... who has to have insurance, who gets to pay more... what the plan has to have, the deductibles.... but none of that addresses the COSTS of providing healthcare... from an accounting prospective, this is the 'income' side... yes, we will get more income in the system which might mean the amount of 'income' coming from my specific plan will go down.... but I still will go to the same doctor, get the same tests, get the same results... which means the 'cost' side is the same.... I do not call this 'health care reform'.... but welfare for the poor (which seems to include a good part of the middle class)....
But maybe you do not need certain tests and certain treatments for a good outcome. There is much to be done on the good medicine side as well as the dollars and cents side. For example, I read an article that areas with high numbers of cardiac surgeons (per capita) there were far more bypasses and other cardiac procedures than areas with lower numbers of these specialists. But the outcomes were the same. Maybe a bit of rationalization when looking for work to do? Our health care sector needs to be encouraged towards best practices. Something to think about when thinking about what is the best way to compensate for care.
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Old 07-15-2009, 04:25 PM   #78
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That's the key. This is welfare for primarily low income and to a limited extent middle income folks. This proposal will guarantee insurance to all at SOME price, and to the low and middle income folks at a limited price. Welfare = full price premium - limited price premium
IMO, "welfare" is a loaded term along the lines of "class warfare" and stuff like that. It evokes an emotional response rather than a more measured one. I suppose it is "welfare," but I don't know that those terms are all that helpful in respectful and open-minded public policy debate.

Like many, though, I share a concern that if the nation goes more and more to higher taxes on the affluent and more subsidies for the lower incomes, you can conceivably reduce the "incremental value" of work to the point where people decide it's not worth working longer and/or harder, and it's not worth it to try to increase earning power (and the amount one pays in taxes).

Health care is not a right, IMO, no matter what some say. Health care is, on the other hand, a basic human good that I believe a compassionate and affluent society should want to see available to all, where inability to pay or preexisting conditions are not barriers to having affordable access to preventative and pallative care. But in wanting to find ways that we can accomplish this, U.S. policymakers should try not to eliminate what's *good* about the health care system, and they should realize that you can only go down the tax-and-subsidize route so many times before the ants look over and realize they are busting their ass and have little more than the grasshopper to show for it. If such a critical mass of ants realized this and became grasshoppers, it's game over; the republic would be doomed when enough people believe earning more money is a sucker's game.

We must do better. But that's also not the same as "we have to do something," because when things seem like they can't possibly be worse, they definitely can. Change for change's sake alone is not a good idea. Many ill-advised things have occurred in history because of a desperate public's desire to "do something."
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Old 07-15-2009, 04:31 PM   #79
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OK, it is interesting that the high risk pool doesn't seem to cost all that much more to insure. By keeping costs reasonable for people, they are more likely to just get the insurance rather than try to game the system and wait until they are sick, and that lowers the total "riskiness" of that pool.

I think it all points back to the basics, we need to get everyone in a program to avoid the selection issues (on both sides), and we need to control costs, while giving people some reasonable choice and say in some matters (some of which they may need to pay for).

Am I interpreting this correctly? If the premiums are ~ 110% of "similar plans" (I assume you mean what a large employer would be charged per employee), and the premiums cover ~50% of the cost, that means the true cost is ~ 220% of "similar plans", a little more than double. Which isn't bad, esp if you just cannot get ins.

So essentially, Minnesota is "forcing" the ins cos to cast a wider net, take in more risk and spread the costs across the group (which is what ins is all about). The downside is maybe to the mega corp that negotiated a good rate, maybe because steadily employed people are healthier on average, or they have health clubs, etc... they are going to pay more.
But not much more when you spread it out over the whole state. The issue actually isn't the risk pool or Minnesota care, which people love here in Minnesota. It is medicaid, which is for the very poor who fit into certain pigeon holes, as it is poorly funded, suffering both whims of the feds and the states.

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Maybe that is what we need, but like others it is bothering me that this seems to be nothing but cost shifting, rather than tangible efforts to reduce costs. I keep hearing we have the highest costs for health care in the US and not always better outcomes, we should be able to find places to cut. What's next - when I buy a new car, there will be a 10% fee to help pay for a car for some person that just can't afford it? Hey, it's only 10%, and it will help someone.... I guess I just get tired of the "you have so we will take it" as the *first* line of response. Did they say they are going to pay for this from taxes from the top 1%? So 1% are going to pay their health care, and then pay the gap for another 99 people on top of that?

-ERD50
I talk about this every once in a while. This is where you need the experts. This is why it is important to listen to people like Rich and Meadbh when they talk about evidence based medicine. Or when they talk about checklists in hospital rooms before doing a procedure (first, wash you hands. . . ). This is where it is important to look at the differences between different clinics and hospitals and why certain ones have as good or better outcomes at a lower cost. I think that one thing we can do is try to figure out a mechanism to reward best practices.
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Old 07-15-2009, 05:02 PM   #80
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Originally Posted by ziggy29 View Post
IMO, "welfare" is a loaded term along the lines of "class warfare" and stuff like that. It evokes an emotional response rather than a more measured one. I suppose it is "welfare," but I don't know that those terms are all that helpful in respectful and open-minded public policy debate.
I guess it is semantics to me. I used the term "welfare" as shorthand for a wealth transfer mechanism. Or in the general meaning of the word "welfare" - ie - for others' benefit and welfare.

I was simply trying to be descriptive of what the House Democrat's bill proposes to do - mandate insurance for everyone (or pay a penalty) and then subsidize the cost of that plan for low and middle income participants through a wealth transfer mechanism. There, less emotionally charged? It is politically correct I guess. Although the House Democrat's bill was notably light on who they are hitting up to pay for this plan. Long on the pro's and short on the cons.

And move me from the ant column to the grasshopper column on this one it looks like.
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