I'm uncertain.
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-----Original Message-----
From: "Maynard, A." <[log in to unmask]>
Date: Tue, 23 Mar 2010 09:08:33
To: <[log in to unmask]>
Why is uncertainty a plague?
Adam Oliver wrote:
> Tom,
>
> It's true the Thatcher 'snatched' the milk when she was in charge of
> education. Pity that didn't stop her from winning three general
> elections, two of them by landslide.
>
> Life is plagued with uncertainty.
>
> Sent using BlackBerry® from Orange
>
> ------------------------------------------------------------------------
> *From: * Tom Foubister <[log in to unmask]>
> *Date: *Mon, 22 Mar 2010 19:10:47 +0000
> *To: *<[log in to unmask]>
>
> Thank you for this Joe - is this a case of classic incremental reform
> in a country where even incremental reform is painful and has all the
> air of a big bang about it?
>
> I can only think that the Democrats won't suffer for this in future
> elections - once coverage has been extended (however poor that
> coverage is, and whatever the associated problems), to 'roll back'
> reform would look like Congress/the President was taking something
> valued away. Margaret Thatcher never managed to shake off the moniker
> Milk Snatcher after withdrawing free milk from primary schools. But
> maybe I'm underestimating the strength of feeling here?
>
> Tom
> ------------------------------------------------------------------------
> *From: * Joseph White <[log in to unmask]>
> *Date: *Mon, 22 Mar 2010 10:09:13 -0400
> *To: *<[log in to unmask]>
>
> Hi Adam and all,
>
> Well, the pessimist and congressional scholar in me says, "first lets
> see the Senate deliver."
>
> But the odds are good. So: any policy or political lessons?
>
> Not sure, but a few comments:
>
> 1) This is still a far cry from what any other rich democracy does.
> a) It might cover about 95%, if ever implemented (remember, the
> main provisions do not take effect until a year after the next
> President is inaugurated, meaning there is a real chance of repeal).
> b) Compared to a private-insurance-based, individual mandate
> system in a country like Switzerland, it:
> 1) Has a much less standard benefit package
> 2) Puts the poor in an inferior second tier, Medicaid
> coverage which is likely to have worse access due to some providers
> refusing to participate due to the unusually low fees
> 3) Has much weaker cost controls because of the absence of
> anything resembling all-payer regulation
> 4) I'm not sure but it seems to require a large portion of
> the public to pay much more for health coverage, both in premiums and
> out-of-pocket, in relationship to income, than would be the case in
> Switzerland. The subsidies are based on the cost of covering about
> 70% of total costs through the insurance, though there is extra
> cost-sharing coverage for some lower-income people; and with U.S. care
> being so much more expensive to begin with, the net effect has to
> require much higher payments than in other countries.
>
> 2) The regulatory structure, though better than the status quo, is
> quite weak. Most of the core regulation of the individual and
> small-group markets is left to the states, which are expected to set
> up the "exchanges". (Tim can go into this at greater length,
> including how I'm wrong). Benefit packages are allowed to vary in
> actuarial value (there are four levels), and within a given actuarial
> value plans can reach that value in different ways. This likely poses
> an extremely difficult regulatory task, since of course the whole
> point of varying plans, to the insurers, will be to come up with plans
> that have the same actuarial values on average but market them
> appropriately so that they have less value to the people to whom they
> are sold. Whether the insurers can manage this will remain to be
> seen. At any rate, the regulatory task is harder than in Switzerland
> or the Netherlands, because of the greater variation allowed, and yet
> the regulatory apparatus is weaker.
>
> 3) The whole bill does very little to improve the insurance currently
> used by the largest group of Americans, namely insurance received
> through employers with more than 50 employees. It does almost nothing
> to reduce the costs of that coverage. It provides a bit of protection
> against the risk that people will lose insurance currently provided
> through those employers. First, employers which do not just drop
> coverage before the penalties go into effect will, when those
> penalties take effect, have to figure that cost into the
> cost-benefit-analysis of what they gain by dropping coverage. Second,
> employees who lose their covered jobs or whose employers drop coverage
> will at least have somewhere else to go (the exchanges). But the
> legislation still leaves most U.S. employers in the ridiculous
> position of having, as isolated purchasers, to try to win bargaining
> battles with the insurers (who find it easier to pass on the
> providers' costs than to fight the providers).
>
> So I think it's important to understand that, while this legislation
> will (if implemented) be a big improvement on the U.S. status quo, it
> is still a long way from what I have called the "international
> standard." If the Republicans were a bit more sane, it would be seen
> as what it is: a fallback position from what most Democrats really
> wanted, and a moderate compromise.
>
> That leads to one observation about politics.
>
> 4) The U.S. has become a viciously partisan political system. For
> years, people believed that the U.S. was a relatively consensual
> political system, with much less ideological conflict than in most
> European systems. This was probably misguided even back in the 1960s,
> as the U.S. left was centrist in European terms but the U.S. right was
> way to the right of a normal European conservative party, even then.
> But at that time the two parties were themselves more internally
> diverse. That's gone now; there is still some diversity in the
> Democratic party but less than in the past, and the Republicans are
> pretty monolithic. The Democrats passed (maybe) this legislation with
> only Democratic votes; and in the end they probably passed it in the
> House mainly because some of the more uncertain Democrats decided
> they just couldn't let the other side win. This means that shifting
> control of the government could lead to policy alternation of a type
> that makes the British "stop-go" of the 1960s look stable.
> Ironically, the only stabilizer is the hated, undemocratic, Senate
> filibuster. And that can be avoided, somewhat, with reconciliation.
> At any rate, this is another reason to be unsure of whether the key
> parts of this legislation will be implemented. But it also means
> that, in the end, the process was a matter of the Democrats who were
> pretty much liberals and mostly in safe constituencies negotiating
> with the Democrats who are less liberal and less safe. The latter
> represented what used to be considered moderate Republican positions.
> In the end, the bill was a compromise, that appears to be about to
> pass because of a degree of partisan loyalty that is unusual for
> Democrats. All along the key question was whether the swing Democrats
> would decide it was safer not to vote for a bill, or whether that was
> actually more risky because, if they did nothing, Democrats would look
> ineffectual. Enough chose the latter -- pending the Senate.
>
> cheers,
> Joe
>
> On Sun, Mar 21, 2010 at 10:50 PM, Adam Oliver <[log in to unmask]
> <mailto:[log in to unmask]>> wrote:
>
> So, US health care reform has passed. I'd be interested in
> reactions from those who commented over the last year; e.g. Tim,
> Joe, David W. Etc. Etc.
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>
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