Obamacare Before and After

For a long time we didn't get health insurance from our jobs. I purchased health insurance for my family on the individual market. Last spring, I switch to a new employer that does provide health insurance. If we hadn't switched, I expect we would have been one of those families being told that because of Obamacare, we would be losing our health insurance plan. It wouldn't surprise me to learn that our previous insurer is no longer selling individual insurance in New Hampshire.

But that's OK. We didn't like our plan. We didn't care if we could keep it.

I didn't like the sign up process. The price quoted to me online was totally misleading. I couldn't sign up on online at all. I had to contact an independent broker to actually navigate the process. The actual price was much higher than the one quoted on the website.

I didn't like the fact that they wouldn't insure my entire family. They would insure some of us, but they would not sell a policy to cover my son - who is a generally healthy, normal kid. He was born prematurely with a low birth-weight. Preexisting condition. For him we had to buy a separate, more expensive plan. From a different insurer.

They wouldn't cover maternity. That would be too risky given our history. We aren't planning to have more kids. But I didn't like the idea of a for-profit health insurance company making that decision for us. Whether or not to have children is the kind of decision we should be able to make for ourselves.

We didn't really like having a $5,000 per-person deductible. The insurance didn't end up covering much of anything. If we had more than one incident in a year we could be out $10,000+ in addition to the money we were paying in premiums. That didn't happen every year. But it did happen.

We contacted the insurance company when the law changed and they could no longer reject children due to preexisting conditions. They waffled, delayed, and refused to quote us a new price for a policy that covered our entire family. When they finally relented, they jacked up the price so much that we were better off sticking with the separate plans. I didn't like that.

One time my wife had knee surgery at our local hospital. We were informed that the hospital was in-network. But the anesthesiologist in the hospital was not in the network. So, we were supposed to pay for that. We appealed that decision and won. But the insurance took the novel approach of simply never, ever paying the money they agreed to pay. I didn't like being told a dozen times, over many phone conversations, over several years that this would be taken care of. I didn't like collection agents calling us to demand the money that the insurance company had promised, but never paid.

We did not like our insurance plan. But we kept it. We renewed that plan year after year, ever as they kept jacking up the premiums. We kept our plan because there is no way we would take the risk of going without health insurance. We kept our plan because the alternatives were worse. Other options had ever more strict underwriting requirements and wouldn't sell  us policies at all. Or they were ever more expensive. Or provided even worse coverage.

I supported the ACA and was very much looking forward to being able to purchase insurance on the health care exchange. We started getting insurance through my new job before the exchanges were launched. But it's instructive to compare what's available now compared to what we were going through.

The insurance exchange in New Hampshire is far from ideal. We're part of the federal exchange and have had to deal with the complications that came with that. What's worse is that there is no competition, and not much to choose from within our exchange. Currently, there is exactly one insurance company that offers policies through our state exchange.

The good news that the sole insurer is the biggest, most reputable insurer in the state. They can no longer pick and choose among members of our family. They don't get to decide if we're allowed to have more children. And getting an accurate quote from the web site was quick and easy

Under our old plans, we were paying a total of $832 per month for multiple plans, each with a $5,000 per person deductible. On the exchange today, a comparable plan would cost us $730 a month. Even without subsides, we could save over $1,200 a year. Or we could pay what we're paying now for superior coverage, fewer hassles, and a more reputable insurer.

I've been a supporter of health care reform. I didn't support that effort because I wanted everything to stay the same. I recognized that system was terrible. The whole point of the reforms was to change it.

That's not a promise that was broken. It's a promise that was kept.

Romney's $716 Billion Medicare Ad Campaign

Romney and Ryan have a new ad up explaining that they won't keep the cost controls Obama added to Medicare:

The ad complains that changes made in the ACA cut $716 billion dollars from Medicare spending over the next 10 years. This is true. Most of the cost reductions come from two changes to Medicare:

• Medicare Advantage: Medicare Advantage is an option that allows Medicare recipients to purchase private plans instead. The program will continue, but previously we paid 14% for the private plans than we pay for traditional Medicare plans. Under the ACA the playing field is leveled. We pay the same amount for the private and public plans, and save many billions of dollars.

• IPAB: The Independent Payment Advisory board is a an independent body with the mandate of controlling Medicare costs. They are charged with insuring that Medicaid costs don't grow faster than GDP + 1%. Previously, Medicare didn't really have a budget and so health care costs have been growing out of control. The IPAB is there to find inefficiencies and set policies to insure Medicare stays within its budget.

These changes, along with anti-fraud initiatives and other pilot programs, are on track to reduce Medicare spending by $716 billion over the next decade without a reduction in benefits.

Mitt Romney and Paul Ryan have pledged to get rid of these changes. They promise to spend an extra $716 billion on Medicare. 

The Romney and Ryan plans call for a similar mix of private and public plans competing on price. Cost growth is subject the same caps on rates. But their plan doesn't go into effect until 2023 at the earliest. That would mean pissing away the 716 billion dollars with another decade of runaway health care costs. And even then, they don't actually do anything to control health costs. The limited growth rate just applies to the voucher you'll get. The cost of the health plans can continue to rise, unconstrained. Patients will have to make up the difference with their own money.

They plan to convert Medicare to a voucher program. They waste a ton of money in the next decade. Over the long term, costs to taxpayers and consumers continue to rise. And even when it's fully implemented, their plan still costs the government and taxpayers more than the laws they seek to repeal.

Under Romney and Ryan that $716 billion doesn't get us a reformed Medicare system. It doesn't reduce the deficit. It doesn't provide affordable health care to all Americans.

It just allows them to run that ad.

Of Course the Individual Mandate is Constitutional

There’s lots hand-wringing going on today about the ongoing health care reform case before the Supreme Court. I don’t get it.

The question before the court is whether congress has the power to assess a tax penalty against people who can afford to purchase health insurance but decline to do so. It’s clear (to me anyhow) that congress does have that authority. It has it under both the commerce clause and under their taxation authority.

Health care costs have obvious implications regarding interstate commerce and interstate economic activity. Health care is a multi-trillion dollar industry. Every state, every municipality, every company, every family in this country has been pummeled by rising health care costs in recent years. The national deficit derives in no small part from rising health care costs. There are vast implications of escalating health care costs and with dealing with the uninsured. These implications transcend state borders.

If you travel to another state and get into a car accident, you will wind up in a hospital in that state. Whether or not you have insurance, whether or not you can pay your bill, whether or not the other people in that state will have to cover the cost of your care -- these are issues of interstate commerce.

The individual mandate is specifically designed to encourage people, who might otherwise take their chances on foregoing health insurance, to purchase policies from the upcoming health care exchanges. These exchanges will include national and inter-state plans. The entire point of the mandate is that it is essential in controlling costs in the plans offered in the health care exchanges, which will be available across state lines.

The counter argument is typified by the broccoli conundrum. If congress can assess a penalty for going without health insurance, where does does this slippery slope lead? Where does it end? If the tax us for not having health insurance can they tax us for not eating broccoli?

This is the flimsiest of straw men. The commerce clause ends when the activity being regulated is no longer relevant to interstate commerce. Since there is no economic necessity that compels the consumption of broccoli congress could not do so under the commerce clause.

But if congress can’t compel us to eat our vegetables using the commerce clause, they probably could do so using the tax code. The tax code is already riddled with exemptions, rebates, and penalties for all kinds of activities. That’s what the tax code is. You already pay a penalty for not owning a home, for not being married, for not having kids, for not being blind and for working for a living instead of cashing a dividend check. On the corporate side it’s even worse. No doubt there is someone somewhere facing tax implications for the manner and extent to which they do or do not produce broccoli.

A tax penalty for choosing to forgo health insurance is not extraordinary. And the punishment for ignoring the individual mandate is a tax penalty. You can’t be arrested. It’s not a crime. There’s no fine. When it comes time to pay your income tax, your health care decisions will contribute to the amount you owe the IRS when you file your taxes. And if you decide you aren’t going to pay this tax penalty - if you say screw health insurance and screw the tax penalty too -- that’s ok! There’s no penalty for that either. If you decide not to pay what you owe due to the individual mandate, the laws specifies that there’s nothing they can do about it.

The individual mandate is important to controlling health care costs across the nation and across state lines. That’s why it exists. That’s why it’s in the law. And that’s why we’re arguing over it. The enforcement mechanism is a tax penalty and a limply enforced one as well. Laws along these lines are well within the authority of congress.

"I Like Being Able to Fire People"

Romney really stepped in it on the eve of what is supposed to be his big win tomorrow in the New Hampshire primary.

“I like being able to fire people” is a line that is sure to haunt him. He’s not talking about his Bain Capital days - during which he surely did fire a lot of people. But the comment reveals him to be someone deeply out of touch with our times and the modern climate. Nobody with any experience with unemployment or a shred of compassion for those who have actually lost their jobs would think to say those words.

What Mitt is actually talking about is health insurance. He likes being able to “fire” his health insurer. This too is deeply misguided. The services a health insurer provides is paying your medical bills. When you’re staring at huge medical bills, that your insurer has refused to pay for, being able to “fire” your insurance company isn’t going to be much comfort.

If you do “fire” your insurance company, well, then you and your family won’t have health insurance. And if Mitt Romney has his way, then nobody will be obligated to sell you a new insurance policy on account of the “pre-existing condition” that caused the trouble in the first place.

Mitt Romney might “like being able to fire people.” That won’t get people to like him.

Health Care Economics: A Personal Case Study

Our family has health insurance. But our plan has a high deductible. We pay for first $5,000.00 in medical expense each year before the insurance kicks in. Part of the reason we got a plan with such a high deductible is that it saved us money on premiums. The other reason is that, after watching our premiums soar up year after year, we wanted to be responsible for our own health care utilization. With $5,000 of our own money on the line we had an incentive to consume health care services wisely. We would be the change we were looking for.

But managing your health care bills is not so easy. We learned that the hard way.


The Case

At first our decision to go with the high deductible plan looked like a good bet. Other than routine checkups, we had minimal issues. Then I got the call. One day last spring Christine fainted at work. She felt woozy all of sudden and sat down. The school nurse checked her out, called for an ambulance, and called me. I ran over. I arrived in time to check in and see how she was feeling before the ambulance took her to the emergency room.

At the ER, we were mostly ignored while the staff dealt with more severe cases. Eventually a doctor appeared. They ran a few blood tests. They ruled out anything that was an immediate concern. Then they kind of shrugged and sent us home.

Over the next few days Christine’s wooziness and weakness came and went. She always felt a little “off”. Sometimes she was too weak to stand. She missed a lot of work. Christine visited her doctor twice. They ran a few more tests. Then her doctor suggested an MRI.

We scheduled the MRI. Christine started to feel better and we thought about cancelling. Then she had another dizzy spell. Whatever was causing these spells had been doing it for three weeks now. Something was wrong and we had no idea what it was. We kept the MRI appointment.

We didn’t hear the MRI results right away. Christine started to feel better. And the problem went away. Eventually, we learned that the MRI didn’t show anything interesting.

Whatever the problem was, it went away on its own. At no point did Christine take any medication or undergo any treatment. We never even got a firm diagnosis. In this case, the outcome was the same as if she had never gone to the doctor at all.


The Bills

The ride in the ambulance cost: $758.60

The visit to the ER cost: $2,061.38

The visits to the doctor cost: $524.49

The MRI cost: $3,367.52


Health Care Economics

Before we consider the economic factors at work here, I would like to consider this question:

Why do I have such a crappy television?

We have a old, not at all flat, and rather small television. I have considered purchasing a new television on several occasions. There are lots televisions available. There are many manufacturers. Sometimes there are sales. Each year the price of new 42” flat-screen gets lower and lower. Over the years we have spent lots and lots of money on lots of different things. But we have consistently chosen to not spend our money on a new television.

This is classical market economics at work. There is competition based on quality and price. Information is available on the cost and features of each model. Retailers compete to get me to buy from them. I can make an informed decision about whether the product is worth the cost. And I can decide not to purchase anything at all.

Notice that when it comes to health care, none of these basic market principles apply.

The school did not consult with us or get a quote from the ambulance service before calling for it. The minute you set foot in an ER the meter is running and nobody is going to tell you how high. As she handed over her credit card, Christine asked the woman at the intake desk how much her scheduled MRI would cost. The response was “How should I know?”. When you get the bill, learn what the MRI cost and decide maybe it wasn’t worth the three thousand dollars, you can’t return it for a refund. And since you’re dealing with your health, something more important to you than money, you can’t opt out.

The principles of competition and selection that control costs everywhere else don’t apply to American health care. In other countries the government is paying the bills and sets the price -- controlling costs by fiat. But not in the US. With neither market forces nor government price controls, the entire system is price-blind, and costs rise without constraint. Even if we can’t control these costs we still have to pay for them - through rising insurance premiums, higher taxes, and shocking bills that arrive in the mail.

Bringing our nation’s health care costs under control will require application of some basic market principles, stronger government intervention, and a cultural shift to recognize the costs and limitations of modern medicine.

Our doctor would likely be shocked by the suggestion that she factor in the costs of tests and treatment. The doctor has a hard enough time sorting out sets of vague symptoms and trying to keep us healthy. She’s recommended the MRI because it might show something serious she can’t detect with a stethoscope. Her instincts, training, concern for her patients, concern for malpractice suits, and her own salary are all aligned. All of her incentives are pointing in the direction that says do more. But the doctor needs to recognize that, while we are deeply concerned about our health, it is not our only concern. She does us no favors by being blind to or concealing the costs. The patient is on the hook for the bill. The cost portion needs to included in the cost-benefit analysis.

We also need to recognize that, when it comes to our health, and the health of those we love, traditional cost-benefit analysis does not always apply. In an emergency, when dealing with a horrifying unknown, or with any serious medical condition - we will want more than we can pay for. The rational answer to the question of “Shall we save your life?” will always be “yes”. Cost be damned. You can’t take it with you. It is assured that some people will require vastly more medical resources than others. And at some point in our lives, most all of us are going required significantly more medical care that we can afford. We need private and public insurance plans to insure, at any given moment, the the large number of healthy people are paying in, and covering the costs of the few who need the most. Government regulation is needed to insure access and costs are broadly distributed. When market forces can’t produce an efficient outcome we require governmental intervention.

The major shift that needs to happen is cultural. Americans don’t like to talk about money. We don’t like to talk about our health. And we definitely don’t like to talk about, or even know about, our medical bills. But we are the ones who vote for the those who enact policies. We are the ones who either ask the questions of our doctors, or don’t. We are the ones have to pay the taxes, pay for the premiums, and pay the bills.


P.S. This isn’t really meant as a tale of personal woe. Paying out $5,000 sucks but won’t be an unbearable burden for us. In that other great American tradition, we recently refinanced our home to a lower rate. We took out a little extra to help cover the bills. Maybe we’ll even buy a new television.

You Lie!

You do lie, of course. I lie. All of us human beings do a fair bit of lying. We should not find it surprising or outrageous that politicians also lie. If you won't vote for politicians who lie, then you won't vote. President Obama is both a person and a politician, so yes, he lies. Anyone can be painted with that brush, and most people have been. It's surprising there is any bristle left on it.

Everyone lies, but we lie to varying degrees, frequencies, and for various nefarious and not-so-nefarious purposes. Among human beings, and certainly among politicians that have ascended to the office of the presidency, Barak Obama strikes me as one of the more honest ones. He has not been in politics, and certainly not been president, long enough to abandon his aspirations. He has not kept all his campaign promises. But he's been busy. He deserves some time and space to determine which promises and priorities he'll continue to pursue. We should not be appalled by inevitable compromise. Some commitments will go unfulfilled. Circumstances will change. He'll change his mind. Some dreams will die.

We still honor honesty, and should continue to ask for it. When the president was speaking to the congress last Wednesday he was articulating his principles. President Obama was describing his desires and expectations from the bills that congress is authoring. When the president said his plan would not use public money to pay for the health insurance of illegal immigrants, that was a statement of principle. The facts, the text of the bills, are still subject to amendment and change.

Congressman Wilson, and many of his more courteous colleagues, presumably agree that taxpayers should not purchase insurance for the undocumented. They may suspect that Obama's agreement is insincere, or that the current text is inadequate. Rather than assault him, why not just hold him to his word? Congress is authoring the bill. Joe Wilson is a Congressman. Why not work to insure the bill contains the principles that both Wilson and Obama say they support?

Obama wants the public option to be funded, not by taxpayers, but by subscriber premiums. He speaks of fair competition between the public and private insurers. Obama says he doesn't want a single payer plan and offers a market-based approach. He says, constantly, that he intends to (mostly) leave private employer-provided plans alone. Obama says he wants the plan to be fully funded, to reduce medical costs in the long run, and not add a dime to deficit.

Congressional Republicans don't argue that these are bad ideas. Instead, they argue, that Obama's health care reforms must be stopped because Democrats can't be trusted! So, don't trust them. Laws are written with words and those words have meaning. The GOP should be negotiating to insure their shared principles are signed into law.

Republicans, including New Hampshire's own Senator Gregg and that forgettable gentleman that spoke after Obama's speech, all claim they recognize the real and urgent need for health care reform. When described, the Republican plans sound a lot like what Obama is proposing. But when it comes to negotiating in good faith, the GOP is just yelling from the sidelines.

Of course, when Republicans say they support health care reform, they may be lying.

Me and Scott Brown's Mom: How I Took Down a Fence, Sparked the Tea Party Movement, and Almost Killed Health Care Reform

In the winter of 2003 my wife Christine and I purchased our home from the Brown family. At that time George Bush was President, health care reform was a distant dream, and Scott Brown toiled in obscurity. On that day, as we signed those papers, we had no way of knowing what would transpire in days ahead. We had no way of knowing how our fate would intertwine with that of the Brown family. We could not know how our rash decisions in the years to come might endanger the health of this great nation. Now we know. Only now, can this story be told.

That fateful winter the Brown family was divesting their holdings in Portsmouth following the untimely death of Scott Brown's Grandfather. Their lands were substantial. Standing in what is now our yard, members of the Brown family could look out in any direction and rightly say that everything they laid their eyes upon belonged to them. The houses are in there pretty tight. You can't really see very far. Nonetheless, such a sight must have instilled in the Browns a sense of majesty and pride. Unless they were looking through the window at the pile of black trash bags and the random metal step ladder the tenants kept in the dining room. That was not so majestic.

This corner of Portsmouth was the Land of Brown. It has been thus for many a generation. The sale our home was held up due to a title dispute. Some great ancestor had been willed a portion of the land in the 1860's. The land hadn't been bought or sold since. The lawyers had to locate the papers lost during the Civil War before the sale could proceed.

Proceed it did. We moved into our first home and set about repainting, renovating, and making it our own. This was a time of transition for the Brown family as well. They sold most of the property in the area keeping only the duplex behind our our house as a rental unit. With the substantial income generated by the sale of these homes members of the Brown family would have the opportunity to follow their dreams. An ambitious Brown might have found the means to go into politics, become a nude model in a woman's magazine, or buy a truck.

Looking back now, I can see that the years that followed were, for us, a time of peace and stability. A contributing factor in the neighborhood tranquility was an lovingly constructed but decaying set of white picket fences that ran along each of the property lines, separating all the homes and duplexes. Those who know me best may not be surprised that I purchased a home with a white picket fence. They might also suspect that the painting and maintenance of such a fence is not a task I approach with a lot of energy or enthusiasm.

It was during the fateful spring of 2008 that we decided to take down the back fence. Many have questioned our motivation in this. But our reasons were simple. We had a fence on our property. And we didn't want it. The previous summer, the neighbors had all collaborated on a coordinated fence painting project. The Browns declined to participate claiming the fence was ours to maintain. Considering this and the property line, Christine asked me if we might take down the fence. We would have a more pleasant view from the back porch. Our children would have more space to frolic with their friends and neighbors. I said "Ummm. Sure." The die was cast. Saws and crowbars were deployed. The fence came down. 

For a time the decision to take down the fence seemed like the right one. The new view was an improvement and the neighborhood boys enjoyed multi-family nerf battles. But the good times would not last. Within two weeks Scott Brown's Mom discovered the section of fence had been removed. She was not amused.

Christine observed Scott Brown's Mom examining the space where the fence had been and went outside to confer. My wife was met with a flood accusation. Scott Brown's Grandfather had constructed that fence with his own hand. Why would we tear down a perfectly good fence? Like the Little Tailor confronting an angry giant with a piece of cheese, Christine tore off a chunk of fence remnant with her hand and presented it to Scott Brown's Mom. Scott Brown's Mom was not intimidated by this show of strength. Neither was she convinced of the fence's imperfection. She stormed off cursing our names. We knew she would return.

The men came the next day. They inserted thin metal posts in the ground and attached a 4 foot tall, bright orange, thin, plastic snow fence that ran the full length of the property line. The new fence was an abomination. It came be known as the Fuck You fence. It was a flimsy eyesore that mocked us with it's vastness, it's pointlessness and it's cheapness. It served no aesthetic or protective purpose other than to say "fuck you" to all who gazed upon it.

I placed a call to Scott Brown's Mom seeking to negotiate a settlement between our warring factions. Sadly, the call was not returned and the stand-off continued. For weeks we endured the tyranny of the orange snow fence. Then, one day, we looked out. The Fuck You fence was gone.

That same day, Scott Brown's Mom returned. Christine saw her exploring the fenceless void. Once again she went out in the spirit of inquiry and to extend a neighborly hand. Christine was subject to yet another verbal assault. This one was even more violent, sustained, and expletive laden than the last one. The orange snow fence had not been deliberately taken down by Scott Brown's Mom. It had been dismantled. This was vandalism. Sabotage.

Scott Brown's Mom found the orange fence rolled up on the ground. She tossed it into her car and departed in a storm of rage and recrimination. This would not be the end. This crime would not go unavenged. The police would be looking into this matter.

No doubt the fine officers of Portsmouth Police Department heard about the severed snow fence. They committed all the resources to the investigation that a crime of this severity warranted. And they must have conducted their inquires with great cunning and discretion as their presence went undetected by all.

Within the neighborhood, the case was the subject of intense speculation. Who would dare to perform this brazen deed? Who could have snuck out and struck down the dreaded fence in the dead of night? A thorough canvasing of the neighbors was conducted as well as a full forensic investigation. My son held up a thin strip of orange plastic before me. "Look Dad. This was cut. With scissors." The culprit was never identified.

The new fence was erected within the week. This fence would not be so small or flimsy. Nor would the new fences be constrained by the dimensions of the missing segment. Soon the house behind ours was wrapped end to end in a 9 foot stockade, creating the general impression of a frontier fort meant to repel Apache. But it wasn't quite as ugly as the Fuck You fence.

With the lines of demarcation so firmly established, tranquility returned to the neighborhood. We thought this would the last time we would have to concern ourselves with the Browns. But, of course it wasn't the end. It was just the beginning. 

During the winter of 2010 the nation was embroiled in a great debate about reforming the countries patchwork, expensive health care system. Contributing to that debate was a small but very vocal group of radical right-wing pseudo-revolutionaries that called themselves the Tea Party. At that time Scott Brown was a Massachusetts State Senator. Following the death of Ted Kennedy a special election was being held to determine who would fill the seat of the Lion of the Senate. Scott Brown aimed the win that seat. The Tea Party prepared to rally behind him.

At first glance, it is surprising that hard-line members of the Tea Party would make common cause with a moderate Republican like Scott Brown. The Tea Party was violently opposed to health care reform. Scott Brown has been an advocate and supporter of the Massachusetts health care reforms that had become the model for the national system. What could they possibly have in common?

That winter the Tea Party risked obsolescence. Without an electoral victory they would be forever branded an insignificant fringe movement. They were propped up by partisan media executives that hyped and magnified their every utterance. But their message was incoherent. Their numbers small. And they were seen as beholden to the paranoid ramblings of a crackpot television show host. If they could be seen as crucial to victory in Massachusetts it would catapult them to national prominence. More than anything, the Tea Party was enraged by what they saw as the systemic destruction of the barriers, carefully constructed by the Founding Fathers, between the rights of individuals and the powers of government. They turned to someone who was similarly enraged about the careful dismantling of barriers erected by fathers. They turned to Scott Brown. The Tea Party wanted victory. Scott Brown wanted revenge.

As a state senator Scott Brown's powers dissipated at the New Hampshire border. In the United States Senate he might hold the power to stop health care reform. From this mighty perch he would be able to strike our health, our pocketbook, and our ideals. His formidable will combined with the power of the Tea Party proved unstoppable. He won the election.

But would Scott Brown be too late to stop health care reform? In the weeks before the special election the reform bill had already passed the US Senate with an overwhelming majority. But Scott Brown was sure the Democratic majority would want to try and pass it through the Senate again. This time he would be waiting. With Scott Brown, the Republicans had a 41 seat super-minority. If they stood together they could not be overwhelmed. Heath care reform would be totally impossible. Because lots of people on television said so.

Panic ensued among Democrats and health care reform advocates. Suddenly the dreams of health care reform seemed to be unobtainable. The plan of Scott Brown and the Tea Party was working perfectly.

Just when it seemed that all hope was lost, a Democratic strategist discovered a little-known procedure called "reconciliation". This obscure parliamentary provision has only been used before by every single session of Congress to pass nearly every major piece of legislation in the past 30 years: including the Bush tax cuts, COBRA, and Medicare expansion. It was a bold  gambit but it might just work. They tried it. It worked. Health care reform became law. Scott Brown would not have his revenge.

Are we safe? Or is it just a matter of time before this feud changes form and the battle is joined anew? Even as I write this words, I cannot say what the future will hold. I don't know what fate awaits me, my family, or health care reform. Will we ever be able to extend a hand across the barriers that come between us? I fear there are some rifts that can never be repaired.

Finally, Health Care Reform

They passed it. The President will sign it. The Senate will debate and pass the clean-up "reconciliation" bill. But, mostly, the drama is behind us.

This law is the most significant piece of legislation in decades. It is also far less sweeping than it's critics claim and fear. It is comprehensive, smart, and essential reform. It is not a government take over of health care.

The irony is after a year of arguing and endless hour of debate and breathless news coverage, most Americans have little concept of what the law will actually do. This is a strange by-product of the process. The bill's broad framework has remained consistent, but the details have always been a moving target. In the media, and especially from the right-wing media, there been a relentless focus on the daily talking points, conflict, partisan hyperbole, and politics over policy. Misinformation crowded out information from the beginning. So, it bears repeating what this law will actually do.

 The core components of health care reform are:

• Private insurance companies can join health care exchanges that will be able to sell insurance nation-wide.
• Health insurance companies will not be able to reject individuals because of their health history.
• Some people who don't have health insurance will get a tax credit to help purchase it.
• There are a number of policies and pilot programs aimed at controlling health care costs.
• It will be paid for by extending the %2.6 Medicare surcharge to include income greater $250K.

Most Americans will see no significant change to their health care insurance, to their relationship with their doctor, or to their taxes. For most Americans this is no big deal. Health care reform is a big deal for the uninsured, for people (like my family) who buy individual insurance, for anyone who loses their job, or wants to change job, or wants to start a new business, and for anyone dealing with chronic illness. The safety net just got stronger and wider.

This is also a big deal for anyone who cares about the effect of rising health care costs on their personal, state, local, and business finances or who cares about the national debt and deficit.

 For anyone craving more detail about what this law will actually do, I'll direct you to the excellent Ezra Klein who explains it all in great clarity and detail.

 Unlike the policy details, the politics of health care reform have probably gotten too much attention. Nonetheless, I'll offer my thoughts.

 A nice summary of the politics of health care reform comes from Lamar Alexander's comments during the President's conference:  

'Your stories are a lot like the stories I hear. When I went home for Christmas after we had that 25 days of consecutive debate and voted on Christmas Eve on health care, a friend of mine from Tullahoma, Tennessee, said, "I hope you'll kill that health care bill."

And then, before the words were out of his mouth, he said, "But we've got to do something about health care costs. My wife has breast cancer. She got it 11 years ago. Our insurance is $2,000 a month. We couldn't afford it if our employer weren't helping us do that. So we've got to do something."

And that's about -- that's where we are.'

Lamar's friend from Tullahoma captures the sentiments from the right and much of the American electorate. Reform opponents have been so vigorous and relentless in demonizing health care reform that even those who need it most, and who will benefit the most when it become law, are terrified and angry about it.

It is my hope that when health care reform becomes law some of the smoke will clear. Americans will realize that these are sensible, centrist reforms that provide great benefit to all Americans at relatively modest cost. It's my hope that the American people will realize that the tales of tyranny, taxation, redistribution, rationing, death panels, and government takeover bear little resemblance to the policies being enacted into law. It's my hope that people will recognize who has been feeding them this pack of lies and stop listening to them. And stop voting for them.

 The President and the Democrats should celebrate this victory. They should be proud of it. They have succeeded against mighty opposition from every quarter. They have prevailed where many have failed. This is good policy. It is also good politics. Victory polls better than defeat. The juicy sausage will be much more popular than the sausage making. I'm grateful for my own representatives Congresswoman Carol Shea-Porter and Senator Jean Shaheen. Both of them stood tall through it all and kept their promises to all of us.

Yes, we can.

FBB Part 4: Health Care

Critics of health care reform claim that now is not the time for it. With massive deficits and in the midst of a serious recession this is the wrong time to reform our health care system. President Obama has said the opposite. "Put simply, our health care problem is our deficit problem. Nothing else even comes close." The president is correct.

For more than a decade, private health care costs have had an average increase of more than 10% per year. The federal Medicare program cost $217 billion in 2000 and accounted for 2.3% of GDP. 10 years later Medicare cost $453 billion which is 3.5% of GDP. For the government, medical costs are growing faster than then economy. For the private sector it is worse.

Rising medical costs wiped out median income growth over the last 10 years despite rising productivity. Employers are cutting back on medical benefits they can no longer afford and passing the extra costs onto their employees. State budgets are swamped by rising Medicaid expenses. Municipal budgets are being squeezed.

We need to control rising health care costs in this country. That won't happen without comprehensive reform. Here, the status quo can not help us. Things are bad now. On our current path they continue to get worse. Much worse.

It may seem impossible to reign in medical costs. But many other countries manage to attain similar outcomes and life expectancy at half the cost. The nice thing about having a bloated, inefficient, patchwork system with few market incentives, local monopolies and inadequate cost control is this: There's room for improvement.

As a first step we must enact the health care reform bills before Congress today. Making affordable health insurance available to all Americans is a moral imperative. It will be an achievement worthy of celebration. It is also essential to control cost. Broader access to insurance will mean fewer emergency room visits, fewer medical bankruptcies, and fewer unpaid medical bills that get passed on as cost hikes for paying customers. Giving Americans access to a national health care exchange will provide more options and break local insurance monopolies. Eliminating exclusion based on health care history will mean health insurers will no longer be able to compete via risk management. They will no longer make profits by finding healthy customers and barring those that might get sick. Health insurance companies will be forced to compete by providing superior products at attractive prices. Instead of competing to keep away sick people they will have to learn to efficiently take care of them.

Beyond the basics of the bill, authors of the health care reform bill deserve a lot of credit for their thoroughness and dedication to creative cost control. The bill introduces market-based reforms such as price transparency. It includes a number of technical measures designed to reduce cost without cutting benefits. And much of the bill's frequently-maligned bulk comes for a host of pilot programs and experiments. These are designed to be tested on a small scale before the most successful ones are implemented and replicated nation-wide.

This is essential reform. We cannot afford to let it fail.

There are critics from across the ideological spectrum who say the cost cutting measures in the health care reform bill are insufficient. They may be correct. The current effort is an indispensable step. It it a giant leap forward. But really taming health care cost inflation may require we do even more.

There is a deep divide between the left and the right on the proper solution to health care cost inflation. Reformers on the right claim the insurance model itself is the source of the problem. Because consumers of care are separated from its cost they consume more than they otherwise would. People over-utilize and overpay because the bill is paid by someone else.

Reformers on the left point to model used in Europe, and Canada, and well, most every country on Earth. The public health is treated as a public good. The government provides for the health care of its citizens and manages the cost. It can control cost via massive purchasing power and regulatory authority.

If it to comes to Health Care Reform Part II (Secret of the Ooze?) the recommendation from Bank Slate health care economics team is that the American solution should borrow from both the left and the right. Do both. The government should offer a variety of public options and Medicare buy-ins. Some of these options should control cost aggressively. Some public plans should be less constrained. All plans should be priced to consumers to reflect their actual cost. Private health insurers should also be free to offer HSAs, high deductible plans, and other options that do more to put health care choices (and cost burdens) in the hands of consumers. Everyone gets their mandate. Poor people get their vouchers. Americans get to vote with their dollars and their feet.

Of all the budget problems we face, rising health care costs pose the greatest risk to our nations financial health. The one thing we can least afford to do is nothing at all.

Part 4 of the Bank Slate Federal Budget Blueprint series.

Shoot the Hostage

Alright, pop quiz. You're President of the United States. You've almost passed health care reform. You're past the House. You're past the Senate. You're almost there. You can taste it.

But you've got problems.

You've got two bills. They're about the same. They do what they need to do. But all you hear about are the flaws. Everybody is yelling and screaming. You need everyone to agree on everything or you're screwed. And Joe Lieberman might just screw you for the sake of screwing you.

You've a special election in Massachusetts coming up. And you've got your big State of the Union speech coming right at you. Like a bus.

Got that hotshot? What do you do?

Throw the special election. Take the Senate out of the equation. Have the candidate insult the Red Sox. They won't be able to drag her across the finish line. You can pass health care with a majority in the House. Clear shot.

It gets better.

After you throw the election, you watch everyone panic. Act like big reform is impossible now. What happens then? All the lefties that have been blasting you coming running to the rescue.

That Senate bill starts to look pretty darn good when the alternative is complete failure. Sullivan, Klein, Krugman, DailyKos, the single-payers, the public opters, the Medicare expanders, the bloggers, and the papers. Everyone is singing the same tune. The Senate bill will cover the uninsured. The Senate bill will cut costs. The Senate bill will sort out the insurance companies. The Senate bill is what we need. Everyone is on your side and singing the praises of your health care plan.

Just in time for your big speech...

Massachusetts Politics Get Even More Stupid

"I have two reactions to the election in Massachusetts. One, I am disappointed. Two, I feel strongly that the Democratic majority in congress must respect the process and make no effort to bypass the electoral results. If Martha Coakley had won, I believe we could have worked out a reasonable compromise between the House and Senate health care bills. But since Scott Brown has won and the Republicans now have 41 votes in the senate, that approach is no longer appropriate. I am hopeful that some Republican senators will be willing to discuss a revised version of health care reform. Because I do not think that the country would be well served by the health care status quo. But our respect for democratic procedures must rule out any effort to pass a health care bill as if the Massachusetts election had not happened. Going forward, I hope there will be a serious effort to change the senate rule which means that 59 are not enough to pass major legislation, but those are the rules by which the health care bill was considered, and it would be wrong to change them in the middle of this process,"

- Barney Frank.

Wow. Barney, I love you, man. But this is batshit insane.

The Senate passed a health care reform bill with 60 votes. The rules are stupid. The rules are paralyzing this country. But we played by the rules. The Senate passed health care reform. This already happened.

The House can, and should, vote for the Senate bill and send it to the President to sign into law.

You should do this because:

• It would be really good for the country.
• We need to fix our dysfunctional health care system.
• It would be the greatest legislative accomplishment in my lifetime.
• We've been fighting for this for decades.
• A large majority of American voters sent you to Washington to do this.
• Democrats will get annihilated in the next election if they fail. Again.

Do you and your colleagues think you can improve on the bill in some way? Would you like to, say... change some of the tax formulas or add a solid Public Option? You should pass a new bill and send it to the Senate for consideration. If members of the Senate support these changes, the Senate can -- still playing by the rules -- pass that bill through the reconciliation process. This, according to the rules, requires "only" 51 votes. This is also known as a majority.

That's the game. Those are the rules. You're winning. We're winning. Unless we decide to lose.

Oh, and read this...

Update: Frank has backed away from the statement quoted above. Thank you Barney.

Memo to Massachusetts

To all my good friends in Massachusetts:

You may have found the last year to be, politically, somewhat disappointing. You were probably happy to see Bush leave office. Now we have President Obama and very substantial Democratic majorities in both the House and Senate. And yet it seems like not much has changed. However lofty the goals of the Obama administration, however high our hopes for hope and change, the results have been... what... uninspiring?

Part of the problem is that governing, and trying to solve big problems, involves lots of compromise, horse-trading, and some raw politics. Necessary, but uninspiring stuff. But there's more at work here.

In the aftermath of the Bush era, the GOP had employed a very deliberate, simple, and systematic strategy.

In the media, and especially on right-wing radio and TV, the GOP has relentlessly hammered Obama and the Democrats without much regard for the actual truth of their allegations or the actual source of our woes. They are much more interested in demonizing Democrats than solving our problems. They are very good at it.

Meanwhile, in the United States Senate it is easy to for the minority to keep the majority from getting anything done. By refusing the play ball, not allowing votes to proceed, and vilifying everything that comes before them, the Senate GOP has quite successfully gummed up the works. In order to do anything at all, each and every Democratic Senator and both independent Senators (one of whom is Joe Lieberman) must agree to it. Forging this kind of consensus has been ugly business.

It's something of a historical fluke that it's even possible for one party to be able to scrape together 60 senate votes on its own. Margins like that don't happen often.

If the voters of Massachusetts, if you, elect Scott Brown it will be impossible for the US Senate to do anything at all without Republican votes. The Republicans, including Scott Brown, have promised that they will not get those votes.

This will be the ultimate vindication of the GOP strategy of paralysis, paranoia, foot-dragging and vilification.


I'm not very familiar with the politics or history of Martha Coakley. My sense is she is something of a machine-candidate mediocrity. You probably deserve better.

Will Scott Brown be better?

Quick Health Care Reform Note

• The bill going forward is a good bill. It's an important bill. It's not perfect but it is the best bill we'll get. Anyone who says they support health care reform but think this bill should be killed is a fool. Or they are lying. Or both.
  
• Hate Joe Lieberman if you want, but there's really no reason to hate him more than the 40 other non-Democratic Senators who aren't even negotiating on this. They are the ones really working to kill it dead.
  
• Read Ezra Klein's blog. He is doing fantastic reporting on health care reform and is just about the only writer who seems to really know what is in the bill and why it matters. He also explains it clearly and frequently.

Dear Senator Gregg

Dear Senator Gregg,

I am writing to you once again, to ask you to support the health care reform. I do not doubt that you are under a lot of pressure to oppose reform. You may have the sincere intention of opposing the current bills. But supporting reform now is the right thing to do. I think you know this.

I do not claim to be a steady supporter of yours. I do think of you as a moderate, sensible voice in the Senate. I appreciate that you are not prone to the partisan hyperbole that seems to permeate so much our national debate. There was a time when you sought to be a member the Obama administration and when they sought to have you. You know they are not monsters. You also know the severity and extent of the problems this administration faces. As you enter your final year as US Senator you have a unique, historical opportunity to do something important.

In your Washington Times editorial of 7/17/2009 you wrote:

"Our health care system is broken and must be fixed. We also agree that we must reform how we pay for this system, and, at the same time, reduce the number of people who lack coverage without disrupting the coverage that insured people already have.

We must encourage quality of care and reduce the skyrocketing medical bills so many families face. These are goals President Obama has endorsed and these should be the center of our bipartisan health reform efforts."

In that article and in subsequent comments you have been highly critical of ongoing reform efforts. Many of these criticisms are legitimate. But you were correct in recognizing the failings of our current system. These problems must be addressed. You should also recognize that the proposed legislation does, however imperfectly, address these concerns. It will vastly reduce the number of uninsured. It will not disrupt current insurance systems. It will not add to the budget deficit. It does make a first, tentative, but essential, attempt to control skyrocketing medical bills. These are important reforms. They are essential for controlling state and federal budgets. The are need by New Hampshire families and business facing ever-escalating costs. They are necessary for the millions of Americans who can't get and can't afford insurance.

Our system is broken. It must be fixed. If we do not reform this system this year when will we? How will we control medical costs in the future? In what year, under which administration, will tens of millions of uninsured, working Americans be able to obtain health insurance? How many more years will pass before we can put a stop to the medical-bill bankruptcies? What will happen to state, federal, business and household budgets during those years? I work for a small company. In the past two years my family's health insurance premiums have increased by 55%. Most insurers in New Hampshire won't sell insurance to my family because my son has a "pre-existing condition". In what year will there be a system that works for my family?

If you are opposed to health care reform out of your own self-interest, or because for political reasons -- if you are voting to maintain the status quo because you think it will hurt one political party or advance another -- then you must realized your reasoning is inadequate and sad. Do you believe that the current health reform bills will make things worse for citizens of this country? Do you think perpetuation of the status quo will be good for my family, and your family, and the people of New Hampshire? Even if you believe this, you know this system is broken. You know this administration is willing to compromise. You know there are deals to be made. You can work to produce a bill that is worthy of your support. You know that all laws are a product of compromise and are all imperfect. You know that the worst thing we could do is nothing at all.

Fixing our health insurance system is not easy. Easy or not, it is broken. It must be fixed. You serve the citizens of this state in the United States Senate. You have the power to fix this. You have the responsibility to fix this. You have been given the opportunity to fix this. The people of this country are relying on you to do what is right. Easy or not. Politically expedient or not. We have put our trust in you.

Scenes from Health Care Town Hell

Last Saturday I spent a rainy afternoon attending a Health Care Town Hall, here in Portsmouth, NH. This was my chance to make my voice heard, and to participate in the great debate of our day. In the finest tradition of our republic, I and about 150 of my fellow citizens, gathered to address our Congresswoman and to grapple with the thorny question of how best to insure the future health and well-being of the people of this great nation.

Despite dire warnings, the time spent waiting to get into the event went pleasantly. There was a remarkable lack of screaming, and most of the signs seemed to be of the pre-fab, pro-reform variety. I was tapping my toes to the tunes of the local Leftist Marching Band. Everyone was on their best behavior, and my line-neighbors where in good spirits despite waiting in the rain.

After being searched and wanded and passing through several layers of security I was into the main event. Clearly Congresswoman Shea-Porter was preparing for any contingency. If things to too rowdy we would be subjected a power-point presentation consisting of the artistic works for Norman Rockwell. Fortunately, it never came to that.

As I grabbed an empty chair in the middle section, signs of division began to show. Along the sides of the room there were several photographers. The baseball-cap-equipped man seated in front of me singled out the only one with a dark complexion and demanded to know why he was taking pictures of us. A murmur of approval went up around me. I began to realize that the group I was seated in the midst of, were, perhaps, not Obama voters.

Making the most of my situation, I struck up a conversation with the gentleman next to me and asked for his thoughts on Obama's health care reforms. He was opposed. We agreed that the bill itself did not constitute a government takeover, and came to a rough consensus on the contours of the slippery slope. Still, my neighbor wasn't going to get behind the Obama plan.

"I'm a long-term strategic thinker. Always have been. Maybe this bill won't lead to a government takeover. Maybe it won't happen for another 20 or 30 years. But I won't let them take that first step."

My conversation with the long-term thinker (henceforth to be dubbed L.T.) , would turn out to be very fortuitous. He would be my Virgil, my guide throughout the madness, the key to my understanding the events that followed.

At last, Representative Shea-Porter arrived, and the event could begin. The Congresswoman had been swept into office from relative obscurity in what was probably the biggest upset in the 2006 congressional elections. She had survived a reelection rematch in 2008, but was still relatively new to the job. This was the first time I had really seen her in action.

Shea-Porter welcomed us and established some ground rules. The chance to ask questions would be established by lottery. This upset some people who seemed to think priority should come by order or appearance or ranked by belligerence. Shea-Porter had an actual uniformed boy scout draw the numbers --establishing unassailable fairness of the system.

Before the audience Q&A kicked off, the Congresswoman had some invited guests provide their testimonials. One of her guests was a local woman named Laurie McCray. Laurie told the story of trying to buy insurance for her family, which was a kind of nightmare version of my own. Laurie's family members have some "pre-existing conditions" so their insurance policy, which has an obscene deductible and so covers nothing, costs them $2400 a month. And it still doesn't include their son, who has downs syndrome.

Although we came from all sides the political spectrum, naturally, Laurie's story had a profound effect on all of us. There was a shared sense that if it was impossible for a hard-working middle-class family to even buy insurance, then the system was truly broken. Our humanity united us, and there was collective acknowledgement that something had to be done.

Naw, I'm just kidding. That crowd wasn't going to agree on anything. As Laurie's allotted 2 minutes expired there were outbursts. "Time's up!" "Next!". As the next question would indicate, the extent of our differences extended to the very purpose and nature of the event we were attending.

"I've called your office every day for weeks to find out when you were going to face your constituents, who pay your salary, at a health care town-hall meeting." he announced. "I've been waiting since 8AM" (to get into this health care town-hall meeting). "I've been waiting for my number to be called, so I can ask my question, and now my number has been called, and I'm going to ask my question!" His question... "Why are you afraid to have a health care town hall meeting?!?"

The next questioner took things further down the rabbit hole, jumping right to "This is a Nazi plan." He then stepped back, gave a little smile, looking around the room. Clearly, he was impressed with his own courage and creativity and felt it would lead to YouTube stardom. To the audience's credit, there were more groans than gasps. I watched to see if Shea-Porter would go all Barney Frank on him. She went with "I may detest what you say, but I will defend to the death your right to say it." But her heart wasn't in it. "Nazi" has been done to death.

Judging by the boos and clapping, the room was evenly divided between reform advocates and opponents. The opponents were far more boisterous, better prepared with little speeches, and far more memorable. Advocates tended to just thank the Congresswoman, or ask a real question. I was thinking my question would be something really penetrating like: "Since the current system of ever-escalating costs is bankrupting so many citizens, businesses, states, and our federal government, and we have a vast and ever-growing number of uninsured people falling through the cracks in this failing system, do you support President Obama's modest effort to move to more rational, more competitive system, where everyone might be able to get some health insurance?" Shea-Porter indicated in her opening statement that she did support the current plan. So, I was kind of scrambling to come up with a new question.

Since incisive interlocutor didn't seem to be my role in this little drama, my major contribution was that of anti-heckler heckler. I often found myself shouting at someone who was trying to shout down someone else. My moment of triumph came when a grumpy guy jumped in, for the fourth time, with "I waited in the rain for two hours!" and was met with a chorus of "We all did!". I totally started that.

One woman said this was a socialist plan that was taking away our freedoms. She didn't specify which ones. The next speech came from someone who was going on about how there where 35 czars in the Obama administration, and why did he need so many czars? Shea-Porter actually argued with the guy about the precise number of czars there really were. This seemed a little beside the point. My seat-neighbor, L.T., seemed to find the czar argument compelling. I asked if he was aware that they weren't, actually, real czars. The czar nickname is kind of a joke. L.T. informed me that it was "the media" that called them czars. I was envisioning Glen Beck deciding to dub various bureaucrats as czars and then freaking out because there are so many government czars. It's a perfect, paranoid-delusion, feedback loop.

Apparently, one of the czars is even a communist czar. A guy named Van Jones declared himself a communist in 1992. The speaker was going on about his evil communist ideology. I wasn't familiar with the work of comrade Jones myself. Once again, I turned to L.T. for guidance. I did kind of snort in his face when L.T. informed me Van Jones is a "green jobs advisor", but L.T. took it well. I guess we were supposed to be scared that he's a communist. It seems more a comment on the sorry state of communist infiltration these days. Joseph McCarthy had a list of 200 card-carrying communists in the State Department alone. Obama just has one communist? Does he even carry his card? I think those cards are only good for 10 years.

Congresswoman Shea-Porter stayed pretty calm and patient throughout. She was asked if she had read the bill. Clearly she had. She was on a committee that helped draft it, and she was able to quote specific sections, or point out what had been removed or amended. She seemed committed to real reform without being overly dogmatic. When things got rowdy she was able to calm the room with a school-marmy "I can wait." And then she waited. It worked surprisingly well.

In the end there had been a lot of sound and fury of unclear significance. As we filed out, no doubt most of us left with the same opinion of health care reform we had come in with. We had said our bit, shouted at our congressional representative, or shouted at people shouting at our congressional representative, and participated in the democratic process.

Will we, as a country, overcome what divides us, come together and pass some real health care reform? Apparently the democrats, socialists, fascists, Nazis, czarists, and communists all support reform. If they can agree, there's hope for all of us.

Premiums Part II: This Time It's Personal

We hear a lot about how expensive the American health care system is. The true costs are obscured for a lot of Americans. Our employer or the government picks up the tab. There may be a problem, but it's not our problem.

Unhappily, this is not the case for me.

It's not that anyone in my family is sick, or that we don't have insurance. We're healthy. We're insured. However, neither Christine's nor my employer pay for our health insurance. We get to purchase our own. We get to pay the premiums. We notice when they go up.

Five years ago, when yet another tech start-up that employed me went belly-up, I did a brief stint as a consultant. I purchased a $1000 deductible plan from Anthem BCBS for a reasonable rate. We kept the plan and over the years the cost bumped up each spring. In the spring of 2008 our premiums were a mostly-reasonable $765 per month. In April we got a premium hike of over 20%. Anthem assured me this was not a mistake. This April they went up again to $1191 per month.

After a 55% jump in two years, I wanted out. It's not hard to think of ways I would rather spend $1200 every month.

As I shopped around for other health insurance options I had an unpleasant discovery. One of my children has a "pre-existing condition". Nobody would sell us a family policy. Nobody would insure my son. This came as a shock. I had assumed "pre-existing conditions" only applied to people who were, you know, sick. AIDS? Diabetes? It has to be something expensive and potentially lethal, right? We had none of that. The kids are never at the doctors and never miss school. I was looking to spend lots of money on an insurance policy that I had no expectation we would really need. Nobody was willing to sell me one.

Because my son was already insured with Anthem, they couldn't reject him altogether. Three of us got our own "family plan" with a $5000 annual deductible from Celtic. My son stayed on his own plan with Anthem. Total cost $657 per month. Cheaper, but with our deductible, we'll pay all our own bills, and insurance covers next to nothing.

This has been an educational experience for me. It is the lens through which I now view health care reform. Shopping for insurance has made clear to me the limitations of relying on for-profit companies to provide health insurance, and the extent of the monopoly power insurers have. No family wants to risk going without insurance. Insurers can raise rates without fear. To the extent that they compete, they compete to get customers who won't require health care. They are very conservative about guessing who those customers will be. For-profit health insurance companies don't make their money by healing the sick. They make their money by avoiding anyone who might get sick.

We hear about the high cost of health care for individuals and small business. The thought of paying $1200 a month in premiums brought that home for me, because I was writing the checks. This situation isn't very different for people who get insurance from their employer. The average employer-sponsored plan for a family of four cost nearly $13,000 a year -- not much less than I was paying.
The rising cost of health insurance is everyone's problem. The for-profit companies we have rely on are part of that problem.

Premium Health Care

President Obama was asked a good question at one of his town hall meetings last week. The question went to the heart of the confusion about the public option. Obama's answer missed the point.

The question was something like "If there's a public option, and I get my health insurance from my employer, can I just quit my company plan and jump on the public option?" The unspoken follow-ups are: "If lots of people do this, won't it cost a ton of money? Wouldn't that require a huge tax increase to pay for it? Wouldn't that be a government take over of health care - exactly what people are so up in arms about?"

Obama went on about how the CBO says his plan will cost less than $100 billion per year, how they will get some savings from efficiency, how they won't raise taxes on the middle class. All true. But beside the point.

The real reason you probably won't want to jump off your employer-provided plan, and onto the government one, is that doing so will cost you a lot of money. The public option is not an entitlement. It won't be given away or paid for in tax dollars. They will charge their subscribers premiums, just like any health insurance provider. This is why it won't require huge tax increases. This is why, unless your employer offers the government plan (and maybe even if it does), it may not be such a great deal.

Having a non-profit, member funded, health plan that anyone can buy into, may still be a great option for those who choose it. Some people don't want to have to pay for a government-run, public health care system with their tax dollars. Those people are in luck. They won't have to.

The Slippery Slope

"Government takeover of health care" is constant refrain from health care reform opponents these days. It is an article of faith that the "public option" in the various bills will lead to the end of the private system and everyone will end up getting their health insurance from the government. Once there's a public option that anyone can join, via the power of the slippery slope, it'll only be matter of time before the takeover is complete.

That reform opponents would have this fear and make this claim is not too surprising. More interestingly, the left, and reform supporters seem to have same expectation. They would really prefer a single payer plan. Obama isn't pushing for one. But through the public option and via the slippery slope we'll get there. Somehow.

Both sides are wrong about the power of the slippery slope. If we've learned anything about the current and historical efforts to reform health care, we have learned that it's not easy to change anything. The status quo is one big boulder. The slope may be slippery, but it's steep and goes uphill.

There is relatively little debate about the text and the implications of the bills themselves. Despite the hopes and fears of of the left and the right, the bills themselves are what's important. That's what we're going to get. And this is good thing...