Last week’s National Journal poll of political bloggers asked “What’s the most likely outcome this year of President Obama’s health care reform initiative?” The plurality choice on the Left, and the majority choice on the Right, was “Scaled-back legislation will be enacted.” I agreed: “Remember, even after the defeat of Hillarycare, many of its sub-elements were later enacted even by Republican Congresses. While time ran out on Hillarycare in the fall of 1994, this year the Obamacare supporters have nearly a year left to get something done.”
The second question asked about the political effects of the Citizens United decision. Seventy percent of the Left thought it would help Republicans a lot. Only 6 percent on the Right thought the same, while another 33 percent thought it would help a little. The leading choice on the Right was “not much impact.” That was my view, based on empirical experience: “Based on the experience of about half of the states, which never restricted the free speech rights of people in corporations, it’s hard to see much of a partisan impact from respecting the First Amendment.”
CrazyTrain says:
Based on the experience of about half of the states, which never restricted the free speech rights of people in corporations
No state, or the federal government, ever “restricted the free speech rights of people in corporations.” Rather, free speech rights of corporations as corporations was restricted. Whether that is constitutional is a difficult issues (as evidenced by the 5-4 decision we just saw, along with the diverse group of supporters and retractors of the relevant restrictions). However, the issue should be correctly stated if you wish to defend a certain view of it (same goes for people misleadingly talking about “corporate personhood” as somehow being the dominant issue in the case).
February 2, 2010, 6:29 pmChris Travers says:
I predict it will help encumbants, which currently means the democrats.
February 2, 2010, 6:30 pmAllan Walstad says:
The Supreme Court overturned this: that I and others cannot pool our resources in organizations like NRA and the Sierra Club, organized as corporations, to keep ourselves informed and get out our message out at election time. That was a damnable violation of the 1st amendment rights of people like myself.
Restrictions on free speech help incumbents. Reducing the restrictions improves the odds for challengers, particularly those who are not favored by the collectivist media.
February 2, 2010, 8:02 pmChris Travers says:
As for health care reform, I think a scaled-back plan will almost certainly be enacted in the near- to medium-term.
This is better anyway. We need a succession of modest reforms, not a 2000 page bill…..
February 2, 2010, 8:28 pmyankee says:
The legislation has already been massively scaled back from the original quasi-proposal, which was itself a very scaled-back proposal due to preemptive concessions to the insurance lobby. How much more scaled-back can it get? What are they going to, send the insurance industry a polite letter?
February 2, 2010, 9:02 pmChris Travers says:
Maybe institute interstate insurance gateways but leave the rest of the requirements off? Maybe remove the personal mandate?
February 2, 2010, 9:15 pmeyesay says:
“Scaled-back health legislation is likely” could be uttered only by someone who really does not understand health care reform at all.
The United States is the only industrialized democracy in the world without some form of national health care. Some countries, such as Canada, cover health care on a single-payer basis. This works pretty well, and one obvious way to do that in the United States would be to abolish the minimum age for Medicare and just make Medicare universal. This, by the way, is quite popular with the public, despite what you read on right wing blogs or hear on FauxNews. But owing to the reluctance of some federal legislators to support single payer, the next best alternative to single payer is to keep the present system of private insurance companies, based mainly on employers, with the proviso that insurance companies can’t refuse to cover pre-existing conditions and can’t charge high amounts for them either. The corollary to that is the requirement that everyone has to have insurance, because otherwise, healthy people would not get insurance until they get sick, which means there wouldn’t be premiums in the system to pay for the coverage when it’s needed. And, in turn, the corollary to requiring people to have insurance is to subsidize the cost for those with low incomes, because otherwise they can’t afford it. And guess what? That’s the bill that the House passed and that’s the bill that the Senate passed.
It can’t be simplified further, because if you eliminate a subsidy for the poor, they won’t be able to afford insurance, so you won’t be able to make it mandatory, and if you don’t make it mandatory, you can’t have a requirement that insurers have to cover everybody regardless of pre-existing conditions. All that remains is for the House of Representatives to grok the political reality of today and pass the Senate bill and send it to President Obama for his signature, and the United States will join the rest of the civilized world in having a national heath plan that covers everybody, or almost everybody, anyway.
Don’t imagine that a scaled-back health care bill can pass. It can’t. Republicans refuse to support health care at all because they know that it will be immensely popular with the voters and they don’t want the voters to thank the Democrats for it. Democrats won’t pass a plan that fails to achieve at least near-universal coverage. Right now, unless one or more Senate Republicans come to their senses and realize that national health care would please the voters, help the economy, save money, and improve heath care, the only way forward is to pass the Senate bill.
February 2, 2010, 9:15 pmbyomtov says:
Chris Travers,
Maybe remove the personal mandate?
Remove the personal mandate and you remove the ability to require insurance companies to cover people at any sort of reasonable rate regardless of pre-existing conditions. It’s that simple.
The basics of the plan are very straightforward, idiotic rhetoric about socialism, death panels, etc. notwithstanding.
If you want to guarantee that people can get coverage you have to mandate coverage. Otherwise you have people buying insurance while they’re in the ambulance. And if you are going to mandate insurance you have to help out those who can’t afford it. It’s a triangle.
If you don’t like the idea, fine. If you don’t care that people who lose their jobs may not be able to buy health insurance, that’s your opinion and you’re entitled to it. But don’t pretend that the three-way logical relationship doesn’t hold.
February 2, 2010, 10:02 pmChris Travers says:
But you have just shown how it CAN be scaled back. A second thing to note is that the legislation has increased in both size and complexity in the process of what proponents is what already scaled it back. Scaling back isn’t the right word to use for a process that turned a 1300 page bill into a 2000 page bill.
The first thing to be done might be to offer a subsidy to the poor, but dont make it mandatory, etc. Or one could focus on current inefficiencies, such as interstate insurance exchange plans, billing gateways, and the like.
The only folks who dont think things can be scaled back are those who want to rip out the autochthonous systems of state regulation and replace it with a shiny new federal bureaucracy which (they hope) will work perfectly right from the start.
February 2, 2010, 10:15 pmAllan Walstad says:
Back in 1776 we were pretty much the only democratic republic, too. Fine with me.
If you’re concerned about people who can’t afford the level of medical care you want them to have, by all means contribute charitably to their aid. Kindly stop seeking to have the pols and their enforcement squads rob your neighbors to assuage your emotions. By the way, anybody who seeks to have insurers cover people with pre-existing conditions simply has no idea of what “insurance” is. What you want is the equivalent of my buying insurance to cover me for damages when someone slips and falls on my property, after it happened. Where does the money come from? From the pockets of customers who paid their premiums over the years. It’s just robbery.
February 2, 2010, 10:18 pmrpt says:
When has the NRA ever been restricted in its lobbying and expenditures? Please….
February 2, 2010, 10:23 pmrpt says:
“Don’t get sick. If you do, die quickly,”…but please don’t rob anyone as you do. Maybe ideologically correct, but somewhat less than human.
February 2, 2010, 10:28 pmBenP says:
Not to mention completely false, because today if you DO get sick you get to go to the Hospital and get treatment anyway and the hospital gets to pick up the tab, (and charge us all for the part you won’t be able to pay) or possibly medicaid/medicare if you’re poor enough or old enough, then we all get to pick up your tab already.
February 2, 2010, 10:36 pmChris Travers says:
I think that states should regulate what level of pre-existing conditions are important in this case.
For example, just because someone has type I diabetes shouldn’t preclude diabetes-related treatments for the rest of his/her life if he/she must change insurers or do without insurance for a year. I don’t want the federal government involved.
February 2, 2010, 11:05 pmConstantin says:
Yeah, it works so well that the guys running the place come here for treatment when they get really sick.
February 2, 2010, 11:28 pmA. Zarkov says:
The personal mandate is not constitutional– it’s that simple. Now that Obama has insulted Justice Kennedy to his face, in public, he might not be inclined to rule in way Obama would like.
February 3, 2010, 12:38 ameyesay says:
Oh, Constantin, there we go again with the scare stories about Canadians who can’t get health care. Sure, you can cherry-pick the statistics and find that for this operation or that condition, waiting times are longer in Canada. But all-in-all, the Canadian system works very well; they cover everyone at a lower cost per capita than we pay for not covering everyone, and their life expectancy is higher (80.2 years vs. 78.2 years). Most Americans are not libertarians and most Americans realize e pluribus unum means we’re all in this together, and national health care is an idea whose time has come.
February 3, 2010, 12:43 amA. Zarkov says:
Life expectancy (at birth) is a poor metric for judging how well a medical system performs.
1. According to Dr. Arthur Garson author of the boom Medical Care Half Truths and professor at the Virginia School of Medicine, medical care contributes about 10% to human longevity. The rest is pretty much lifestyle and genetics.
2. Life expectancy is influenced by infant mortality. In the US, hospitals take heroic measures to save the lives of premature births. The Europeans classify as stillborn babies we classify as live. This means you can’t compare European and U.S. infant mortality statistics. Our rate comes out higher because of all those high risk cases the Europeans don’t try to save. I don’t know if this applies to Canada.
3. If you still insist on using mortality as a measure than you need to look at the force of mortality, which is a whole curve and not a single. number. From this curve you can compute conditional probabilities. For example the probability that a black person aged 60 will live another 5 years is greater than that for a white person. Yet the life expectancy for whites is greater.
4. The demographics are very different between the U.S. and Canada. We have many more blacks who have a high rate of infant mortality. You need to compare the different racial groups separately. About 15% of the US is Hispanic, and Hispanics have a higher life expectancy than whites.
Canada could have a better medical system, but your numbers don’t show that for all the reasons given above.
February 3, 2010, 1:08 amConstantin says:
(1) Apparently they don’t. How’s that bill coming?
(2) Another scare story. Again, the people that run Canada flee the place when push comes to shove and they need fixed.
(3) Did the memo go out that “we’re all in this together” is the new catchphrase for the socialists around here? I’m noticing it more and more in lefty speeches, and even in some groveling advertisements. I’m in “this” with everybody to the extent the Constitution requires it. Otherwise, I’m in it with my family and other people with whom I choose to associate as a free man.
February 3, 2010, 1:10 amBrian Garst says:
So the question is: Do they think it will help the right because they don’t like it, or do they not like it because they think it will help the right? I’m leaning toward the latter, which is pretty despicable.
February 3, 2010, 2:04 amThe Volokh Conspiracy » Blog Archive » Bloggers: Scaled-back … | Ffici Health says:
[...] Link: The Volokh Conspiracy » Blog Archive » Bloggers: Scaled-back … [...]
February 3, 2010, 2:05 amBrian Garst says:
And there can’t possibly be any factors other than the quality of health care that might impact quality of life? C’mon. Our countries are different, with different demographics, different behaviors, etc. That doesn’t tell us anything.
If you look at specific treatments, which do measure actual health outcomes, America outperforms. Want to survive cancer? You’re better off in the U.S. than anywhere else.
Argumentum ad populum and begging the question.
February 3, 2010, 2:12 amBrett Bellmore says:
Interesting; So the rate that it’s reasonable to charge isn’t a function of costs?
Speaking as a cancer patient, whose insurance is paying out the cost of a luxury car every few weeks, without complaint, but who will probably be uninsurable if I change jobs, I’m not impressed with this bill. The basic problem with our health care financing is that the insurance is tied to the employer, not the insured, so changing jobs terminates your relationship with the insurer, and requires you to establish a relationship with a new insurer.
Turning what ought to be a long term, repeat game into a series of one off encounters between sick people and insurance companies that didn’t collect premiums from them when they were healthy.
The bill does NOTHING to sever that tie between insurance and employer. It simply preserves the bad incentives, and then orders people not to act according to them. Stupid, stupid, stupid.
February 3, 2010, 7:35 amPersonFromPorlock says:
Is there anyone here who doubts that ‘scaled back’ today equals ‘scaled up’ tomorrow? It’s just the nature of federal programs, which is why we ought not to start until we have a pretty good idea of where we’ll end up.
February 3, 2010, 9:00 amKen Arromdee says:
Wouldn’t title 1 of HIPAA cover this? If you switch jobs your old insurance would be creditable coverage and your new insurance would have to cover preexisting conditions.
February 3, 2010, 10:36 amJohn Dewey says:
rpt: “When has the NRA ever been restricted in its lobbying and expenditures?”
McCain-Feingold, until it was ruled unconstitutional, prevented all corporations from buying broadcast advertisements which mentioned a candidate’s name 60 days prior to a federal election. It thus restricted expenditures by Exxon, by the NRA, by Right To Life, by the Environmental Defense Fund, by the Sierra Club, and by every other incorporated organization.
February 3, 2010, 10:41 amravenshrike says:
Among other things we shoot more people. And knife more people. And have a higher drowning rate. Until all variables are normalized along with definitions of terms, life expectancy rates do nothing to describe the health care of a country.
February 3, 2010, 11:28 ameyesay says:
A. Zarkov wrote that U.S. life expectancy is because we save more sick babies that end up not living as long, that other countries wouldn’t save and don’t count in life expectancy statistics. He and others also refer to demographics. More blacks means higher infant mortality and lower life expectancy.
Ravenshrike wrote that lower U.S. life expectancy could be attributable to that “we shoot more people. And knife more people. And have a higher drowning rate.”
Other countries have blacks with lower infant mortality rate and higher life expectancy than the United States. We have not reached the goal of a color-blind society and blacks still receive inferior health care, which is one reason we need national health care. Most shootings, knifings, and drownings don’t affect infants, so the infant mortality rate should avoid Ravenshrike’s critique. The United States ranks 33rd according to the U.N. or 46th according to the CIA. According to both sources, Cuba has a lower infant mortality rate than the United States. So much for the idea that national health care is bad for health.
Brian Garst wrote that the fact that most Americans favor national health care is “Argumentum ad populum and begging the question.” The question is, “Should the United States have national health care?” That is a political question, which is why the will of the majority should carry great weight.
February 3, 2010, 12:22 pmJabli Izvesti says:
The court decision has become a political football.It however is not going to make any significant difference for campaign finance as long as corporate lobbyists have free access to both the political parties.Moreover,big political donors like Soros can pose as social reformers and confuse the picture successfully.
February 3, 2010, 1:01 pmbyomtov says:
Zarkov,
The personal mandate is not constitutional– it’s that simple.
Well, that settles it then. No need for any further discussion.
Now that Obama has insulted Justice Kennedy to his face, in public, he might not be inclined to rule in way Obama would like.
Isn’t it you who are insulting Kennedy? Obama described the decision accurately and that’s an insult, but claiming that Kennedy will let personal pique influence a future decision isn’t?
February 3, 2010, 1:27 pmlrC says:
>Some countries, such as Canada, cover health care on a single-payer basis. This works pretty well
Why don’t you guys just copy and pass the Canada Health Act?
>If you want to guarantee that people can get coverage you have to mandate coverage. Otherwise you have people buying insurance while they’re in the ambulance. And if you are going to mandate insurance you have to help out those who can’t afford it. It’s a triangle.
And apparently it takes 2000 pages to legislate such a simple triangle. Surely nothing else could be hidden in there.
February 3, 2010, 2:22 pmChris Travers says:
On this point, the senate bill has an imaginative solution. Basically the conclusion is that blacks and hispanics are underserved medically (which may be). The solution to that problem is to lower the legal requirements for serving ethnic minorities, particularly where long-term care is involved.
Under the senate bill, long-term care facilities who hire individuals who abuse patients, or who fail to keep records of their measures to prevent hiring of such people can have their fines reduced quite dramatically if they are serving ethnic minorities. I call this the “Jim Crow” provision because it ensures substandard facilities for blacks and latinos. It may even be a good argument for preserving section 5 of the voting rights act……
February 3, 2010, 3:36 pmleo marvin says:
The Constitution doesn’t require us to spend a penny to prevent crime. So, provided none of those people you choose to associate with are in a hospital about to be burned down, that’s their problem, right? Why should you pay cops to prevent it or to catch whoever did it?
February 3, 2010, 4:05 pmA. Zarkov says:
U.S. hospitals try to save high risk premature births that other countries classify as stillborn. Naturally many of the high risk don’t make it. The stillborns in other countries are not counted as infant deaths. We have been through all this before on another thread years ago. I posted a link to a CBO report that discusses the details. The ranking you quoted is not meaningful.
My basic point is life expectancy is not a good measure of how well a medical system performs for all the reasons I listed.
February 3, 2010, 8:22 pmA. Zarkov says:
Whether I’m insulting Kennedy of not is immaterial. I’m not promoting legislation he might have to rule on.
Hispanics live longer than whites. If anything they need less long-term care by your reasoning.
February 3, 2010, 8:25 pmChris Travers says:
My reasoning? I suppose you missed he sarcasm in that first paragraph…..
I think that any law which systematically reduces penalties for crimes against minorities needs to be defeated soundly. That includes the current Senate bill.
February 3, 2010, 8:44 pmA. Zarkov says:
Whoops. I was being dense and misread you. Sorry. I agree.
February 3, 2010, 10:29 pmeyesay says:
Zarkov, please post your link(s) again to support your claims that “U.S. hospitals try to save high risk premature births that other countries classify as stillborn. Naturally many of the high risk don’t make it. The stillborns in other countries are not counted as infant deaths. We have been through all this before on another thread years ago. I posted a link to a CBO report that discusses the details.”
February 3, 2010, 11:50 pmA. Zarkov says:
CBO Staff Memorandum: Factors Contributing to the Infant Mortality Ranking of the United States. Here is the pdf file. This is the relevant paragraph, but I urge you to read the whole thing.
February 4, 2010, 4:57 ameyesay says:
Zarkov, thanks. That was a 1992 report and its most recent data set was 1986-1988, which is 22 to 24 years ago. The data on low birthweight rates in developed countries are mostly from 1980 (with some as old as from 1977). So most of that data is now 30 years old and some is older than that. A lot could have happened in the past 30 years in the practices of other countries to “attempt to resuscitate newborns weighing less than 500 grams.” Got anything more up to date, or do you want to stop using 30 year old data to explain why it is OK for the United States to rank 46th in infant mortality?
February 4, 2010, 11:53 amA. Zarkov says:
Got any data that contradicts the CBO report? Can you show me that the infant mortality figures from the US and other countries are now comparable? There really is no reason they should be unless there were some kind of international standard.
February 4, 2010, 12:13 pmeyesay says:
A. Zarkov, you are obviously not a mother. Any woman I know who gives birth wants her baby to survive and thrive. If a woman in France, Germany, Taiwan, or any other country with modern hospitals gave birth to a half-kilo baby, she wouldn’t say, “Oh, well, I guess my baby will have to die. She would say, “Save my baby!” It is not credible that if the United States has routinely saved half-kilo babies for over twenty years, they would still be left to die in Canada, England, or Belgium.
Also, civilized nations of the world, that is to say, the ones that have national health care, also have much better prenatal care than we do here in the United States. Our inferior prenatal care leads to higher rates of low birth weight babies. If that higher rate of low birth weight babies makes our infant mortality rate higher and our life expectancy lower, the right way to fix it is to improve prenatal care, rather than trying to change the definition of a live birth for the purposes of infant mortality and life expectancy statistics.
You’re the one who brought up this argument about different practices regarding premature births in the United States. You’re the one whose ace in the hole is a report based on thirty-year-old statistics. Don’t be trying to shift the burden on me, especially when it is utterly incredible that mommies in other countries would tolerate allowing their babies to die when the United States routinely saves similar babies.
February 4, 2010, 4:21 pmA. Zarkov says:
Why wouldn’t the same apply 20 years ago? Did the women in other countries change their attitudes after 1990? A one pound newborn has no chance of survival without extremely expensive heroic measures. The report is quite clear that foreign doctors were much less inclined to apply such measures, and such newborns were simply not classified as live births.
In any case is a difference between 6/1000 and 4/1000 all that significant? If the US had 4/1000 it would rank with Switzerland, a country with very few blacks. The white infant mortality in the US is about 4/1000. Look at the figures in terms of survival probabilities.
1-.006= 0.994 and 1-.004= .996
Here we see the survival probabilities are trivially different. Same data, different viewpoint. Now we can ask the question: how much is it worth to improve the survival probability from 0.994 to 0.996, a change of 0.2%? That sounds a whole lot different than asking how much is it worth to drop the infant mortality rate from 6/1000 to 4/1000, a change of 50%. Which is the right way of looking at this 0.2% or 50%? Let’s do a hypothetical choice between two airplanes.
How much extra would you pay to ride on an airplane with an accident rate of say 4/million as opposed to 6/million? An extra $50 per ticket? Sounds like good value in terms of the accident rate reduction, but if you look at the deal in terms of survival the question becomes: how much would you pay to increase your survival probability from 0.999994 to 0.999996, an increase of .00002%? Probably nothing. Same numbers different viewpoint. This is what happens when small risks are involved.
February 4, 2010, 7:32 pmeyesay says:
Zarkov: Presumably, in the 1980s, saving a half-kilo baby was still an extraordinary heroic measure. But that was twenty to thirty years ago, and presumably by now, papers have been written and published and the non-U.S. medical world knows how to do what we pioneered back in the 1980s, and their citizens are demanding it.
There are about 4.2 million births in the United States each year. An infant mortality rate of 4 per thousand means 16,800 infant deaths a year. An infant mortality rate of 6 per thousand means 25,200 infant deaths a year. The difference is 8,400 more U.S. infants dying each year. I don’t know about you, but I think this is a big deal. This is the equivalent of more than two 9/11 events every year. We know how to achieve 4 infant deaths per 1000 live births. Providing the same quality prenatal care for poor people as we do for everyone else would help a lot. E pluribus unum.
February 4, 2010, 8:04 pmA. Zarkov says:
It would be a big deal for (say) Singapore, but certainly not for India. We cannot make a judgment about 8,400 with some kind of normalizing factor. This brings us back to either survival or mortality rates. The reason the US is at 6/1000 instead of 4/1000 is the US black population. The black rate has dropped from about 12/1000 to 8/1000 over the last 30 years, but I suspect there is little the medical system can do as the higher rate is most likely related to behavior or genetics. Even if the medical system could do something it might be prohibitively expensive, and the money could be spent somewhere else to greater benefit. So to answer your question, I don’t think 8,400 is a big deal for a country with 303 million people.
February 4, 2010, 11:40 pm