One of my persistent criticism of Americans is that for most of us our formal education in morals and ethics, if any, ended in primary school. Every thing else we picked up on the streets. Colby King’s latest column asserts the moral imperative of the PPACA:
Forty-nine million Americans do not have health insurance. For many of them, the ability to deal with their illnesses and injuries depends on their ability to pay. Lacking the money, some of them just go without the care they need. Better to put food on the table for the kids than to check out that awful pain in the gut. Can’t afford to do both.
[…]
Gaining access to no-cost preventive services to stay healthy, which Obamacare provides, is not a sign of indifference. Neither is giving senior citizens discounts on their prescription drugs, or allowing young adults to get health insurance on their parents’ plan, or ending insurance company abuses. Those steps represent the caring actions of government.
Sadly, the design, structure, and implementation of the PPACA undercuts his argument seriously.
The PPACA is a system for ensuring that more Americans have healthcare insurance. It neither guarantees that all Americans will have healthcare insurance nor does it provide that, having insurance, they will have access to healthcare, nor that the healthcare to which they have access will be effective. Mr. King draws too straight a line between insurance and care. While I agree that a society that denies care to a large chunk of its people has a serious moral problem, I don’t think there’s a similarly compelling moral argument for insurance.
Additionally, while there is a good moral argument for the rich subsidizing the healthcare of the poor, I don’t think there is a similarly compelling moral argument that the healthcare insurance of families of four with a family income of $82,425 should be subsized by families of four with a family incomes of $82,426. But that’s the way the PPACA is structured.
Finally, I don’t think that Mr. King takes his argument far enough. Who is worse, someone who argues against the PPACA on the grounds that its design and structure are inherently flawed or someone who argues for it, benefits from its enactment into law, and then drops the ball so that its execution is seriously if not fatally flawed?
If everything depends on one’s unknowable intentions, Mr. King needs to make his argument that those who opposed the PPACA intended to harm the poor. He doesn’t do that in his column.
Who is worse, someone who argues against the PPACA on the grounds that its design and structure are inherently flawed or someone who argues for it, benefits from its enactment into law, and then drops the ball so that its execution is seriously if not fatally flawed?
WRECKER!
I think it is sufficient to note that those who opposed the ACA had (and have) no plan that they were (are) willing to try to put into policy. This was our only shot at reform. No reform we pass is likely to be universal as long as we have so many illegal immigrants and we have some version of the Tea Party running around.
Absent insurance, those without have near zero access to health care. With insurance they have access, remembering that a long waiting time is shorter than an infinite one. Besides, I fully expect the provider side to pick up the slack except among PCPs. They are a separate issue unto themselves.
Steve, I think you’re claiming to know a lot more than you actually know. What was the Democrats’ healthcare plan in 2007? After all, they had control of both houses of Congress. Somehow they came up with a plan a relatively short time later. You cannot infer the impossibility of enacting a plan from the previous absence of a plan.
You’ve inferred that the PPACA is the only possible plan from the absence of a Republican plan prior to 2009. Since there was no Democratic plan prior to 2009, that’s a pretty weak inference.
Additionally, you’ve implicitly asserted that there is no care without insurance. Since that’s manifestly untrue, you are, presumably, exaggerating to make a point.
I think it’s true that without subsidy healthcare is too expensive for many people, unaffordable. As structured, the PPACA covers much, much more territory than that. A more modest standard for baseline insurance plans, for example, would have solved the problem at lower cost. Multiple standards (depending on one’s circumstances) would have been more controversial but also would have solved the problem, presumably at the cost of higher subsidies for some of the standard plans.
Finally, giving insurance to one person while in effect taking it away from another does not support a strong moral case. We’ll be able to make a better assessment over whether the PPACA is moral or not when the dust has settled. Making such a judgment now is premature. That judgment could only be arrived at by evaluating intentions and I think those are very difficult to determine.
Maybe people overlook the contrasting minutia of morality, such as the differences between reasoned, directed-to-the-needy versus slathered-on, class-warfare, bleeding heart liberal type of moralities.
The former, IMO, creates a compassionate case for medical care access focusing on those with limited to no financial means — i.e. walk-in clinics, government subsidies/vouchers, low-cost medical insurance pools etc — while continuing to support/allow the greater number to exercise their own health care criteria, absent government input or mandates . Mix in tort reform, free-market ideas/innovation, a fearlessness to genuinely address/reform medicare entitlements, fiscal inadequacies/fraud, and a below-par medicaid system, without putting undo burdens on any generation, and a far less onerous and fairly placed kind of morality would be implemented in HC changes.
The latter, what we are wrangling with currently, puts the onus on the majority, wrecking havoc and involuntary changes of healthcare in order to insure the uninsured — some of which who will continue to be uninterested in accessing even ‘free’ insurance, at least according to CBO projections. In Thanksgiving terms, it’s similar to cooking all entrees and sides at the same temperature, with an end result of having a few eatable dishes, while the rest are either undercooked or burned.
It’s rough to have to choose between healthcare and food on the family table, but I can already see it coming: Obamafood.
Just think how much more secure and happy Amerikans would feel if they could just pay a few hundred bucks a month for food, be limited to one or two grocery stores, and subsidize the kosher, halal and japanese food next door! Not to mention that there are no overseas Krogers or HCAs in their network, so screwed they are by Obamacare and Obamafood when they travel.
Obamasex next?
In Steve’s world ‘proposals’ don’t count. The ideas contained within said proposals are consequently vacuous and/or irrelevant, as to overarching discussions on what to do about HC reform.
What counts, and what Steve acknowledges, is something irreverently passed under a low bar — such as a Congress having high democratic majorities to unilaterally pass something without regards or appeasement to it’s opposing political count parts . Deviousness also seems to be overlooked, as to a law’s suppressed surprises and untowards hardship it creates on the masses already having health insurance. To me, this is evidence of the will and hand of tyranny, rather than due process being earnestly applied by a government representing justice, temperance, morality and fair play for all people.
Absent insurance, those without have near zero access to health care.
Bullshit. I’ve been without insurance prior to the passage of the PPACA, and had need of healthcare, and got it. That doesn’t mean the system before was good, but to claim that no health insurance is the same thing as having zero access to healthcare is fucking egregious in its sheer dishonesty.
Dave- The Dems tried, poorly, to pass reform when Clinton was in office. I am sure you remember the ads. I keep trying to emphasize that it is not just the presence or absence of a plan, but the willingness to try to pass one. That does not exist in the GOP. They are trapped. In order to provide care for more people you need to spend more money, absent a major change in our system. They wont do that.
Yes, if you have money and no insurance you can get health care. If you have no money and no insurance you can get emergency care, most of the time. Some hospitals manage to not provide the emergency care they should. It is not a high priority issue for law enforcement.
I have no problem with changing the standards, but I would like for them to be cost effective if we are using tax money. If we eliminate maternity care, do we pay more in the long run? One of the problems we face when health care is not provided by a unified plan for everyone in the country, is that some costs just get passed on since insurers will never see those costs. Anyway, as I have said, the ACA provides a framework that would let us do this if we want. Absent its existence, we could not. We would have no reform.
There is little or no evidence that we are taking insurance away from some people to give it to others.
Morals without intentions? Sigh. The intent of the law was pretty clear. It was to increase access. It also makes some attempts to address quality and costs, but those were secondary. I think you could say they had a moral obligation to devise a plan that was likely to work, and that could successfully be made into law. Given the structure of our govt., I think they did that. It could have been better. They could have phased out the subsidies better. They could have trusted their own plan enough to let people keep the insurance they had, and just made them pay penalties if they wanted to enter the plan later. Etc.
Steve
In Steve’s world a proposal is not enough. Many “proposals” are just red meat to fire up the base, or cover to make it look like you have a plan, knowing you couldnt get your own party to vote for it. What matters is being willing to put votes on the line. Any health care plan that pays for care for the poor is going to get demagogued after the fact. Political careers will end. Or rather, passing a plan that you fund will do this. Americans love tax cuts. They love new services. Provide a new service AND pay for it and then you face issues. I will readily concede that the GOP is willing to pass health care law with new services if they dont have to fund it.
Steve
The ACA provides a framework that would let us do this if we want.
The ACA is far more than a framework. What it does is utterly change the perimeters, criteria, and access to HC networks for most people. That’s why it’s called a “comprehensive” plan, not just a plan attending to and correcting cost overruns or the absence of HC access to a minority of people, prior to it’s enactment.
What matters is being willing to put votes on the line.
However, putting votes on the line when you have a Congress majority based in absolute willingness to do the will of the President, means nothing as to the quality or fairness associated with such a bill. This was a bill disliked by most of the public, imbued with the political cunning to pay-off enough dems, while alienating all of the GOP, in order to eventually hail the passage of a very flawed law on the eve of a national holiday at the end of an embattled year. Garbage in —-> garbage out.
Me:
Ellipsis:
That reminds me of a story. Back when I was in the antiques business (a hobby that made a little money—I never made my living do it) I went to a lot of auctions. One day I was at an auction, seated next to a crusty, elderly character who was a self-made millionaire in the days when a million was a lot of money. I engaged him in conversation and he proceeded to tell me the story of his life. After a while, I said “Fascinating.” He said, that’s the difference a college education makes. You say ‘Fascinating.’ I say ‘Bullshit!’.
“You say ‘Fascinating.’ I say ‘Bullshit!’.”
College educations often politely nudges one to circle the nail, rather than hitting it. Enrollment in the University of life, though, generates a far more accurate swing, where one aims for the nail, hitting it directly on the head.
“This was our only shot at reform. No reform we pass is likely to be universal as long as we have so many illegal immigrants and we have some version of the Tea Party running around.”
I don’t see how you can possibly come to this conclusion. Only? Let’s posit that food, clothing and shelter………..and healthcare services are basic necessities to provided for those who cannot in a relatively wealth society. Were the projects the only solution to housing for the poor? Our “only shot?”
Here in Chicago this man’s inhumanity to man was shut down because it was poorly thought out, poorly executed and just became a complete disaster. Hardly our only shot. Sounds like where Obamacare is headed.
Illegal immigrants? Talk to the Democrats, because they want the votes. And I know its fashionable to just say “Tea Party” and think the argument is won, but these are just people who don’t believe in large government solutions, ever increasing taxation (which really isn’t spent on the stated goal of the poor) and national finances that are headed to “Grecian Formula” due to ObamaCare-like transfer programs. The War on Poverty has never ended and has been all but lost. The Tea Partyers seem closer to reality than liberal zealots.
The CBO has stated that the number of people who will be uninsured after ObamaCare is fully implemented – say, in the year 2070? – will drop from 50MM to 30MM. While the system we have, and becoming oh-so-painfully obvious an awful lot of people liked, is destroyed. I simply cannot think of a worse, or immoral solution.
It simply defys all logic and shocks the conscience to believe the politicians don’t have other motives than providing health insurance to all.
The moral issue I’ve been thinking about is whether a bad result is worse if the government is the cause or the market is the cause.
I know someone who lost his home several years ago because of a screw-up in a government program intended to help people invest in high minority/high poverty neighborhoods. He got federal government money to make capital improvements to his home, and as a part of the program, the government placed a lien on the home, just to prevent the owner from flipping it for a period of years. In this case, the government accidentally spread the value of all such government aid in the city that year on his property, causing a default on the primary mortgage. The feds pointed the finger at the city, and vice versa. He didn’t have a lawyer. The government told him everything would be taken care of, but when he showed up at the foreclosure the city greeted him with the good news that they had worked it out so that he didn’t owe anything once title transferred to the new homeowner.
A lot of people lose their home every year, but what should I think about that program? I’m sure more people benefit from that program than lose their homes. But I hate the image of the smiling government employee, congratulating the fellow that just lost his home with the good news of his hard fought efforts on his behalf. Mr. Potter doesn’t represent me, but the government does, and I feel responsible for the government fucks-up that I don’t when its private enterprise. If it was up to me, I would not have such a program.
The main issue I see with government “morality” is that government should only make promises it can reasonably keep. Obviously there will always be unintended consequences and things you can’t foresee. But there is a lot that is foreseen that is ignored or kicked down the road. Anyone from Generation X understands this particularly well as we have grown up understanding that government promises are always subject to political realities and demographic math.
But when a bill that even proponents don’t understand (Nancy Pelosi – “…we have to pass the bill so that you can find out what’s in it…”) passes, then government is making false promises. I think it’s immoral to sell legislation that you don’t even understand, or legislation that is subject to the non-trivial machinations of the regulatory bureaucracy (see the PPACA and Frank-Dodd).
Just as another example, take the cancelled policies in he individual market thanks to the PPACA. Although this was reported last spring in a few articles, the Executive made every effort to downplay the negative effects of existing individual market plans, even while HHS was writing rules that would result in what’s happening today. The chickens came home to roost politically with that.
steve,
Whether or not the GoP has/had a plan is not relevant. The disaster that is today’s GoP and conservative movement does not excuse mistakes and bad legislation passed by Democrats.
Just as a general point, IMO, neither party is interested in good government. Despite the debacle of the PPACA no one of political consequence is talking about systemic reforms in the federal bureaucracy – it’s a topic that partisans and the beltway establishment is blind to…
Drew- That is the correct number, after the Supreme Court ruling, since many states are projected to not expand Medicaid as was initially planned. The ACA was written with the assumption that those with incomes below the poverty level would be eligible for Medicaid. Since people under the poverty level are not eligible for subsidies, they cannot afford insurance. Add these people to the illegals and you have the large majority of your 30 million uninsured.
Just to bring you back to earth, who is it that keeps stopping immigration reform efforts? What exactly has the Tea PArty accomplished other than shutting down the government and passing lots of socially conservative bills in the states? As we all know, it is Medicare which makes up the large, large majority of our future debt. Where is the Tea Party rhetoric on cutting Medicare? There is none. They want to cut spending they dont like, and maintain or increase spending they do like. And cut taxes. Sure, I think there are many who actually do believe in smaller govt, but the policy they influence does not lead anywhere except to chaos.
Steve
And that provision was based on the assumption the federal government could force the states to expand medicaid by withholding all money from states that refused the expansion….What about the other assumptions in the ACA – not looking too good in hindsight.
It really depends on what the reform is.
And those who believe in more government have lead us where exactly?
In my view that’s a key problem with the particular style that technocracy is taking in the U. S. When laws are passed that not only give but require broad regulatory discretion, their consequences are not only unforeseen but unforeseeable. Sometimes from week to week.
In my estimate it’s that there are two differing consensuses. Among lawmakers there’s a broad consensus in favor of legalization and more immigration. Among voters there’s an equally broad consensus supporting less immigration or maintaining it at about the same level and enforcement first. That gap means that Congressmen have the choice between keeping their donors and keeping their jobs. They choose, prudently, to delay.
IMO there are individual issues that would have popular support and could pass the Congress. The insistence on comprehensive immigration support, in essence a device for imposing unpopular measures along with popular ones, prevents those issues from being enacted into law.
Which specific immigration reform measures do the GOP support, in particular its Tea Party? Other than building a wall, is there anything they can vote for? As of a week ago, the Dems have said they will accept a piecemeal approach if it gets done. However, I am not seeing any of the pieces or their parts being discussed. I think he cant get it past his own caucus, but I guess we will see.
http://politicalticker.blogs.cnn.com/2013/11/21/boehner-insists-immigration-reform-absolutely-not-dead/
Steve
Judging by recent public statements by Speaker John Boehner, an expansion of H-1B visas and some version of the DREAM Act have a chance of getting to the floor. I don’t much care what the most extreme Republican members of the House do or don’t want. It’s what can get to the floor that matters.
Whenever you have a bill with “comprehensive” attached, there is usually a combination of good/bad, popular/unpopular attached. The PPACA is one of the best examples demonstrating how “big’ is not always better, contrasting the positivity of taking on controversial changes gradually, more piecemeal, in being not only a less bunglesome approach, but also has a greater likelihood of gaining a bi-partisan consensus.
As Dave said, the R’s have already signaled they will be addressing immigration in that fashion. The PPACA would have fared much better, as well, had the dems been less aggressive/greedy, finessing portions of HC reform and working with congressional cohorts, rather than provoking them, in order to pass something smaller/workable instead of focusing so much on creating a big ‘legacy’ with lots of political fanfare.