Our health care system, with or without the ACA, is a mess. People disagree about the reasons it is a mess or what specific aspects of it are most problematic, but anyone can see this isn't working. The fundamental flaw is one thing that nobody in the Republican Party has the balls (being as male-heavy as it is in Congress, the gendered euphemism is appropriate here) to address.
On the surface it seems like the choice between a pure free market and a pure single payer system for health care would give us two options that both work as self-contained entities with very different consequences. A free market system would cost less for many individuals, cost more for others, and leave some people unable to afford health care at all. A single payer system would guarantee service to everyone but raise issues of overall cost (depending on how it were run) and how efficiently service could be provided.
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The problem in the U.S. is not that we have picked the wrong one of these options, but that we have neither of them.
The loophole that makes our system the enormous clusterbang that it is results from Republicans not having the courage to back up their tough talk on people who can't afford health care. As long as the law requires Emergency Rooms to take people irrespective of ability to pay, the system we use today is guaranteed to be an expensive mess. A system that requires people to buy insurance from a for-profit insurance industry or face a penalty is going to leave some people uncovered. Those people are going to get sick and get in car accidents just like everyone else.
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When they do, they end up getting services they have no intention of or ability to pay for. The costs get passed on to everyone else. This is why health care in the U.S. has been such a disaster – because we treat it like an industry rather than a social service.
The logical solution is to have a single-payer system in which people don't have to go to the ER when they have the flu because it's the only service provider they have access to that can't reject them for being uninsured and poor. The alternative, though, is for the Republicans to sack up and change the law that requires ERs to take uninsured patients.
If they really are committed to the idea of health care as a product, the provision of which is governed by the invisible hand, then go all the way. Tell people, "If you don't have insurance, the ER will leave you outside on the sidewalk and lock the door. Hospitals don't have to treat you anymore, even if you're comatose, until they determine what you can afford."
That's abhorrent, of course, but they don't seem to have any problem being abhorrent as long as they know that their poorest constituents can get into a hospital somehow (and then suffer under a mountain of medical debt they can't begin to pay back, which is a win for the debt collection industry). Nonsense. Take away the safety net. If you want a market in which health care is treated the same as any other product or service, then stand behind your ideology and let's do this for real. See how it looks in practice. Let people experience it. See how they like it.
It's the only way for Americans to make an informed choice, after all, on the merits of treating access to medical care as an issue of personal responsibility and a privilege one must earn.
Retired Labor Thug says:
This Modest Proposal signifies action I assumed the Republicans were willing to take legislatively had the American Wealth Care Act become reality.
Sarah says:
Been saying this for years. Thanks for saying it better.
Sarah says:
Also another major problem with a "free market" system is that customers must be able to make *informed choices* and even if we work on price transparency (we won't), customers won't make good choices when it's life or death.
Major Kong says:
I believe some of the better systems are actually public/private hybrids like the French system. We pay an awful lot for the level of care we actually get.
NoelB says:
The fact that we are the only country in the world that has a "health care industry" tells you all you need to know about the clusterfuck dumpster fire that is our health care system.
Andrew Laurence says:
@NoelB: Every country has a health care industry. Health care workers won't work for free, hospitals don't build themselves, etc. The difference is how health care is financed. We ALREADY have single payer. It's called Medicare, and it works fairly well for the sickest people we have, so why wouldn't it work even better if it covered ALL people? I think it would. Private insurance companies only skim money off the top. They don't provide an ounce of care to anyone. They're like the Mafia, only legal. I don't have a problem with profit, but you need to add value. Otherwise it's just extortion.
In a system where anyone could go to their family doctor during business hours, or an urgent care center after hours, there would be no need to turn away non-emergent cases at the ER, because there would be no reason for anyone to go to an ER unless they were having a life-threatening emergency; i.e., trauma, heart attack, stroke, accidental amputation, severe burns, a few other things. Your standard broken limbs and stuff that really can't wait but won't kill you could be handled in urgent care. And as far as paying, just show your Medicare card. You've already paid through your taxes. Simple, fair, low stress. Now all you have to do is worry about getting well, not paying for it.
Would some people engage in riskier behavior because they no longer have to worry about the cost of treatment? Perhaps, but I suspect this effect would be limited because people are averse to pain and suffering.
Michael says:
Not directly related—but I think tangentially part of the mess.
https://arstechnica.com/science/2017/03/mayo-clinic-under-fire-for-prioritizing-patients-with-private-insurance/
democommie says:
@ Andrew Laurence:
We have TWO single payer systems, Medicare/Medicaid and the VA Healthcare system. The VA DOES negotiate for drug pricing.
Aurora S says:
@Andrew Laurence–
That "but people will engage in riskier behavior if they don't have to worry about the cost of treatment" bullshit is such a ridiculously privileged notion…only someone who's never actually had to badly neglect their health because they can't afford basic bodily upkeep would conjure that one up, as an excuse to feel justified in actively depriving others of equal access to healthcare. This derives directly from the lovely American tendency to equate wealth with morality.
If you're taking stupid risks with your health, you're not doing it because you have carefully weighed the risks and benefits of doing so, and I promise that cost of treatment isn't a factor. Self-preservation and the loathing of pain are deeply ingrained instincts. "Now I can stuff my hand in this paper shredder because I won't be crippled by debt forever if it doesn't turn out in my favor!" said no one ever. What about the absurdly rich oligarchs who don't have to worry about the cost of getting sick as it stands? Are they more inclined to risking their health than the unwashed? Maybe we should ask Paul Ryan or one of his goons next time he trots this one out.
Ormond Otvos says:
Health care is a symptom of unregulated capitalism that teaches greed as morality.
You can't shame these people by pointing out their behavior. They think it's a feature, not a bug.
Aurora S says:
@Michael–
That happens everywhere, and you're right. The way that it's done in the medical field is that Medicare and Medicaid-funded plans are treated like any other insurance policies they can choose to accept or not. So in a way, it's not like single-payer at all. I used to work in a doctors office and we stopped accepting Medicare patients, and people would scream at me about how it was "Obamacare" that was doing this and how illegal it was. It's perfectly legal, and Obamacare had zero to do with it. People think that just because they've paid into Medicare all of their lives it somehow entitles them to receiving medical care. Not in the US of A. The doctors chose to no longer accept it because they were getting bigger payouts from private insurers. They would take it from an existing patient that had become eligible for Medicare–they didn't want to seem heartless, you know.
Jack the Cold Warrior says:
I've had VA Healthcare since 2009. Simply, it is the best care with the least stress I've ever had. Since I don't have a major service connected disability or a Purple Heart, I do pay copays, but there are negligible to what I'd have to pay thru a health insurance. Company.
$9 for drug copay. Extensive formulary. VA negotiates prices with drug suppliers and other venders. Durable medical goods are free. Including wheelchairs, walkers, wound care supplies, etc.
The Koch's and others are behind the media blitz that trashes VA wait times, care, etc, because they hate working examples that contradict their libertarian dogma. They'd love to see the VA privatized so they and their billionaire buddies can suck up that lovely govt money. Greed heads.
Like any big organization, the VA has problems and makes mistakes, but health mistakes nationwide cost billions every year. Have had tremendous problems from private health insurance companies denying care/coverage.
We should keep and strengthen the VA and have Medicaid for all!
Jack the Cold Warrior says:
—and Medicare for all! [correction!]
paintedjaguar says:
US Medicare is NOT a single-payer system. Here's why:
https://www.opednews.com/populum/page.php?f=Medicare-is-not-a-single-p-by-Dominique-Lord-111116-326.html
When people say they want Medicare-For-All, most really mean they want something at least as good as Canadian Medicare. Hopefully something better, since the US already spends more government funds to provide healthcare than any other developed nation, and if you include out-of-pocket spending then you're looking at multiples of what it costs other countries to provide both universal coverage and better outcomes than the US.
To say we aren't getting our money's worth is a ridiculous understatement.
Talisker says:
Well said, Ed. And kudos for the Watchmen illustration. Better than the (still good) alternative of Arnie at the end of Predator, yelling, "Come on! Do it now! Kill me!"
This is how the USA spends more public money on health care than most other industrialised countries, while achieving worse health outcomes.
The US health insurance industry takes up some non-trivial percentage of GDP, 1 or 2% IIRC. That's not doctors or hospitals, just the insurance bureaucracy. So the USA is spending this colossal sum of money on deciding who is entitled to medical treatment, where and how much.
Most other countries adopt the single-payer model, with independently run health care providers paid for by government. It's a lot more efficient, more humane, and better for public health. Republicans in Congress (and it must be said, about half the Democrats) won't countenance adopting it.
Some may be dumb enough to believe the official explanation, that they are defending the free market from the godless forces of socialism. Unofficially, they lack the testicular (or ovarian) fortitude for the fight that would ensue, if they tried to legislate the health insurance industry out of existence. So the whole sorry arrangement staggers on, with all the practical benefit of Easter Island statue construction, but without even any cool monuments to show for it.
R E G says:
No – letting people die won't change anything. They already die everyday.
The problem is culture. Somehow the culture needs to shift it's belief from "healthcare is a privilege" to "healthcare is a right".
During my lifetime the culture has changed enough that wife beating and drunk driving have become unacceptable. For a while it appeared open racism might pass away too. Change is possible.
America certainly has the dollars, skills, ingenuity etc to provide healthcare to all. What it doesn't have – and other western democracies do- is a belief that healthcare is a basic human right.
Monte Davis says:
Jack the Cold Warrior: "VA negotiates prices with drug suppliers and other vendors…"
B-but that's SOCIALISM! Big Government muscle struggling mom 'n' pop pharma companies! Next you'll be stripping employees of their right to work by letting them gang up on employers in so-called "unions." You don't understand the proper scope and limits of the wondrous free market, fella.
Monte Davis says:
"muscle" ->"muscling"
X-RWU says:
A couple of observations…
1. I occasionally look at right-leaning websites just to see what the other side is saying, and you should see the commenters beginning to get seriously angry on Breitbart, with comments like "remember who voted for you, Trump!"
2. This is going far back as the immediate aftermath of the election, but now you've got a certain kind of people now begging Trump not to take away either their Obamacare, ranging from ignorance that O-care and the ACA were the same thing to pleas to Trump not to take it away ("I'm an elderly veteran, please don't take it away!").
Seriously, anyone else annoyed when some people just can abide their own declared beliefs and rules for life? Maybe we should have a law to force people to live by their choices, no matter how badly that ends up for them, i.e. If you spend your entire life ranting about the poor and what they get, then you don't get welfare and food stamps when it happens to you.
Oh, and nice touch with the "Watchmen" thing, Ed.
Matt says:
One word, applicable to nearly every conservative policy position: COWARDICE.
They don't want to enact a policy like that because it removes the fig leaf of "That person could've gotten care (if they were willing to take on unending debt) but they waited until their cancer was terminal because reasons". It's vitally important to conservatives that the terrible outcomes of their polices come about with some facsimile of "choice" because Gawd forbid they actually take the sort of responsibility for their actions that they love to fob off on others.
democommie says:
People have been telling me for the last 40+ years what a horrible waste of money and enabler of sloth and crime WELFARE is. They seem never to be able to grok that WE ALL receive some form of welfare, most on a daily basis from a gummint that at even its most dysfunctional state (in the U.S. at least) is STILL vastly better at providing those benefits than any private entity, for profit or not, is able to do.
The roads we drive on, the water that comes out of our tap and later disappears into a massive collection system so that we don't have refuse and human waste running in gutters outside of the homes that are built to conform to codes instead of being thrown together like the hovels in the Favelas of Rio and other slums around the world.
The single major difference between our national welfare system and that of most other nations is that it is not truly a national system. The various welfare systems of the 50 states, several territories and special places like D.C. are comprised of a multitude of state and local regulations that are tacked on or used as filters.
Means testing that varies from one state to another; per capita incomes, rental subsidies, COLA in metro areas v those in rural areas and a staggering volume of historical indices and other data and statistics make it possible to say that in one place a family of four that has a net income of less than $55,000 qualifies for an EBT subsidy, while in another state that same family needs to be making less that $26,000. While there is variation in prices for basic commodities they aren't that great. It mostly comes down to how state legislatures arrive at the determination of who "DESERVES" help.
There is and has been much debate about how to better monitor, deliver and assess the benefit of welfare programs. Welfare fraud is massive–but not at the level of individuals. There are no gangs of Cadillac Welfare Queen. There is plenty of well organized fraud and theft of gummint dollaz–and it's all being done by doctors, lawyers, counselors, policing agencies, charter schools and other private/public entities.
So, welfare and its administration/misadministration is a vexing issue. I can see why so many people just throw up their hands and say, "Get alla them bums offa welfare!". It's always the easiest "solution". I used to hear that refrain, a lot–and I still do–and my answer to that is always the same. What I tell them is the following:
"Let me know when you're ready to start rounding people up and killing them. Let me know when you can stomach that and the sight of corpses littering the streets after bad weather or heat waves or natural disasters. Let me know when the thought of the young woman who waits on you every morning at the local 'Grab'n'gulp' should just puil herself up by her bootstraps and put herself through college while working at a minimum wage job–and not have her child/children receive proper nutrtion or healthcare, while smiling and not spitting in your $5 mochalatte (which you, btw, do not feel compelled to leave a tip for).
Let me know when all of that shit is okay with you and THEN dismantle the systems that keep that from happening and even actually allow some people to escape the generational poverty that is the only 'lifestyle' they've ever had.".
I've been saying that for years. These days, people actually look to one side or the other of my line of sight and say that they ARE ready for that.
They voted for Trumpligula. Fuck them.
@X-RWU:
"Maybe we should have a law to force people to live by their choices, no matter how badly that ends up for them, i.e."
But, we already have that silly; it's the law that says being born poor is a sin, getting poor any other way is a sin and that the rich shall inherit the earth. Don't bleeve me? Lookit allathem rich fucks what run the show!
c u n d gulag says:
We already have the dreaded "SOSHLIZM" in this country:
-First, there the military. Arguably, the most socialist entity in this country, since a unit is only as good as its weakest member. So, everyone works to improve that individuals performance, to meet standards.
-Second, the VA. Sure, it needs some work done on it. But before he passed away, I saw the VA in our area improve dramatically from the "Baby Doc" Bush years, to the Obama years.
-Then, there's Medicare and Medicaid. 'Nuff said!
Also, in some senses, ALL insurance – home, auto, personal, health – is socialist. Everyone in the pool puts in money, and it goes to those who need it due to fires, accidents, death, etc.
So, to any really fucking stupid Americans who still fear "SOSHULIZM!", that ship sailed off back in the 30's, if not earlier.
Thanks Ed, for putting this issues into plain terms so that thinking people can understand why we're in the mess we're in.
Now, how do we get this through to the t-RUMPLE-Thin-Skin followers, and the uber-"Christian" "Hartland Murka" crowd?
c u n d gulag says:
SHOOT!
In my comment, the person who passed-away, was my beloved father, who was 86 1/2 when he died.
His care in his last decade, was superb. And they helped provide hospice help, so that he died at home, as he and we wanted.
Sorry for any confusion…
Andrew Laurence says:
@Aurora S: I did say the riskier behavior would be limited. I'm not thinking of hands in paper shredders. I'm thinking more aggressive driving, riskier sexual behavior, and extreme sports, and going to the doctor for colds and flu and things that will pass on their own.
Andrew Laurence says:
I hadn't considered that providers are entitled to turn away Medicare and Medicaid patients. That would be less of an issue when EVERYONE was a Medicare patient, because most doctors and hospitals can't fill their schedules only with those who can pay cash for every possible thing they might need done, particularly when everyone is paying higher taxss in lieu of health insurance premiums. Even so, I'd make it mandatory for providers to take Medicare.
Ellis Weiner says:
Another flaw (read: joke) is the thinking that health care consists of consumer "choice." Say you go to buy a car, and the salesman says, "I'm afraid my analysis of your situation requires that you buy the undercoating." Do you buy it, because he knows best? Because he's spent twelve years in car salesman school, internship, residency, and board certification study?
You get the idea. Health care is the one field in which you "buy" services because someone tells you to. Republicans who pretend otherwise should go to hell, come back, and go to hell again.
Brutus says:
File this under Be Careful What You Wish For. Problem is, our Republican (in name only) controllers are getting a lot of what they wish for, and so far, very little of it seems to be coming ’round to bite them in the ass. From my perspective, there is nothing they want so badly as a system that doesn’t work. Why they want to wreck things, only to be in power/office not to fix them but to wreck them further, escapes me. The simple fact that a stable, functioning society is a common good extending to everyone does not seem to dawn on those who believe they can retreat behind the fortified walls of their estates, or better yet, float offshore on board their yachts, while the Great Reset purges the bottom two or three quintiles. But I warn, this inevitable convulsion will not go according to plan. History shows such events never do.
Champagneblame says:
I've heard our health insurance system (with tax deductions for employer-paid insurance) as "socialism for white people" and that seems pretty accurate. We have subsidized health care in the US for those that can get it…
jcdenton says:
This is a sort-of inaccurate portrayal of what drives costs in America's health care system. In 2014, the total US hospital revenue was 923 billion. The cost of uninsured health care was 41 billion, less than 5%.
Also, given that the cost of procedures in the US can differ by as much as a factor of 10 or more (an appendectomy can range between $10K and $100K within a 100-mile radius in CA), it's important to note that what drives up costs is often simply a question of what hospitals can get away with.
There is one general rule of thumb. Any country that can negotiate with pharma and health care providers en masse gets cheaper rates. Otherwise, it's difficult to pin down exactly what drives up health care costs (besides desperation, obviously).
fastEddie says:
We have a giant welfare state for middle class white people paid for with tax credits and deductions. Interestingly, the poor brown folks aren't able to take advantage of any of it. Quite a coincidence.
https://www.forbes.com/sites/chrisladd/2017/03/13/unspeakable-realities-block-universal-health-coverage-in-the-us/#695c17a9186a
Andrew Laurencr says:
Poor whites can't participate, but middle- and upper-class nonwhites can. Pretty sure it's not racially driven.
geoff says:
@democommie, awesome rant, sir. Don't forget to tell the assholes that Bubba and Newt "end(ed) welfare as we [knew] it" over 20 years ago.
anotherbozo says:
Surprised to see Ed flogging the impossible, a single-payer system. Maybe I'm missing something, but blocking it would be two of the biggest "industries" in the country — big pharma and the health insurance giants. Might as well argue for unilaterial disarmament of the military. If Ed sees a plausible way around those humongous road blocks, I'd love to read about it. Those entities could double-team every congressman or repopulate the legislature with toadies if they feel at all threatened, no?
Mike says:
I agree entirely. We should absolutely allow hospitals to turn away patients who cannot pay.
Aurora S says:
@Andrew Laurence
I didn't think this was a thing you came up with. It's one of those "giving out condoms in clinics will only encourage people to have sex, and that's BAAADDD!!!!" lines of logic used by GOP swindlers. The, "But if more people have access to healthcare, more people will use it!" complaint a la the Republicans really lays their priorities bare. They view healthcare as a commodity upon which scarcity depends, and have their base believing that it's the *other guys* that are going to be affected. You know, the colored ones in those inner cities, those Welfare Queen and drug dealing moochers. The Liberal Elites want to make sure to enable this moocher class, on your dime! They think they're better'n you!
Andrew Laurence says:
@Aurora S: No one needs encouragement to engage in sex, drugs, and rock and roll. My only point was that free resources tend to be oversubscribed, like free highways at rush hour or free parking at the mall during Christmas shopping season. At my office, we used to get free sodas. People left half-empty cans lying around. now we pay 25¢ and the sodas get consumed. The charge doesn't have to be much, and I already stated that the effect will be limited, as most people find illness and injury unpleasant, but hypochondriacs and attention seekers do exist. I'm still for single payer, though.
MS says:
What few people realize until it happens to them is that only emergency care is required to be provided without considering ability to pay, and it's certainly not free – you'll be charged.
So if you do get into an auto wreck, you'll be treated, but then you'll be bankrupt.
And if you get cancer, you won't be treated, because cancer is not an emergent condition. Yes, it will kill you in six months without treatment. Oh well. Just provide the initial downpayment of $35,000 cash and we'll start treatment.
Canada does not have either a health insurance industry or a health billing industry or even a health industry. Plenty of people are employed in healthcare, but the provincial insurers aren't there to deny care, just to manage cashflow. Billing is trivial – learn one system, that's it. It changes slowly. And while there are plenty of private enterprises providing healthcare, the government looks askance at the US trend of "grow until you're huge, then buy the government". Consolidations and the sort of aggressive insurance-farming practiced in the USA are discouraged. There are a few doctors who still scam the system – every year there's some newspaper article about Doctor X who billed for 10,000 hours of work last year. But now Doctor X is known, and since the government is the only payer… guess who gets scrutinized next year. THAT'S what keeps healthcare costs in check.
And if you get cancer, no matter how rich or poor you are, you'll be starting treatment next week.
mojrim says:
@Andrew Laurence: You really are mistaken about risky behavior here. I suspect you have unconsciously allowed the concept of "choice" to affect your thinking on a subject where it has no bearing. These people have done an exceptional job of framing the debate to make medicine seem like a consumer good subject to and affecting market choices. Nothing could be further from the truth.
To begin with, there are literally zero substantive choices for a patient to make. Certainly one can choose between this or that therapy, this or that doctor, vaccination or assholery, etc… but those are false options. Self preservation and pain avoidance are (as with any species) hard coded behaviors. They can be overcome, but rarely and with great effort, and only for some greater cause. In the end you will take all the treatment you can get in a desperate bid to stay alive and ambulatory. Economists call this "demand inelasticity" and it's why costs keep rising no matter how much "choice" we give people.
The same principle applies to their (our) behavior. Risky behavior is a product of youth, epigenetics, and instruction. I spent two years on a CV in the eighties. We were young and
risk tolerantreckless, had free health care, and all STDs were curable. More than anything it was the last element that drove our sexual behavior, along with the fact that we were young and kept pulling into Subic Naval Station. If you had told us that sickbay was going to start charging for penicillin nothing short of $500 would have slowed anyone down. The culture has since changed in the services: It is no longer cool to be pissing razor blades while you brag about the hookers you had at the last port. That alone has abated the behavior.People will take risks with their body according to (a) need for adrenalin, (b) perceived risk of pain and loss, and (c) social group approval of said behavior. We still have no problem finding plenty of kids eager to jump out of planes, or swim out of submarine airlocks, or whatever, because it's fun and makes everyone like you.
Katydid says:
I debated whether or not to speak up on this, and have decided to share. As I write this, my best friend lays dying. For lack of health care. They were bankrupted a couple of years ago when her husband's botched emergency appendectomy led to more emergency surgery to fix the problems, which were denied by their health insurance. They lost the case for malpractice even though he entered the hospital with a burst appendix and left almost completely disabled. Meanwhile, she's been dealing for 50 years with a congenital heart problem that needs constant medication but is completely manageable with care. The problem? After being medically bankrupt, they couldn't afford to meet the deductible on their high-deductible health insurance plan, so she began skipping meds to make them last, leading to needing heart surgery, which is so far out of their ability to pay for that it's not even a dream. She told none of her friends because it's humiliating to work and not be able to afford to see a doctor.
So what do you do in that situation? You die. And that's exactly what she's doing.
Andrew Laurence says:
@mojrim: I understand that health care is not a consumer choice, but hypochondriacs and attention-seekers exist in every society. I suspect they would add only minuscule costs, and their existence is no reason not to enact single payer.
Andrew Laurence says:
@Katydid: I'm so sorry to hear about your friend. That is just heartbreaking and inexcusable. Is it too late for her medication to work if she could get it? How much does it cost per month? Can it be purchased more cheaply in Canada or Mexico? Maybe some fundraising efforts would help. I'd be happy to pitch in some. This is exactly the reason we need single payer. Even if you value human life not a whit (and I do value it quite a bit), it's just plain foolish to allow a taxpayer to die and thus stop paying taxes when her death can be prevented.
jcdenton says:
@anotherbozo
In many countries, the transition from govt to state-provided services can be relatively bloodless. In the US, it may require people to tear down their faith in Capitalism and Capitalism in general. You may need to storm the Bastille. I'm not joking.
@Andrew Laurence
There is some concern in overusing the Emergency Room for minor complaints in Canada as well. We've gotten around this in three ways. 1) Triage prevents people with minor issues from seeing a doctor any earlier than 4-12 hours in the ER. Once you go through that experience, you're a lot less likely to show up with the sniffles. 2) family doctors now provide more shorter appointments to take care of those kinds of issues. 3) Walk-In clinics can address the overflow from 1) and 2). It's not perfect, but it's a good start.
@Katydid
I'm very sorry to hear about your friend. That shit is horrible.
jcdenton says:
@Katydid
To add to what @Andrew Laurence mentioned, can you start a small gofundme campaign on her behalf to help pay for the meds? I guess the best thing we have these days besides rage is crowdsourcing.
April says:
@Aurora "Now I can stuff my hand in this paper shredder because I won't be crippled by debt forever if it doesn't turn out in my favor!" said no one ever."
I laughed so hard I scared my dog! Thanks for the 5AM guffaw!
democommie says:
@ MS:
Yeah, that sounds great, for canadahoovians but NOT for us red-blooded, GODlovin'fearin' troopatriot MurKKKans.
Damn it, man, we're the last of the rugged individulaists, all 330+M of us. We're like the 4 Yorkshiremen X 82.5M or so. We cling to our gunz, our biblez and our right to die of horrifyin' diseases rather than deprive our kids of their birthright doublewidemethlab.
Besides, Alex Jones says that all Canadians are dead. So there!
democommie says:
@ jcdenton and others who suggest such things.
Your heart is in the right place but the folks I want to see doing Gofundme are the fucking pols. I don't want anyone to have to raise money to get any sort of healthcare that makes sense (examples that do not make sense abound).
Katydid says:
Thanks you guys–we had a gofundme last year to buy durable medical equipment for my friend's husband (remember, permanently disabled due to malpractice) and it caused much embarrassment and heartache and injured pride, so no–she won't accept a gofundme or any other form of help. Several of us have offered to pay the $10k deductible for the insurance policy *but* that's just the deductible…the surgery runs another $60k plus follow-on care, rehab hospital, and regular follow-ups at a doctor's office…any guesses how much of this the insurance policy actually pays for even after the deductible? About 70%. And they have no money.
So, she's 56 years old and dying. Her husband thinks she'll be gone before the weekend. He doesn't expect to last much longer than that because he needs assistance with daily living but was turned down for Social Security Disability and can't afford to hire home health care, much less go to a nursing home. He's 58 years old.
Let me get back to the cause of all of this–a burst appendix. Five years ago, they were Mr.-and-Mrs.-Average-Middle-Class-College-Educated-Office-Workers.
A bit of gallows humor; the mail's here, including a note from my own insurance. I got a pneumonia shot back in February because I provide respite care to my elderly parents and my doctor recommended I get it to keep them safe. The cost for the physician's assistant who gave me the shot (not covered by insurance): $34. The cost of the five-minute appointment: $180 (insurance paid $160). Cost of the shot itself: $300 (insurance covered $280). I fully understand how anything more serious than that can bankrupt someone.
Katydid says:
P.S. Thanks, Aurora–I'm going to go run out in traffic now because I have health insurance, wooooo!
mothra says:
Katydid: that is completely dreadful. I don't know if it is too late or not, but it might be worth a call to her congresscritter to see if she can get help somehow. Jesus, that sucks. And I am sure there are thousands, if not millions of Americans just like her.
Yeah, the reason we don't have single payer or any kind of sensible health care system is because of the greed of health care providers. Doctors DO turn away Medicare/Medicaid patients–and so do hospitals–because they don't like the reimbursement rates and they can get more from insured parties. Pharmaceutical companies don't give a shit and charge ridiculous prices for their drugs in the USA. It's reprehensible.
You know what's going to be fun? When Tom Price floats his plan of allowing providers to engage in balance billing–where they can go after Medicare/Medicaid recipients for the "full" price of treatment. Again, reprehensible.
Berkeley '74 says:
The problem is that there are too many poor people. Way too many. They
can't pay for health care, they have no income to cover that, they can
barely pay their rent, food and transport to their low wage multiple
jobs. Not only do the poor not have the ability to pay for their
health care, but their living circumstances amplify the problem because
being poor causes more health problems.
This doesn't mean they won't 'use' health care, after all, calling
911 is free and emergency rooms can't turn people away to die in the
streets. That is one solution to the problem, just turn away poor
people and allow them to die in the streets. If we aren't going to do
that, then the question is, how is this service going to be paid for ?
Who is going to pick up the tab ? The ordinary answer is that the rest
of society is going to pay for it one way or another. By using
emergency rooms for health care, everyone else is paying through higher
premiums on insurance that does exist. Or, we work up some kind of
taxing scheme where people who do have money pay the health care for
those that do not have money. The ACA was a weak attempt at that, and
even that weak attempt is being objected to since ordinary citizens
with a modicum of income feel like they are unfairly paying for poor
people.
This problem has been answered in many countries around the world.
Everyone is taxed as taxes usually are structured, those that have
more wealth pay more tax than those that don't.
Andrew Laurence says:
@Berkeley '74: Those who have more INCOME pay more tax than those who don't. Wealth is generally not taxed.
mago says:
Been ranting on this subject overly much, so no comment except to say this is an uncivilized country bent on inflicting unnecessary suffering.
Sorry about that tragedy, Kd.
Katydid says:
@Mothra; it's too late to contact a congresscritter; this woman is literally dying (and lives in a red state so what's even the point?). I called a local pharmacy to see what the heart meds cost: $600/month, but you need a doctor's prescription, which means a doctor appointment (add another $180 to the meds).
Re: poor people; a huge reason for bankruptcy in the USA is overwhelming medical bills. Not allowing them to use emergency rooms is just cruel–nobody hangs out in the ER because they've got nothing better to do with their time.
jcdenton says:
@Berkley '74
I'm going to make the point again that uninsured visits take up less than 5% of total hospital revenue (900+ billion in 2014, goes up by about 100 billion per year). Uninsured poor people are barely making a scratch in the trillion-dollar health industry. Please don't blame skyrocketing health care costs on them.
However, there are some obvious mechanisms that are driving prices upwards: unchecked greed, absence of regulation, and the basic inelastic nature of health care. People will try to get health care or literally die trying. There are few other commodities (aside from food, water, warmth and oxygen) so fundamental to human survival. In other words, the basic mechanics of Capitalism are what is driving the prices of health care upwards. If a hospital can charge more, it will (as others have pointed out).
@democommie
Sorry, I offer crowdsourcing because pitchforks and molotov cocktails don't help in this specific case.
Katydid says:
Bottom line; health insurance (and actual healthcare) is a real issue in people's lives. The ACA wasn't the be-all of healthcare, but it was better than anything we had before it and whatever the Repubs come up with is guaranteed to be worse.
Katydid says:
@jcdenton; you said a mouthful. Look at the obscene salaries healthcare CEOs make, and you see where our healthcare dollars go. It's not the walk-in with strep throat who needs $4 worth of antibiotics.
democommie says:
@jc denton:
Your sentiments and suggestions are laudable. It just pisses me the fuck off that it even needs to be considered.
I have done pro-bono photography for years. Over the last 20-30 years I have photographed a lot of fundraisers for everything from the local SPCA's Spay&Neuter clinics to chicken b-b-q's to raise money for someone's child, father, mother, gay partner or other loved one to help defray the expenses of travel for chemo, meals and lodging, various items not provided for by insurance policies. A lot of stuff. It is heartening to see the outpouring of love from so many people, particularly when the ones who need the help are often not related to them. But it STILL pisses me the fuck off that it has to be done.
It's not JUST the patient that is affected by the illness or injury. It's everyone in their circle of friends and family. It's their students when they are teachers, the waitress's "regulars", the auto parts or hardware store counterman's customers who rely on him to help them with the minutae of automotive and hardware materials. And, if you're feeling a lump in your groin, or your breast or you don't seem to be able to keep up when you're walking–due to a suddenly developed shortness of breath–WHILE knowing that you have shit health insurance and ONE asset, your home. Well, it's not conducive to peace of mind.
I have medicare (no part "B"–can't afford it) and the VA Healthcare system. I have never used medicare for a doctor's visit or any labs. Almost all of my meds are furnished by VA and I have no co-pays because of my financial situation. The one thing I have that is worth more than most other features of any healthplan I've ever had is that no matter what happens, no matter what I need from the VA I won't be seeing a bill, so I don't have to worry about how I'm going to pay, if I LIVE. A world where I am the proverbial one-eyed man in the country of the blind, for that reason, is a fucked up world.
X-RWU says:
@democommie- were you being sarcastic or serious? No, I don't think being poor is a crime or a choice (and f*** anyone who honestly thinks that). Perhaps with the very rare exception of some devout folks of whatever religion they follow, no one, NO ONE, chooses to be poor.
@Katydid- I really don't know what to say, other than it truly stinks and I feel your pain at watching a loved one pass away.
April says:
I've been thinking about this for a while…
Meaning NO disrespect for gofundme's for health issues (or other such needs) and certainly not dissing sending money to charitable causes such as PP (which I do) it occurs to me that isn't this what the repugs want us to become? That is, a population who is required to go begging for help from others whenever we need it (since obviously THEY never will have to)? When it was announced that meals-on-wheels might be cut, MOW got a ton of donations. I see that as both good and bad, bad because it reinforces their idea that government isn't needed to solve such problems.
This bothers me. I'm starting to think that supporting such causes might hurt us (us being people who want a civilized country) in the long run. Then again, who among us (the same us) don't want to help if we can? Should we allow things to deteriorate, and people to suffer in the short end for a more long-term goal? This is a real quandary to me.
Let me add my sympathies for your friend, KD.
E* says:
An illustration of where we're at with healthcare in this country: My for-real plan for a major health emergency is that my husband and I divorce asap to try to protect at least half of our assets from the ensuing financial massacre. This is not a foolproof plan. It involves some quick finagling (impossible in a situation similar to that of Kadydid's friend's?), a whole heck of a lot of trust, and loss of whatever benefits are afforded immediate kin. I have decent insurance and this is the plan. What a crock of shit.
Also, re: the idea that we be informed health consumers: also a crock of shit. I'm currently undergoing an adventure in the health system involving a joint. Unlikely to be fatal unless I find myself unable to flee from a rabid capybara, so I have the luxury of being picky about treatment. I *always* ask, "What is the cost for this? Are there cheaper options?", and it's like I've asked the doctor to participate in a threesome with one of the medical technicians. It's simply NOT done in polite company. But I have a high deductible and I've been told to be informed, so I'm trying. The doctor doesn't know, of course, and nor does anyone in his office, nor anyone at my insurance company. Believe me, I'm trying. It's an exercise in frustration. ("Sorry, ma'am, you'll have to ask your medical provider/insurer/barista/a person who is not me.")
@Katydid: I'm not religious, but whatever part of me is my soul is crying for your friend right now. A primordial prayer for a miracle, because we, collectively as a society, have failed her and her family so completely.
E* says:
P.S. "Decent insurance" = just about as good as anybody else's insurance right now. It's obviously crap.
jcdenton says:
@April
This is basically the quandary of every revolutionary/progressive, more or less. Work inside the system to make slow but steady progress using its own tools or accelerate its collapse in the hope of being able to make significant and fundamental changes. The breakdown of pros and cons usually looks something like this:
i) Slow and steady:
Pros:
-Society isn't on fire. Less reason for mass violence.
-More chance for organic acceptance of changes.
Cons:
-Slow, perhaps incremental changes. May not see changes in own lifetime.
-Appear to be a sellout. Movement can lose credibility unless tightly focused.
ii) Rapid decline and revolution
Pros:
-Serious social changes can be implemented quickly.
-Can sweep away the old order in its entirety.
Cons:
-High likelihood of mass violence, starvation, etc.
-No idea who would rise to power in post-X society. Could be your ideological enemies.
@X-RWU
I'm pretty sure he was being sarcastic.
democommie says:
@X-RWU:
I see the comment I left last night went into the oubliette of lost gems*! Yes, it was sarcasm.
I have talked to numerous people in meatlife who are successful through no fault of their own, but can't empathize with folks who are not successful despite working hard and playing by the rules.
The buddhists have a "term"** for the unenlightened, they call them, "unripe". I generally see them as selfish assholes.
* on value of such "gems", ymmv
** or so I am told
Deggjr says:
fastEddie, thanks for the Forbes link.
VCB says:
We finally get a meaty health policy debate on G&T, and I miss it! Anyway, let me start by saying this: this is where I live, professionally, and this debate here is miles above the usual type of stuff I hear among debating groups of obstensible professionals. This is one of the myriad reasons I love the G&T.
Anyway, since I spend a large chunk of my life explaining the US health system to foreign nationals, I feel there is great benefit in keeping it simple. To me, there are 2 basic types of universal coverage: (1) crank up income taxes and offer decently broad coverage at little-to-no patient cost (Canada, UK, EU G5, Japan, Australia, New Zealand, a few others), or (2) keep income taxes lower and offer only basic coverage to all, with everything else out-of-pocket (Indonesia, China, Thailand, etc). Singapore is sui generis, Poland has a kind of interesting variation in between the 2 poles, etc. But basically you choose between higher taxes or lower coverage. FWIW, inside those 2 categories, they manage costs differently (Italy and Spain by randomly imposing low pricing on branded drugs, Japan through bi-annual price cuts across the board, UK by devolving budget to counties, etc). The US is outside that framework more or less (with the noted exceptions of Medicare and Tricare), but I would argue that the Democratic party has been slowly moving us closer to (1) and that ACA was intended as a step in that direction.
So the US issue is that, if I reframe Ed a bit here and essentially agree with him violently, Republicans want the coverage of (1) with the tax rates of (2), and they are noodling around with the key moral question of "how do we give only the deserving folks full coverage while limiting access to others and thus avoiding 45% income tax?" The standard dodges and weaving that have carried them through 30+ years of incoherent health policy are starting to fail, because (just my opinion) since ACA the rhetoric has become so over-the-top that it's hamstrung the ability to dodge and weave. As noted in the OP, sowing and reaping, chickens home to roost.
Again FWIW, when I talk to American friends who are outside of healthcare (finance, law, etc) they invariably understand that their marginal income tax goes up with each expansion of healthcare coverage, and no matter how religious and ethical they claim to be, they find some gymnastic backflip of reason to explain why it can't be the right course of action at this time. So the past Republican platforms have exploited that too, but now again it's starting to become too draconian for any but the most sociopathic to feel comfortable rationalizing away.
Totoro says:
@VCB: "Poland has a kind of interesting variation in between the 2 poles"
ISWYDT.
Getting back to the impossibility of single payer, if zero insurance companies are willing to go into a particular market then the govt should be able to step in with Medicare/Medicaid for those folks. Wyoming just has too few people to have a viable risk pool so the choices are quite poor. California is large enough (50x WY) so the markets work pretty well. Not perfect, but not death-spiral. If we can break the Hastert rule then moderate Rs and the Ds can get things done. If tRump thinks its a "win" he might go for it.
democommie says:
@ VCB:
"So the US issue is that, if I reframe Ed a bit here and essentially agree with him violently, Republicans want the coverage of (1) with the tax rates of (2), and they are noodling around with the key moral question of "how do we give only the deserving folks full coverage while limiting access to others and thus avoiding 45% income tax?"
No.
The GOP wants NO public health care.
They are saying that they want to fix it, and relieve those who were being screwed by Obummercare (those same people that had no coverage, in many cases, prior to the ACA being passed) and its SKYHIGH premiums.
The GOP, at least since 1976, has been nothing but a lobbyinglegislative organization for the extremely wealthy, bigoted, racist, uberKKKristian fuckheadz*.
Whatever the publicly declared outcome, the only thing those fucks are interested in is keepin' the uppities down, punishing the "sinnerz" and transferring wealth–always upward.
* Many of the ultra wealthy are not actually racist, misogynist, etc., so much as they are aemoral sociopaths. A huge slice of the racist, misogynistic, xenophobic, ad nauseum are NOT the ultra wealthy–thus they are convenient, useful idiots.
Tim H. says:
jcdenton, I believe that on their best days, conservatives have about half of a plan, when, as recently, they choose to not work with others, it increases the chances that the society will break without overt revolution, survivors will be in a position to reassemble something. Given that the Civil War so comprehensively demonstrated the flaws of a society optimized for elites, I find the level of stupidity breathtaking.
Katydid, so sorry to hear of your friend's plight, may her passing be gentle.
mothra says:
So sorry, Katydid. So, so sorry.
democommie says:
@mojrim:
Did you ever get my e-mail. I didn't see your address until several days ago and I sent an e-mail as soon as I had a minute. Not sure if it went through or not.
Katydid says:
Thank you again to everyone. I hadn't seen my friend since Christmas, and everyone looks stressed and peaked around the holidays so it didn't occur to me to grill her about her health. She's been in frequent email contact since then (several times a day); just too ashamed to mention that she couldn't afford the medication that was keeping her alive. Over the past month she lost hope that the medical situation would improve at all under the GEB, and since her congenital heart issue needs lifelong medication to keep her alive, she chose to stop stressing about medication she couldn't afford.
In my life, I've had several "soshulizzm!" healthcare plans; first as a military dependent, then as active duty military, and also some "back-door care" in England when I needed some dental work that my non-military (because I was no longer military) insurance didn't cover. The British dentist assured me that he made a fine salary every month and he wasn't worried about recouping the cost of fixing my cracked tooth.
I've also seen socialized healthcare in Holland, courtesy of my friends–when their child fell off the porch in a holiday rental on an island in the North Sea, the doctor came to them with a portable x-ray machine and ruled out a break. There was no paperwork to fill out, no deductibles to argue over for months. I had the same kind of care in the military; show your military ID and that's the end of it (disclaimer; I've been out for over a decade and the rules may have changed since then).
There's no reason why we can't have something similar for everyone except people don't want it to be so.
mojrim says:
@katydid: I'm so sorry. Really nothing else to say.
@andrew: I'll agree to a statistically irrelevant minority abusing the system in that way, but hypochondriacs and munchausen cases are generally not deterred by market pricing to begin with.
@democommie: Did you not get my reply?
April says:
VCB – In China (for the natives – most expats have a good insurance policy provided by the company) while the fees are very low, if you want good care you have to bribe the doctor (the old "red envelope") I'm sure there is probably a standardish set rate, but I can't find out more because it's not something that most Chinese people are willing to talk about. And the hospitals outside the international sections are so bad – filthy, dilapidated – that it's positively scary. Then again, most Chinese buildings are in really shitty condition because there just isn't any interest in putting money into something so "meaningless" (Our school toilet doesn't flush very well so there's always shit in the bowl.), construction standards are very low ("No regulations!! Yeah that's the way to go!"), and no body gives a shit (except in my school's toilet. Bada boom.) Then again, to be fair, your average construction worker makes about 300$ a month and while living conditions are cheap, they aren't THAT cheap. We're talking pretty mean lives, here.
OT – I just got a formal email from my English-teacher-to-be-next-year (native speaking American – former Army Ranger as he signs all his posts!) who wrote "it's" when it's "its". Facepalm. Gonna be a long year……sigh.
X-RWU says:
@ democommie & jcdenton – Sorry for my being so slow, guys; it was late last night, I was tired and ready to collapse, and so my reading comprehension wasn't 100%.
democommie says:
@mojrim:
I'm a fucking idiot! I just went to check my e-mail, nothing there. So, I went to my "sent" to see when mine went out, nothing THERE! WTF?
Then the penny dropped–it's on your Gmail account, democommie, you moron.
I'm at an open mic, trying to decide whether I hate these people enough to sing a tune I wrote a long time ago about my family. The song's not bad but I was shitty guitar player before the carpal tunnel and arthritis kicked in.
I will try to address your points, and they are good ones, later tonight or in the morning.
@ X-RWU:
Not your bad, mine. Cheers.
Katydid says:
@April; a co-worker's son took 4 years of Chinese (not sure which dialect) in high school and then went over to China to teach English. He's 20. Not sure his English is up to par because American kids just don't learn it in school and god knows they don't read (unless it's a text, and that's all emojis now). I expect his conversational English is at least on par with his students' conversational English…
April says:
Katy – I'm confused. Your co-worker's son is not sure HIS English is up to par? Isn't he American?
democommie says:
@ Katydid&April:
Well, I'm sure that if he YELLS LOUD ENOUGH they will understand–they might understand that he's an idiot, but they'll understand. {;>)
April says:
DC – one of the (many many) things that drives me crazy (ok, it's a short trip! badda boom) is when someone speaks to me in Chinese and I reply, in Chinese, "I don't speak or understand Chinese" they will then almost inevitably start speaking to me (obvs in Chinese) like we're long lost buddies. I used to repeat the phrase, but nowadays I just start speaking to them in fast English, including such stuff like "Man, you people are so stupid that even though I've just told you I don't understand you continue to speak to me and your mother fucks pigs too…" in one long diatribe. Eventually they get the message.
democommie says:
April:
Been there, done that–but it's usually when I'm dealing with Trumpliguturds or other congenital political morons.
Every once in a while I see someone with a chinese ideogram, or a string of them, tatooed on their arm, neck or head (or across their chests just under the collarbones–you got oneathem you best be staying fit, just sayin'). I usually don't say anything but sometimes I'll just look at it, then do a double take and maybe even squint a little while moving my lips as if I'm reading at the level of Liberty U. Law School graduate.
Then, I'll say: "Do you know what that says?". They always reply that it's from the Tao or it's one of those ideograms that combines several either conflicting or not obviously sympatico pieces to make up a whole like "opportunity". I then tell them that it really says, "By the inner light of Buddha, these fucking gwailo will let you ink ANYTHING on their bodies, LOL!".
VCB says:
@democommie: very slight argument on your point. I think in their dreams of a perfect Randian universe, the Republicans want no involvement whatsoever in healthcare. But I believe — and I could be wrong, even so — that most know their elective careers would be over if Medicare went away, and most are starting to understand that the breadth of where people feel it's a right to have some coverage is increasing. So maybe we're saying the same thing, now that I type it out.
@April: I spent a few months working on "increased transparency" in the vaccine chain in China. It was…..eye opening.
Shirley0401 says:
@E*
"Also, re: the idea that we be informed health consumers: also a crock of shit."
I tried to price-shop when I had a pretty straightforward ankle fracture awhile back. Not an emergency, had already gone thorough my options and decided on a course of action. I live in an area with a lot of options. (Multiple large hospitals, outpatient centers, a long list of specialists, &c). I had spoken to my insurance company, so I knew who/what was covered or not.
I was *still* unable to get a straight answer about what anything would cost. And I was told multiple times that I had to make an appointment and come in before I would learn who the anesthesiologist would be, and whether or not they were covered. It was nuts.
It sucked, and it exposed the lie at the heart of the argument we need to apply market principles to health care (and fking everything else).
But that's not even my real point. Here's my real point: ALMOST NOBODY I KNOW actually wants to make these decisions for themselves. I, and almost everyone I know, would much rather have confidence that the licensure process works and practitioners are competent, be told where/when to show up, and then not have to worry about all this crap while we're suffering with whatever our injuries or conditions are.
Watching this debate happen, I'm reminded of the way 401Ks slowly replaced pensions on the back of arguments that "people want to take control of their retirement." Was that ever true? I have a shitty-paying state job with bennies and a pension. Everyone I know is jealous of the pension (and, living in SC, I suspect it'll be gone by the time I retire, but that's another issue). Very few people want to control their retirement. Most people would much rather have security, even if it meant their potential upside might be reduced. Because most people aren't financial planners, anymore than they're healthcare experts.
You want a restaurant to succeed or fail based on how good their product is for the price, relative to competition? Sure, fine. Same for widgets and sodapop and flatscreen teevees.
Healthcare (or retirement, or education, or &c) shouldn't work that way. People are pretty good at deciding whose baked cod they prefer, and how much they're willing to spend on dinner. I much prefer the people who know what they're doing make decisions for me when it's in reference to something a) I know very little about, and b) could potentially mean the difference between life/death, security/penury, or the likely trajectory of my theoretical child's life.
Shirley0401 says:
@April
You identify a big problem, and structural disadvantage for those on the left. Republicans are more than willing to let poor people die (especially if they're brown and/or live in cities) in exchange for lower taxes on the wealthy.
From a purely strategic standpoint, it's pretty clear to me that what the Democrats should do for as long as they're out of power is simply let the Republicans show voters who they are (greedy immoral sociopaths) and what they stand for (maximum profits for corporations and tax cuts for rich people, at any cost). The problem is that doing so will leave thousands (conservatively) to literally die.
Everyone has to figure out what their own morals will allow. I, for one, think blue states should take care of their own, and leave voters in red states to suffer the consequences of the choices they've made. And they need to be clear while doing so in communicating what they're doing. They should also clamor, loudly, for funding parity, as blue states currently pay out, on balance, far more than they take in from federal taxes.
I write this as a resident of a blue city in a red state, so I'll personally be harmed by it. But I think it's necessary. Possibly without meaning to (because they spend so much time talking to each other, and so little spending time with normal breathing voters who don't spend hours neck-deep in policy discussions) I think Democrats have spent too much energy softening the worst effects of Republican policies on voters. They should spend less time doing that, and more time pointing out exactly what the Republicans are doing.
It sucks, and it doesn't feel good. But too many voters are either truly too stupid or pay far too little attention for well-intentioned tinkering with policy to register. If anything's going to work it's going to be true-life examples of "the middle class people who are dying so rich people could get tax cuts," not "we disagree with our Republican colleagues about the best way to slow the rise of costs while continuing to ensure quality care and choice in the healthcare marketplace."
The Pale Scot says:
"They should also clamor, loudly, for funding parity, as blue states currently pay out, on balance, far more than they take in from federal taxes."
My solution. Have your state income tax (and municipal if so) payment deducted from your Federal income tax bill. Put the Feds at the back of the tax receipt line. Ideally, a state will arrange their tax code so has to leave the Feds with nada.
And the great thing is that this appears to to be just what the conservanuts say they want. Starve the government? Fine, You do what ever you want in AL, Miss, etc. You just won't be doing it with blue state money. They'll be investing all of that previously going to the Feds tax revenue on state priorities