Can anyone explain why they didn't just expand Medicaid....

[clacy]

For the poor and those who did not qualify for health care elsewhere, rather than to implode the current system?  The framework for Medicaid was already in place.

Seems very simple to me. 

[Pointedstick]

Lack of creativity? Sheer stupidity? Bad marketing? Total political ineptitude? (this is the Democratic party, we're talking about, after all ) I have hard time believing that the majority that passed Obamacare couldn't have gotten a major medicaid expansion passed as well. They might even have peeled off a few Republicans.

[clacy]

Lack of creativity? Sheer stupidity? Bad marketing? Total political ineptitude? (this is the Democratic party, we're talking about, after all ) I have hard time believing that the majority that passed Obamacare couldn't have gotten a major medicaid expansion passed as well. They might even have peeled off a few Republicans.

Yes, I'm a fan of the path of least resistance and a Medicaid expansion would have created far few unintended consequences that goes hand and hand with any new legislation.

[moda0306]

clacy,

I would say that health costs/coverage is a 3-pronged problem:

1) General increase in expensiveness of coverage with not the coordinating benefits in health.

2) Some people being uninsurable in the individual insurance market (thus presenting a huge risk to people of becoming poor).

3) Poor people, whether they're insurable or not, not being able to "afford" coverage. (I put afford in quotes because I think not being able to "afford" proper protection is a misprioritization of expenditures rather than an actual financial constraint)


I think most of us can sort of generally agree that these are broad problems with the current healthcare system... where we differ is what CAUSES these problems. 


The problem with expanding Medicaid (even if we can accept the premise that it actually helps solve any problems) is that it is largely focused on the problem explained in #3.  If I'm of modest wealth and income, but can't get individual health insurance because I'm uninsurable (or it would be super-expensive), then even an expanded #3 help could only help me once I'm on the cusp of bankruptcy due to an unaffordable medical event.  If I get sick, I can't work anymore (hopefully I got a good disability policy), and I can't worki

Expanding MEDICARE would be something that would generally potentially help with #2 AND #3, and arguably #1, but it doesn't go away with higher incomes (though it does cost high-income-people more), so it would be a larger "takeover" of the system and thus less appealing to conservatives & libertarians.



I'm more of a fan of expanding Medicare than Medicaid.  There would be individual insurance that you could get to supplement it, covering more "luxurious" medical needs (for lack of a better term).  I actually love Warren Mosler's combo-platter of HSA's and Medicare for all once your expenses rise above a certain amount every year.  I think phasing things out with income is one of the biggest sources of wasted time and "system-gaming" and moral hazards out there, and I also think it creates a lot of unnecessary classist animosities.  The government provides roads & parks not just to the poor, but for everyone.  If more of our government programs looked more like a citizens dividend and less like a disappearing benefit, it might cost us more on paper, but so much less in wasted time, moral hazard loss, and animosity towards those "others" that get a benefit that I've been phased out of.  I also don't like when the government tries to use businesses as the provider of public benefits.  Get employers out of having to deal with health insurance.  I totally agree with conservatives on that.  However, we all know that our agreement ends when we discuss how to handle it from there .

But this is just my opinion.  I realize there are other models, and plenty of reasons to hate bureaucratic entities. 

[Pointedstick]

While we're at it, eliminate 401k's and simply allow each citizen access to a self directed IRA with 401k limits.  There's no reason to have employers involved.  The only thing worse than government bureaucracy is government bureaucracy + employer bureaucracy.

OMG YES!

There are many, many ways in which the government could continue to use legislation to encourage people to behave in certain ways that would be dramatically more effective and inexpensive than the status quo. However, due to the incentives governing government, they will simply almost never be implemented.

[Pointedstick]

I'm more of a fan of expanding Medicare than Medicaid.  There would be individual insurance that you could get to supplement it, covering more "luxurious" medical needs (for lack of a better term).  I actually love Warren Mosler's combo-platter of HSA's and Medicare for all once your expenses rise above a certain amount every year.  I think phasing things out with income is one of the biggest sources of wasted time and "system-gaming" and moral hazards out there, and I also think it creates a lot of unnecessary classist animosities.  The government provides roads & parks not just to the poor, but for everyone.  If more of our government programs looked more like a citizens dividend and less like a disappearing benefit, it might cost us more on paper, but so much less in wasted time, moral hazard loss, and animosity towards those "others" that get a benefit that I've been phased out of.  I also don't like when the government tries to use businesses as the provider of public benefits.  Get employers out of having to deal with health insurance.  I totally agree with conservatives on that.  However, we all know that our agreement ends when we discuss how to handle it from there .

While we're dreaming but not dreaming so far as to imagine a government-free world , here's my prescription:

1. Remove the eligibility age for Medicare.
2. Change Medicare so that it pays 100% for actual emergency treatment (heart attack, broken arm, difficulty breathing, etc) and long-term disability care for those actually unable to work (quadriplegia, downs syndrome, alzheimers, etc), and 0% for anything else.
3. Repeal Obamacare, Medicaid, SCHIP, COBRA, the VA system, etc; everything else.

This way, the government would pay for everyone's catastrophic and disability care, but people would have to pay for everything else themselves, either through insurance or out-of-pocket, ensuring a healthy market there. And if they couldn't afford it? Tough cookies. Grow up and earn some more money, or stop spending it like an idiot.

Of course, my own reasoning applies: this will never happen. It's just fun intellectual masturbation.

[moda0306]

While we're at it, eliminate 401k's and simply allow each citizen access to a self directed IRA with 401k limits.  There's no reason to have employers involved.  The only thing worse than government bureaucracy is government bureaucracy + employer bureaucracy.

OMG YES!

There are many, many ways in which the government could continue to use legislation to encourage people to behave in certain ways that would be dramatically more effective and inexpensive than the status quo. However, due to the incentives governing government, they will simply almost never be implemented.

This might be the first time we've had this trifecta, but I agree 100%.  The ONLY advantage I can see to the employer-based plans is one they've only recently enacted legislation on, and that is having employees automatically enrolled.  This is just a behavioral gimmick... but it works.

I think the government could set something similar up though... If you contribute to your IRA/Roth, perhaps up to 5% of your income or something, you get some sort of government "match."  This may sound like blasphemy, but think about it, your employer doesn't have to pay FICA/MEDICARE/Fed/State income tax on their contributions to your 401(k).  Give individuals a 1-2% government match on your 5% contribution (up to some standard amount), and they wouldn't really lose anything on the deal, because now employers all over the place aren't getting the sweetheart deal.  Also, let people hold certain i-bond-esque bonds in the account if they want.

We're already so far down the rabbit hole of emplyer-sponsored retirement plans, though, that I wonder how long it would take to see any meaningful benefit to upending the system.

[moda0306]

I'm more of a fan of expanding Medicare than Medicaid.  There would be individual insurance that you could get to supplement it, covering more "luxurious" medical needs (for lack of a better term).  I actually love Warren Mosler's combo-platter of HSA's and Medicare for all once your expenses rise above a certain amount every year.  I think phasing things out with income is one of the biggest sources of wasted time and "system-gaming" and moral hazards out there, and I also think it creates a lot of unnecessary classist animosities.  The government provides roads & parks not just to the poor, but for everyone.  If more of our government programs looked more like a citizens dividend and less like a disappearing benefit, it might cost us more on paper, but so much less in wasted time, moral hazard loss, and animosity towards those "others" that get a benefit that I've been phased out of.  I also don't like when the government tries to use businesses as the provider of public benefits.  Get employers out of having to deal with health insurance.  I totally agree with conservatives on that.  However, we all know that our agreement ends when we discuss how to handle it from there .

While we're dreaming but not dreaming so far as to imagine a government-free world , here's my prescription:

1. Remove the eligibility age for Medicare.
2. Change Medicare so that it pays 100% for actual emergency treatment (heart attack, broken arm, difficulty breathing, etc) and long-term disability care for those actually unable to work (quadriplegia, downs syndrome, alzheimers, etc), and 0% for anything else.
3. Repeal Obamacare, Medicaid, SCHIP, COBRA, the VA system, etc; everything else.

This way, the government would pay for everyone's catastrophic and disability care, but people would have to pay for everything else themselves, either through insurance or out-of-pocket, ensuring a healthy market there. And if they couldn't afford it? Tough cookies. Grow up and earn some more money, or stop spending it like an idiot.

Of course, my own reasoning applies: this will never happen. It's just fun intellectual masturbation.

I'm sure we'd disagree when it came to the details... but I agree with almost everything you said.  Warren Mosler adds an HSA-type account that might be up for debate due to the money the gov't throws into it, but those are details that could be worked out.

And I'd even be ok with hiring all the laid-off bureaucrats to build a wall against our Mexican border.

We should form a statist/anarchist/common-sense unity party...  that would go nowhere. Screw it, let's just get drunk in Chicago sometime.

[Mountaineer]

I'm more of a fan of expanding Medicare than Medicaid.  There would be individual insurance that you could get to supplement it, covering more "luxurious" medical needs (for lack of a better term).  I actually love Warren Mosler's combo-platter of HSA's and Medicare for all once your expenses rise above a certain amount every year.  I think phasing things out with income is one of the biggest sources of wasted time and "system-gaming" and moral hazards out there, and I also think it creates a lot of unnecessary classist animosities.  The government provides roads & parks not just to the poor, but for everyone.  If more of our government programs looked more like a citizens dividend and less like a disappearing benefit, it might cost us more on paper, but so much less in wasted time, moral hazard loss, and animosity towards those "others" that get a benefit that I've been phased out of.  I also don't like when the government tries to use businesses as the provider of public benefits.  Get employers out of having to deal with health insurance.  I totally agree with conservatives on that.  However, we all know that our agreement ends when we discuss how to handle it from there .

While we're dreaming but not dreaming so far as to imagine a government-free world , here's my prescription:

1. Remove the eligibility age for Medicare.
2. Change Medicare so that it pays 100% for actual emergency treatment (heart attack, broken arm, difficulty breathing, etc) and long-term disability care for those actually unable to work (quadriplegia, downs syndrome, alzheimers, etc), and 0% for anything else.
3. Repeal Obamacare, Medicaid, SCHIP, COBRA, the VA system, etc; everything else.

This way, the government would pay for everyone's catastrophic and disability care, but people would have to pay for everything else themselves, either through insurance or out-of-pocket, ensuring a healthy market there. And if they couldn't afford it? Tough cookies. Grow up and earn some more money, or stop spending it like an idiot.

Of course, my own reasoning applies: this will never happen. It's just fun intellectual masturbation.

I'm sure we'd disagree when it came to the details... but I agree with almost everything you said.  Warren Mosler adds an HSA-type account that might be up for debate due to the money the gov't throws into it, but those are details that could be worked out.

And I'd even be ok with hiring all the laid-off bureaucrats to build a wall against our Mexican border.

We should form a statist/anarchist/common-sense unity party...  that would go nowhere. Screw it, let's just get drunk in Chicago sometime.

Why not in Camden, NJ?  Then we would not have to worry about the future. 

... Mountaineer

[Pointedstick]

We should form a statist/anarchist/common-sense unity party...  that would go nowhere. Screw it, let's just get drunk in Chicago sometime.

That would be the Technocracy party, no? IMHO, technocracy is the ultimate evolution of "good governance." I think that the only government that can actually work (defined here as "using force for socially beneficial ends that improve happiness/wealth/good outcomes in the aggregate") is if you get rational subject matter experts to come up with slick, streamlined, effective, inexpensive solutions to actual problems. The contemporary government I can think of that comes closest is that of Singapore.

Problem #1 is that the venn diagram of people who are rational subject matter experts, the people who are attracted to coercive power over others, and the people who are gentle and fair with the power they have, don't really overlap much, if at all.

Problem #2 is that even if a gaggle of such people could be found and organized into a political party or movement, most people would never vote for these technocrats in a representative society. And if the technocrats forced their way to power in a non-democratic manner, they would be legitimizing rule by the strong, and it would very quickly be revealed that the technocrats were weaker than the warlords, gangs, and organized criminals.

[moda0306]

We should form a statist/anarchist/common-sense unity party...  that would go nowhere. Screw it, let's just get drunk in Chicago sometime.

That would be the Technocracy party, no? IMHO, technocracy is the ultimate evolution of "good governance." I think that the only government that can actually work (defined here as "using force for socially beneficial ends that improve happiness/wealth/good outcomes in the aggregate") is if you get rational subject matter experts to come up with slick, streamlined, effective, inexpensive solutions to actual problems. The contemporary government I can think of that comes closest is that of Singapore.

Problem #1 is that the venn diagram of people who are rational subject matter experts, the people who are attracted to coercive power over others, and the people who are gentle and fair with the power they have, don't really overlap much, if at all.

Problem #2 is that even if a gaggle of such people could be found and organized into a political part/movement, most people would never vote for these technocrats in a representative society. And if the technocrats forced their way to power in a non-democratic manner, they would be legitimizing rule by the strong, and it would very quickly be revealed that the technocrats were weaker than the warlords, gangs, and organized criminals.

Dude.  Post of the month. Use this in your book.

I hope you appreciate how much it hurts a statist thug like myself to say that.

[Pointedstick]

Dude.  Post of the month. Use this in your book.

I hope you appreciate how much it hurts a statist thug like myself to say that.

 

You can bet that some form of this will be in the "why government can't work" chapter. I've had these thoughts churning around for a while and have been trying to figure out how to best express them to statist thugs such as yourself!

[moda0306]

Can you give me a summary on what you like about Singapore's government?

[Pointedstick]

Can you give me a summary on what you like about Singapore's government?

I'm not sure I do like it very much, and I certainly need to do some more study. But in my admittedly cursory research so far, what strikes me is how their government is efficient. Every time the Singaporean government sets out to do something, it seems to manage to actually do it, quickly and cheaply. This is to say nothing about what those aims are, of course. Drugs and guns are banned and possession is heavily criminalized, for example. Their laws regarding libel and slander are extremely harsh by American standards. ...And so on and so forth.

But the point is, when their government sets out to do something, it actually gets done, unlike in our system of government, where either nothing gets done, or the thing that does get done is a monstrous perversion of what anybody wanted, takes a decade to even get off the ground, and clocks in at five times the estimated cost.

And I believe their taxes are very low and the government actually operates certain enterprises as a business, turning a profit. I could be wrong about that, though. Like I said, I need to look into it more closely.